{ "cells": [ { "cell_type": "code", "execution_count": null, "metadata": {}, "outputs": [], "source": [ "import os\n", "work_directory = r\"D:\\Project Multimedika\\Projek 2\\fullstack_summarizer_and_bot_development\\backend\"\n", "os.chdir(work_directory)" ] }, { "cell_type": "code", "execution_count": 2, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend'" ] }, "execution_count": 2, "metadata": {}, "output_type": "execute_result" } ], "source": [ "%pwd" ] }, { "cell_type": "code", "execution_count": 4, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "Collecting nbconvert\n", " Downloading nbconvert-7.16.4-py3-none-any.whl.metadata (8.5 kB)\n", "Requirement already satisfied: beautifulsoup4 in c:\\users\\hamza\\anaconda3\\envs\\fullstack\\lib\\site-packages (from nbconvert) (4.12.3)\n", "Collecting bleach!=5.0.0 (from nbconvert)\n", " Downloading 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"source": [ "import nest_asyncio\n", "from dotenv import load_dotenv\n", "import os\n", "\n", "load_dotenv()\n", "\n", "nest_asyncio.apply()\n", "\n", "from llama_parse import LlamaParse\n", "from llama_index.core import SimpleDirectoryReader\n", "\n", "parser = LlamaParse(\n", " api_key=os.getenv(\"LLAMA_PARSE_API_KEY\"), # can also be set in your env as LLAMA_CLOUD_API_KEY\n", " result_type=\"markdown\", # \"markdown\" and \"text\" are available\n", " verbose=True,\n", ")\n", "\n", "file_extractor = {\".pdf\": parser}\n", "documents = SimpleDirectoryReader(\n", " \"./research/data\", file_extractor=file_extractor\n", ").load_data()" ] }, { "cell_type": "code", "execution_count": 8, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[Document(id_='dc35d195-e8f7-4102-9f5c-c2d73abeb48c', embedding=None, metadata={'file_path': 'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend\\\\research\\\\data\\\\main.pdf', 'file_name': 'main.pdf', 'file_type': 'application/pdf', 'file_size': 3342958, 'creation_date': '2024-09-25', 'last_modified_date': '2024-09-24'}, excluded_embed_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], excluded_llm_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], relationships={}, text='# IL-22: A key inflammatory mediator as a biomarker and potential therapeutic target for lung cancer\\n\\n# Ling Xu a,1, Peng Cao a,1, Jianpeng Wang b,1, Peng Zhang a, Shuhui Hu a, Chao Cheng a, Hua Wang c,*\\n\\n# a Department of Interventional Pulmonary Diseases, The Anhui Chest Hospital, Hefei, China\\n\\n# b First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China\\n\\n# c Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China\\n\\n# A R T I C L E I N F O\\n\\n# A B S T R A C T\\n\\n# Keywords:\\n\\nLung cancer, one of the most prevalent cancers worldwide, stands as the primary cause of cancer-related deaths. As is well-known, the utmost crucial risk factor contributing to lung cancer is smoking. In recent years, remarkable progress has been made in treating lung cancer, particularly non-small cell lung cancer (NSCLC). Nevertheless, the absence of effective and accurate biomarkers for diagnosing and treating lung cancer remains a pressing issue. Interleukin 22 (IL-22) is a member of the IL-10 cytokine family. It exerts biological functions (including induction of proliferation and anti-apoptotic signaling pathways, enhancement of tissue regeneration and immunity defense) by binding to heterodimeric receptors containing type 1 receptor chain (R1) and type 2 receptor chain (R2). IL-22 has been identified as a pro-cancer factor since dysregulation of the IL-22-IL-22R system has been implicated in the development of different cancers, including lung, breast, gastric, pancreatic, and colon cancers. In this review, we discuss the differential expression, regulatory role, and potential clinical significance of IL-22 in lung cancer, while shedding light on innovative approaches for the future.\\n\\n# 1. Introduction\\n\\nLung cancer is a heterogeneous disease in which cells in the lung grow aberrantly culminating in the formation of tumors. Typically, these tumors present as nodules or masses discernible through pulmonary imaging techniques [1]. In the year 2020, the global incidence of lung cancer surpassed a staggering 2.2 million cases, leading to approximately 1.8 million tragic fatalities. When considering age-standardized rates, the morbidity and mortality figures stand at 22.4 and 18.0 per 100,000 individuals respectively [2]. Generally, lung cancer is considered to be intricately linked to a multitude of factors including but not limited to smoking, genetic predisposition, occupational exposures, as well as the deleterious effects of air and environmental pollution [3,4]. Among the risk factors for lung cancer, smoking dominates overwhelmingly, with about two-thirds of lung cancer deaths globally caused by it [5]. In recent years, the drug resistance phenomenon of lung cancer to chemotherapy and targeted therapy has become more and more prominent [6–8]. Therefore, it is of heightened importance to find new therapeutic targets.\\n\\n# * Corresponding author. Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China.\\n\\n# E-mail address: wanghua@ahmu.edu.cn (H. Wang).\\n\\n# 1 These authors have contributed equally to this work and share first authorship.\\n\\nhttps://doi.org/10.1016/j.heliyon.2024.e35901\\n\\nReceived 13 August 2023; Received in revised form 5 August 2024; Accepted 6 August 2024\\n\\nAvailable online 10 August 2024\\n\\n2405-8440/© 2024 The Authors. Published by Elsevier Ltd. (http://creativecommons.org/licenses/by-nc-nd/4.0/).\\n\\nThis is an open access article under the CC BY-NC-ND license', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='bc2de09b-4e34-492a-9504-b658339e14a3', embedding=None, metadata={'file_path': 'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend\\\\research\\\\data\\\\main.pdf', 'file_name': 'main.pdf', 'file_type': 'application/pdf', 'file_size': 3342958, 'creation_date': '2024-09-25', 'last_modified_date': '2024-09-24'}, excluded_embed_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], excluded_llm_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# 1. Introduction\\n\\nIL-22 is an IL-10 family cytokine produced by T cells and innate lymphocytes. Like all other IL-10 family members, the IL-22 structure contains six α-helices (termed helices A to F). They are arranged in an antiparallel conformation and produce a single bundled protein [9]. IL-22 coordinates mucosal immune defense and tissue regeneration through pleiotropic effects including pro-survival signaling, cell migration, dysplasia, and angiogenesis. These molecules act by targeting the heterodimeric transmembrane receptor complex composed of IL-22R1 and IL-10R2 and by activating subsequent signaling pathways (including JAK/STAT signaling pathway, p38 MAPK signaling pathway, and PI3K/AKT signaling pathway) [10]. It is well known that IL-22 is widely expressed in human tissues and organs, including lung, liver, heart, kidney, pancreas, gastrointestinal tract, skin, blood, adipose, and synovial tissues [11]. Meanwhile, IL-22 is also found to be broadly expressed in pathological states such as cancer, infectious diseases, tissue injury, chronic inflammatory diseases, and Graft-Versus-Host Disease [11–14]. In most cancer diseases, excessively elevated levels of IL-22 are considered to be detrimental [15–19]. For instance, a recent study has demonstrated that IL-22 promotes extravasation of tumor cells in liver metastasis [20]. Over the past few years, there has been a surge in research focusing on the relationship between IL-22 and lung cancer. Particularly in patients with NSCLC, researchers have discovered up-regulated expression of IL-22 in serum, malignant pleural effusion, and tumor tissues, and the levels of IL-22Rα1 in tumor cells and tissues are also increased [21–24]. Although emerging studies have revealed that IL-22 is closely correlated with lung cancer in terms of tissue, cell and pathological changes, the specific function and mechanism remain to be explored. In the present review, we mainly summarized the regulatory function and clinical role of IL-22 in lung cancer. In addition, the feasibility of IL-22 as a biomarker for lung cancer and directions for future research were also discussed. It is reasonable to hypothesize that IL-22 may serve as a potential target in the treatment of lung cancer.\\n\\n# 2. Overview of lung cancer\\n\\nLung cancer is a malignant disease characterized by high morbidity and mortality [25]. According to the data of GLOBOCAN, lung cancer is the second most common cancer in 2020 and the main cause of cancer death worldwide, with about one-tenth (11.4 %) of cancer diagnoses and one-fifth (18.0 %) of deaths [5]. When it comes to gender, the incidence and mortality rates of lung cancer were on the rise in females but declining in males in most countries over the past decade [2]. The 5-year survival rate of lung cancer patients varies by 4–17 % in light of stage and region [26]. As predicted by the American Cancer Society, more than 120,000 people will die of lung cancer in the United States in 2023. The good news is that although the incidence is stable or increasing, the overall mortality is decreasing at an accelerated pace [27]. From the perspective of histopathology and biological behavior, lung cancer can be divided into NSCLC and SCLC, among which the former mainly includes several common types such as adenocarcinoma, squamous cell carcinoma, and large cell carcinoma [25]. The pathogenesis of lung cancer primarily involves the following aspects: chromosome changes; abnormal immune response; abnormal activation of developmental pathways; dysregulation of tumor suppressor genes, proto-oncogenes, and signaling pathways; and the up-regulation of receptor tyrosine kinases, growth factors, and cell markers. These abnormal changes cause an imbalance between lung cell proliferation and apoptosis, which leads to lung cancer [28–31]. For example, when exposed to risk factors continuously, the production of ROS, chemokines, and cytokines increases in lung cells, which leads to DNA damage and gives rise to inflammation and other pathobiological changes that ultimately promote carcinogenesis. At the same time, the anti-tumor immune function of macrophages, T lymphocytes, B lymphocytes, and NK cells gets suppressed, failing recognition and clearance of malignant cells, and eventually bringing about the formation of tumors [32]. In the early stage of the disease, it is usually considered to be asymptomatic, while may manifest as cough, dyspnea, chest pain, hemoptysis, hoarseness, and so on in the middle and advanced period [33]. In principle, the treatment of lung cancer depends largely on the type, stage and condition of the patient’s disease. Currently, the main treatment approaches for lung cancer include surgery, chemotherapy, and radiotherapy. Among them, platinum-containing double drugs are preferred for chemotherapy. Radiation therapy is mainly applied in the control of the local lesion. Furthermore, targeted therapy for EGFR, ALK, ROS1, and other gene mutations and immunotherapy to inhibit PD-1/PD-L1 also plays an irreplaceable role as emerging breakthrough therapeutic means [25,34–39]. Compared with chemotherapy, targeted therapy can prominently enhance the survival rate and tolerance of patients with NSCLC [40,41]. The combination of chemotherapy and immunotherapy has also shown a more notable curative effect over chemotherapy alone [42,43]. Additionally, there has been a growing body of research focusing on natural product therapy, local ablative therapy, and chimeric antigen receptor (CAR)-T-cell therapy lately [44–51]. In principle, the treatments of lung cancer are individualized depending largely on the type, stage, and condition of patients. Unfortunately, the limited sensitivity of NSCLC patients to chemotherapy and immunotherapy drugs has proven to be a major obstacle to clinical treatment. Denk D et al. suggested that inflammation is ubiquitous in carcinogenesis. In his study, he noted that interfering with individual cytokines and their respective signaling pathways holds great promise for the development and improvement of current clinical cancer therapies [52]. IL-22 is a new type of cytokine discovered in 2000 and has gradually attracted attention due to its role in tumor diseases. In recent years, multiple studies have reported the positive role of IL-22 in enhancing chemotherapy resistance in human lung cancer patients. This positive effect is related to the function of IL-22 in promoting lung cancer cell proliferation and inhibiting lung cancer cell apoptosis. Results showed that IL-22 activated the EGFR/AKT/ERK signaling pathway [52], STAT3, and ERK1/2 signaling pathways [24] in drug-treated lung cancer cells, thereby attenuating the pro-apoptotic effect of the drug on lung cancer cells.\\n\\n# 3. Function role of IL-22 in lung cancer\\n\\nIL-22 is a cytokine first identified by Dumoutier et al. in IL-9-induced murine T cells over 20 years ago and was once called IL-10-related T cell-derived inducible factor (IL-10-TIF) [53]. In human beings, the IL-22 gene lies in chromosome 12q15, next to the gene.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='137684ca-6ce0-413c-9836-7cbb099e258f', embedding=None, metadata={'file_path': 'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend\\\\research\\\\data\\\\main.pdf', 'file_name': 'main.pdf', 'file_type': 'application/pdf', 'file_size': 3342958, 'creation_date': '2024-09-25', 'last_modified_date': '2024-09-24'}, excluded_embed_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], excluded_llm_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\nthat encodes IFN-γ [54]. When the body is in homeostasis, the most important source of IL-22 is Group 3 innate lymphoid cells (ILC3) [14]. Different from other common cytokines, IL-22 is generally thought to be produced only by hematopoietic origin immune cells, whereas it mainly acts on non-hematopoietic cells due to its receptor distribution [55]. Recently, researchers have found that non-hematopoietic cells represented by fibroblasts can also produce IL-22 under certain circumstances [11]. IL-22 is known to act by binding to its receptor (IL-22R), which is synthesized from the IL-22R1 and IL-10R2 subunits [56]. Thereinto, IL-22R1 expression is thought to be restricted to epithelial cells in organs such as the lung, liver, intestine, and skin, while the latter is universally expressed [11,57]. IL-22BP, also known as IL-22RA2, is a soluble IL-22 receptor that binds specifically to IL-22 and prevents it from binding to IL-22R1. All currently known functions of IL-22BP are achieved by inhibiting IL-22 [58,59]. Broadly speaking, the primary function of IL-22 in the body is to promote cell proliferation and tissue protection [60]. Sometimes, excessive activation of this function may lead to pathological results. This dual effect is reflected in both inflammatory and tumor-related diseases. In the short term, the production of IL-22 can play a protective role in anti-inflammatory and tumor prevention, while the uncontrolled generation of IL-22 may promote inflammation and tumor formation [13,18]. The duality of IL-22 reveals that it could be a potential drug target, and the tight regulation of IL-22 is crucial in the treatment of a variety of diseases. In Fig. 1, We summarize the role of IL-22 in lung cancer.\\n\\nIn general, the expression levels of IL-22 in vivo are regulated by a variety of cytokines and genes. For instance, IL-1β and IL-23 can induce the production of IL-22 independently, and the two act synergistically [11]. What’s more, Cornelia Voigt described a novel mechanism whereby cancer cells promote tumor growth by releasing IL-1β to induce IL-22 production by memory CD4+ T cells [61]. According to an animal experiment, IL-1β can enhance the proliferation of epithelial cells and promote lung tumorigenesis [62]. IL-23 has been proven to promote proliferation in NSCLC by Anne-Marie Baird et al. [63]. Although IL-23 is thought to be able to induce macrophages to produce IL-22, this study by Anne-Marie Baird et al. cannot directly prove whether the proliferation-promoting effect of IL-23 on NSCLC cells is related to IL-23’s promotion of IL-22 production. IL-23 is also thought to promote the expression of IL-26 by macrophages. Like IL-22, IL-26 is part of the IL-10 family. Researchers demonstrated for the first time that IL-26 is involved in the generation of malignant pleural effusions [64]. They reported that IL-26 promotes the generation of malignant pleural effusion by mediating the infiltration of CD4+IL-22+T cells in malignant pleural effusion and stimulating CD4+ IL-22+ T cells to secrete IL-22. Recently, the Notch-AhR-IL-22 axis is thought to be involved in the pathogenesis of LUAD. It is corroborated that in LUAD patients, elevated Notch1 facilitates IL-22 generation by CD4+ T cells via aryl hydrocarbon receptors (AhR) [65]. In NSCLC, Notch signaling can both promote tumorigenesis and inhibit tumor progression, which mainly depends on its regulation of the\\n\\n|Class I: Proliferation, apoptosis, and invasion|Class II: Regulating tumor microenvironment|\\n|---|---|\\n|Proliferation|Lung cancer tissue|\\n|NK cells| |\\n|T cells|Apoptosis|\\n|Lung cancer cells| |\\n|C01se|Metastasis|\\n|Lung cancer cells|Infiltrated immune cells|\\n|CASPASE| |\\n|Multidrug resistance| |\\n|IL-22 Ko| |\\n|IL-6|Lymphocyte|\\n|TNF-a|Total WBC|\\n|IL-1a|Macrophage|\\n|Neutrophil| |\\n\\n|Class III: Angiogenesis|Class IV: Cancer stem cell|\\n|---|---|\\n|IL-22|STAT3 signaling pathway|\\n|Lung cancer tissue| |\\n|Aangiogenic switch| |\\n|IL-22| |\\n|Vascular endothelial cell|Cancer stem cells|\\n| |Lung cancer cells|\\n\\nFig. 1. IL-22 plays four main functions during the progression of lung cancer. 1) Promote lung cancer cell proliferation and invasion, and inhibit lung cancer cell apoptosis; 2) Regulate the abundance of immune cells in lung cancer tissues and activate the inflammatory microenvironment; 3) Promote cancer angiogenesis; 4) Activate lung cancer stem cells.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='40493e25-7e57-4f65-9d37-8e21a13e8a3a', embedding=None, metadata={'file_path': 'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend\\\\research\\\\data\\\\main.pdf', 'file_name': 'main.pdf', 'file_type': 'application/pdf', 'file_size': 3342958, 'creation_date': '2024-09-25', 'last_modified_date': '2024-09-24'}, excluded_embed_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], excluded_llm_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\nTransformation between neuroendocrine and non-neuroendocrine. For patients with SCLC containing Notch active tumor cells, the application of Notch inhibitors may be an effective treatment [66]. Moreover, the expression of IL-22 is also regulated by miR-26. In cutaneous T-cell lymphoma (CTCL) cells, transfection of miR-26 resulted in a remarkable decrease in the expression levels of IL-22 and IL-22 mRNA [67]. In human NSCLC, Yi He et al. found that the expression levels of miR-26 were lower in tumor tissues compared to paracancerous tissue. As a functional miRNA, miR-26 was further proved by the team to inhibit autophagy and induce apoptosis of NSCLC cells both in vitro and in vivo [68]. On the other hand, IL-22 has also been shown to regulate other cytokines. Studies have shown that the production of IL-22 generally reduces Th1-type immune responses. This action may be coordinated with the protective effect of IL-22R-expressing tissue cells to reduce collateral damage in the context of infection and inflammation [69]. Besides, animal experiments have indicated that IL-22 can also promote B-cell responses by inducing CXCL13 in tertiary lymphoid follicles [70,71]. In the latest murine lung cancer model, IL-22 was discovered to induce NK cells to overexpress CD155, thus mediating the immune evasion of tumor cells [72]. As a transmembrane adhesive molecule, CD155 has been proven to inhibit T and NK cell-mediated anti-tumor immune responses, thereby promoting tumor progression (Fig. 2) [73–75].\\n\\nIn the occurrence and development of pulmonary diseases, IL-22 is considered to play an important role. As previously demonstrated in an epicutaneously sensitized mice experiment, IL-22 promotes the development of neutrophil and eosinophile-mediated airway inflammation and airway hyperresponsiveness stimulated by intranasal antigens [76]. The conclusion implies that blocking IL-22 may be helpful for the treatment of bronchial asthma. When it comes to chronic obstructive pulmonary disease (COPD), the expression levels of both IL-22 and its receptor in COPD patients were higher than those of healthy controls. This result was confirmed in mice with experimental COPD induced by cigarette smoke. What’s more, researchers also found that cigarette smoke-induced inappropriate activation of pulmonary neutrophils decreased in IL-22-deficient mice with COPD. This suggests that IL-22 may be involved in the pathogenesis of COPD. The research further manifested that IL-22 promotes cigarette smoke-induced airway remodeling, pulmonary neutrophil inflammation, and the impairment of pulmonary function, and is involved in the pathogenesis of COPD [77]. While in pulmonary infectious diseases such as pneumonia, tuberculosis, and pulmonary mycosis, it is thought that IL-22 appears to take a protective and preventive part [78–83]. For good measure, in the bleomycin-induced pulmonary fibrosis model, the degree of pulmonary fibrosis in IL-22 knockout mice was aggravated, and injection of recombinant IL-22 alleviated the severe fibrosis in IL-22 knockout mice. This latest research has suggested the potential anti-fibrotic effect of IL-22 [84].\\n\\nIn recent years, differential expression of IL-22 has also been discovered in various specimens of lung cancer (Table 1). In the first place, the mean levels of IL-22 in the plasma of NSCLC patients were significantly higher than that of the reference cohort [21,85]. The plasma levels of IL-22 were observed to elevate along with the increase in lung cancer staging [85]. In addition, Immunohistochemistry analysis showed that IL-22 expression was up-regulated in NSCLC tumor specimens in comparison to that in the adjacent tissues. RT-qPCR analysis also revealed similar differences in IL-22 mRNA expression between lung cancer tissues and normal tissues [24,86]. Interestingly, Yi Bi et al. compared IL-22 levels between tissues and serum of patients with primary NSCLC and their paired recurrent lung cancer specimens and the expression levels of IL-22 were found to be obviously up-regulated in the latter group [23]. Apart from this, IL-22 expression was also detected in bronchoalveolar lavage fluid (BALF). As reported by an article in 2016, IL-22 levels were...\\n\\n|CD155|NK Cell|L|\\n|---|---|---|\\n|T Cell|IL-22|Impaired function|\\n| |Lung metastases| |\\n\\nFig. 2. IL-22 induces NK cells to overexpress CD155, which binds to NK cell activation receptor CD226. Over-activation leads to a decrease in the amount of CD226 and impaired NK cell function, thereby mediating tumor cell immune escape.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='2743fb75-4561-4ebf-b3a3-98c9ab31ae9c', embedding=None, metadata={'file_path': 'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend\\\\research\\\\data\\\\main.pdf', 'file_name': 'main.pdf', 'file_type': 'application/pdf', 'file_size': 3342958, 'creation_date': '2024-09-25', 'last_modified_date': '2024-09-24'}, excluded_embed_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], excluded_llm_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# Table 1\\n\\nDifferential expression of IL-22/IL-22 mRNA/IL-22R1 mRNA in various samples in lung cancer. +: Up-regulated.\\n\\n|Molecule|Samples|Expression|P value|Ref. (PMID)|\\n|---|---|---|---|---|\\n|IL-22|Plasma|+|0.0013|24956177|\\n|IL-22 mRNA|Tissues|+|0.0313|18927282|\\n|IL-22|Pleural effusion|+|0.0051|18927282|\\n|IL-22 mRNA, IL-22|Tissues, serum|+|<0.01|26983629|\\n|IL-22R1 mRNA|Tissues|+|<0.05|26983629|\\n|IL-22|BALF|+|<0.001|27388918|\\n\\nSignificantly higher in BALF from lung cancer patients compared with control group. The researchers expanded the cohort to patients with lung metastases from other malignancies and found that IL-22 concentrations remained higher than controls [87]. These results implied that IL-22 in BALF may be a biomarker for lung cancer. Over and above, researchers also found the trace of IL-22 in pleural effusion [88,89]. One study has revealed that IL-22 levels were higher in malignant pleural effusion as against tuberculous pleural effusion [24]. These differential expressions prompt that IL-22 may participate in the occurrence and development of lung cancer (Table 2).\\n\\nThe link between inflammatory processes and cancer has long been recognized [90]. Related studies hint that inflammatory responses play a vital role in different phases of tumor occurrence, development, and metastasis [91–93]. The function of IL-22 in cancer is extremely complicated. Initially, IL-22 may prevent tumorigenesis by reducing chronic inflammation, promoting barrier function, and inducing tissue regeneration. On the contrary, if IL-22 is excessively expressed under persistent chronic inflammation, then malignant cells may utilize this signal to facilitate its progression [11]. In the lung tumor microenvironment, uncontrolled expression of IL-22 can amplify inflammation by inducing various inflammatory mediators alone or in concert with other cytokines [94]. As illustrated by a cellular experiment, IL-22 could promote the proliferation of A549 and H125 cells belonging to the NSCLC cell lines, thereby enhancing the ability of tumor cell migration and invasion [23]. An in vitro experiment in 2018 has confirmed that IL-22 can directly act on endothelial cells to stimulate tumor angiogenesis [95]. To some extent, this enhances the ability of tumor cells to absorb nutrients and distant metastasis. From another perspective, this provides new ideas for anti-angiogenic therapy of tumors. Nasim Khosravi suggested that IL-22 promotes tumor progression by inducing a pro-tumor immune response and protective stem cell properties of tumor cells [94]. It is also reported that after 12h of serum starvation, the proportion of apoptotic lung cancer cells transfected with the IL-22 gene was significantly lower than that of control lung cancer cells. In addition, the apoptosis-inducing and anti-proliferative effects of chemotherapeutic drugs on lung cancer cells were inhibited in IL-22 transgenic cell lines [24]. Simultaneously, the apoptosis of lung cancer cells induced by gefitinib was also significantly reduced 48 h after IL-22 exposure [96]. On the contrary, exposure to IL-22R1 blocking antibodies or in vitro transfection of IL-22-RNA interference plasmid leads to apoptosis of lung cancer cells [24]. Zhiliang Huang et al. found that the apoptosis rate of paclitaxel-treated lung cancer cells in the IL-22 siRNA transfection group was significantly increased compared with the control group [22]. Apart from this, IL-22 antibody treated mice and IL-22-deficient mice were found to be protected from the formation of pulmonary metastases caused by colon cancer, while IL-22 overexpression promoted metastases [20]. In short, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and migration of lung cancer cells, the growth of tumor tissues, and the generation of lung metastatic cancer.\\n\\n# 4. Regulatory role of IL-22 in lung cancer\\n\\nNumerous signaling pathways are involved in the regulation of IL-22 in lung cancer, including PI3K/AKT, JAK-STAT3, p38 MAPK signaling pathways, and so on. In the following, we will elaborate on the regulatory role of IL-22 in lung cancer from the point of view of each major signaling pathway (Fig. 3).\\n\\n# Table 2\\n\\nPotential clinical role of IL-22, its receptors and producing cells in lung cancer.\\n\\n|Sample sources|Clinical function|Conclusion|Ref. (PMID)|\\n|---|---|---|---|\\n|Patients|Diagnosis|IL-22 levels were significantly higher in lung cancer patients than control group.|24956177, 27388918|\\n|Patients|Prognosis assessment|IL-22R1 levels were associated with poorer prognosis.|26846835|\\n|Patients|Disease assessment|The levels of IL-22-producing Th22 cells were positively correlated with TNM stage and lymph node metastasis.|35669104|\\n|Patients|Efficacy prediction|IL-22 expression levels were associated with EGFR-TKI efficacy.|31750252|\\n|Mice model|Treatment|IL-22-deficient mice had a lower metastatic load of lung cancer.|36630913|\\n|Mice model|Treatment|Gene ablation of IL-22 resulted in a marked reduction in the number and size of lung tumors.|29764837|', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='31560940-3f9f-4575-97e3-351a97a0607e', embedding=None, metadata={'file_path': 'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend\\\\research\\\\data\\\\main.pdf', 'file_name': 'main.pdf', 'file_type': 'application/pdf', 'file_size': 3342958, 'creation_date': '2024-09-25', 'last_modified_date': '2024-09-24'}, excluded_embed_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], excluded_llm_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# 4.1. PI3K/Akt signaling pathway\\n\\nPI3K/Akt signaling pathway is one of the core intracellular signaling pathways, which plays a critical role in regulating cell growth, survival, metabolism, movement, and proliferation [97]. As a downstream effector of receptor tyrosine kinases (RTKs) and G-protein-coupled receptors (GPCRs), PI3K is a group of lipid kinases consisting of three subunits. It can be divided into three categories according to various functions and structures. Thereinto Class IA PI3K is a heterodimer of the p110 catalytic subunit and the p58 regulatory subunit, and it is primarily related to human tumors [98,99]. As we all know, PI3K can catalyze phosphatidylinositol [4, 5]-bisphosphate (PIP2) to phosphatidylinositol [3–5]-trisphosphate (PIP3). Serine/threonine protein kinase (Akt), as the main downstream molecule of the PI3K signaling pathway, is mainly activated by PIP3-driven plasma membrane recruitment and phosphorylation. The mammalian target of rapamycin (mTOR), a major downstream signaling molecule in the PI3K/Akt signaling pathway, is considered to be a modified protein kinase in the form of mTORC1 and mTORC2. The first is mainly activated by the PI3K/Akt signaling pathway, and mTORC2 further activates Akt by directly phosphorylating its hydrophobic motif (Ser473) [100].\\n\\nPI3K/Akt signaling pathway is considered to be the chief regulatory factor of idiopathic pulmonary fibrosis (IPF), it may directly participate in the formation of IPF or promote the occurrence and development of fibrosis in collaboration with other pathways [97]. Several studies have declared that certain natural products like resveratrol and Danhong injection can provide neuroprotective effects by activating the PI3K/Akt/mTOR signaling pathway [101,102]. Furthermore, the relationship between the PI3K/Akt/mTOR signaling pathway and cancer has been most intensively studied. Activation of the PI3K/Akt/mTOR signaling pathway is believed to promote the occurrence, proliferation, and progression of a variety of cancers, including breast cancer, ovarian cancer, prostate cancer, etc. [99,100,103]. In addition, it is also an important cause of tumor drug resistance [104]. In NSCLC, KRAS, EGFR, and PTEN mutations are believed to activate the PI3K/Akt/mTOR signaling pathway [105]. As demonstrated in a previous article, upregulation of the PI3K signaling pathway was identified as an early and reversible event in the pathogenesis of NSCLC [106]. One experiment has confirmed that the PI3K/Akt signaling pathway promotes the proliferation of LUAD cells mainly through anti-apoptosis [107]. Additionally, as revealed in a cellular study, IL-22 produced by CAFs markedly improves the proliferation and invasion of lung cancer cell, and lessens apoptosis by activating the PI3K/Akt/mTOR signaling pathway [86]. For good measure, it has been found that Akt phosphorylation in NSCLC cells is facilitated by different concentrations of IL-22 in a time- and dose-dependent way [23]. Collectively, the PI3K/Akt/mTOR signaling pathway plays a significant role in the relationship between IL-22 and lung cancer. It is worth mentioning that IL-22 does not seem to always activate the PI3K/Akt/mTOR signaling pathway. Meng Yuxia et al. found that IL-22 inhibits the activity of the PI3K/Akt/mTOR signaling pathway in mouse liver fibrosis tissue [108]. This opposite finding may be related to the dual function of IL-22. Further study on the impact of IL-22 on the PI3K/Akt/mTOR signaling pathway in different disease processes will help us better understand the specific mechanism of IL-22’s function in the human body. This will facilitate.\\n\\n|IL-22|PI3K|JAK|P38 MAPK|\\n|---|---|---|---|\\n|NK cell|AKT|mTOR| |\\n|Antitumor drugs|Gene expression| |Metastasis|\\n|Apoptosis|Proliferation|EMT|Invasion|\\n| |Lung tumor cell| | |\\n\\nFig. 3. IL-22 promotes the proliferation, migration and epithelial-mesenchymal transition of lung cancer cells through PI3K/Akt, JAK-STAT3, p38 MAPK and other signaling pathways, and antagonizes the apoptosis of lung cancer cells induced by anti-tumor drugs.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='0f295d75-2e39-485d-ab98-37f250a244d3', embedding=None, metadata={'file_path': 'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend\\\\research\\\\data\\\\main.pdf', 'file_name': 'main.pdf', 'file_type': 'application/pdf', 'file_size': 3342958, 'creation_date': '2024-09-25', 'last_modified_date': '2024-09-24'}, excluded_embed_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], excluded_llm_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], relationships={}, text='# L. Xu et al. Heliyon 10 (2024) e35901\\n\\n# IL-22-related clinical drug development.\\n\\n# 4.2. JAK/STAT signaling pathway\\n\\nThe JAK/STAT signaling pathway is also an important communication center for cell function, and aberrant alterations in its components are associated with numerous human diseases. JAK/STAT is an evolutionarily conserved signaling pathway consisting of JAKs, STATs, and ligand-receptor complexes. There are four major members of the JAK family, all of which are composed of non-receptor tyrosine protein kinases. The STAT family contains six members which consist of 750–900 amino acids. The JAK/STAT signaling pathway is mainly thought to mediate inflammation, apoptosis, hematopoiesis, tissue repair, immune regulation, and adipogenesis [109]. In autoimmune diseases such as rheumatoid arthritis (RA), activation of the JAK-STAT signaling pathway leads to the progression of joint injury through overexpression of the matrix metalloproteinase gene, apoptosis of chondrocytes, and apoptotic resistance in synovial tissue [110,111]. In addition, in a 2020 study by Meyer LK, the inhibition of the JAK-STAT signaling pathway was found to sensitize CD8+ T cells to dexamethasone-induced excessive inflammatory cell apoptosis [112]. Song et al. have long discovered that the lifespan of NSCLC cells was notably reduced after inhibiting STAT3 [113]. In a murine lung model, overexpression of STAT3 in alveolar type II cells led to severe lung inflammation and eventually to the formation of LUAD [114]. Further, down-regulation of STAT3 was found to result in enhanced NK cell immunity in both human and murine NSCLC cells, which suggests that STAT3 plays an inhibitory role against tumor NK cell immunity [115,116]. A study last year disclosed that IL-22 triggers JAK-STAT3 pathway phosphorylation in NSCLC cells in a time- and dose-dependent manner, thus promoting the proliferation and metastasis of tumor cells [23,96]. Another study demonstrated that the overexpression of IL-22 protected lung cancer cells against apoptosis induced by serum starvation and chemotherapy drugs by activating STAT3 and its downstream anti-apoptotic proteins [24].\\n\\n# 4.3. p38 MAPK signaling pathway\\n\\nThe p38 mitogen-activated protein kinases (MAPK) signaling pathway takes a crucial role in signaling cascades induced by various cellular stimuli. There are four p38 kinase members in the mammalian mitogen-activated protein (MAP) family, which play momentous roles in extracellular stimulation-mediated proliferation, inflammation, differentiation, apoptosis, senescence, and tumorigenesis [117]. In the classical pathway, the p38 MAPK signaling pathway is activated by cascade phosphorylation [118]. In a hepatitis C virus (HCV) experiment, researchers demonstrated that virus-induced activation of the p38 MAPK signaling pathway promotes viral infection, and blocking activation of this pathway may be an antiviral approach [117]. According to Dan He in 2020, mTORC1 drives intestinal stem cell aging via the p38 MAPK-p53 signaling pathway [119]. The p38 MAPK signaling pathway has long been demonstrated to exhibit a major oncogenic role in LUAD [120–122]. Yinan Guo et al. found evidence that the p38 MAPK signaling pathway can promote EMT and metastasis of NSCLC both in vitro and in vivo [123]. In addition, a study published in 2017 proposed that the p38 MAPK signaling pathway activates stem cell properties of LUAD cells by regulating GLI1 [124]. What’s more, in lung cancer models, researchers found that the p38 MAPK signaling pathway inhibited the stem cell properties of lung CSCs and promoted their proliferation and differentiation, thereby leading to tumorigenesis. More importantly, they also elucidated that the p38 MAPK and PI3K/AKT signaling pathways have unique and synergistic roles in regulating lung CSCs self-renewal as carcinogenic and/or stem cell signaling pathways [107]. This provides a new idea for the stem cell-based treatment of lung cancer. In NSCLC, IL-22 in vivo and in vitro were both verified to activate the p38 MAPK signaling pathway. The collected evidence from this study confirmed the negative immunomodulatory role of IL-22 in the disease [96].\\n\\n# 5. Clinical role of IL-22 in lung cancer\\n\\nCurrently, there is still a lack of efficient biomarkers for the diagnosis and treatment of lung cancer. In recent years, the value of the interleukin family as biomarkers and therapeutic targets of lung cancer has been deeply investigated [125–132]. Of these, IL-1 and IL-6 have been studied most extensively in lung cancer. Bo Yuan’s findings in mice experiments supported IL-1β as a potential target for the prevention and treatment of LUAD patients with Kras mutations [129]. In a clinical trial of the anti-IL-1β antibody canakinumab, researchers found that 300 mg canakinumab significantly reduced lung cancer mortality compared with the control group (HR 0.49 [95%CI 0.31–0.75]; p = 0.0009) [133]. In plasma samples or tumor tissues from NSCLC, researchers revealed that patients with lower baseline IL-6 concentrations benefited more from immunotherapy. The study elucidated the role of IL-6 in predicting the efficacy of immunotherapy in patients with NSCLC [128]. Furthermore, in one lung cancer study, the survival hazard ratio before and after chemotherapy for high versus low IL-6 levels was 1.25 (95%CI 0.73–2.13) and 3.66 (95%CI 2.18–6.15), respectively. It is suggested that IL-6 may be a prognostic indicator of survival in patients with advanced NSCLC receiving chemotherapy [127]. Some scholars have also described the potential value of IL-11 as a biomarker for the diagnosis and prognosis of NSCLC [125]. In addition, another research has shown that changes in serum IL-8 levels in NSCLC patients could reflect and predict the response to immunotherapy [130]. Kaplan-Meier survival analysis showed that the overall survival outcome of NSCLC patients with high IL-22R1 expression was significantly lower than that of patients with low IL-22R1 expression (p = 0.022). Multivariate regression analysis also confirmed an association between IL-22R1 levels and poorer outcomes (HR 1.5, 95%CI 1.2–1.9; p = 0.0011). This suggested that high expression of IL-22R1 is an independent factor for low overall survival in NSCLC [134]. What’s more, the levels of IL-22-producing Th22 cells in peripheral blood were positively correlated with TNM stage, lymph node metastasis, and clinical tumor markers of lung cancer (p < 0.01) [96]. The above indicates the significance of IL-22 as a biomarker in the diagnosis and disease assessment of lung cancer. Apart from this, Renhua Guo’s team found that the expression of IL-22 in the EGFR-TKI resistant group was higher than that in sensitive.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='0e1070b2-dc17-429f-942b-e95c1b8d1a47', embedding=None, metadata={'file_path': 'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend\\\\research\\\\data\\\\main.pdf', 'file_name': 'main.pdf', 'file_type': 'application/pdf', 'file_size': 3342958, 'creation_date': '2024-09-25', 'last_modified_date': '2024-09-24'}, excluded_embed_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], excluded_llm_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\ngroup in NSCLC, and the expression level was correlated with the efficacy of EGFR-TKI in plasma [135]. Therefore, it is reasonable to suspect that IL-22 may be a new biomarker to overcome EGFR-TKI resistance in NSCLC. In terms of animal models, some investigators implanted Line-1 lung cancer cells into wild-type and IL-22-deficient mice simultaneously, and found reduced intrapulmonary metastasis in the latter group, which is independent of primary tumor size. Besides, they performed forced metastasis by intravenous injection of lung cancer cells, and the results further confirmed the lower metastatic load in mice with IL-22 deletion [72]. In another model of Kras-mutated lung cancer in mice, gene ablation of IL-22 resulted in a marked reduction in tumor number and size. The authors also analyzed the association between IL-22R1 expression and survival in patients with KRAS mutant lung adenocarcinoma, the results showed that high expression of IL-22R1 was an independent indicator of poorer relapse-free survival [94]. Taken together, these pieces of evidence highlight the potential clinical role of IL-22, IL-22R, and IL-22-producing cells in the treatment of lung cancer (Table 2).\\n\\n# 6. Future perspectives\\n\\n# 6.1. CRISPR-Cas13a technical\\n\\nAt present, mounting clinical trials based on IL-22 are being carried out in full swing worldwide, mainly involving ulcerative colitis, alcoholic cirrhosis, GVHD, and psoriasis [12,14,54,60]. However, there are presently no clinical trials based on IL-22 in lung cancer. As described previously, reduced intrapulmonary metastasis was found in IL-22-deficient mice as well as in IL-22-suppressed NSCLC cells [20,72]. In addition, blocking IL-22R1 or knockout of the IL-22 gene both retarded the progression of lung cancer [24,94]. These findings provide a new train of thought for the down-regulation of IL-22 in treating lung cancer.\\n\\nIn recent years, the research on gene editing treatment for various diseases has become more and more popular [136–138]. CRISPR-Cas13a is an effective tool for knocking out specific RNA sequences, it has been shown to induce the death of glioma cells that overexpress EGFR, which is one of the subtypes of EGFR mutation in glioma. Apart from this, the CRISPR-Cas13a gene-editing system can also inhibit the formation of intracranial tumors in mice with glioma [139]. In a collagen-induced mouse model, injection of gene-edited human amniotic mesenchymal stem cells that overexpressed IL-10 increased proteoglycan expression in joint tissue and reduced the inflammatory response and production of various inflammatory cytokines [137]. In the world’s first human phase I clinical trial utilizing CRISPR-Cas9 in the treatment of advanced NSCLC, researchers have demonstrated the feasibility and safety of gene-edited T-cell therapy targeting the PD-1 gene [140]. Thus, genome editing strategies have the potential to treat lung cancer by altering IL-22 expression levels. In the future, the role of pulmonary precision delivery based on CRISPR-Cas13 gene-editing components targeting the IL-22 mRNA in lung cancer therapy should not be ignored. CRISPR-Cas13 is expected to be further integrated.\\n\\n# IL-22 mRNA\\n\\n# Cas13a\\n\\n# Crispr-Cas13a Combined With\\n\\n# Figure\\n\\n# Single-base edition\\n\\n# Single-cell sequencing\\n\\n# Lung cancer\\n\\nFig. 4. Crispr-cas13-based IL-22 mRNA editing can be utilized for lung cancer therapy by combining with emerging technologies such as single-base editing and single-cell sequencing.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='188092c1-09ae-4347-a9ed-1a92ffd10697', embedding=None, metadata={'file_path': 'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend\\\\research\\\\data\\\\main.pdf', 'file_name': 'main.pdf', 'file_type': 'application/pdf', 'file_size': 3342958, 'creation_date': '2024-09-25', 'last_modified_date': '2024-09-24'}, excluded_embed_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], excluded_llm_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\nwith the latest technologies such as single-base editing and single-cell sequencing to promote the treatment of lung cancer to a new level (Fig. 4).\\n\\n# 6.2. Small interfering RNA\\n\\nSmall interfering RNA (siRNA) is a double-stranded RNA molecule composed of 21–23 nucleotides. In cells, siRNA forms functional complexes by binding to the RNA-induced silencing complex (RISC). RISC in the functional complex specifically recognizes and binds to the target mRNA, leading to degradation of the target mRNA and thereby silencing the expression of the target gene. Compared with traditional therapies such as small molecules and protein drugs, siRNA technology has many advantages:\\n\\n1. siRNA is highly specific. siRNA can only silence homologous genes, while unrelated genes are not affected.\\n2. siRNA can silence genes by using RISC.\\n3. siRNA can be designed to target different genes through sequence design, and can even target targets that were previously considered “undruggable”.\\n4. siRNA does not activate the innate immune system.\\n\\nTwenty years after the discovery of the RNA interference mechanism, the first siRNA drugs (including Patisiran, Givosiran, Lumasiran, Inclisiran, Vutrisiran) were approved for clinical use by the U.S. Food and Drug Administration (FDA) and the European Medicines Agency from 2018 to 2022 [141,142]. NFKBIZ is an upstream target of IL-23, IL-36 and IL-17A. In the study of Mandal A et al. [143], NFKBIZ-siRNA significantly reduces the mRNA levels of multiple pro-inflammatory cytokines, including IL-17, IL-19, IL-22, etc., in the skin tissue of psoriasis mice, thereby alleviating the condition of the mice. The safety evaluation results of NFKBIZ-siRNA preparations show that NFKBIZ-siRNA preparations can complex with nucleic acids without affecting biological activity and show no toxicity. TGF-β is a pleiotropic regulatory cytokine that can regulate a variety of ILs including IL-22 and IL-17 to affect the composition of the tumor microenvironment [144]. Currently, Sirnaomics has developed an siRNA drug that targets TGF-β (called STP705). Recently, the drug has completed phase II clinical trials in the United States and achieved positive results. The role of ILs in cancer has been extensively studied. In recent years, the positive role of IL-22 in lung cancer has received attention. The researchers believe that knocking down IL-22 mRNA levels in the lesions of lung cancer patients will help prolong the survival of lung cancer patients and improve the cure rate of lung cancer patients. For example, Zhang Wei et al. found that IL-22-siRNA slowed tumor growth in NSCLC model mice. In addition, they reported that the therapeutic effect of IL-22-siRNA combined with chemotherapy drugs (5-FU and carboplatin) on NSCLC mice was better than that of chemotherapy drugs alone [24]. In an in vitro assay [145], cell line PC9 cells (NSCLC) transfected with PDLIM5-siRNA targeting the PDLIM5 gene had reduced growth viability and exhibited higher apoptotic rates. In the chemotherapy drug gefitinib-resistant cell line PC9 cells, PDLIM5-siRNA still showed significant anti-tumor effects. These results indicate that siRNA-based therapy has good application in the clinical treatment of NSCLC, especially in drug-resistant patients. Based on these findings, we believe that the development of IL-22-siRNA drugs for lung cancer treatment has clinical potential and theoretical basis.\\n\\n# 6.3. Nanoparticle drug delivery systems\\n\\nOn the other hand, given the toxicity and erratic efficacy of current anti-tumor drugs, research on novel drug carriers in lung cancer.\\n\\n|Different types of nanomaterials|Targeting agent|IL-22-related drug|\\n|---|---|---|\\n|Lung precision delivery|Lung precision delivery|Lung precision delivery|\\n\\nFig. 5. Precision delivery of various nanomaterials containing IL-22 related drugs for the treatment of lung cancer.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='8e85abce-e0a4-48b0-b5e2-1e1eb022a31f', embedding=None, metadata={'file_path': 'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend\\\\research\\\\data\\\\main.pdf', 'file_name': 'main.pdf', 'file_type': 'application/pdf', 'file_size': 3342958, 'creation_date': '2024-09-25', 'last_modified_date': '2024-09-24'}, excluded_embed_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], excluded_llm_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\nis also of vital significance. Nanoparticles containing targeted drugs can be delivered to the intended site using carriers with affinity for various specific tissues or lesions [146,147]. In an in vivo mice lung model, combined delivery of sorafenib and crizotinib by polymer nanoparticles significantly reduced tumor progression and toxic side effects, and improved survival rate [148]. Moreover, Maofan Zhang demonstrated that the efficacy of dual-drug-loaded polymeric nanoparticles with etoposide and cisplatin was significantly superior to conventional chemotherapy modality without causing additional toxicity [149]. These imply that nanomaterials loaded with IL-22-related drugs may also have more unique advantages. Therefore, the utilization of novel nanomaterials loaded with IL-22 antibodies and IL-22 inhibitors like IL-22BP for targeted therapy of lung tumors is also a promising research direction (Fig. 5).\\n\\n# 7. Conclusion\\n\\nIn this review, we provided a comprehensive analysis of the role of IL-22 in the immune microenvironment and its involvement in major signaling pathways in the context of lung cancer. Put in a nutshell, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and metastasis of lung cancer cells and the growth of tumor tissues. Additionally, the potential clinical significance of IL-22 in the diagnosis, treatment, and prognosis evaluation of lung cancer was further confirmed. Next, the prospects of IL-22 in combination with gene editing and novel nanomaterials in the treatment of lung cancer have been discussed. With the general increase in drug resistance to chemotherapy, targeted therapy, and immunotherapy in lung cancer, it is also necessary to study in depth to discover the correlation between IL-22 and the mechanism of drug resistance. To sum up, the potential of IL-22 as a biomarker for lung cancer still remains to be explored. Further research on the molecular, physiological effects and mechanism of IL-22 in lung cancer as well as the conduction of standardized clinical trials are expected to inject fresh blood into the diagnosis and treatment of lung cancer.\\n\\n# Financial support\\n\\nNone.\\n\\n# Data availability statement\\n\\nNot applicable.\\n\\n# CRediT authorship contribution statement\\n\\nLing Xu: Writing – original draft.\\n\\nPeng Cao: Visualization.\\n\\nJianpeng Wang: Writing – review & editing.\\n\\nPeng Zhang: Validation.\\n\\nShuhui Hu: Validation.\\n\\nChao Cheng: Writing – review & editing.\\n\\nHua Wang: Writing – review & editing, Supervision, Conceptualization.\\n\\n# Declaration of competing interest\\n\\nThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\\n\\n# Acknowledgements\\n\\nNone.\\n\\n# Abbreviations\\n\\n|non-small cell lung cancer|NSCLC|\\n|---|---|\\n|Interleukin-22|IL-22|\\n|chimeric antigen receptor|CAR|\\n|IL-10-related T cell-derived inducible factor|IL-10-TIF|\\n|Group 3 innate lymphoid cells|ILC3|\\n|IL-22 receptor|IL-22R|\\n|aryl hydrocarbon receptors|AhR|\\n|chronic obstructive pulmonary disease|COPD|\\n|cutaneous T-cell lymphoma|CTCL|\\n|bronchoalveolar lavage fluid|BALF|\\n|receptor tyrosine kinases|RTKs|\\n|G-protein-coupled receptors|GPCRs|\\n|Mammalian target of rapamycin|mTOR|\\n|idiopathic pulmonary fibrosis|IPF|\\n|rheumatoid arthritis|RA|', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='4fd1b797-86e4-4eb9-ad08-b114d5981521', embedding=None, metadata={'file_path': 'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend\\\\research\\\\data\\\\main.pdf', 'file_name': 'main.pdf', 'file_type': 'application/pdf', 'file_size': 3342958, 'creation_date': '2024-09-25', 'last_modified_date': '2024-09-24'}, excluded_embed_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], excluded_llm_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# Abbreviations\\n\\n|Term|Abbreviation|\\n|---|---|\\n|mitogen-activated protein kinases|MAPK|\\n|mitogen-activated protein|MAP|\\n|hepatitis C virus|HCV|\\n\\n# References\\n\\n1. S. Lareau, C. Slatore, R. Smyth, Lung cancer, Am. J. Respir. Crit. Care Med. 204 (12) (2021) P21–P22.\\n2. J. Huang, Y. Deng, M.S. Tin, V. Lok, C.H. Ngai, L. Zhang, et al., Distribution, risk factors, and temporal trends for lung cancer incidence and mortality: a global analysis, Chest 161 (4) (2022) 1101–1111.\\n3. B.C. Bade, C.S. Dela Cruz, Lung cancer 2020: epidemiology, etiology, and prevention, Clin. Chest Med. 41 (1) (2020) 1–24.\\n4. J. Malhotra, M. Malvezzi, E. Negri, C. La Vecchia, P. Boffetta, Risk factors for lung cancer worldwide, Eur. Respir. J. 48 (3) (2016) 889–902.\\n5. H. Sung, J. Ferlay, R.L. Siegel, M. Laversanne, I. Soerjomataram, A. 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Fang, et al., Interleukin-22 secreted by cancer-associated fibroblasts regulates the proliferation and metastasis of lung cancer cells via the PI3K-Akt-mTOR signaling pathway, Am J Transl Res 11 (7) (2019) 4077–4088.\\n43. A. Tufman, R.M. Huber, S. Volk, F. Aigner, M. Edelmann, F. Gamarra, et al., Interleukin-22 is elevated in lavage from patients with lung cancer and other pulmonary diseases, BMC Cancer 16 (2016) 409.\\n44. Z.J. Ye, Q. Zhou, W. Yin, M.L. Yuan, W.B. Yang, F. Xiang, et al., Interleukin 22-producing CD4+ T cells in malignant pleural effusion, Cancer Lett. 326 (1) (2012) 23–32.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='2b78082a-df27-45ec-91e0-63b42a5e3ba2', embedding=None, metadata={'file_path': 'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend\\\\research\\\\data\\\\main.pdf', 'file_name': 'main.pdf', 'file_type': 'application/pdf', 'file_size': 3342958, 'creation_date': '2024-09-25', 'last_modified_date': '2024-09-24'}, excluded_embed_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], excluded_llm_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# References\\n\\n1. Y. Niu, Q. Zhou, Th17 cells and their related cytokines: vital players in progression of malignant pleural effusion, Cell. Mol. Life Sci. 79 (4) (2022) 194.\\n2. R. Khandia, A. Munjal, Interplay between inflammation and cancer, Adv Protein Chem Struct Biol 119 (2020) 199–245.\\n3. R. Singh, M.K. Mishra, H. Aggarwal, Inflammation, immunity, and cancer, Mediat. Inflamm. 2017 (2017) 6027305.\\n4. A. Fishbein, B.D. Hammock, C.N. Serhan, D. Panigrahy, Carcinogenesis: failure of resolution of inflammation? Pharmacol. Ther. 218 (2021) 107670.\\n5. D. Hanahan, L.M. Coussens, Accessories to the crime: functions of cells recruited to the tumor microenvironment, Cancer Cell 21 (3) (2012) 309–322.\\n6. N. Khosravi, M.S. Caetano, A.M. Cumpian, N. Unver, C. De la Garza Ramos, O. Noble, et al., IL22 promotes Kras-mutant lung cancer by induction of a protumor immune response and protection of stemness properties, Cancer Immunol. 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Badoiu, C. Stefani, M. Greabu, PI3K/AKT/mTOR signaling pathway in breast cancer: from molecular landscape to clinical aspects, Int. J. Mol. Sci. 22 (1) (2020).\\n13. Y. Hou, K. Wang, W. Wan, Y. Cheng, X. Pu, X. Ye, Resveratrol provides neuroprotection by regulating the JAK2/STAT3/PI3K/AKT/mTOR pathway after stroke in rats, Genes Dis 5 (3) (2018) 245–255.\\n14. C. Feng, H. Wan, Y. Zhang, L. Yu, C. Shao, Y. He, et al., Neuroprotective effect of Danhong injection on cerebral ischemia-reperfusion injury in rats by activation of the PI3K-Akt pathway, Front. Pharmacol. 11 (2020) 298.\\n15. B.Y. Shorning, M.S. Dass, M.J. Smalley, H.B. Pearson, The PI3K-AKT-mTOR pathway and prostate cancer: at the crossroads of AR, MAPK, and WNT signaling, Int. J. Mol. Sci. 21 (12) (2020).\\n16. R. Liu, Y. Chen, G. Liu, C. Li, Y. Song, Z. Cao, et al., PI3K/AKT pathway as a key link modulates the multidrug resistance of cancers, Cell Death Dis. 11 (9) (2020) 797.\\n17. M.J. Sanaei, S. Razi, A. Pourbagheri-Sigaroodi, D. Bashash, The PI3K/Akt/mTOR pathway in lung cancer; oncogenic alterations, therapeutic opportunities, challenges, and a glance at the application of nanoparticles, Transl Oncol 18 (2022) 101364.\\n18. A.M. Gustafson, R. Soldi, C. Anderlin, M.B. Scholand, J. Qian, X. Zhang, et al., Airway PI3K pathway activation is an early and reversible event in lung cancer development, Sci. Transl. Med. 2 (26) (2010) 26ra5.\\n19. J. Li, J. Wang, D. Xie, Q. Pei, X. Wan, H.R. Xing, et al., Characteristics of the PI3K/AKT and MAPK/ERK pathways involved in the maintenance of self-renewal in lung cancer stem-like cells, Int. J. Biol. Sci. 17 (5) (2021) 1191–1202.\\n20. Y.X. Meng, R. Zhao, L.J. Huo, Interleukin-22 alleviates alcohol-associated hepatic fibrosis, inhibits autophagy, and suppresses the PI3K/AKT/mTOR pathway in mice, Alcohol Clin. Exp. Res. 47 (3) (2023) 448–458.\\n21. X. Hu, J. Li, M. Fu, X. Zhao, W. 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Y. Li, H. Du, Y. Qin, J. Roberts, O.W. Cummings, C. Yan, Activation of the signal transducers and activators of the transcription 3 pathway in alveolar epithelial cells induces inflammation and adenocarcinomas in mouse lung, Cancer Res. 67 (18) (2007) 8494–8503.\\n27. S. Ihara, H. Kida, H. Arase, L.P. Tripathi, Y.A. Chen, T. Kimura, et al., Inhibitory roles of signal transducer and activator of transcription 3 in antitumor immunity during carcinogen-induced lung tumorigenesis, Cancer Res. 72 (12) (2012) 2990–2999.\\n28. J. Mohrherr, I.Z. Uras, H.P. Moll, E. Casanova, STAT3: versatile functions in non-small cell lung cancer, Cancers 12 (5) (2020).\\n29. Y. Cheng, F. Sun, L. Wang, M. Gao, Y. Xie, Y. Sun, et al., Virus-induced p38 MAPK activation facilitates viral infection, Theranostics 10 (26) (2020) 12223–12240.\\n30. Y. Xu, Q. Sun, F. Yuan, H. Dong, H. Zhang, R. Geng, et al., RND2 attenuates apoptosis and autophagy in glioblastoma cells by targeting the p38 MAPK signalling pathway, J. Exp. Clin. Cancer Res. : CR 39 (1) (2020) 174.\\n31. D. He, H. Wu, J. Xiang, X. Ruan, P. Peng, Y. Ruan, et al., Gut stem cell aging is driven by mTORC1 via a p38 MAPK-p53 pathway, Nat. Commun. 11 (1) (2020) 37.\\n32. O. Dreesen, A.H. Brivanlou, Signaling pathways in cancer and embryonic stem cells, Stem Cell Rev. 3 (1) (2007) 7–17.\\n33. X.M. Hou, T. Zhang, Z. Da, X.A. Wu, CHPF promotes lung adenocarcinoma proliferation and anti-apoptosis via the MAPK pathway, Pathol. Res. Pract. 215 (5) (2019) 988–994.\\n34. Y.C. Wang, D.W. Wu, T.C. Wu, L. Wang, C.Y. Chen, H. Lee, Dioscin overcome TKI resistance in EGFR-mutated lung adenocarcinoma cells via down-regulation of tyrosine phosphatase SHP2 expression, Int. J. Biol. Sci. 14 (1) (2018) 47–56.\\n35. Y. Guo, M. Jiang, X. Zhao, M. Gu, Z. Wang, S. Xu, et al., Cyclophilin A promotes non-small cell lung cancer metastasis via p38 MAPK, Thorac Cancer 9 (1) (2018) 120–128.\\n36. A. Po, M. Silvano, E. Miele, C. Capalbo, A. Eramo, V. Salvati, et al., Noncanonical GLI1 signaling promotes stemness features and in vivo growth in lung adenocarcinoma, Oncogene 36 (32) (2017) 4641–4652.\\n37. J.H. Leung, B. Ng, W.W. Lim, Interleukin-11: a potential biomarker and molecular therapeutic target in non-small cell lung cancer, Cells 11 (14) (2022).\\n38. H. Wang, F. Zhou, C. Zhao, L. Cheng, C. Zhou, M. Qiao, et al., Interleukin-10 is a promising marker for immune-related adverse events in patients with non-small cell lung cancer receiving immunotherapy, Front. Immunol. 13 (2022) 840313.\\n39. C.H. Chang, C.F. Hsiao, Y.M. Yeh, G.C. Chang, Y.H. Tsai, Y.M. Chen, et al., Circulating interleukin-6 level is a prognostic marker for survival in advanced nonsmall cell lung cancer patients treated with chemotherapy, Int. J. Cancer 132 (9) (2013) 1977–1985.\\n40. C. Liu, L. Yang, H. Xu, S. Zheng, Z. Wang, S. Wang, et al., Systematic analysis of IL-6 as a predictive biomarker and desensitizer of immunotherapy responses in patients with non-small cell lung cancer, BMC Med. 20 (1) (2022) 187.\\n41. B. Yuan, M.J. Clowers, W.V. Velasco, S. Peng, Q. Peng, Y. Shi, et al., Targeting IL-1beta as an immunopreventive and therapeutic modality for K-ras-mutant lung cancer, JCI Insight 7 (11) (2022).\\n42. M.F. Sanmamed, J.L. Perez-Gracia, K.A. Schalper, J.P. Fusco, A. Gonzalez, M.E. Rodriguez-Ruiz, et al., Changes in serum interleukin-8 (IL-8) levels reflect and predict response to anti-PD-1 treatment in melanoma and non-small-cell lung cancer patients, Ann. Oncol. 28 (8) (2017) 1988–1995.\\n43. M. Joerger, S.P. Finn, S. Cuffe, A.T. Byrne, S.G. Gray, The IL-17-Th1/Th17 pathway: an attractive target for lung cancer therapy? Expert Opin. Ther. Targets 20 (11) (2016) 1339–1356.\\n44. M.S. Kim, E. Kim, J.S. Heo, D.J. Bae, J.U. Lee, T.H. Lee, et al., Circulating IL-33 level is associated with the progression of lung cancer, Lung Cancer 90 (2) (2015) 346–351.\\n45. P.M. Ridker, J.G. MacFadyen, T. Thuren, B.M. Everett, P. Libby, R.J. Glynn, et al., Effect of interleukin-1beta inhibition with canakinumab on incident lung cancer in patients with atherosclerosis: exploratory results from a randomised, double-blind, placebo-controlled trial, Lancet 390 (10105) (2017) 1833–1842.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='25ed2ac4-2335-4978-a8a5-0efb3e061be1', embedding=None, metadata={'file_path': 'D:\\\\Project Multimedika\\\\Projek 2\\\\fullstack_summarizer_and_bot_development\\\\backend\\\\research\\\\data\\\\main.pdf', 'file_name': 'main.pdf', 'file_type': 'application/pdf', 'file_size': 3342958, 'creation_date': '2024-09-25', 'last_modified_date': '2024-09-24'}, excluded_embed_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], excluded_llm_metadata_keys=['file_name', 'file_type', 'file_size', 'creation_date', 'last_modified_date', 'last_accessed_date'], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# References\\n\\n1. А. Guillon, F. Gueugnon, K. Mavridis, E. Dalloneau, Y. Jouan, P. Diot, et al., Interleukin-22 receptor is overexpressed in nonsmall cell lung cancer and portends a poor prognosis, Eur. Respir. J. 47 (4) (2016) 1277–1280.\\n2. X. Wang, J. Xu, J. Chen, S. Jin, J. Yao, T. Yu, et al., IL-22 confers EGFR-TKI resistance in NSCLC via the АKT and ERK signaling pathways, Front. Oncol. 9 (2019) 1167.\\n3. N. Zabaleta, L. Torella, N.D. Weber, G. Gonzalez-Аseguinolaza, mRNА and gene editing: late breaking therapies in liver diseases, Hepatology 76 (3) (2022) 869–887.\\n4. D.S. Chae, Y.J. Park, S.W. Kim, Аnti-arthritogenic property of interleukin 10-expressing human amniotic MSCs generated by gene editing in collagen-induced arthritis, Int. J. Mol. Sci. 23 (14) (2022).\\n5. E. Vermersch, C. Jouve, J.S. Hulot, CRISPR/Cas9 gene-editing strategies in cardiovascular cells, Cardiovasc. Res. 116 (5) (2020) 894–907.\\n6. Q. Wang, X. Liu, J. Zhou, C. Yang, G. Wang, Y. Tan, et al., The CRISPR-Cas13a gene-editing system induces collateral cleavage of RNА in glioma cells, Аdv. Sci. 6 (20) (2019) 1901299.\\n7. Y. Lu, J. Xue, T. Deng, X. Zhou, K. Yu, L. Deng, et al., Safety and feasibility of CRISPR-edited T cells in patients with refractory non-small-cell lung cancer, Nat. Med. 26 (5) (2020) 732–740.\\n8. S.M. Hoy, Patisiran: first global approval, Drugs 78 (15) (2018) 1625–1631.\\n9. H. Wood, FDА approves patisiran to treat hereditary transthyretin amyloidosis, Nat. Rev. Neurol. 14 (10) (2018) 570.\\n10. А. Mandal, N. Kumbhojkar, C. Reilly, V. Dharamdasani, А. Ukidve, D.E. Ingber, et al., Treatment of psoriasis with NFKBIZ siRNА using topical ionic liquid formulations, Sci. Аdv. 6 (30) (2020) eabb6049.\\n11. T. Fabre, M.F. Molina, G. Soucy, J.P. Goulet, B. Willems, J.P. Villeneuve, et al., Type 3 cytokines IL-17А and IL-22 drive TGF-beta-dependent liver fibrosis, Sci Immunol. 3 (28) (2018).\\n12. C. Su, X. Ren, F. Yang, B. Li, H. Wu, H. Li, et al., Ultrasound-sensitive siRNА-loaded nanobubbles fabrication and antagonism in drug resistance for NSCLC, Drug Deliv. 29 (1) (2022) 99–110.\\n13. M.E. Аikins, C. Xu, J.J. Moon, Engineered nanoparticles for cancer vaccination and immunotherapy, Аcc. Chem. Res. 53 (10) (2020) 2094–2105.\\n14. S. Li, S. Xu, X. Liang, Y. Xue, J. Mei, Y. Ma, et al., Nanotechnology: breaking the current treatment limits of lung cancer, Аdv. Healthcare Mater. 10 (12) (2021) e2100078.\\n15. T. Zhong, X. Liu, H. Li, J. Zhang, Co-delivery of sorafenib and crizotinib encapsulated with polymeric nanoparticles for the treatment of in vivo lung cancer animal model, Drug Deliv. 28 (1) (2021) 2108–2118.\\n16. M. Zhang, CTt Hagan, H. Foley, X. Tian, F. Yang, K.M. Аu, et al., Co-delivery of etoposide and cisplatin in dual-drug loaded nanoparticles synergistically improves chemoradiotherapy in non-small cell lung cancer models, Аcta Biomater. 124 (2021) 327–335.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n')]" ] }, "execution_count": 8, "metadata": {}, "output_type": "execute_result" } ], "source": [ "documents" ] }, { "cell_type": "code", "execution_count": 14, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "Error while parsing the file '': file_name must be provided in extra_info when passing bytes\n", "Read document 1 : \n", "\n", "\n", "[]\n", "Error while parsing the file '': file_name must be provided in extra_info when passing bytes\n", "Read document 2 : \n", "\n", "\n", "[]\n" ] } ], "source": [ "import nest_asyncio\n", "\n", "nest_asyncio.apply()\n", "\n", "from llama_parse import LlamaParse\n", "\n", "parser = LlamaParse(\n", " api_key=os.getenv(\"LLAMA_PARSE_API_KEY\"), # can also be set in your env as LLAMA_CLOUD_API_KEY\n", " result_type=\"markdown\", # \"markdown\" and \"text\" are available\n", " num_workers=4, # if multiple files passed, split in `num_workers` API calls\n", " verbose=True,\n", " language=\"en\", # Optionally you can define a language, default=en\n", ")\n", "\n", "with open(\"./research/data/main.pdf\", \"rb\") as f:\n", " documents = parser.load_data(f)\n", " print(\"Read document 1 : \\n\\n\")\n", " print(documents)\n", "\n", "# you can also pass file bytes directly\n", "with open(\"./research/data/main.pdf\", \"rb\") as f:\n", " file_bytes = f.read()\n", " documents = parser.load_data(file_bytes)\n", " print(\"Read document 2 : \\n\\n\")\n", " print(documents)\n" ] }, { "cell_type": "code", "execution_count": 15, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "Started parsing the file under job_id bc7110d4-30b8-4094-9b16-f8019bca2217\n" ] }, { "data": { "text/plain": [ "[Document(id_='87da7732-6866-43c2-9991-17b3c06a9fdb', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# IL-22: A key inflammatory mediator as a biomarker and potential therapeutic target for lung cancer\\n\\n# Ling Xu a,1, Peng Cao a,1, Jianpeng Wang b,1, Peng Zhang a, Shuhui Hu a, Chao Cheng a, Hua Wang c,*\\n\\n# a Department of Interventional Pulmonary Diseases, The Anhui Chest Hospital, Hefei, China\\n\\n# b First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China\\n\\n# c Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China\\n\\n# A R T I C L E I N F O\\n\\n# A B S T R A C T\\n\\n# Keywords:\\n\\nLung cancer, one of the most prevalent cancers worldwide, stands as the primary cause of cancer-related deaths. As is well-known, the utmost crucial risk factor contributing to lung cancer is smoking. In recent years, remarkable progress has been made in treating lung cancer, particularly non-small cell lung cancer (NSCLC). Nevertheless, the absence of effective and accurate biomarkers for diagnosing and treating lung cancer remains a pressing issue. Interleukin 22 (IL-22) is a member of the IL-10 cytokine family. It exerts biological functions (including induction of proliferation and anti-apoptotic signaling pathways, enhancement of tissue regeneration and immunity defense) by binding to heterodimeric receptors containing type 1 receptor chain (R1) and type 2 receptor chain (R2). IL-22 has been identified as a pro-cancer factor since dysregulation of the IL-22-IL-22R system has been implicated in the development of different cancers, including lung, breast, gastric, pancreatic, and colon cancers. In this review, we discuss the differential expression, regulatory role, and potential clinical significance of IL-22 in lung cancer, while shedding light on innovative approaches for the future.\\n\\n# 1. Introduction\\n\\nLung cancer is a heterogeneous disease in which cells in the lung grow aberrantly culminating in the formation of tumors. Typically, these tumors present as nodules or masses discernible through pulmonary imaging techniques [1]. In the year 2020, the global incidence of lung cancer surpassed a staggering 2.2 million cases, leading to approximately 1.8 million tragic fatalities. When considering age-standardized rates, the morbidity and mortality figures stand at 22.4 and 18.0 per 100,000 individuals respectively [2]. Generally, lung cancer is considered to be intricately linked to a multitude of factors including but not limited to smoking, genetic predisposition, occupational exposures, as well as the deleterious effects of air and environmental pollution [3,4]. Among the risk factors for lung cancer, smoking dominates overwhelmingly, with about two-thirds of lung cancer deaths globally caused by it [5]. In recent years, the drug resistance phenomenon of lung cancer to chemotherapy and targeted therapy has become more and more prominent [6–8]. Therefore, it is of heightened importance to find new therapeutic targets.\\n\\n# * Corresponding author. Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China.\\n\\n# E-mail address: wanghua@ahmu.edu.cn (H. Wang).\\n\\n# 1 These authors have contributed equally to this work and share first authorship.\\n\\nhttps://doi.org/10.1016/j.heliyon.2024.e35901\\n\\nReceived 13 August 2023; Received in revised form 5 August 2024; Accepted 6 August 2024\\n\\nAvailable online 10 August 2024\\n\\n2405-8440/© 2024 The Authors. Published by Elsevier Ltd. (http://creativecommons.org/licenses/by-nc-nd/4.0/).\\n\\nThis is an open access article under the CC BY-NC-ND license', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='03ae712d-04f2-4fd1-92a2-03c925d72a92', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# 1. Introduction\\n\\nIL-22 is an IL-10 family cytokine produced by T cells and innate lymphocytes. Like all other IL-10 family members, the IL-22 structure contains six α-helices (termed helices A to F). They are arranged in an antiparallel conformation and produce a single bundled protein [9]. IL-22 coordinates mucosal immune defense and tissue regeneration through pleiotropic effects including pro-survival signaling, cell migration, dysplasia, and angiogenesis. These molecules act by targeting the heterodimeric transmembrane receptor complex composed of IL-22R1 and IL-10R2 and by activating subsequent signaling pathways (including JAK/STAT signaling pathway, p38 MAPK signaling pathway, and PI3K/AKT signaling pathway) [10]. It is well known that IL-22 is widely expressed in human tissues and organs, including lung, liver, heart, kidney, pancreas, gastrointestinal tract, skin, blood, adipose, and synovial tissues [11]. Meanwhile, IL-22 is also found to be broadly expressed in pathological states such as cancer, infectious diseases, tissue injury, chronic inflammatory diseases, and Graft-Versus-Host Disease [11–14]. In most cancer diseases, excessively elevated levels of IL-22 are considered to be detrimental [15–19]. For instance, a recent study has demonstrated that IL-22 promotes extravasation of tumor cells in liver metastasis [20]. Over the past few years, there has been a surge in research focusing on the relationship between IL-22 and lung cancer. Particularly in patients with NSCLC, researchers have discovered up-regulated expression of IL-22 in serum, malignant pleural effusion, and tumor tissues, and the levels of IL-22Rα1 in tumor cells and tissues are also increased [21–24]. Although emerging studies have revealed that IL-22 is closely correlated with lung cancer in terms of tissue, cell and pathological changes, the specific function and mechanism remain to be explored. In the present review, we mainly summarized the regulatory function and clinical role of IL-22 in lung cancer. In addition, the feasibility of IL-22 as a biomarker for lung cancer and directions for future research were also discussed. It is reasonable to hypothesize that IL-22 may serve as a potential target in the treatment of lung cancer.\\n\\n# 2. Overview of lung cancer\\n\\nLung cancer is a malignant disease characterized by high morbidity and mortality [25]. According to the data of GLOBOCAN, lung cancer is the second most common cancer in 2020 and the main cause of cancer death worldwide, with about one-tenth (11.4 %) of cancer diagnoses and one-fifth (18.0 %) of deaths [5]. When it comes to gender, the incidence and mortality rates of lung cancer were on the rise in females but declining in males in most countries over the past decade [2]. The 5-year survival rate of lung cancer patients varies by 4–17 % in light of stage and region [26]. As predicted by the American Cancer Society, more than 120,000 people will die of lung cancer in the United States in 2023. The good news is that although the incidence is stable or increasing, the overall mortality is decreasing at an accelerated pace [27]. From the perspective of histopathology and biological behavior, lung cancer can be divided into NSCLC and SCLC, among which the former mainly includes several common types such as adenocarcinoma, squamous cell carcinoma, and large cell carcinoma [25]. The pathogenesis of lung cancer primarily involves the following aspects: chromosome changes; abnormal immune response; abnormal activation of developmental pathways; dysregulation of tumor suppressor genes, proto-oncogenes, and signaling pathways; and the up-regulation of receptor tyrosine kinases, growth factors, and cell markers. These abnormal changes cause an imbalance between lung cell proliferation and apoptosis, which leads to lung cancer [28–31]. For example, when exposed to risk factors continuously, the production of ROS, chemokines, and cytokines increases in lung cells, which leads to DNA damage and gives rise to inflammation and other pathobiological changes that ultimately promote carcinogenesis. At the same time, the anti-tumor immune function of macrophages, T lymphocytes, B lymphocytes, and NK cells gets suppressed, failing recognition and clearance of malignant cells, and eventually bringing about the formation of tumors [32]. In the early stage of the disease, it is usually considered to be asymptomatic, while may manifest as cough, dyspnea, chest pain, hemoptysis, hoarseness, and so on in the middle and advanced period [33]. In principle, the treatment of lung cancer depends largely on the type, stage and condition of the patient’s disease. Currently, the main treatment approaches for lung cancer include surgery, chemotherapy, and radiotherapy. Among them, platinum-containing double drugs are preferred for chemotherapy. Radiation therapy is mainly applied in the control of the local lesion. Furthermore, targeted therapy for EGFR, ALK, ROS1, and other gene mutations and immunotherapy to inhibit PD-1/PD-L1 also plays an irreplaceable role as emerging breakthrough therapeutic means [25,34–39]. Compared with chemotherapy, targeted therapy can prominently enhance the survival rate and tolerance of patients with NSCLC [40,41]. The combination of chemotherapy and immunotherapy has also shown a more notable curative effect over chemotherapy alone [42,43]. Additionally, there has been a growing body of research focusing on natural product therapy, local ablative therapy, and chimeric antigen receptor (CAR)-T-cell therapy lately [44–51]. In principle, the treatments of lung cancer are individualized depending largely on the type, stage, and condition of patients. Unfortunately, the limited sensitivity of NSCLC patients to chemotherapy and immunotherapy drugs has proven to be a major obstacle to clinical treatment. Denk D et al. suggested that inflammation is ubiquitous in carcinogenesis. In his study, he noted that interfering with individual cytokines and their respective signaling pathways holds great promise for the development and improvement of current clinical cancer therapies [52]. IL-22 is a new type of cytokine discovered in 2000 and has gradually attracted attention due to its role in tumor diseases. In recent years, multiple studies have reported the positive role of IL-22 in enhancing chemotherapy resistance in human lung cancer patients. This positive effect is related to the function of IL-22 in promoting lung cancer cell proliferation and inhibiting lung cancer cell apoptosis. Results showed that IL-22 activated the EGFR/AKT/ERK signaling pathway [52], STAT3, and ERK1/2 signaling pathways [24] in drug-treated lung cancer cells, thereby attenuating the pro-apoptotic effect of the drug on lung cancer cells.\\n\\n# 3. Function role of IL-22 in lung cancer\\n\\nIL-22 is a cytokine first identified by Dumoutier et al. in IL-9-induced murine T cells over 20 years ago and was once called IL-10-related T cell-derived inducible factor (IL-10-TIF) [53]. In human beings, the IL-22 gene lies in chromosome 12q15, next to the gene.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='8f865355-e081-4d71-b589-9c696acf72dd', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\nthat encodes IFN-γ [54]. When the body is in homeostasis, the most important source of IL-22 is Group 3 innate lymphoid cells (ILC3) [14]. Different from other common cytokines, IL-22 is generally thought to be produced only by hematopoietic origin immune cells, whereas it mainly acts on non-hematopoietic cells due to its receptor distribution [55]. Recently, researchers have found that non-hematopoietic cells represented by fibroblasts can also produce IL-22 under certain circumstances [11]. IL-22 is known to act by binding to its receptor (IL-22R), which is synthesized from the IL-22R1 and IL-10R2 subunits [56]. Thereinto, IL-22R1 expression is thought to be restricted to epithelial cells in organs such as the lung, liver, intestine, and skin, while the latter is universally expressed [11,57]. IL-22BP, also known as IL-22RA2, is a soluble IL-22 receptor that binds specifically to IL-22 and prevents it from binding to IL-22R1. All currently known functions of IL-22BP are achieved by inhibiting IL-22 [58,59]. Broadly speaking, the primary function of IL-22 in the body is to promote cell proliferation and tissue protection [60]. Sometimes, excessive activation of this function may lead to pathological results. This dual effect is reflected in both inflammatory and tumor-related diseases. In the short term, the production of IL-22 can play a protective role in anti-inflammatory and tumor prevention, while the uncontrolled generation of IL-22 may promote inflammation and tumor formation [13,18]. The duality of IL-22 reveals that it could be a potential drug target, and the tight regulation of IL-22 is crucial in the treatment of a variety of diseases. In Fig. 1, We summarize the role of IL-22 in lung cancer.\\n\\nIn general, the expression levels of IL-22 in vivo are regulated by a variety of cytokines and genes. For instance, IL-1β and IL-23 can induce the production of IL-22 independently, and the two act synergistically [11]. What’s more, Cornelia Voigt described a novel mechanism whereby cancer cells promote tumor growth by releasing IL-1β to induce IL-22 production by memory CD4+ T cells [61]. According to an animal experiment, IL-1β can enhance the proliferation of epithelial cells and promote lung tumorigenesis [62]. IL-23 has been proven to promote proliferation in NSCLC by Anne-Marie Baird et al. [63]. Although IL-23 is thought to be able to induce macrophages to produce IL-22, this study by Anne-Marie Baird et al. cannot directly prove whether the proliferation-promoting effect of IL-23 on NSCLC cells is related to IL-23’s promotion of IL-22 production. IL-23 is also thought to promote the expression of IL-26 by macrophages. Like IL-22, IL-26 is part of the IL-10 family. Researchers demonstrated for the first time that IL-26 is involved in the generation of malignant pleural effusions [64]. They reported that IL-26 promotes the generation of malignant pleural effusion by mediating the infiltration of CD4+IL-22+T cells in malignant pleural effusion and stimulating CD4+ IL-22+ T cells to secrete IL-22. Recently, the Notch-AhR-IL-22 axis is thought to be involved in the pathogenesis of LUAD. It is corroborated that in LUAD patients, elevated Notch1 facilitates IL-22 generation by CD4+ T cells via aryl hydrocarbon receptors (AhR) [65]. In NSCLC, Notch signaling can both promote tumorigenesis and inhibit tumor progression, which mainly depends on its regulation of the\\n\\n|Class I: Proliferation, apoptosis, and invasion|Class II: Regulating tumor microenvironment|\\n|---|---|\\n|Proliferation|Lung cancer tissue|\\n|NK cells| |\\n|T cells|Apoptosis|\\n|Lung cancer cells| |\\n|C01se|Metastasis|\\n|Lung cancer cells|Infiltrated immune cells|\\n|CASPASE| |\\n|Multidrug resistance| |\\n|IL-22 Ko| |\\n|IL-6|Lymphocyte|\\n|TNF-a|Total WBC|\\n|IL-1a|Macrophage|\\n|Neutrophil| |\\n\\n|Class III: Angiogenesis|Class IV: Cancer stem cell|\\n|---|---|\\n|IL-22|STAT3 signaling pathway|\\n|Lung cancer tissue| |\\n|Aangiogenic switch| |\\n|IL-22| |\\n|Vascular endothelial cell|Cancer stem cells|\\n| |Lung cancer cells|\\n\\nFig. 1. IL-22 plays four main functions during the progression of lung cancer. 1) Promote lung cancer cell proliferation and invasion, and inhibit lung cancer cell apoptosis; 2) Regulate the abundance of immune cells in lung cancer tissues and activate the inflammatory microenvironment; 3) Promote cancer angiogenesis; 4) Activate lung cancer stem cells.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='89a03af3-1e13-4347-9561-8a166e8c035b', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\nTransformation between neuroendocrine and non-neuroendocrine. For patients with SCLC containing Notch active tumor cells, the application of Notch inhibitors may be an effective treatment [66]. Moreover, the expression of IL-22 is also regulated by miR-26. In cutaneous T-cell lymphoma (CTCL) cells, transfection of miR-26 resulted in a remarkable decrease in the expression levels of IL-22 and IL-22 mRNA [67]. In human NSCLC, Yi He et al. found that the expression levels of miR-26 were lower in tumor tissues compared to paracancerous tissue. As a functional miRNA, miR-26 was further proved by the team to inhibit autophagy and induce apoptosis of NSCLC cells both in vitro and in vivo [68]. On the other hand, IL-22 has also been shown to regulate other cytokines. Studies have shown that the production of IL-22 generally reduces Th1-type immune responses. This action may be coordinated with the protective effect of IL-22R-expressing tissue cells to reduce collateral damage in the context of infection and inflammation [69]. Besides, animal experiments have indicated that IL-22 can also promote B-cell responses by inducing CXCL13 in tertiary lymphoid follicles [70,71]. In the latest murine lung cancer model, IL-22 was discovered to induce NK cells to overexpress CD155, thus mediating the immune evasion of tumor cells [72]. As a transmembrane adhesive molecule, CD155 has been proven to inhibit T and NK cell-mediated anti-tumor immune responses, thereby promoting tumor progression (Fig. 2) [73–75].\\n\\nIn the occurrence and development of pulmonary diseases, IL-22 is considered to play an important role. As previously demonstrated in an epicutaneously sensitized mice experiment, IL-22 promotes the development of neutrophil and eosinophile-mediated airway inflammation and airway hyperresponsiveness stimulated by intranasal antigens [76]. The conclusion implies that blocking IL-22 may be helpful for the treatment of bronchial asthma. When it comes to chronic obstructive pulmonary disease (COPD), the expression levels of both IL-22 and its receptor in COPD patients were higher than those of healthy controls. This result was confirmed in mice with experimental COPD induced by cigarette smoke. What’s more, researchers also found that cigarette smoke-induced inappropriate activation of pulmonary neutrophils decreased in IL-22-deficient mice with COPD. This suggests that IL-22 may be involved in the pathogenesis of COPD. The research further manifested that IL-22 promotes cigarette smoke-induced airway remodeling, pulmonary neutrophil inflammation, and the impairment of pulmonary function, and is involved in the pathogenesis of COPD [77]. While in pulmonary infectious diseases such as pneumonia, tuberculosis, and pulmonary mycosis, it is thought that IL-22 appears to take a protective and preventive part [78–83]. For good measure, in the bleomycin-induced pulmonary fibrosis model, the degree of pulmonary fibrosis in IL-22 knockout mice was aggravated, and injection of recombinant IL-22 alleviated the severe fibrosis in IL-22 knockout mice. This latest research has suggested the potential anti-fibrotic effect of IL-22 [84].\\n\\nIn recent years, differential expression of IL-22 has also been discovered in various specimens of lung cancer (Table 1). In the first place, the mean levels of IL-22 in the plasma of NSCLC patients were significantly higher than that of the reference cohort [21,85]. The plasma levels of IL-22 were observed to elevate along with the increase in lung cancer staging [85]. In addition, Immunohistochemistry analysis showed that IL-22 expression was up-regulated in NSCLC tumor specimens in comparison to that in the adjacent tissues. RT-qPCR analysis also revealed similar differences in IL-22 mRNA expression between lung cancer tissues and normal tissues [24,86]. Interestingly, Yi Bi et al. compared IL-22 levels between tissues and serum of patients with primary NSCLC and their paired recurrent lung cancer specimens and the expression levels of IL-22 were found to be obviously up-regulated in the latter group [23]. Apart from this, IL-22 expression was also detected in bronchoalveolar lavage fluid (BALF). As reported by an article in 2016, IL-22 levels were...\\n\\n|CD155|NK Cell|L|\\n|---|---|---|\\n|T Cell|IL-22|Impaired function|\\n| |Lung metastases| |\\n\\nFig. 2. IL-22 induces NK cells to overexpress CD155, which binds to NK cell activation receptor CD226. Over-activation leads to a decrease in the amount of CD226 and impaired NK cell function, thereby mediating tumor cell immune escape.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='87dc46a7-0628-4738-b798-3a7498229f8b', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# Table 1\\n\\nDifferential expression of IL-22/IL-22 mRNA/IL-22R1 mRNA in various samples in lung cancer. +: Up-regulated.\\n\\n|Molecule|Samples|Expression|P value|Ref. (PMID)|\\n|---|---|---|---|---|\\n|IL-22|Plasma|+|0.0013|24956177|\\n|IL-22 mRNA|Tissues|+|0.0313|18927282|\\n|IL-22|Pleural effusion|+|0.0051|18927282|\\n|IL-22 mRNA, IL-22|Tissues, serum|+|<0.01|26983629|\\n|IL-22R1 mRNA|Tissues|+|<0.05|26983629|\\n|IL-22|BALF|+|<0.001|27388918|\\n\\nSignificantly higher in BALF from lung cancer patients compared with control group. The researchers expanded the cohort to patients with lung metastases from other malignancies and found that IL-22 concentrations remained higher than controls [87]. These results implied that IL-22 in BALF may be a biomarker for lung cancer. Over and above, researchers also found the trace of IL-22 in pleural effusion [88,89]. One study has revealed that IL-22 levels were higher in malignant pleural effusion as against tuberculous pleural effusion [24]. These differential expressions prompt that IL-22 may participate in the occurrence and development of lung cancer (Table 2).\\n\\nThe link between inflammatory processes and cancer has long been recognized [90]. Related studies hint that inflammatory responses play a vital role in different phases of tumor occurrence, development, and metastasis [91–93]. The function of IL-22 in cancer is extremely complicated. Initially, IL-22 may prevent tumorigenesis by reducing chronic inflammation, promoting barrier function, and inducing tissue regeneration. On the contrary, if IL-22 is excessively expressed under persistent chronic inflammation, then malignant cells may utilize this signal to facilitate its progression [11]. In the lung tumor microenvironment, uncontrolled expression of IL-22 can amplify inflammation by inducing various inflammatory mediators alone or in concert with other cytokines [94]. As illustrated by a cellular experiment, IL-22 could promote the proliferation of A549 and H125 cells belonging to the NSCLC cell lines, thereby enhancing the ability of tumor cell migration and invasion [23]. An in vitro experiment in 2018 has confirmed that IL-22 can directly act on endothelial cells to stimulate tumor angiogenesis [95]. To some extent, this enhances the ability of tumor cells to absorb nutrients and distant metastasis. From another perspective, this provides new ideas for anti-angiogenic therapy of tumors. Nasim Khosravi suggested that IL-22 promotes tumor progression by inducing a pro-tumor immune response and protective stem cell properties of tumor cells [94]. It is also reported that after 12h of serum starvation, the proportion of apoptotic lung cancer cells transfected with the IL-22 gene was significantly lower than that of control lung cancer cells. In addition, the apoptosis-inducing and anti-proliferative effects of chemotherapeutic drugs on lung cancer cells were inhibited in IL-22 transgenic cell lines [24]. Simultaneously, the apoptosis of lung cancer cells induced by gefitinib was also significantly reduced 48 h after IL-22 exposure [96]. On the contrary, exposure to IL-22R1 blocking antibodies or in vitro transfection of IL-22-RNA interference plasmid leads to apoptosis of lung cancer cells [24]. Zhiliang Huang et al. found that the apoptosis rate of paclitaxel-treated lung cancer cells in the IL-22 siRNA transfection group was significantly increased compared with the control group [22]. Apart from this, IL-22 antibody treated mice and IL-22-deficient mice were found to be protected from the formation of pulmonary metastases caused by colon cancer, while IL-22 overexpression promoted metastases [20]. In short, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and migration of lung cancer cells, the growth of tumor tissues, and the generation of lung metastatic cancer.\\n\\n# 4. Regulatory role of IL-22 in lung cancer\\n\\nNumerous signaling pathways are involved in the regulation of IL-22 in lung cancer, including PI3K/AKT, JAK-STAT3, p38 MAPK signaling pathways, and so on. In the following, we will elaborate on the regulatory role of IL-22 in lung cancer from the point of view of each major signaling pathway (Fig. 3).\\n\\n# Table 2\\n\\nPotential clinical role of IL-22, its receptors and producing cells in lung cancer.\\n\\n|Sample sources|Clinical function|Conclusion|Ref. (PMID)|\\n|---|---|---|---|\\n|Patients|Diagnosis|IL-22 levels were significantly higher in lung cancer patients than control group.|24956177, 27388918|\\n|Patients|Prognosis assessment|IL-22R1 levels were associated with poorer prognosis.|26846835|\\n|Patients|Disease assessment|The levels of IL-22-producing Th22 cells were positively correlated with TNM stage and lymph node metastasis.|35669104|\\n|Patients|Efficacy prediction|IL-22 expression levels were associated with EGFR-TKI efficacy.|31750252|\\n|Mice model|Treatment|IL-22-deficient mice had a lower metastatic load of lung cancer.|36630913|\\n|Mice model|Treatment|Gene ablation of IL-22 resulted in a marked reduction in the number and size of lung tumors.|29764837|', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='75a235a9-b907-42f9-bf9e-c4383d2f37c6', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# 4.1. PI3K/Akt signaling pathway\\n\\nPI3K/Akt signaling pathway is one of the core intracellular signaling pathways, which plays a critical role in regulating cell growth, survival, metabolism, movement, and proliferation [97]. As a downstream effector of receptor tyrosine kinases (RTKs) and G-protein-coupled receptors (GPCRs), PI3K is a group of lipid kinases consisting of three subunits. It can be divided into three categories according to various functions and structures. Thereinto Class IA PI3K is a heterodimer of the p110 catalytic subunit and the p58 regulatory subunit, and it is primarily related to human tumors [98,99]. As we all know, PI3K can catalyze phosphatidylinositol [4, 5]-bisphosphate (PIP2) to phosphatidylinositol [3–5]-trisphosphate (PIP3). Serine/threonine protein kinase (Akt), as the main downstream molecule of the PI3K signaling pathway, is mainly activated by PIP3-driven plasma membrane recruitment and phosphorylation. The mammalian target of rapamycin (mTOR), a major downstream signaling molecule in the PI3K/Akt signaling pathway, is considered to be a modified protein kinase in the form of mTORC1 and mTORC2. The first is mainly activated by the PI3K/Akt signaling pathway, and mTORC2 further activates Akt by directly phosphorylating its hydrophobic motif (Ser473) [100].\\n\\nPI3K/Akt signaling pathway is considered to be the chief regulatory factor of idiopathic pulmonary fibrosis (IPF), it may directly participate in the formation of IPF or promote the occurrence and development of fibrosis in collaboration with other pathways [97]. Several studies have declared that certain natural products like resveratrol and Danhong injection can provide neuroprotective effects by activating the PI3K/Akt/mTOR signaling pathway [101,102]. Furthermore, the relationship between the PI3K/Akt/mTOR signaling pathway and cancer has been most intensively studied. Activation of the PI3K/Akt/mTOR signaling pathway is believed to promote the occurrence, proliferation, and progression of a variety of cancers, including breast cancer, ovarian cancer, prostate cancer, etc. [99,100,103]. In addition, it is also an important cause of tumor drug resistance [104]. In NSCLC, KRAS, EGFR, and PTEN mutations are believed to activate the PI3K/Akt/mTOR signaling pathway [105]. As demonstrated in a previous article, upregulation of the PI3K signaling pathway was identified as an early and reversible event in the pathogenesis of NSCLC [106]. One experiment has confirmed that the PI3K/Akt signaling pathway promotes the proliferation of LUAD cells mainly through anti-apoptosis [107]. Additionally, as revealed in a cellular study, IL-22 produced by CAFs markedly improves the proliferation and invasion of lung cancer cell, and lessens apoptosis by activating the PI3K/Akt/mTOR signaling pathway [86]. For good measure, it has been found that Akt phosphorylation in NSCLC cells is facilitated by different concentrations of IL-22 in a time- and dose-dependent way [23]. Collectively, the PI3K/Akt/mTOR signaling pathway plays a significant role in the relationship between IL-22 and lung cancer. It is worth mentioning that IL-22 does not seem to always activate the PI3K/Akt/mTOR signaling pathway. Meng Yuxia et al. found that IL-22 inhibits the activity of the PI3K/Akt/mTOR signaling pathway in mouse liver fibrosis tissue [108]. This opposite finding may be related to the dual function of IL-22. Further study on the impact of IL-22 on the PI3K/Akt/mTOR signaling pathway in different disease processes will help us better understand the specific mechanism of IL-22’s function in the human body. This will facilitate.\\n\\n|IL-22|PI3K|JAK|P38 MAPK|\\n|---|---|---|---|\\n|NK cell|AKT|mTOR| |\\n|Antitumor drugs|Gene expression| |Metastasis|\\n|Apoptosis|Proliferation|EMT|Invasion|\\n| |Lung tumor cell| | |\\n\\nFig. 3. IL-22 promotes the proliferation, migration and epithelial-mesenchymal transition of lung cancer cells through PI3K/Akt, JAK-STAT3, p38 MAPK and other signaling pathways, and antagonizes the apoptosis of lung cancer cells induced by anti-tumor drugs.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='8ceb46e8-38ee-4d80-9676-6c5c6d179d80', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al. Heliyon 10 (2024) e35901\\n\\n# IL-22-related clinical drug development.\\n\\n# 4.2. JAK/STAT signaling pathway\\n\\nThe JAK/STAT signaling pathway is also an important communication center for cell function, and aberrant alterations in its components are associated with numerous human diseases. JAK/STAT is an evolutionarily conserved signaling pathway consisting of JAKs, STATs, and ligand-receptor complexes. There are four major members of the JAK family, all of which are composed of non-receptor tyrosine protein kinases. The STAT family contains six members which consist of 750–900 amino acids. The JAK/STAT signaling pathway is mainly thought to mediate inflammation, apoptosis, hematopoiesis, tissue repair, immune regulation, and adipogenesis [109]. In autoimmune diseases such as rheumatoid arthritis (RA), activation of the JAK-STAT signaling pathway leads to the progression of joint injury through overexpression of the matrix metalloproteinase gene, apoptosis of chondrocytes, and apoptotic resistance in synovial tissue [110,111]. In addition, in a 2020 study by Meyer LK, the inhibition of the JAK-STAT signaling pathway was found to sensitize CD8+ T cells to dexamethasone-induced excessive inflammatory cell apoptosis [112]. Song et al. have long discovered that the lifespan of NSCLC cells was notably reduced after inhibiting STAT3 [113]. In a murine lung model, overexpression of STAT3 in alveolar type II cells led to severe lung inflammation and eventually to the formation of LUAD [114]. Further, down-regulation of STAT3 was found to result in enhanced NK cell immunity in both human and murine NSCLC cells, which suggests that STAT3 plays an inhibitory role against tumor NK cell immunity [115,116]. A study last year disclosed that IL-22 triggers JAK-STAT3 pathway phosphorylation in NSCLC cells in a time- and dose-dependent manner, thus promoting the proliferation and metastasis of tumor cells [23,96]. Another study demonstrated that the overexpression of IL-22 protected lung cancer cells against apoptosis induced by serum starvation and chemotherapy drugs by activating STAT3 and its downstream anti-apoptotic proteins [24].\\n\\n# 4.3. p38 MAPK signaling pathway\\n\\nThe p38 mitogen-activated protein kinases (MAPK) signaling pathway takes a crucial role in signaling cascades induced by various cellular stimuli. There are four p38 kinase members in the mammalian mitogen-activated protein (MAP) family, which play momentous roles in extracellular stimulation-mediated proliferation, inflammation, differentiation, apoptosis, senescence, and tumorigenesis [117]. In the classical pathway, the p38 MAPK signaling pathway is activated by cascade phosphorylation [118]. In a hepatitis C virus (HCV) experiment, researchers demonstrated that virus-induced activation of the p38 MAPK signaling pathway promotes viral infection, and blocking activation of this pathway may be an antiviral approach [117]. According to Dan He in 2020, mTORC1 drives intestinal stem cell aging via the p38 MAPK-p53 signaling pathway [119]. The p38 MAPK signaling pathway has long been demonstrated to exhibit a major oncogenic role in LUAD [120–122]. Yinan Guo et al. found evidence that the p38 MAPK signaling pathway can promote EMT and metastasis of NSCLC both in vitro and in vivo [123]. In addition, a study published in 2017 proposed that the p38 MAPK signaling pathway activates stem cell properties of LUAD cells by regulating GLI1 [124]. What’s more, in lung cancer models, researchers found that the p38 MAPK signaling pathway inhibited the stem cell properties of lung CSCs and promoted their proliferation and differentiation, thereby leading to tumorigenesis. More importantly, they also elucidated that the p38 MAPK and PI3K/AKT signaling pathways have unique and synergistic roles in regulating lung CSCs self-renewal as carcinogenic and/or stem cell signaling pathways [107]. This provides a new idea for the stem cell-based treatment of lung cancer. In NSCLC, IL-22 in vivo and in vitro were both verified to activate the p38 MAPK signaling pathway. The collected evidence from this study confirmed the negative immunomodulatory role of IL-22 in the disease [96].\\n\\n# 5. Clinical role of IL-22 in lung cancer\\n\\nCurrently, there is still a lack of efficient biomarkers for the diagnosis and treatment of lung cancer. In recent years, the value of the interleukin family as biomarkers and therapeutic targets of lung cancer has been deeply investigated [125–132]. Of these, IL-1 and IL-6 have been studied most extensively in lung cancer. Bo Yuan’s findings in mice experiments supported IL-1β as a potential target for the prevention and treatment of LUAD patients with Kras mutations [129]. In a clinical trial of the anti-IL-1β antibody canakinumab, researchers found that 300 mg canakinumab significantly reduced lung cancer mortality compared with the control group (HR 0.49 [95%CI 0.31–0.75]; p = 0.0009) [133]. In plasma samples or tumor tissues from NSCLC, researchers revealed that patients with lower baseline IL-6 concentrations benefited more from immunotherapy. The study elucidated the role of IL-6 in predicting the efficacy of immunotherapy in patients with NSCLC [128]. Furthermore, in one lung cancer study, the survival hazard ratio before and after chemotherapy for high versus low IL-6 levels was 1.25 (95%CI 0.73–2.13) and 3.66 (95%CI 2.18–6.15), respectively. It is suggested that IL-6 may be a prognostic indicator of survival in patients with advanced NSCLC receiving chemotherapy [127]. Some scholars have also described the potential value of IL-11 as a biomarker for the diagnosis and prognosis of NSCLC [125]. In addition, another research has shown that changes in serum IL-8 levels in NSCLC patients could reflect and predict the response to immunotherapy [130]. Kaplan-Meier survival analysis showed that the overall survival outcome of NSCLC patients with high IL-22R1 expression was significantly lower than that of patients with low IL-22R1 expression (p = 0.022). Multivariate regression analysis also confirmed an association between IL-22R1 levels and poorer outcomes (HR 1.5, 95%CI 1.2–1.9; p = 0.0011). This suggested that high expression of IL-22R1 is an independent factor for low overall survival in NSCLC [134]. What’s more, the levels of IL-22-producing Th22 cells in peripheral blood were positively correlated with TNM stage, lymph node metastasis, and clinical tumor markers of lung cancer (p < 0.01) [96]. The above indicates the significance of IL-22 as a biomarker in the diagnosis and disease assessment of lung cancer. Apart from this, Renhua Guo’s team found that the expression of IL-22 in the EGFR-TKI resistant group was higher than that in sensitive.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='da26883c-dab1-4da8-bcc5-fdbad1a58553', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\ngroup in NSCLC, and the expression level was correlated with the efficacy of EGFR-TKI in plasma [135]. Therefore, it is reasonable to suspect that IL-22 may be a new biomarker to overcome EGFR-TKI resistance in NSCLC. In terms of animal models, some investigators implanted Line-1 lung cancer cells into wild-type and IL-22-deficient mice simultaneously, and found reduced intrapulmonary metastasis in the latter group, which is independent of primary tumor size. Besides, they performed forced metastasis by intravenous injection of lung cancer cells, and the results further confirmed the lower metastatic load in mice with IL-22 deletion [72]. In another model of Kras-mutated lung cancer in mice, gene ablation of IL-22 resulted in a marked reduction in tumor number and size. The authors also analyzed the association between IL-22R1 expression and survival in patients with KRAS mutant lung adenocarcinoma, the results showed that high expression of IL-22R1 was an independent indicator of poorer relapse-free survival [94]. Taken together, these pieces of evidence highlight the potential clinical role of IL-22, IL-22R, and IL-22-producing cells in the treatment of lung cancer (Table 2).\\n\\n# 6. Future perspectives\\n\\n# 6.1. CRISPR-Cas13a technical\\n\\nAt present, mounting clinical trials based on IL-22 are being carried out in full swing worldwide, mainly involving ulcerative colitis, alcoholic cirrhosis, GVHD, and psoriasis [12,14,54,60]. However, there are presently no clinical trials based on IL-22 in lung cancer. As described previously, reduced intrapulmonary metastasis was found in IL-22-deficient mice as well as in IL-22-suppressed NSCLC cells [20,72]. In addition, blocking IL-22R1 or knockout of the IL-22 gene both retarded the progression of lung cancer [24,94]. These findings provide a new train of thought for the down-regulation of IL-22 in treating lung cancer.\\n\\nIn recent years, the research on gene editing treatment for various diseases has become more and more popular [136–138]. CRISPR-Cas13a is an effective tool for knocking out specific RNA sequences, it has been shown to induce the death of glioma cells that overexpress EGFR, which is one of the subtypes of EGFR mutation in glioma. Apart from this, the CRISPR-Cas13a gene-editing system can also inhibit the formation of intracranial tumors in mice with glioma [139]. In a collagen-induced mouse model, injection of gene-edited human amniotic mesenchymal stem cells that overexpressed IL-10 increased proteoglycan expression in joint tissue and reduced the inflammatory response and production of various inflammatory cytokines [137]. In the world’s first human phase I clinical trial utilizing CRISPR-Cas9 in the treatment of advanced NSCLC, researchers have demonstrated the feasibility and safety of gene-edited T-cell therapy targeting the PD-1 gene [140]. Thus, genome editing strategies have the potential to treat lung cancer by altering IL-22 expression levels. In the future, the role of pulmonary precision delivery based on CRISPR-Cas13 gene-editing components targeting the IL-22 mRNA in lung cancer therapy should not be ignored. CRISPR-Cas13 is expected to be further integrated.\\n\\n# IL-22 mRNA\\n\\n# Cas13a\\n\\n# Crispr-Cas13a Combined With\\n\\n# Figure\\n\\n# Single-base edition\\n\\n# Single-cell sequencing\\n\\n# Lung cancer\\n\\nFig. 4. Crispr-cas13-based IL-22 mRNA editing can be utilized for lung cancer therapy by combining with emerging technologies such as single-base editing and single-cell sequencing.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='879717af-4d28-425c-85de-a9cd4fbb7ae8', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\nwith the latest technologies such as single-base editing and single-cell sequencing to promote the treatment of lung cancer to a new level (Fig. 4).\\n\\n# 6.2. Small interfering RNA\\n\\nSmall interfering RNA (siRNA) is a double-stranded RNA molecule composed of 21–23 nucleotides. In cells, siRNA forms functional complexes by binding to the RNA-induced silencing complex (RISC). RISC in the functional complex specifically recognizes and binds to the target mRNA, leading to degradation of the target mRNA and thereby silencing the expression of the target gene. Compared with traditional therapies such as small molecules and protein drugs, siRNA technology has many advantages:\\n\\n1. siRNA is highly specific. siRNA can only silence homologous genes, while unrelated genes are not affected.\\n2. siRNA can silence genes by using RISC.\\n3. siRNA can be designed to target different genes through sequence design, and can even target targets that were previously considered “undruggable”.\\n4. siRNA does not activate the innate immune system.\\n\\nTwenty years after the discovery of the RNA interference mechanism, the first siRNA drugs (including Patisiran, Givosiran, Lumasiran, Inclisiran, Vutrisiran) were approved for clinical use by the U.S. Food and Drug Administration (FDA) and the European Medicines Agency from 2018 to 2022 [141,142]. NFKBIZ is an upstream target of IL-23, IL-36 and IL-17A. In the study of Mandal A et al. [143], NFKBIZ-siRNA significantly reduces the mRNA levels of multiple pro-inflammatory cytokines, including IL-17, IL-19, IL-22, etc., in the skin tissue of psoriasis mice, thereby alleviating the condition of the mice. The safety evaluation results of NFKBIZ-siRNA preparations show that NFKBIZ-siRNA preparations can complex with nucleic acids without affecting biological activity and show no toxicity. TGF-β is a pleiotropic regulatory cytokine that can regulate a variety of ILs including IL-22 and IL-17 to affect the composition of the tumor microenvironment [144]. Currently, Sirnaomics has developed an siRNA drug that targets TGF-β (called STP705). Recently, the drug has completed phase II clinical trials in the United States and achieved positive results. The role of ILs in cancer has been extensively studied. In recent years, the positive role of IL-22 in lung cancer has received attention. The researchers believe that knocking down IL-22 mRNA levels in the lesions of lung cancer patients will help prolong the survival of lung cancer patients and improve the cure rate of lung cancer patients. For example, Zhang Wei et al. found that IL-22-siRNA slowed tumor growth in NSCLC model mice. In addition, they reported that the therapeutic effect of IL-22-siRNA combined with chemotherapy drugs (5-FU and carboplatin) on NSCLC mice was better than that of chemotherapy drugs alone [24]. In an in vitro assay [145], cell line PC9 cells (NSCLC) transfected with PDLIM5-siRNA targeting the PDLIM5 gene had reduced growth viability and exhibited higher apoptotic rates. In the chemotherapy drug gefitinib-resistant cell line PC9 cells, PDLIM5-siRNA still showed significant anti-tumor effects. These results indicate that siRNA-based therapy has good application in the clinical treatment of NSCLC, especially in drug-resistant patients. Based on these findings, we believe that the development of IL-22-siRNA drugs for lung cancer treatment has clinical potential and theoretical basis.\\n\\n# 6.3. Nanoparticle drug delivery systems\\n\\nOn the other hand, given the toxicity and erratic efficacy of current anti-tumor drugs, research on novel drug carriers in lung cancer.\\n\\n|Different types of nanomaterials|Targeting agent|IL-22-related drug|\\n|---|---|---|\\n|Lung precision delivery|Lung precision delivery|Lung precision delivery|\\n\\nFig. 5. Precision delivery of various nanomaterials containing IL-22 related drugs for the treatment of lung cancer.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='2ca21b8f-6b73-4c9d-b1b4-5a18c9bc6af2', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\nis also of vital significance. Nanoparticles containing targeted drugs can be delivered to the intended site using carriers with affinity for various specific tissues or lesions [146,147]. In an in vivo mice lung model, combined delivery of sorafenib and crizotinib by polymer nanoparticles significantly reduced tumor progression and toxic side effects, and improved survival rate [148]. Moreover, Maofan Zhang demonstrated that the efficacy of dual-drug-loaded polymeric nanoparticles with etoposide and cisplatin was significantly superior to conventional chemotherapy modality without causing additional toxicity [149]. These imply that nanomaterials loaded with IL-22-related drugs may also have more unique advantages. Therefore, the utilization of novel nanomaterials loaded with IL-22 antibodies and IL-22 inhibitors like IL-22BP for targeted therapy of lung tumors is also a promising research direction (Fig. 5).\\n\\n# 7. Conclusion\\n\\nIn this review, we provided a comprehensive analysis of the role of IL-22 in the immune microenvironment and its involvement in major signaling pathways in the context of lung cancer. Put in a nutshell, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and metastasis of lung cancer cells and the growth of tumor tissues. Additionally, the potential clinical significance of IL-22 in the diagnosis, treatment, and prognosis evaluation of lung cancer was further confirmed. Next, the prospects of IL-22 in combination with gene editing and novel nanomaterials in the treatment of lung cancer have been discussed. With the general increase in drug resistance to chemotherapy, targeted therapy, and immunotherapy in lung cancer, it is also necessary to study in depth to discover the correlation between IL-22 and the mechanism of drug resistance. To sum up, the potential of IL-22 as a biomarker for lung cancer still remains to be explored. Further research on the molecular, physiological effects and mechanism of IL-22 in lung cancer as well as the conduction of standardized clinical trials are expected to inject fresh blood into the diagnosis and treatment of lung cancer.\\n\\n# Financial support\\n\\nNone.\\n\\n# Data availability statement\\n\\nNot applicable.\\n\\n# CRediT authorship contribution statement\\n\\nLing Xu: Writing – original draft.\\n\\nPeng Cao: Visualization.\\n\\nJianpeng Wang: Writing – review & editing.\\n\\nPeng Zhang: Validation.\\n\\nShuhui Hu: Validation.\\n\\nChao Cheng: Writing – review & editing.\\n\\nHua Wang: Writing – review & editing, Supervision, Conceptualization.\\n\\n# Declaration of competing interest\\n\\nThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\\n\\n# Acknowledgements\\n\\nNone.\\n\\n# Abbreviations\\n\\n|non-small cell lung cancer|NSCLC|\\n|---|---|\\n|Interleukin-22|IL-22|\\n|chimeric antigen receptor|CAR|\\n|IL-10-related T cell-derived inducible factor|IL-10-TIF|\\n|Group 3 innate lymphoid cells|ILC3|\\n|IL-22 receptor|IL-22R|\\n|aryl hydrocarbon receptors|AhR|\\n|chronic obstructive pulmonary disease|COPD|\\n|cutaneous T-cell lymphoma|CTCL|\\n|bronchoalveolar lavage fluid|BALF|\\n|receptor tyrosine kinases|RTKs|\\n|G-protein-coupled receptors|GPCRs|\\n|Mammalian target of rapamycin|mTOR|\\n|idiopathic pulmonary fibrosis|IPF|\\n|rheumatoid arthritis|RA|', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='f1e0224e-8de8-4f70-90c9-5376b0ba332a', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# Abbreviations\\n\\n|Term|Abbreviation|\\n|---|---|\\n|mitogen-activated protein kinases|MAPK|\\n|mitogen-activated protein|MAP|\\n|hepatitis C virus|HCV|\\n\\n# References\\n\\n1. S. Lareau, C. Slatore, R. Smyth, Lung cancer, Am. J. Respir. Crit. Care Med. 204 (12) (2021) P21–P22.\\n2. J. Huang, Y. Deng, M.S. Tin, V. Lok, C.H. Ngai, L. Zhang, et al., Distribution, risk factors, and temporal trends for lung cancer incidence and mortality: a global analysis, Chest 161 (4) (2022) 1101–1111.\\n3. B.C. Bade, C.S. Dela Cruz, Lung cancer 2020: epidemiology, etiology, and prevention, Clin. Chest Med. 41 (1) (2020) 1–24.\\n4. J. Malhotra, M. Malvezzi, E. Negri, C. La Vecchia, P. Boffetta, Risk factors for lung cancer worldwide, Eur. Respir. J. 48 (3) (2016) 889–902.\\n5. H. Sung, J. Ferlay, R.L. Siegel, M. Laversanne, I. Soerjomataram, A. 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Lee, et al., Circulating IL-33 level is associated with the progression of lung cancer, Lung Cancer 90 (2) (2015) 346–351.\\n45. P.M. Ridker, J.G. MacFadyen, T. Thuren, B.M. Everett, P. Libby, R.J. Glynn, et al., Effect of interleukin-1beta inhibition with canakinumab on incident lung cancer in patients with atherosclerosis: exploratory results from a randomised, double-blind, placebo-controlled trial, Lancet 390 (10105) (2017) 1833–1842.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='5382af97-d1ed-4bb8-8958-0b4588650fe5', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# References\\n\\n1. А. Guillon, F. Gueugnon, K. Mavridis, E. Dalloneau, Y. Jouan, P. Diot, et al., Interleukin-22 receptor is overexpressed in nonsmall cell lung cancer and portends a poor prognosis, Eur. Respir. J. 47 (4) (2016) 1277–1280.\\n2. X. Wang, J. Xu, J. Chen, S. Jin, J. Yao, T. Yu, et al., IL-22 confers EGFR-TKI resistance in NSCLC via the АKT and ERK signaling pathways, Front. Oncol. 9 (2019) 1167.\\n3. N. Zabaleta, L. Torella, N.D. Weber, G. Gonzalez-Аseguinolaza, mRNА and gene editing: late breaking therapies in liver diseases, Hepatology 76 (3) (2022) 869–887.\\n4. D.S. Chae, Y.J. Park, S.W. Kim, Аnti-arthritogenic property of interleukin 10-expressing human amniotic MSCs generated by gene editing in collagen-induced arthritis, Int. J. Mol. Sci. 23 (14) (2022).\\n5. E. Vermersch, C. Jouve, J.S. Hulot, CRISPR/Cas9 gene-editing strategies in cardiovascular cells, Cardiovasc. Res. 116 (5) (2020) 894–907.\\n6. Q. Wang, X. Liu, J. Zhou, C. Yang, G. Wang, Y. 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Аu, et al., Co-delivery of etoposide and cisplatin in dual-drug loaded nanoparticles synergistically improves chemoradiotherapy in non-small cell lung cancer models, Аcta Biomater. 124 (2021) 327–335.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n')]" ] }, "execution_count": 15, "metadata": {}, "output_type": "execute_result" } ], "source": [ "import nest_asyncio\n", "\n", "nest_asyncio.apply()\n", "\n", "from llama_parse import LlamaParse\n", "\n", "parser = LlamaParse(\n", " api_key=os.getenv(\"LLAMA_PARSE_API_KEY\"), # can also be set in your env as LLAMA_CLOUD_API_KEY\n", " result_type=\"markdown\", # \"markdown\" and \"text\" are available\n", " num_workers=4, # if multiple files passed, split in `num_workers` API calls\n", " verbose=True,\n", " language=\"en\", # Optionally you can define a language, default=en\n", ")\n", "\n", "# sync\n", "documents = parser.load_data(\"./research/data/main.pdf\")\n", "documents\n", "# # async\n", "# documents = await parser.aload_data(\"./my_file.pdf\")\n" ] }, { "cell_type": "code", "execution_count": 18, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "Metadata added to page 1\n", "Metadata added to page 2\n", "Metadata added to page 3\n", "Metadata added to page 4\n", "Metadata added to page 5\n", "Metadata added to page 6\n", "Metadata added to page 7\n", "Metadata added to page 8\n", "Metadata added to page 9\n", "Metadata added to page 10\n", "Metadata added to page 11\n", "Metadata added to page 12\n", "Metadata added to page 13\n", "Metadata added to page 14\n" ] }, { "data": { "text/plain": [ "[Document(id_='87da7732-6866-43c2-9991-17b3c06a9fdb', embedding=None, metadata={'title': 'title', 'author': 'tes author', 'category': 'tes kategori', 'year': 2010, 'publisher': 'tes publisher', 'page_number': 1}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# IL-22: A key inflammatory mediator as a biomarker and potential therapeutic target for lung cancer\\n\\n# Ling Xu a,1, Peng Cao a,1, Jianpeng Wang b,1, Peng Zhang a, Shuhui Hu a, Chao Cheng a, Hua Wang c,*\\n\\n# a Department of Interventional Pulmonary Diseases, The Anhui Chest Hospital, Hefei, China\\n\\n# b First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China\\n\\n# c Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China\\n\\n# A R T I C L E I N F O\\n\\n# A B S T R A C T\\n\\n# Keywords:\\n\\nLung cancer, one of the most prevalent cancers worldwide, stands as the primary cause of cancer-related deaths. As is well-known, the utmost crucial risk factor contributing to lung cancer is smoking. In recent years, remarkable progress has been made in treating lung cancer, particularly non-small cell lung cancer (NSCLC). Nevertheless, the absence of effective and accurate biomarkers for diagnosing and treating lung cancer remains a pressing issue. Interleukin 22 (IL-22) is a member of the IL-10 cytokine family. It exerts biological functions (including induction of proliferation and anti-apoptotic signaling pathways, enhancement of tissue regeneration and immunity defense) by binding to heterodimeric receptors containing type 1 receptor chain (R1) and type 2 receptor chain (R2). IL-22 has been identified as a pro-cancer factor since dysregulation of the IL-22-IL-22R system has been implicated in the development of different cancers, including lung, breast, gastric, pancreatic, and colon cancers. In this review, we discuss the differential expression, regulatory role, and potential clinical significance of IL-22 in lung cancer, while shedding light on innovative approaches for the future.\\n\\n# 1. Introduction\\n\\nLung cancer is a heterogeneous disease in which cells in the lung grow aberrantly culminating in the formation of tumors. Typically, these tumors present as nodules or masses discernible through pulmonary imaging techniques [1]. In the year 2020, the global incidence of lung cancer surpassed a staggering 2.2 million cases, leading to approximately 1.8 million tragic fatalities. When considering age-standardized rates, the morbidity and mortality figures stand at 22.4 and 18.0 per 100,000 individuals respectively [2]. Generally, lung cancer is considered to be intricately linked to a multitude of factors including but not limited to smoking, genetic predisposition, occupational exposures, as well as the deleterious effects of air and environmental pollution [3,4]. Among the risk factors for lung cancer, smoking dominates overwhelmingly, with about two-thirds of lung cancer deaths globally caused by it [5]. In recent years, the drug resistance phenomenon of lung cancer to chemotherapy and targeted therapy has become more and more prominent [6–8]. Therefore, it is of heightened importance to find new therapeutic targets.\\n\\n# * Corresponding author. Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China.\\n\\n# E-mail address: wanghua@ahmu.edu.cn (H. Wang).\\n\\n# 1 These authors have contributed equally to this work and share first authorship.\\n\\nhttps://doi.org/10.1016/j.heliyon.2024.e35901\\n\\nReceived 13 August 2023; Received in revised form 5 August 2024; Accepted 6 August 2024\\n\\nAvailable online 10 August 2024\\n\\n2405-8440/© 2024 The Authors. Published by Elsevier Ltd. (http://creativecommons.org/licenses/by-nc-nd/4.0/).\\n\\nThis is an open access article under the CC BY-NC-ND license', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='03ae712d-04f2-4fd1-92a2-03c925d72a92', embedding=None, metadata={'title': 'title', 'author': 'tes author', 'category': 'tes kategori', 'year': 2010, 'publisher': 'tes publisher', 'page_number': 2}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# 1. Introduction\\n\\nIL-22 is an IL-10 family cytokine produced by T cells and innate lymphocytes. Like all other IL-10 family members, the IL-22 structure contains six α-helices (termed helices A to F). They are arranged in an antiparallel conformation and produce a single bundled protein [9]. IL-22 coordinates mucosal immune defense and tissue regeneration through pleiotropic effects including pro-survival signaling, cell migration, dysplasia, and angiogenesis. These molecules act by targeting the heterodimeric transmembrane receptor complex composed of IL-22R1 and IL-10R2 and by activating subsequent signaling pathways (including JAK/STAT signaling pathway, p38 MAPK signaling pathway, and PI3K/AKT signaling pathway) [10]. It is well known that IL-22 is widely expressed in human tissues and organs, including lung, liver, heart, kidney, pancreas, gastrointestinal tract, skin, blood, adipose, and synovial tissues [11]. Meanwhile, IL-22 is also found to be broadly expressed in pathological states such as cancer, infectious diseases, tissue injury, chronic inflammatory diseases, and Graft-Versus-Host Disease [11–14]. In most cancer diseases, excessively elevated levels of IL-22 are considered to be detrimental [15–19]. For instance, a recent study has demonstrated that IL-22 promotes extravasation of tumor cells in liver metastasis [20]. Over the past few years, there has been a surge in research focusing on the relationship between IL-22 and lung cancer. Particularly in patients with NSCLC, researchers have discovered up-regulated expression of IL-22 in serum, malignant pleural effusion, and tumor tissues, and the levels of IL-22Rα1 in tumor cells and tissues are also increased [21–24]. Although emerging studies have revealed that IL-22 is closely correlated with lung cancer in terms of tissue, cell and pathological changes, the specific function and mechanism remain to be explored. In the present review, we mainly summarized the regulatory function and clinical role of IL-22 in lung cancer. In addition, the feasibility of IL-22 as a biomarker for lung cancer and directions for future research were also discussed. It is reasonable to hypothesize that IL-22 may serve as a potential target in the treatment of lung cancer.\\n\\n# 2. Overview of lung cancer\\n\\nLung cancer is a malignant disease characterized by high morbidity and mortality [25]. According to the data of GLOBOCAN, lung cancer is the second most common cancer in 2020 and the main cause of cancer death worldwide, with about one-tenth (11.4 %) of cancer diagnoses and one-fifth (18.0 %) of deaths [5]. When it comes to gender, the incidence and mortality rates of lung cancer were on the rise in females but declining in males in most countries over the past decade [2]. The 5-year survival rate of lung cancer patients varies by 4–17 % in light of stage and region [26]. As predicted by the American Cancer Society, more than 120,000 people will die of lung cancer in the United States in 2023. The good news is that although the incidence is stable or increasing, the overall mortality is decreasing at an accelerated pace [27]. From the perspective of histopathology and biological behavior, lung cancer can be divided into NSCLC and SCLC, among which the former mainly includes several common types such as adenocarcinoma, squamous cell carcinoma, and large cell carcinoma [25]. The pathogenesis of lung cancer primarily involves the following aspects: chromosome changes; abnormal immune response; abnormal activation of developmental pathways; dysregulation of tumor suppressor genes, proto-oncogenes, and signaling pathways; and the up-regulation of receptor tyrosine kinases, growth factors, and cell markers. These abnormal changes cause an imbalance between lung cell proliferation and apoptosis, which leads to lung cancer [28–31]. For example, when exposed to risk factors continuously, the production of ROS, chemokines, and cytokines increases in lung cells, which leads to DNA damage and gives rise to inflammation and other pathobiological changes that ultimately promote carcinogenesis. At the same time, the anti-tumor immune function of macrophages, T lymphocytes, B lymphocytes, and NK cells gets suppressed, failing recognition and clearance of malignant cells, and eventually bringing about the formation of tumors [32]. In the early stage of the disease, it is usually considered to be asymptomatic, while may manifest as cough, dyspnea, chest pain, hemoptysis, hoarseness, and so on in the middle and advanced period [33]. In principle, the treatment of lung cancer depends largely on the type, stage and condition of the patient’s disease. Currently, the main treatment approaches for lung cancer include surgery, chemotherapy, and radiotherapy. Among them, platinum-containing double drugs are preferred for chemotherapy. Radiation therapy is mainly applied in the control of the local lesion. Furthermore, targeted therapy for EGFR, ALK, ROS1, and other gene mutations and immunotherapy to inhibit PD-1/PD-L1 also plays an irreplaceable role as emerging breakthrough therapeutic means [25,34–39]. Compared with chemotherapy, targeted therapy can prominently enhance the survival rate and tolerance of patients with NSCLC [40,41]. The combination of chemotherapy and immunotherapy has also shown a more notable curative effect over chemotherapy alone [42,43]. Additionally, there has been a growing body of research focusing on natural product therapy, local ablative therapy, and chimeric antigen receptor (CAR)-T-cell therapy lately [44–51]. In principle, the treatments of lung cancer are individualized depending largely on the type, stage, and condition of patients. Unfortunately, the limited sensitivity of NSCLC patients to chemotherapy and immunotherapy drugs has proven to be a major obstacle to clinical treatment. Denk D et al. suggested that inflammation is ubiquitous in carcinogenesis. In his study, he noted that interfering with individual cytokines and their respective signaling pathways holds great promise for the development and improvement of current clinical cancer therapies [52]. IL-22 is a new type of cytokine discovered in 2000 and has gradually attracted attention due to its role in tumor diseases. In recent years, multiple studies have reported the positive role of IL-22 in enhancing chemotherapy resistance in human lung cancer patients. This positive effect is related to the function of IL-22 in promoting lung cancer cell proliferation and inhibiting lung cancer cell apoptosis. Results showed that IL-22 activated the EGFR/AKT/ERK signaling pathway [52], STAT3, and ERK1/2 signaling pathways [24] in drug-treated lung cancer cells, thereby attenuating the pro-apoptotic effect of the drug on lung cancer cells.\\n\\n# 3. Function role of IL-22 in lung cancer\\n\\nIL-22 is a cytokine first identified by Dumoutier et al. in IL-9-induced murine T cells over 20 years ago and was once called IL-10-related T cell-derived inducible factor (IL-10-TIF) [53]. In human beings, the IL-22 gene lies in chromosome 12q15, next to the gene.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='8f865355-e081-4d71-b589-9c696acf72dd', embedding=None, metadata={'title': 'title', 'author': 'tes author', 'category': 'tes kategori', 'year': 2010, 'publisher': 'tes publisher', 'page_number': 3}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\nthat encodes IFN-γ [54]. When the body is in homeostasis, the most important source of IL-22 is Group 3 innate lymphoid cells (ILC3) [14]. Different from other common cytokines, IL-22 is generally thought to be produced only by hematopoietic origin immune cells, whereas it mainly acts on non-hematopoietic cells due to its receptor distribution [55]. Recently, researchers have found that non-hematopoietic cells represented by fibroblasts can also produce IL-22 under certain circumstances [11]. IL-22 is known to act by binding to its receptor (IL-22R), which is synthesized from the IL-22R1 and IL-10R2 subunits [56]. Thereinto, IL-22R1 expression is thought to be restricted to epithelial cells in organs such as the lung, liver, intestine, and skin, while the latter is universally expressed [11,57]. IL-22BP, also known as IL-22RA2, is a soluble IL-22 receptor that binds specifically to IL-22 and prevents it from binding to IL-22R1. All currently known functions of IL-22BP are achieved by inhibiting IL-22 [58,59]. Broadly speaking, the primary function of IL-22 in the body is to promote cell proliferation and tissue protection [60]. Sometimes, excessive activation of this function may lead to pathological results. This dual effect is reflected in both inflammatory and tumor-related diseases. In the short term, the production of IL-22 can play a protective role in anti-inflammatory and tumor prevention, while the uncontrolled generation of IL-22 may promote inflammation and tumor formation [13,18]. The duality of IL-22 reveals that it could be a potential drug target, and the tight regulation of IL-22 is crucial in the treatment of a variety of diseases. In Fig. 1, We summarize the role of IL-22 in lung cancer.\\n\\nIn general, the expression levels of IL-22 in vivo are regulated by a variety of cytokines and genes. For instance, IL-1β and IL-23 can induce the production of IL-22 independently, and the two act synergistically [11]. What’s more, Cornelia Voigt described a novel mechanism whereby cancer cells promote tumor growth by releasing IL-1β to induce IL-22 production by memory CD4+ T cells [61]. According to an animal experiment, IL-1β can enhance the proliferation of epithelial cells and promote lung tumorigenesis [62]. IL-23 has been proven to promote proliferation in NSCLC by Anne-Marie Baird et al. [63]. Although IL-23 is thought to be able to induce macrophages to produce IL-22, this study by Anne-Marie Baird et al. cannot directly prove whether the proliferation-promoting effect of IL-23 on NSCLC cells is related to IL-23’s promotion of IL-22 production. IL-23 is also thought to promote the expression of IL-26 by macrophages. Like IL-22, IL-26 is part of the IL-10 family. Researchers demonstrated for the first time that IL-26 is involved in the generation of malignant pleural effusions [64]. They reported that IL-26 promotes the generation of malignant pleural effusion by mediating the infiltration of CD4+IL-22+T cells in malignant pleural effusion and stimulating CD4+ IL-22+ T cells to secrete IL-22. Recently, the Notch-AhR-IL-22 axis is thought to be involved in the pathogenesis of LUAD. It is corroborated that in LUAD patients, elevated Notch1 facilitates IL-22 generation by CD4+ T cells via aryl hydrocarbon receptors (AhR) [65]. In NSCLC, Notch signaling can both promote tumorigenesis and inhibit tumor progression, which mainly depends on its regulation of the\\n\\n|Class I: Proliferation, apoptosis, and invasion|Class II: Regulating tumor microenvironment|\\n|---|---|\\n|Proliferation|Lung cancer tissue|\\n|NK cells| |\\n|T cells|Apoptosis|\\n|Lung cancer cells| |\\n|C01se|Metastasis|\\n|Lung cancer cells|Infiltrated immune cells|\\n|CASPASE| |\\n|Multidrug resistance| |\\n|IL-22 Ko| |\\n|IL-6|Lymphocyte|\\n|TNF-a|Total WBC|\\n|IL-1a|Macrophage|\\n|Neutrophil| |\\n\\n|Class III: Angiogenesis|Class IV: Cancer stem cell|\\n|---|---|\\n|IL-22|STAT3 signaling pathway|\\n|Lung cancer tissue| |\\n|Aangiogenic switch| |\\n|IL-22| |\\n|Vascular endothelial cell|Cancer stem cells|\\n| |Lung cancer cells|\\n\\nFig. 1. IL-22 plays four main functions during the progression of lung cancer. 1) Promote lung cancer cell proliferation and invasion, and inhibit lung cancer cell apoptosis; 2) Regulate the abundance of immune cells in lung cancer tissues and activate the inflammatory microenvironment; 3) Promote cancer angiogenesis; 4) Activate lung cancer stem cells.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='89a03af3-1e13-4347-9561-8a166e8c035b', embedding=None, metadata={'title': 'title', 'author': 'tes author', 'category': 'tes kategori', 'year': 2010, 'publisher': 'tes publisher', 'page_number': 4}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\nTransformation between neuroendocrine and non-neuroendocrine. For patients with SCLC containing Notch active tumor cells, the application of Notch inhibitors may be an effective treatment [66]. Moreover, the expression of IL-22 is also regulated by miR-26. In cutaneous T-cell lymphoma (CTCL) cells, transfection of miR-26 resulted in a remarkable decrease in the expression levels of IL-22 and IL-22 mRNA [67]. In human NSCLC, Yi He et al. found that the expression levels of miR-26 were lower in tumor tissues compared to paracancerous tissue. As a functional miRNA, miR-26 was further proved by the team to inhibit autophagy and induce apoptosis of NSCLC cells both in vitro and in vivo [68]. On the other hand, IL-22 has also been shown to regulate other cytokines. Studies have shown that the production of IL-22 generally reduces Th1-type immune responses. This action may be coordinated with the protective effect of IL-22R-expressing tissue cells to reduce collateral damage in the context of infection and inflammation [69]. Besides, animal experiments have indicated that IL-22 can also promote B-cell responses by inducing CXCL13 in tertiary lymphoid follicles [70,71]. In the latest murine lung cancer model, IL-22 was discovered to induce NK cells to overexpress CD155, thus mediating the immune evasion of tumor cells [72]. As a transmembrane adhesive molecule, CD155 has been proven to inhibit T and NK cell-mediated anti-tumor immune responses, thereby promoting tumor progression (Fig. 2) [73–75].\\n\\nIn the occurrence and development of pulmonary diseases, IL-22 is considered to play an important role. As previously demonstrated in an epicutaneously sensitized mice experiment, IL-22 promotes the development of neutrophil and eosinophile-mediated airway inflammation and airway hyperresponsiveness stimulated by intranasal antigens [76]. The conclusion implies that blocking IL-22 may be helpful for the treatment of bronchial asthma. When it comes to chronic obstructive pulmonary disease (COPD), the expression levels of both IL-22 and its receptor in COPD patients were higher than those of healthy controls. This result was confirmed in mice with experimental COPD induced by cigarette smoke. What’s more, researchers also found that cigarette smoke-induced inappropriate activation of pulmonary neutrophils decreased in IL-22-deficient mice with COPD. This suggests that IL-22 may be involved in the pathogenesis of COPD. The research further manifested that IL-22 promotes cigarette smoke-induced airway remodeling, pulmonary neutrophil inflammation, and the impairment of pulmonary function, and is involved in the pathogenesis of COPD [77]. While in pulmonary infectious diseases such as pneumonia, tuberculosis, and pulmonary mycosis, it is thought that IL-22 appears to take a protective and preventive part [78–83]. For good measure, in the bleomycin-induced pulmonary fibrosis model, the degree of pulmonary fibrosis in IL-22 knockout mice was aggravated, and injection of recombinant IL-22 alleviated the severe fibrosis in IL-22 knockout mice. This latest research has suggested the potential anti-fibrotic effect of IL-22 [84].\\n\\nIn recent years, differential expression of IL-22 has also been discovered in various specimens of lung cancer (Table 1). In the first place, the mean levels of IL-22 in the plasma of NSCLC patients were significantly higher than that of the reference cohort [21,85]. The plasma levels of IL-22 were observed to elevate along with the increase in lung cancer staging [85]. In addition, Immunohistochemistry analysis showed that IL-22 expression was up-regulated in NSCLC tumor specimens in comparison to that in the adjacent tissues. RT-qPCR analysis also revealed similar differences in IL-22 mRNA expression between lung cancer tissues and normal tissues [24,86]. Interestingly, Yi Bi et al. compared IL-22 levels between tissues and serum of patients with primary NSCLC and their paired recurrent lung cancer specimens and the expression levels of IL-22 were found to be obviously up-regulated in the latter group [23]. Apart from this, IL-22 expression was also detected in bronchoalveolar lavage fluid (BALF). As reported by an article in 2016, IL-22 levels were...\\n\\n|CD155|NK Cell|L|\\n|---|---|---|\\n|T Cell|IL-22|Impaired function|\\n| |Lung metastases| |\\n\\nFig. 2. IL-22 induces NK cells to overexpress CD155, which binds to NK cell activation receptor CD226. Over-activation leads to a decrease in the amount of CD226 and impaired NK cell function, thereby mediating tumor cell immune escape.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='87dc46a7-0628-4738-b798-3a7498229f8b', embedding=None, metadata={'title': 'title', 'author': 'tes author', 'category': 'tes kategori', 'year': 2010, 'publisher': 'tes publisher', 'page_number': 5}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# Table 1\\n\\nDifferential expression of IL-22/IL-22 mRNA/IL-22R1 mRNA in various samples in lung cancer. +: Up-regulated.\\n\\n|Molecule|Samples|Expression|P value|Ref. (PMID)|\\n|---|---|---|---|---|\\n|IL-22|Plasma|+|0.0013|24956177|\\n|IL-22 mRNA|Tissues|+|0.0313|18927282|\\n|IL-22|Pleural effusion|+|0.0051|18927282|\\n|IL-22 mRNA, IL-22|Tissues, serum|+|<0.01|26983629|\\n|IL-22R1 mRNA|Tissues|+|<0.05|26983629|\\n|IL-22|BALF|+|<0.001|27388918|\\n\\nSignificantly higher in BALF from lung cancer patients compared with control group. The researchers expanded the cohort to patients with lung metastases from other malignancies and found that IL-22 concentrations remained higher than controls [87]. These results implied that IL-22 in BALF may be a biomarker for lung cancer. Over and above, researchers also found the trace of IL-22 in pleural effusion [88,89]. One study has revealed that IL-22 levels were higher in malignant pleural effusion as against tuberculous pleural effusion [24]. These differential expressions prompt that IL-22 may participate in the occurrence and development of lung cancer (Table 2).\\n\\nThe link between inflammatory processes and cancer has long been recognized [90]. Related studies hint that inflammatory responses play a vital role in different phases of tumor occurrence, development, and metastasis [91–93]. The function of IL-22 in cancer is extremely complicated. Initially, IL-22 may prevent tumorigenesis by reducing chronic inflammation, promoting barrier function, and inducing tissue regeneration. On the contrary, if IL-22 is excessively expressed under persistent chronic inflammation, then malignant cells may utilize this signal to facilitate its progression [11]. In the lung tumor microenvironment, uncontrolled expression of IL-22 can amplify inflammation by inducing various inflammatory mediators alone or in concert with other cytokines [94]. As illustrated by a cellular experiment, IL-22 could promote the proliferation of A549 and H125 cells belonging to the NSCLC cell lines, thereby enhancing the ability of tumor cell migration and invasion [23]. An in vitro experiment in 2018 has confirmed that IL-22 can directly act on endothelial cells to stimulate tumor angiogenesis [95]. To some extent, this enhances the ability of tumor cells to absorb nutrients and distant metastasis. From another perspective, this provides new ideas for anti-angiogenic therapy of tumors. Nasim Khosravi suggested that IL-22 promotes tumor progression by inducing a pro-tumor immune response and protective stem cell properties of tumor cells [94]. It is also reported that after 12h of serum starvation, the proportion of apoptotic lung cancer cells transfected with the IL-22 gene was significantly lower than that of control lung cancer cells. In addition, the apoptosis-inducing and anti-proliferative effects of chemotherapeutic drugs on lung cancer cells were inhibited in IL-22 transgenic cell lines [24]. Simultaneously, the apoptosis of lung cancer cells induced by gefitinib was also significantly reduced 48 h after IL-22 exposure [96]. On the contrary, exposure to IL-22R1 blocking antibodies or in vitro transfection of IL-22-RNA interference plasmid leads to apoptosis of lung cancer cells [24]. Zhiliang Huang et al. found that the apoptosis rate of paclitaxel-treated lung cancer cells in the IL-22 siRNA transfection group was significantly increased compared with the control group [22]. Apart from this, IL-22 antibody treated mice and IL-22-deficient mice were found to be protected from the formation of pulmonary metastases caused by colon cancer, while IL-22 overexpression promoted metastases [20]. In short, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and migration of lung cancer cells, the growth of tumor tissues, and the generation of lung metastatic cancer.\\n\\n# 4. Regulatory role of IL-22 in lung cancer\\n\\nNumerous signaling pathways are involved in the regulation of IL-22 in lung cancer, including PI3K/AKT, JAK-STAT3, p38 MAPK signaling pathways, and so on. In the following, we will elaborate on the regulatory role of IL-22 in lung cancer from the point of view of each major signaling pathway (Fig. 3).\\n\\n# Table 2\\n\\nPotential clinical role of IL-22, its receptors and producing cells in lung cancer.\\n\\n|Sample sources|Clinical function|Conclusion|Ref. (PMID)|\\n|---|---|---|---|\\n|Patients|Diagnosis|IL-22 levels were significantly higher in lung cancer patients than control group.|24956177, 27388918|\\n|Patients|Prognosis assessment|IL-22R1 levels were associated with poorer prognosis.|26846835|\\n|Patients|Disease assessment|The levels of IL-22-producing Th22 cells were positively correlated with TNM stage and lymph node metastasis.|35669104|\\n|Patients|Efficacy prediction|IL-22 expression levels were associated with EGFR-TKI efficacy.|31750252|\\n|Mice model|Treatment|IL-22-deficient mice had a lower metastatic load of lung cancer.|36630913|\\n|Mice model|Treatment|Gene ablation of IL-22 resulted in a marked reduction in the number and size of lung tumors.|29764837|', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='75a235a9-b907-42f9-bf9e-c4383d2f37c6', embedding=None, metadata={'title': 'title', 'author': 'tes author', 'category': 'tes kategori', 'year': 2010, 'publisher': 'tes publisher', 'page_number': 6}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# 4.1. PI3K/Akt signaling pathway\\n\\nPI3K/Akt signaling pathway is one of the core intracellular signaling pathways, which plays a critical role in regulating cell growth, survival, metabolism, movement, and proliferation [97]. As a downstream effector of receptor tyrosine kinases (RTKs) and G-protein-coupled receptors (GPCRs), PI3K is a group of lipid kinases consisting of three subunits. It can be divided into three categories according to various functions and structures. Thereinto Class IA PI3K is a heterodimer of the p110 catalytic subunit and the p58 regulatory subunit, and it is primarily related to human tumors [98,99]. As we all know, PI3K can catalyze phosphatidylinositol [4, 5]-bisphosphate (PIP2) to phosphatidylinositol [3–5]-trisphosphate (PIP3). Serine/threonine protein kinase (Akt), as the main downstream molecule of the PI3K signaling pathway, is mainly activated by PIP3-driven plasma membrane recruitment and phosphorylation. The mammalian target of rapamycin (mTOR), a major downstream signaling molecule in the PI3K/Akt signaling pathway, is considered to be a modified protein kinase in the form of mTORC1 and mTORC2. The first is mainly activated by the PI3K/Akt signaling pathway, and mTORC2 further activates Akt by directly phosphorylating its hydrophobic motif (Ser473) [100].\\n\\nPI3K/Akt signaling pathway is considered to be the chief regulatory factor of idiopathic pulmonary fibrosis (IPF), it may directly participate in the formation of IPF or promote the occurrence and development of fibrosis in collaboration with other pathways [97]. Several studies have declared that certain natural products like resveratrol and Danhong injection can provide neuroprotective effects by activating the PI3K/Akt/mTOR signaling pathway [101,102]. Furthermore, the relationship between the PI3K/Akt/mTOR signaling pathway and cancer has been most intensively studied. Activation of the PI3K/Akt/mTOR signaling pathway is believed to promote the occurrence, proliferation, and progression of a variety of cancers, including breast cancer, ovarian cancer, prostate cancer, etc. [99,100,103]. In addition, it is also an important cause of tumor drug resistance [104]. In NSCLC, KRAS, EGFR, and PTEN mutations are believed to activate the PI3K/Akt/mTOR signaling pathway [105]. As demonstrated in a previous article, upregulation of the PI3K signaling pathway was identified as an early and reversible event in the pathogenesis of NSCLC [106]. One experiment has confirmed that the PI3K/Akt signaling pathway promotes the proliferation of LUAD cells mainly through anti-apoptosis [107]. Additionally, as revealed in a cellular study, IL-22 produced by CAFs markedly improves the proliferation and invasion of lung cancer cell, and lessens apoptosis by activating the PI3K/Akt/mTOR signaling pathway [86]. For good measure, it has been found that Akt phosphorylation in NSCLC cells is facilitated by different concentrations of IL-22 in a time- and dose-dependent way [23]. Collectively, the PI3K/Akt/mTOR signaling pathway plays a significant role in the relationship between IL-22 and lung cancer. It is worth mentioning that IL-22 does not seem to always activate the PI3K/Akt/mTOR signaling pathway. Meng Yuxia et al. found that IL-22 inhibits the activity of the PI3K/Akt/mTOR signaling pathway in mouse liver fibrosis tissue [108]. This opposite finding may be related to the dual function of IL-22. Further study on the impact of IL-22 on the PI3K/Akt/mTOR signaling pathway in different disease processes will help us better understand the specific mechanism of IL-22’s function in the human body. This will facilitate.\\n\\n|IL-22|PI3K|JAK|P38 MAPK|\\n|---|---|---|---|\\n|NK cell|AKT|mTOR| |\\n|Antitumor drugs|Gene expression| |Metastasis|\\n|Apoptosis|Proliferation|EMT|Invasion|\\n| |Lung tumor cell| | |\\n\\nFig. 3. IL-22 promotes the proliferation, migration and epithelial-mesenchymal transition of lung cancer cells through PI3K/Akt, JAK-STAT3, p38 MAPK and other signaling pathways, and antagonizes the apoptosis of lung cancer cells induced by anti-tumor drugs.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='8ceb46e8-38ee-4d80-9676-6c5c6d179d80', embedding=None, metadata={'title': 'title', 'author': 'tes author', 'category': 'tes kategori', 'year': 2010, 'publisher': 'tes publisher', 'page_number': 7}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al. Heliyon 10 (2024) e35901\\n\\n# IL-22-related clinical drug development.\\n\\n# 4.2. JAK/STAT signaling pathway\\n\\nThe JAK/STAT signaling pathway is also an important communication center for cell function, and aberrant alterations in its components are associated with numerous human diseases. JAK/STAT is an evolutionarily conserved signaling pathway consisting of JAKs, STATs, and ligand-receptor complexes. There are four major members of the JAK family, all of which are composed of non-receptor tyrosine protein kinases. The STAT family contains six members which consist of 750–900 amino acids. The JAK/STAT signaling pathway is mainly thought to mediate inflammation, apoptosis, hematopoiesis, tissue repair, immune regulation, and adipogenesis [109]. In autoimmune diseases such as rheumatoid arthritis (RA), activation of the JAK-STAT signaling pathway leads to the progression of joint injury through overexpression of the matrix metalloproteinase gene, apoptosis of chondrocytes, and apoptotic resistance in synovial tissue [110,111]. In addition, in a 2020 study by Meyer LK, the inhibition of the JAK-STAT signaling pathway was found to sensitize CD8+ T cells to dexamethasone-induced excessive inflammatory cell apoptosis [112]. Song et al. have long discovered that the lifespan of NSCLC cells was notably reduced after inhibiting STAT3 [113]. In a murine lung model, overexpression of STAT3 in alveolar type II cells led to severe lung inflammation and eventually to the formation of LUAD [114]. Further, down-regulation of STAT3 was found to result in enhanced NK cell immunity in both human and murine NSCLC cells, which suggests that STAT3 plays an inhibitory role against tumor NK cell immunity [115,116]. A study last year disclosed that IL-22 triggers JAK-STAT3 pathway phosphorylation in NSCLC cells in a time- and dose-dependent manner, thus promoting the proliferation and metastasis of tumor cells [23,96]. Another study demonstrated that the overexpression of IL-22 protected lung cancer cells against apoptosis induced by serum starvation and chemotherapy drugs by activating STAT3 and its downstream anti-apoptotic proteins [24].\\n\\n# 4.3. p38 MAPK signaling pathway\\n\\nThe p38 mitogen-activated protein kinases (MAPK) signaling pathway takes a crucial role in signaling cascades induced by various cellular stimuli. There are four p38 kinase members in the mammalian mitogen-activated protein (MAP) family, which play momentous roles in extracellular stimulation-mediated proliferation, inflammation, differentiation, apoptosis, senescence, and tumorigenesis [117]. In the classical pathway, the p38 MAPK signaling pathway is activated by cascade phosphorylation [118]. In a hepatitis C virus (HCV) experiment, researchers demonstrated that virus-induced activation of the p38 MAPK signaling pathway promotes viral infection, and blocking activation of this pathway may be an antiviral approach [117]. According to Dan He in 2020, mTORC1 drives intestinal stem cell aging via the p38 MAPK-p53 signaling pathway [119]. The p38 MAPK signaling pathway has long been demonstrated to exhibit a major oncogenic role in LUAD [120–122]. Yinan Guo et al. found evidence that the p38 MAPK signaling pathway can promote EMT and metastasis of NSCLC both in vitro and in vivo [123]. In addition, a study published in 2017 proposed that the p38 MAPK signaling pathway activates stem cell properties of LUAD cells by regulating GLI1 [124]. What’s more, in lung cancer models, researchers found that the p38 MAPK signaling pathway inhibited the stem cell properties of lung CSCs and promoted their proliferation and differentiation, thereby leading to tumorigenesis. More importantly, they also elucidated that the p38 MAPK and PI3K/AKT signaling pathways have unique and synergistic roles in regulating lung CSCs self-renewal as carcinogenic and/or stem cell signaling pathways [107]. This provides a new idea for the stem cell-based treatment of lung cancer. In NSCLC, IL-22 in vivo and in vitro were both verified to activate the p38 MAPK signaling pathway. The collected evidence from this study confirmed the negative immunomodulatory role of IL-22 in the disease [96].\\n\\n# 5. Clinical role of IL-22 in lung cancer\\n\\nCurrently, there is still a lack of efficient biomarkers for the diagnosis and treatment of lung cancer. In recent years, the value of the interleukin family as biomarkers and therapeutic targets of lung cancer has been deeply investigated [125–132]. Of these, IL-1 and IL-6 have been studied most extensively in lung cancer. Bo Yuan’s findings in mice experiments supported IL-1β as a potential target for the prevention and treatment of LUAD patients with Kras mutations [129]. In a clinical trial of the anti-IL-1β antibody canakinumab, researchers found that 300 mg canakinumab significantly reduced lung cancer mortality compared with the control group (HR 0.49 [95%CI 0.31–0.75]; p = 0.0009) [133]. In plasma samples or tumor tissues from NSCLC, researchers revealed that patients with lower baseline IL-6 concentrations benefited more from immunotherapy. The study elucidated the role of IL-6 in predicting the efficacy of immunotherapy in patients with NSCLC [128]. Furthermore, in one lung cancer study, the survival hazard ratio before and after chemotherapy for high versus low IL-6 levels was 1.25 (95%CI 0.73–2.13) and 3.66 (95%CI 2.18–6.15), respectively. It is suggested that IL-6 may be a prognostic indicator of survival in patients with advanced NSCLC receiving chemotherapy [127]. Some scholars have also described the potential value of IL-11 as a biomarker for the diagnosis and prognosis of NSCLC [125]. In addition, another research has shown that changes in serum IL-8 levels in NSCLC patients could reflect and predict the response to immunotherapy [130]. Kaplan-Meier survival analysis showed that the overall survival outcome of NSCLC patients with high IL-22R1 expression was significantly lower than that of patients with low IL-22R1 expression (p = 0.022). Multivariate regression analysis also confirmed an association between IL-22R1 levels and poorer outcomes (HR 1.5, 95%CI 1.2–1.9; p = 0.0011). This suggested that high expression of IL-22R1 is an independent factor for low overall survival in NSCLC [134]. What’s more, the levels of IL-22-producing Th22 cells in peripheral blood were positively correlated with TNM stage, lymph node metastasis, and clinical tumor markers of lung cancer (p < 0.01) [96]. The above indicates the significance of IL-22 as a biomarker in the diagnosis and disease assessment of lung cancer. Apart from this, Renhua Guo’s team found that the expression of IL-22 in the EGFR-TKI resistant group was higher than that in sensitive.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='da26883c-dab1-4da8-bcc5-fdbad1a58553', embedding=None, metadata={'title': 'title', 'author': 'tes author', 'category': 'tes kategori', 'year': 2010, 'publisher': 'tes publisher', 'page_number': 8}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\ngroup in NSCLC, and the expression level was correlated with the efficacy of EGFR-TKI in plasma [135]. Therefore, it is reasonable to suspect that IL-22 may be a new biomarker to overcome EGFR-TKI resistance in NSCLC. In terms of animal models, some investigators implanted Line-1 lung cancer cells into wild-type and IL-22-deficient mice simultaneously, and found reduced intrapulmonary metastasis in the latter group, which is independent of primary tumor size. Besides, they performed forced metastasis by intravenous injection of lung cancer cells, and the results further confirmed the lower metastatic load in mice with IL-22 deletion [72]. In another model of Kras-mutated lung cancer in mice, gene ablation of IL-22 resulted in a marked reduction in tumor number and size. The authors also analyzed the association between IL-22R1 expression and survival in patients with KRAS mutant lung adenocarcinoma, the results showed that high expression of IL-22R1 was an independent indicator of poorer relapse-free survival [94]. Taken together, these pieces of evidence highlight the potential clinical role of IL-22, IL-22R, and IL-22-producing cells in the treatment of lung cancer (Table 2).\\n\\n# 6. Future perspectives\\n\\n# 6.1. CRISPR-Cas13a technical\\n\\nAt present, mounting clinical trials based on IL-22 are being carried out in full swing worldwide, mainly involving ulcerative colitis, alcoholic cirrhosis, GVHD, and psoriasis [12,14,54,60]. However, there are presently no clinical trials based on IL-22 in lung cancer. As described previously, reduced intrapulmonary metastasis was found in IL-22-deficient mice as well as in IL-22-suppressed NSCLC cells [20,72]. In addition, blocking IL-22R1 or knockout of the IL-22 gene both retarded the progression of lung cancer [24,94]. These findings provide a new train of thought for the down-regulation of IL-22 in treating lung cancer.\\n\\nIn recent years, the research on gene editing treatment for various diseases has become more and more popular [136–138]. CRISPR-Cas13a is an effective tool for knocking out specific RNA sequences, it has been shown to induce the death of glioma cells that overexpress EGFR, which is one of the subtypes of EGFR mutation in glioma. Apart from this, the CRISPR-Cas13a gene-editing system can also inhibit the formation of intracranial tumors in mice with glioma [139]. In a collagen-induced mouse model, injection of gene-edited human amniotic mesenchymal stem cells that overexpressed IL-10 increased proteoglycan expression in joint tissue and reduced the inflammatory response and production of various inflammatory cytokines [137]. In the world’s first human phase I clinical trial utilizing CRISPR-Cas9 in the treatment of advanced NSCLC, researchers have demonstrated the feasibility and safety of gene-edited T-cell therapy targeting the PD-1 gene [140]. Thus, genome editing strategies have the potential to treat lung cancer by altering IL-22 expression levels. In the future, the role of pulmonary precision delivery based on CRISPR-Cas13 gene-editing components targeting the IL-22 mRNA in lung cancer therapy should not be ignored. CRISPR-Cas13 is expected to be further integrated.\\n\\n# IL-22 mRNA\\n\\n# Cas13a\\n\\n# Crispr-Cas13a Combined With\\n\\n# Figure\\n\\n# Single-base edition\\n\\n# Single-cell sequencing\\n\\n# Lung cancer\\n\\nFig. 4. Crispr-cas13-based IL-22 mRNA editing can be utilized for lung cancer therapy by combining with emerging technologies such as single-base editing and single-cell sequencing.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='879717af-4d28-425c-85de-a9cd4fbb7ae8', embedding=None, metadata={'title': 'title', 'author': 'tes author', 'category': 'tes kategori', 'year': 2010, 'publisher': 'tes publisher', 'page_number': 9}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\nwith the latest technologies such as single-base editing and single-cell sequencing to promote the treatment of lung cancer to a new level (Fig. 4).\\n\\n# 6.2. Small interfering RNA\\n\\nSmall interfering RNA (siRNA) is a double-stranded RNA molecule composed of 21–23 nucleotides. In cells, siRNA forms functional complexes by binding to the RNA-induced silencing complex (RISC). RISC in the functional complex specifically recognizes and binds to the target mRNA, leading to degradation of the target mRNA and thereby silencing the expression of the target gene. Compared with traditional therapies such as small molecules and protein drugs, siRNA technology has many advantages:\\n\\n1. siRNA is highly specific. siRNA can only silence homologous genes, while unrelated genes are not affected.\\n2. siRNA can silence genes by using RISC.\\n3. siRNA can be designed to target different genes through sequence design, and can even target targets that were previously considered “undruggable”.\\n4. siRNA does not activate the innate immune system.\\n\\nTwenty years after the discovery of the RNA interference mechanism, the first siRNA drugs (including Patisiran, Givosiran, Lumasiran, Inclisiran, Vutrisiran) were approved for clinical use by the U.S. Food and Drug Administration (FDA) and the European Medicines Agency from 2018 to 2022 [141,142]. NFKBIZ is an upstream target of IL-23, IL-36 and IL-17A. In the study of Mandal A et al. [143], NFKBIZ-siRNA significantly reduces the mRNA levels of multiple pro-inflammatory cytokines, including IL-17, IL-19, IL-22, etc., in the skin tissue of psoriasis mice, thereby alleviating the condition of the mice. The safety evaluation results of NFKBIZ-siRNA preparations show that NFKBIZ-siRNA preparations can complex with nucleic acids without affecting biological activity and show no toxicity. TGF-β is a pleiotropic regulatory cytokine that can regulate a variety of ILs including IL-22 and IL-17 to affect the composition of the tumor microenvironment [144]. Currently, Sirnaomics has developed an siRNA drug that targets TGF-β (called STP705). Recently, the drug has completed phase II clinical trials in the United States and achieved positive results. The role of ILs in cancer has been extensively studied. In recent years, the positive role of IL-22 in lung cancer has received attention. The researchers believe that knocking down IL-22 mRNA levels in the lesions of lung cancer patients will help prolong the survival of lung cancer patients and improve the cure rate of lung cancer patients. For example, Zhang Wei et al. found that IL-22-siRNA slowed tumor growth in NSCLC model mice. In addition, they reported that the therapeutic effect of IL-22-siRNA combined with chemotherapy drugs (5-FU and carboplatin) on NSCLC mice was better than that of chemotherapy drugs alone [24]. In an in vitro assay [145], cell line PC9 cells (NSCLC) transfected with PDLIM5-siRNA targeting the PDLIM5 gene had reduced growth viability and exhibited higher apoptotic rates. In the chemotherapy drug gefitinib-resistant cell line PC9 cells, PDLIM5-siRNA still showed significant anti-tumor effects. These results indicate that siRNA-based therapy has good application in the clinical treatment of NSCLC, especially in drug-resistant patients. Based on these findings, we believe that the development of IL-22-siRNA drugs for lung cancer treatment has clinical potential and theoretical basis.\\n\\n# 6.3. Nanoparticle drug delivery systems\\n\\nOn the other hand, given the toxicity and erratic efficacy of current anti-tumor drugs, research on novel drug carriers in lung cancer.\\n\\n|Different types of nanomaterials|Targeting agent|IL-22-related drug|\\n|---|---|---|\\n|Lung precision delivery|Lung precision delivery|Lung precision delivery|\\n\\nFig. 5. Precision delivery of various nanomaterials containing IL-22 related drugs for the treatment of lung cancer.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='2ca21b8f-6b73-4c9d-b1b4-5a18c9bc6af2', embedding=None, metadata={'title': 'title', 'author': 'tes author', 'category': 'tes kategori', 'year': 2010, 'publisher': 'tes publisher', 'page_number': 10}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\nis also of vital significance. Nanoparticles containing targeted drugs can be delivered to the intended site using carriers with affinity for various specific tissues or lesions [146,147]. In an in vivo mice lung model, combined delivery of sorafenib and crizotinib by polymer nanoparticles significantly reduced tumor progression and toxic side effects, and improved survival rate [148]. Moreover, Maofan Zhang demonstrated that the efficacy of dual-drug-loaded polymeric nanoparticles with etoposide and cisplatin was significantly superior to conventional chemotherapy modality without causing additional toxicity [149]. These imply that nanomaterials loaded with IL-22-related drugs may also have more unique advantages. Therefore, the utilization of novel nanomaterials loaded with IL-22 antibodies and IL-22 inhibitors like IL-22BP for targeted therapy of lung tumors is also a promising research direction (Fig. 5).\\n\\n# 7. Conclusion\\n\\nIn this review, we provided a comprehensive analysis of the role of IL-22 in the immune microenvironment and its involvement in major signaling pathways in the context of lung cancer. Put in a nutshell, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and metastasis of lung cancer cells and the growth of tumor tissues. Additionally, the potential clinical significance of IL-22 in the diagnosis, treatment, and prognosis evaluation of lung cancer was further confirmed. Next, the prospects of IL-22 in combination with gene editing and novel nanomaterials in the treatment of lung cancer have been discussed. With the general increase in drug resistance to chemotherapy, targeted therapy, and immunotherapy in lung cancer, it is also necessary to study in depth to discover the correlation between IL-22 and the mechanism of drug resistance. To sum up, the potential of IL-22 as a biomarker for lung cancer still remains to be explored. Further research on the molecular, physiological effects and mechanism of IL-22 in lung cancer as well as the conduction of standardized clinical trials are expected to inject fresh blood into the diagnosis and treatment of lung cancer.\\n\\n# Financial support\\n\\nNone.\\n\\n# Data availability statement\\n\\nNot applicable.\\n\\n# CRediT authorship contribution statement\\n\\nLing Xu: Writing – original draft.\\n\\nPeng Cao: Visualization.\\n\\nJianpeng Wang: Writing – review & editing.\\n\\nPeng Zhang: Validation.\\n\\nShuhui Hu: Validation.\\n\\nChao Cheng: Writing – review & editing.\\n\\nHua Wang: Writing – review & editing, Supervision, Conceptualization.\\n\\n# Declaration of competing interest\\n\\nThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\\n\\n# Acknowledgements\\n\\nNone.\\n\\n# Abbreviations\\n\\n|non-small cell lung cancer|NSCLC|\\n|---|---|\\n|Interleukin-22|IL-22|\\n|chimeric antigen receptor|CAR|\\n|IL-10-related T cell-derived inducible factor|IL-10-TIF|\\n|Group 3 innate lymphoid cells|ILC3|\\n|IL-22 receptor|IL-22R|\\n|aryl hydrocarbon receptors|AhR|\\n|chronic obstructive pulmonary disease|COPD|\\n|cutaneous T-cell lymphoma|CTCL|\\n|bronchoalveolar lavage fluid|BALF|\\n|receptor tyrosine kinases|RTKs|\\n|G-protein-coupled receptors|GPCRs|\\n|Mammalian target of rapamycin|mTOR|\\n|idiopathic pulmonary fibrosis|IPF|\\n|rheumatoid arthritis|RA|', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='f1e0224e-8de8-4f70-90c9-5376b0ba332a', embedding=None, metadata={'title': 'title', 'author': 'tes author', 'category': 'tes kategori', 'year': 2010, 'publisher': 'tes publisher', 'page_number': 11}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='# L. Xu et al.\\n\\n# Heliyon 10 (2024) e35901\\n\\n# Abbreviations\\n\\n|Term|Abbreviation|\\n|---|---|\\n|mitogen-activated protein kinases|MAPK|\\n|mitogen-activated protein|MAP|\\n|hepatitis C virus|HCV|\\n\\n# References\\n\\n1. S. Lareau, C. Slatore, R. Smyth, Lung cancer, Am. J. Respir. Crit. Care Med. 204 (12) (2021) P21–P22.\\n2. J. Huang, Y. Deng, M.S. Tin, V. Lok, C.H. Ngai, L. Zhang, et al., Distribution, risk factors, and temporal trends for lung cancer incidence and mortality: a global analysis, Chest 161 (4) (2022) 1101–1111.\\n3. B.C. Bade, C.S. Dela Cruz, Lung cancer 2020: epidemiology, etiology, and prevention, Clin. Chest Med. 41 (1) (2020) 1–24.\\n4. J. Malhotra, M. Malvezzi, E. Negri, C. La Vecchia, P. Boffetta, Risk factors for lung cancer worldwide, Eur. Respir. J. 48 (3) (2016) 889–902.\\n5. H. Sung, J. Ferlay, R.L. Siegel, M. Laversanne, I. Soerjomataram, A. 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Li, et al., Ultrasound-sensitive siRNА-loaded nanobubbles fabrication and antagonism in drug resistance for NSCLC, Drug Deliv. 29 (1) (2022) 99–110.\\n13. M.E. Аikins, C. Xu, J.J. Moon, Engineered nanoparticles for cancer vaccination and immunotherapy, Аcc. Chem. Res. 53 (10) (2020) 2094–2105.\\n14. S. Li, S. Xu, X. Liang, Y. Xue, J. Mei, Y. Ma, et al., Nanotechnology: breaking the current treatment limits of lung cancer, Аdv. Healthcare Mater. 10 (12) (2021) e2100078.\\n15. T. Zhong, X. Liu, H. Li, J. Zhang, Co-delivery of sorafenib and crizotinib encapsulated with polymeric nanoparticles for the treatment of in vivo lung cancer animal model, Drug Deliv. 28 (1) (2021) 2108–2118.\\n16. M. Zhang, CTt Hagan, H. Foley, X. Tian, F. Yang, K.M. Аu, et al., Co-delivery of etoposide and cisplatin in dual-drug loaded nanoparticles synergistically improves chemoradiotherapy in non-small cell lung cancer models, Аcta Biomater. 124 (2021) 327–335.', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n')]" ] }, "execution_count": 18, "metadata": {}, "output_type": "execute_result" } ], "source": [ "metadata = {\n", " \"title\": \"title\",\n", " \"author\": \"tes author\",\n", " \"category\": \"tes kategori\",\n", " \"year\": 2010,\n", " \"publisher\": \"tes publisher\"\n", "}\n", "\n", "def add_metadata(documents, metadata):\n", " \"\"\"Add metadata to each document and include page number.\"\"\"\n", " for page_number, document in enumerate(documents, start=1):\n", " # Ensure the document has a metadata attribute\n", " if not hasattr(document, \"metadata\") or document.metadata is None:\n", " document.metadata = {}\n", " \n", " # Update metadata with page number\n", " document.metadata[\"page_number\"] = page_number\n", " document.metadata.update(metadata)\n", " \n", " \n", " print(f\"Metadata added to page {page_number}\")\n", " # self.logger.log_action(f\"Metadata added to document {document.id_}\", action_type=\"METADATA\")\n", " \n", " return documents\n", "\n", "add_metadata(documents, metadata)\n", "\n" ] }, { "cell_type": "markdown", "metadata": {}, "source": [ "# Riser Llama Parse" ] }, { "cell_type": "code", "execution_count": 2, "metadata": {}, "outputs": [], "source": [ "import os\n", "work_directory = r\"D:\\Project_Multimedika\\Projek_2\\fullstack_summarizer_and_bot_development\\backend\"\n", "os.chdir(work_directory)" ] }, { "cell_type": "code", "execution_count": 3, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "'D:\\\\Project_Multimedika\\\\Projek_2\\\\fullstack_summarizer_and_bot_development\\\\backend'" ] }, "execution_count": 3, "metadata": {}, "output_type": "execute_result" } ], "source": [ "%pwd" ] }, { "cell_type": "markdown", "metadata": {}, "source": [ "# Llamaparse S3 Bucket" ] }, { "cell_type": "code", "execution_count": 3, "metadata": {}, "outputs": [], "source": [ "import os\n", "import asyncio\n", "from dotenv import load_dotenv\n", "from typing import List\n", "from llama_index.core.schema import TextNode\n", "import aiohttp\n", "from io import BytesIO\n", "\n", "from botocore.exceptions import ClientError\n", "from botocore.config import Config\n", "# from botocore.client import Config, BaseClient\n", "\n", "from boto3.session import Session\n", "\n", "from pydantic import PrivateAttr\n", "from llama_parse import LlamaParse\n", "from llama_parse.utils import (\n", " nest_asyncio_err,\n", " nest_asyncio_msg,\n", ")\n", "\n", "\n", "load_dotenv()\n", "\n", "\n", "class S3ImageSaver:\n", " def __init__(self, bucket_name, access_key=None, secret_key=None, region_name=None):\n", " self.bucket_name = bucket_name\n", " self.region_name = region_name\n", " self.session = Session(\n", " aws_access_key_id=access_key,\n", " aws_secret_access_key=secret_key,\n", " region_name=self.region_name\n", " )\n", " self.s3_client = self.session.client(\n", " 's3',\n", " config=Config(signature_version='s3v4', region_name=self.region_name)\n", " )\n", "\n", " def save_image(self, image_path):\n", " \"\"\"Saves an image to the S3 bucket.\"\"\"\n", " try:\n", " title = \"test\"\n", " s3_key = f\"images/{title}/{os.path.basename(image_path)}\"\n", " with open(image_path, 'rb') as f:\n", "\n", " self.s3_client.upload_fileobj(f, self.bucket_name, f\"images/{title}/{os.path.basename(image_path)}\")\n", " s3_url = f\"https://{self.bucket_name}.s3.{self.region_name}.amazonaws.com/{s3_key}\"\n", " print(f\"Image saved to S3 bucket: {s3_url}\")\n", " return s3_url\n", " except ClientError as e:\n", " print(f\"Error saving image to S3: {e}\")\n", " return None\n", "\n", "class LlamaParseWithS3(LlamaParse):\n", " _s3_image_saver: S3ImageSaver = PrivateAttr()\n", "\n", " def __init__(self, *args, s3_image_saver=None, **kwargs):\n", " super().__init__(*args, **kwargs)\n", " self._s3_image_saver = s3_image_saver or S3ImageSaver(\n", " bucket_name=os.getenv(\"S3_BUCKET_NAME\"),\n", " access_key=os.getenv(\"AWS_ACCESS_KEY_ID\"),\n", " secret_key=os.getenv(\"AWS_SECRET_ACCESS_KEY\"),\n", " region_name=\"us-west-2\"\n", " )\n", " \n", " async def aget_images(\n", " self, json_result: List[dict], download_path: str\n", " ) -> List[dict]:\n", " \"\"\"Download images from the parsed result.\"\"\"\n", " headers = {\"Authorization\": f\"Bearer {self.api_key}\"}\n", "\n", " # make the download path\n", " if not os.path.exists(download_path):\n", " os.makedirs(download_path)\n", "\n", " try:\n", " images = []\n", " for result in json_result:\n", " job_id = result[\"job_id\"]\n", " for page in result[\"pages\"]:\n", " if self.verbose:\n", " print(f\"> Image for page {page['page']}: {page['images']}\")\n", " for image in page[\"images\"]:\n", " image_name = image[\"name\"]\n", "\n", " # get the full path\n", " image_path = os.path.join(\n", " download_path, f\"{image_name}\"\n", " )\n", "\n", " # get a valid image path\n", " if not image_path.endswith(\".png\"):\n", " if not image_path.endswith(\".jpg\"):\n", " image_path += \".png\"\n", "\n", " image[\"path\"] = image_path\n", " image[\"job_id\"] = job_id\n", "\n", " image[\"original_file_path\"] = result.get(\"file_path\", None)\n", "\n", " image[\"page_number\"] = page[\"page\"]\n", " with open(image_path, \"wb\") as f:\n", " image_url = f\"{self.base_url}/api/parsing/job/{job_id}/result/image/{image_name}\"\n", " async with self.client_context() as client:\n", " res = await client.get(\n", " image_url, headers=headers, timeout=self.max_timeout\n", " )\n", " res.raise_for_status()\n", " f.write(res.content)\n", " images.append(image)\n", " return images\n", " except Exception as e:\n", " print(\"Error while downloading images from the parsed result:\", e)\n", " if self.ignore_errors:\n", " return []\n", " else:\n", " raise e\n", "\n", " async def aget_images_s3(self, json_result: List[dict]) -> List[dict]:\n", " \"\"\"Download images from the parsed result and save them to S3.\"\"\"\n", " headers = {\"Authorization\": f\"Bearer {self.api_key}\"}\n", " \n", " images = await self.aget_images(json_result, download_path=\"/tmp/\") # Download to temporary location\n", "\n", " for image in images:\n", " image_path = image[\"path\"]\n", " try:\n", " s3_url = self._s3_image_saver.save_image(image_path) # No need to pass data, S3 reads from file\n", " # Add the S3 URL to the image data\n", " if s3_url:\n", " image[\"image_link\"] = s3_url \n", " except Exception as e:\n", " print(f\"Error saving image to S3: {image_path} - {e}\")\n", " finally:\n", " os.remove(image_path) # Clean up temporary file\n", "\n", " return images\n", "\n", " def get_images(self, json_result: List[dict]) -> List[dict]:\n", " \"\"\"Download images from the parsed result and save them to S3.\"\"\"\n", " try:\n", " return asyncio.run(self.aget_images_s3(json_result))\n", " except RuntimeError as e:\n", " if nest_asyncio_err in str(e):\n", " raise RuntimeError(nest_asyncio_msg)\n", " else:\n", " raise e" ] }, { "cell_type": "code", "execution_count": 4, "metadata": {}, "outputs": [], "source": [ "ins = \"\"\"\n", "You are a highly proficient language model designed to convert pages from PDF, PPT and other files into structured markdown text. Your goal is to accurately transcribe text, represent formulas in LaTeX MathJax notation, and identify and describe images, particularly graphs and other graphical elements.\n", "\n", "You have been tasked with creating a markdown copy of each page from the provided PDF or PPT image. You should write the number of the figure, and keep it in your markdown text. Each image description must include a full description of the content, a summary of the graphical object.\n", "\n", "Maintain the sequence of all the elements.\n", "\n", "For the following element, follow the requirement of extraction:\n", "for Text:\n", " - Extract all readable text from the page.\n", " - Exclude any diagonal text, headers, and footers.\n", "\n", "for Text which includes hyperlink:\n", " -Extract hyperlink and present it with the text\n", "\n", "for Formulas:\n", " - Identify and convert all formulas into LaTeX MathJax notation.\n", "\n", "for Image Identification and Description:\n", " - Identify all images, graphs, and other graphical elements on the page.\n", " - For each image or graph, note the figure number and include it in the description as \"Figure X\" where X is the figure number.\n", " - If the image has graph , extract the graph as image . DO NOT convert it into a table or extract the wording inside the graph.\n", " - If image contains wording that is hard to extract , flag it with instead of parsing.\n", " - If the image has a subtitle or caption, include it in the description.\n", " - If the image has a formula convert it into LaTeX MathJax notation.\n", " - If the image has a organisation chart , convert it into a hierachical understandable format.\n", " - If the image contain process flow , capture it as a whole image instead of separate into blocks of images.\n", "\n", "for Table:\n", " - Try to retain the columns and structure of the table and extract it into markdown format.\n", "\n", "# OUTPUT INSTRUCTIONS\n", "\n", "- Ensure all formulas are in LaTeX MathJax notation.\n", "- Exclude any diagonal text, headers, and footers from the output.\n", "- For each image and graph, provide a detailed description,caption if there's any and summary. Clearly denote the figure number for each image in the format \"Figure X\" if it is noticed in the context.\n", "\"\"\"" ] }, { "cell_type": "code", "execution_count": 5, "metadata": {}, "outputs": [], "source": [ "import os\n", "import nest_asyncio\n", "from dotenv import load_dotenv\n", "\n", "load_dotenv()\n", "\n", "nest_asyncio.apply()\n", "\n", "s3_image_saver = S3ImageSaver(\n", " bucket_name= os.getenv(\"S3_BUCKET_NAME\"),\n", " access_key=os.getenv(\"AWS_ACCESS_KEY_ID\"),\n", " secret_key=os.getenv(\"AWS_SECRET_ACCESS_KEY\"),\n", " region_name=\"us-west-2\"\n", ")\n", "s3_parser = LlamaParseWithS3(\n", " api_key=os.getenv(\"LLAMA_PARSE_API_KEY\"), # can also be set in your env as LLAMA_CLOUD_API_KEY\n", " parsing_instruction=ins,\n", " result_type=\"markdown\", # \"markdown\" and \"text\" are available\n", " verbose=True,\n", " language=\"en\", # Optionally you can define a language, default=en\n", " s3_image_saver=s3_image_saver\n", ")" ] }, { "cell_type": "code", "execution_count": 20, "metadata": {}, "outputs": [], "source": [ "parser_text = LlamaParseWithS3( \n", " api_key=os.getenv(\"LLAMA_PARSE_API_KEY\"), # can also be set in your env as LLAMA_CLOUD_API_KEY\n", " parsing_instruction=ins,\n", " result_type=\"text\", # \"markdown\" and \"text\" are available\n", " s3_image_saver=s3_image_saver)" ] }, { "cell_type": "code", "execution_count": 21, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "Parsing text...\n", "Started parsing the file under job_id c4ec882b-63f7-420d-934f-8884965d9442\n" ] } ], "source": [ "print(f\"Parsing text...\")\n", "docs_text = parser_text.load_data(\"./research/data/main.pdf\")" ] }, { "cell_type": "code", "execution_count": 22, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[Document(id_='c8d60e98-6816-49dc-a14d-2b0300bd892d', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text=' Heliyon 10 (2024) e35901\\n Heliyon\\n Contents lists available at ScienceDirect\\n Heliyon N\\n journal homepage: www.cell.com/heliyon\\n\\n Review article\\n\\n IL-22: A key inflammatory mediator as a biomarker and potential\\n therapeutic target for lung cancer\\n Ling Xu a,1, Peng Cao a,1, Jianpeng Wang b,1, Peng Zhang a, Shuhui Hu a,\\n Chao Chenga, Hua Wang c,*\\n a Department of Interventional Pulmonary Diseases, The Anhui Chest Hospital, Hefei, China\\n b First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China\\n c Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Inflammation and Immune Mediated Diseases Laboratory of\\n Anhui Province, Anhui Medical University, Hefei, China\\n\\n A R T I C L E I N F O A B S T R A C T\\n\\n Keywords: Lung cancer, one of the most prevalent cancers worldwide, stands as the primary cause of cancer-\\n IL-22 related deaths. As is well-known, the utmost crucial risk factor contributing to lung cancer is\\n Lung cancer smoking. In recent years, remarkable progress has been made in treating lung cancer, particularly\\n Biomarker non-small cell lung cancer (NSCLC). Nevertheless, the absence of effective and accurate bio-\\n Inflammation immunology markers for diagnosing and treating lung cancer remains a pressing issue. Interleukin 22 (IL-22) is\\n a member of the IL-10 cytokine family. It exerts biological functions (including induction of\\n proliferation and anti-apoptotic signaling pathways, enhancement of tissue regeneration and\\n immunity defense) by binding to heterodimeric receptors containing type 1 receptor chain (R1)\\n and type 2 receptor chain (R2). IL-22 has been identified as a pro-cancer factor since dysregu-\\n lation of the IL-22-IL-22R system has been implicated in the development of different cancers,\\n including lung, breast, gastric, pancreatic, and colon cancers. In this review, we discuss the dif-\\n ferential expression, regulatory role, and potential clinical significance of IL-22 in lung cancer,\\n while shedding light on innovative approaches for the future.\\n\\n 1. Introduction\\n\\n Lung cancer is a heterogeneous disease in which cells in the lung grow aberrantly culminating in the formation of tumors. Typically,\\n these tumors present as nodules or masses discernible through pulmonary imaging techniques [1]. In the year 2020, the global\\n incidence of lung cancer surpassed a staggering 2.2 million cases, leading to approximately 1.8 million tragic fatalities. When\\n considering age-standardized rates, the morbidity and mortality figures stand at 22.4 and 18.0 per 100,000 individuals respectively\\n [2]. Generally, lung cancer is considered to be intricately linked to a multitude of factors including but not limited to smoking, genetic\\n predisposition, occupational exposures, as well as the deleterious effects of air and environmental pollution [3,4]. Among the risk\\n factors for lung cancer, smoking dominates overwhelmingly, with about two-thirds of lung cancer deaths globally caused by it [5]. In\\n recent years, the drug resistance phenomenon of lung cancer to chemotherapy and targeted therapy has become more and more\\n prominent [6–8]. Therefore, it is of heightened importance to find new therapeutic targets.\\n\\n * Corresponding author. Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China.\\n E-mail address: wanghua@ahmu.edu.cn (H. Wang).\\n 1 These authors have contributed equally to this work and share first authorship.\\n\\nhttps://doi.org/10.1016/j.heliyon.2024.e35901\\nReceived 13 August 2023; Received in revised form 5 August 2024; Accepted 6 August 2024\\nAvailable online 10 August 2024\\n2405-8440/© 2024 The Authors. Published by Elsevier Ltd.\\n(http://creativecommons.org/licenses/by-nc-nd/4.0/).\\n\\n\\n\\nThis is an open access article under the CC BY-NC-ND license', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='a1aa8152-f68c-46c1-a059-bfb3c4cc767f', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='L. Xu et al. Heliyon 10 (2024) e35901\\n\\n IL-22 is an IL-10 family cytokine produced by T cells and innate lymphocytes. Like all other IL-10 family members, the IL-22\\nstructure contains six α-helices (termed helices A to F). They are arranged in an antiparallel conformation and produce a single\\nbundled protein [9]. IL-22 coordinates mucosal immune defense and tissue regeneration through pleiotropic effects including pro-\\nsurvival signaling, cell migration, dysplasia, and angiogenesis. These molecules act by targeting the heterodimeric transmembrane\\nreceptor complex composed of IL-22R1 and IL-10R2 and by activating subsequent signaling pathways (including JAK/STAT signaling\\npathway, p38 MAPK signaling pathway, and PI3K/AKT signaling pathway) [10]. It is well known that IL-22 is widely expressed in\\nhuman tissues and organs, including lung, liver, heart, kidney, pancreas, gastrointestinal tract, skin, blood, adipose, and synovial\\ntissues [11]. Meanwhile, IL-22 is also found to be broadly expressed in pathological states such as cancer, infectious diseases, tissue\\ninjury, chronic inflammatory diseases, and Graft-Versus-Host Disease [11–14]. In most cancer diseases, excessively elevated levels of\\nIL-22 are considered to be detrimental [15–19]. For instance, a recent study has demonstrated that IL-22 promotes extravasation of\\ntumor cells in liver metastasis [20]. Over the past few years, there has been a surge in research focusing on the relationship between\\nIL-22 and lung cancer. Particularly in patients with NSCLC, researchers have discovered up-regulated expression of IL-22 in serum,\\nmalignant pleural effusion, and tumor tissues, and the levels of IL-22Rα1 in tumor cells and tissues are also increased [21–24].\\n Although emerging studies have revealed that IL-22 is closely correlated with lung cancer in terms of tissue, cell and pathological\\nchanges, the specific function and mechanism remain to be explored. In the present review, we mainly summarized the regulatory\\nfunction and clinical role of IL-22 in lung cancer. In addition, the feasibility of IL-22 as a biomarker for lung cancer and directions for\\nfuture research were also discussed. It is reasonable to hypothesize that IL-22 may serve as a potential target in the treatment of lung\\ncancer.\\n\\n2. Overview of lung cancer\\n\\n Lung cancer is a malignant disease characterized by high morbidity and mortality [25]. According to the data of GLOBOCAN, lung\\ncancer is the second most common cancer in 2020 and the main cause of cancer death worldwide, with about one-tenth (11.4 %) of\\ncancer diagnoses and one-fifth (18.0 %) of deaths [5]. When it comes to gender, the incidence and mortality rates of lung cancer were\\non the rise in females but declining in males in most countries over the past decade [2]. The 5-year survival rate of lung cancer patients\\nvaries by 4–17 % in light of stage and region [26]. As predicted by the American Cancer Society, more than 120,000 people will die of\\nlung cancer in the United States in 2023. The good news is that although the incidence is stable or increasing, the overall mortality is\\ndecreasing at an accelerated pace [27]. From the perspective of histopathology and biological behavior, lung cancer can be divided\\ninto NSCLC and SCLC, among which the former mainly includes several common types such as adenocarcinoma, squamous cell\\ncarcinoma, and large cell carcinoma [25]. The pathogenesis of lung cancer primarily involves the following aspects: chromosome\\nchanges; abnormal immune response; abnormal activation of developmental pathways; dysregulation of tumor suppressor genes,\\nproto-oncogenes, and signaling pathways; and the up-regulation of receptor tyrosine kinases, growth factors, and cell markers. These\\nabnormal changes cause an imbalance between lung cell proliferation and apoptosis, which leads to lung cancer [28–31]. For example,\\nwhen exposed to risk factors continuously, the production of ROS, chemokines, and cytokines increases in lung cells, which leads to\\nDNA damage and gives rise to inflammation and other pathobiological changes that ultimately promote carcinogenesis. At the same\\ntime, the anti-tumor immune function of macrophages, T lymphocytes, B lymphocytes, and NK cells gets suppressed, failing recog-\\nnition and clearance of malignant cells, and eventually bringing about the formation of tumors [32]. In the early stage of the disease, it\\nis usually considered to be asymptomatic, while may manifest as cough, dyspnea, chest pain, hemoptysis, hoarseness, and so on in the\\nmiddle and advanced period [33]. In principle, the treatment of lung cancer depends largely on the type, stage and condition of the\\npatient’s disease. Currently, the main treatment approaches for lung cancer include surgery, chemotherapy, and radiotherapy. Among\\nthem, platinum-containing double drugs are preferred for chemotherapy. Radiation therapy is mainly applied in the control of the local\\nlesion. Furthermore, targeted therapy for EGFR, ALK, ROS1, and other gene mutations and immunotherapy to inhibit PD-1/PD-L1 also\\nplays an irreplaceable role as emerging breakthrough therapeutic means [25,34–39]. Compared with chemotherapy, targeted therapy\\ncan prominently enhance the survival rate and tolerance of patients with NSCLC [40,41]. The combination of chemotherapy and\\nimmunotherapy has also shown a more notable curative effect over chemotherapy alone [42,43]. Additionally, there has been a\\ngrowing body of research focusing on natural product therapy, local ablative therapy, and chimeric antigen receptor (CAR)-T-cell\\ntherapy lately [44–51]. In principle, the treatments of lung cancer are individualized depending largely on the type, stage, and\\ncondition of patients. Unfortunately, the limited sensitivity of NSCLC patients to chemotherapy and immunotherapy drugs has proven\\nto be a major obstacle to clinical treatment. Denk D et al. suggested that inflammation is ubiquitous in carcinogenesis. In his study, he\\nnoted that interfering with individual cytokines and their respective signaling pathways holds great promise for the development and\\nimprovement of current clinical cancer therapies [52]. IL-22 is a new type of cytokine discovered in 2000 and has gradually attracted\\nattention due to its role in tumor diseases. In recent years, multiple studies have reported the positive role of IL-22 in enhancing\\nchemotherapy resistance in human lung cancer patients. This positive effect is related to the function of IL-22 in promoting lung cancer\\ncell proliferation and inhibiting lung cancer cell apoptosis. Results showed that IL-22 activated the EGFR/AKT/ERK signaling pathway\\n[52], STAT3, and ERK1/2 signaling pathways [24] in drug-treated lung cancer cells, thereby attenuating the pro-apoptotic effect of the\\ndrug on lung cancer cells.\\n\\n3. Function role of IL-22 in lung cancer\\n\\n IL-22 is a cytokine first identified by Dumoutier et al. in IL-9-induced murine T cells over 20 years ago and was once called IL-10-\\nrelated T cell-derived inducible factor (IL-10-TIF) [53]. In human-beings, the IL-22 gene lies in chromosome 12q15, next to the gene\\n\\n 2', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='74f3d0c4-7a73-4ee9-aa2f-f89ecef46312', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='L. Xu et al. Heliyon 10 (2024) e35901\\n\\nthat encodes IFN-γ [54]. When the body is in homeostasis, the most important source of IL-22 is Group 3 innate lymphoid cells (ILC3)\\n[14]. Different from other common cytokines, IL-22 is generally thought to be produced only by hematopoietic origin immune cells,\\nwhereas it mainly acts on non-hematopoietic cells due to its receptor distribution [55]. Recently, researchers have found that\\nnon-hematopoietic cells represented by fibroblasts can also produce IL-22 under certain circumstances [11]. IL-22 is known to act by\\nbinding to its receptor (IL-22R), which is synthesized from the IL-22R1 and IL-10R2 subunits [56]. Thereinto, IL-22R1 expression is\\nthought to be restricted to epithelial cells in organs such as the lung, liver, intestine, and skin, while the latter is universally expressed\\n[11,57]. IL-22BP, also known as IL-22RA2, is a soluble IL-22 receptor that binds specifically to IL-22 and prevents it from binding to\\nIL-22R1. All currently known functions of IL-22BP are achieved by inhibiting IL-22 [58,59]. Broadly speaking, the primary function of\\nIL-22 in the body is to promote cell proliferation and tissue protection [60]. Sometimes, excessive activation of this function may lead\\nto pathological results. This dual effect is reflected in both inflammatory and tumor-related diseases. In the short term, the production\\nof IL-22 can play a protective role in anti-inflammatory and tumor prevention, while the uncontrolled generation of IL-22 may promote\\ninflammation and tumor formation [13,18]. The duality of IL-22 reveals that it could be a potential drug target, and the tight regu-\\nlation of IL-22 is crucial in the treatment of a variety of diseases. In Fig. 1, We summarize the role of IL-22 in lung cancer.\\n In general, the expression levels of IL-22 in vivo are regulated by a variety of cytokines and genes. For instance, IL-1β and IL-23 can\\ninduce the production of IL-22 independently, and the two act synergistically [11]. What’s more, Cornelia Voigt described a novel\\nmechanism whereby cancer cells promote tumor growth by releasing IL-1β to induce IL-22 production by memory CD4+ T cells [61].\\nAccording to an animal experiment, IL-1β can enhance the proliferation of epithelial cells and promote lung tumorigenesis [62]. IL-23\\nhas been proven to promote proliferation in NSCLC by Anne-Marie Baird et al. [63]. Although IL-23 is thought to be able to induce\\nmacrophages to produce IL-22, this study by Anne-Marie Baird et al. cannot directly prove whether the proliferation-promoting effect\\nof IL-23 on NSCLC cells is related to IL-23’s promotion of IL-22 production. related to ability. IL-23 is also thought to promote the\\nexpression of IL-26 by macrophages. Like IL-22, IL-26 is part of the IL-10 family. Researchers demonstrated for the first time that IL-26\\nis involved in the generation of malignant pleural effusions [64]. They reported that IL-26 promotes the generation of malignant\\npleural effusion by mediating the infiltration of CD4+IL-22+T cells in malignant pleural effusion and stimulating CD4+ IL-22+ T cells\\nto secrete IL-22. Recently, the Notch-AhR-IL-22 axis is thought to be involved in the pathogenesis of LUAD. It is corroborated that in\\nLUAD patients, elevated Notch1 facilitates IL-22 generation by CD4+ T cells via aryl hydrocarbon receptors (AhR) [65]. In NSCLC,\\nNotch signaling can both promote tumorigenesis and inhibit tumor progression, which mainly depends on its regulation of the\\n Class I: Proliferation, apoptosis, and invasion Class II: Regulating tumor microenvironment\\n Proliferation Lung cancer tissue\\n NK cells Lung \" epithelial cells\\n T cells Apoptosis\\n Lung cancer cells\\n C01se\\n Metastasis Lung cancercells Intiltrated immune cells\\n TNF-a Total WBC\\n CASPASE IL-la Macrophage\\n Multidrug IL-22 Ko Neutrophil\\n Cnchonk C resistance IL-6 Lymphocyte\\n Class III: Angiogenesis Class IV: Cancer stem cell\\n IL-22\\n oxygen- and STAT3 signaling pathway\\n Lung cancer tissue nutrient supplyby perfusion\\n Aangiogenic Oct4\\n switch Sox2\\n IL-22 Nanog\\n MUN\\n Vascular endothelial cell Cancer stem cells Lung cancer cells\\nFig. 1. IL-22 plays four main functions during the progression of lung cancer. 1) Promote lung cancer cell proliferation and invasion, and inhibit\\nlung cancer cell apoptosis; 2) Regulate the abundance of immune cells in lung cancer tissues and activate the inflammatory microenvironment; 3)\\nPromote cancer angiogenesis; 4) Activate lung cancer stem cells.\\n\\n 3', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='9f128569-a8cf-455b-ab48-deacb4f6fb42', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='L. Xu et al. Heliyon 10 (2024) e35901\\n\\ntransformation between neuroendocrine and non-neuroendocrine. For patients with SCLC containing Notch active tumor cells, the\\napplication of Notch inhibitors may be an effective treatment [66]. Moreover, the expression of IL-22 is also regulated by miR-26. In\\ncutaneous T-cell lymphoma (CTCL) cells, transfection of miR-26 resulted in a remarkable decrease in the expression levels of IL-22 and\\nIL-22 mRNA [67]. In human NSCLC, Yi He et al. found that the expression levels of miR-26 were lower in tumor tissues compared to\\nparacancerous tissue. As a functional miRNA, miR-26 was further proved by the team to inhibit autophagy and induce apoptosis of\\nNSCLC cells both in vitro and in vivo [68]. On the other hand, IL-22 has also been shown to regulate other cytokines. Studies have\\nshown that the production of IL-22 generally reduces Th1-type immune responses. This action may be coordinated with the protective\\neffect of IL-22R-expressing tissue cells to reduce collateral damage in the context of infection and inflammation [69]. Besides, animal\\nexperiments have indicated that IL-22 can also promote B-cell responses by inducing CXCL13 in tertiary lymphoid follicles [70,71]. In\\nthe latest murine lung cancer model, IL-22 was discovered to induce NK cells to overexpress CD155, thus mediating the immune\\nevasion of tumor cells [72]. As a transmembrane adhesive molecule, CD155 has been proven to inhibit T and NK cell-mediated\\nanti-tumor immune responses, thereby promoting tumor progression (Fig. 2) [73–75].\\n In the occurrence and development of pulmonary diseases, IL-22 is considered to play an important role. As previously demon-\\nstrated in an epicutaneously sensitized mice experiment, IL-22 promotes the development of neutrophil and eosinophile-mediated\\nairway inflammation and airway hyperresponsiveness stimulated by intranasal antigens [76]. The conclusion implies that blocking\\nIL-22 may be helpful for the treatment of bronchial asthma. When it comes to chronic obstructive pulmonary disease (COPD), the\\nexpression levels of both IL-22 and its receptor in COPD patients were higher than those of healthy controls. This result was confirmed\\nin mice with experimental COPD induced by cigarette smoke. What’s more, researchers also found that cigarette smoke-induced\\ninappropriate activation of pulmonary neutrophils decreased in IL-22-deficient mice with COPD. This suggests that IL-22 may be\\ninvolved in the pathogenesis of COPD. The research further manifested that IL-22 promotes cigarette smoke-induced airway\\nremodeling, pulmonary neutrophil inflammation, and the impairment of pulmonary function, and is involved in the pathogenesis of\\nCOPD [77]. While in pulmonary infectious diseases such as pneumonia, tuberculosis, and pulmonary mycosis, it is thought that IL-22\\nappears to take a protective and preventive part [78–83]. For good measure, in the bleomycin-induced pulmonary fibrosis model, the\\ndegree of pulmonary fibrosis in IL-22 knockout mice was aggravated, and injection of recombinant IL-22 alleviated the severe fibrosis\\nin IL-22 knockout mice. This latest research has suggested the potential antifibrotic effect of IL-22 [84].\\n In recent years, differential expression of IL-22 has also been discovered in various specimens of lung cancer (Table 1). In the first\\nplace, the mean levels of IL-22 in the plasma of NSCLC patients were significantly higher than that of the reference cohort [21,85]. The\\nplasma levels of IL-22 were observed to elevate along with the increase in lung cancer staging [85]. In addition, Immunohistochemistry\\nanalysis showed that IL-22 expression was up-regulated in NSCLC tumor specimens in comparison to that in the adjacent tissues.\\nRT-qPCR analysis also revealed similar differences in IL-22 mRNA expression between lung cancer tissues and normal tissues [24,86].\\nInterestingly, Yi Bi et al. compared IL-22 levels between tissues and serum of patients with primary NSCLC and their paired recurrent\\nlung cancer specimens and the expression levels of IL-22 were found to be obviously up-regulated in the latter group [23]. Apart from\\nthis, IL-22 expression was also detected in bronchoalveolar lavage fluid (BALF). As reported by an article in 2016, IL-22 levels were\\n CD155\\n NK Cell L\\n T Cell\\n 1\\n IL-22 Impaired f funcion CD226 1\\n Lung metastases\\n Immune evasion oflung cancer cells\\nFig. 2. IL-22 induces NK cells to overexpress CD155, which binds to NK cell activation receptor CD226. Over-activation leads to a decrease in the\\namount of CD226 and impaired NK cell function, thereby mediating tumor cell immune escape.\\n\\n 4', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='d0dae582-f72f-4259-b6ed-725f9fd7faaf', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='L. Xu et al. Heliyon 10 (2024) e35901\\n\\nTable 1\\nDifferential expression of IL-22/IL-22 mRNA/IL-22R1 mRNA in various samples in lung cancer. +: Up-regulated.\\n Molecule Samples Expression P value Ref. (PMID)\\n IL-22 Plasma þ 0.0013 24956177\\n IL-22 mRNA Tissues þ 0.0313 18927282\\n IL-22 Pleural effusion þ 0.0051 18927282\\n IL-22 mRNA, IL-22 Tissues, serum þ <0.01 26983629\\n IL-22R1 mRNA Tissues þ <0.05 26983629\\n IL-22 BALF þ <0.001 27388918\\n\\nsignificantly higher in BALF from lung cancer patients compared with control group. The researchers expanded the cohort to patients\\nwith lung metastases from other malignancies and found that IL-22 concentrations remained higher than controls [87]. These results\\nimplied that IL-22 in BALF may be a biomarker for lung cancer. Over and above, researchers also found the trace of IL-22 in pleural\\neffusion [88,89]. One study has revealed that IL-22 levels were higher in malignant pleural effusion as against tuberculous pleural\\neffusion [24]. These differential expressions prompt that IL-22 may participate in the occurrence and development of lung cancer\\n(Table 2).\\n The link between inflammatory processes and cancer has long been recognized [90]. Related studies hint that inflammatory re-\\nsponses play a vital role in different phases of tumor occurrence, development, and metastasis [91–93]. The function of IL-22 in cancer\\nis extremely complicated. Initially, IL-22 may prevent tumorigenesis by reducing chronic inflammation, promoting barrier function,\\nand inducing tissue regeneration. On the contrary, if IL-22 is excessively expressed under persistent chronic inflammation, then\\nmalignant cells may utilize this signal to facilitate its progression [11]. In the lung tumor microenvironment, uncontrolled expression\\nof IL-22 can amplify inflammation by inducing various inflammatory mediators alone or in concert with other cytokines [94]. As\\nillustrated by a cellular experiment, IL-22 could promote the proliferation of A549 and H125 cells belonging to the NSCLC cell lines,\\nthereby enhancing the ability of tumor cell migration and invasion [23]. An in vitro experiment in 2018 has confirmed that IL-22 can\\ndirectly act on endothelial cells to stimulate tumor angiogenesis [95]. To some extent, this enhances the ability of tumor cells to absorb\\nnutrients and distant metastasis. From another perspective, this provides new ideas for anti-angiogenic therapy of tumors. Nasim\\nKhosravi suggested that IL-22 promotes tumor progression by inducing a pro-tumor immune response and protective stem cell\\nproperties of tumor cells [94]. It is also reported that after 12h of serum starvation, the proportion of apoptotic lung cancer cells\\ntransfected with the IL-22 gene was significantly lower than that of control lung cancer cells. In addition, the apoptosis-inducing and\\nanti-proliferative effects of chemotherapeutic drugs on lung cancer cells were inhibited in IL-22 transgenic cell lines [24]. Simulta-\\nneously, the apoptosis of lung cancer cells induced by gefitinib was also significantly reduced 48 h after IL-22 exposure [96]. On the\\ncontrary, exposure to IL-22R1 blocking antibodies or in vitro transfection of IL-22-RNA interference plasmid leads to apoptosis of lung\\ncancer cells [24]. Zhiliang Huang et al. found that the apoptosis rate of paclitaxel-treated lung cancer cells in the IL-22 siRNA\\ntransfection group was significantly increased compared with the control group [22]. Apart from this, IL-22 antibody treated mice and\\nIL-22-deficient mice were found to be protected from the formation of pulmonary metastases caused by colon cancer, while IL-22\\noverexpression promoted metastases [20]. In short, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of\\nlung cancer cells by anti-tumor drugs but also promotes the proliferation and migration of lung cancer cells, the growth of tumor\\ntissues, and the generation of lung metastatic cancer.\\n\\n4. Regulatory role of IL-22 in lung cancer\\n\\n Numerous signaling pathways are involved in the regulation of IL-22 in lung cancer, including PI3K/AKT, JAK-STAT3, p38 MAPK\\nsignaling pathways, and so on. In the following, we will elaborate on the regulatory role of IL-22 in lung cancer from the point of view\\nof each major signaling pathway (Fig. 3).\\n\\nTable 2\\nPotential clinical role of IL-22, its receptors and producing cells in lung cancer.\\n Sample Clinical function Conclusion Ref. (PMID)\\n sources\\n Patients Diagnosis IL-22 levels were significantly higher in lung cancer patients than control group. 24956177,\\n 27388918\\n Patients Prognosis IL-22R1 levels were associated with poorer prognosis. 26846835\\n assessment\\n Patients Disease assessment The levels of IL-22-producing Th22 cells were positively correlated with TNM stage and lymph node 35669104\\n metastasis.\\n Patients Efficacy prediction IL-22 expression levels were associated with EGFR-TKI efficacy. 31750252\\n Mice model Treatment IL-22-deficient mice had a lower metastatic load of lung cancer. 36630913\\n Mice model Treatment Gene ablation of IL-22 resulted in a marked reduction in the number and size of lung tumors. 29764837\\n\\n 5', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='134756a4-8f84-402d-b808-dcaba6dac5b7', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='L. Xu et al. Heliyon 10 (2024) e35901\\n\\n4.1. PI3K/Akt signaling pathway\\n\\n PI3K/AKT signaling pathway is one of the core intracellular signaling pathways, which plays a critical role in regulating cell\\ngrowth, survival, metabolism, movement, and proliferation [97]. As a downstream effector of receptor tyrosine kinases (RTKs) and\\nG-protein-coupled receptors (GPCRs), PI3K is a group of lipid kinases consisting of three subunits. It can be divided into three cate-\\ngories according to various functions and structures. Thereinto Class IA PI3K is a heterodimer of the p110 catalytic subunit and the p58\\nregulatory subunit, and it is primarily related to human tumors [98,99]. As we all know, PI3K can catalyze phosphatidylinositol [4,\\n5]-bisphosphate (PIP2) to phosphatidylinositol [3–5]-trisphosphate (PIP3). Serine/threonine protein kinase (AKT), as the main\\ndownstream molecule of the PI3K signaling pathway, is mainly activated by PIP3-driven plasma membrane recruitment and phos-\\nphorylation. The mammalian target of rapamycin (mTOR), a major downstream signaling molecule in the PIK3/AKT signaling\\npathway, is considered to be a modified protein kinase in the form of mTORC1 and mTORC2. The first is mainly activated by the\\nPI3K/AKT signaling pathway, and mTORC2 further activates AKT by directly phosphorylating its hydrophobic motif (Ser473) [100].\\nPI3K/Akt signaling pathway is considered to be the chief regulatory factor of idiopathic pulmonary fibrosis (IPF), it may directly\\nparticipate in the formation of IPF or promote the occurrence and development of fibrosis in collaboration with other pathways [97].\\nSeveral studies have declared that certain natural products like resveratrol and Danhong injection can provide neuroprotective effects\\nby activating the PI3K/AKT/mTOR signaling pathway [101,102]. Furthermore, the relationship between the PI3K/AKT/mTOR\\nsignaling pathway and cancer has been most intensively studied. Activation of the PI3K/AKT/mTOR signaling pathway is believed to\\npromote the occurrence, proliferation, and progression of a variety of cancers, including breast cancer, ovarian cancer, prostate cancer,\\netc. [99,100,103]. In addition, it is also an important cause of tumor drug resistance [104]. In NSCLC, KRAS, EGFR, and PTEN mu-\\ntations are believed to activate the PI3K/Akt/mTOR signaling pathway [105]. As demonstrated in a previous article, upregulation of\\nthe PI3K signaling pathway was identified as an early and reversible event in the pathogenesis of NSCLC [106]. One experiment has\\nconfirmed that the PI3K/AKT signaling pathway promotes the proliferation of LUAD cells mainly through anti-apoptosis [107].\\nAdditionally, as revealed in a cellular study, IL-22 produced by CAFs markedly improves the proliferation and invasion of lung cancer\\ncell, and lessens apoptosis by activating the PI3K/Akt/mTOR signaling pathway [86]. For good measure, it has been found that AKT\\nphosphorylation in NSCLC cells is facilitated by different concentrations of IL-22 in a time- and dose-dependent way [23]. Collectively,\\nthe PI3K/Akt/mTOR signaling pathway plays a significant role in the relationship between IL-22 and lung cancer. It is worth\\nmentioning that IL-22 does not seem to always activate the PI3K/Akt/mTOR signaling pathway. Meng Yuxia et al. found that IL-22\\ninhibits the activity of the PI3K/AKT/mTOR signaling pathway in mouse liver fibrosis tissue [108]. This opposite finding may be\\nrelated to the dual function of IL-22. Further study on the impact of IL-22 on the PI3K/AKT/mTOR signaling pathway in different\\ndisease processes will help us better understand the specific mechanism of IL-22’s function in the human body. This will facilitate\\n IL 22\\n PI3K JAK\\n P38 MAPK\\n NK ccll\\n AKT STAT3\\n mTOR\\n Antitumor drugs Gene expression\\n Metastasis\\n Nucleus\\n Apoptosis Proliferation EMT Invasion\\n Lung tumor ccll\\nFig. 3. IL-22 promotes the proliferation, migration and epithelial-mesenchymal transition of lung cancer cells through PI3K/AKT, JAK-STAT3, p38\\nMAPK and other signaling pathways, and antagonizes the apoptosis of lung cancer cells induced by anti-tumor drugs.\\n\\n 6', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='9abea758-db62-49e8-a07e-4f2d62426c47', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='L. Xu et al. Heliyon 10 (2024) e35901\\n\\nIL-22-related clinical drug development.\\n\\n4.2. JAK/STAT signaling pathway\\n\\n The JAK/STAT signaling pathway is also an important communication center for cell function, and aberrant alterations in its\\ncomponents are associated with numerous human diseases. JAK/STAT is an evolutionarily conserved signaling pathway consisting of\\nJAKs, STATs, and ligand-receptor complexes. There are four major members of the JAK family, all of which are composed of non-\\nreceptor tyrosine protein kinases. The STAT family contains six members which consist of 750–900 amino acids. The JAK/STAT\\nsignaling pathway is mainly thought to mediate inflammation, apoptosis, hematopoiesis, tissue repair, immune regulation, and adi-\\npogenesis [109]. In autoimmune diseases such as rheumatoid arthritis (RA), activation of the JAK-STAT signaling pathway leads to the\\nprogression of joint injury through overexpression of the matrix metalloproteinase gene, apoptosis of chondrocytes, and apoptotic\\nresistance in synovial tissue [110,111]. In addition, in a 2020 study by Meyer LK, the inhibition of the JAK-STAT signaling pathway\\nwas found to sensitize CD8+ T cells to dexamethasone-induced excessive inflammatory cell apoptosis [112]. Song et al. have long\\ndiscovered that the lifespan of NSCLC cells was notably reduced after inhibiting STAT3 [113]. In a murine lung model, overexpression\\nof STAT3 in alveolar type II cells led to severe lung inflammation and eventually to the formation of LUAD [114]. Further, down-\\nregulation of STAT3 was found to result in enhanced NK cell immunity in both human and murine NSCLC cells, which suggests that\\nSTAT3 plays an inhibitory role against tumor NK cell immunity [115,116]. A study last year disclosed that IL-22 triggers JAK-STAT3\\npathway phosphorylation in NSCLC cells in a time- and dose-dependent manner, thus promoting the proliferation and metastasis of\\ntumor cells [23,96]. Another study demonstrated that the overexpression of IL-22 protected lung cancer cells against apoptosis induced\\nby serum starvation and chemotherapy drugs by activating STAT3 and its downstream anti-apoptotic proteins [24].\\n\\n4.3. p38 MAPK signaling pathway\\n\\n The p38 mitogen-activated protein kinases (MAPK) signaling pathway takes a crucial role in signaling cascades induced by various\\ncellular stimuli. There are four p38 kinase members in the mammalian mitogen-activated protein (MAP) family, which play\\nmomentous roles in extracellular stimulation-mediated proliferation, inflammation, differentiation, apoptosis, senescence, and\\ntumorigenesis [117]. In the classical pathway, the p38 MAPK signaling pathway is activated by cascade phosphorylation [118]. In a\\nhepatitis C virus (HCV) experiment, researchers demonstrated that virus-induced activation of the p38 MAPK signaling pathway\\npromotes viral infection, and blocking activation of this pathway may be an antiviral approach [117]. According to Dan He in 2020,\\nmTORC1 drives intestinal stem cell aging via the p38 MAPK-p53 signaling pathway [119]. The p38 MAPK signaling pathway has long\\nbeen demonstrated to exhibit a major oncogenic role in LUAD [120–122]. Yinan Guo et al. found evidence that the p38 MAPK signaling\\npathway can promote EMT and metastasis of NSCLC both in vitro and in vivo [123]. In addition, a study published in 2017 proposed\\nthat the p38 MAPK signaling pathway activates stem cell properties of LUAD cells by regulating GLI1 [124]. What’s more, in lung\\ncancer models, researchers found that the p38 MAPK signaling pathway inhibited the stem cell properties of lung CSCs and promoted\\ntheir proliferation and differentiation, thereby leading to tumorigenesis. More importantly, they also elucidated that the p38 MAPK\\nand PI3K/AKT signaling pathways have unique and synergistic roles in regulating lung CSCs self-renewal as carcinogenic and/or stem\\ncell signaling pathways [107]. This provides a new idea for the stem cell-based treatment of lung cancer. In NSCLC, IL-22 in vivo and in\\nvitro were both verified to activate the p38 MAPK signaling pathway. The collected evidence from this study confirmed the negative\\nimmunomodulatory role of IL-22 in the disease [96].\\n\\n5. Clinical role of IL-22 in lung cancer\\n\\n Currently, there is still a lack of efficient biomarkers for the diagnosis and treatment of lung cancer. In recent years, the value of the\\ninterleukin family as biomarkers and therapeutic targets of lung cancer has been deeply investigated [125–132]. Of these, IL-1 and IL-6\\nhave been studied most extensively in lung cancer. Bo Yuan’s findings in mice experiments supported IL-1β as a potential target for the\\nprevention and treatment of LUAD patients with Kras mutations [129]. In a clinical trial of the anti-IL-1β antibody canakinumab,\\nresearchers found that 300 mg canakinumab significantly reduced lung cancer mortality compared with the control group (HR 0.49\\n[95%CI 0.31–0.75]; p = 0.0009) [133]. In plasma samples or tumor tissues from NSCLC, researchers revealed that patients with lower\\nbaseline IL-6 concentrations benefited more from immunotherapy. The study elucidated the role of IL-6 in predicting the efficacy of\\nimmunotherapy in patients with NSCLC [128]. Furthermore, in one lung cancer study, the survival hazard ratio before and after\\nchemotherapy for high versus low IL-6 levels was 1.25 (95%CI 0.73–2.13) and 3.66 (95%CI 2.18–6.15), respectively. It is suggested\\nthat IL-6 maybe a prognostic indicator of survival in patients with advanced NSCLC receiving chemotherapy [127]. Some scholars have\\nalso described the potential value of IL-11 as a biomarker for the diagnosis and prognosis of NSCLC [125]. In addition, another research\\nhas shown that changes in serum IL-8 levels in NSCLC patients could reflect and predict the response to immunotherapy [130].\\nKaplan-Meier survival analysis showed that the overall survival outcome of NSCLC patients with high IL-22R1 expression was\\nsignificantly lower than that of patients with low IL-22R1 expression (p = 0.022). Multivariate regression analysis also confirmed an\\nassociation between IL-22R1 levels and poorer outcomes (HR 1.5, 95%CI 1.2–1.9; p = 0.0011). This suggested that high expression of\\nIL-22R1 is an independent factor for low overall survival in NSCLC [134]. What’s more, the levels of IL-22-producing Th22 cells in\\nperipheral blood were positively correlated with TNM stage, lymph node metastasis, and clinical tumor markers of lung cancer (p <\\n0.01) [96]. The above indicates the significance of IL-22 as a biomarker in the diagnosis and disease assessment of lung cancer. Apart\\nfrom this, Renhua Guo’s team found that the expression of IL-22 in the EGFR-TKI resistant group was higher than that in sensitive\\n\\n 7', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='c161be57-784a-4dbc-b9c8-84f21b1867a2', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='L. Xu et al. Heliyon 10 (2024) e35901\\n\\ngroup in NSCLC, and the expression level was correlated with the efficacy of EGFR-TKI in plasma [135]. Therefore, it is reasonable to\\nsuspect that IL-22 may be a new biomarker to overcome EGFR-TKI resistance in NSCLC. In terms of animal models, some investigators\\nimplanted Line-1 lung cancer cells into wild-type and IL-22-deficient mice simultaneously, and found reduced intrapulmonary\\nmetastasis in the latter group, which is independent of primary tumor size. Besides, they performed forced metastasis by intravenous\\ninjection of lung cancer cells, and the results further confirmed the lower metastatic load in mice with IL-22 deletion [72]. In another\\nmodel of Kras-mutated lung cancer in mice, gene ablation of IL-22 resulted in a marked reduction in tumor number and size. The\\nauthors also analyzed the association between IL-22R1 expression and survival in patients with KRAS mutant lung adenocarcinoma,\\nthe results showed that high expression of IL-22R1 was an independent indicator of poorer relapse-free survival [94]. Taken together,\\nthese pieces of evidence highlight the potential clinical role of IL-22, IL-22R, and IL-22-producing cells in the treatment of lung cancer\\n(Table 2).\\n\\n6. Future perspectives\\n\\n6.1. CRISPR-Cas13a technical\\n\\n At present, mounting clinical trials based on IL-22 are being carried out in full swing worldwide, mainly involving ulcerative colitis,\\nalcoholic cirrhosis, GVHD, and psoriasis [12,14,54,60]. However, there are presently no clinical trials based on IL-22 in lung cancer. As\\ndescribed previously, reduced intrapulmonary metastasis was found in IL-22-deficient mice as well as in IL-22-suppressed NSCLC cells\\n[20,72]. In addition, blocking IL-22R1 or knockout of the IL-22 gene both retarded the progression of lung cancer [24,94]. These\\nfindings provide a new train of thought for the down-regulation of IL-22 in treating lung cancer.\\n In recent years, the research on gene editing treatment for various diseases has become more and more popular [136–138].\\nCRISPR-Cas13a is an effective tool for knocking out specific RNA sequences, it has been shown to induce the death of glioma cells that\\noverexpress EGFR, which is one of the subtypes of EGFR mutation in glioma. Apart from this, the CRISPR-Cas13a gene-editing system\\ncan also inhibit the formation of intracranial tumors in mice with glioma [139]. In a collagen-induced mouse model, injection of\\ngene-edited human amniotic mesenchymal stem cells that overexpressed IL-10 increased proteoglycan expression in joint tissue and\\nreduced the inflammatory response and production of various inflammatory cytokines [137]. In the world’s first human phase I clinical\\ntrial utilizing CRISPR-Cas9 in the treatment of advanced NSCLC, researchers have demonstrated the feasibility and safety of\\ngene-edited T-cell therapy targeting the PD-1 gene [140]. Thus, genome editing strategies have the potential to treat lung cancer by\\naltering IL-22 expression levels. In the future, the role of pulmonary precision delivery based on CRISPR-Cas13 gene-editing com-\\nponents targeting the IL-22 mRNA in lung cancer therapy should not be ignored. CRISPR-Cas13 is expected to be further integrated\\n IL-22 mRNA\\n Cas13a\\n Crispr-Cas13a\\n Combined With\\n Flgure\\n Single-base edition Single-cell sequencing\\n Lung cancer\\nFig. 4. Crispr-cas13-based IL-22 mRNA editing can be utilized for lung cancer therapy by combining with emerging technologies such as single-base\\nediting and single-cell sequencing.\\n\\n 8', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='ee77ff29-ad76-4fe4-ad6c-b789e7581a4f', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='L. Xu et al. Heliyon 10 (2024) e35901\\n\\nwith the latest technologies such as single-base editing and single-cell sequencing to promote the treatment of lung cancer to a new\\nlevel (Fig. 4).\\n\\n6.2. Small interfering RNA\\n\\n Small interfering RNA (siRNA) is a double-stranded RNA molecule composed of 21–23 nucleotides. In cells, siRNA forms functional\\ncomplexes by binding to the RNA-induced silencing complex (RISC). RISC in the functional complex specifically recognizes and binds\\nto the target mRNA, leading to degradation of the target mRNA and thereby silencing the expression of the target gene. Compared with\\ntraditional therapies such as small molecules and protein drugs, siRNA technology has many advantages: 1) siRNA is highly specific.\\nsiRNA can only silence homologous genes, while unrelated genes are not affected. 2) siRNA can silence genes by using RISC. 3) siRNA\\ncan be designed to target different genes through sequence design, and can even target targets that were previously considered\\n“undruggable”. 4) siRNA does not activate the innate immune system. Twenty years after the discovery of the RNA interference\\nmechanism, the first siRNA drugs (including Patisiran, Givosiran, Lumasiran, Inclisiran, Vutrisiran) were approved for clinical use by\\nthe U.S. Food and Drug Administration (FDA) and the European Medicines Agency from 2018 to 2022 [141,142]. NFKBIZ is an up-\\nstream target of IL-23, IL-36 and IL-17A. In the study of Mandal A et al. [143], NFKBIZ-siRNA significantly reduces the mRNA levels of\\nmultiple pro-inflammatory cytokines, including IL-17, IL-19, IL-22, etc., in the skin tissue of psoriasis mice, thereby alleviating the\\ncondition of the mice. The safety evaluation results of NFKBIZ-siRNA preparations show that NFKBIZ-siRNA preparations can complex\\nwith nucleic acids without affecting biological activity and show no toxicity. TGF-β is a pleiotropic regulatory cytokine that can\\nregulate a variety of ILs including IL-22 and IL-17 to affect the composition of the tumor microenvironment [144]. Currently, Sir-\\nnaomics has developed an siRNA drug that targets TGF-β (called STP705). Recently, the drug has completed phase II clinical trials in\\nthe United States and achieved positive results. The role of ILs in cancer has been extensively studied. In recent years, the positive role\\nof IL-22 in lung cancer has received attention. The researchers believe that knocking down IL-22mRNA levels in the lesions of lung\\ncancer patients will help prolong the survival of lung cancer patients and improve the cure rate of lung cancer patients. For example,\\nZhang Wei et al. found that IL-22-siRNA slowed tumor growth in NSCLC model mice. In addition, they reported that the therapeutic\\neffect of IL-22-siRNA combined with chemotherapy drugs (5-FU and carboplatin) on NSCLC mice was better than that of chemotherapy\\ndrugs alone [24]. In an in vitro assay [145], cell line PC9 cells (NSCLC) transfected with PDLIM5-siRNA targeting the PDLIM5 gene had\\nreduced growth viability and exhibited higher apoptotic rates. In the chemotherapy drug gefitinib-resistant cell line PC9 cells,\\nPDLIM5-siRNA still showed significant anti-tumor effects. These results indicate that siRNA-based therapy has good application in the\\nclinical treatment of NSCLC, especially in drug-resistant patients. Based on these findings, we believe that the development of\\nIL-22-siRNA drugs for lung cancer treatment has clinical potential and theoretical basis.\\n\\n6.3. Nanoparticle drug delivery systems\\n\\n On the other hand, given the toxicity and erratic efficacy of current anti-tumor drugs, research on novel drug carriers in lung cancer\\n IL-22-related drug\\n Au Targeting agent\\n Different types of nanomaterials\\n Lung precisiondelivery\\n Lung Cancer\\n Fig. 5. Precision delivery of various nanomaterials containing IL-22 related drugs for the treatment of lung cancer.\\n\\n 9', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='265f246d-fea9-430c-b000-ee216c106adf', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='L. Xu et al. Heliyon 10 (2024) e35901\\n\\nis also of vital significance. Nanoparticles containing targeted drugs can be delivered to the intended site using carriers with affinity for\\nvarious specific tissues or lesions [146,147]. In an in vivo mice lung model, combined delivery of sorafenib and crizotinib by polymer\\nnanoparticles significantly reduced tumor progression and toxic side effects, and improved survival rate [148]. Moreover, Maofan\\nZhang demonstrated that the efficacy of dual-drug-loaded polymeric nanoparticles with etoposide and cisplatin was significantly\\nsuperior to conventional chemotherapy modality without causing additional toxicity [149]. These imply that nanomaterials loaded\\nwith IL-22-related drugs may also have more unique advantages. Therefore, the utilization of novel nanomaterials loaded with IL-22\\nantibodies and IL-22 inhibitors like IL-22BP for targeted therapy of lung tumors is also a promising research direction (Fig. 5).\\n\\n7. Conclusion\\n\\n In this review, we provided a comprehensive analysis of the role of IL-22 in the immune microenvironment and its involvement in\\nmajor signaling pathways in the context of lung cancer. Put in a nutshell, IL-22 not only antagonizes the induction of apoptosis and cell\\ncycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and metastasis of lung cancer cells and the\\ngrowth of tumor tissues. Additionally, the potential clinical significance of IL-22 in the diagnosis, treatment, and prognosis evaluation\\nof lung cancer was further confirmed. Next, the prospects of IL-22 in combination with gene editing and novel nanomaterials in the\\ntreatment of lung cancer have been discussed. With the general increase in drug resistance to chemotherapy, targeted therapy, and\\nimmunotherapy in lung cancer, it is also necessary to study in depth to discover the correlation between IL-22 and the mechanism of\\ndrug resistance. To sum up, the potential of IL-22 as a biomarker for lung cancer still remains to be explored. Further research on the\\nmolecular, physiological effects and mechanism of IL-22 in lung cancer as well as the conduction of standardized clinical trials are\\nexpected to inject fresh blood into the diagnosis and treatment of lung cancer.\\n\\nFinancial support\\n\\n None.\\n\\nData availability statement\\n\\n Not applicable.\\n\\nCRediT authorship contribution statement\\n\\n Ling Xu: Writing – original draft. Peng Cao: Visualization. Jianpeng Wang: Writing – review & editing. Peng Zhang: Validation.\\nShuhui Hu: Validation. Chao Cheng: Writing – review & editing. Hua Wang: Writing – review & editing, Supervision,\\nConceptualization.\\n\\nDeclaration of competing interest\\n\\n The authors declare that they have no known competing financial interests or personal relationships that could have appeared to\\ninfluence the work reported in this paper.\\n\\nAcknowledgements\\n\\n None.\\n\\nAbbreviations\\n\\nnon-small cell lung cancer NSCLC\\nInterleukin-22 IL-22\\nchimeric antigen receptor CAR\\nIL-10-related T cell-derived inducible factor IL-10-TIF\\nGroup 3 innate lymphoid cells ILC3\\nIL -22 receptor IL-22R\\naryl hydrocarbon receptors AhR\\nchronic obstructive pulmonary disease COPD\\ncutaneous T-cell lymphoma CTCL\\nbronchoalveolar lavage fluid BALF\\nreceptor tyrosine kinases RTKs\\nG-protein-coupled receptors GPCRs\\nMammalian target of rapamycin mTOR\\nidiopathic pulmonary fibrosis IPF\\nrheumatoid arthritis RA\\n\\n 10', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='e92166e7-bb08-494b-9cfc-b75262a72cbb', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='L. 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Au, et al., Co-delivery of etoposide and cisplatin in dual-drug loaded nanoparticles synergistically\\n improves chemoradiotherapy in non-small cell lung cancer models, Acta Biomater. 124 (2021) 327–335.\\n\\n 14', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n')]" ] }, "execution_count": 22, "metadata": {}, "output_type": "execute_result" } ], "source": [ "docs_text" ] }, { "cell_type": "code", "execution_count": 6, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "Parsing slide deck...\n", "Started parsing the file under job_id fff0eaa9-d44a-4c46-9011-32be250821b1\n" ] } ], "source": [ "print(f\"Parsing slide deck...\")\n", "md_json_objs = s3_parser.get_json_result(\"./research/data/main.pdf\")" ] }, { "cell_type": "code", "execution_count": 7, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[{'page': 1,\n", " 'text': ' Heliyon 10 (2024) e35901\\n Heliyon\\n Contents lists available at ScienceDirect\\n Heliyon N\\n journal homepage: www.cell.com/heliyon\\n\\n Review article\\n\\n IL-22: A key inflammatory mediator as a biomarker and potential\\n therapeutic target for lung cancer\\n Ling Xu a,1, Peng Cao a,1, Jianpeng Wang b,1, Peng Zhang a, Shuhui Hu a,\\n Chao Chenga, Hua Wang c,*\\n a Department of Interventional Pulmonary Diseases, The Anhui Chest Hospital, Hefei, China\\n b First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China\\n c Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Inflammation and Immune Mediated Diseases Laboratory of\\n Anhui Province, Anhui Medical University, Hefei, China\\n\\n A R T I C L E I N F O A B S T R A C T\\n\\n Keywords: Lung cancer, one of the most prevalent cancers worldwide, stands as the primary cause of cancer-\\n IL-22 related deaths. As is well-known, the utmost crucial risk factor contributing to lung cancer is\\n Lung cancer smoking. In recent years, remarkable progress has been made in treating lung cancer, particularly\\n Biomarker non-small cell lung cancer (NSCLC). Nevertheless, the absence of effective and accurate bio-\\n Inflammation immunology markers for diagnosing and treating lung cancer remains a pressing issue. Interleukin 22 (IL-22) is\\n a member of the IL-10 cytokine family. It exerts biological functions (including induction of\\n proliferation and anti-apoptotic signaling pathways, enhancement of tissue regeneration and\\n immunity defense) by binding to heterodimeric receptors containing type 1 receptor chain (R1)\\n and type 2 receptor chain (R2). IL-22 has been identified as a pro-cancer factor since dysregu-\\n lation of the IL-22-IL-22R system has been implicated in the development of different cancers,\\n including lung, breast, gastric, pancreatic, and colon cancers. In this review, we discuss the dif-\\n ferential expression, regulatory role, and potential clinical significance of IL-22 in lung cancer,\\n while shedding light on innovative approaches for the future.\\n\\n 1. Introduction\\n\\n Lung cancer is a heterogeneous disease in which cells in the lung grow aberrantly culminating in the formation of tumors. Typically,\\n these tumors present as nodules or masses discernible through pulmonary imaging techniques [1]. In the year 2020, the global\\n incidence of lung cancer surpassed a staggering 2.2 million cases, leading to approximately 1.8 million tragic fatalities. When\\n considering age-standardized rates, the morbidity and mortality figures stand at 22.4 and 18.0 per 100,000 individuals respectively\\n [2]. Generally, lung cancer is considered to be intricately linked to a multitude of factors including but not limited to smoking, genetic\\n predisposition, occupational exposures, as well as the deleterious effects of air and environmental pollution [3,4]. Among the risk\\n factors for lung cancer, smoking dominates overwhelmingly, with about two-thirds of lung cancer deaths globally caused by it [5]. In\\n recent years, the drug resistance phenomenon of lung cancer to chemotherapy and targeted therapy has become more and more\\n prominent [6–8]. Therefore, it is of heightened importance to find new therapeutic targets.\\n\\n * Corresponding author. Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China.\\n E-mail address: wanghua@ahmu.edu.cn (H. Wang).\\n 1 These authors have contributed equally to this work and share first authorship.\\n\\nhttps://doi.org/10.1016/j.heliyon.2024.e35901\\nReceived 13 August 2023; Received in revised form 5 August 2024; Accepted 6 August 2024\\nAvailable online 10 August 2024\\n2405-8440/© 2024 The Authors. Published by Elsevier Ltd.\\n(http://creativecommons.org/licenses/by-nc-nd/4.0/).\\n\\n\\n\\nThis is an open access article under the CC BY-NC-ND license',\n", " 'md': '```markdown\\n# IL-22: A Key Inflammatory Mediator as a Biomarker and Potential Therapeutic Target for Lung Cancer\\n\\n**Authors:**\\nLing Xu, Peng Cao, Jianpeng Wang, Peng Zhang, Shuhui Hu, Chao Cheng, Hua Wang\\n**Affiliations:**\\n- Department of Interventional Pulmonary Diseases, The Anhui Chest Hospital, Hefei, China\\n- First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China\\n- Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China\\n\\n## Abstract\\n\\n**Keywords:**\\nLung cancer, IL-22, Biomarker, Inflammation immunology\\n\\nLung cancer, one of the most prevalent cancers worldwide, stands as the primary cause of cancer-related deaths. The utmost crucial risk factor contributing to lung cancer is smoking. In recent years, remarkable progress has been made in treating lung cancer, particularly non-small cell lung cancer (NSCLC). Nevertheless, the absence of effective and accurate biomarkers for diagnosing and treating lung cancer remains a pressing issue. Interleukin 22 (IL-22) is a member of the IL-10 cytokine family. It exerts biological functions (including induction of proliferation and anti-apoptotic signaling pathways, enhancement of tissue regeneration and immunity defense) by binding to heterodimeric receptors containing type 1 receptor chain (R1) and type 2 receptor chain (R2). IL-22 has been identified as a pro-cancer factor since dysregulation of the IL-22-IL-22R system has been implicated in the development of different cancers, including lung, breast, gastric, pancreatic, and colon cancers. In this review, we discuss the differential expression, regulatory role, and potential clinical significance of IL-22 in lung cancer, while shedding light on innovative approaches for the future.\\n\\n## 1. Introduction\\n\\nLung cancer is a heterogeneous disease in which cells in the lung grow aberrantly culminating in the formation of tumors. Typically, these tumors present as nodules or masses discernible through pulmonary imaging techniques. In the year 2020, the global incidence of lung cancer surpassed a staggering 2.2 million cases, leading to approximately 1.8 million tragic fatalities. When considering age-standardized rates, the morbidity and mortality figures stand at 22.4 and 18.0 per 100,000 individuals respectively. Generally, lung cancer is considered to be intricately linked to a multitude of factors including but not limited to smoking, genetic predisposition, occupational exposures, as well as the deleterious effects of air and environmental pollution. Among the risk factors for lung cancer, smoking dominates overwhelmingly, with about two-thirds of lung cancer deaths globally caused by it. In recent years, the drug resistance phenomenon of lung cancer to chemotherapy and targeted therapy has become more and more prominent. Therefore, it is of heightened importance to find new therapeutic targets.\\n\\n*Corresponding author. Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China. E-mail address: wanghua@ahmu.edu.cn (H. Wang).*\\n\\n**DOI:** [10.1016/j.heliyon.2024.e35901](https://doi.org/10.1016/j.heliyon.2024.e35901)\\n**Received:** 13 August 2023; **Revised:** 5 August 2024; **Accepted:** 6 August 2024; **Available online:** 10 August 2024\\n**License:** This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).\\n```',\n", " 'images': [{'name': 'img_p0_1.png',\n", " 'height': 155,\n", " 'width': 123,\n", " 'x': 448.554,\n", " 'y': 53.517501999999965,\n", " 'original_width': 236,\n", " 'original_height': 298}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 461.92, 'y': 81.67, 'w': 29.5, 'h': 28.62}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'IL-22: A Key Inflammatory Mediator as a Biomarker and Potential Therapeutic Target for Lung Cancer',\n", " 'md': '# IL-22: A Key Inflammatory Mediator as a Biomarker and Potential Therapeutic Target for Lung Cancer',\n", " 'bBox': {'x': 39, 'y': 81.67, 'w': 452.42, 'h': 28.62}},\n", " {'type': 'text',\n", " 'value': '**Authors:**\\nLing Xu, Peng Cao, Jianpeng Wang, Peng Zhang, Shuhui Hu, Chao Cheng, Hua Wang\\n**Affiliations:**\\n- Department of Interventional Pulmonary Diseases, The Anhui Chest Hospital, Hefei, China\\n- First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China\\n- Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China',\n", " 'md': '**Authors:**\\nLing Xu, Peng Cao, Jianpeng Wang, Peng Zhang, Shuhui Hu, Chao Cheng, Hua Wang\\n**Affiliations:**\\n- Department of Interventional Pulmonary Diseases, The Anhui Chest Hospital, Hefei, China\\n- First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China\\n- Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China',\n", " 'bBox': {'x': 39, 'y': 81.67, 'w': 452.42, 'h': 28.62}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abstract',\n", " 'md': '## Abstract',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': '**Keywords:**\\nLung cancer, IL-22, Biomarker, Inflammation immunology\\n\\nLung cancer, one of the most prevalent cancers worldwide, stands as the primary cause of cancer-related deaths. The utmost crucial risk factor contributing to lung cancer is smoking. In recent years, remarkable progress has been made in treating lung cancer, particularly non-small cell lung cancer (NSCLC). Nevertheless, the absence of effective and accurate biomarkers for diagnosing and treating lung cancer remains a pressing issue. Interleukin 22 (IL-22) is a member of the IL-10 cytokine family. It exerts biological functions (including induction of proliferation and anti-apoptotic signaling pathways, enhancement of tissue regeneration and immunity defense) by binding to heterodimeric receptors containing type 1 receptor chain (R1) and type 2 receptor chain (R2). IL-22 has been identified as a pro-cancer factor since dysregulation of the IL-22-IL-22R system has been implicated in the development of different cancers, including lung, breast, gastric, pancreatic, and colon cancers. In this review, we discuss the differential expression, regulatory role, and potential clinical significance of IL-22 in lung cancer, while shedding light on innovative approaches for the future.',\n", " 'md': '**Keywords:**\\nLung cancer, IL-22, Biomarker, Inflammation immunology\\n\\nLung cancer, one of the most prevalent cancers worldwide, stands as the primary cause of cancer-related deaths. The utmost crucial risk factor contributing to lung cancer is smoking. In recent years, remarkable progress has been made in treating lung cancer, particularly non-small cell lung cancer (NSCLC). Nevertheless, the absence of effective and accurate biomarkers for diagnosing and treating lung cancer remains a pressing issue. Interleukin 22 (IL-22) is a member of the IL-10 cytokine family. It exerts biological functions (including induction of proliferation and anti-apoptotic signaling pathways, enhancement of tissue regeneration and immunity defense) by binding to heterodimeric receptors containing type 1 receptor chain (R1) and type 2 receptor chain (R2). IL-22 has been identified as a pro-cancer factor since dysregulation of the IL-22-IL-22R system has been implicated in the development of different cancers, including lung, breast, gastric, pancreatic, and colon cancers. In this review, we discuss the differential expression, regulatory role, and potential clinical significance of IL-22 in lung cancer, while shedding light on innovative approaches for the future.',\n", " 'bBox': {'x': 39, 'y': 81.67, 'w': 452.42, 'h': 28.62}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': '1. Introduction',\n", " 'md': '## 1. Introduction',\n", " 'bBox': {'x': 39, 'y': 81.67, 'w': 452.42, 'h': 28.62}},\n", " {'type': 'text',\n", " 'value': 'Lung cancer is a heterogeneous disease in which cells in the lung grow aberrantly culminating in the formation of tumors. Typically, these tumors present as nodules or masses discernible through pulmonary imaging techniques. In the year 2020, the global incidence of lung cancer surpassed a staggering 2.2 million cases, leading to approximately 1.8 million tragic fatalities. When considering age-standardized rates, the morbidity and mortality figures stand at 22.4 and 18.0 per 100,000 individuals respectively. Generally, lung cancer is considered to be intricately linked to a multitude of factors including but not limited to smoking, genetic predisposition, occupational exposures, as well as the deleterious effects of air and environmental pollution. Among the risk factors for lung cancer, smoking dominates overwhelmingly, with about two-thirds of lung cancer deaths globally caused by it. In recent years, the drug resistance phenomenon of lung cancer to chemotherapy and targeted therapy has become more and more prominent. Therefore, it is of heightened importance to find new therapeutic targets.\\n\\n*Corresponding author. Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China. E-mail address: wanghua@ahmu.edu.cn (H. Wang).*\\n\\n**DOI:** [10.1016/j.heliyon.2024.e35901](https://doi.org/10.1016/j.heliyon.2024.e35901)\\n**Received:** 13 August 2023; **Revised:** 5 August 2024; **Accepted:** 6 August 2024; **Available online:** 10 August 2024\\n**License:** This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).\\n```',\n", " 'md': 'Lung cancer is a heterogeneous disease in which cells in the lung grow aberrantly culminating in the formation of tumors. Typically, these tumors present as nodules or masses discernible through pulmonary imaging techniques. In the year 2020, the global incidence of lung cancer surpassed a staggering 2.2 million cases, leading to approximately 1.8 million tragic fatalities. When considering age-standardized rates, the morbidity and mortality figures stand at 22.4 and 18.0 per 100,000 individuals respectively. Generally, lung cancer is considered to be intricately linked to a multitude of factors including but not limited to smoking, genetic predisposition, occupational exposures, as well as the deleterious effects of air and environmental pollution. Among the risk factors for lung cancer, smoking dominates overwhelmingly, with about two-thirds of lung cancer deaths globally caused by it. In recent years, the drug resistance phenomenon of lung cancer to chemotherapy and targeted therapy has become more and more prominent. Therefore, it is of heightened importance to find new therapeutic targets.\\n\\n*Corresponding author. Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China. E-mail address: wanghua@ahmu.edu.cn (H. Wang).*\\n\\n**DOI:** [10.1016/j.heliyon.2024.e35901](https://doi.org/10.1016/j.heliyon.2024.e35901)\\n**Received:** 13 August 2023; **Revised:** 5 August 2024; **Accepted:** 6 August 2024; **Available online:** 10 August 2024\\n**License:** This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).\\n```',\n", " 'bBox': {'x': 38, 'y': 57.67, 'w': 467.25, 'h': 28.62}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ','},\n", " {'text': ', Peng Cao a Chao Cheng'},\n", " {'text': 'a ,'},\n", " {'text': '1 , Jianpeng Wang b , Hua Wang'},\n", " {'text': ','},\n", " {'text': ', Peng Zhang'},\n", " {'text': 'a , Shuhui Hu a ,'},\n", " {'text': ', Hua Wang c'},\n", " {'text': ','},\n", " {'text': '*'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '– 8]. Therefore, it is of heightened importance to find new therapeutic targets.'},\n", " {'text': ''},\n", " {'url': 'mailto:wanghua@ahmu.edu.cn', 'text': ''},\n", " {'url': 'http://www.sciencedirect.com/science/journal/24058440',\n", " 'text': ''},\n", " {'url': 'https://www.cell.com/heliyon', 'text': ''},\n", " {'url': 'https://doi.org/10.1016/j.heliyon.2024.e35901',\n", " 'text': 'https://doi.org/10.1016/j.heliyon.2024.e35901'},\n", " {'url': 'https://doi.org/10.1016/j.heliyon.2024.e35901', 'text': ''},\n", " {'url': 'https://doi.org/10.1016/j.heliyon.2024.e35901', 'text': ''},\n", " {'url': 'http://creativecommons.org/licenses/by-nc-nd/4.0/', 'text': ''}]},\n", " {'page': 2,\n", " 'text': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\n IL-22 is an IL-10 family cytokine produced by T cells and innate lymphocytes. Like all other IL-10 family members, the IL-22\\nstructure contains six α-helices (termed helices A to F). They are arranged in an antiparallel conformation and produce a single\\nbundled protein [9]. IL-22 coordinates mucosal immune defense and tissue regeneration through pleiotropic effects including pro-\\nsurvival signaling, cell migration, dysplasia, and angiogenesis. These molecules act by targeting the heterodimeric transmembrane\\nreceptor complex composed of IL-22R1 and IL-10R2 and by activating subsequent signaling pathways (including JAK/STAT signaling\\npathway, p38 MAPK signaling pathway, and PI3K/AKT signaling pathway) [10]. It is well known that IL-22 is widely expressed in\\nhuman tissues and organs, including lung, liver, heart, kidney, pancreas, gastrointestinal tract, skin, blood, adipose, and synovial\\ntissues [11]. Meanwhile, IL-22 is also found to be broadly expressed in pathological states such as cancer, infectious diseases, tissue\\ninjury, chronic inflammatory diseases, and Graft-Versus-Host Disease [11–14]. In most cancer diseases, excessively elevated levels of\\nIL-22 are considered to be detrimental [15–19]. For instance, a recent study has demonstrated that IL-22 promotes extravasation of\\ntumor cells in liver metastasis [20]. Over the past few years, there has been a surge in research focusing on the relationship between\\nIL-22 and lung cancer. Particularly in patients with NSCLC, researchers have discovered up-regulated expression of IL-22 in serum,\\nmalignant pleural effusion, and tumor tissues, and the levels of IL-22Rα1 in tumor cells and tissues are also increased [21–24].\\n Although emerging studies have revealed that IL-22 is closely correlated with lung cancer in terms of tissue, cell and pathological\\nchanges, the specific function and mechanism remain to be explored. In the present review, we mainly summarized the regulatory\\nfunction and clinical role of IL-22 in lung cancer. In addition, the feasibility of IL-22 as a biomarker for lung cancer and directions for\\nfuture research were also discussed. It is reasonable to hypothesize that IL-22 may serve as a potential target in the treatment of lung\\ncancer.\\n\\n2. Overview of lung cancer\\n\\n Lung cancer is a malignant disease characterized by high morbidity and mortality [25]. According to the data of GLOBOCAN, lung\\ncancer is the second most common cancer in 2020 and the main cause of cancer death worldwide, with about one-tenth (11.4 %) of\\ncancer diagnoses and one-fifth (18.0 %) of deaths [5]. When it comes to gender, the incidence and mortality rates of lung cancer were\\non the rise in females but declining in males in most countries over the past decade [2]. The 5-year survival rate of lung cancer patients\\nvaries by 4–17 % in light of stage and region [26]. As predicted by the American Cancer Society, more than 120,000 people will die of\\nlung cancer in the United States in 2023. The good news is that although the incidence is stable or increasing, the overall mortality is\\ndecreasing at an accelerated pace [27]. From the perspective of histopathology and biological behavior, lung cancer can be divided\\ninto NSCLC and SCLC, among which the former mainly includes several common types such as adenocarcinoma, squamous cell\\ncarcinoma, and large cell carcinoma [25]. The pathogenesis of lung cancer primarily involves the following aspects: chromosome\\nchanges; abnormal immune response; abnormal activation of developmental pathways; dysregulation of tumor suppressor genes,\\nproto-oncogenes, and signaling pathways; and the up-regulation of receptor tyrosine kinases, growth factors, and cell markers. These\\nabnormal changes cause an imbalance between lung cell proliferation and apoptosis, which leads to lung cancer [28–31]. For example,\\nwhen exposed to risk factors continuously, the production of ROS, chemokines, and cytokines increases in lung cells, which leads to\\nDNA damage and gives rise to inflammation and other pathobiological changes that ultimately promote carcinogenesis. At the same\\ntime, the anti-tumor immune function of macrophages, T lymphocytes, B lymphocytes, and NK cells gets suppressed, failing recog-\\nnition and clearance of malignant cells, and eventually bringing about the formation of tumors [32]. In the early stage of the disease, it\\nis usually considered to be asymptomatic, while may manifest as cough, dyspnea, chest pain, hemoptysis, hoarseness, and so on in the\\nmiddle and advanced period [33]. In principle, the treatment of lung cancer depends largely on the type, stage and condition of the\\npatient’s disease. Currently, the main treatment approaches for lung cancer include surgery, chemotherapy, and radiotherapy. Among\\nthem, platinum-containing double drugs are preferred for chemotherapy. Radiation therapy is mainly applied in the control of the local\\nlesion. Furthermore, targeted therapy for EGFR, ALK, ROS1, and other gene mutations and immunotherapy to inhibit PD-1/PD-L1 also\\nplays an irreplaceable role as emerging breakthrough therapeutic means [25,34–39]. Compared with chemotherapy, targeted therapy\\ncan prominently enhance the survival rate and tolerance of patients with NSCLC [40,41]. The combination of chemotherapy and\\nimmunotherapy has also shown a more notable curative effect over chemotherapy alone [42,43]. Additionally, there has been a\\ngrowing body of research focusing on natural product therapy, local ablative therapy, and chimeric antigen receptor (CAR)-T-cell\\ntherapy lately [44–51]. In principle, the treatments of lung cancer are individualized depending largely on the type, stage, and\\ncondition of patients. Unfortunately, the limited sensitivity of NSCLC patients to chemotherapy and immunotherapy drugs has proven\\nto be a major obstacle to clinical treatment. Denk D et al. suggested that inflammation is ubiquitous in carcinogenesis. In his study, he\\nnoted that interfering with individual cytokines and their respective signaling pathways holds great promise for the development and\\nimprovement of current clinical cancer therapies [52]. IL-22 is a new type of cytokine discovered in 2000 and has gradually attracted\\nattention due to its role in tumor diseases. In recent years, multiple studies have reported the positive role of IL-22 in enhancing\\nchemotherapy resistance in human lung cancer patients. This positive effect is related to the function of IL-22 in promoting lung cancer\\ncell proliferation and inhibiting lung cancer cell apoptosis. Results showed that IL-22 activated the EGFR/AKT/ERK signaling pathway\\n[52], STAT3, and ERK1/2 signaling pathways [24] in drug-treated lung cancer cells, thereby attenuating the pro-apoptotic effect of the\\ndrug on lung cancer cells.\\n\\n3. Function role of IL-22 in lung cancer\\n\\n IL-22 is a cytokine first identified by Dumoutier et al. in IL-9-induced murine T cells over 20 years ago and was once called IL-10-\\nrelated T cell-derived inducible factor (IL-10-TIF) [53]. In human-beings, the IL-22 gene lies in chromosome 12q15, next to the gene\\n\\n 2',\n", " 'md': '```markdown\\n# IL-22 and Lung Cancer\\n\\n## IL-22 Overview\\nIL-22 is an IL-10 family cytokine produced by T cells and innate lymphocytes. Like all other IL-10 family members, the IL-22 structure contains six α-helices (termed helices A to F). They are arranged in an antiparallel conformation and produce a single bundled protein. IL-22 coordinates mucosal immune defense and tissue regeneration through pleiotropic effects including pro-survival signaling, cell migration, dysplasia, and angiogenesis. These molecules act by targeting the heterodimeric transmembrane receptor complex composed of IL-22R1 and IL-10R2 and by activating subsequent signaling pathways (including JAK/STAT signaling pathway, p38 MAPK signaling pathway, and PI3K/AKT signaling pathway).\\n\\nIL-22 is widely expressed in human tissues and organs, including lung, liver, heart, kidney, pancreas, gastrointestinal tract, skin, blood, adipose, and synovial tissues. It is also found to be broadly expressed in pathological states such as cancer, infectious diseases, tissue injury, chronic inflammatory diseases, and Graft-Versus-Host Disease. In most cancer diseases, excessively elevated levels of IL-22 are considered to be detrimental. For instance, a recent study has demonstrated that IL-22 promotes extravasation of tumor cells in liver metastasis.\\n\\nOver the past few years, there has been a surge in research focusing on the relationship between IL-22 and lung cancer. Particularly in patients with NSCLC, researchers have discovered up-regulated expression of IL-22 in serum, malignant pleural effusion, and tumor tissues, and the levels of IL-22Rα1 in tumor cells and tissues are also increased. Although emerging studies have revealed that IL-22 is closely correlated with lung cancer in terms of tissue, cell, and pathological changes, the specific function and mechanism remain to be explored.\\n\\nIn the present review, we mainly summarized the regulatory function and clinical role of IL-22 in lung cancer. In addition, the feasibility of IL-22 as a biomarker for lung cancer and directions for future research were also discussed. It is reasonable to hypothesize that IL-22 may serve as a potential target in the treatment of lung cancer.\\n\\n## Overview of Lung Cancer\\nLung cancer is a malignant disease characterized by high morbidity and mortality. According to the data of GLOBOCAN, lung cancer is the second most common cancer in 2020 and the main cause of cancer death worldwide, with about one-tenth (11.4%) of cancer diagnoses and one-fifth (18.0%) of deaths. When it comes to gender, the incidence and mortality rates of lung cancer were on the rise in females but declining in males in most countries over the past decade. The 5-year survival rate of lung cancer patients varies by 4–17% in light of stage and region.\\n\\nAs predicted by the American Cancer Society, more than 120,000 people will die of lung cancer in the United States in 2023. The good news is that although the incidence is stable or increasing, the overall mortality is decreasing at an accelerated pace. From the perspective of histopathology and biological behavior, lung cancer can be divided into NSCLC and SCLC, among which the former mainly includes several common types such as adenocarcinoma, squamous cell carcinoma, and large cell carcinoma.\\n\\nThe pathogenesis of lung cancer primarily involves the following aspects: chromosome changes; abnormal immune response; abnormal activation of developmental pathways; dysregulation of tumor suppressor genes, proto-oncogenes, and signaling pathways; and the up-regulation of receptor tyrosine kinases, growth factors, and cell markers. These abnormal changes cause an imbalance between lung cell proliferation and apoptosis, which leads to lung cancer.\\n\\nFor example, when exposed to risk factors continuously, the production of ROS, chemokines, and cytokines increases in lung cells, which leads to DNA damage and gives rise to inflammation and other pathobiological changes that ultimately promote carcinogenesis. At the same time, the anti-tumor immune function of macrophages, T lymphocytes, B lymphocytes, and NK cells gets suppressed, failing recognition and clearance of malignant cells, and eventually bringing about the formation of tumors.\\n\\nIn the early stage of the disease, it is usually considered to be asymptomatic, while it may manifest as cough, dyspnea, chest pain, hemoptysis, hoarseness, and so on in the middle and advanced period. In principle, the treatment of lung cancer depends largely on the type, stage, and condition of the patient’s disease. Currently, the main treatment approaches for lung cancer include surgery, chemotherapy, and radiotherapy. Among them, platinum-containing double drugs are preferred for chemotherapy. Radiation therapy is mainly applied in the control of the local lesion.\\n\\nFurthermore, targeted therapy for EGFR, ALK, ROS1, and other gene mutations and immunotherapy to inhibit PD-1/PD-L1 also plays an irreplaceable role as emerging breakthrough therapeutic means. Compared with chemotherapy, targeted therapy can prominently enhance the survival rate and tolerance of patients with NSCLC. The combination of chemotherapy and immunotherapy has also shown a more notable curative effect over chemotherapy alone.\\n\\nAdditionally, there has been a growing body of research focusing on natural product therapy, local ablative therapy, and chimeric antigen receptor (CAR)-T-cell therapy lately. In principle, the treatments of lung cancer are individualized depending largely on the type, stage, and condition of patients. Unfortunately, the limited sensitivity of NSCLC patients to chemotherapy and immunotherapy drugs has proven to be a major obstacle to clinical treatment.\\n\\nDenk D et al. suggested that inflammation is ubiquitous in carcinogenesis. In his study, he noted that interfering with individual cytokines and their respective signaling pathways holds great promise for the development and improvement of current clinical cancer therapies. IL-22 is a new type of cytokine discovered in 2000 and has gradually attracted attention due to its role in tumor diseases. In recent years, multiple studies have reported the positive role of IL-22 in enhancing chemotherapy resistance in human lung cancer patients. This positive effect is related to the function of IL-22 in promoting lung cancer cell proliferation and inhibiting lung cancer cell apoptosis. Results showed that IL-22 activated the EGFR/AKT/ERK signaling pathway, STAT3, and ERK1/2 signaling pathways in drug-treated lung cancer cells, thereby attenuating the pro-apoptotic effect of the drug on lung cancer cells.\\n\\n## Function Role of IL-22 in Lung Cancer\\nIL-22 is a cytokine first identified by Dumoutier et al. in IL-9-induced murine T cells over 20 years ago and was once called IL-10-related T cell-derived inducible factor (IL-10-TIF).\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'IL-22 and Lung Cancer',\n", " 'md': '# IL-22 and Lung Cancer',\n", " 'bBox': {'x': 270, 'y': 707.68, 'w': 3.59, 'h': 6.38}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'IL-22 Overview',\n", " 'md': '## IL-22 Overview',\n", " 'bBox': {'x': 270, 'y': 707.68, 'w': 3.59, 'h': 6.38}},\n", " {'type': 'text',\n", " 'value': 'IL-22 is an IL-10 family cytokine produced by T cells and innate lymphocytes. Like all other IL-10 family members, the IL-22 structure contains six α-helices (termed helices A to F). They are arranged in an antiparallel conformation and produce a single bundled protein. IL-22 coordinates mucosal immune defense and tissue regeneration through pleiotropic effects including pro-survival signaling, cell migration, dysplasia, and angiogenesis. These molecules act by targeting the heterodimeric transmembrane receptor complex composed of IL-22R1 and IL-10R2 and by activating subsequent signaling pathways (including JAK/STAT signaling pathway, p38 MAPK signaling pathway, and PI3K/AKT signaling pathway).\\n\\nIL-22 is widely expressed in human tissues and organs, including lung, liver, heart, kidney, pancreas, gastrointestinal tract, skin, blood, adipose, and synovial tissues. It is also found to be broadly expressed in pathological states such as cancer, infectious diseases, tissue injury, chronic inflammatory diseases, and Graft-Versus-Host Disease. In most cancer diseases, excessively elevated levels of IL-22 are considered to be detrimental. For instance, a recent study has demonstrated that IL-22 promotes extravasation of tumor cells in liver metastasis.\\n\\nOver the past few years, there has been a surge in research focusing on the relationship between IL-22 and lung cancer. Particularly in patients with NSCLC, researchers have discovered up-regulated expression of IL-22 in serum, malignant pleural effusion, and tumor tissues, and the levels of IL-22Rα1 in tumor cells and tissues are also increased. Although emerging studies have revealed that IL-22 is closely correlated with lung cancer in terms of tissue, cell, and pathological changes, the specific function and mechanism remain to be explored.\\n\\nIn the present review, we mainly summarized the regulatory function and clinical role of IL-22 in lung cancer. In addition, the feasibility of IL-22 as a biomarker for lung cancer and directions for future research were also discussed. It is reasonable to hypothesize that IL-22 may serve as a potential target in the treatment of lung cancer.',\n", " 'md': 'IL-22 is an IL-10 family cytokine produced by T cells and innate lymphocytes. Like all other IL-10 family members, the IL-22 structure contains six α-helices (termed helices A to F). They are arranged in an antiparallel conformation and produce a single bundled protein. IL-22 coordinates mucosal immune defense and tissue regeneration through pleiotropic effects including pro-survival signaling, cell migration, dysplasia, and angiogenesis. These molecules act by targeting the heterodimeric transmembrane receptor complex composed of IL-22R1 and IL-10R2 and by activating subsequent signaling pathways (including JAK/STAT signaling pathway, p38 MAPK signaling pathway, and PI3K/AKT signaling pathway).\\n\\nIL-22 is widely expressed in human tissues and organs, including lung, liver, heart, kidney, pancreas, gastrointestinal tract, skin, blood, adipose, and synovial tissues. It is also found to be broadly expressed in pathological states such as cancer, infectious diseases, tissue injury, chronic inflammatory diseases, and Graft-Versus-Host Disease. In most cancer diseases, excessively elevated levels of IL-22 are considered to be detrimental. For instance, a recent study has demonstrated that IL-22 promotes extravasation of tumor cells in liver metastasis.\\n\\nOver the past few years, there has been a surge in research focusing on the relationship between IL-22 and lung cancer. Particularly in patients with NSCLC, researchers have discovered up-regulated expression of IL-22 in serum, malignant pleural effusion, and tumor tissues, and the levels of IL-22Rα1 in tumor cells and tissues are also increased. Although emerging studies have revealed that IL-22 is closely correlated with lung cancer in terms of tissue, cell, and pathological changes, the specific function and mechanism remain to be explored.\\n\\nIn the present review, we mainly summarized the regulatory function and clinical role of IL-22 in lung cancer. In addition, the feasibility of IL-22 as a biomarker for lung cancer and directions for future research were also discussed. It is reasonable to hypothesize that IL-22 may serve as a potential target in the treatment of lung cancer.',\n", " 'bBox': {'x': 39, 'y': 59.68, 'w': 466.27, 'h': 8.53}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Overview of Lung Cancer',\n", " 'md': '## Overview of Lung Cancer',\n", " 'bBox': {'x': 51, 'y': 257.68, 'w': 93.71, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': 'Lung cancer is a malignant disease characterized by high morbidity and mortality. According to the data of GLOBOCAN, lung cancer is the second most common cancer in 2020 and the main cause of cancer death worldwide, with about one-tenth (11.4%) of cancer diagnoses and one-fifth (18.0%) of deaths. When it comes to gender, the incidence and mortality rates of lung cancer were on the rise in females but declining in males in most countries over the past decade. The 5-year survival rate of lung cancer patients varies by 4–17% in light of stage and region.\\n\\nAs predicted by the American Cancer Society, more than 120,000 people will die of lung cancer in the United States in 2023. The good news is that although the incidence is stable or increasing, the overall mortality is decreasing at an accelerated pace. From the perspective of histopathology and biological behavior, lung cancer can be divided into NSCLC and SCLC, among which the former mainly includes several common types such as adenocarcinoma, squamous cell carcinoma, and large cell carcinoma.\\n\\nThe pathogenesis of lung cancer primarily involves the following aspects: chromosome changes; abnormal immune response; abnormal activation of developmental pathways; dysregulation of tumor suppressor genes, proto-oncogenes, and signaling pathways; and the up-regulation of receptor tyrosine kinases, growth factors, and cell markers. These abnormal changes cause an imbalance between lung cell proliferation and apoptosis, which leads to lung cancer.\\n\\nFor example, when exposed to risk factors continuously, the production of ROS, chemokines, and cytokines increases in lung cells, which leads to DNA damage and gives rise to inflammation and other pathobiological changes that ultimately promote carcinogenesis. At the same time, the anti-tumor immune function of macrophages, T lymphocytes, B lymphocytes, and NK cells gets suppressed, failing recognition and clearance of malignant cells, and eventually bringing about the formation of tumors.\\n\\nIn the early stage of the disease, it is usually considered to be asymptomatic, while it may manifest as cough, dyspnea, chest pain, hemoptysis, hoarseness, and so on in the middle and advanced period. In principle, the treatment of lung cancer depends largely on the type, stage, and condition of the patient’s disease. Currently, the main treatment approaches for lung cancer include surgery, chemotherapy, and radiotherapy. Among them, platinum-containing double drugs are preferred for chemotherapy. Radiation therapy is mainly applied in the control of the local lesion.\\n\\nFurthermore, targeted therapy for EGFR, ALK, ROS1, and other gene mutations and immunotherapy to inhibit PD-1/PD-L1 also plays an irreplaceable role as emerging breakthrough therapeutic means. Compared with chemotherapy, targeted therapy can prominently enhance the survival rate and tolerance of patients with NSCLC. The combination of chemotherapy and immunotherapy has also shown a more notable curative effect over chemotherapy alone.\\n\\nAdditionally, there has been a growing body of research focusing on natural product therapy, local ablative therapy, and chimeric antigen receptor (CAR)-T-cell therapy lately. In principle, the treatments of lung cancer are individualized depending largely on the type, stage, and condition of patients. Unfortunately, the limited sensitivity of NSCLC patients to chemotherapy and immunotherapy drugs has proven to be a major obstacle to clinical treatment.\\n\\nDenk D et al. suggested that inflammation is ubiquitous in carcinogenesis. In his study, he noted that interfering with individual cytokines and their respective signaling pathways holds great promise for the development and improvement of current clinical cancer therapies. IL-22 is a new type of cytokine discovered in 2000 and has gradually attracted attention due to its role in tumor diseases. In recent years, multiple studies have reported the positive role of IL-22 in enhancing chemotherapy resistance in human lung cancer patients. This positive effect is related to the function of IL-22 in promoting lung cancer cell proliferation and inhibiting lung cancer cell apoptosis. Results showed that IL-22 activated the EGFR/AKT/ERK signaling pathway, STAT3, and ERK1/2 signaling pathways in drug-treated lung cancer cells, thereby attenuating the pro-apoptotic effect of the drug on lung cancer cells.',\n", " 'md': 'Lung cancer is a malignant disease characterized by high morbidity and mortality. According to the data of GLOBOCAN, lung cancer is the second most common cancer in 2020 and the main cause of cancer death worldwide, with about one-tenth (11.4%) of cancer diagnoses and one-fifth (18.0%) of deaths. When it comes to gender, the incidence and mortality rates of lung cancer were on the rise in females but declining in males in most countries over the past decade. The 5-year survival rate of lung cancer patients varies by 4–17% in light of stage and region.\\n\\nAs predicted by the American Cancer Society, more than 120,000 people will die of lung cancer in the United States in 2023. The good news is that although the incidence is stable or increasing, the overall mortality is decreasing at an accelerated pace. From the perspective of histopathology and biological behavior, lung cancer can be divided into NSCLC and SCLC, among which the former mainly includes several common types such as adenocarcinoma, squamous cell carcinoma, and large cell carcinoma.\\n\\nThe pathogenesis of lung cancer primarily involves the following aspects: chromosome changes; abnormal immune response; abnormal activation of developmental pathways; dysregulation of tumor suppressor genes, proto-oncogenes, and signaling pathways; and the up-regulation of receptor tyrosine kinases, growth factors, and cell markers. These abnormal changes cause an imbalance between lung cell proliferation and apoptosis, which leads to lung cancer.\\n\\nFor example, when exposed to risk factors continuously, the production of ROS, chemokines, and cytokines increases in lung cells, which leads to DNA damage and gives rise to inflammation and other pathobiological changes that ultimately promote carcinogenesis. At the same time, the anti-tumor immune function of macrophages, T lymphocytes, B lymphocytes, and NK cells gets suppressed, failing recognition and clearance of malignant cells, and eventually bringing about the formation of tumors.\\n\\nIn the early stage of the disease, it is usually considered to be asymptomatic, while it may manifest as cough, dyspnea, chest pain, hemoptysis, hoarseness, and so on in the middle and advanced period. In principle, the treatment of lung cancer depends largely on the type, stage, and condition of the patient’s disease. Currently, the main treatment approaches for lung cancer include surgery, chemotherapy, and radiotherapy. Among them, platinum-containing double drugs are preferred for chemotherapy. Radiation therapy is mainly applied in the control of the local lesion.\\n\\nFurthermore, targeted therapy for EGFR, ALK, ROS1, and other gene mutations and immunotherapy to inhibit PD-1/PD-L1 also plays an irreplaceable role as emerging breakthrough therapeutic means. Compared with chemotherapy, targeted therapy can prominently enhance the survival rate and tolerance of patients with NSCLC. The combination of chemotherapy and immunotherapy has also shown a more notable curative effect over chemotherapy alone.\\n\\nAdditionally, there has been a growing body of research focusing on natural product therapy, local ablative therapy, and chimeric antigen receptor (CAR)-T-cell therapy lately. In principle, the treatments of lung cancer are individualized depending largely on the type, stage, and condition of patients. Unfortunately, the limited sensitivity of NSCLC patients to chemotherapy and immunotherapy drugs has proven to be a major obstacle to clinical treatment.\\n\\nDenk D et al. suggested that inflammation is ubiquitous in carcinogenesis. In his study, he noted that interfering with individual cytokines and their respective signaling pathways holds great promise for the development and improvement of current clinical cancer therapies. IL-22 is a new type of cytokine discovered in 2000 and has gradually attracted attention due to its role in tumor diseases. In recent years, multiple studies have reported the positive role of IL-22 in enhancing chemotherapy resistance in human lung cancer patients. This positive effect is related to the function of IL-22 in promoting lung cancer cell proliferation and inhibiting lung cancer cell apoptosis. Results showed that IL-22 activated the EGFR/AKT/ERK signaling pathway, STAT3, and ERK1/2 signaling pathways in drug-treated lung cancer cells, thereby attenuating the pro-apoptotic effect of the drug on lung cancer cells.',\n", " 'bBox': {'x': 39, 'y': 237.68, 'w': 466.27, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Function Role of IL-22 in Lung Cancer',\n", " 'md': '## Function Role of IL-22 in Lung Cancer',\n", " 'bBox': {'x': 51, 'y': 655.68, 'w': 140.93, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': 'IL-22 is a cytokine first identified by Dumoutier et al. in IL-9-induced murine T cells over 20 years ago and was once called IL-10-related T cell-derived inducible factor (IL-10-TIF).\\n```',\n", " 'md': 'IL-22 is a cytokine first identified by Dumoutier et al. in IL-9-induced murine T cells over 20 years ago and was once called IL-10-related T cell-derived inducible factor (IL-10-TIF).\\n```',\n", " 'bBox': {'x': 50, 'y': 676.68, 'w': 454.29, 'h': 7.97}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '– 14]. In most cancer diseases, excessively elevated levels of'},\n", " {'text': '– 19]. For instance, a recent study has demonstrated that IL-22 promotes extravasation of'},\n", " {'text': ''},\n", " {'text': '– 24].'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '– 31]. For example,'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '– 39]. Compared with chemotherapy, targeted therapy'},\n", " {'url': 'https://fanyi.so.com/', 'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '– 51]. In principle, the treatments of lung cancer are individualized depending largely on the type, stage, and'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 3,\n", " 'text': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nthat encodes IFN-γ [54]. When the body is in homeostasis, the most important source of IL-22 is Group 3 innate lymphoid cells (ILC3)\\n[14]. Different from other common cytokines, IL-22 is generally thought to be produced only by hematopoietic origin immune cells,\\nwhereas it mainly acts on non-hematopoietic cells due to its receptor distribution [55]. Recently, researchers have found that\\nnon-hematopoietic cells represented by fibroblasts can also produce IL-22 under certain circumstances [11]. IL-22 is known to act by\\nbinding to its receptor (IL-22R), which is synthesized from the IL-22R1 and IL-10R2 subunits [56]. Thereinto, IL-22R1 expression is\\nthought to be restricted to epithelial cells in organs such as the lung, liver, intestine, and skin, while the latter is universally expressed\\n[11,57]. IL-22BP, also known as IL-22RA2, is a soluble IL-22 receptor that binds specifically to IL-22 and prevents it from binding to\\nIL-22R1. All currently known functions of IL-22BP are achieved by inhibiting IL-22 [58,59]. Broadly speaking, the primary function of\\nIL-22 in the body is to promote cell proliferation and tissue protection [60]. Sometimes, excessive activation of this function may lead\\nto pathological results. This dual effect is reflected in both inflammatory and tumor-related diseases. In the short term, the production\\nof IL-22 can play a protective role in anti-inflammatory and tumor prevention, while the uncontrolled generation of IL-22 may promote\\ninflammation and tumor formation [13,18]. The duality of IL-22 reveals that it could be a potential drug target, and the tight regu-\\nlation of IL-22 is crucial in the treatment of a variety of diseases. In Fig. 1, We summarize the role of IL-22 in lung cancer.\\n In general, the expression levels of IL-22 in vivo are regulated by a variety of cytokines and genes. For instance, IL-1β and IL-23 can\\ninduce the production of IL-22 independently, and the two act synergistically [11]. What’s more, Cornelia Voigt described a novel\\nmechanism whereby cancer cells promote tumor growth by releasing IL-1β to induce IL-22 production by memory CD4+ T cells [61].\\nAccording to an animal experiment, IL-1β can enhance the proliferation of epithelial cells and promote lung tumorigenesis [62]. IL-23\\nhas been proven to promote proliferation in NSCLC by Anne-Marie Baird et al. [63]. Although IL-23 is thought to be able to induce\\nmacrophages to produce IL-22, this study by Anne-Marie Baird et al. cannot directly prove whether the proliferation-promoting effect\\nof IL-23 on NSCLC cells is related to IL-23’s promotion of IL-22 production. related to ability. IL-23 is also thought to promote the\\nexpression of IL-26 by macrophages. Like IL-22, IL-26 is part of the IL-10 family. Researchers demonstrated for the first time that IL-26\\nis involved in the generation of malignant pleural effusions [64]. They reported that IL-26 promotes the generation of malignant\\npleural effusion by mediating the infiltration of CD4+IL-22+T cells in malignant pleural effusion and stimulating CD4+ IL-22+ T cells\\nto secrete IL-22. Recently, the Notch-AhR-IL-22 axis is thought to be involved in the pathogenesis of LUAD. It is corroborated that in\\nLUAD patients, elevated Notch1 facilitates IL-22 generation by CD4+ T cells via aryl hydrocarbon receptors (AhR) [65]. In NSCLC,\\nNotch signaling can both promote tumorigenesis and inhibit tumor progression, which mainly depends on its regulation of the\\n Class I: Proliferation, apoptosis, and invasion Class II: Regulating tumor microenvironment\\n Proliferation Lung cancer tissue\\n NK cells Lung \" epithelial cells\\n T cells Apoptosis\\n Lung cancer cells\\n C01se\\n Metastasis Lung cancercells Intiltrated immune cells\\n TNF-a Total WBC\\n CASPASE IL-la Macrophage\\n Multidrug IL-22 Ko Neutrophil\\n Cnchonk C resistance IL-6 Lymphocyte\\n Class III: Angiogenesis Class IV: Cancer stem cell\\n IL-22\\n oxygen- and STAT3 signaling pathway\\n Lung cancer tissue nutrient supplyby perfusion\\n Aangiogenic Oct4\\n switch Sox2\\n IL-22 Nanog\\n MUN\\n Vascular endothelial cell Cancer stem cells Lung cancer cells\\nFig. 1. IL-22 plays four main functions during the progression of lung cancer. 1) Promote lung cancer cell proliferation and invasion, and inhibit\\nlung cancer cell apoptosis; 2) Regulate the abundance of immune cells in lung cancer tissues and activate the inflammatory microenvironment; 3)\\nPromote cancer angiogenesis; 4) Activate lung cancer stem cells.\\n\\n 3',\n", " 'md': '```markdown\\n## Page Content\\n\\nL. Xu et al. Heliyon 10 (2024) e35901\\n\\nWhen the body is in homeostasis, the most important source of IL-22 is Group 3 innate lymphoid cells (ILC3) [14]. Different from other common cytokines, IL-22 is generally thought to be produced only by hematopoietic origin immune cells, whereas it mainly acts on non-hematopoietic cells due to its receptor distribution [55]. Recently, researchers have found that non-hematopoietic cells represented by fibroblasts can also produce IL-22 under certain circumstances [11]. IL-22 is known to act by binding to its receptor (IL-22R), which is synthesized from the IL-22R1 and IL-10R2 subunits [56]. Thereinto, IL-22R1 expression is thought to be restricted to epithelial cells in organs such as the lung, liver, intestine, and skin, while the latter is universally expressed [11,57]. IL-22BP, also known as IL-22RA2, is a soluble IL-22 receptor that binds specifically to IL-22 and prevents it from binding to IL-22R1. All currently known functions of IL-22BP are achieved by inhibiting IL-22 [58,59]. Broadly speaking, the primary function of IL-22 in the body is to promote cell proliferation and tissue protection [60]. Sometimes, excessive activation of this function may lead to pathological results. This dual effect is reflected in both inflammatory and tumor-related diseases. In the short term, the production of IL-22 can play a protective role in anti-inflammatory and tumor prevention, while the uncontrolled generation of IL-22 may promote inflammation and tumor formation [13,18]. The duality of IL-22 reveals that it could be a potential drug target, and the tight regulation of IL-22 is crucial in the treatment of a variety of diseases.\\n\\nIn general, the expression levels of IL-22 in vivo are regulated by a variety of cytokines and genes. For instance, IL-1β and IL-23 can induce the production of IL-22 independently, and the two act synergistically [11]. What’s more, Cornelia Voigt described a novel mechanism whereby cancer cells promote tumor growth by releasing IL-1β to induce IL-22 production by memory CD4+ T cells [61]. According to an animal experiment, IL-1β can enhance the proliferation of epithelial cells and promote lung tumorigenesis [62]. IL-23 has been proven to promote proliferation in NSCLC by Anne-Marie Baird et al. [63]. Although IL-23 is thought to be able to induce macrophages to produce IL-22, this study by Anne-Marie Baird et al. cannot directly prove whether the proliferation-promoting effect of IL-23 on NSCLC cells is related to IL-23’s promotion of IL-22 production. IL-23 is also thought to promote the expression of IL-26 by macrophages. Like IL-22, IL-26 is part of the IL-10 family. Researchers demonstrated for the first time that IL-26 is involved in the generation of malignant pleural effusions [64]. They reported that IL-26 promotes the generation of malignant pleural effusion by mediating the infiltration of CD4+IL-22+T cells in malignant pleural effusion and stimulating CD4+ IL-22+ T cells to secrete IL-22. Recently, the Notch-AhR-IL-22 axis is thought to be involved in the pathogenesis of LUAD. It is corroborated that in LUAD patients, elevated Notch1 facilitates IL-22 generation by CD4+ T cells via aryl hydrocarbon receptors (AhR) [65]. In NSCLC, Notch signaling can both promote tumorigenesis and inhibit tumor progression, which mainly depends on its regulation of the.\\n\\n### Figure 1\\nIL-22 plays four main functions during the progression of lung cancer:\\n1. Promote lung cancer cell proliferation and invasion, and inhibit lung cancer cell apoptosis.\\n2. Regulate the abundance of immune cells in lung cancer tissues and activate the inflammatory microenvironment.\\n3. Promote cancer angiogenesis.\\n4. Activate lung cancer stem cells.\\n\\n**Summary of Figure 1**: The figure illustrates the multifaceted role of IL-22 in lung cancer, highlighting its involvement in cell proliferation, immune regulation, angiogenesis, and cancer stem cell activation. The diagram likely includes various cell types and signaling pathways associated with these functions.\\n\\n```',\n", " 'images': [{'name': 'img_p2_1.png',\n", " 'height': 666,\n", " 'width': 978,\n", " 'x': 45.3543,\n", " 'y': 343.515812,\n", " 'original_width': 1890,\n", " 'original_height': 1286}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nWhen the body is in homeostasis, the most important source of IL-22 is Group 3 innate lymphoid cells (ILC3) [14]. Different from other common cytokines, IL-22 is generally thought to be produced only by hematopoietic origin immune cells, whereas it mainly acts on non-hematopoietic cells due to its receptor distribution [55]. Recently, researchers have found that non-hematopoietic cells represented by fibroblasts can also produce IL-22 under certain circumstances [11]. IL-22 is known to act by binding to its receptor (IL-22R), which is synthesized from the IL-22R1 and IL-10R2 subunits [56]. Thereinto, IL-22R1 expression is thought to be restricted to epithelial cells in organs such as the lung, liver, intestine, and skin, while the latter is universally expressed [11,57]. IL-22BP, also known as IL-22RA2, is a soluble IL-22 receptor that binds specifically to IL-22 and prevents it from binding to IL-22R1. All currently known functions of IL-22BP are achieved by inhibiting IL-22 [58,59]. Broadly speaking, the primary function of IL-22 in the body is to promote cell proliferation and tissue protection [60]. Sometimes, excessive activation of this function may lead to pathological results. This dual effect is reflected in both inflammatory and tumor-related diseases. In the short term, the production of IL-22 can play a protective role in anti-inflammatory and tumor prevention, while the uncontrolled generation of IL-22 may promote inflammation and tumor formation [13,18]. The duality of IL-22 reveals that it could be a potential drug target, and the tight regulation of IL-22 is crucial in the treatment of a variety of diseases.\\n\\nIn general, the expression levels of IL-22 in vivo are regulated by a variety of cytokines and genes. For instance, IL-1β and IL-23 can induce the production of IL-22 independently, and the two act synergistically [11]. What’s more, Cornelia Voigt described a novel mechanism whereby cancer cells promote tumor growth by releasing IL-1β to induce IL-22 production by memory CD4+ T cells [61]. According to an animal experiment, IL-1β can enhance the proliferation of epithelial cells and promote lung tumorigenesis [62]. IL-23 has been proven to promote proliferation in NSCLC by Anne-Marie Baird et al. [63]. Although IL-23 is thought to be able to induce macrophages to produce IL-22, this study by Anne-Marie Baird et al. cannot directly prove whether the proliferation-promoting effect of IL-23 on NSCLC cells is related to IL-23’s promotion of IL-22 production. IL-23 is also thought to promote the expression of IL-26 by macrophages. Like IL-22, IL-26 is part of the IL-10 family. Researchers demonstrated for the first time that IL-26 is involved in the generation of malignant pleural effusions [64]. They reported that IL-26 promotes the generation of malignant pleural effusion by mediating the infiltration of CD4+IL-22+T cells in malignant pleural effusion and stimulating CD4+ IL-22+ T cells to secrete IL-22. Recently, the Notch-AhR-IL-22 axis is thought to be involved in the pathogenesis of LUAD. It is corroborated that in LUAD patients, elevated Notch1 facilitates IL-22 generation by CD4+ T cells via aryl hydrocarbon receptors (AhR) [65]. In NSCLC, Notch signaling can both promote tumorigenesis and inhibit tumor progression, which mainly depends on its regulation of the.',\n", " 'md': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nWhen the body is in homeostasis, the most important source of IL-22 is Group 3 innate lymphoid cells (ILC3) [14]. Different from other common cytokines, IL-22 is generally thought to be produced only by hematopoietic origin immune cells, whereas it mainly acts on non-hematopoietic cells due to its receptor distribution [55]. Recently, researchers have found that non-hematopoietic cells represented by fibroblasts can also produce IL-22 under certain circumstances [11]. IL-22 is known to act by binding to its receptor (IL-22R), which is synthesized from the IL-22R1 and IL-10R2 subunits [56]. Thereinto, IL-22R1 expression is thought to be restricted to epithelial cells in organs such as the lung, liver, intestine, and skin, while the latter is universally expressed [11,57]. IL-22BP, also known as IL-22RA2, is a soluble IL-22 receptor that binds specifically to IL-22 and prevents it from binding to IL-22R1. All currently known functions of IL-22BP are achieved by inhibiting IL-22 [58,59]. Broadly speaking, the primary function of IL-22 in the body is to promote cell proliferation and tissue protection [60]. Sometimes, excessive activation of this function may lead to pathological results. This dual effect is reflected in both inflammatory and tumor-related diseases. In the short term, the production of IL-22 can play a protective role in anti-inflammatory and tumor prevention, while the uncontrolled generation of IL-22 may promote inflammation and tumor formation [13,18]. The duality of IL-22 reveals that it could be a potential drug target, and the tight regulation of IL-22 is crucial in the treatment of a variety of diseases.\\n\\nIn general, the expression levels of IL-22 in vivo are regulated by a variety of cytokines and genes. For instance, IL-1β and IL-23 can induce the production of IL-22 independently, and the two act synergistically [11]. What’s more, Cornelia Voigt described a novel mechanism whereby cancer cells promote tumor growth by releasing IL-1β to induce IL-22 production by memory CD4+ T cells [61]. According to an animal experiment, IL-1β can enhance the proliferation of epithelial cells and promote lung tumorigenesis [62]. IL-23 has been proven to promote proliferation in NSCLC by Anne-Marie Baird et al. [63]. Although IL-23 is thought to be able to induce macrophages to produce IL-22, this study by Anne-Marie Baird et al. cannot directly prove whether the proliferation-promoting effect of IL-23 on NSCLC cells is related to IL-23’s promotion of IL-22 production. IL-23 is also thought to promote the expression of IL-26 by macrophages. Like IL-22, IL-26 is part of the IL-10 family. Researchers demonstrated for the first time that IL-26 is involved in the generation of malignant pleural effusions [64]. They reported that IL-26 promotes the generation of malignant pleural effusion by mediating the infiltration of CD4+IL-22+T cells in malignant pleural effusion and stimulating CD4+ IL-22+ T cells to secrete IL-22. Recently, the Notch-AhR-IL-22 axis is thought to be involved in the pathogenesis of LUAD. It is corroborated that in LUAD patients, elevated Notch1 facilitates IL-22 generation by CD4+ T cells via aryl hydrocarbon receptors (AhR) [65]. In NSCLC, Notch signaling can both promote tumorigenesis and inhibit tumor progression, which mainly depends on its regulation of the.',\n", " 'bBox': {'x': 39, 'y': 39.68, 'w': 466.27, 'h': 11.97}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 1',\n", " 'md': '### Figure 1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': 'IL-22 plays four main functions during the progression of lung cancer:\\n1. Promote lung cancer cell proliferation and invasion, and inhibit lung cancer cell apoptosis.\\n2. Regulate the abundance of immune cells in lung cancer tissues and activate the inflammatory microenvironment.\\n3. Promote cancer angiogenesis.\\n4. Activate lung cancer stem cells.\\n\\n**Summary of Figure 1**: The figure illustrates the multifaceted role of IL-22 in lung cancer, highlighting its involvement in cell proliferation, immune regulation, angiogenesis, and cancer stem cell activation. The diagram likely includes various cell types and signaling pathways associated with these functions.\\n\\n```',\n", " 'md': 'IL-22 plays four main functions during the progression of lung cancer:\\n1. Promote lung cancer cell proliferation and invasion, and inhibit lung cancer cell apoptosis.\\n2. Regulate the abundance of immune cells in lung cancer tissues and activate the inflammatory microenvironment.\\n3. Promote cancer angiogenesis.\\n4. Activate lung cancer stem cells.\\n\\n**Summary of Figure 1**: The figure illustrates the multifaceted role of IL-22 in lung cancer, highlighting its involvement in cell proliferation, immune regulation, angiogenesis, and cancer stem cell activation. The diagram likely includes various cell types and signaling pathways associated with these functions.\\n\\n```',\n", " 'bBox': {'x': 46.75, 'y': 381.06, 'w': 241.18, 'h': 11.13}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 4,\n", " 'text': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\ntransformation between neuroendocrine and non-neuroendocrine. For patients with SCLC containing Notch active tumor cells, the\\napplication of Notch inhibitors may be an effective treatment [66]. Moreover, the expression of IL-22 is also regulated by miR-26. In\\ncutaneous T-cell lymphoma (CTCL) cells, transfection of miR-26 resulted in a remarkable decrease in the expression levels of IL-22 and\\nIL-22 mRNA [67]. In human NSCLC, Yi He et al. found that the expression levels of miR-26 were lower in tumor tissues compared to\\nparacancerous tissue. As a functional miRNA, miR-26 was further proved by the team to inhibit autophagy and induce apoptosis of\\nNSCLC cells both in vitro and in vivo [68]. On the other hand, IL-22 has also been shown to regulate other cytokines. Studies have\\nshown that the production of IL-22 generally reduces Th1-type immune responses. This action may be coordinated with the protective\\neffect of IL-22R-expressing tissue cells to reduce collateral damage in the context of infection and inflammation [69]. Besides, animal\\nexperiments have indicated that IL-22 can also promote B-cell responses by inducing CXCL13 in tertiary lymphoid follicles [70,71]. In\\nthe latest murine lung cancer model, IL-22 was discovered to induce NK cells to overexpress CD155, thus mediating the immune\\nevasion of tumor cells [72]. As a transmembrane adhesive molecule, CD155 has been proven to inhibit T and NK cell-mediated\\nanti-tumor immune responses, thereby promoting tumor progression (Fig. 2) [73–75].\\n In the occurrence and development of pulmonary diseases, IL-22 is considered to play an important role. As previously demon-\\nstrated in an epicutaneously sensitized mice experiment, IL-22 promotes the development of neutrophil and eosinophile-mediated\\nairway inflammation and airway hyperresponsiveness stimulated by intranasal antigens [76]. The conclusion implies that blocking\\nIL-22 may be helpful for the treatment of bronchial asthma. When it comes to chronic obstructive pulmonary disease (COPD), the\\nexpression levels of both IL-22 and its receptor in COPD patients were higher than those of healthy controls. This result was confirmed\\nin mice with experimental COPD induced by cigarette smoke. What’s more, researchers also found that cigarette smoke-induced\\ninappropriate activation of pulmonary neutrophils decreased in IL-22-deficient mice with COPD. This suggests that IL-22 may be\\ninvolved in the pathogenesis of COPD. The research further manifested that IL-22 promotes cigarette smoke-induced airway\\nremodeling, pulmonary neutrophil inflammation, and the impairment of pulmonary function, and is involved in the pathogenesis of\\nCOPD [77]. While in pulmonary infectious diseases such as pneumonia, tuberculosis, and pulmonary mycosis, it is thought that IL-22\\nappears to take a protective and preventive part [78–83]. For good measure, in the bleomycin-induced pulmonary fibrosis model, the\\ndegree of pulmonary fibrosis in IL-22 knockout mice was aggravated, and injection of recombinant IL-22 alleviated the severe fibrosis\\nin IL-22 knockout mice. This latest research has suggested the potential antifibrotic effect of IL-22 [84].\\n In recent years, differential expression of IL-22 has also been discovered in various specimens of lung cancer (Table 1). In the first\\nplace, the mean levels of IL-22 in the plasma of NSCLC patients were significantly higher than that of the reference cohort [21,85]. The\\nplasma levels of IL-22 were observed to elevate along with the increase in lung cancer staging [85]. In addition, Immunohistochemistry\\nanalysis showed that IL-22 expression was up-regulated in NSCLC tumor specimens in comparison to that in the adjacent tissues.\\nRT-qPCR analysis also revealed similar differences in IL-22 mRNA expression between lung cancer tissues and normal tissues [24,86].\\nInterestingly, Yi Bi et al. compared IL-22 levels between tissues and serum of patients with primary NSCLC and their paired recurrent\\nlung cancer specimens and the expression levels of IL-22 were found to be obviously up-regulated in the latter group [23]. Apart from\\nthis, IL-22 expression was also detected in bronchoalveolar lavage fluid (BALF). As reported by an article in 2016, IL-22 levels were\\n CD155\\n NK Cell L\\n T Cell\\n 1\\n IL-22 Impaired f funcion CD226 1\\n Lung metastases\\n Immune evasion oflung cancer cells\\nFig. 2. IL-22 induces NK cells to overexpress CD155, which binds to NK cell activation receptor CD226. Over-activation leads to a decrease in the\\namount of CD226 and impaired NK cell function, thereby mediating tumor cell immune escape.\\n\\n 4',\n", " 'md': '```markdown\\n## Page Content\\n\\nL. Xu et al. Heliyon 10 (2024) e35901\\n\\nThe transformation between neuroendocrine and non-neuroendocrine. For patients with SCLC containing Notch active tumor cells, the application of Notch inhibitors may be an effective treatment [66]. Moreover, the expression of IL-22 is also regulated by miR-26. In cutaneous T-cell lymphoma (CTCL) cells, transfection of miR-26 resulted in a remarkable decrease in the expression levels of IL-22 and IL-22 mRNA [67]. In human NSCLC, Yi He et al. found that the expression levels of miR-26 were lower in tumor tissues compared to paracancerous tissue. As a functional miRNA, miR-26 was further proved by the team to inhibit autophagy and induce apoptosis of NSCLC cells both in vitro and in vivo [68]. On the other hand, IL-22 has also been shown to regulate other cytokines. Studies have shown that the production of IL-22 generally reduces Th1-type immune responses. This action may be coordinated with the protective effect of IL-22R-expressing tissue cells to reduce collateral damage in the context of infection and inflammation [69]. Besides, animal experiments have indicated that IL-22 can also promote B-cell responses by inducing CXCL13 in tertiary lymphoid follicles [70,71]. In the latest murine lung cancer model, IL-22 was discovered to induce NK cells to overexpress CD155, thus mediating the immune evasion of tumor cells [72]. As a transmembrane adhesive molecule, CD155 has been proven to inhibit T and NK cell-mediated anti-tumor immune responses, thereby promoting tumor progression (Fig. 2) [73–75].\\n\\nIn the occurrence and development of pulmonary diseases, IL-22 is considered to play an important role. As previously demonstrated in an epicutaneously sensitized mice experiment, IL-22 promotes the development of neutrophil and eosinophile-mediated airway inflammation and airway hyperresponsiveness stimulated by intranasal antigens [76]. The conclusion implies that blocking IL-22 may be helpful for the treatment of bronchial asthma. When it comes to chronic obstructive pulmonary disease (COPD), the expression levels of both IL-22 and its receptor in COPD patients were higher than those of healthy controls. This result was confirmed in mice with experimental COPD induced by cigarette smoke. What’s more, researchers also found that cigarette smoke-induced inappropriate activation of pulmonary neutrophils decreased in IL-22-deficient mice with COPD. This suggests that IL-22 may be involved in the pathogenesis of COPD. The research further manifested that IL-22 promotes cigarette smoke-induced airway remodeling, pulmonary neutrophil inflammation, and the impairment of pulmonary function, and is involved in the pathogenesis of COPD [77]. While in pulmonary infectious diseases such as pneumonia, tuberculosis, and pulmonary mycosis, it is thought that IL-22 appears to take a protective and preventive part [78–83]. For good measure, in the bleomycin-induced pulmonary fibrosis model, the degree of pulmonary fibrosis in IL-22 knockout mice was aggravated, and injection of recombinant IL-22 alleviated the severe fibrosis in IL-22 knockout mice. This latest research has suggested the potential antifibrotic effect of IL-22 [84].\\n\\nIn recent years, differential expression of IL-22 has also been discovered in various specimens of lung cancer (Table 1). In the first place, the mean levels of IL-22 in the plasma of NSCLC patients were significantly higher than that of the reference cohort [21,85]. The plasma levels of IL-22 were observed to elevate along with the increase in lung cancer staging [85]. In addition, Immunohistochemistry analysis showed that IL-22 expression was up-regulated in NSCLC tumor specimens in comparison to that in the adjacent tissues. RT-qPCR analysis also revealed similar differences in IL-22 mRNA expression between lung cancer tissues and normal tissues [24,86]. Interestingly, Yi Bi et al. compared IL-22 levels between tissues and serum of patients with primary NSCLC and their paired recurrent lung cancer specimens and the expression levels of IL-22 were found to be obviously up-regulated in the latter group [23]. Apart from this, IL-22 expression was also detected in bronchoalveolar lavage fluid (BALF). As reported by an article in 2016, IL-22 levels were .\\n\\n## Figure Description\\n\\n**Figure 2**: IL-22 induces NK cells to overexpress CD155, which binds to NK cell activation receptor CD226. Over-activation leads to a decrease in the amount of CD226 and impaired NK cell function, thereby mediating tumor cell immune escape.\\n\\n- **Summary**: This figure illustrates the mechanism by which IL-22 influences NK cell activity through the overexpression of CD155, leading to immune evasion by tumor cells. The diagram likely includes arrows indicating the interactions between IL-22, NK cells, and CD155, as well as the resulting effects on immune function.\\n```',\n", " 'images': [{'name': 'img_p3_1.png',\n", " 'height': 527,\n", " 'width': 766,\n", " 'x': 94.337,\n", " 'y': 417.552202,\n", " 'original_width': 1481,\n", " 'original_height': 1018}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nThe transformation between neuroendocrine and non-neuroendocrine. For patients with SCLC containing Notch active tumor cells, the application of Notch inhibitors may be an effective treatment [66]. Moreover, the expression of IL-22 is also regulated by miR-26. In cutaneous T-cell lymphoma (CTCL) cells, transfection of miR-26 resulted in a remarkable decrease in the expression levels of IL-22 and IL-22 mRNA [67]. In human NSCLC, Yi He et al. found that the expression levels of miR-26 were lower in tumor tissues compared to paracancerous tissue. As a functional miRNA, miR-26 was further proved by the team to inhibit autophagy and induce apoptosis of NSCLC cells both in vitro and in vivo [68]. On the other hand, IL-22 has also been shown to regulate other cytokines. Studies have shown that the production of IL-22 generally reduces Th1-type immune responses. This action may be coordinated with the protective effect of IL-22R-expressing tissue cells to reduce collateral damage in the context of infection and inflammation [69]. Besides, animal experiments have indicated that IL-22 can also promote B-cell responses by inducing CXCL13 in tertiary lymphoid follicles [70,71]. In the latest murine lung cancer model, IL-22 was discovered to induce NK cells to overexpress CD155, thus mediating the immune evasion of tumor cells [72]. As a transmembrane adhesive molecule, CD155 has been proven to inhibit T and NK cell-mediated anti-tumor immune responses, thereby promoting tumor progression (Fig. 2) [73–75].\\n\\nIn the occurrence and development of pulmonary diseases, IL-22 is considered to play an important role. As previously demonstrated in an epicutaneously sensitized mice experiment, IL-22 promotes the development of neutrophil and eosinophile-mediated airway inflammation and airway hyperresponsiveness stimulated by intranasal antigens [76]. The conclusion implies that blocking IL-22 may be helpful for the treatment of bronchial asthma. When it comes to chronic obstructive pulmonary disease (COPD), the expression levels of both IL-22 and its receptor in COPD patients were higher than those of healthy controls. This result was confirmed in mice with experimental COPD induced by cigarette smoke. What’s more, researchers also found that cigarette smoke-induced inappropriate activation of pulmonary neutrophils decreased in IL-22-deficient mice with COPD. This suggests that IL-22 may be involved in the pathogenesis of COPD. The research further manifested that IL-22 promotes cigarette smoke-induced airway remodeling, pulmonary neutrophil inflammation, and the impairment of pulmonary function, and is involved in the pathogenesis of COPD [77]. While in pulmonary infectious diseases such as pneumonia, tuberculosis, and pulmonary mycosis, it is thought that IL-22 appears to take a protective and preventive part [78–83]. For good measure, in the bleomycin-induced pulmonary fibrosis model, the degree of pulmonary fibrosis in IL-22 knockout mice was aggravated, and injection of recombinant IL-22 alleviated the severe fibrosis in IL-22 knockout mice. This latest research has suggested the potential antifibrotic effect of IL-22 [84].\\n\\nIn recent years, differential expression of IL-22 has also been discovered in various specimens of lung cancer (Table 1). In the first place, the mean levels of IL-22 in the plasma of NSCLC patients were significantly higher than that of the reference cohort [21,85]. The plasma levels of IL-22 were observed to elevate along with the increase in lung cancer staging [85]. In addition, Immunohistochemistry analysis showed that IL-22 expression was up-regulated in NSCLC tumor specimens in comparison to that in the adjacent tissues. RT-qPCR analysis also revealed similar differences in IL-22 mRNA expression between lung cancer tissues and normal tissues [24,86]. Interestingly, Yi Bi et al. compared IL-22 levels between tissues and serum of patients with primary NSCLC and their paired recurrent lung cancer specimens and the expression levels of IL-22 were found to be obviously up-regulated in the latter group [23]. Apart from this, IL-22 expression was also detected in bronchoalveolar lavage fluid (BALF). As reported by an article in 2016, IL-22 levels were .',\n", " 'md': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nThe transformation between neuroendocrine and non-neuroendocrine. For patients with SCLC containing Notch active tumor cells, the application of Notch inhibitors may be an effective treatment [66]. Moreover, the expression of IL-22 is also regulated by miR-26. In cutaneous T-cell lymphoma (CTCL) cells, transfection of miR-26 resulted in a remarkable decrease in the expression levels of IL-22 and IL-22 mRNA [67]. In human NSCLC, Yi He et al. found that the expression levels of miR-26 were lower in tumor tissues compared to paracancerous tissue. As a functional miRNA, miR-26 was further proved by the team to inhibit autophagy and induce apoptosis of NSCLC cells both in vitro and in vivo [68]. On the other hand, IL-22 has also been shown to regulate other cytokines. Studies have shown that the production of IL-22 generally reduces Th1-type immune responses. This action may be coordinated with the protective effect of IL-22R-expressing tissue cells to reduce collateral damage in the context of infection and inflammation [69]. Besides, animal experiments have indicated that IL-22 can also promote B-cell responses by inducing CXCL13 in tertiary lymphoid follicles [70,71]. In the latest murine lung cancer model, IL-22 was discovered to induce NK cells to overexpress CD155, thus mediating the immune evasion of tumor cells [72]. As a transmembrane adhesive molecule, CD155 has been proven to inhibit T and NK cell-mediated anti-tumor immune responses, thereby promoting tumor progression (Fig. 2) [73–75].\\n\\nIn the occurrence and development of pulmonary diseases, IL-22 is considered to play an important role. As previously demonstrated in an epicutaneously sensitized mice experiment, IL-22 promotes the development of neutrophil and eosinophile-mediated airway inflammation and airway hyperresponsiveness stimulated by intranasal antigens [76]. The conclusion implies that blocking IL-22 may be helpful for the treatment of bronchial asthma. When it comes to chronic obstructive pulmonary disease (COPD), the expression levels of both IL-22 and its receptor in COPD patients were higher than those of healthy controls. This result was confirmed in mice with experimental COPD induced by cigarette smoke. What’s more, researchers also found that cigarette smoke-induced inappropriate activation of pulmonary neutrophils decreased in IL-22-deficient mice with COPD. This suggests that IL-22 may be involved in the pathogenesis of COPD. The research further manifested that IL-22 promotes cigarette smoke-induced airway remodeling, pulmonary neutrophil inflammation, and the impairment of pulmonary function, and is involved in the pathogenesis of COPD [77]. While in pulmonary infectious diseases such as pneumonia, tuberculosis, and pulmonary mycosis, it is thought that IL-22 appears to take a protective and preventive part [78–83]. For good measure, in the bleomycin-induced pulmonary fibrosis model, the degree of pulmonary fibrosis in IL-22 knockout mice was aggravated, and injection of recombinant IL-22 alleviated the severe fibrosis in IL-22 knockout mice. This latest research has suggested the potential antifibrotic effect of IL-22 [84].\\n\\nIn recent years, differential expression of IL-22 has also been discovered in various specimens of lung cancer (Table 1). In the first place, the mean levels of IL-22 in the plasma of NSCLC patients were significantly higher than that of the reference cohort [21,85]. The plasma levels of IL-22 were observed to elevate along with the increase in lung cancer staging [85]. In addition, Immunohistochemistry analysis showed that IL-22 expression was up-regulated in NSCLC tumor specimens in comparison to that in the adjacent tissues. RT-qPCR analysis also revealed similar differences in IL-22 mRNA expression between lung cancer tissues and normal tissues [24,86]. Interestingly, Yi Bi et al. compared IL-22 levels between tissues and serum of patients with primary NSCLC and their paired recurrent lung cancer specimens and the expression levels of IL-22 were found to be obviously up-regulated in the latter group [23]. Apart from this, IL-22 expression was also detected in bronchoalveolar lavage fluid (BALF). As reported by an article in 2016, IL-22 levels were .',\n", " 'bBox': {'x': 39, 'y': 39.68, 'w': 466.27, 'h': 31.51}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure Description',\n", " 'md': '## Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': '**Figure 2**: IL-22 induces NK cells to overexpress CD155, which binds to NK cell activation receptor CD226. Over-activation leads to a decrease in the amount of CD226 and impaired NK cell function, thereby mediating tumor cell immune escape.\\n\\n- **Summary**: This figure illustrates the mechanism by which IL-22 influences NK cell activity through the overexpression of CD155, leading to immune evasion by tumor cells. The diagram likely includes arrows indicating the interactions between IL-22, NK cells, and CD155, as well as the resulting effects on immune function.\\n```',\n", " 'md': '**Figure 2**: IL-22 induces NK cells to overexpress CD155, which binds to NK cell activation receptor CD226. Over-activation leads to a decrease in the amount of CD226 and impaired NK cell function, thereby mediating tumor cell immune escape.\\n\\n- **Summary**: This figure illustrates the mechanism by which IL-22 influences NK cell activity through the overexpression of CD155, leading to immune evasion by tumor cells. The diagram likely includes arrows indicating the interactions between IL-22, NK cells, and CD155, as well as the resulting effects on immune function.\\n```',\n", " 'bBox': {'x': 39, 'y': 428.67, 'w': 384.88, 'h': 31.51}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '– 75].'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '– 83]. For good measure, in the bleomycin-induced pulmonary fibrosis model, the'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 5,\n", " 'text': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nTable 1\\nDifferential expression of IL-22/IL-22 mRNA/IL-22R1 mRNA in various samples in lung cancer. +: Up-regulated.\\n Molecule Samples Expression P value Ref. (PMID)\\n IL-22 Plasma þ 0.0013 24956177\\n IL-22 mRNA Tissues þ 0.0313 18927282\\n IL-22 Pleural effusion þ 0.0051 18927282\\n IL-22 mRNA, IL-22 Tissues, serum þ <0.01 26983629\\n IL-22R1 mRNA Tissues þ <0.05 26983629\\n IL-22 BALF þ <0.001 27388918\\n\\nsignificantly higher in BALF from lung cancer patients compared with control group. The researchers expanded the cohort to patients\\nwith lung metastases from other malignancies and found that IL-22 concentrations remained higher than controls [87]. These results\\nimplied that IL-22 in BALF may be a biomarker for lung cancer. Over and above, researchers also found the trace of IL-22 in pleural\\neffusion [88,89]. One study has revealed that IL-22 levels were higher in malignant pleural effusion as against tuberculous pleural\\neffusion [24]. These differential expressions prompt that IL-22 may participate in the occurrence and development of lung cancer\\n(Table 2).\\n The link between inflammatory processes and cancer has long been recognized [90]. Related studies hint that inflammatory re-\\nsponses play a vital role in different phases of tumor occurrence, development, and metastasis [91–93]. The function of IL-22 in cancer\\nis extremely complicated. Initially, IL-22 may prevent tumorigenesis by reducing chronic inflammation, promoting barrier function,\\nand inducing tissue regeneration. On the contrary, if IL-22 is excessively expressed under persistent chronic inflammation, then\\nmalignant cells may utilize this signal to facilitate its progression [11]. In the lung tumor microenvironment, uncontrolled expression\\nof IL-22 can amplify inflammation by inducing various inflammatory mediators alone or in concert with other cytokines [94]. As\\nillustrated by a cellular experiment, IL-22 could promote the proliferation of A549 and H125 cells belonging to the NSCLC cell lines,\\nthereby enhancing the ability of tumor cell migration and invasion [23]. An in vitro experiment in 2018 has confirmed that IL-22 can\\ndirectly act on endothelial cells to stimulate tumor angiogenesis [95]. To some extent, this enhances the ability of tumor cells to absorb\\nnutrients and distant metastasis. From another perspective, this provides new ideas for anti-angiogenic therapy of tumors. Nasim\\nKhosravi suggested that IL-22 promotes tumor progression by inducing a pro-tumor immune response and protective stem cell\\nproperties of tumor cells [94]. It is also reported that after 12h of serum starvation, the proportion of apoptotic lung cancer cells\\ntransfected with the IL-22 gene was significantly lower than that of control lung cancer cells. In addition, the apoptosis-inducing and\\nanti-proliferative effects of chemotherapeutic drugs on lung cancer cells were inhibited in IL-22 transgenic cell lines [24]. Simulta-\\nneously, the apoptosis of lung cancer cells induced by gefitinib was also significantly reduced 48 h after IL-22 exposure [96]. On the\\ncontrary, exposure to IL-22R1 blocking antibodies or in vitro transfection of IL-22-RNA interference plasmid leads to apoptosis of lung\\ncancer cells [24]. Zhiliang Huang et al. found that the apoptosis rate of paclitaxel-treated lung cancer cells in the IL-22 siRNA\\ntransfection group was significantly increased compared with the control group [22]. Apart from this, IL-22 antibody treated mice and\\nIL-22-deficient mice were found to be protected from the formation of pulmonary metastases caused by colon cancer, while IL-22\\noverexpression promoted metastases [20]. In short, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of\\nlung cancer cells by anti-tumor drugs but also promotes the proliferation and migration of lung cancer cells, the growth of tumor\\ntissues, and the generation of lung metastatic cancer.\\n\\n4. Regulatory role of IL-22 in lung cancer\\n\\n Numerous signaling pathways are involved in the regulation of IL-22 in lung cancer, including PI3K/AKT, JAK-STAT3, p38 MAPK\\nsignaling pathways, and so on. In the following, we will elaborate on the regulatory role of IL-22 in lung cancer from the point of view\\nof each major signaling pathway (Fig. 3).\\n\\nTable 2\\nPotential clinical role of IL-22, its receptors and producing cells in lung cancer.\\n Sample Clinical function Conclusion Ref. (PMID)\\n sources\\n Patients Diagnosis IL-22 levels were significantly higher in lung cancer patients than control group. 24956177,\\n 27388918\\n Patients Prognosis IL-22R1 levels were associated with poorer prognosis. 26846835\\n assessment\\n Patients Disease assessment The levels of IL-22-producing Th22 cells were positively correlated with TNM stage and lymph node 35669104\\n metastasis.\\n Patients Efficacy prediction IL-22 expression levels were associated with EGFR-TKI efficacy. 31750252\\n Mice model Treatment IL-22-deficient mice had a lower metastatic load of lung cancer. 36630913\\n Mice model Treatment Gene ablation of IL-22 resulted in a marked reduction in the number and size of lung tumors. 29764837\\n\\n 5',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Table 1\\nDifferential expression of IL-22/IL-22 mRNA/IL-22R1 mRNA in various samples in lung cancer. +: Up-regulated.\\n\\n| Molecule | Samples | Expression | P value | Ref. (PMID) |\\n|---------------------|----------------------------------|------------|----------|--------------|\\n| IL-22 | Plasma | + | 0.0013 | 24956177 |\\n| IL-22 mRNA | Tissues | + | 0.0313 | 18927282 |\\n| IL-22 | Pleural effusion | + | 0.0051 | 18927282 |\\n| IL-22 mRNA, IL-22 | Tissues, serum | + | <0.01 | 26983629 |\\n| IL-22R1 mRNA | Tissues | + | <0.05 | 26983629 |\\n| IL-22 | BALF | + | <0.001 | 27388918 |\\n\\nIL-22 is significantly higher in BALF from lung cancer patients compared with the control group. The researchers expanded the cohort to patients with lung metastases from other malignancies and found that IL-22 concentrations remained higher than controls. These results implied that IL-22 in BALF may be a biomarker for lung cancer. Additionally, researchers found traces of IL-22 in pleural effusion. One study revealed that IL-22 levels were higher in malignant pleural effusion compared to tuberculous pleural effusion. These differential expressions suggest that IL-22 may participate in the occurrence and development of lung cancer (Table 2).\\n\\nThe link between inflammatory processes and cancer has long been recognized. Related studies indicate that inflammatory responses play a vital role in different phases of tumor occurrence, development, and metastasis. The function of IL-22 in cancer is extremely complicated. Initially, IL-22 may prevent tumorigenesis by reducing chronic inflammation, promoting barrier function, and inducing tissue regeneration. Conversely, if IL-22 is excessively expressed under persistent chronic inflammation, malignant cells may utilize this signal to facilitate its progression. In the lung tumor microenvironment, uncontrolled expression of IL-22 can amplify inflammation by inducing various inflammatory mediators alone or in concert with other cytokines.\\n\\nAs illustrated by a cellular experiment, IL-22 could promote the proliferation of A549 and H125 cells belonging to the NSCLC cell lines, thereby enhancing the ability of tumor cell migration and invasion. An in vitro experiment in 2018 confirmed that IL-22 can directly act on endothelial cells to stimulate tumor angiogenesis. This enhances the ability of tumor cells to absorb nutrients and facilitates distant metastasis. From another perspective, this provides new ideas for anti-angiogenic therapy of tumors.\\n\\nNasim Khosravi suggested that IL-22 promotes tumor progression by inducing a pro-tumor immune response and protective stem cell properties of tumor cells. It is reported that after 12 hours of serum starvation, the proportion of apoptotic lung cancer cells transfected with the IL-22 gene was significantly lower than that of control lung cancer cells. Additionally, the apoptosis-inducing and anti-proliferative effects of chemotherapeutic drugs on lung cancer cells were inhibited in IL-22 transgenic cell lines. Simultaneously, the apoptosis of lung cancer cells induced by gefitinib was significantly reduced 48 hours after IL-22 exposure. Conversely, exposure to IL-22R1 blocking antibodies or in vitro transfection of IL-22-RNA interference plasmid leads to apoptosis of lung cancer cells.\\n\\nZhiliang Huang et al. found that the apoptosis rate of paclitaxel-treated lung cancer cells in the IL-22 siRNA transfection group was significantly increased compared with the control group. Apart from this, IL-22 antibody treated mice and IL-22-deficient mice were found to be protected from the formation of pulmonary metastases caused by colon cancer, while IL-22 overexpression promoted metastases. In short, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and migration of lung cancer cells, the growth of tumor tissues, and the generation of lung metastatic cancer.\\n\\n## Regulatory role of IL-22 in lung cancer\\n\\nNumerous signaling pathways are involved in the regulation of IL-22 in lung cancer, including PI3K/AKT, JAK-STAT3, p38 MAPK signaling pathways, and so on. In the following, we will elaborate on the regulatory role of IL-22 in lung cancer from the point of view of each major signaling pathway (Figure 3).\\n\\n## Table 2\\nPotential clinical role of IL-22, its receptors and producing cells in lung cancer.\\n\\n| Sample | Clinical function | Conclusion | Ref. (PMID) |\\n|---------------|---------------------------|----------------------------------------------------------------------------------------------------------------|-----------------------------|\\n| Patients | Diagnosis | IL-22 levels were significantly higher in lung cancer patients than control group. | 24956177, 27388918 |\\n| Patients | Prognosis assessment | IL-22R1 levels were associated with poorer prognosis. | 26846835 |\\n| Patients | Disease assessment | The levels of IL-22-producing Th22 cells were positively correlated with TNM stage and lymph node metastasis. | 35669104 |\\n| Patients | Efficacy prediction | IL-22 expression levels were associated with EGFR-TKI efficacy. | 31750252 |\\n| Mice model | Treatment | IL-22-deficient mice had a lower metastatic load of lung cancer. | 36630913 |\\n| Mice model | Treatment | Gene ablation of IL-22 resulted in a marked reduction in the number and size of lung tumors. | 29764837 |\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 1',\n", " 'md': '## Table 1',\n", " 'bBox': {'x': 39, 'y': 59.68, 'w': 25.19, 'h': 7.17}},\n", " {'type': 'text',\n", " 'value': 'Differential expression of IL-22/IL-22 mRNA/IL-22R1 mRNA in various samples in lung cancer. +: Up-regulated.',\n", " 'md': 'Differential expression of IL-22/IL-22 mRNA/IL-22R1 mRNA in various samples in lung cancer. +: Up-regulated.',\n", " 'bBox': {'x': 39, 'y': 69.68, 'w': 358.54, 'h': 7.17}},\n", " {'type': 'table',\n", " 'rows': [['Molecule', 'Samples', 'Expression', 'P value', 'Ref. (PMID)'],\n", " ['IL-22', 'Plasma', '+', '0.0013', '24956177'],\n", " ['IL-22 mRNA', 'Tissues', '+', '0.0313', '18927282'],\n", " ['IL-22', 'Pleural effusion', '+', '0.0051', '18927282'],\n", " ['IL-22 mRNA, IL-22', 'Tissues, serum', '+', '<0.01', '26983629'],\n", " ['IL-22R1 mRNA', 'Tissues', '+', '<0.05', '26983629'],\n", " ['IL-22', 'BALF', '+', '<0.001', '27388918']],\n", " 'md': '| Molecule | Samples | Expression | P value | Ref. (PMID) |\\n|---------------------|----------------------------------|------------|----------|--------------|\\n| IL-22 | Plasma | + | 0.0013 | 24956177 |\\n| IL-22 mRNA | Tissues | + | 0.0313 | 18927282 |\\n| IL-22 | Pleural effusion | + | 0.0051 | 18927282 |\\n| IL-22 mRNA, IL-22 | Tissues, serum | + | <0.01 | 26983629 |\\n| IL-22R1 mRNA | Tissues | + | <0.05 | 26983629 |\\n| IL-22 | BALF | + | <0.001 | 27388918 |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Molecule\",\"Samples\",\"Expression\",\"P value\",\"Ref. (PMID)\"\\n\"IL-22\",\"Plasma\",\"+\",\"0.0013\",\"24956177\"\\n\"IL-22 mRNA\",\"Tissues\",\"+\",\"0.0313\",\"18927282\"\\n\"IL-22\",\"Pleural effusion\",\"+\",\"0.0051\",\"18927282\"\\n\"IL-22 mRNA, IL-22\",\"Tissues, serum\",\"+\",\"<0.01\",\"26983629\"\\n\"IL-22R1 mRNA\",\"Tissues\",\"+\",\"<0.05\",\"26983629\"\\n\"IL-22\",\"BALF\",\"+\",\"<0.001\",\"27388918\"',\n", " 'bBox': {'x': 44, 'y': 82.68, 'w': 53.49, 'h': 6.38}},\n", " {'type': 'text',\n", " 'value': 'IL-22 is significantly higher in BALF from lung cancer patients compared with the control group. The researchers expanded the cohort to patients with lung metastases from other malignancies and found that IL-22 concentrations remained higher than controls. These results implied that IL-22 in BALF may be a biomarker for lung cancer. Additionally, researchers found traces of IL-22 in pleural effusion. One study revealed that IL-22 levels were higher in malignant pleural effusion compared to tuberculous pleural effusion. These differential expressions suggest that IL-22 may participate in the occurrence and development of lung cancer (Table 2).\\n\\nThe link between inflammatory processes and cancer has long been recognized. Related studies indicate that inflammatory responses play a vital role in different phases of tumor occurrence, development, and metastasis. The function of IL-22 in cancer is extremely complicated. Initially, IL-22 may prevent tumorigenesis by reducing chronic inflammation, promoting barrier function, and inducing tissue regeneration. Conversely, if IL-22 is excessively expressed under persistent chronic inflammation, malignant cells may utilize this signal to facilitate its progression. In the lung tumor microenvironment, uncontrolled expression of IL-22 can amplify inflammation by inducing various inflammatory mediators alone or in concert with other cytokines.\\n\\nAs illustrated by a cellular experiment, IL-22 could promote the proliferation of A549 and H125 cells belonging to the NSCLC cell lines, thereby enhancing the ability of tumor cell migration and invasion. An in vitro experiment in 2018 confirmed that IL-22 can directly act on endothelial cells to stimulate tumor angiogenesis. This enhances the ability of tumor cells to absorb nutrients and facilitates distant metastasis. From another perspective, this provides new ideas for anti-angiogenic therapy of tumors.\\n\\nNasim Khosravi suggested that IL-22 promotes tumor progression by inducing a pro-tumor immune response and protective stem cell properties of tumor cells. It is reported that after 12 hours of serum starvation, the proportion of apoptotic lung cancer cells transfected with the IL-22 gene was significantly lower than that of control lung cancer cells. Additionally, the apoptosis-inducing and anti-proliferative effects of chemotherapeutic drugs on lung cancer cells were inhibited in IL-22 transgenic cell lines. Simultaneously, the apoptosis of lung cancer cells induced by gefitinib was significantly reduced 48 hours after IL-22 exposure. Conversely, exposure to IL-22R1 blocking antibodies or in vitro transfection of IL-22-RNA interference plasmid leads to apoptosis of lung cancer cells.\\n\\nZhiliang Huang et al. found that the apoptosis rate of paclitaxel-treated lung cancer cells in the IL-22 siRNA transfection group was significantly increased compared with the control group. Apart from this, IL-22 antibody treated mice and IL-22-deficient mice were found to be protected from the formation of pulmonary metastases caused by colon cancer, while IL-22 overexpression promoted metastases. In short, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and migration of lung cancer cells, the growth of tumor tissues, and the generation of lung metastatic cancer.',\n", " 'md': 'IL-22 is significantly higher in BALF from lung cancer patients compared with the control group. The researchers expanded the cohort to patients with lung metastases from other malignancies and found that IL-22 concentrations remained higher than controls. These results implied that IL-22 in BALF may be a biomarker for lung cancer. Additionally, researchers found traces of IL-22 in pleural effusion. One study revealed that IL-22 levels were higher in malignant pleural effusion compared to tuberculous pleural effusion. These differential expressions suggest that IL-22 may participate in the occurrence and development of lung cancer (Table 2).\\n\\nThe link between inflammatory processes and cancer has long been recognized. Related studies indicate that inflammatory responses play a vital role in different phases of tumor occurrence, development, and metastasis. The function of IL-22 in cancer is extremely complicated. Initially, IL-22 may prevent tumorigenesis by reducing chronic inflammation, promoting barrier function, and inducing tissue regeneration. Conversely, if IL-22 is excessively expressed under persistent chronic inflammation, malignant cells may utilize this signal to facilitate its progression. In the lung tumor microenvironment, uncontrolled expression of IL-22 can amplify inflammation by inducing various inflammatory mediators alone or in concert with other cytokines.\\n\\nAs illustrated by a cellular experiment, IL-22 could promote the proliferation of A549 and H125 cells belonging to the NSCLC cell lines, thereby enhancing the ability of tumor cell migration and invasion. An in vitro experiment in 2018 confirmed that IL-22 can directly act on endothelial cells to stimulate tumor angiogenesis. This enhances the ability of tumor cells to absorb nutrients and facilitates distant metastasis. From another perspective, this provides new ideas for anti-angiogenic therapy of tumors.\\n\\nNasim Khosravi suggested that IL-22 promotes tumor progression by inducing a pro-tumor immune response and protective stem cell properties of tumor cells. It is reported that after 12 hours of serum starvation, the proportion of apoptotic lung cancer cells transfected with the IL-22 gene was significantly lower than that of control lung cancer cells. Additionally, the apoptosis-inducing and anti-proliferative effects of chemotherapeutic drugs on lung cancer cells were inhibited in IL-22 transgenic cell lines. Simultaneously, the apoptosis of lung cancer cells induced by gefitinib was significantly reduced 48 hours after IL-22 exposure. Conversely, exposure to IL-22R1 blocking antibodies or in vitro transfection of IL-22-RNA interference plasmid leads to apoptosis of lung cancer cells.\\n\\nZhiliang Huang et al. found that the apoptosis rate of paclitaxel-treated lung cancer cells in the IL-22 siRNA transfection group was significantly increased compared with the control group. Apart from this, IL-22 antibody treated mice and IL-22-deficient mice were found to be protected from the formation of pulmonary metastases caused by colon cancer, while IL-22 overexpression promoted metastases. In short, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and migration of lung cancer cells, the growth of tumor tissues, and the generation of lung metastatic cancer.',\n", " 'bBox': {'x': 39, 'y': 82.68, 'w': 466.25, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Regulatory role of IL-22 in lung cancer',\n", " 'md': '## Regulatory role of IL-22 in lung cancer',\n", " 'bBox': {'x': 44, 'y': 95.68, 'w': 149.09, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': 'Numerous signaling pathways are involved in the regulation of IL-22 in lung cancer, including PI3K/AKT, JAK-STAT3, p38 MAPK signaling pathways, and so on. In the following, we will elaborate on the regulatory role of IL-22 in lung cancer from the point of view of each major signaling pathway (Figure 3).',\n", " 'md': 'Numerous signaling pathways are involved in the regulation of IL-22 in lung cancer, including PI3K/AKT, JAK-STAT3, p38 MAPK signaling pathways, and so on. In the following, we will elaborate on the regulatory role of IL-22 in lung cancer from the point of view of each major signaling pathway (Figure 3).',\n", " 'bBox': {'x': 39, 'y': 95.68, 'w': 466.23, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 2',\n", " 'md': '## Table 2',\n", " 'bBox': {'x': 39, 'y': 569.68, 'w': 25.19, 'h': 7.17}},\n", " {'type': 'text',\n", " 'value': 'Potential clinical role of IL-22, its receptors and producing cells in lung cancer.',\n", " 'md': 'Potential clinical role of IL-22, its receptors and producing cells in lung cancer.',\n", " 'bBox': {'x': 39, 'y': 95.68, 'w': 252.05, 'h': 7.17}},\n", " {'type': 'table',\n", " 'rows': [['Sample', 'Clinical function', 'Conclusion', 'Ref. (PMID)'],\n", " ['Patients',\n", " 'Diagnosis',\n", " 'IL-22 levels were significantly higher in lung cancer patients than control group.',\n", " '24956177, 27388918'],\n", " ['Patients',\n", " 'Prognosis assessment',\n", " 'IL-22R1 levels were associated with poorer prognosis.',\n", " '26846835'],\n", " ['Patients',\n", " 'Disease assessment',\n", " 'The levels of IL-22-producing Th22 cells were positively correlated with TNM stage and lymph node metastasis.',\n", " '35669104'],\n", " ['Patients',\n", " 'Efficacy prediction',\n", " 'IL-22 expression levels were associated with EGFR-TKI efficacy.',\n", " '31750252'],\n", " ['Mice model',\n", " 'Treatment',\n", " 'IL-22-deficient mice had a lower metastatic load of lung cancer.',\n", " '36630913'],\n", " ['Mice model',\n", " 'Treatment',\n", " 'Gene ablation of IL-22 resulted in a marked reduction in the number and size of lung tumors.',\n", " '29764837']],\n", " 'md': '| Sample | Clinical function | Conclusion | Ref. (PMID) |\\n|---------------|---------------------------|----------------------------------------------------------------------------------------------------------------|-----------------------------|\\n| Patients | Diagnosis | IL-22 levels were significantly higher in lung cancer patients than control group. | 24956177, 27388918 |\\n| Patients | Prognosis assessment | IL-22R1 levels were associated with poorer prognosis. | 26846835 |\\n| Patients | Disease assessment | The levels of IL-22-producing Th22 cells were positively correlated with TNM stage and lymph node metastasis. | 35669104 |\\n| Patients | Efficacy prediction | IL-22 expression levels were associated with EGFR-TKI efficacy. | 31750252 |\\n| Mice model | Treatment | IL-22-deficient mice had a lower metastatic load of lung cancer. | 36630913 |\\n| Mice model | Treatment | Gene ablation of IL-22 resulted in a marked reduction in the number and size of lung tumors. | 29764837 |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Sample\",\"Clinical function\",\"Conclusion\",\"Ref. (PMID)\"\\n\"Patients\",\"Diagnosis\",\"IL-22 levels were significantly higher in lung cancer patients than control group.\",\"24956177, 27388918\"\\n\"Patients\",\"Prognosis assessment\",\"IL-22R1 levels were associated with poorer prognosis.\",\"26846835\"\\n\"Patients\",\"Disease assessment\",\"The levels of IL-22-producing Th22 cells were positively correlated with TNM stage and lymph node metastasis.\",\"35669104\"\\n\"Patients\",\"Efficacy prediction\",\"IL-22 expression levels were associated with EGFR-TKI efficacy.\",\"31750252\"\\n\"Mice model\",\"Treatment\",\"IL-22-deficient mice had a lower metastatic load of lung cancer.\",\"36630913\"\\n\"Mice model\",\"Treatment\",\"Gene ablation of IL-22 resulted in a marked reduction in the number and size of lung tumors.\",\"29764837\"',\n", " 'bBox': {'x': 44, 'y': 82.68, 'w': 284.34, 'h': 516.38}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '– 93]. The function of IL-22 in cancer'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 6,\n", " 'text': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\n4.1. PI3K/Akt signaling pathway\\n\\n PI3K/AKT signaling pathway is one of the core intracellular signaling pathways, which plays a critical role in regulating cell\\ngrowth, survival, metabolism, movement, and proliferation [97]. As a downstream effector of receptor tyrosine kinases (RTKs) and\\nG-protein-coupled receptors (GPCRs), PI3K is a group of lipid kinases consisting of three subunits. It can be divided into three cate-\\ngories according to various functions and structures. Thereinto Class IA PI3K is a heterodimer of the p110 catalytic subunit and the p58\\nregulatory subunit, and it is primarily related to human tumors [98,99]. As we all know, PI3K can catalyze phosphatidylinositol [4,\\n5]-bisphosphate (PIP2) to phosphatidylinositol [3–5]-trisphosphate (PIP3). Serine/threonine protein kinase (AKT), as the main\\ndownstream molecule of the PI3K signaling pathway, is mainly activated by PIP3-driven plasma membrane recruitment and phos-\\nphorylation. The mammalian target of rapamycin (mTOR), a major downstream signaling molecule in the PIK3/AKT signaling\\npathway, is considered to be a modified protein kinase in the form of mTORC1 and mTORC2. The first is mainly activated by the\\nPI3K/AKT signaling pathway, and mTORC2 further activates AKT by directly phosphorylating its hydrophobic motif (Ser473) [100].\\nPI3K/Akt signaling pathway is considered to be the chief regulatory factor of idiopathic pulmonary fibrosis (IPF), it may directly\\nparticipate in the formation of IPF or promote the occurrence and development of fibrosis in collaboration with other pathways [97].\\nSeveral studies have declared that certain natural products like resveratrol and Danhong injection can provide neuroprotective effects\\nby activating the PI3K/AKT/mTOR signaling pathway [101,102]. Furthermore, the relationship between the PI3K/AKT/mTOR\\nsignaling pathway and cancer has been most intensively studied. Activation of the PI3K/AKT/mTOR signaling pathway is believed to\\npromote the occurrence, proliferation, and progression of a variety of cancers, including breast cancer, ovarian cancer, prostate cancer,\\netc. [99,100,103]. In addition, it is also an important cause of tumor drug resistance [104]. In NSCLC, KRAS, EGFR, and PTEN mu-\\ntations are believed to activate the PI3K/Akt/mTOR signaling pathway [105]. As demonstrated in a previous article, upregulation of\\nthe PI3K signaling pathway was identified as an early and reversible event in the pathogenesis of NSCLC [106]. One experiment has\\nconfirmed that the PI3K/AKT signaling pathway promotes the proliferation of LUAD cells mainly through anti-apoptosis [107].\\nAdditionally, as revealed in a cellular study, IL-22 produced by CAFs markedly improves the proliferation and invasion of lung cancer\\ncell, and lessens apoptosis by activating the PI3K/Akt/mTOR signaling pathway [86]. For good measure, it has been found that AKT\\nphosphorylation in NSCLC cells is facilitated by different concentrations of IL-22 in a time- and dose-dependent way [23]. Collectively,\\nthe PI3K/Akt/mTOR signaling pathway plays a significant role in the relationship between IL-22 and lung cancer. It is worth\\nmentioning that IL-22 does not seem to always activate the PI3K/Akt/mTOR signaling pathway. Meng Yuxia et al. found that IL-22\\ninhibits the activity of the PI3K/AKT/mTOR signaling pathway in mouse liver fibrosis tissue [108]. This opposite finding may be\\nrelated to the dual function of IL-22. Further study on the impact of IL-22 on the PI3K/AKT/mTOR signaling pathway in different\\ndisease processes will help us better understand the specific mechanism of IL-22’s function in the human body. This will facilitate\\n IL 22\\n PI3K JAK\\n P38 MAPK\\n NK ccll\\n AKT STAT3\\n mTOR\\n Antitumor drugs Gene expression\\n Metastasis\\n Nucleus\\n Apoptosis Proliferation EMT Invasion\\n Lung tumor ccll\\nFig. 3. IL-22 promotes the proliferation, migration and epithelial-mesenchymal transition of lung cancer cells through PI3K/AKT, JAK-STAT3, p38\\nMAPK and other signaling pathways, and antagonizes the apoptosis of lung cancer cells induced by anti-tumor drugs.\\n\\n 6',\n", " 'md': '```markdown\\n# Page Content\\n\\n## 4.1. PI3K/Akt Signaling Pathway\\n\\nThe PI3K/AKT signaling pathway is one of the core intracellular signaling pathways, which plays a critical role in regulating cell growth, survival, metabolism, movement, and proliferation [97]. As a downstream effector of receptor tyrosine kinases (RTKs) and G-protein-coupled receptors (GPCRs), PI3K is a group of lipid kinases consisting of three subunits. It can be divided into three categories according to various functions and structures. Class IA PI3K is a heterodimer of the p110 catalytic subunit and the p58 regulatory subunit, and it is primarily related to human tumors [98,99].\\n\\nAs we all know, PI3K can catalyze phosphatidylinositol [4, 5]-bisphosphate (PIP2) to phosphatidylinositol [3–5]-trisphosphate (PIP3). Serine/threonine protein kinase (AKT), as the main downstream molecule of the PI3K signaling pathway, is mainly activated by PIP3-driven plasma membrane recruitment and phosphorylation. The mammalian target of rapamycin (mTOR), a major downstream signaling molecule in the PI3K/AKT signaling pathway, is considered to be a modified protein kinase in the form of mTORC1 and mTORC2. The first is mainly activated by the PI3K/AKT signaling pathway, and mTORC2 further activates AKT by directly phosphorylating its hydrophobic motif (Ser473) [100].\\n\\nThe PI3K/Akt signaling pathway is considered to be the chief regulatory factor of idiopathic pulmonary fibrosis (IPF); it may directly participate in the formation of IPF or promote the occurrence and development of fibrosis in collaboration with other pathways [97]. Several studies have declared that certain natural products like resveratrol and Danhong injection can provide neuroprotective effects by activating the PI3K/AKT/mTOR signaling pathway [101,102]. Furthermore, the relationship between the PI3K/AKT/mTOR signaling pathway and cancer has been most intensively studied. Activation of the PI3K/AKT/mTOR signaling pathway is believed to promote the occurrence, proliferation, and progression of a variety of cancers, including breast cancer, ovarian cancer, prostate cancer, etc. [99,100,103]. In addition, it is also an important cause of tumor drug resistance [104].\\n\\nIn NSCLC, KRAS, EGFR, and PTEN mutations are believed to activate the PI3K/Akt/mTOR signaling pathway [105]. As demonstrated in a previous article, upregulation of the PI3K signaling pathway was identified as an early and reversible event in the pathogenesis of NSCLC [106]. One experiment has confirmed that the PI3K/AKT signaling pathway promotes the proliferation of LUAD cells mainly through anti-apoptosis [107]. Additionally, as revealed in a cellular study, IL-22 produced by CAFs markedly improves the proliferation and invasion of lung cancer cells and lessens apoptosis by activating the PI3K/Akt/mTOR signaling pathway [86].\\n\\nFor good measure, it has been found that AKT phosphorylation in NSCLC cells is facilitated by different concentrations of IL-22 in a time- and dose-dependent way [23]. Collectively, the PI3K/Akt/mTOR signaling pathway plays a significant role in the relationship between IL-22 and lung cancer. It is worth mentioning that IL-22 does not seem to always activate the PI3K/Akt/mTOR signaling pathway. Meng Yuxia et al. found that IL-22 inhibits the activity of the PI3K/AKT/mTOR signaling pathway in mouse liver fibrosis tissue [108]. This opposite finding may be related to the dual function of IL-22. Further study on the impact of IL-22 on the PI3K/AKT/mTOR signaling pathway in different disease processes will help us better understand the specific mechanism of IL-22’s function in the human body.\\n\\n### Diagram Description\\n\\n**Figure 3**: IL-22 promotes the proliferation, migration, and epithelial-mesenchymal transition of lung cancer cells through PI3K/AKT, JAK-STAT3, p38 MAPK, and other signaling pathways, and antagonizes the apoptosis of lung cancer cells induced by anti-tumor drugs.\\n\\n- The diagram illustrates the interaction of various signaling pathways (PI3K, JAK, P38 MAPK) with IL-22 and their effects on lung cancer cells, including proliferation, migration, epithelial-mesenchymal transition (EMT), and apoptosis.\\n- The diagram includes elements such as:\\n- **IL-22**: A cytokine involved in the signaling.\\n- **PI3K**: A key signaling molecule in the pathway.\\n- **AKT**: A downstream effector activated by PI3K.\\n- **mTOR**: Another downstream target involved in cell growth and metabolism.\\n- **Gene expression**: Indicates the outcome of the signaling pathways.\\n- **Nucleus**: Represents the site of gene expression.\\n- **Lung tumor cell**: The target cells affected by these pathways.\\n\\nThe diagram visually summarizes the complex interactions and outcomes of the signaling pathways in the context of lung cancer.\\n```',\n", " 'images': [{'name': 'img_p5_1.png',\n", " 'height': 596,\n", " 'width': 675,\n", " 'x': 115.654,\n", " 'y': 385.58421200000004,\n", " 'original_width': 1304,\n", " 'original_height': 1151}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': '4.1. PI3K/Akt Signaling Pathway',\n", " 'md': '## 4.1. PI3K/Akt Signaling Pathway',\n", " 'bBox': {'x': 39, 'y': 59.68, 'w': 94.98, 'h': 9.27}},\n", " {'type': 'text',\n", " 'value': 'The PI3K/AKT signaling pathway is one of the core intracellular signaling pathways, which plays a critical role in regulating cell growth, survival, metabolism, movement, and proliferation [97]. As a downstream effector of receptor tyrosine kinases (RTKs) and G-protein-coupled receptors (GPCRs), PI3K is a group of lipid kinases consisting of three subunits. It can be divided into three categories according to various functions and structures. Class IA PI3K is a heterodimer of the p110 catalytic subunit and the p58 regulatory subunit, and it is primarily related to human tumors [98,99].\\n\\nAs we all know, PI3K can catalyze phosphatidylinositol [4, 5]-bisphosphate (PIP2) to phosphatidylinositol [3–5]-trisphosphate (PIP3). Serine/threonine protein kinase (AKT), as the main downstream molecule of the PI3K signaling pathway, is mainly activated by PIP3-driven plasma membrane recruitment and phosphorylation. The mammalian target of rapamycin (mTOR), a major downstream signaling molecule in the PI3K/AKT signaling pathway, is considered to be a modified protein kinase in the form of mTORC1 and mTORC2. The first is mainly activated by the PI3K/AKT signaling pathway, and mTORC2 further activates AKT by directly phosphorylating its hydrophobic motif (Ser473) [100].\\n\\nThe PI3K/Akt signaling pathway is considered to be the chief regulatory factor of idiopathic pulmonary fibrosis (IPF); it may directly participate in the formation of IPF or promote the occurrence and development of fibrosis in collaboration with other pathways [97]. Several studies have declared that certain natural products like resveratrol and Danhong injection can provide neuroprotective effects by activating the PI3K/AKT/mTOR signaling pathway [101,102]. Furthermore, the relationship between the PI3K/AKT/mTOR signaling pathway and cancer has been most intensively studied. Activation of the PI3K/AKT/mTOR signaling pathway is believed to promote the occurrence, proliferation, and progression of a variety of cancers, including breast cancer, ovarian cancer, prostate cancer, etc. [99,100,103]. In addition, it is also an important cause of tumor drug resistance [104].\\n\\nIn NSCLC, KRAS, EGFR, and PTEN mutations are believed to activate the PI3K/Akt/mTOR signaling pathway [105]. As demonstrated in a previous article, upregulation of the PI3K signaling pathway was identified as an early and reversible event in the pathogenesis of NSCLC [106]. One experiment has confirmed that the PI3K/AKT signaling pathway promotes the proliferation of LUAD cells mainly through anti-apoptosis [107]. Additionally, as revealed in a cellular study, IL-22 produced by CAFs markedly improves the proliferation and invasion of lung cancer cells and lessens apoptosis by activating the PI3K/Akt/mTOR signaling pathway [86].\\n\\nFor good measure, it has been found that AKT phosphorylation in NSCLC cells is facilitated by different concentrations of IL-22 in a time- and dose-dependent way [23]. Collectively, the PI3K/Akt/mTOR signaling pathway plays a significant role in the relationship between IL-22 and lung cancer. It is worth mentioning that IL-22 does not seem to always activate the PI3K/Akt/mTOR signaling pathway. Meng Yuxia et al. found that IL-22 inhibits the activity of the PI3K/AKT/mTOR signaling pathway in mouse liver fibrosis tissue [108]. This opposite finding may be related to the dual function of IL-22. Further study on the impact of IL-22 on the PI3K/AKT/mTOR signaling pathway in different disease processes will help us better understand the specific mechanism of IL-22’s function in the human body.',\n", " 'md': 'The PI3K/AKT signaling pathway is one of the core intracellular signaling pathways, which plays a critical role in regulating cell growth, survival, metabolism, movement, and proliferation [97]. As a downstream effector of receptor tyrosine kinases (RTKs) and G-protein-coupled receptors (GPCRs), PI3K is a group of lipid kinases consisting of three subunits. It can be divided into three categories according to various functions and structures. Class IA PI3K is a heterodimer of the p110 catalytic subunit and the p58 regulatory subunit, and it is primarily related to human tumors [98,99].\\n\\nAs we all know, PI3K can catalyze phosphatidylinositol [4, 5]-bisphosphate (PIP2) to phosphatidylinositol [3–5]-trisphosphate (PIP3). Serine/threonine protein kinase (AKT), as the main downstream molecule of the PI3K signaling pathway, is mainly activated by PIP3-driven plasma membrane recruitment and phosphorylation. The mammalian target of rapamycin (mTOR), a major downstream signaling molecule in the PI3K/AKT signaling pathway, is considered to be a modified protein kinase in the form of mTORC1 and mTORC2. The first is mainly activated by the PI3K/AKT signaling pathway, and mTORC2 further activates AKT by directly phosphorylating its hydrophobic motif (Ser473) [100].\\n\\nThe PI3K/Akt signaling pathway is considered to be the chief regulatory factor of idiopathic pulmonary fibrosis (IPF); it may directly participate in the formation of IPF or promote the occurrence and development of fibrosis in collaboration with other pathways [97]. Several studies have declared that certain natural products like resveratrol and Danhong injection can provide neuroprotective effects by activating the PI3K/AKT/mTOR signaling pathway [101,102]. Furthermore, the relationship between the PI3K/AKT/mTOR signaling pathway and cancer has been most intensively studied. Activation of the PI3K/AKT/mTOR signaling pathway is believed to promote the occurrence, proliferation, and progression of a variety of cancers, including breast cancer, ovarian cancer, prostate cancer, etc. [99,100,103]. In addition, it is also an important cause of tumor drug resistance [104].\\n\\nIn NSCLC, KRAS, EGFR, and PTEN mutations are believed to activate the PI3K/Akt/mTOR signaling pathway [105]. As demonstrated in a previous article, upregulation of the PI3K signaling pathway was identified as an early and reversible event in the pathogenesis of NSCLC [106]. One experiment has confirmed that the PI3K/AKT signaling pathway promotes the proliferation of LUAD cells mainly through anti-apoptosis [107]. Additionally, as revealed in a cellular study, IL-22 produced by CAFs markedly improves the proliferation and invasion of lung cancer cells and lessens apoptosis by activating the PI3K/Akt/mTOR signaling pathway [86].\\n\\nFor good measure, it has been found that AKT phosphorylation in NSCLC cells is facilitated by different concentrations of IL-22 in a time- and dose-dependent way [23]. Collectively, the PI3K/Akt/mTOR signaling pathway plays a significant role in the relationship between IL-22 and lung cancer. It is worth mentioning that IL-22 does not seem to always activate the PI3K/Akt/mTOR signaling pathway. Meng Yuxia et al. found that IL-22 inhibits the activity of the PI3K/AKT/mTOR signaling pathway in mouse liver fibrosis tissue [108]. This opposite finding may be related to the dual function of IL-22. Further study on the impact of IL-22 on the PI3K/AKT/mTOR signaling pathway in different disease processes will help us better understand the specific mechanism of IL-22’s function in the human body.',\n", " 'bBox': {'x': 39, 'y': 59.68, 'w': 466.27, 'h': 9.27}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diagram Description',\n", " 'md': '### Diagram Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': '**Figure 3**: IL-22 promotes the proliferation, migration, and epithelial-mesenchymal transition of lung cancer cells through PI3K/AKT, JAK-STAT3, p38 MAPK, and other signaling pathways, and antagonizes the apoptosis of lung cancer cells induced by anti-tumor drugs.\\n\\n- The diagram illustrates the interaction of various signaling pathways (PI3K, JAK, P38 MAPK) with IL-22 and their effects on lung cancer cells, including proliferation, migration, epithelial-mesenchymal transition (EMT), and apoptosis.\\n- The diagram includes elements such as:\\n- **IL-22**: A cytokine involved in the signaling.\\n- **PI3K**: A key signaling molecule in the pathway.\\n- **AKT**: A downstream effector activated by PI3K.\\n- **mTOR**: Another downstream target involved in cell growth and metabolism.\\n- **Gene expression**: Indicates the outcome of the signaling pathways.\\n- **Nucleus**: Represents the site of gene expression.\\n- **Lung tumor cell**: The target cells affected by these pathways.\\n\\nThe diagram visually summarizes the complex interactions and outcomes of the signaling pathways in the context of lung cancer.\\n```',\n", " 'md': '**Figure 3**: IL-22 promotes the proliferation, migration, and epithelial-mesenchymal transition of lung cancer cells through PI3K/AKT, JAK-STAT3, p38 MAPK, and other signaling pathways, and antagonizes the apoptosis of lung cancer cells induced by anti-tumor drugs.\\n\\n- The diagram illustrates the interaction of various signaling pathways (PI3K, JAK, P38 MAPK) with IL-22 and their effects on lung cancer cells, including proliferation, migration, epithelial-mesenchymal transition (EMT), and apoptosis.\\n- The diagram includes elements such as:\\n- **IL-22**: A cytokine involved in the signaling.\\n- **PI3K**: A key signaling molecule in the pathway.\\n- **AKT**: A downstream effector activated by PI3K.\\n- **mTOR**: Another downstream target involved in cell growth and metabolism.\\n- **Gene expression**: Indicates the outcome of the signaling pathways.\\n- **Nucleus**: Represents the site of gene expression.\\n- **Lung tumor cell**: The target cells affected by these pathways.\\n\\nThe diagram visually summarizes the complex interactions and outcomes of the signaling pathways in the context of lung cancer.\\n```',\n", " 'bBox': {'x': 144.86, 'y': 446.29, 'w': 65.83, 'h': 9.27}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '5]-bisphosphate (PIP2) to phosphatidylinositol [3'},\n", " {'text': '– 5]-trisphosphate (PIP3). Serine/threonine protein kinase (AKT), as the main'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 7,\n", " 'text': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nIL-22-related clinical drug development.\\n\\n4.2. JAK/STAT signaling pathway\\n\\n The JAK/STAT signaling pathway is also an important communication center for cell function, and aberrant alterations in its\\ncomponents are associated with numerous human diseases. JAK/STAT is an evolutionarily conserved signaling pathway consisting of\\nJAKs, STATs, and ligand-receptor complexes. There are four major members of the JAK family, all of which are composed of non-\\nreceptor tyrosine protein kinases. The STAT family contains six members which consist of 750–900 amino acids. The JAK/STAT\\nsignaling pathway is mainly thought to mediate inflammation, apoptosis, hematopoiesis, tissue repair, immune regulation, and adi-\\npogenesis [109]. In autoimmune diseases such as rheumatoid arthritis (RA), activation of the JAK-STAT signaling pathway leads to the\\nprogression of joint injury through overexpression of the matrix metalloproteinase gene, apoptosis of chondrocytes, and apoptotic\\nresistance in synovial tissue [110,111]. In addition, in a 2020 study by Meyer LK, the inhibition of the JAK-STAT signaling pathway\\nwas found to sensitize CD8+ T cells to dexamethasone-induced excessive inflammatory cell apoptosis [112]. Song et al. have long\\ndiscovered that the lifespan of NSCLC cells was notably reduced after inhibiting STAT3 [113]. In a murine lung model, overexpression\\nof STAT3 in alveolar type II cells led to severe lung inflammation and eventually to the formation of LUAD [114]. Further, down-\\nregulation of STAT3 was found to result in enhanced NK cell immunity in both human and murine NSCLC cells, which suggests that\\nSTAT3 plays an inhibitory role against tumor NK cell immunity [115,116]. A study last year disclosed that IL-22 triggers JAK-STAT3\\npathway phosphorylation in NSCLC cells in a time- and dose-dependent manner, thus promoting the proliferation and metastasis of\\ntumor cells [23,96]. Another study demonstrated that the overexpression of IL-22 protected lung cancer cells against apoptosis induced\\nby serum starvation and chemotherapy drugs by activating STAT3 and its downstream anti-apoptotic proteins [24].\\n\\n4.3. p38 MAPK signaling pathway\\n\\n The p38 mitogen-activated protein kinases (MAPK) signaling pathway takes a crucial role in signaling cascades induced by various\\ncellular stimuli. There are four p38 kinase members in the mammalian mitogen-activated protein (MAP) family, which play\\nmomentous roles in extracellular stimulation-mediated proliferation, inflammation, differentiation, apoptosis, senescence, and\\ntumorigenesis [117]. In the classical pathway, the p38 MAPK signaling pathway is activated by cascade phosphorylation [118]. In a\\nhepatitis C virus (HCV) experiment, researchers demonstrated that virus-induced activation of the p38 MAPK signaling pathway\\npromotes viral infection, and blocking activation of this pathway may be an antiviral approach [117]. According to Dan He in 2020,\\nmTORC1 drives intestinal stem cell aging via the p38 MAPK-p53 signaling pathway [119]. The p38 MAPK signaling pathway has long\\nbeen demonstrated to exhibit a major oncogenic role in LUAD [120–122]. Yinan Guo et al. found evidence that the p38 MAPK signaling\\npathway can promote EMT and metastasis of NSCLC both in vitro and in vivo [123]. In addition, a study published in 2017 proposed\\nthat the p38 MAPK signaling pathway activates stem cell properties of LUAD cells by regulating GLI1 [124]. What’s more, in lung\\ncancer models, researchers found that the p38 MAPK signaling pathway inhibited the stem cell properties of lung CSCs and promoted\\ntheir proliferation and differentiation, thereby leading to tumorigenesis. More importantly, they also elucidated that the p38 MAPK\\nand PI3K/AKT signaling pathways have unique and synergistic roles in regulating lung CSCs self-renewal as carcinogenic and/or stem\\ncell signaling pathways [107]. This provides a new idea for the stem cell-based treatment of lung cancer. In NSCLC, IL-22 in vivo and in\\nvitro were both verified to activate the p38 MAPK signaling pathway. The collected evidence from this study confirmed the negative\\nimmunomodulatory role of IL-22 in the disease [96].\\n\\n5. Clinical role of IL-22 in lung cancer\\n\\n Currently, there is still a lack of efficient biomarkers for the diagnosis and treatment of lung cancer. In recent years, the value of the\\ninterleukin family as biomarkers and therapeutic targets of lung cancer has been deeply investigated [125–132]. Of these, IL-1 and IL-6\\nhave been studied most extensively in lung cancer. Bo Yuan’s findings in mice experiments supported IL-1β as a potential target for the\\nprevention and treatment of LUAD patients with Kras mutations [129]. In a clinical trial of the anti-IL-1β antibody canakinumab,\\nresearchers found that 300 mg canakinumab significantly reduced lung cancer mortality compared with the control group (HR 0.49\\n[95%CI 0.31–0.75]; p = 0.0009) [133]. In plasma samples or tumor tissues from NSCLC, researchers revealed that patients with lower\\nbaseline IL-6 concentrations benefited more from immunotherapy. The study elucidated the role of IL-6 in predicting the efficacy of\\nimmunotherapy in patients with NSCLC [128]. Furthermore, in one lung cancer study, the survival hazard ratio before and after\\nchemotherapy for high versus low IL-6 levels was 1.25 (95%CI 0.73–2.13) and 3.66 (95%CI 2.18–6.15), respectively. It is suggested\\nthat IL-6 maybe a prognostic indicator of survival in patients with advanced NSCLC receiving chemotherapy [127]. Some scholars have\\nalso described the potential value of IL-11 as a biomarker for the diagnosis and prognosis of NSCLC [125]. In addition, another research\\nhas shown that changes in serum IL-8 levels in NSCLC patients could reflect and predict the response to immunotherapy [130].\\nKaplan-Meier survival analysis showed that the overall survival outcome of NSCLC patients with high IL-22R1 expression was\\nsignificantly lower than that of patients with low IL-22R1 expression (p = 0.022). Multivariate regression analysis also confirmed an\\nassociation between IL-22R1 levels and poorer outcomes (HR 1.5, 95%CI 1.2–1.9; p = 0.0011). This suggested that high expression of\\nIL-22R1 is an independent factor for low overall survival in NSCLC [134]. What’s more, the levels of IL-22-producing Th22 cells in\\nperipheral blood were positively correlated with TNM stage, lymph node metastasis, and clinical tumor markers of lung cancer (p <\\n0.01) [96]. The above indicates the significance of IL-22 as a biomarker in the diagnosis and disease assessment of lung cancer. Apart\\nfrom this, Renhua Guo’s team found that the expression of IL-22 in the EGFR-TKI resistant group was higher than that in sensitive\\n\\n 7',\n", " 'md': '```markdown\\n# IL-22-related Clinical Drug Development\\n\\n## 4.2. JAK/STAT Signaling Pathway\\n\\nThe JAK/STAT signaling pathway is an important communication center for cell function, and aberrant alterations in its components are associated with numerous human diseases. JAK/STAT is an evolutionarily conserved signaling pathway consisting of JAKs, STATs, and ligand-receptor complexes. There are four major members of the JAK family, all of which are composed of non-receptor tyrosine protein kinases. The STAT family contains six members which consist of 750–900 amino acids. The JAK/STAT signaling pathway is mainly thought to mediate inflammation, apoptosis, hematopoiesis, tissue repair, immune regulation, and adipogenesis [109].\\n\\nIn autoimmune diseases such as rheumatoid arthritis (RA), activation of the JAK-STAT signaling pathway leads to the progression of joint injury through overexpression of the matrix metalloproteinase gene, apoptosis of chondrocytes, and apoptotic resistance in synovial tissue [110,111]. In addition, in a 2020 study by Meyer LK, the inhibition of the JAK-STAT signaling pathway was found to sensitize CD8+ T cells to dexamethasone-induced excessive inflammatory cell apoptosis [112]. Song et al. have long discovered that the lifespan of NSCLC cells was notably reduced after inhibiting STAT3 [113]. In a murine lung model, overexpression of STAT3 in alveolar type II cells led to severe lung inflammation and eventually to the formation of LUAD [114].\\n\\nFurther, down-regulation of STAT3 was found to result in enhanced NK cell immunity in both human and murine NSCLC cells, which suggests that STAT3 plays an inhibitory role against tumor NK cell immunity [115,116]. A study last year disclosed that IL-22 triggers JAK-STAT3 pathway phosphorylation in NSCLC cells in a time- and dose-dependent manner, thus promoting the proliferation and metastasis of tumor cells [23,96]. Another study demonstrated that the overexpression of IL-22 protected lung cancer cells against apoptosis induced by serum starvation and chemotherapy drugs by activating STAT3 and its downstream anti-apoptotic proteins [24].\\n\\n## 4.3. p38 MAPK Signaling Pathway\\n\\nThe p38 mitogen-activated protein kinases (MAPK) signaling pathway takes a crucial role in signaling cascades induced by various cellular stimuli. There are four p38 kinase members in the mammalian mitogen-activated protein (MAP) family, which play momentous roles in extracellular stimulation-mediated proliferation, inflammation, differentiation, apoptosis, senescence, and tumorigenesis [117].\\n\\nIn the classical pathway, the p38 MAPK signaling pathway is activated by cascade phosphorylation [118]. In a hepatitis C virus (HCV) experiment, researchers demonstrated that virus-induced activation of the p38 MAPK signaling pathway promotes viral infection, and blocking activation of this pathway may be an antiviral approach [117]. According to Dan He in 2020, mTORC1 drives intestinal stem cell aging via the p38 MAPK-p53 signaling pathway [119]. The p38 MAPK signaling pathway has long been demonstrated to exhibit a major oncogenic role in LUAD [120–122].\\n\\nYinan Guo et al. found evidence that the p38 MAPK signaling pathway can promote EMT and metastasis of NSCLC both in vitro and in vivo [123]. In addition, a study published in 2017 proposed that the p38 MAPK signaling pathway activates stem cell properties of LUAD cells by regulating GLI1 [124]. What’s more, in lung cancer models, researchers found that the p38 MAPK signaling pathway inhibited the stem cell properties of lung CSCs and promoted their proliferation and differentiation, thereby leading to tumorigenesis.\\n\\nMore importantly, they also elucidated that the p38 MAPK and PI3K/AKT signaling pathways have unique and synergistic roles in regulating lung CSCs self-renewal as carcinogenic and/or stem cell signaling pathways [107]. This provides a new idea for the stem cell-based treatment of lung cancer. In NSCLC, IL-22 in vivo and in vitro were both verified to activate the p38 MAPK signaling pathway. The collected evidence from this study confirmed the negative immunomodulatory role of IL-22 in the disease [96].\\n\\n## 5. Clinical Role of IL-22 in Lung Cancer\\n\\nCurrently, there is still a lack of efficient biomarkers for the diagnosis and treatment of lung cancer. In recent years, the value of the interleukin family as biomarkers and therapeutic targets of lung cancer has been deeply investigated [125–132]. Of these, IL-1 and IL-6 have been studied most extensively in lung cancer. Bo Yuan’s findings in mice experiments supported IL-1β as a potential target for the prevention and treatment of LUAD patients with Kras mutations [129].\\n\\nIn a clinical trial of the anti-IL-1β antibody canakinumab, researchers found that 300 mg canakinumab significantly reduced lung cancer mortality compared with the control group (HR 0.49 [95%CI 0.31–0.75]; p = 0.0009) [133]. In plasma samples or tumor tissues from NSCLC, researchers revealed that patients with lower baseline IL-6 concentrations benefited more from immunotherapy. The study elucidated the role of IL-6 in predicting the efficacy of immunotherapy in patients with NSCLC [128].\\n\\nFurthermore, in one lung cancer study, the survival hazard ratio before and after chemotherapy for high versus low IL-6 levels was 1.25 (95%CI 0.73–2.13) and 3.66 (95%CI 2.18–6.15), respectively. It is suggested that IL-6 may be a prognostic indicator of survival in patients with advanced NSCLC receiving chemotherapy [127]. Some scholars have also described the potential value of IL-11 as a biomarker for the diagnosis and prognosis of NSCLC [125].\\n\\nIn addition, another research has shown that changes in serum IL-8 levels in NSCLC patients could reflect and predict the response to immunotherapy [130]. Kaplan-Meier survival analysis showed that the overall survival outcome of NSCLC patients with high IL-22R1 expression was significantly lower than that of patients with low IL-22R1 expression (p = 0.022). Multivariate regression analysis also confirmed an association between IL-22R1 levels and poorer outcomes (HR 1.5, 95%CI 1.2–1.9; p = 0.0011). This suggested that high expression of IL-22R1 is an independent factor for low overall survival in NSCLC [134].\\n\\nWhat’s more, the levels of IL-22-producing Th22 cells in peripheral blood were positively correlated with TNM stage, lymph node metastasis, and clinical tumor markers of lung cancer (p < 0.01) [96]. The above indicates the significance of IL-22 as a biomarker in the diagnosis and disease assessment of lung cancer. Apart from this, Renhua Guo’s team found that the expression of IL-22 in the EGFR-TKI resistant group was higher than that in sensitive.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'IL-22-related Clinical Drug Development',\n", " 'md': '# IL-22-related Clinical Drug Development',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': '4.2. JAK/STAT Signaling Pathway',\n", " 'md': '## 4.2. JAK/STAT Signaling Pathway',\n", " 'bBox': {'x': 39, 'y': 80.68, 'w': 99.68, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': 'The JAK/STAT signaling pathway is an important communication center for cell function, and aberrant alterations in its components are associated with numerous human diseases. JAK/STAT is an evolutionarily conserved signaling pathway consisting of JAKs, STATs, and ligand-receptor complexes. There are four major members of the JAK family, all of which are composed of non-receptor tyrosine protein kinases. The STAT family contains six members which consist of 750–900 amino acids. The JAK/STAT signaling pathway is mainly thought to mediate inflammation, apoptosis, hematopoiesis, tissue repair, immune regulation, and adipogenesis [109].\\n\\nIn autoimmune diseases such as rheumatoid arthritis (RA), activation of the JAK-STAT signaling pathway leads to the progression of joint injury through overexpression of the matrix metalloproteinase gene, apoptosis of chondrocytes, and apoptotic resistance in synovial tissue [110,111]. In addition, in a 2020 study by Meyer LK, the inhibition of the JAK-STAT signaling pathway was found to sensitize CD8+ T cells to dexamethasone-induced excessive inflammatory cell apoptosis [112]. Song et al. have long discovered that the lifespan of NSCLC cells was notably reduced after inhibiting STAT3 [113]. In a murine lung model, overexpression of STAT3 in alveolar type II cells led to severe lung inflammation and eventually to the formation of LUAD [114].\\n\\nFurther, down-regulation of STAT3 was found to result in enhanced NK cell immunity in both human and murine NSCLC cells, which suggests that STAT3 plays an inhibitory role against tumor NK cell immunity [115,116]. A study last year disclosed that IL-22 triggers JAK-STAT3 pathway phosphorylation in NSCLC cells in a time- and dose-dependent manner, thus promoting the proliferation and metastasis of tumor cells [23,96]. Another study demonstrated that the overexpression of IL-22 protected lung cancer cells against apoptosis induced by serum starvation and chemotherapy drugs by activating STAT3 and its downstream anti-apoptotic proteins [24].',\n", " 'md': 'The JAK/STAT signaling pathway is an important communication center for cell function, and aberrant alterations in its components are associated with numerous human diseases. JAK/STAT is an evolutionarily conserved signaling pathway consisting of JAKs, STATs, and ligand-receptor complexes. There are four major members of the JAK family, all of which are composed of non-receptor tyrosine protein kinases. The STAT family contains six members which consist of 750–900 amino acids. The JAK/STAT signaling pathway is mainly thought to mediate inflammation, apoptosis, hematopoiesis, tissue repair, immune regulation, and adipogenesis [109].\\n\\nIn autoimmune diseases such as rheumatoid arthritis (RA), activation of the JAK-STAT signaling pathway leads to the progression of joint injury through overexpression of the matrix metalloproteinase gene, apoptosis of chondrocytes, and apoptotic resistance in synovial tissue [110,111]. In addition, in a 2020 study by Meyer LK, the inhibition of the JAK-STAT signaling pathway was found to sensitize CD8+ T cells to dexamethasone-induced excessive inflammatory cell apoptosis [112]. Song et al. have long discovered that the lifespan of NSCLC cells was notably reduced after inhibiting STAT3 [113]. In a murine lung model, overexpression of STAT3 in alveolar type II cells led to severe lung inflammation and eventually to the formation of LUAD [114].\\n\\nFurther, down-regulation of STAT3 was found to result in enhanced NK cell immunity in both human and murine NSCLC cells, which suggests that STAT3 plays an inhibitory role against tumor NK cell immunity [115,116]. A study last year disclosed that IL-22 triggers JAK-STAT3 pathway phosphorylation in NSCLC cells in a time- and dose-dependent manner, thus promoting the proliferation and metastasis of tumor cells [23,96]. Another study demonstrated that the overexpression of IL-22 protected lung cancer cells against apoptosis induced by serum starvation and chemotherapy drugs by activating STAT3 and its downstream anti-apoptotic proteins [24].',\n", " 'bBox': {'x': 39, 'y': 80.68, 'w': 466.26, 'h': 10.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': '4.3. p38 MAPK Signaling Pathway',\n", " 'md': '## 4.3. p38 MAPK Signaling Pathway',\n", " 'bBox': {'x': 39, 'y': 278.68, 'w': 100.02, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': 'The p38 mitogen-activated protein kinases (MAPK) signaling pathway takes a crucial role in signaling cascades induced by various cellular stimuli. There are four p38 kinase members in the mammalian mitogen-activated protein (MAP) family, which play momentous roles in extracellular stimulation-mediated proliferation, inflammation, differentiation, apoptosis, senescence, and tumorigenesis [117].\\n\\nIn the classical pathway, the p38 MAPK signaling pathway is activated by cascade phosphorylation [118]. In a hepatitis C virus (HCV) experiment, researchers demonstrated that virus-induced activation of the p38 MAPK signaling pathway promotes viral infection, and blocking activation of this pathway may be an antiviral approach [117]. According to Dan He in 2020, mTORC1 drives intestinal stem cell aging via the p38 MAPK-p53 signaling pathway [119]. The p38 MAPK signaling pathway has long been demonstrated to exhibit a major oncogenic role in LUAD [120–122].\\n\\nYinan Guo et al. found evidence that the p38 MAPK signaling pathway can promote EMT and metastasis of NSCLC both in vitro and in vivo [123]. In addition, a study published in 2017 proposed that the p38 MAPK signaling pathway activates stem cell properties of LUAD cells by regulating GLI1 [124]. What’s more, in lung cancer models, researchers found that the p38 MAPK signaling pathway inhibited the stem cell properties of lung CSCs and promoted their proliferation and differentiation, thereby leading to tumorigenesis.\\n\\nMore importantly, they also elucidated that the p38 MAPK and PI3K/AKT signaling pathways have unique and synergistic roles in regulating lung CSCs self-renewal as carcinogenic and/or stem cell signaling pathways [107]. This provides a new idea for the stem cell-based treatment of lung cancer. In NSCLC, IL-22 in vivo and in vitro were both verified to activate the p38 MAPK signaling pathway. The collected evidence from this study confirmed the negative immunomodulatory role of IL-22 in the disease [96].',\n", " 'md': 'The p38 mitogen-activated protein kinases (MAPK) signaling pathway takes a crucial role in signaling cascades induced by various cellular stimuli. There are four p38 kinase members in the mammalian mitogen-activated protein (MAP) family, which play momentous roles in extracellular stimulation-mediated proliferation, inflammation, differentiation, apoptosis, senescence, and tumorigenesis [117].\\n\\nIn the classical pathway, the p38 MAPK signaling pathway is activated by cascade phosphorylation [118]. In a hepatitis C virus (HCV) experiment, researchers demonstrated that virus-induced activation of the p38 MAPK signaling pathway promotes viral infection, and blocking activation of this pathway may be an antiviral approach [117]. According to Dan He in 2020, mTORC1 drives intestinal stem cell aging via the p38 MAPK-p53 signaling pathway [119]. The p38 MAPK signaling pathway has long been demonstrated to exhibit a major oncogenic role in LUAD [120–122].\\n\\nYinan Guo et al. found evidence that the p38 MAPK signaling pathway can promote EMT and metastasis of NSCLC both in vitro and in vivo [123]. In addition, a study published in 2017 proposed that the p38 MAPK signaling pathway activates stem cell properties of LUAD cells by regulating GLI1 [124]. What’s more, in lung cancer models, researchers found that the p38 MAPK signaling pathway inhibited the stem cell properties of lung CSCs and promoted their proliferation and differentiation, thereby leading to tumorigenesis.\\n\\nMore importantly, they also elucidated that the p38 MAPK and PI3K/AKT signaling pathways have unique and synergistic roles in regulating lung CSCs self-renewal as carcinogenic and/or stem cell signaling pathways [107]. This provides a new idea for the stem cell-based treatment of lung cancer. In NSCLC, IL-22 in vivo and in vitro were both verified to activate the p38 MAPK signaling pathway. The collected evidence from this study confirmed the negative immunomodulatory role of IL-22 in the disease [96].',\n", " 'bBox': {'x': 39, 'y': 278.68, 'w': 466.27, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': '5. Clinical Role of IL-22 in Lung Cancer',\n", " 'md': '## 5. Clinical Role of IL-22 in Lung Cancer',\n", " 'bBox': {'x': 39, 'y': 477.68, 'w': 136.34, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': 'Currently, there is still a lack of efficient biomarkers for the diagnosis and treatment of lung cancer. In recent years, the value of the interleukin family as biomarkers and therapeutic targets of lung cancer has been deeply investigated [125–132]. Of these, IL-1 and IL-6 have been studied most extensively in lung cancer. Bo Yuan’s findings in mice experiments supported IL-1β as a potential target for the prevention and treatment of LUAD patients with Kras mutations [129].\\n\\nIn a clinical trial of the anti-IL-1β antibody canakinumab, researchers found that 300 mg canakinumab significantly reduced lung cancer mortality compared with the control group (HR 0.49 [95%CI 0.31–0.75]; p = 0.0009) [133]. In plasma samples or tumor tissues from NSCLC, researchers revealed that patients with lower baseline IL-6 concentrations benefited more from immunotherapy. The study elucidated the role of IL-6 in predicting the efficacy of immunotherapy in patients with NSCLC [128].\\n\\nFurthermore, in one lung cancer study, the survival hazard ratio before and after chemotherapy for high versus low IL-6 levels was 1.25 (95%CI 0.73–2.13) and 3.66 (95%CI 2.18–6.15), respectively. It is suggested that IL-6 may be a prognostic indicator of survival in patients with advanced NSCLC receiving chemotherapy [127]. Some scholars have also described the potential value of IL-11 as a biomarker for the diagnosis and prognosis of NSCLC [125].\\n\\nIn addition, another research has shown that changes in serum IL-8 levels in NSCLC patients could reflect and predict the response to immunotherapy [130]. Kaplan-Meier survival analysis showed that the overall survival outcome of NSCLC patients with high IL-22R1 expression was significantly lower than that of patients with low IL-22R1 expression (p = 0.022). Multivariate regression analysis also confirmed an association between IL-22R1 levels and poorer outcomes (HR 1.5, 95%CI 1.2–1.9; p = 0.0011). This suggested that high expression of IL-22R1 is an independent factor for low overall survival in NSCLC [134].\\n\\nWhat’s more, the levels of IL-22-producing Th22 cells in peripheral blood were positively correlated with TNM stage, lymph node metastasis, and clinical tumor markers of lung cancer (p < 0.01) [96]. The above indicates the significance of IL-22 as a biomarker in the diagnosis and disease assessment of lung cancer. Apart from this, Renhua Guo’s team found that the expression of IL-22 in the EGFR-TKI resistant group was higher than that in sensitive.\\n```',\n", " 'md': 'Currently, there is still a lack of efficient biomarkers for the diagnosis and treatment of lung cancer. In recent years, the value of the interleukin family as biomarkers and therapeutic targets of lung cancer has been deeply investigated [125–132]. Of these, IL-1 and IL-6 have been studied most extensively in lung cancer. Bo Yuan’s findings in mice experiments supported IL-1β as a potential target for the prevention and treatment of LUAD patients with Kras mutations [129].\\n\\nIn a clinical trial of the anti-IL-1β antibody canakinumab, researchers found that 300 mg canakinumab significantly reduced lung cancer mortality compared with the control group (HR 0.49 [95%CI 0.31–0.75]; p = 0.0009) [133]. In plasma samples or tumor tissues from NSCLC, researchers revealed that patients with lower baseline IL-6 concentrations benefited more from immunotherapy. The study elucidated the role of IL-6 in predicting the efficacy of immunotherapy in patients with NSCLC [128].\\n\\nFurthermore, in one lung cancer study, the survival hazard ratio before and after chemotherapy for high versus low IL-6 levels was 1.25 (95%CI 0.73–2.13) and 3.66 (95%CI 2.18–6.15), respectively. It is suggested that IL-6 may be a prognostic indicator of survival in patients with advanced NSCLC receiving chemotherapy [127]. Some scholars have also described the potential value of IL-11 as a biomarker for the diagnosis and prognosis of NSCLC [125].\\n\\nIn addition, another research has shown that changes in serum IL-8 levels in NSCLC patients could reflect and predict the response to immunotherapy [130]. Kaplan-Meier survival analysis showed that the overall survival outcome of NSCLC patients with high IL-22R1 expression was significantly lower than that of patients with low IL-22R1 expression (p = 0.022). Multivariate regression analysis also confirmed an association between IL-22R1 levels and poorer outcomes (HR 1.5, 95%CI 1.2–1.9; p = 0.0011). This suggested that high expression of IL-22R1 is an independent factor for low overall survival in NSCLC [134].\\n\\nWhat’s more, the levels of IL-22-producing Th22 cells in peripheral blood were positively correlated with TNM stage, lymph node metastasis, and clinical tumor markers of lung cancer (p < 0.01) [96]. The above indicates the significance of IL-22 as a biomarker in the diagnosis and disease assessment of lung cancer. Apart from this, Renhua Guo’s team found that the expression of IL-22 in the EGFR-TKI resistant group was higher than that in sensitive.\\n```',\n", " 'bBox': {'x': 39, 'y': 498.68, 'w': 466.28, 'h': 7.97}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '– 122]. Yinan Guo et al. found evidence that the p38 MAPK signaling'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '– 132]. Of these, IL-1 and IL-6'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 8,\n", " 'text': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\ngroup in NSCLC, and the expression level was correlated with the efficacy of EGFR-TKI in plasma [135]. Therefore, it is reasonable to\\nsuspect that IL-22 may be a new biomarker to overcome EGFR-TKI resistance in NSCLC. In terms of animal models, some investigators\\nimplanted Line-1 lung cancer cells into wild-type and IL-22-deficient mice simultaneously, and found reduced intrapulmonary\\nmetastasis in the latter group, which is independent of primary tumor size. Besides, they performed forced metastasis by intravenous\\ninjection of lung cancer cells, and the results further confirmed the lower metastatic load in mice with IL-22 deletion [72]. In another\\nmodel of Kras-mutated lung cancer in mice, gene ablation of IL-22 resulted in a marked reduction in tumor number and size. The\\nauthors also analyzed the association between IL-22R1 expression and survival in patients with KRAS mutant lung adenocarcinoma,\\nthe results showed that high expression of IL-22R1 was an independent indicator of poorer relapse-free survival [94]. Taken together,\\nthese pieces of evidence highlight the potential clinical role of IL-22, IL-22R, and IL-22-producing cells in the treatment of lung cancer\\n(Table 2).\\n\\n6. Future perspectives\\n\\n6.1. CRISPR-Cas13a technical\\n\\n At present, mounting clinical trials based on IL-22 are being carried out in full swing worldwide, mainly involving ulcerative colitis,\\nalcoholic cirrhosis, GVHD, and psoriasis [12,14,54,60]. However, there are presently no clinical trials based on IL-22 in lung cancer. As\\ndescribed previously, reduced intrapulmonary metastasis was found in IL-22-deficient mice as well as in IL-22-suppressed NSCLC cells\\n[20,72]. In addition, blocking IL-22R1 or knockout of the IL-22 gene both retarded the progression of lung cancer [24,94]. These\\nfindings provide a new train of thought for the down-regulation of IL-22 in treating lung cancer.\\n In recent years, the research on gene editing treatment for various diseases has become more and more popular [136–138].\\nCRISPR-Cas13a is an effective tool for knocking out specific RNA sequences, it has been shown to induce the death of glioma cells that\\noverexpress EGFR, which is one of the subtypes of EGFR mutation in glioma. Apart from this, the CRISPR-Cas13a gene-editing system\\ncan also inhibit the formation of intracranial tumors in mice with glioma [139]. In a collagen-induced mouse model, injection of\\ngene-edited human amniotic mesenchymal stem cells that overexpressed IL-10 increased proteoglycan expression in joint tissue and\\nreduced the inflammatory response and production of various inflammatory cytokines [137]. In the world’s first human phase I clinical\\ntrial utilizing CRISPR-Cas9 in the treatment of advanced NSCLC, researchers have demonstrated the feasibility and safety of\\ngene-edited T-cell therapy targeting the PD-1 gene [140]. Thus, genome editing strategies have the potential to treat lung cancer by\\naltering IL-22 expression levels. In the future, the role of pulmonary precision delivery based on CRISPR-Cas13 gene-editing com-\\nponents targeting the IL-22 mRNA in lung cancer therapy should not be ignored. CRISPR-Cas13 is expected to be further integrated\\n IL-22 mRNA\\n Cas13a\\n Crispr-Cas13a\\n Combined With\\n Flgure\\n Single-base edition Single-cell sequencing\\n Lung cancer\\nFig. 4. Crispr-cas13-based IL-22 mRNA editing can be utilized for lung cancer therapy by combining with emerging technologies such as single-base\\nediting and single-cell sequencing.\\n\\n 8',\n", " 'md': '```markdown\\n# Page Content\\n\\nL. Xu et al. Heliyon 10 (2024) e35901\\n\\nThe expression level was correlated with the efficacy of EGFR-TKI in plasma [135]. Therefore, it is reasonable to suspect that IL-22 may be a new biomarker to overcome EGFR-TKI resistance in NSCLC. In terms of animal models, some investigators implanted Line-1 lung cancer cells into wild-type and IL-22-deficient mice simultaneously, and found reduced intrapulmonary metastasis in the latter group, which is independent of primary tumor size. Besides, they performed forced metastasis by intravenous injection of lung cancer cells, and the results further confirmed the lower metastatic load in mice with IL-22 deletion [72]. In another model of Kras-mutated lung cancer in mice, gene ablation of IL-22 resulted in a marked reduction in tumor number and size. The authors also analyzed the association between IL-22R1 expression and survival in patients with KRAS mutant lung adenocarcinoma, the results showed that high expression of IL-22R1 was an independent indicator of poorer relapse-free survival [94]. Taken together, these pieces of evidence highlight the potential clinical role of IL-22, IL-22R, and IL-22-producing cells in the treatment of lung cancer (Table 2).\\n\\n## Future Perspectives\\n\\n### CRISPR-Cas13a Technical\\n\\nAt present, mounting clinical trials based on IL-22 are being carried out in full swing worldwide, mainly involving ulcerative colitis, alcoholic cirrhosis, GVHD, and psoriasis [12,14,54,60]. However, there are presently no clinical trials based on IL-22 in lung cancer. As described previously, reduced intrapulmonary metastasis was found in IL-22-deficient mice as well as in IL-22-suppressed NSCLC cells [20,72]. In addition, blocking IL-22R1 or knockout of the IL-22 gene both retarded the progression of lung cancer [24,94]. These findings provide a new train of thought for the down-regulation of IL-22 in treating lung cancer.\\n\\nIn recent years, the research on gene editing treatment for various diseases has become more and more popular [136–138]. CRISPR-Cas13a is an effective tool for knocking out specific RNA sequences, it has been shown to induce the death of glioma cells that overexpress EGFR, which is one of the subtypes of EGFR mutation in glioma. Apart from this, the CRISPR-Cas13a gene-editing system can also inhibit the formation of intracranial tumors in mice with glioma [139]. In a collagen-induced mouse model, injection of gene-edited human amniotic mesenchymal stem cells that overexpressed IL-10 increased proteoglycan expression in joint tissue and reduced the inflammatory response and production of various inflammatory cytokines [137]. In the world’s first human phase I clinical trial utilizing CRISPR-Cas9 in the treatment of advanced NSCLC, researchers have demonstrated the feasibility and safety of gene-edited T-cell therapy targeting the PD-1 gene [140]. Thus, genome editing strategies have the potential to treat lung cancer by altering IL-22 expression levels. In the future, the role of pulmonary precision delivery based on CRISPR-Cas13 gene-editing components targeting the IL-22 mRNA in lung cancer therapy should not be ignored. CRISPR-Cas13 is expected to be further integrated.\\n\\n## Figure 4\\n\\nCrispr-cas13-based IL-22 mRNA editing can be utilized for lung cancer therapy by combining with emerging technologies such as single-base editing and single-cell sequencing.\\n\\n![Crispr-cas13-based IL-22 mRNA editing]()\\n```',\n", " 'images': [{'name': 'img_p7_1.png',\n", " 'height': 592,\n", " 'width': 767,\n", " 'x': 94.2803,\n", " 'y': 387.36891199999997,\n", " 'original_width': 1482,\n", " 'original_height': 1144}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nThe expression level was correlated with the efficacy of EGFR-TKI in plasma [135]. Therefore, it is reasonable to suspect that IL-22 may be a new biomarker to overcome EGFR-TKI resistance in NSCLC. In terms of animal models, some investigators implanted Line-1 lung cancer cells into wild-type and IL-22-deficient mice simultaneously, and found reduced intrapulmonary metastasis in the latter group, which is independent of primary tumor size. Besides, they performed forced metastasis by intravenous injection of lung cancer cells, and the results further confirmed the lower metastatic load in mice with IL-22 deletion [72]. In another model of Kras-mutated lung cancer in mice, gene ablation of IL-22 resulted in a marked reduction in tumor number and size. The authors also analyzed the association between IL-22R1 expression and survival in patients with KRAS mutant lung adenocarcinoma, the results showed that high expression of IL-22R1 was an independent indicator of poorer relapse-free survival [94]. Taken together, these pieces of evidence highlight the potential clinical role of IL-22, IL-22R, and IL-22-producing cells in the treatment of lung cancer (Table 2).',\n", " 'md': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nThe expression level was correlated with the efficacy of EGFR-TKI in plasma [135]. Therefore, it is reasonable to suspect that IL-22 may be a new biomarker to overcome EGFR-TKI resistance in NSCLC. In terms of animal models, some investigators implanted Line-1 lung cancer cells into wild-type and IL-22-deficient mice simultaneously, and found reduced intrapulmonary metastasis in the latter group, which is independent of primary tumor size. Besides, they performed forced metastasis by intravenous injection of lung cancer cells, and the results further confirmed the lower metastatic load in mice with IL-22 deletion [72]. In another model of Kras-mutated lung cancer in mice, gene ablation of IL-22 resulted in a marked reduction in tumor number and size. The authors also analyzed the association between IL-22R1 expression and survival in patients with KRAS mutant lung adenocarcinoma, the results showed that high expression of IL-22R1 was an independent indicator of poorer relapse-free survival [94]. Taken together, these pieces of evidence highlight the potential clinical role of IL-22, IL-22R, and IL-22-producing cells in the treatment of lung cancer (Table 2).',\n", " 'bBox': {'x': 39, 'y': 39.68, 'w': 466.28, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Future Perspectives',\n", " 'md': '## Future Perspectives',\n", " 'bBox': {'x': 51, 'y': 174.68, 'w': 74.63, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'CRISPR-Cas13a Technical',\n", " 'md': '### CRISPR-Cas13a Technical',\n", " 'bBox': {'x': 57, 'y': 195.68, 'w': 86.32, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': 'At present, mounting clinical trials based on IL-22 are being carried out in full swing worldwide, mainly involving ulcerative colitis, alcoholic cirrhosis, GVHD, and psoriasis [12,14,54,60]. However, there are presently no clinical trials based on IL-22 in lung cancer. As described previously, reduced intrapulmonary metastasis was found in IL-22-deficient mice as well as in IL-22-suppressed NSCLC cells [20,72]. In addition, blocking IL-22R1 or knockout of the IL-22 gene both retarded the progression of lung cancer [24,94]. These findings provide a new train of thought for the down-regulation of IL-22 in treating lung cancer.\\n\\nIn recent years, the research on gene editing treatment for various diseases has become more and more popular [136–138]. CRISPR-Cas13a is an effective tool for knocking out specific RNA sequences, it has been shown to induce the death of glioma cells that overexpress EGFR, which is one of the subtypes of EGFR mutation in glioma. Apart from this, the CRISPR-Cas13a gene-editing system can also inhibit the formation of intracranial tumors in mice with glioma [139]. In a collagen-induced mouse model, injection of gene-edited human amniotic mesenchymal stem cells that overexpressed IL-10 increased proteoglycan expression in joint tissue and reduced the inflammatory response and production of various inflammatory cytokines [137]. In the world’s first human phase I clinical trial utilizing CRISPR-Cas9 in the treatment of advanced NSCLC, researchers have demonstrated the feasibility and safety of gene-edited T-cell therapy targeting the PD-1 gene [140]. Thus, genome editing strategies have the potential to treat lung cancer by altering IL-22 expression levels. In the future, the role of pulmonary precision delivery based on CRISPR-Cas13 gene-editing components targeting the IL-22 mRNA in lung cancer therapy should not be ignored. CRISPR-Cas13 is expected to be further integrated.',\n", " 'md': 'At present, mounting clinical trials based on IL-22 are being carried out in full swing worldwide, mainly involving ulcerative colitis, alcoholic cirrhosis, GVHD, and psoriasis [12,14,54,60]. However, there are presently no clinical trials based on IL-22 in lung cancer. As described previously, reduced intrapulmonary metastasis was found in IL-22-deficient mice as well as in IL-22-suppressed NSCLC cells [20,72]. In addition, blocking IL-22R1 or knockout of the IL-22 gene both retarded the progression of lung cancer [24,94]. These findings provide a new train of thought for the down-regulation of IL-22 in treating lung cancer.\\n\\nIn recent years, the research on gene editing treatment for various diseases has become more and more popular [136–138]. CRISPR-Cas13a is an effective tool for knocking out specific RNA sequences, it has been shown to induce the death of glioma cells that overexpress EGFR, which is one of the subtypes of EGFR mutation in glioma. Apart from this, the CRISPR-Cas13a gene-editing system can also inhibit the formation of intracranial tumors in mice with glioma [139]. In a collagen-induced mouse model, injection of gene-edited human amniotic mesenchymal stem cells that overexpressed IL-10 increased proteoglycan expression in joint tissue and reduced the inflammatory response and production of various inflammatory cytokines [137]. In the world’s first human phase I clinical trial utilizing CRISPR-Cas9 in the treatment of advanced NSCLC, researchers have demonstrated the feasibility and safety of gene-edited T-cell therapy targeting the PD-1 gene [140]. Thus, genome editing strategies have the potential to treat lung cancer by altering IL-22 expression levels. In the future, the role of pulmonary precision delivery based on CRISPR-Cas13 gene-editing components targeting the IL-22 mRNA in lung cancer therapy should not be ignored. CRISPR-Cas13 is expected to be further integrated.',\n", " 'bBox': {'x': 39, 'y': 216.68, 'w': 466.27, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 4',\n", " 'md': '## Figure 4',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': 'Crispr-cas13-based IL-22 mRNA editing can be utilized for lung cancer therapy by combining with emerging technologies such as single-base editing and single-cell sequencing.\\n\\n![Crispr-cas13-based IL-22 mRNA editing]()\\n```',\n", " 'md': 'Crispr-cas13-based IL-22 mRNA editing can be utilized for lung cancer therapy by combining with emerging technologies such as single-base editing and single-cell sequencing.\\n\\n![Crispr-cas13-based IL-22 mRNA editing]()\\n```',\n", " 'bBox': {'x': 39, 'y': 420.29, 'w': 465.74, 'h': 9.27}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '– 138].'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 9,\n", " 'text': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nwith the latest technologies such as single-base editing and single-cell sequencing to promote the treatment of lung cancer to a new\\nlevel (Fig. 4).\\n\\n6.2. Small interfering RNA\\n\\n Small interfering RNA (siRNA) is a double-stranded RNA molecule composed of 21–23 nucleotides. In cells, siRNA forms functional\\ncomplexes by binding to the RNA-induced silencing complex (RISC). RISC in the functional complex specifically recognizes and binds\\nto the target mRNA, leading to degradation of the target mRNA and thereby silencing the expression of the target gene. Compared with\\ntraditional therapies such as small molecules and protein drugs, siRNA technology has many advantages: 1) siRNA is highly specific.\\nsiRNA can only silence homologous genes, while unrelated genes are not affected. 2) siRNA can silence genes by using RISC. 3) siRNA\\ncan be designed to target different genes through sequence design, and can even target targets that were previously considered\\n“undruggable”. 4) siRNA does not activate the innate immune system. Twenty years after the discovery of the RNA interference\\nmechanism, the first siRNA drugs (including Patisiran, Givosiran, Lumasiran, Inclisiran, Vutrisiran) were approved for clinical use by\\nthe U.S. Food and Drug Administration (FDA) and the European Medicines Agency from 2018 to 2022 [141,142]. NFKBIZ is an up-\\nstream target of IL-23, IL-36 and IL-17A. In the study of Mandal A et al. [143], NFKBIZ-siRNA significantly reduces the mRNA levels of\\nmultiple pro-inflammatory cytokines, including IL-17, IL-19, IL-22, etc., in the skin tissue of psoriasis mice, thereby alleviating the\\ncondition of the mice. The safety evaluation results of NFKBIZ-siRNA preparations show that NFKBIZ-siRNA preparations can complex\\nwith nucleic acids without affecting biological activity and show no toxicity. TGF-β is a pleiotropic regulatory cytokine that can\\nregulate a variety of ILs including IL-22 and IL-17 to affect the composition of the tumor microenvironment [144]. Currently, Sir-\\nnaomics has developed an siRNA drug that targets TGF-β (called STP705). Recently, the drug has completed phase II clinical trials in\\nthe United States and achieved positive results. The role of ILs in cancer has been extensively studied. In recent years, the positive role\\nof IL-22 in lung cancer has received attention. The researchers believe that knocking down IL-22mRNA levels in the lesions of lung\\ncancer patients will help prolong the survival of lung cancer patients and improve the cure rate of lung cancer patients. For example,\\nZhang Wei et al. found that IL-22-siRNA slowed tumor growth in NSCLC model mice. In addition, they reported that the therapeutic\\neffect of IL-22-siRNA combined with chemotherapy drugs (5-FU and carboplatin) on NSCLC mice was better than that of chemotherapy\\ndrugs alone [24]. In an in vitro assay [145], cell line PC9 cells (NSCLC) transfected with PDLIM5-siRNA targeting the PDLIM5 gene had\\nreduced growth viability and exhibited higher apoptotic rates. In the chemotherapy drug gefitinib-resistant cell line PC9 cells,\\nPDLIM5-siRNA still showed significant anti-tumor effects. These results indicate that siRNA-based therapy has good application in the\\nclinical treatment of NSCLC, especially in drug-resistant patients. Based on these findings, we believe that the development of\\nIL-22-siRNA drugs for lung cancer treatment has clinical potential and theoretical basis.\\n\\n6.3. Nanoparticle drug delivery systems\\n\\n On the other hand, given the toxicity and erratic efficacy of current anti-tumor drugs, research on novel drug carriers in lung cancer\\n IL-22-related drug\\n Au Targeting agent\\n Different types of nanomaterials\\n Lung precisiondelivery\\n Lung Cancer\\n Fig. 5. Precision delivery of various nanomaterials containing IL-22 related drugs for the treatment of lung cancer.\\n\\n 9',\n", " 'md': '```markdown\\n# Page Content\\n\\n## 6.2. Small interfering RNA\\n\\nSmall interfering RNA (siRNA) is a double-stranded RNA molecule composed of 21–23 nucleotides. In cells, siRNA forms functional complexes by binding to the RNA-induced silencing complex (RISC). RISC in the functional complex specifically recognizes and binds to the target mRNA, leading to degradation of the target mRNA and thereby silencing the expression of the target gene. Compared with traditional therapies such as small molecules and protein drugs, siRNA technology has many advantages:\\n\\n1. siRNA is highly specific. siRNA can only silence homologous genes, while unrelated genes are not affected.\\n2. siRNA can silence genes by using RISC.\\n3. siRNA can be designed to target different genes through sequence design, and can even target targets that were previously considered “undruggable”.\\n4. siRNA does not activate the innate immune system.\\n\\nTwenty years after the discovery of the RNA interference mechanism, the first siRNA drugs (including Patisiran, Givosiran, Lumasiran, Inclisiran, Vutrisiran) were approved for clinical use by the U.S. Food and Drug Administration (FDA) and the European Medicines Agency from 2018 to 2022 [141,142]. NFKBIZ is an upstream target of IL-23, IL-36, and IL-17A. In the study of Mandal A et al. [143], NFKBIZ-siRNA significantly reduces the mRNA levels of multiple pro-inflammatory cytokines, including IL-17, IL-19, IL-22, etc., in the skin tissue of psoriasis mice, thereby alleviating the condition of the mice. The safety evaluation results of NFKBIZ-siRNA preparations show that NFKBIZ-siRNA preparations can complex with nucleic acids without affecting biological activity and show no toxicity. TGF-β is a pleiotropic regulatory cytokine that can regulate a variety of ILs including IL-22 and IL-17 to affect the composition of the tumor microenvironment [144]. Currently, Sirnaomics has developed an siRNA drug that targets TGF-β (called STP705). Recently, the drug has completed phase II clinical trials in the United States and achieved positive results. The role of ILs in cancer has been extensively studied. In recent years, the positive role of IL-22 in lung cancer has received attention. The researchers believe that knocking down IL-22 mRNA levels in the lesions of lung cancer patients will help prolong the survival of lung cancer patients and improve the cure rate of lung cancer patients. For example, Zhang Wei et al. found that IL-22-siRNA slowed tumor growth in NSCLC model mice. In addition, they reported that the therapeutic effect of IL-22-siRNA combined with chemotherapy drugs (5-FU and carboplatin) on NSCLC mice was better than that of chemotherapy drugs alone [24]. In an in vitro assay [145], cell line PC9 cells (NSCLC) transfected with PDLIM5-siRNA targeting the PDLIM5 gene had reduced growth viability and exhibited higher apoptotic rates. In the chemotherapy drug gefitinib-resistant cell line PC9 cells, PDLIM5-siRNA still showed significant anti-tumor effects. These results indicate that siRNA-based therapy has good application in the clinical treatment of NSCLC, especially in drug-resistant patients. Based on these findings, we believe that the development of IL-22-siRNA drugs for lung cancer treatment has clinical potential and theoretical basis.\\n\\n## 6.3. Nanoparticle drug delivery systems\\n\\nOn the other hand, given the toxicity and erratic efficacy of current anti-tumor drugs, research on novel drug carriers in lung cancer is ongoing.\\n\\n### Figure 5\\n**Caption:** Precision delivery of various nanomaterials containing IL-22 related drugs for the treatment of lung cancer.\\n\\n**Description:** Figure 5 illustrates the precision delivery of various types of nanomaterials that are designed to carry IL-22 related drugs specifically for lung cancer treatment. The diagram likely includes different types of nanoparticles and their targeting mechanisms, emphasizing the advancements in drug delivery systems aimed at improving therapeutic outcomes in lung cancer patients.\\n```',\n", " 'images': [{'name': 'img_p8_1.png',\n", " 'height': 529,\n", " 'width': 767,\n", " 'x': 94.2803,\n", " 'y': 426.325992,\n", " 'original_width': 1482,\n", " 'original_height': 1021}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': '6.2. Small interfering RNA',\n", " 'md': '## 6.2. Small interfering RNA',\n", " 'bBox': {'x': 39, 'y': 93.68, 'w': 74.19, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': 'Small interfering RNA (siRNA) is a double-stranded RNA molecule composed of 21–23 nucleotides. In cells, siRNA forms functional complexes by binding to the RNA-induced silencing complex (RISC). RISC in the functional complex specifically recognizes and binds to the target mRNA, leading to degradation of the target mRNA and thereby silencing the expression of the target gene. Compared with traditional therapies such as small molecules and protein drugs, siRNA technology has many advantages:\\n\\n1. siRNA is highly specific. siRNA can only silence homologous genes, while unrelated genes are not affected.\\n2. siRNA can silence genes by using RISC.\\n3. siRNA can be designed to target different genes through sequence design, and can even target targets that were previously considered “undruggable”.\\n4. siRNA does not activate the innate immune system.\\n\\nTwenty years after the discovery of the RNA interference mechanism, the first siRNA drugs (including Patisiran, Givosiran, Lumasiran, Inclisiran, Vutrisiran) were approved for clinical use by the U.S. Food and Drug Administration (FDA) and the European Medicines Agency from 2018 to 2022 [141,142]. NFKBIZ is an upstream target of IL-23, IL-36, and IL-17A. In the study of Mandal A et al. [143], NFKBIZ-siRNA significantly reduces the mRNA levels of multiple pro-inflammatory cytokines, including IL-17, IL-19, IL-22, etc., in the skin tissue of psoriasis mice, thereby alleviating the condition of the mice. The safety evaluation results of NFKBIZ-siRNA preparations show that NFKBIZ-siRNA preparations can complex with nucleic acids without affecting biological activity and show no toxicity. TGF-β is a pleiotropic regulatory cytokine that can regulate a variety of ILs including IL-22 and IL-17 to affect the composition of the tumor microenvironment [144]. Currently, Sirnaomics has developed an siRNA drug that targets TGF-β (called STP705). Recently, the drug has completed phase II clinical trials in the United States and achieved positive results. The role of ILs in cancer has been extensively studied. In recent years, the positive role of IL-22 in lung cancer has received attention. The researchers believe that knocking down IL-22 mRNA levels in the lesions of lung cancer patients will help prolong the survival of lung cancer patients and improve the cure rate of lung cancer patients. For example, Zhang Wei et al. found that IL-22-siRNA slowed tumor growth in NSCLC model mice. In addition, they reported that the therapeutic effect of IL-22-siRNA combined with chemotherapy drugs (5-FU and carboplatin) on NSCLC mice was better than that of chemotherapy drugs alone [24]. In an in vitro assay [145], cell line PC9 cells (NSCLC) transfected with PDLIM5-siRNA targeting the PDLIM5 gene had reduced growth viability and exhibited higher apoptotic rates. In the chemotherapy drug gefitinib-resistant cell line PC9 cells, PDLIM5-siRNA still showed significant anti-tumor effects. These results indicate that siRNA-based therapy has good application in the clinical treatment of NSCLC, especially in drug-resistant patients. Based on these findings, we believe that the development of IL-22-siRNA drugs for lung cancer treatment has clinical potential and theoretical basis.',\n", " 'md': 'Small interfering RNA (siRNA) is a double-stranded RNA molecule composed of 21–23 nucleotides. In cells, siRNA forms functional complexes by binding to the RNA-induced silencing complex (RISC). RISC in the functional complex specifically recognizes and binds to the target mRNA, leading to degradation of the target mRNA and thereby silencing the expression of the target gene. Compared with traditional therapies such as small molecules and protein drugs, siRNA technology has many advantages:\\n\\n1. siRNA is highly specific. siRNA can only silence homologous genes, while unrelated genes are not affected.\\n2. siRNA can silence genes by using RISC.\\n3. siRNA can be designed to target different genes through sequence design, and can even target targets that were previously considered “undruggable”.\\n4. siRNA does not activate the innate immune system.\\n\\nTwenty years after the discovery of the RNA interference mechanism, the first siRNA drugs (including Patisiran, Givosiran, Lumasiran, Inclisiran, Vutrisiran) were approved for clinical use by the U.S. Food and Drug Administration (FDA) and the European Medicines Agency from 2018 to 2022 [141,142]. NFKBIZ is an upstream target of IL-23, IL-36, and IL-17A. In the study of Mandal A et al. [143], NFKBIZ-siRNA significantly reduces the mRNA levels of multiple pro-inflammatory cytokines, including IL-17, IL-19, IL-22, etc., in the skin tissue of psoriasis mice, thereby alleviating the condition of the mice. The safety evaluation results of NFKBIZ-siRNA preparations show that NFKBIZ-siRNA preparations can complex with nucleic acids without affecting biological activity and show no toxicity. TGF-β is a pleiotropic regulatory cytokine that can regulate a variety of ILs including IL-22 and IL-17 to affect the composition of the tumor microenvironment [144]. Currently, Sirnaomics has developed an siRNA drug that targets TGF-β (called STP705). Recently, the drug has completed phase II clinical trials in the United States and achieved positive results. The role of ILs in cancer has been extensively studied. In recent years, the positive role of IL-22 in lung cancer has received attention. The researchers believe that knocking down IL-22 mRNA levels in the lesions of lung cancer patients will help prolong the survival of lung cancer patients and improve the cure rate of lung cancer patients. For example, Zhang Wei et al. found that IL-22-siRNA slowed tumor growth in NSCLC model mice. In addition, they reported that the therapeutic effect of IL-22-siRNA combined with chemotherapy drugs (5-FU and carboplatin) on NSCLC mice was better than that of chemotherapy drugs alone [24]. In an in vitro assay [145], cell line PC9 cells (NSCLC) transfected with PDLIM5-siRNA targeting the PDLIM5 gene had reduced growth viability and exhibited higher apoptotic rates. In the chemotherapy drug gefitinib-resistant cell line PC9 cells, PDLIM5-siRNA still showed significant anti-tumor effects. These results indicate that siRNA-based therapy has good application in the clinical treatment of NSCLC, especially in drug-resistant patients. Based on these findings, we believe that the development of IL-22-siRNA drugs for lung cancer treatment has clinical potential and theoretical basis.',\n", " 'bBox': {'x': 39, 'y': 93.68, 'w': 466.27, 'h': 9.27}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': '6.3. Nanoparticle drug delivery systems',\n", " 'md': '## 6.3. Nanoparticle drug delivery systems',\n", " 'bBox': {'x': 39, 'y': 388.68, 'w': 116.34, 'h': 12.05}},\n", " {'type': 'text',\n", " 'value': 'On the other hand, given the toxicity and erratic efficacy of current anti-tumor drugs, research on novel drug carriers in lung cancer is ongoing.',\n", " 'md': 'On the other hand, given the toxicity and erratic efficacy of current anti-tumor drugs, research on novel drug carriers in lung cancer is ongoing.',\n", " 'bBox': {'x': 50, 'y': 409.68, 'w': 454.28, 'h': 9.27}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 5',\n", " 'md': '### Figure 5',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': '**Caption:** Precision delivery of various nanomaterials containing IL-22 related drugs for the treatment of lung cancer.\\n\\n**Description:** Figure 5 illustrates the precision delivery of various types of nanomaterials that are designed to carry IL-22 related drugs specifically for lung cancer treatment. The diagram likely includes different types of nanoparticles and their targeting mechanisms, emphasizing the advancements in drug delivery systems aimed at improving therapeutic outcomes in lung cancer patients.\\n```',\n", " 'md': '**Caption:** Precision delivery of various nanomaterials containing IL-22 related drugs for the treatment of lung cancer.\\n\\n**Description:** Figure 5 illustrates the precision delivery of various types of nanomaterials that are designed to carry IL-22 related drugs specifically for lung cancer treatment. The diagram likely includes different types of nanoparticles and their targeting mechanisms, emphasizing the advancements in drug delivery systems aimed at improving therapeutic outcomes in lung cancer patients.\\n```',\n", " 'bBox': {'x': 130.91, 'y': 582, 'w': 44.52, 'h': 12.05}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 10,\n", " 'text': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nis also of vital significance. Nanoparticles containing targeted drugs can be delivered to the intended site using carriers with affinity for\\nvarious specific tissues or lesions [146,147]. In an in vivo mice lung model, combined delivery of sorafenib and crizotinib by polymer\\nnanoparticles significantly reduced tumor progression and toxic side effects, and improved survival rate [148]. Moreover, Maofan\\nZhang demonstrated that the efficacy of dual-drug-loaded polymeric nanoparticles with etoposide and cisplatin was significantly\\nsuperior to conventional chemotherapy modality without causing additional toxicity [149]. These imply that nanomaterials loaded\\nwith IL-22-related drugs may also have more unique advantages. Therefore, the utilization of novel nanomaterials loaded with IL-22\\nantibodies and IL-22 inhibitors like IL-22BP for targeted therapy of lung tumors is also a promising research direction (Fig. 5).\\n\\n7. Conclusion\\n\\n In this review, we provided a comprehensive analysis of the role of IL-22 in the immune microenvironment and its involvement in\\nmajor signaling pathways in the context of lung cancer. Put in a nutshell, IL-22 not only antagonizes the induction of apoptosis and cell\\ncycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and metastasis of lung cancer cells and the\\ngrowth of tumor tissues. Additionally, the potential clinical significance of IL-22 in the diagnosis, treatment, and prognosis evaluation\\nof lung cancer was further confirmed. Next, the prospects of IL-22 in combination with gene editing and novel nanomaterials in the\\ntreatment of lung cancer have been discussed. With the general increase in drug resistance to chemotherapy, targeted therapy, and\\nimmunotherapy in lung cancer, it is also necessary to study in depth to discover the correlation between IL-22 and the mechanism of\\ndrug resistance. To sum up, the potential of IL-22 as a biomarker for lung cancer still remains to be explored. Further research on the\\nmolecular, physiological effects and mechanism of IL-22 in lung cancer as well as the conduction of standardized clinical trials are\\nexpected to inject fresh blood into the diagnosis and treatment of lung cancer.\\n\\nFinancial support\\n\\n None.\\n\\nData availability statement\\n\\n Not applicable.\\n\\nCRediT authorship contribution statement\\n\\n Ling Xu: Writing – original draft. Peng Cao: Visualization. Jianpeng Wang: Writing – review & editing. Peng Zhang: Validation.\\nShuhui Hu: Validation. Chao Cheng: Writing – review & editing. Hua Wang: Writing – review & editing, Supervision,\\nConceptualization.\\n\\nDeclaration of competing interest\\n\\n The authors declare that they have no known competing financial interests or personal relationships that could have appeared to\\ninfluence the work reported in this paper.\\n\\nAcknowledgements\\n\\n None.\\n\\nAbbreviations\\n\\nnon-small cell lung cancer NSCLC\\nInterleukin-22 IL-22\\nchimeric antigen receptor CAR\\nIL-10-related T cell-derived inducible factor IL-10-TIF\\nGroup 3 innate lymphoid cells ILC3\\nIL -22 receptor IL-22R\\naryl hydrocarbon receptors AhR\\nchronic obstructive pulmonary disease COPD\\ncutaneous T-cell lymphoma CTCL\\nbronchoalveolar lavage fluid BALF\\nreceptor tyrosine kinases RTKs\\nG-protein-coupled receptors GPCRs\\nMammalian target of rapamycin mTOR\\nidiopathic pulmonary fibrosis IPF\\nrheumatoid arthritis RA\\n\\n 10',\n", " 'md': '```markdown\\n# Page Content\\n\\nL. Xu et al. Heliyon 10 (2024) e35901\\n\\nNanoparticles containing targeted drugs can be delivered to the intended site using carriers with affinity for various specific tissues or lesions [146,147]. In an in vivo mice lung model, combined delivery of sorafenib and crizotinib by polymer nanoparticles significantly reduced tumor progression and toxic side effects, and improved survival rate [148]. Moreover, Maofan Zhang demonstrated that the efficacy of dual-drug-loaded polymeric nanoparticles with etoposide and cisplatin was significantly superior to conventional chemotherapy modality without causing additional toxicity [149]. These imply that nanomaterials loaded with IL-22-related drugs may also have more unique advantages. Therefore, the utilization of novel nanomaterials loaded with IL-22 antibodies and IL-22 inhibitors like IL-22BP for targeted therapy of lung tumors is also a promising research direction (Figure 5).\\n\\n## 7. Conclusion\\n\\nIn this review, we provided a comprehensive analysis of the role of IL-22 in the immune microenvironment and its involvement in major signaling pathways in the context of lung cancer. Put in a nutshell, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and metastasis of lung cancer cells and the growth of tumor tissues. Additionally, the potential clinical significance of IL-22 in the diagnosis, treatment, and prognosis evaluation of lung cancer was further confirmed. Next, the prospects of IL-22 in combination with gene editing and novel nanomaterials in the treatment of lung cancer have been discussed. With the general increase in drug resistance to chemotherapy, targeted therapy, and immunotherapy in lung cancer, it is also necessary to study in depth to discover the correlation between IL-22 and the mechanism of drug resistance. To sum up, the potential of IL-22 as a biomarker for lung cancer still remains to be explored. Further research on the molecular, physiological effects and mechanism of IL-22 in lung cancer as well as the conduction of standardized clinical trials are expected to inject fresh blood into the diagnosis and treatment of lung cancer.\\n\\n## Financial Support\\n\\nNone.\\n\\n## Data Availability Statement\\n\\nNot applicable.\\n\\n## CRediT Authorship Contribution Statement\\n\\n- Ling Xu: Writing – original draft.\\n- Peng Cao: Visualization.\\n- Jianpeng Wang: Writing – review & editing.\\n- Peng Zhang: Validation.\\n- Shuhui Hu: Validation.\\n- Chao Cheng: Writing – review & editing.\\n- Hua Wang: Writing – review & editing, Supervision, Conceptualization.\\n\\n## Declaration of Competing Interest\\n\\nThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\\n\\n## Acknowledgements\\n\\nNone.\\n\\n## Abbreviations\\n\\n- non-small cell lung cancer: NSCLC\\n- Interleukin-22: IL-22\\n- chimeric antigen receptor: CAR\\n- IL-10-related T cell-derived inducible factor: IL-10-TIF\\n- Group 3 innate lymphoid cells: ILC3\\n- IL-22 receptor: IL-22R\\n- aryl hydrocarbon receptors: AhR\\n- chronic obstructive pulmonary disease: COPD\\n- cutaneous T-cell lymphoma: CTCL\\n- bronchoalveolar lavage fluid: BALF\\n- receptor tyrosine kinases: RTKs\\n- G-protein-coupled receptors: GPCRs\\n- Mammalian target of rapamycin: mTOR\\n- idiopathic pulmonary fibrosis: IPF\\n- rheumatoid arthritis: RA\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nNanoparticles containing targeted drugs can be delivered to the intended site using carriers with affinity for various specific tissues or lesions [146,147]. In an in vivo mice lung model, combined delivery of sorafenib and crizotinib by polymer nanoparticles significantly reduced tumor progression and toxic side effects, and improved survival rate [148]. Moreover, Maofan Zhang demonstrated that the efficacy of dual-drug-loaded polymeric nanoparticles with etoposide and cisplatin was significantly superior to conventional chemotherapy modality without causing additional toxicity [149]. These imply that nanomaterials loaded with IL-22-related drugs may also have more unique advantages. Therefore, the utilization of novel nanomaterials loaded with IL-22 antibodies and IL-22 inhibitors like IL-22BP for targeted therapy of lung tumors is also a promising research direction (Figure 5).',\n", " 'md': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nNanoparticles containing targeted drugs can be delivered to the intended site using carriers with affinity for various specific tissues or lesions [146,147]. In an in vivo mice lung model, combined delivery of sorafenib and crizotinib by polymer nanoparticles significantly reduced tumor progression and toxic side effects, and improved survival rate [148]. Moreover, Maofan Zhang demonstrated that the efficacy of dual-drug-loaded polymeric nanoparticles with etoposide and cisplatin was significantly superior to conventional chemotherapy modality without causing additional toxicity [149]. These imply that nanomaterials loaded with IL-22-related drugs may also have more unique advantages. Therefore, the utilization of novel nanomaterials loaded with IL-22 antibodies and IL-22 inhibitors like IL-22BP for targeted therapy of lung tumors is also a promising research direction (Figure 5).',\n", " 'bBox': {'x': 39, 'y': 39.68, 'w': 466.26, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': '7. Conclusion',\n", " 'md': '## 7. Conclusion',\n", " 'bBox': {'x': 39, 'y': 142.68, 'w': 42.14, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': 'In this review, we provided a comprehensive analysis of the role of IL-22 in the immune microenvironment and its involvement in major signaling pathways in the context of lung cancer. Put in a nutshell, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and metastasis of lung cancer cells and the growth of tumor tissues. Additionally, the potential clinical significance of IL-22 in the diagnosis, treatment, and prognosis evaluation of lung cancer was further confirmed. Next, the prospects of IL-22 in combination with gene editing and novel nanomaterials in the treatment of lung cancer have been discussed. With the general increase in drug resistance to chemotherapy, targeted therapy, and immunotherapy in lung cancer, it is also necessary to study in depth to discover the correlation between IL-22 and the mechanism of drug resistance. To sum up, the potential of IL-22 as a biomarker for lung cancer still remains to be explored. Further research on the molecular, physiological effects and mechanism of IL-22 in lung cancer as well as the conduction of standardized clinical trials are expected to inject fresh blood into the diagnosis and treatment of lung cancer.',\n", " 'md': 'In this review, we provided a comprehensive analysis of the role of IL-22 in the immune microenvironment and its involvement in major signaling pathways in the context of lung cancer. Put in a nutshell, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and metastasis of lung cancer cells and the growth of tumor tissues. Additionally, the potential clinical significance of IL-22 in the diagnosis, treatment, and prognosis evaluation of lung cancer was further confirmed. Next, the prospects of IL-22 in combination with gene editing and novel nanomaterials in the treatment of lung cancer have been discussed. With the general increase in drug resistance to chemotherapy, targeted therapy, and immunotherapy in lung cancer, it is also necessary to study in depth to discover the correlation between IL-22 and the mechanism of drug resistance. To sum up, the potential of IL-22 as a biomarker for lung cancer still remains to be explored. Further research on the molecular, physiological effects and mechanism of IL-22 in lung cancer as well as the conduction of standardized clinical trials are expected to inject fresh blood into the diagnosis and treatment of lung cancer.',\n", " 'bBox': {'x': 39, 'y': 163.68, 'w': 466.28, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Financial Support',\n", " 'md': '## Financial Support',\n", " 'bBox': {'x': 39, 'y': 278.68, 'w': 67.07, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': 'None.',\n", " 'md': 'None.',\n", " 'bBox': {'x': 50, 'y': 299.68, 'w': 20.74, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Data Availability Statement',\n", " 'md': '## Data Availability Statement',\n", " 'bBox': {'x': 39, 'y': 320.68, 'w': 103.71, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': 'Not applicable.',\n", " 'md': 'Not applicable.',\n", " 'bBox': {'x': 50, 'y': 341.68, 'w': 53.64, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'CRediT Authorship Contribution Statement',\n", " 'md': '## CRediT Authorship Contribution Statement',\n", " 'bBox': {'x': 39, 'y': 362.68, 'w': 161.94, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': '- Ling Xu: Writing – original draft.\\n- Peng Cao: Visualization.\\n- Jianpeng Wang: Writing – review & editing.\\n- Peng Zhang: Validation.\\n- Shuhui Hu: Validation.\\n- Chao Cheng: Writing – review & editing.\\n- Hua Wang: Writing – review & editing, Supervision, Conceptualization.',\n", " 'md': '- Ling Xu: Writing – original draft.\\n- Peng Cao: Visualization.\\n- Jianpeng Wang: Writing – review & editing.\\n- Peng Zhang: Validation.\\n- Shuhui Hu: Validation.\\n- Chao Cheng: Writing – review & editing.\\n- Hua Wang: Writing – review & editing, Supervision, Conceptualization.',\n", " 'bBox': {'x': 39, 'y': 393.68, 'w': 65.96, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Declaration of Competing Interest',\n", " 'md': '## Declaration of Competing Interest',\n", " 'bBox': {'x': 39, 'y': 425.68, 'w': 128.53, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': 'The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.',\n", " 'md': 'The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.',\n", " 'bBox': {'x': 39, 'y': 446.68, 'w': 465.29, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Acknowledgements',\n", " 'md': '## Acknowledgements',\n", " 'bBox': {'x': 39, 'y': 477.68, 'w': 73.84, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': 'None.',\n", " 'md': 'None.',\n", " 'bBox': {'x': 50, 'y': 299.68, 'w': 20.74, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abbreviations',\n", " 'md': '## Abbreviations',\n", " 'bBox': {'x': 39, 'y': 519.68, 'w': 53.06, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': '- non-small cell lung cancer: NSCLC\\n- Interleukin-22: IL-22\\n- chimeric antigen receptor: CAR\\n- IL-10-related T cell-derived inducible factor: IL-10-TIF\\n- Group 3 innate lymphoid cells: ILC3\\n- IL-22 receptor: IL-22R\\n- aryl hydrocarbon receptors: AhR\\n- chronic obstructive pulmonary disease: COPD\\n- cutaneous T-cell lymphoma: CTCL\\n- bronchoalveolar lavage fluid: BALF\\n- receptor tyrosine kinases: RTKs\\n- G-protein-coupled receptors: GPCRs\\n- Mammalian target of rapamycin: mTOR\\n- idiopathic pulmonary fibrosis: IPF\\n- rheumatoid arthritis: RA\\n```',\n", " 'md': '- non-small cell lung cancer: NSCLC\\n- Interleukin-22: IL-22\\n- chimeric antigen receptor: CAR\\n- IL-10-related T cell-derived inducible factor: IL-10-TIF\\n- Group 3 innate lymphoid cells: ILC3\\n- IL-22 receptor: IL-22R\\n- aryl hydrocarbon receptors: AhR\\n- chronic obstructive pulmonary disease: COPD\\n- cutaneous T-cell lymphoma: CTCL\\n- bronchoalveolar lavage fluid: BALF\\n- receptor tyrosine kinases: RTKs\\n- G-protein-coupled receptors: GPCRs\\n- Mammalian target of rapamycin: mTOR\\n- idiopathic pulmonary fibrosis: IPF\\n- rheumatoid arthritis: RA\\n```',\n", " 'bBox': {'x': 95, 'y': 540.68, 'w': 66.13, 'h': 7.97}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'url': 'https://fanyi.so.com/?src=onebox', 'text': ''}]},\n", " {'page': 11,\n", " 'text': 'L. Xu et al. Heliyon 10 (2024) e35901\\n\\nmitogen-activated protein kinases MAPK\\nmitogen-activated protein MAP\\nhepatitis C virus HCV\\n\\nReferences\\n\\n [1] S. Lareau, C. Slatore, R. Smyth, Lung cancer, Am. J. Respir. Crit. Care Med. 204 (12) (2021) P21–P22.\\n [2] J. Huang, Y. Deng, M.S. Tin, V. Lok, C.H. Ngai, L. Zhang, et al., Distribution, risk factors, and temporal trends for lung cancer incidence and mortality: a global\\n analysis, Chest 161 (4) (2022) 1101–1111.\\n [3] B.C. Bade, C.S. Dela Cruz, Lung cancer 2020: epidemiology, etiology, and prevention, Clin. Chest Med. 41 (1) (2020) 1–24.\\n [4] J. Malhotra, M. Malvezzi, E. Negri, C. La Vecchia, P. Boffetta, Risk factors for lung cancer worldwide, Eur. Respir. J. 48 (3) (2016) 889–902.\\n [5] H. Sung, J. Ferlay, R.L. Siegel, M. Laversanne, I. Soerjomataram, A. Jemal, et al., Global cancer statistics 2020: GLOBOCAN estimates of incidence and\\n mortality worldwide for 36 cancers in 185 countries, CA A Cancer J. Clin. 71 (3) (2021) 209–249.\\n [6] Y. Jin, Y. Chen, H. Tang, X. Hu, S.M. Hubert, Q. Li, et al., Activation of PI3K/AKT pathway is a potential mechanism of treatment resistance in small cell lung\\n cancer, Clin. Cancer Res. 28 (3) (2022) 526–539.\\n [7] S. Kobold, S. Volk, T. Clauditz, N.J. Kupper, S. Minner, A. Tufman, et al., Interleukin-22 is frequently expressed in small- and large-cell lung cancer and\\n promotes growth in chemotherapy-resistant cancer cells, J. Thorac. Oncol. 8 (8) (2013) 1032–1042.\\n [8] K.Y. Lee, P.W. Shueng, C.M. Chou, B.X. Lin, M.H. Lin, D.Y. Kuo, et al., Elevation of CD109 promotes metastasis and drug resistance in lung cancer via\\n activation of EGFR-AKT-mTOR signaling, Cancer Sci. 111 (5) (2020) 1652–1662.\\n [9] R.A. Nagem, D. Colau, L. Dumoutier, J.C. Renauld, C. Ogata, I. Polikarpov, Crystal structure of recombinant human interleukin-22, Structure 10 (8) (2002)\\n 1051–1062.\\n [10] D. Lejeune, L. Dumoutier, S. Constantinescu, W. Kruijer, J.J. 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Gandhi, D. Rodriguez-Abreu, S. Gadgeel, E. Esteban, E. Felip, F. De Angelis, et al., Pembrolizumab plus chemotherapy in metastatic non-small-cell lung\\n cancer, N. Engl. J. Med. 378 (22) (2018) 2078–2092.\\n [43] Y. Yang, Z. Wang, J. Fang, Q. Yu, B. Han, S. Cang, et al., Efficacy and safety of sintilimab plus pemetrexed and platinum as first-line treatment for locally\\n advanced or metastatic nonsquamous NSCLC: a randomized, double-blind, phase 3 study (oncology pRogram by InnovENT anti-PD-1-11), J. Thorac. Oncol. 15\\n (10) (2020) 1636–1646.\\n [44] S. Dong, X. Guo, F. Han, Z. He, Y. Wang, Emerging role of natural products in cancer immunotherapy, Acta Pharm. Sin. B 12 (3) (2022) 1163–1185.\\n\\n 11',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Abbreviations\\n- mitogen-activated protein kinases: MAPK\\n- mitogen-activated protein: MAP\\n- hepatitis C virus: HCV\\n\\n## References\\n1. S. Lareau, C. Slatore, R. Smyth, Lung cancer, *Am. J. Respir. Crit. Care Med.* 204 (12) (2021) P21–P22.\\n2. J. Huang, Y. Deng, M.S. Tin, V. Lok, C.H. Ngai, L. Zhang, et al., Distribution, risk factors, and temporal trends for lung cancer incidence and mortality: a global analysis, *Chest* 161 (4) (2022) 1101–1111.\\n3. B.C. Bade, C.S. Dela Cruz, Lung cancer 2020: epidemiology, etiology, and prevention, *Clin. Chest Med.* 41 (1) (2020) 1–24.\\n4. J. Malhotra, M. Malvezzi, E. Negri, C. La Vecchia, P. Boffetta, Risk factors for lung cancer worldwide, *Eur. Respir. J.* 48 (3) (2016) 889–902.\\n5. H. Sung, J. Ferlay, R.L. Siegel, M. Laversanne, I. Soerjomataram, A. Jemal, et al., Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries, *CA A Cancer J. Clin.* 71 (3) (2021) 209–249.\\n6. Y. Jin, Y. Chen, H. Tang, X. Hu, S.M. Hubert, Q. Li, et al., Activation of PI3K/AKT pathway is a potential mechanism of treatment resistance in small cell lung cancer, *Clin. Cancer Res.* 28 (3) (2022) 526–539.\\n7. S. Kobold, S. Volk, T. Clauditz, N.J. Kupper, S. Minner, A. Tufman, et al., Interleukin-22 is frequently expressed in small- and large-cell lung cancer and promotes growth in chemotherapy-resistant cancer cells, *J. Thorac. Oncol.* 8 (8) (2013) 1032–1042.\\n8. K.Y. Lee, P.W. Shueng, C.M. Chou, B.X. Lin, M.H. Lin, D.Y. Kuo, et al., Elevation of CD109 promotes metastasis and drug resistance in lung cancer via activation of EGFR-AKT-mTOR signaling, *Cancer Sci.* 111 (5) (2020) 1652–1662.\\n9. R.A. Nagem, D. Colau, L. Dumoutier, J.C. Renauld, C. Ogata, I. Polikarpov, Crystal structure of recombinant human interleukin-22, *Structure* 10 (8) (2002) 1051–1062.\\n10. D. Lejeune, L. Dumoutier, S. Constantinescu, W. Kruijer, J.J. Schuringa, J.C. Renauld, Interleukin-22 (IL-22) activates the JAK/STAT, ERK, JNK, and p38 MAP kinase pathways in a rat hepatoma cell line. Pathways that are shared with and distinct from IL-10, *J. Biol. Chem.* 277 (37) (2002) 33676–33682.\\n11. J.A. Dudakov, A.M. Hanash, M.R. van den Brink, Interleukin-22: immunobiology and pathology, *Annu. Rev. Immunol.* 33 (2015) 747–785.\\n12. Lanfranca M. Perusina, Y. Lin, J. Fang, W. Zou, T. Frankel, Biological and pathological activities of interleukin-22, *J. Mol. Med. (Berl.)* 94 (5) (2016) 523–534.\\n13. L.A. Zenewicz, R.A. Flavell, Recent advances in IL-22 biology, *Int. Immunol.* 23 (3) (2011) 159–163.\\n14. Y. Wu, J. Min, C. Ge, J. Shu, D. Tian, Y. Yuan, et al., Interleukin 22 in liver injury, inflammation and cancer, *Int. J. Biol. Sci.* 16 (13) (2020) 2405–2413.\\n15. Y. Zhu, T. Shi, X. Lu, Z. Xu, J. Qu, Z. Zhang, et al., Fungal-induced glycolysis in macrophages promotes colon cancer by enhancing innate lymphoid cell secretion of IL-22, *EMBO J.* 40 (11) (2021) e105320.\\n16. A.D. Giannou, J. Lucke, D. Kleinschmidt, A.M. Shiri, B. Steglich, M. Nawrocki, et al., A critical role of the IL-22-IL-22 binding protein Axis in hepatocellular carcinoma, *Cancers* 14 (24) (2022).\\n17. X. Xuan, J. Zhou, Z. Tian, Y. Lin, J. Song, Z. Ruan, et al., ILC3 cells promote the proliferation and invasion of pancreatic cancer cells through IL-22/AKT signaling, *Clin. Transl. Oncol.* 22 (4) (2020) 563–575.\\n18. L.G. Perez, J. Kempski, H.M. McGee, P. Pelzcar, T. Agalioti, A. Giannou, et al., TGF-beta signaling in Th17 cells promotes IL-22 production and colitis-associated colon cancer, *Nat. Commun.* 11 (1) (2020) 2608.\\n19. K. Kim, G. Kim, J.Y. Kim, H.J. Yun, S.C. Lim, H.S. Choi, Interleukin-22 promotes epithelial cell transformation and breast tumorigenesis via MAP3K8 activation, *Carcinogenesis* 35 (6) (2014) 1352–1361.\\n20. A.D. Giannou, J. Kempski, A.M. Shiri, J. Lucke, T. Zhang, L. Zhao, et al., Tissue resident iNKT17 cells facilitate cancer cell extravasation in liver metastasis via interleukin-22, *Immunity* 56 (1) (2023) 125–142 e12.\\n21. P. Hernandez, K. Gronke, A. Diefenbach, A catch-22: interleukin-22 and cancer, *Eur. J. Immunol.* 48 (1) (2018) 15–31.\\n22. Z. Huang, Y. Gao, D. Hou, Interleukin-22 enhances chemoresistance of lung adenocarcinoma cells to paclitaxel, *Hum. Cell* 33 (3) (2020) 850–858.\\n23. Y. Bi, J. Cao, S. Jin, L. Lv, L. Qi, F. Liu, et al., Interleukin-22 promotes lung cancer cell proliferation and migration via the IL-22R1/STAT3 and IL-22R1/AKT signaling pathways, *Mol. Cell. Biochem.* 415 (1–2) (2016) 1–11.\\n24. W. Zhang, Y. Chen, H. Wei, C. Zheng, R. Sun, J. Zhang, et al., Antiapoptotic activity of autocrine interleukin-22 and therapeutic effects of interleukin-22-small interfering RNA on human lung cancer xenografts, *Clin. Cancer Res.* 14 (20) (2008) 6432–6439.\\n25. A.A. Thai, B.J. Solomon, L.V. Sequist, J.F. Gainor, R.S. Heist, Lung cancer, *Lancet* 398 (10299) (2021) 535–554.\\n26. F.R. Hirsch, G.V. Scagliotti, J.L. Mulshine, R. Kwon, W.J. Curran Jr., Y.L. Wu, et al., Lung cancer: current therapies and new targeted treatments, *Lancet* 389 (10066) (2017) 299–311.\\n27. R.L. Siegel, K.D. Miller, N.S. Wagle, A. Jemal, Cancer statistics, 2023, *CA A Cancer J. Clin.* 73 (1) (2023) 17–48.\\n28. S. Zochbauer-Muller, A.F. Gazdar, J.D. Minna, Molecular pathogenesis of lung cancer, *Annu. Rev. Physiol.* 64 (2002) 681–708.\\n29. S.P. D’Angelo, M.C. Pietanza, The molecular pathogenesis of small cell lung cancer, *Cancer Biol. Ther.* 10 (1) (2010) 1–10.\\n30. Y.E. Miller, Pathogenesis of lung cancer: 100 year report, *Am. J. Respir. Cell Mol. Biol.* 33 (3) (2005) 216–223.\\n31. M. Sato, D.S. Shames, A.F. Gazdar, J.D. Minna, A translational view of the molecular pathogenesis of lung cancer, *J. Thorac. Oncol.* 2 (4) (2007) 327–343.\\n32. E. Taucher, I. Mykoliuk, J. Lindenmann, F.M. Smolle-Juettner, Implications of the immune landscape in COPD and lung cancer: smoking versus other causes, *Front. Immunol.* 13 (2022) 846605.\\n33. F. Nasim, B.F. Sabath, G.A. Eapen, Lung cancer, *Med. Clin.* 103 (3) (2019) 463–473.\\n34. G. Butschak, A. Kuster, B. Schulze, A. Graffi, Temperature dependent pH-instability of some alpha-L-arabinofuranosidases, *Arch. Geschwulstforsch.* 59 (3) (1989) 165–170.\\n35. S.M. Gadgeel, S.S. Ramalingam, G.P. Kalemkerian, Treatment of lung cancer, *Radiol. Clin.* 50 (5) (2012) 961–974.\\n36. C. Zappa, S.A. Mousa, Non-small cell lung cancer: current treatment and future advances, *Transl. Lung Cancer Res.* 5 (3) (2016) 288–300.\\n37. N. Duma, R. Santana-Davila, J.R. Molina, Non-small cell lung cancer: epidemiology, screening, diagnosis, and treatment, *Mayo Clin. Proc.* 94 (8) (2019) 1623–1640.\\n38. S. Wang, S. Zimmermann, K. Parikh, A.S. Mansfield, A.A. Adjei, Current diagnosis and management of small-cell lung cancer, *Mayo Clin. Proc.* 94 (8) (2019) 1599–1622.\\n39. M. Wang, R.S. Herbst, C. Boshoff, Toward personalized treatment approaches for non-small-cell lung cancer, *Nat. Med.* 27 (8) (2021) 1345–1356.\\n40. L.V. Sequist, J.C. Yang, N. Yamamoto, K. O’Byrne, V. Hirsh, T. Mok, et al., Phase III study of afatinib or cisplatin plus pemetrexed in patients with metastatic lung adenocarcinoma with EGFR mutations, *J. Clin. Oncol.* 31 (27) (2013) 3327–3334.\\n41. J. He, C. Su, W. Liang, S. Xu, L. Wu, X. Fu, et al., Icotinib versus chemotherapy as adjuvant treatment for stage II-IIIA EGFR-mutant non-small-cell lung cancer (EVIDENCE): a randomised, open-label, phase 3 trial, *Lancet Respir. Med.* 9 (9) (2021) 1021–1029.\\n42. L. Gandhi, D. Rodriguez-Abreu, S. Gadgeel, E. Esteban, E. Felip, F. De Angelis, et al., Pembrolizumab plus chemotherapy in metastatic non-small-cell lung cancer, *N. Engl. J. Med.* 378 (22) (2018) 2078–2092.\\n43. Y. Yang, Z. Wang, J. Fang, Q. Yu, B. Han, S. Cang, et al., Efficacy and safety of sintilimab plus pemetrexed and platinum as first-line treatment for locally advanced or metastatic nonsquamous NSCLC: a randomized, double-blind, phase 3 study (oncology pRogram by InnovENT anti-PD-1-11), *J. Thorac. Oncol.* 15 (10) (2020) 1636–1646.\\n44. S. Dong, X. Guo, F. Han, Z. He, Y. Wang, Emerging role of natural products in cancer immunotherapy, *Acta Pharm. Sin. B* 12 (3) (2022) 1163–1185.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abbreviations',\n", " 'md': '## Abbreviations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': '- mitogen-activated protein kinases: MAPK\\n- mitogen-activated protein: MAP\\n- hepatitis C virus: HCV',\n", " 'md': '- mitogen-activated protein kinases: MAPK\\n- mitogen-activated protein: MAP\\n- hepatitis C virus: HCV',\n", " 'bBox': {'x': 39, 'y': 59.68, 'w': 147.05, 'h': 7.97}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'References',\n", " 'md': '## References',\n", " 'bBox': {'x': 39, 'y': 126.68, 'w': 41.21, 'h': 7.97}},\n", " {'type': 'text',\n", " 'value': '1. S. Lareau, C. Slatore, R. Smyth, Lung cancer, *Am. J. Respir. Crit. Care Med.* 204 (12) (2021) P21–P22.\\n2. J. Huang, Y. Deng, M.S. Tin, V. Lok, C.H. Ngai, L. Zhang, et al., Distribution, risk factors, and temporal trends for lung cancer incidence and mortality: a global analysis, *Chest* 161 (4) (2022) 1101–1111.\\n3. B.C. Bade, C.S. Dela Cruz, Lung cancer 2020: epidemiology, etiology, and prevention, *Clin. Chest Med.* 41 (1) (2020) 1–24.\\n4. J. Malhotra, M. Malvezzi, E. Negri, C. La Vecchia, P. Boffetta, Risk factors for lung cancer worldwide, *Eur. Respir. J.* 48 (3) (2016) 889–902.\\n5. H. Sung, J. Ferlay, R.L. Siegel, M. Laversanne, I. Soerjomataram, A. Jemal, et al., Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries, *CA A Cancer J. Clin.* 71 (3) (2021) 209–249.\\n6. Y. Jin, Y. Chen, H. Tang, X. Hu, S.M. Hubert, Q. Li, et al., Activation of PI3K/AKT pathway is a potential mechanism of treatment resistance in small cell lung cancer, *Clin. Cancer Res.* 28 (3) (2022) 526–539.\\n7. S. Kobold, S. Volk, T. Clauditz, N.J. Kupper, S. Minner, A. Tufman, et al., Interleukin-22 is frequently expressed in small- and large-cell lung cancer and promotes growth in chemotherapy-resistant cancer cells, *J. Thorac. Oncol.* 8 (8) (2013) 1032–1042.\\n8. K.Y. Lee, P.W. Shueng, C.M. Chou, B.X. Lin, M.H. Lin, D.Y. Kuo, et al., Elevation of CD109 promotes metastasis and drug resistance in lung cancer via activation of EGFR-AKT-mTOR signaling, *Cancer Sci.* 111 (5) (2020) 1652–1662.\\n9. R.A. Nagem, D. Colau, L. Dumoutier, J.C. Renauld, C. Ogata, I. Polikarpov, Crystal structure of recombinant human interleukin-22, *Structure* 10 (8) (2002) 1051–1062.\\n10. D. Lejeune, L. Dumoutier, S. Constantinescu, W. Kruijer, J.J. Schuringa, J.C. Renauld, Interleukin-22 (IL-22) activates the JAK/STAT, ERK, JNK, and p38 MAP kinase pathways in a rat hepatoma cell line. Pathways that are shared with and distinct from IL-10, *J. Biol. Chem.* 277 (37) (2002) 33676–33682.\\n11. J.A. Dudakov, A.M. Hanash, M.R. van den Brink, Interleukin-22: immunobiology and pathology, *Annu. Rev. Immunol.* 33 (2015) 747–785.\\n12. Lanfranca M. Perusina, Y. Lin, J. Fang, W. Zou, T. Frankel, Biological and pathological activities of interleukin-22, *J. Mol. Med. (Berl.)* 94 (5) (2016) 523–534.\\n13. L.A. Zenewicz, R.A. Flavell, Recent advances in IL-22 biology, *Int. Immunol.* 23 (3) (2011) 159–163.\\n14. Y. Wu, J. Min, C. Ge, J. Shu, D. Tian, Y. Yuan, et al., Interleukin 22 in liver injury, inflammation and cancer, *Int. J. Biol. Sci.* 16 (13) (2020) 2405–2413.\\n15. Y. Zhu, T. Shi, X. Lu, Z. Xu, J. Qu, Z. Zhang, et al., Fungal-induced glycolysis in macrophages promotes colon cancer by enhancing innate lymphoid cell secretion of IL-22, *EMBO J.* 40 (11) (2021) e105320.\\n16. A.D. Giannou, J. Lucke, D. Kleinschmidt, A.M. Shiri, B. Steglich, M. Nawrocki, et al., A critical role of the IL-22-IL-22 binding protein Axis in hepatocellular carcinoma, *Cancers* 14 (24) (2022).\\n17. X. Xuan, J. Zhou, Z. Tian, Y. Lin, J. Song, Z. Ruan, et al., ILC3 cells promote the proliferation and invasion of pancreatic cancer cells through IL-22/AKT signaling, *Clin. Transl. Oncol.* 22 (4) (2020) 563–575.\\n18. L.G. Perez, J. Kempski, H.M. McGee, P. Pelzcar, T. Agalioti, A. Giannou, et al., TGF-beta signaling in Th17 cells promotes IL-22 production and colitis-associated colon cancer, *Nat. Commun.* 11 (1) (2020) 2608.\\n19. K. Kim, G. Kim, J.Y. Kim, H.J. Yun, S.C. Lim, H.S. Choi, Interleukin-22 promotes epithelial cell transformation and breast tumorigenesis via MAP3K8 activation, *Carcinogenesis* 35 (6) (2014) 1352–1361.\\n20. A.D. Giannou, J. Kempski, A.M. Shiri, J. Lucke, T. Zhang, L. Zhao, et al., Tissue resident iNKT17 cells facilitate cancer cell extravasation in liver metastasis via interleukin-22, *Immunity* 56 (1) (2023) 125–142 e12.\\n21. P. Hernandez, K. Gronke, A. Diefenbach, A catch-22: interleukin-22 and cancer, *Eur. J. Immunol.* 48 (1) (2018) 15–31.\\n22. Z. Huang, Y. Gao, D. Hou, Interleukin-22 enhances chemoresistance of lung adenocarcinoma cells to paclitaxel, *Hum. Cell* 33 (3) (2020) 850–858.\\n23. Y. Bi, J. Cao, S. Jin, L. Lv, L. Qi, F. Liu, et al., Interleukin-22 promotes lung cancer cell proliferation and migration via the IL-22R1/STAT3 and IL-22R1/AKT signaling pathways, *Mol. Cell. Biochem.* 415 (1–2) (2016) 1–11.\\n24. W. Zhang, Y. Chen, H. Wei, C. Zheng, R. Sun, J. Zhang, et al., Antiapoptotic activity of autocrine interleukin-22 and therapeutic effects of interleukin-22-small interfering RNA on human lung cancer xenografts, *Clin. Cancer Res.* 14 (20) (2008) 6432–6439.\\n25. A.A. Thai, B.J. Solomon, L.V. Sequist, J.F. Gainor, R.S. Heist, Lung cancer, *Lancet* 398 (10299) (2021) 535–554.\\n26. F.R. Hirsch, G.V. Scagliotti, J.L. Mulshine, R. Kwon, W.J. Curran Jr., Y.L. Wu, et al., Lung cancer: current therapies and new targeted treatments, *Lancet* 389 (10066) (2017) 299–311.\\n27. R.L. Siegel, K.D. Miller, N.S. Wagle, A. Jemal, Cancer statistics, 2023, *CA A Cancer J. Clin.* 73 (1) (2023) 17–48.\\n28. S. Zochbauer-Muller, A.F. Gazdar, J.D. Minna, Molecular pathogenesis of lung cancer, *Annu. Rev. Physiol.* 64 (2002) 681–708.\\n29. S.P. D’Angelo, M.C. Pietanza, The molecular pathogenesis of small cell lung cancer, *Cancer Biol. Ther.* 10 (1) (2010) 1–10.\\n30. Y.E. Miller, Pathogenesis of lung cancer: 100 year report, *Am. J. Respir. Cell Mol. Biol.* 33 (3) (2005) 216–223.\\n31. M. Sato, D.S. Shames, A.F. Gazdar, J.D. Minna, A translational view of the molecular pathogenesis of lung cancer, *J. Thorac. Oncol.* 2 (4) (2007) 327–343.\\n32. E. Taucher, I. Mykoliuk, J. Lindenmann, F.M. Smolle-Juettner, Implications of the immune landscape in COPD and lung cancer: smoking versus other causes, *Front. Immunol.* 13 (2022) 846605.\\n33. F. Nasim, B.F. Sabath, G.A. Eapen, Lung cancer, *Med. Clin.* 103 (3) (2019) 463–473.\\n34. G. Butschak, A. Kuster, B. Schulze, A. Graffi, Temperature dependent pH-instability of some alpha-L-arabinofuranosidases, *Arch. Geschwulstforsch.* 59 (3) (1989) 165–170.\\n35. S.M. Gadgeel, S.S. Ramalingam, G.P. Kalemkerian, Treatment of lung cancer, *Radiol. Clin.* 50 (5) (2012) 961–974.\\n36. C. Zappa, S.A. Mousa, Non-small cell lung cancer: current treatment and future advances, *Transl. Lung Cancer Res.* 5 (3) (2016) 288–300.\\n37. N. Duma, R. Santana-Davila, J.R. Molina, Non-small cell lung cancer: epidemiology, screening, diagnosis, and treatment, *Mayo Clin. Proc.* 94 (8) (2019) 1623–1640.\\n38. S. Wang, S. Zimmermann, K. Parikh, A.S. Mansfield, A.A. Adjei, Current diagnosis and management of small-cell lung cancer, *Mayo Clin. Proc.* 94 (8) (2019) 1599–1622.\\n39. M. Wang, R.S. Herbst, C. Boshoff, Toward personalized treatment approaches for non-small-cell lung cancer, *Nat. Med.* 27 (8) (2021) 1345–1356.\\n40. L.V. Sequist, J.C. Yang, N. Yamamoto, K. O’Byrne, V. Hirsh, T. Mok, et al., Phase III study of afatinib or cisplatin plus pemetrexed in patients with metastatic lung adenocarcinoma with EGFR mutations, *J. Clin. Oncol.* 31 (27) (2013) 3327–3334.\\n41. J. He, C. Su, W. Liang, S. Xu, L. Wu, X. Fu, et al., Icotinib versus chemotherapy as adjuvant treatment for stage II-IIIA EGFR-mutant non-small-cell lung cancer (EVIDENCE): a randomised, open-label, phase 3 trial, *Lancet Respir. Med.* 9 (9) (2021) 1021–1029.\\n42. L. Gandhi, D. Rodriguez-Abreu, S. Gadgeel, E. Esteban, E. Felip, F. De Angelis, et al., Pembrolizumab plus chemotherapy in metastatic non-small-cell lung cancer, *N. Engl. J. Med.* 378 (22) (2018) 2078–2092.\\n43. Y. Yang, Z. Wang, J. Fang, Q. Yu, B. Han, S. Cang, et al., Efficacy and safety of sintilimab plus pemetrexed and platinum as first-line treatment for locally advanced or metastatic nonsquamous NSCLC: a randomized, double-blind, phase 3 study (oncology pRogram by InnovENT anti-PD-1-11), *J. Thorac. Oncol.* 15 (10) (2020) 1636–1646.\\n44. S. Dong, X. Guo, F. Han, Z. He, Y. Wang, Emerging role of natural products in cancer immunotherapy, *Acta Pharm. Sin. B* 12 (3) (2022) 1163–1185.\\n```',\n", " 'md': '1. S. Lareau, C. Slatore, R. Smyth, Lung cancer, *Am. J. Respir. Crit. Care Med.* 204 (12) (2021) P21–P22.\\n2. J. Huang, Y. Deng, M.S. Tin, V. Lok, C.H. Ngai, L. Zhang, et al., Distribution, risk factors, and temporal trends for lung cancer incidence and mortality: a global analysis, *Chest* 161 (4) (2022) 1101–1111.\\n3. B.C. Bade, C.S. Dela Cruz, Lung cancer 2020: epidemiology, etiology, and prevention, *Clin. Chest Med.* 41 (1) (2020) 1–24.\\n4. J. Malhotra, M. Malvezzi, E. Negri, C. La Vecchia, P. Boffetta, Risk factors for lung cancer worldwide, *Eur. Respir. J.* 48 (3) (2016) 889–902.\\n5. H. Sung, J. Ferlay, R.L. Siegel, M. Laversanne, I. Soerjomataram, A. Jemal, et al., Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries, *CA A Cancer J. Clin.* 71 (3) (2021) 209–249.\\n6. Y. Jin, Y. Chen, H. Tang, X. Hu, S.M. Hubert, Q. Li, et al., Activation of PI3K/AKT pathway is a potential mechanism of treatment resistance in small cell lung cancer, *Clin. Cancer Res.* 28 (3) (2022) 526–539.\\n7. S. Kobold, S. Volk, T. Clauditz, N.J. Kupper, S. Minner, A. Tufman, et al., Interleukin-22 is frequently expressed in small- and large-cell lung cancer and promotes growth in chemotherapy-resistant cancer cells, *J. Thorac. Oncol.* 8 (8) (2013) 1032–1042.\\n8. K.Y. Lee, P.W. Shueng, C.M. Chou, B.X. Lin, M.H. Lin, D.Y. Kuo, et al., Elevation of CD109 promotes metastasis and drug resistance in lung cancer via activation of EGFR-AKT-mTOR signaling, *Cancer Sci.* 111 (5) (2020) 1652–1662.\\n9. R.A. Nagem, D. Colau, L. Dumoutier, J.C. Renauld, C. Ogata, I. Polikarpov, Crystal structure of recombinant human interleukin-22, *Structure* 10 (8) (2002) 1051–1062.\\n10. D. Lejeune, L. Dumoutier, S. Constantinescu, W. Kruijer, J.J. Schuringa, J.C. Renauld, Interleukin-22 (IL-22) activates the JAK/STAT, ERK, JNK, and p38 MAP kinase pathways in a rat hepatoma cell line. Pathways that are shared with and distinct from IL-10, *J. Biol. Chem.* 277 (37) (2002) 33676–33682.\\n11. J.A. Dudakov, A.M. Hanash, M.R. van den Brink, Interleukin-22: immunobiology and pathology, *Annu. Rev. Immunol.* 33 (2015) 747–785.\\n12. Lanfranca M. Perusina, Y. Lin, J. Fang, W. Zou, T. Frankel, Biological and pathological activities of interleukin-22, *J. Mol. Med. (Berl.)* 94 (5) (2016) 523–534.\\n13. L.A. Zenewicz, R.A. Flavell, Recent advances in IL-22 biology, *Int. Immunol.* 23 (3) (2011) 159–163.\\n14. Y. Wu, J. Min, C. Ge, J. Shu, D. Tian, Y. Yuan, et al., Interleukin 22 in liver injury, inflammation and cancer, *Int. J. Biol. Sci.* 16 (13) (2020) 2405–2413.\\n15. Y. Zhu, T. Shi, X. Lu, Z. Xu, J. Qu, Z. Zhang, et al., Fungal-induced glycolysis in macrophages promotes colon cancer by enhancing innate lymphoid cell secretion of IL-22, *EMBO J.* 40 (11) (2021) e105320.\\n16. A.D. Giannou, J. Lucke, D. Kleinschmidt, A.M. Shiri, B. Steglich, M. Nawrocki, et al., A critical role of the IL-22-IL-22 binding protein Axis in hepatocellular carcinoma, *Cancers* 14 (24) (2022).\\n17. X. Xuan, J. 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Kilmartin, K.J. O’Byrne, S.G. Gray, IL-23 is pro-proliferative, epigenetically regulated and modulated by\\n chemotherapy in non-small cell lung cancer, Lung Cancer 79 (1) (2013) 83–90.\\n [64] Y. Niu, L. Ye, W. Peng, Z. Wang, X. Wei, X. Wang, et al., IL-26 promotes the pathogenesis of malignant pleural effusion by enhancing CD4(+) IL-22(+) T-cell\\n differentiation and inhibiting CD8(+) T-cell cytotoxicity, J. Leukoc. Biol. 110 (1) (2021) 39–52.\\n [65] B. Pang, C. Hu, N. Xing, L. Xu, S. Zhang, X. Yu, Elevated Notch1 enhances interleukin-22 production by CD4(+) T cells via aryl hydrocarbon receptor in\\n patients with lung adenocarcinoma, Biosci. Rep. 38 (6) (2018).\\n [66] J.S. Lim, A. Ibaseta, M.M. Fischer, B. Cancilla, G. O’Young, S. Cristea, et al., Intratumoural heterogeneity generated by Notch signalling promotes small-cell\\n lung cancer, Nature 545 (7654) (2017) 360–364.\\n [67] Y. Matsuda, S. Ikeda, F. Abe, Y. Takahashi, A. Kitadate, N. Takahashi, et al., Downregulation of miR-26 promotes invasion and metastasis via targeting\\n interleukin-22 in cutaneous T-cell lymphoma, Cancer Sci. 113 (4) (2022) 1208–1219.\\n [68] Y. He, H. Liu, L. Jiang, B. Rui, J. Mei, H. Xiao, miR-26 induces apoptosis and inhibits autophagy in non-small cell lung cancer cells by suppressing TGF-beta1-\\n JNK signaling pathway, Front. Pharmacol. 9 (2018) 1509.\\n [69] H. Lindahl, T. Olsson, Interleukin-22 influences the Th1/Th17 Axis, Front. Immunol. 12 (2021) 618110.\\n [70] E. Klimatcheva, T. Pandina, C. Reilly, S. Torno, H. Bussler, M. Scrivens, et al., CXCL13 antibody for the treatment of autoimmune disorders, BMC Immunol. 16\\n (1) (2015) 6.\\n [71] F. Barone, S. Nayar, J. Campos, T. Cloake, D.R. Withers, K.M. Toellner, et al., IL-22 regulates lymphoid chemokine production and assembly of tertiary\\n lymphoid organs, Proc. Natl. Acad. Sci. U. S. A 112 (35) (2015) 11024–11029.\\n [72] D. Briukhovetska, J. Suarez-Gosalvez, C. Voigt, A. Markota, A.D. Giannou, M. Schubel, et al., T cell-derived interleukin-22 drives the expression of CD155 by\\n cancer cells to suppress NK cell function and promote metastasis, Immunity 56 (1) (2023) 143–161 e11.\\n [73] M. Kasprzak, M. Rudzinska, D. Kmiecik, R. Przybylski, A. Olejnik, Acyl moiety and temperature affects thermo-oxidative degradation of steryl esters.\\n Cytotoxicity of the degradation products, Food Chem. Toxicol. 136 (2020) 111074.\\n [74] R. Molfetta, B. Zitti, M. Lecce, N.D. Milito, H. Stabile, C. Fionda, et al., CD155: a multi-functional molecule in tumor progression, Int. J. Mol. Sci. 21 (3) (2020).\\n [75] J. Gao, Q. Zheng, N. Xin, W. Wang, C. Zhao, CD155, an onco-immunologic molecule in human tumors, Cancer Sci. 108 (10) (2017) 1934–1938.\\n [76] J.M. Leyva-Castillo, J. Yoon, R.S. Geha, IL-22 promotes allergic airway inflammation in epicutaneously sensitized mice, J. Allergy Clin. Immunol. 143 (2)\\n (2019) 619–630 e7.\\n [77] M.R. Starkey, M.W. Plank, P. Casolari, A. Papi, S. Pavlidis, Y. Guo, et al., IL-22 and its receptors are increased in human and experimental COPD and contribute\\n to pathogenesis, Eur. Respir. J. 54 (1) (2019).\\n [78] X. Xu, I.D. Weiss, H.H. Zhang, S.P. Singh, T.A. Wynn, M.S. Wilson, et al., Conventional NK cells can produce IL-22 and promote host defense in Klebsiella\\n pneumoniae pneumonia, J. Immunol. 192 (4) (2014) 1778–1786.\\n [79] P. Treerat, O. Prince, A. Cruz-Lagunas, M. Munoz-Torrico, M.A. Salazar-Lezama, M. Selman, et al., Novel role for IL-22 in protection during chronic\\n Mycobacterium tuberculosis HN878 infection, Mucosal Immunol. 10 (4) (2017) 1069–1081.\\n [80] B. Kone, M. Perez-Cruz, R. Porte, F. Hennegrave, C. Carnoy, P. Gosset, et al., Boosting the IL-22 response using flagellin prevents bacterial infection in cigarette\\n smoke-exposed mice, Clin. Exp. Immunol. 201 (2) (2020) 171–186.\\n [81] M.A. Gessner, J.L. Werner, L.M. Lilly, M.P. Nelson, A.E. Metz, C.W. Dunaway, et al., Dectin-1-dependent interleukin-22 contributes to early innate lung defense\\n against Aspergillus fumigatus, Infect. Immun. 80 (1) (2012) 410–417.\\n [82] S. Ivanov, J. Renneson, J. Fontaine, A. Barthelemy, C. Paget, E.M. Fernandez, et al., Interleukin-22 reduces lung inflammation during influenza A virus\\n infection and protects against secondary bacterial infection, J. Virol. 87 (12) (2013) 6911–6924.\\n [83] H. Guo, D.J. Topham, Interleukin-22 (IL-22) production by pulmonary Natural Killer cells and the potential role of IL-22 during primary influenza virus\\n infection, J. Virol. 84 (15) (2010) 7750–7759.\\n [84] Z. Qu, W. Dou, K. Zhang, L. Duan, D. Zhou, S. Yin, IL-22 inhibits bleomycin-induced pulmonary fibrosis in association with inhibition of IL-17A in mice,\\n Arthritis Res. Ther. 24 (1) (2022) 280.\\n [85] F. Liu, X. Pan, L. Zhou, J. Zhou, B. Chen, J. Shi, et al., Genetic polymorphisms and plasma levels of interleukin-22 contribute to the development of nonsmall\\n cell lung cancer, DNA Cell Biol. 33 (10) (2014) 705–714.\\n [86] H. Li, Q. Zhang, Q. Wu, Y. Cui, H. Zhu, M. Fang, et al., Interleukin-22 secreted by cancer-associated fibroblasts regulates the proliferation and metastasis of\\n lung cancer cells via the PI3K-Akt-mTOR signaling pathway, Am J Transl Res 11 (7) (2019) 4077–4088.\\n [87] A. Tufman, R.M. Huber, S. Volk, F. Aigner, M. Edelmann, F. Gamarra, et al., Interleukin-22 is elevated in lavage from patients with lung cancer and other\\n pulmonary diseases, BMC Cancer 16 (2016) 409.\\n [88] Z.J. Ye, Q. Zhou, W. Yin, M.L. Yuan, W.B. Yang, F. Xiang, et al., Interleukin 22-producing CD4+ T cells in malignant pleural effusion, Cancer Lett. 326 (1)\\n (2012) 23–32.\\n\\n 12',\n", " 'md': '```markdown\\n# References\\n\\n1. Y. Yang, N. Li, T.M. Wang, L. Di, Natural products with activity against lung cancer: a review focusing on the tumor microenvironment, *Int. J. Mol. Sci.* 22 (19) (2021).\\n2. L. Xiang, Y. Gao, S. Chen, J. Sun, J. Wu, X. Meng, Therapeutic potential of Scutellaria baicalensis Georgi in lung cancer therapy, *Phytomedicine* 95 (2022) 153727.\\n3. Z. Chen, K.A. Vallega, H. Chen, J. Zhou, S.S. Ramalingam, S.Y. Sun, The natural product berberine synergizes with osimertinib preferentially against MET-amplified osimertinib-resistant lung cancer via direct MET inhibition, *Pharmacol. Res.* 175 (2022) 105998.\\n4. Z. Li, Z. Feiyue, L. Gaofeng, Traditional Chinese medicine and lung cancer–From theory to practice, *Biomed. Pharmacother.* 137 (2021) 111381.\\n5. J. Qu, Q. Mei, L. Chen, J. Zhou, Chimeric antigen receptor (CAR)-T-cell therapy in non-small-cell lung cancer (NSCLC): current status and future perspectives, *Cancer Immunol. Immunother.* 70 (3) (2021) 619–631.\\n6. S. Srivastava, S.N. Furlan, C.A. Jaeger-Ruckstuhl, M. Sarvothama, C. Berger, K.S. Smythe, et al., Immunogenic chemotherapy enhances recruitment of CAR-T cells to lung tumors and improves antitumor efficacy when combined with checkpoint blockade, *Cancer Cell* 39 (2) (2021) 193–208 e10.\\n7. H. Li, E.B. Harrison, H. Li, K. Hirabayashi, J. Chen, Q.X. Li, et al., Targeting brain lesions of non-small cell lung cancer by enhancing CCL2-mediated CAR-T cell migration, *Nat. Commun.* 13 (1) (2022) 2154.\\n8. D. Denk, F.R. Greten, Inflammation: the incubator of the tumor microenvironment, *Trends Cancer* 8 (11) (2022) 901–914.\\n9. L. Dumoutier, J. Louahed, J.C. Renauld, Cloning and characterization of IL-10-related T cell-derived inducible factor (IL-TIF), a novel cytokine structurally related to IL-10 and inducible by IL-9, *J. Immunol.* 164 (4) (2000) 1814–1819.\\n10. W. Ouyang, A. O’Garra, IL-10 family cytokines IL-10 and IL-22: from basic science to clinical translation, *Immunity* 50 (4) (2019) 871–891.\\n11. S.Z. Hasnain, J. Begun, Interleukin-22: friend or foe? *Immunol. Cell Biol.* 97 (4) (2019) 355–357.\\n12. S. Mossner, M. Kuchner, N. Fazel Modares, B. Knebel, H. Al-Hasani, D.M. Floss, et al., Synthetic interleukin 22 (IL-22) signaling reveals biological activity of homodimeric IL-10 receptor 2 and functional cross-talk with the IL-6 receptor gp130, *J. Biol. Chem.* 295 (35) (2020) 12378–12397.\\n13. D. Lee, H. Jo, C. Go, Y. Jang, N. Chu, S. Bae, et al., The roles of IL-22 and its receptor in the regulation of inflammatory responses in the brain, *Int. J. Mol. Sci.* 23 (2) (2022).\\n14. S. Huber, N. Gagliani, L.A. Zenewicz, F.J. Huber, L. Bosurgi, B. Hu, et al., IL-22BP is regulated by the inflammasome and modulates tumorigenesis in the intestine, *Nature* 491 (7423) (2012) 259–263.\\n15. L.A. Zenewicz, IL-22 binding protein (IL-22BP) in the regulation of IL-22 biology, *Front. Immunol.* 12 (2021) 766586.\\n16. H.X. Wei, B. Wang, B. Li, IL-10 and IL-22 in mucosal immunity: driving protection and pathology, *Front. Immunol.* 11 (2020) 1315.\\n17. C. Voigt, P. May, A. Gottschlich, A. Markota, D. Wenk, I. Gerlach, et al., Cancer cells induce interleukin-22 production from memory CD4(+) T cells via interleukin-1 to promote tumor growth, *Proc. Natl. Acad. Sci. U. S. A.* 114 (49) (2017) 12994–12999.\\n18. A.G. McLoed, T.P. Sherrill, D.S. Cheng, W. Han, J.A. Saxon, L.A. Gleaves, et al., Neutrophil-derived IL-1beta impairs the efficacy of NF-kappaB inhibitors against lung cancer, *Cell Rep.* 16 (1) (2016) 120–132.\\n19. A.M. Baird, J. Leonard, K.M. Naicker, L. Kilmartin, K.J. O’Byrne, S.G. Gray, IL-23 is pro-proliferative, epigenetically regulated and modulated by chemotherapy in non-small cell lung cancer, *Lung Cancer* 79 (1) (2013) 83–90.\\n20. Y. Niu, L. Ye, W. Peng, Z. Wang, X. Wei, X. Wang, et al., IL-26 promotes the pathogenesis of malignant pleural effusion by enhancing CD4(+) IL-22(+) T-cell differentiation and inhibiting CD8(+) T-cell cytotoxicity, *J. Leukoc. Biol.* 110 (1) (2021) 39–52.\\n21. B. Pang, C. Hu, N. Xing, L. Xu, S. Zhang, X. Yu, Elevated Notch1 enhances interleukin-22 production by CD4(+) T cells via aryl hydrocarbon receptor in patients with lung adenocarcinoma, *Biosci. Rep.* 38 (6) (2018).\\n22. J.S. Lim, A. Ibaseta, M.M. Fischer, B. Cancilla, G. O’Young, S. Cristea, et al., Intratumoural heterogeneity generated by Notch signalling promotes small-cell lung cancer, *Nature* 545 (7654) (2017) 360–364.\\n23. Y. Matsuda, S. Ikeda, F. Abe, Y. Takahashi, A. Kitadate, N. Takahashi, et al., Downregulation of miR-26 promotes invasion and metastasis via targeting interleukin-22 in cutaneous T-cell lymphoma, *Cancer Sci.* 113 (4) (2022) 1208–1219.\\n24. Y. He, H. Liu, L. Jiang, B. Rui, J. Mei, H. Xiao, miR-26 induces apoptosis and inhibits autophagy in non-small cell lung cancer cells by suppressing TGF-beta1-JNK signaling pathway, *Front. Pharmacol.* 9 (2018) 1509.\\n25. H. Lindahl, T. Olsson, Interleukin-22 influences the Th1/Th17 Axis, *Front. Immunol.* 12 (2021) 618110.\\n26. E. Klimatcheva, T. Pandina, C. Reilly, S. Torno, H. Bussler, M. Scrivens, et al., CXCL13 antibody for the treatment of autoimmune disorders, *BMC Immunol.* 16 (1) (2015) 6.\\n27. F. Barone, S. Nayar, J. Campos, T. Cloake, D.R. Withers, K.M. Toellner, et al., IL-22 regulates lymphoid chemokine production and assembly of tertiary lymphoid organs, *Proc. Natl. Acad. Sci. U. S. A.* 112 (35) (2015) 11024–11029.\\n28. D. Briukhovetska, J. Suarez-Gosalvez, C. Voigt, A. Markota, A.D. Giannou, M. Schubel, et al., T cell-derived interleukin-22 drives the expression of CD155 by cancer cells to suppress NK cell function and promote metastasis, *Immunity* 56 (1) (2023) 143–161 e11.\\n29. M. Kasprzak, M. Rudzinska, D. Kmiecik, R. Przybylski, A. Olejnik, Acyl moiety and temperature affects thermo-oxidative degradation of steryl esters. Cytotoxicity of the degradation products, *Food Chem. Toxicol.* 136 (2020) 111074.\\n30. R. Molfetta, B. Zitti, M. Lecce, N.D. Milito, H. Stabile, C. Fionda, et al., CD155: a multi-functional molecule in tumor progression, *Int. J. Mol. Sci.* 21 (3) (2020).\\n31. J. Gao, Q. Zheng, N. Xin, W. Wang, C. Zhao, CD155, an onco-immunologic molecule in human tumors, *Cancer Sci.* 108 (10) (2017) 1934–1938.\\n32. J.M. Leyva-Castillo, J. Yoon, R.S. Geha, IL-22 promotes allergic airway inflammation in epicutaneously sensitized mice, *J. Allergy Clin. Immunol.* 143 (2) (2019) 619–630 e7.\\n33. M.R. Starkey, M.W. Plank, P. Casolari, A. Papi, S. Pavlidis, Y. Guo, et al., IL-22 and its receptors are increased in human and experimental COPD and contribute to pathogenesis, *Eur. Respir. J.* 54 (1) (2019).\\n34. X. Xu, I.D. Weiss, H.H. Zhang, S.P. Singh, T.A. Wynn, M.S. Wilson, et al., Conventional NK cells can produce IL-22 and promote host defense in Klebsiella pneumoniae pneumonia, *J. Immunol.* 192 (4) (2014) 1778–1786.\\n35. P. Treerat, O. Prince, A. Cruz-Lagunas, M. Munoz-Torrico, M.A. Salazar-Lezama, M. Selman, et al., Novel role for IL-22 in protection during chronic Mycobacterium tuberculosis HN878 infection, *Mucosal Immunol.* 10 (4) (2017) 1069–1081.\\n36. B. Kone, M. Perez-Cruz, R. Porte, F. Hennegrave, C. Carnoy, P. Gosset, et al., Boosting the IL-22 response using flagellin prevents bacterial infection in cigarette smoke-exposed mice, *Clin. Exp. Immunol.* 201 (2) (2020) 171–186.\\n37. M.A. Gessner, J.L. Werner, L.M. Lilly, M.P. Nelson, A.E. Metz, C.W. Dunaway, et al., Dectin-1-dependent interleukin-22 contributes to early innate lung defense against Aspergillus fumigatus, *Infect. Immun.* 80 (1) (2012) 410–417.\\n38. S. Ivanov, J. Renneson, J. Fontaine, A. Barthelemy, C. Paget, E.M. Fernandez, et al., Interleukin-22 reduces lung inflammation during influenza A virus infection and protects against secondary bacterial infection, *J. Virol.* 87 (12) (2013) 6911–6924.\\n39. H. Guo, D.J. Topham, Interleukin-22 (IL-22) production by pulmonary Natural Killer cells and the potential role of IL-22 during primary influenza virus infection, *J. Virol.* 84 (15) (2010) 7750–7759.\\n40. Z. Qu, W. Dou, K. Zhang, L. Duan, D. Zhou, S. Yin, IL-22 inhibits bleomycin-induced pulmonary fibrosis in association with inhibition of IL-17A in mice, *Arthritis Res. Ther.* 24 (1) (2022) 280.\\n41. F. Liu, X. Pan, L. Zhou, J. Zhou, B. Chen, J. Shi, et al., Genetic polymorphisms and plasma levels of interleukin-22 contribute to the development of nonsmall cell lung cancer, *DNA Cell Biol.* 33 (10) (2014) 705–714.\\n42. H. Li, Q. Zhang, Q. Wu, Y. Cui, H. Zhu, M. Fang, et al., Interleukin-22 secreted by cancer-associated fibroblasts regulates the proliferation and metastasis of lung cancer cells via the PI3K-Akt-mTOR signaling pathway, *Am J Transl Res* 11 (7) (2019) 4077–4088.\\n43. A. Tufman, R.M. Huber, S. Volk, F. Aigner, M. Edelmann, F. Gamarra, et al., Interleukin-22 is elevated in lavage from patients with lung cancer and other pulmonary diseases, *BMC Cancer* 16 (2016) 409.\\n44. Z.J. Ye, Q. Zhou, W. Yin, M.L. Yuan, W.B. Yang, F. Xiang, et al., Interleukin 22-producing CD4+ T cells in malignant pleural effusion, *Cancer Lett.* 326 (1) (2012) 23–32.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'References',\n", " 'md': '# References',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': '1. Y. Yang, N. Li, T.M. Wang, L. Di, Natural products with activity against lung cancer: a review focusing on the tumor microenvironment, *Int. J. Mol. Sci.* 22 (19) (2021).\\n2. L. Xiang, Y. Gao, S. Chen, J. Sun, J. Wu, X. Meng, Therapeutic potential of Scutellaria baicalensis Georgi in lung cancer therapy, *Phytomedicine* 95 (2022) 153727.\\n3. Z. Chen, K.A. Vallega, H. Chen, J. Zhou, S.S. Ramalingam, S.Y. Sun, The natural product berberine synergizes with osimertinib preferentially against MET-amplified osimertinib-resistant lung cancer via direct MET inhibition, *Pharmacol. Res.* 175 (2022) 105998.\\n4. Z. Li, Z. Feiyue, L. Gaofeng, Traditional Chinese medicine and lung cancer–From theory to practice, *Biomed. Pharmacother.* 137 (2021) 111381.\\n5. J. Qu, Q. Mei, L. Chen, J. Zhou, Chimeric antigen receptor (CAR)-T-cell therapy in non-small-cell lung cancer (NSCLC): current status and future perspectives, *Cancer Immunol. Immunother.* 70 (3) (2021) 619–631.\\n6. S. Srivastava, S.N. Furlan, C.A. Jaeger-Ruckstuhl, M. Sarvothama, C. Berger, K.S. Smythe, et al., Immunogenic chemotherapy enhances recruitment of CAR-T cells to lung tumors and improves antitumor efficacy when combined with checkpoint blockade, *Cancer Cell* 39 (2) (2021) 193–208 e10.\\n7. H. Li, E.B. Harrison, H. Li, K. Hirabayashi, J. Chen, Q.X. Li, et al., Targeting brain lesions of non-small cell lung cancer by enhancing CCL2-mediated CAR-T cell migration, *Nat. Commun.* 13 (1) (2022) 2154.\\n8. D. Denk, F.R. Greten, Inflammation: the incubator of the tumor microenvironment, *Trends Cancer* 8 (11) (2022) 901–914.\\n9. L. Dumoutier, J. Louahed, J.C. Renauld, Cloning and characterization of IL-10-related T cell-derived inducible factor (IL-TIF), a novel cytokine structurally related to IL-10 and inducible by IL-9, *J. Immunol.* 164 (4) (2000) 1814–1819.\\n10. W. Ouyang, A. O’Garra, IL-10 family cytokines IL-10 and IL-22: from basic science to clinical translation, *Immunity* 50 (4) (2019) 871–891.\\n11. S.Z. Hasnain, J. Begun, Interleukin-22: friend or foe? *Immunol. Cell Biol.* 97 (4) (2019) 355–357.\\n12. S. Mossner, M. Kuchner, N. Fazel Modares, B. Knebel, H. Al-Hasani, D.M. Floss, et al., Synthetic interleukin 22 (IL-22) signaling reveals biological activity of homodimeric IL-10 receptor 2 and functional cross-talk with the IL-6 receptor gp130, *J. Biol. Chem.* 295 (35) (2020) 12378–12397.\\n13. D. Lee, H. Jo, C. Go, Y. Jang, N. Chu, S. Bae, et al., The roles of IL-22 and its receptor in the regulation of inflammatory responses in the brain, *Int. J. Mol. Sci.* 23 (2) (2022).\\n14. S. Huber, N. Gagliani, L.A. Zenewicz, F.J. Huber, L. Bosurgi, B. Hu, et al., IL-22BP is regulated by the inflammasome and modulates tumorigenesis in the intestine, *Nature* 491 (7423) (2012) 259–263.\\n15. L.A. Zenewicz, IL-22 binding protein (IL-22BP) in the regulation of IL-22 biology, *Front. Immunol.* 12 (2021) 766586.\\n16. H.X. Wei, B. Wang, B. Li, IL-10 and IL-22 in mucosal immunity: driving protection and pathology, *Front. Immunol.* 11 (2020) 1315.\\n17. C. Voigt, P. May, A. Gottschlich, A. Markota, D. Wenk, I. Gerlach, et al., Cancer cells induce interleukin-22 production from memory CD4(+) T cells via interleukin-1 to promote tumor growth, *Proc. Natl. Acad. Sci. U. S. A.* 114 (49) (2017) 12994–12999.\\n18. A.G. McLoed, T.P. Sherrill, D.S. Cheng, W. Han, J.A. Saxon, L.A. Gleaves, et al., Neutrophil-derived IL-1beta impairs the efficacy of NF-kappaB inhibitors against lung cancer, *Cell Rep.* 16 (1) (2016) 120–132.\\n19. A.M. Baird, J. Leonard, K.M. Naicker, L. Kilmartin, K.J. O’Byrne, S.G. Gray, IL-23 is pro-proliferative, epigenetically regulated and modulated by chemotherapy in non-small cell lung cancer, *Lung Cancer* 79 (1) (2013) 83–90.\\n20. Y. Niu, L. Ye, W. Peng, Z. Wang, X. Wei, X. Wang, et al., IL-26 promotes the pathogenesis of malignant pleural effusion by enhancing CD4(+) IL-22(+) T-cell differentiation and inhibiting CD8(+) T-cell cytotoxicity, *J. Leukoc. Biol.* 110 (1) (2021) 39–52.\\n21. B. Pang, C. Hu, N. Xing, L. Xu, S. Zhang, X. Yu, Elevated Notch1 enhances interleukin-22 production by CD4(+) T cells via aryl hydrocarbon receptor in patients with lung adenocarcinoma, *Biosci. Rep.* 38 (6) (2018).\\n22. J.S. Lim, A. Ibaseta, M.M. Fischer, B. Cancilla, G. O’Young, S. Cristea, et al., Intratumoural heterogeneity generated by Notch signalling promotes small-cell lung cancer, *Nature* 545 (7654) (2017) 360–364.\\n23. Y. Matsuda, S. Ikeda, F. Abe, Y. Takahashi, A. Kitadate, N. Takahashi, et al., Downregulation of miR-26 promotes invasion and metastasis via targeting interleukin-22 in cutaneous T-cell lymphoma, *Cancer Sci.* 113 (4) (2022) 1208–1219.\\n24. Y. He, H. Liu, L. Jiang, B. Rui, J. Mei, H. Xiao, miR-26 induces apoptosis and inhibits autophagy in non-small cell lung cancer cells by suppressing TGF-beta1-JNK signaling pathway, *Front. Pharmacol.* 9 (2018) 1509.\\n25. H. Lindahl, T. Olsson, Interleukin-22 influences the Th1/Th17 Axis, *Front. Immunol.* 12 (2021) 618110.\\n26. E. Klimatcheva, T. Pandina, C. Reilly, S. Torno, H. Bussler, M. Scrivens, et al., CXCL13 antibody for the treatment of autoimmune disorders, *BMC Immunol.* 16 (1) (2015) 6.\\n27. F. Barone, S. Nayar, J. Campos, T. Cloake, D.R. Withers, K.M. Toellner, et al., IL-22 regulates lymphoid chemokine production and assembly of tertiary lymphoid organs, *Proc. Natl. Acad. Sci. U. S. A.* 112 (35) (2015) 11024–11029.\\n28. D. Briukhovetska, J. Suarez-Gosalvez, C. Voigt, A. Markota, A.D. Giannou, M. Schubel, et al., T cell-derived interleukin-22 drives the expression of CD155 by cancer cells to suppress NK cell function and promote metastasis, *Immunity* 56 (1) (2023) 143–161 e11.\\n29. M. Kasprzak, M. 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J. Biol. Sci. 17 (5) (2021) 1191–1202.\\n20. Y.X. Meng, R. Zhao, L.J. Huo, Interleukin-22 alleviates alcohol-associated hepatic fibrosis, inhibits autophagy, and suppresses the PI3K/AKT/mTOR pathway in mice, Alcohol Clin. Exp. Res. 47 (3) (2023) 448–458.\\n21. X. Hu, J. Li, M. Fu, X. Zhao, W. Wang, The JAK/STAT signaling pathway: from bench to clinic, Signal Transduct. Targeted Ther. 6 (1) (2021) 402.\\n22. C. Baldini, F.R. Moriconi, S. Galimberti, P. Libby, R. De Caterina, The JAK-STAT pathway: an emerging target for cardiovascular disease in rheumatoid arthritis and myeloproliferative neoplasms, Eur. Heart J. 42 (42) (2021) 4389–4400.\\n23. L. Hu, R. Liu, L. Zhang, Advance in bone destruction participated by JAK/STAT in rheumatoid arthritis and therapeutic effect of JAK/STAT inhibitors, Int. Immunopharm. 111 (2022) 109095.\\n24. L.K. Meyer, K.C. Verbist, S. Albeituni, B.P. Scull, R.C. Bassett, A.N. Stroh, et al., JAK/STAT pathway inhibition sensitizes CD8 T cells to dexamethasone-induced apoptosis in hyperinflammation, Blood 136 (6) (2020) 657–668.\\n25. L. Song, J. Turkson, J.G. Karras, R. Jove, E.B. Haura, Activation of Stat3 by receptor tyrosine kinases and cytokines regulates survival in human non-small cell carcinoma cells, Oncogene 22 (27) (2003) 4150–4165.\\n26. Y. Li, H. Du, Y. Qin, J. Roberts, O.W. Cummings, C. Yan, Activation of the signal transducers and activators of the transcription 3 pathway in alveolar epithelial cells induces inflammation and adenocarcinomas in mouse lung, Cancer Res. 67 (18) (2007) 8494–8503.\\n27. S. Ihara, H. Kida, H. Arase, L.P. Tripathi, Y.A. Chen, T. Kimura, et al., Inhibitory roles of signal transducer and activator of transcription 3 in antitumor immunity during carcinogen-induced lung tumorigenesis, Cancer Res. 72 (12) (2012) 2990–2999.\\n28. J. Mohrherr, I.Z. Uras, H.P. Moll, E. Casanova, STAT3: versatile functions in non-small cell lung cancer, Cancers 12 (5) (2020).\\n29. Y. Cheng, F. Sun, L. Wang, M. Gao, Y. Xie, Y. Sun, et al., Virus-induced p38 MAPK activation facilitates viral infection, Theranostics 10 (26) (2020) 12223–12240.\\n30. Y. Xu, Q. Sun, F. Yuan, H. Dong, H. Zhang, R. Geng, et al., RND2 attenuates apoptosis and autophagy in glioblastoma cells by targeting the p38 MAPK signalling pathway, J. Exp. Clin. Cancer Res. : CR 39 (1) (2020) 174.\\n31. D. He, H. Wu, J. Xiang, X. Ruan, P. Peng, Y. Ruan, et al., Gut stem cell aging is driven by mTORC1 via a p38 MAPK-p53 pathway, Nat. Commun. 11 (1) (2020) 37.\\n32. O. Dreesen, A.H. Brivanlou, Signaling pathways in cancer and embryonic stem cells, Stem Cell Rev. 3 (1) (2007) 7–17.\\n33. X.M. Hou, T. Zhang, Z. Da, X.A. Wu, CHPF promotes lung adenocarcinoma proliferation and anti-apoptosis via the MAPK pathway, Pathol. Res. Pract. 215 (5) (2019) 988–994.\\n34. Y.C. Wang, D.W. Wu, T.C. Wu, L. Wang, C.Y. Chen, H. Lee, Dioscin overcome TKI resistance in EGFR-mutated lung adenocarcinoma cells via down-regulation of tyrosine phosphatase SHP2 expression, Int. J. Biol. Sci. 14 (1) (2018) 47–56.\\n35. Y. Guo, M. Jiang, X. Zhao, M. Gu, Z. Wang, S. Xu, et al., Cyclophilin A promotes non-small cell lung cancer metastasis via p38 MAPK, Thorac Cancer 9 (1) (2018) 120–128.\\n36. A. Po, M. Silvano, E. Miele, C. Capalbo, A. Eramo, V. Salvati, et al., Noncanonical GLI1 signaling promotes stemness features and in vivo growth in lung adenocarcinoma, Oncogene 36 (32) (2017) 4641–4652.\\n37. J.H. Leung, B. Ng, W.W. Lim, Interleukin-11: a potential biomarker and molecular therapeutic target in non-small cell lung cancer, Cells 11 (14) (2022).\\n38. H. Wang, F. Zhou, C. Zhao, L. Cheng, C. Zhou, M. Qiao, et al., Interleukin-10 is a promising marker for immune-related adverse events in patients with non-small cell lung cancer receiving immunotherapy, Front. Immunol. 13 (2022) 840313.\\n39. C.H. Chang, C.F. Hsiao, Y.M. Yeh, G.C. Chang, Y.H. Tsai, Y.M. Chen, et al., Circulating interleukin-6 level is a prognostic marker for survival in advanced nonsmall cell lung cancer patients treated with chemotherapy, Int. J. Cancer 132 (9) (2013) 1977–1985.\\n40. C. Liu, L. Yang, H. Xu, S. Zheng, Z. Wang, S. Wang, et al., Systematic analysis of IL-6 as a predictive biomarker and desensitizer of immunotherapy responses in patients with non-small cell lung cancer, BMC Med. 20 (1) (2022) 187.\\n41. B. Yuan, M.J. Clowers, W.V. Velasco, S. Peng, Q. Peng, Y. Shi, et al., Targeting IL-1beta as an immunopreventive and therapeutic modality for K-ras-mutant lung cancer, JCI Insight 7 (11) (2022).\\n42. M.F. Sanmamed, J.L. Perez-Gracia, K.A. Schalper, J.P. Fusco, A. Gonzalez, M.E. Rodriguez-Ruiz, et al., Changes in serum interleukin-8 (IL-8) levels reflect and predict response to anti-PD-1 treatment in melanoma and non-small-cell lung cancer patients, Ann. Oncol. 28 (8) (2017) 1988–1995.\\n43. M. Joerger, S.P. Finn, S. Cuffe, A.T. Byrne, S.G. Gray, The IL-17-Th1/Th17 pathway: an attractive target for lung cancer therapy? Expert Opin. Ther. Targets 20 (11) (2016) 1339–1356.\\n44. M.S. Kim, E. Kim, J.S. Heo, D.J. Bae, J.U. Lee, T.H. Lee, et al., Circulating IL-33 level is associated with the progression of lung cancer, Lung Cancer 90 (2) (2015) 346–351.\\n45. P.M. Ridker, J.G. MacFadyen, T. Thuren, B.M. Everett, P. Libby, R.J. Glynn, et al., Effect of interleukin-1beta inhibition with canakinumab on incident lung cancer in patients with atherosclerosis: exploratory results from a randomised, double-blind, placebo-controlled trial, Lancet 390 (10105) (2017) 1833–1842.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'References',\n", " 'md': '# References',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': '1. Y. Niu, Q. Zhou, Th17 cells and their related cytokines: vital players in progression of malignant pleural effusion, Cell. Mol. Life Sci. 79 (4) (2022) 194.\\n2. R. Khandia, A. Munjal, Interplay between inflammation and cancer, Adv Protein Chem Struct Biol 119 (2020) 199–245.\\n3. R. Singh, M.K. Mishra, H. Aggarwal, Inflammation, immunity, and cancer, Mediat. Inflamm. 2017 (2017) 6027305.\\n4. A. Fishbein, B.D. Hammock, C.N. Serhan, D. Panigrahy, Carcinogenesis: failure of resolution of inflammation? Pharmacol. Ther. 218 (2021) 107670.\\n5. D. Hanahan, L.M. Coussens, Accessories to the crime: functions of cells recruited to the tumor microenvironment, Cancer Cell 21 (3) (2012) 309–322.\\n6. N. Khosravi, M.S. Caetano, A.M. Cumpian, N. Unver, C. De la Garza Ramos, O. Noble, et al., IL22 promotes Kras-mutant lung cancer by induction of a protumor immune response and protection of stemness properties, Cancer Immunol. Res. 6 (7) (2018) 788–797.\\n7. N.J. Protopsaltis, W. Liang, E. Nudleman, N. Ferrara, Interleukin-22 promotes tumor angiogenesis, Angiogenesis 22 (2) (2019) 311–323.\\n8. Y. Yao, G. Yang, G. Lu, J. Ye, L. Cui, Z. Zeng, et al., Th22 cells/IL-22 serves as a protumor regulator to drive poor prognosis through the JAK-STAT3/MAPK/AKT signaling pathway in non-small-cell lung cancer, J Immunol Res 2022 (2022) 8071234.\\n9. J. Wang, K. Hu, X. Cai, B. Yang, Q. He, J. Wang, et al., Targeting PI3K/AKT signaling for treatment of idiopathic pulmonary fibrosis, Acta Pharm. Sin. B 12 (1) (2022) 18–32.\\n10. J. Yang, J. Nie, X. Ma, Y. Wei, Y. Peng, X. Wei, Targeting PI3K in cancer: mechanisms and advances in clinical trials, Mol. Cancer 18 (1) (2019) 26.\\n11. M.K. Ediriweera, K.H. Tennekoon, S.R. Samarakoon, Role of the PI3K/AKT/mTOR signaling pathway in ovarian cancer: biological and therapeutic significance, Semin. Cancer Biol. 59 (2019) 147–160.\\n12. D. Miricescu, A. Totan, S. Stanescu, II, S.C. Badoiu, C. Stefani, M. Greabu, PI3K/AKT/mTOR signaling pathway in breast cancer: from molecular landscape to clinical aspects, Int. J. Mol. Sci. 22 (1) (2020).\\n13. Y. Hou, K. Wang, W. Wan, Y. Cheng, X. Pu, X. Ye, Resveratrol provides neuroprotection by regulating the JAK2/STAT3/PI3K/AKT/mTOR pathway after stroke in rats, Genes Dis 5 (3) (2018) 245–255.\\n14. C. Feng, H. Wan, Y. Zhang, L. Yu, C. Shao, Y. He, et al., Neuroprotective effect of Danhong injection on cerebral ischemia-reperfusion injury in rats by activation of the PI3K-Akt pathway, Front. Pharmacol. 11 (2020) 298.\\n15. B.Y. Shorning, M.S. Dass, M.J. Smalley, H.B. Pearson, The PI3K-AKT-mTOR pathway and prostate cancer: at the crossroads of AR, MAPK, and WNT signaling, Int. J. Mol. Sci. 21 (12) (2020).\\n16. R. Liu, Y. Chen, G. Liu, C. Li, Y. Song, Z. Cao, et al., PI3K/AKT pathway as a key link modulates the multidrug resistance of cancers, Cell Death Dis. 11 (9) (2020) 797.\\n17. M.J. Sanaei, S. Razi, A. Pourbagheri-Sigaroodi, D. Bashash, The PI3K/Akt/mTOR pathway in lung cancer; oncogenic alterations, therapeutic opportunities, challenges, and a glance at the application of nanoparticles, Transl Oncol 18 (2022) 101364.\\n18. A.M. Gustafson, R. Soldi, C. Anderlind, M.B. Scholand, J. Qian, X. Zhang, et al., Airway PI3K pathway activation is an early and reversible event in lung cancer development, Sci. Transl. Med. 2 (26) (2010) 26ra5.\\n19. J. Li, J. Wang, D. Xie, Q. Pei, X. Wan, H.R. Xing, et al., Characteristics of the PI3K/AKT and MAPK/ERK pathways involved in the maintenance of self-renewal in lung cancer stem-like cells, Int. J. Biol. Sci. 17 (5) (2021) 1191–1202.\\n20. Y.X. Meng, R. Zhao, L.J. Huo, Interleukin-22 alleviates alcohol-associated hepatic fibrosis, inhibits autophagy, and suppresses the PI3K/AKT/mTOR pathway in mice, Alcohol Clin. Exp. Res. 47 (3) (2023) 448–458.\\n21. X. Hu, J. Li, M. Fu, X. Zhao, W. Wang, The JAK/STAT signaling pathway: from bench to clinic, Signal Transduct. Targeted Ther. 6 (1) (2021) 402.\\n22. C. Baldini, F.R. Moriconi, S. Galimberti, P. Libby, R. De Caterina, The JAK-STAT pathway: an emerging target for cardiovascular disease in rheumatoid arthritis and myeloproliferative neoplasms, Eur. Heart J. 42 (42) (2021) 4389–4400.\\n23. L. Hu, R. Liu, L. Zhang, Advance in bone destruction participated by JAK/STAT in rheumatoid arthritis and therapeutic effect of JAK/STAT inhibitors, Int. Immunopharm. 111 (2022) 109095.\\n24. L.K. Meyer, K.C. Verbist, S. Albeituni, B.P. Scull, R.C. Bassett, A.N. Stroh, et al., JAK/STAT pathway inhibition sensitizes CD8 T cells to dexamethasone-induced apoptosis in hyperinflammation, Blood 136 (6) (2020) 657–668.\\n25. L. Song, J. Turkson, J.G. Karras, R. Jove, E.B. Haura, Activation of Stat3 by receptor tyrosine kinases and cytokines regulates survival in human non-small cell carcinoma cells, Oncogene 22 (27) (2003) 4150–4165.\\n26. Y. Li, H. Du, Y. Qin, J. Roberts, O.W. Cummings, C. Yan, Activation of the signal transducers and activators of the transcription 3 pathway in alveolar epithelial cells induces inflammation and adenocarcinomas in mouse lung, Cancer Res. 67 (18) (2007) 8494–8503.\\n27. S. Ihara, H. Kida, H. Arase, L.P. Tripathi, Y.A. Chen, T. Kimura, et al., Inhibitory roles of signal transducer and activator of transcription 3 in antitumor immunity during carcinogen-induced lung tumorigenesis, Cancer Res. 72 (12) (2012) 2990–2999.\\n28. J. Mohrherr, I.Z. Uras, H.P. Moll, E. Casanova, STAT3: versatile functions in non-small cell lung cancer, Cancers 12 (5) (2020).\\n29. Y. Cheng, F. Sun, L. Wang, M. Gao, Y. Xie, Y. Sun, et al., Virus-induced p38 MAPK activation facilitates viral infection, Theranostics 10 (26) (2020) 12223–12240.\\n30. Y. Xu, Q. Sun, F. Yuan, H. Dong, H. Zhang, R. Geng, et al., RND2 attenuates apoptosis and autophagy in glioblastoma cells by targeting the p38 MAPK signalling pathway, J. Exp. Clin. Cancer Res. : CR 39 (1) (2020) 174.\\n31. D. He, H. Wu, J. Xiang, X. Ruan, P. Peng, Y. Ruan, et al., Gut stem cell aging is driven by mTORC1 via a p38 MAPK-p53 pathway, Nat. Commun. 11 (1) (2020) 37.\\n32. O. Dreesen, A.H. Brivanlou, Signaling pathways in cancer and embryonic stem cells, Stem Cell Rev. 3 (1) (2007) 7–17.\\n33. X.M. Hou, T. Zhang, Z. Da, X.A. Wu, CHPF promotes lung adenocarcinoma proliferation and anti-apoptosis via the MAPK pathway, Pathol. Res. Pract. 215 (5) (2019) 988–994.\\n34. Y.C. Wang, D.W. Wu, T.C. Wu, L. Wang, C.Y. Chen, H. Lee, Dioscin overcome TKI resistance in EGFR-mutated lung adenocarcinoma cells via down-regulation of tyrosine phosphatase SHP2 expression, Int. J. Biol. Sci. 14 (1) (2018) 47–56.\\n35. Y. Guo, M. Jiang, X. Zhao, M. Gu, Z. Wang, S. Xu, et al., Cyclophilin A promotes non-small cell lung cancer metastasis via p38 MAPK, Thorac Cancer 9 (1) (2018) 120–128.\\n36. A. Po, M. Silvano, E. Miele, C. Capalbo, A. Eramo, V. Salvati, et al., Noncanonical GLI1 signaling promotes stemness features and in vivo growth in lung adenocarcinoma, Oncogene 36 (32) (2017) 4641–4652.\\n37. J.H. Leung, B. Ng, W.W. Lim, Interleukin-11: a potential biomarker and molecular therapeutic target in non-small cell lung cancer, Cells 11 (14) (2022).\\n38. H. Wang, F. Zhou, C. Zhao, L. Cheng, C. Zhou, M. Qiao, et al., Interleukin-10 is a promising marker for immune-related adverse events in patients with non-small cell lung cancer receiving immunotherapy, Front. Immunol. 13 (2022) 840313.\\n39. C.H. Chang, C.F. Hsiao, Y.M. Yeh, G.C. Chang, Y.H. Tsai, Y.M. Chen, et al., Circulating interleukin-6 level is a prognostic marker for survival in advanced nonsmall cell lung cancer patients treated with chemotherapy, Int. J. Cancer 132 (9) (2013) 1977–1985.\\n40. C. Liu, L. Yang, H. Xu, S. Zheng, Z. Wang, S. Wang, et al., Systematic analysis of IL-6 as a predictive biomarker and desensitizer of immunotherapy responses in patients with non-small cell lung cancer, BMC Med. 20 (1) (2022) 187.\\n41. B. Yuan, M.J. Clowers, W.V. Velasco, S. Peng, Q. Peng, Y. Shi, et al., Targeting IL-1beta as an immunopreventive and therapeutic modality for K-ras-mutant lung cancer, JCI Insight 7 (11) (2022).\\n42. M.F. Sanmamed, J.L. Perez-Gracia, K.A. Schalper, J.P. Fusco, A. Gonzalez, M.E. Rodriguez-Ruiz, et al., Changes in serum interleukin-8 (IL-8) levels reflect and predict response to anti-PD-1 treatment in melanoma and non-small-cell lung cancer patients, Ann. Oncol. 28 (8) (2017) 1988–1995.\\n43. M. Joerger, S.P. Finn, S. Cuffe, A.T. Byrne, S.G. Gray, The IL-17-Th1/Th17 pathway: an attractive target for lung cancer therapy? Expert Opin. Ther. Targets 20 (11) (2016) 1339–1356.\\n44. M.S. Kim, E. Kim, J.S. Heo, D.J. Bae, J.U. Lee, T.H. Lee, et al., Circulating IL-33 level is associated with the progression of lung cancer, Lung Cancer 90 (2) (2015) 346–351.\\n45. P.M. Ridker, J.G. MacFadyen, T. Thuren, B.M. Everett, P. Libby, R.J. Glynn, et al., Effect of interleukin-1beta inhibition with canakinumab on incident lung cancer in patients with atherosclerosis: exploratory results from a randomised, double-blind, placebo-controlled trial, Lancet 390 (10105) (2017) 1833–1842.\\n```',\n", " 'md': '1. Y. Niu, Q. Zhou, Th17 cells and their related cytokines: vital players in progression of malignant pleural effusion, Cell. Mol. Life Sci. 79 (4) (2022) 194.\\n2. R. Khandia, A. Munjal, Interplay between inflammation and cancer, Adv Protein Chem Struct Biol 119 (2020) 199–245.\\n3. R. Singh, M.K. Mishra, H. Aggarwal, Inflammation, immunity, and cancer, Mediat. Inflamm. 2017 (2017) 6027305.\\n4. A. Fishbein, B.D. Hammock, C.N. Serhan, D. Panigrahy, Carcinogenesis: failure of resolution of inflammation? Pharmacol. Ther. 218 (2021) 107670.\\n5. D. Hanahan, L.M. Coussens, Accessories to the crime: functions of cells recruited to the tumor microenvironment, Cancer Cell 21 (3) (2012) 309–322.\\n6. N. Khosravi, M.S. Caetano, A.M. Cumpian, N. Unver, C. De la Garza Ramos, O. Noble, et al., IL22 promotes Kras-mutant lung cancer by induction of a protumor immune response and protection of stemness properties, Cancer Immunol. Res. 6 (7) (2018) 788–797.\\n7. N.J. Protopsaltis, W. Liang, E. Nudleman, N. Ferrara, Interleukin-22 promotes tumor angiogenesis, Angiogenesis 22 (2) (2019) 311–323.\\n8. Y. Yao, G. Yang, G. Lu, J. Ye, L. Cui, Z. Zeng, et al., Th22 cells/IL-22 serves as a protumor regulator to drive poor prognosis through the JAK-STAT3/MAPK/AKT signaling pathway in non-small-cell lung cancer, J Immunol Res 2022 (2022) 8071234.\\n9. J. Wang, K. Hu, X. Cai, B. Yang, Q. He, J. Wang, et al., Targeting PI3K/AKT signaling for treatment of idiopathic pulmonary fibrosis, Acta Pharm. Sin. B 12 (1) (2022) 18–32.\\n10. J. Yang, J. Nie, X. Ma, Y. Wei, Y. Peng, X. Wei, Targeting PI3K in cancer: mechanisms and advances in clinical trials, Mol. Cancer 18 (1) (2019) 26.\\n11. M.K. Ediriweera, K.H. Tennekoon, S.R. Samarakoon, Role of the PI3K/AKT/mTOR signaling pathway in ovarian cancer: biological and therapeutic significance, Semin. Cancer Biol. 59 (2019) 147–160.\\n12. D. Miricescu, A. Totan, S. Stanescu, II, S.C. Badoiu, C. Stefani, M. Greabu, PI3K/AKT/mTOR signaling pathway in breast cancer: from molecular landscape to clinical aspects, Int. J. Mol. Sci. 22 (1) (2020).\\n13. Y. Hou, K. Wang, W. Wan, Y. Cheng, X. Pu, X. Ye, Resveratrol provides neuroprotection by regulating the JAK2/STAT3/PI3K/AKT/mTOR pathway after stroke in rats, Genes Dis 5 (3) (2018) 245–255.\\n14. C. Feng, H. Wan, Y. Zhang, L. Yu, C. Shao, Y. He, et al., Neuroprotective effect of Danhong injection on cerebral ischemia-reperfusion injury in rats by activation of the PI3K-Akt pathway, Front. Pharmacol. 11 (2020) 298.\\n15. B.Y. Shorning, M.S. Dass, M.J. Smalley, H.B. Pearson, The PI3K-AKT-mTOR pathway and prostate cancer: at the crossroads of AR, MAPK, and WNT signaling, Int. J. Mol. Sci. 21 (12) (2020).\\n16. R. Liu, Y. Chen, G. Liu, C. Li, Y. Song, Z. Cao, et al., PI3K/AKT pathway as a key link modulates the multidrug resistance of cancers, Cell Death Dis. 11 (9) (2020) 797.\\n17. M.J. Sanaei, S. Razi, A. Pourbagheri-Sigaroodi, D. Bashash, The PI3K/Akt/mTOR pathway in lung cancer; oncogenic alterations, therapeutic opportunities, challenges, and a glance at the application of nanoparticles, Transl Oncol 18 (2022) 101364.\\n18. A.M. Gustafson, R. Soldi, C. Anderlind, M.B. Scholand, J. Qian, X. Zhang, et al., Airway PI3K pathway activation is an early and reversible event in lung cancer development, Sci. Transl. Med. 2 (26) (2010) 26ra5.\\n19. J. Li, J. Wang, D. Xie, Q. Pei, X. Wan, H.R. Xing, et al., Characteristics of the PI3K/AKT and MAPK/ERK pathways involved in the maintenance of self-renewal in lung cancer stem-like cells, Int. J. Biol. Sci. 17 (5) (2021) 1191–1202.\\n20. Y.X. Meng, R. Zhao, L.J. Huo, Interleukin-22 alleviates alcohol-associated hepatic fibrosis, inhibits autophagy, and suppresses the PI3K/AKT/mTOR pathway in mice, Alcohol Clin. Exp. Res. 47 (3) (2023) 448–458.\\n21. X. Hu, J. Li, M. Fu, X. Zhao, W. Wang, The JAK/STAT signaling pathway: from bench to clinic, Signal Transduct. Targeted Ther. 6 (1) (2021) 402.\\n22. C. Baldini, F.R. Moriconi, S. Galimberti, P. Libby, R. De Caterina, The JAK-STAT pathway: an emerging target for cardiovascular disease in rheumatoid arthritis and myeloproliferative neoplasms, Eur. Heart J. 42 (42) (2021) 4389–4400.\\n23. L. Hu, R. Liu, L. Zhang, Advance in bone destruction participated by JAK/STAT in rheumatoid arthritis and therapeutic effect of JAK/STAT inhibitors, Int. Immunopharm. 111 (2022) 109095.\\n24. L.K. Meyer, K.C. Verbist, S. Albeituni, B.P. Scull, R.C. Bassett, A.N. Stroh, et al., JAK/STAT pathway inhibition sensitizes CD8 T cells to dexamethasone-induced apoptosis in hyperinflammation, Blood 136 (6) (2020) 657–668.\\n25. L. Song, J. Turkson, J.G. Karras, R. Jove, E.B. Haura, Activation of Stat3 by receptor tyrosine kinases and cytokines regulates survival in human non-small cell carcinoma cells, Oncogene 22 (27) (2003) 4150–4165.\\n26. Y. Li, H. Du, Y. Qin, J. Roberts, O.W. Cummings, C. Yan, Activation of the signal transducers and activators of the transcription 3 pathway in alveolar epithelial cells induces inflammation and adenocarcinomas in mouse lung, Cancer Res. 67 (18) (2007) 8494–8503.\\n27. S. Ihara, H. Kida, H. Arase, L.P. Tripathi, Y.A. Chen, T. Kimura, et al., Inhibitory roles of signal transducer and activator of transcription 3 in antitumor immunity during carcinogen-induced lung tumorigenesis, Cancer Res. 72 (12) (2012) 2990–2999.\\n28. J. Mohrherr, I.Z. Uras, H.P. Moll, E. Casanova, STAT3: versatile functions in non-small cell lung cancer, Cancers 12 (5) (2020).\\n29. Y. Cheng, F. Sun, L. Wang, M. Gao, Y. Xie, Y. Sun, et al., Virus-induced p38 MAPK activation facilitates viral infection, Theranostics 10 (26) (2020) 12223–12240.\\n30. Y. Xu, Q. Sun, F. Yuan, H. Dong, H. Zhang, R. Geng, et al., RND2 attenuates apoptosis and autophagy in glioblastoma cells by targeting the p38 MAPK signalling pathway, J. Exp. Clin. Cancer Res. : CR 39 (1) (2020) 174.\\n31. D. He, H. Wu, J. Xiang, X. Ruan, P. Peng, Y. Ruan, et al., Gut stem cell aging is driven by mTORC1 via a p38 MAPK-p53 pathway, Nat. Commun. 11 (1) (2020) 37.\\n32. O. Dreesen, A.H. Brivanlou, Signaling pathways in cancer and embryonic stem cells, Stem Cell Rev. 3 (1) (2007) 7–17.\\n33. X.M. Hou, T. Zhang, Z. Da, X.A. Wu, CHPF promotes lung adenocarcinoma proliferation and anti-apoptosis via the MAPK pathway, Pathol. Res. Pract. 215 (5) (2019) 988–994.\\n34. Y.C. Wang, D.W. Wu, T.C. Wu, L. Wang, C.Y. Chen, H. Lee, Dioscin overcome TKI resistance in EGFR-mutated lung adenocarcinoma cells via down-regulation of tyrosine phosphatase SHP2 expression, Int. J. Biol. Sci. 14 (1) (2018) 47–56.\\n35. Y. Guo, M. Jiang, X. Zhao, M. Gu, Z. Wang, S. Xu, et al., Cyclophilin A promotes non-small cell lung cancer metastasis via p38 MAPK, Thorac Cancer 9 (1) (2018) 120–128.\\n36. A. Po, M. Silvano, E. Miele, C. Capalbo, A. Eramo, V. Salvati, et al., Noncanonical GLI1 signaling promotes stemness features and in vivo growth in lung adenocarcinoma, Oncogene 36 (32) (2017) 4641–4652.\\n37. J.H. Leung, B. Ng, W.W. Lim, Interleukin-11: a potential biomarker and molecular therapeutic target in non-small cell lung cancer, Cells 11 (14) (2022).\\n38. H. Wang, F. Zhou, C. Zhao, L. Cheng, C. Zhou, M. Qiao, et al., Interleukin-10 is a promising marker for immune-related adverse events in patients with non-small cell lung cancer receiving immunotherapy, Front. Immunol. 13 (2022) 840313.\\n39. C.H. Chang, C.F. Hsiao, Y.M. Yeh, G.C. Chang, Y.H. Tsai, Y.M. Chen, et al., Circulating interleukin-6 level is a prognostic marker for survival in advanced nonsmall cell lung cancer patients treated with chemotherapy, Int. J. Cancer 132 (9) (2013) 1977–1985.\\n40. C. Liu, L. Yang, H. Xu, S. Zheng, Z. Wang, S. Wang, et al., Systematic analysis of IL-6 as a predictive biomarker and desensitizer of immunotherapy responses in patients with non-small cell lung cancer, BMC Med. 20 (1) (2022) 187.\\n41. B. Yuan, M.J. Clowers, W.V. Velasco, S. Peng, Q. Peng, Y. Shi, et al., Targeting IL-1beta as an immunopreventive and therapeutic modality for K-ras-mutant lung cancer, JCI Insight 7 (11) (2022).\\n42. M.F. Sanmamed, J.L. Perez-Gracia, K.A. Schalper, J.P. Fusco, A. Gonzalez, M.E. Rodriguez-Ruiz, et al., Changes in serum interleukin-8 (IL-8) levels reflect and predict response to anti-PD-1 treatment in melanoma and non-small-cell lung cancer patients, Ann. Oncol. 28 (8) (2017) 1988–1995.\\n43. M. Joerger, S.P. 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Kim, Anti-arthritogenic property of interleukin 10-expressing human amniotic MSCs generated by gene editing in collagen-induced arthritis, Int. J. Mol. Sci. 23 (14) (2022).\\n5. E. Vermersch, C. Jouve, J.S. Hulot, CRISPR/Cas9 gene-editing strategies in cardiovascular cells, Cardiovasc. Res. 116 (5) (2020) 894–907.\\n6. Q. Wang, X. Liu, J. Zhou, C. Yang, G. Wang, Y. Tan, et al., The CRISPR-Cas13a gene-editing system induces collateral cleavage of RNA in glioma cells, Adv. Sci. 6 (20) (2019) 1901299.\\n7. Y. Lu, J. Xue, T. Deng, X. Zhou, K. Yu, L. Deng, et al., Safety and feasibility of CRISPR-edited T cells in patients with refractory non-small-cell lung cancer, Nat. Med. 26 (5) (2020) 732–740.\\n8. S.M. Hoy, Patisiran: first global approval, Drugs 78 (15) (2018) 1625–1631.\\n9. H. Wood, FDA approves patisiran to treat hereditary transthyretin amyloidosis, Nat. Rev. Neurol. 14 (10) (2018) 570.\\n10. A. Mandal, N. Kumbhojkar, C. Reilly, V. Dharamdasani, A. Ukidve, D.E. Ingber, et al., Treatment of psoriasis with NFKBIZ siRNA using topical ionic liquid formulations, Sci. Adv. 6 (30) (2020) eabb6049.\\n11. T. Fabre, M.F. Molina, G. Soucy, J.P. Goulet, B. Willems, J.P. Villeneuve, et al., Type 3 cytokines IL-17A and IL-22 drive TGF-beta-dependent liver fibrosis, Sci Immunol. 3 (28) (2018).\\n12. C. Su, X. Ren, F. Yang, B. Li, H. Wu, H. Li, et al., Ultrasound-sensitive siRNA-loaded nanobubbles fabrication and antagonism in drug resistance for NSCLC, Drug Deliv. 29 (1) (2022) 99–110.\\n13. M.E. Aikins, C. Xu, J.J. Moon, Engineered nanoparticles for cancer vaccination and immunotherapy, Acc. Chem. Res. 53 (10) (2020) 2094–2105.\\n14. S. Li, S. Xu, X. Liang, Y. Xue, J. Mei, Y. Ma, et al., Nanotechnology: breaking the current treatment limits of lung cancer, Adv. Healthcare Mater. 10 (12) (2021) e2100078.\\n15. T. Zhong, X. Liu, H. Li, J. Zhang, Co-delivery of sorafenib and crizotinib encapsulated with polymeric nanoparticles for the treatment of in vivo lung cancer animal model, Drug Deliv. 28 (1) (2021) 2108–2118.\\n16. M. Zhang, CTt Hagan, H. Foley, X. Tian, F. Yang, K.M. Au, et al., Co-delivery of etoposide and cisplatin in dual-drug loaded nanoparticles synergistically improves chemoradiotherapy in non-small cell lung cancer models, Acta Biomater. 124 (2021) 327–335.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'References',\n", " 'md': '# References',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 544.25, 'h': 742.68}},\n", " {'type': 'text',\n", " 'value': '1. A. Guillon, F. Gueugnon, K. Mavridis, E. Dalloneau, Y. Jouan, P. Diot, et al., Interleukin-22 receptor is overexpressed in nonsmall cell lung cancer and portends a poor prognosis, Eur. Respir. J. 47 (4) (2016) 1277–1280.\\n2. X. Wang, J. Xu, J. Chen, S. Jin, J. Yao, T. Yu, et al., IL-22 confers EGFR-TKI resistance in NSCLC via the AKT and ERK signaling pathways, Front. Oncol. 9 (2019) 1167.\\n3. N. Zabaleta, L. Torella, N.D. Weber, G. Gonzalez-Aseguinolaza, mRNA and gene editing: late breaking therapies in liver diseases, Hepatology 76 (3) (2022) 869–887.\\n4. D.S. Chae, Y.J. Park, S.W. Kim, Anti-arthritogenic property of interleukin 10-expressing human amniotic MSCs generated by gene editing in collagen-induced arthritis, Int. J. Mol. Sci. 23 (14) (2022).\\n5. E. Vermersch, C. Jouve, J.S. Hulot, CRISPR/Cas9 gene-editing strategies in cardiovascular cells, Cardiovasc. Res. 116 (5) (2020) 894–907.\\n6. Q. Wang, X. Liu, J. Zhou, C. Yang, G. Wang, Y. Tan, et al., The CRISPR-Cas13a gene-editing system induces collateral cleavage of RNA in glioma cells, Adv. Sci. 6 (20) (2019) 1901299.\\n7. Y. Lu, J. Xue, T. Deng, X. Zhou, K. Yu, L. Deng, et al., Safety and feasibility of CRISPR-edited T cells in patients with refractory non-small-cell lung cancer, Nat. Med. 26 (5) (2020) 732–740.\\n8. S.M. Hoy, Patisiran: first global approval, Drugs 78 (15) (2018) 1625–1631.\\n9. H. Wood, FDA approves patisiran to treat hereditary transthyretin amyloidosis, Nat. Rev. Neurol. 14 (10) (2018) 570.\\n10. A. Mandal, N. Kumbhojkar, C. Reilly, V. Dharamdasani, A. Ukidve, D.E. Ingber, et al., Treatment of psoriasis with NFKBIZ siRNA using topical ionic liquid formulations, Sci. Adv. 6 (30) (2020) eabb6049.\\n11. T. Fabre, M.F. Molina, G. Soucy, J.P. Goulet, B. Willems, J.P. Villeneuve, et al., Type 3 cytokines IL-17A and IL-22 drive TGF-beta-dependent liver fibrosis, Sci Immunol. 3 (28) (2018).\\n12. C. Su, X. Ren, F. Yang, B. Li, H. Wu, H. Li, et al., Ultrasound-sensitive siRNA-loaded nanobubbles fabrication and antagonism in drug resistance for NSCLC, Drug Deliv. 29 (1) (2022) 99–110.\\n13. M.E. Aikins, C. Xu, J.J. Moon, Engineered nanoparticles for cancer vaccination and immunotherapy, Acc. Chem. Res. 53 (10) (2020) 2094–2105.\\n14. S. Li, S. Xu, X. Liang, Y. Xue, J. Mei, Y. Ma, et al., Nanotechnology: breaking the current treatment limits of lung cancer, Adv. Healthcare Mater. 10 (12) (2021) e2100078.\\n15. T. Zhong, X. Liu, H. Li, J. Zhang, Co-delivery of sorafenib and crizotinib encapsulated with polymeric nanoparticles for the treatment of in vivo lung cancer animal model, Drug Deliv. 28 (1) (2021) 2108–2118.\\n16. M. Zhang, CTt Hagan, H. Foley, X. Tian, F. Yang, K.M. Au, et al., Co-delivery of etoposide and cisplatin in dual-drug loaded nanoparticles synergistically improves chemoradiotherapy in non-small cell lung cancer models, Acta Biomater. 124 (2021) 327–335.\\n```',\n", " 'md': '1. A. Guillon, F. Gueugnon, K. Mavridis, E. Dalloneau, Y. Jouan, P. Diot, et al., Interleukin-22 receptor is overexpressed in nonsmall cell lung cancer and portends a poor prognosis, Eur. Respir. J. 47 (4) (2016) 1277–1280.\\n2. X. Wang, J. Xu, J. Chen, S. Jin, J. Yao, T. Yu, et al., IL-22 confers EGFR-TKI resistance in NSCLC via the AKT and ERK signaling pathways, Front. Oncol. 9 (2019) 1167.\\n3. N. Zabaleta, L. Torella, N.D. Weber, G. Gonzalez-Aseguinolaza, mRNA and gene editing: late breaking therapies in liver diseases, Hepatology 76 (3) (2022) 869–887.\\n4. D.S. Chae, Y.J. Park, S.W. Kim, Anti-arthritogenic property of interleukin 10-expressing human amniotic MSCs generated by gene editing in collagen-induced arthritis, Int. J. Mol. Sci. 23 (14) (2022).\\n5. E. Vermersch, C. Jouve, J.S. Hulot, CRISPR/Cas9 gene-editing strategies in cardiovascular cells, Cardiovasc. Res. 116 (5) (2020) 894–907.\\n6. Q. Wang, X. Liu, J. Zhou, C. Yang, G. Wang, Y. Tan, et al., The CRISPR-Cas13a gene-editing system induces collateral cleavage of RNA in glioma cells, Adv. Sci. 6 (20) (2019) 1901299.\\n7. Y. Lu, J. Xue, T. Deng, X. Zhou, K. Yu, L. Deng, et al., Safety and feasibility of CRISPR-edited T cells in patients with refractory non-small-cell lung cancer, Nat. Med. 26 (5) (2020) 732–740.\\n8. S.M. Hoy, Patisiran: first global approval, Drugs 78 (15) (2018) 1625–1631.\\n9. H. Wood, FDA approves patisiran to treat hereditary transthyretin amyloidosis, Nat. Rev. Neurol. 14 (10) (2018) 570.\\n10. A. Mandal, N. Kumbhojkar, C. Reilly, V. Dharamdasani, A. Ukidve, D.E. Ingber, et al., Treatment of psoriasis with NFKBIZ siRNA using topical ionic liquid formulations, Sci. Adv. 6 (30) (2020) eabb6049.\\n11. T. Fabre, M.F. Molina, G. Soucy, J.P. Goulet, B. Willems, J.P. Villeneuve, et al., Type 3 cytokines IL-17A and IL-22 drive TGF-beta-dependent liver fibrosis, Sci Immunol. 3 (28) (2018).\\n12. C. Su, X. Ren, F. Yang, B. Li, H. Wu, H. Li, et al., Ultrasound-sensitive siRNA-loaded nanobubbles fabrication and antagonism in drug resistance for NSCLC, Drug Deliv. 29 (1) (2022) 99–110.\\n13. M.E. Aikins, C. Xu, J.J. Moon, Engineered nanoparticles for cancer vaccination and immunotherapy, Acc. Chem. Res. 53 (10) (2020) 2094–2105.\\n14. S. Li, S. Xu, X. Liang, Y. Xue, J. Mei, Y. Ma, et al., Nanotechnology: breaking the current treatment limits of lung cancer, Adv. Healthcare Mater. 10 (12) (2021) e2100078.\\n15. T. Zhong, X. Liu, H. Li, J. Zhang, Co-delivery of sorafenib and crizotinib encapsulated with polymeric nanoparticles for the treatment of in vivo lung cancer animal model, Drug Deliv. 28 (1) (2021) 2108–2118.\\n16. M. Zhang, CTt Hagan, H. Foley, X. Tian, F. Yang, K.M. Au, et al., Co-delivery of etoposide and cisplatin in dual-drug loaded nanoparticles synergistically improves chemoradiotherapy in non-small cell lung cancer models, Acta Biomater. 124 (2021) 327–335.\\n```',\n", " 'bBox': {'x': 59, 'y': 58.68, 'w': 444.15, 'h': 6.38}}],\n", " 'status': 'OK',\n", " 'links': [{'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref138',\n", " 'text': ''},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref138',\n", " 'text': '– 1280. X. Wang, J. Xu, J. Chen, S. Jin, J. Yao, T. Yu, et al., IL-22 confers EGFR-TKI resistance in NSCLC via the AKT and ERK signaling pathways, Front. Oncol. 9'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref53',\n", " 'text': ''},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref53',\n", " 'text': 'N. Zabaleta, L. Torella, N.D. Weber, G. Gonzalez-Aseguinolaza, mRNA and gene editing: late breaking therapies in liver diseases, Hepatology 76 (3) (2022)'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref139',\n", " 'text': '869'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref139',\n", " 'text': '– 887.'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref140',\n", " 'text': 'arthritis, Int. J. Mol. Sci. 23 (14) (2022).'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref140',\n", " 'text': ''},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref141',\n", " 'text': '– 907. Q. Wang, X. Liu, J. Zhou, C. Yang, G. Wang, Y. Tan, et al., The CRISPR-Cas13a gene-editing system induces collateral cleavage of RNA in glioma cells, Adv. Sci.'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref142',\n", " 'text': ''},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref142',\n", " 'text': ''},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref143',\n", " 'text': 'Med. 26 (5) (2020) 732'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref143',\n", " 'text': '– 740.'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref144',\n", " 'text': '– 1631. H. Wood, FDA approves patisiran to treat hereditary transthyretin amyloidosis, Nat. Rev. Neurol. 14 (10) (2018) 570.'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref145',\n", " 'text': ''},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref146',\n", " 'text': 'formulations, Sci. Adv. 6 (30) (2020) eabb6049.'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref146',\n", " 'text': 'T. Fabre, M.F. Molina, G. Soucy, J.P. Goulet, B. Willems, J.P. Villeneuve, et al., Type 3 cytokines IL-17A and IL-22 drive TGF-beta-dependent liver fibrosis, Sci'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref147',\n", " 'text': ''},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref147',\n", " 'text': 'C. Su, X. Ren, F. Yang, B. Li, H. Wu, H. Li, et al., Ultrasound-sensitive siRNA-loaded nanobubbles fabrication and antagonism in drug resistance for NSCLC,'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref148',\n", " 'text': ''},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref148',\n", " 'text': '– 110. M.E. Aikins, C. Xu, J.J. Moon, Engineered nanoparticles for cancer vaccination and immunotherapy, Acc. Chem. Res. 53 (10) (2020) 2094'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref154',\n", " 'text': '– 2105.'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref155',\n", " 'text': ''},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref155',\n", " 'text': 'T. Zhong, X. Liu, H. Li, J. Zhang, Co-delivery of sorafenib and crizotinib encapsulated with polymeric nanoparticles for the treatment of in vivo lung cancer'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref156',\n", " 'text': ''},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref156',\n", " 'text': '– 2118. M. Zhang, CTt Hagan, H. Foley, X. Tian, F. Yang, K.M. Au, et al., Co-delivery of etoposide and cisplatin in dual-drug loaded nanoparticles synergistically'},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref157',\n", " 'text': ''},\n", " {'url': 'http://refhub.elsevier.com/S2405-8440(24)11932-9/sref157',\n", " 'text': '– 335.'}]}]" ] }, "execution_count": 7, "metadata": {}, "output_type": "execute_result" } ], "source": [ "md_json_list = md_json_objs[0][\"pages\"]\n", "md_json_list" ] }, { "cell_type": "code", "execution_count": 8, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "> Image for page 1: [{'name': 'img_p0_1.png', 'height': 155, 'width': 123, 'x': 448.554, 'y': 53.517501999999965, 'original_width': 236, 'original_height': 298}]\n", "> Image for page 2: []\n", "> Image for page 3: [{'name': 'img_p2_1.png', 'height': 666, 'width': 978, 'x': 45.3543, 'y': 343.515812, 'original_width': 1890, 'original_height': 1286}]\n", "> Image for page 4: [{'name': 'img_p3_1.png', 'height': 527, 'width': 766, 'x': 94.337, 'y': 417.552202, 'original_width': 1481, 'original_height': 1018}]\n", "> Image for page 5: []\n", "> Image for page 6: [{'name': 'img_p5_1.png', 'height': 596, 'width': 675, 'x': 115.654, 'y': 385.58421200000004, 'original_width': 1304, 'original_height': 1151}]\n", "> Image for page 7: []\n", "> Image for page 8: [{'name': 'img_p7_1.png', 'height': 592, 'width': 767, 'x': 94.2803, 'y': 387.36891199999997, 'original_width': 1482, 'original_height': 1144}]\n", "> Image for page 9: [{'name': 'img_p8_1.png', 'height': 529, 'width': 767, 'x': 94.2803, 'y': 426.325992, 'original_width': 1482, 'original_height': 1021}]\n", "> Image for page 10: []\n", "> Image for page 11: []\n", "> Image for page 12: []\n", "> Image for page 13: []\n", "> Image for page 14: []\n", "Image saved to S3 bucket: https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p0_1.png\n", "Image saved to S3 bucket: https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png\n", "Image saved to S3 bucket: https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png\n", "Image saved to S3 bucket: https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p5_1.png\n", "Image saved to S3 bucket: https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png\n", "Image saved to S3 bucket: https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png\n" ] } ], "source": [ "image_dicts = s3_parser.get_images(md_json_objs)" ] }, { "cell_type": "code", "execution_count": 9, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[{'name': 'img_p0_1.png',\n", " 'height': 155,\n", " 'width': 123,\n", " 'x': 448.554,\n", " 'y': 53.517501999999965,\n", " 'original_width': 236,\n", " 'original_height': 298,\n", " 'path': '/tmp/img_p0_1.png',\n", " 'job_id': 'fff0eaa9-d44a-4c46-9011-32be250821b1',\n", " 'original_file_path': './research/data/main.pdf',\n", " 'page_number': 1,\n", " 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p0_1.png'},\n", " {'name': 'img_p2_1.png',\n", " 'height': 666,\n", " 'width': 978,\n", " 'x': 45.3543,\n", " 'y': 343.515812,\n", " 'original_width': 1890,\n", " 'original_height': 1286,\n", " 'path': '/tmp/img_p2_1.png',\n", " 'job_id': 'fff0eaa9-d44a-4c46-9011-32be250821b1',\n", " 'original_file_path': './research/data/main.pdf',\n", " 'page_number': 3,\n", " 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png'},\n", " {'name': 'img_p3_1.png',\n", " 'height': 527,\n", " 'width': 766,\n", " 'x': 94.337,\n", " 'y': 417.552202,\n", " 'original_width': 1481,\n", " 'original_height': 1018,\n", " 'path': '/tmp/img_p3_1.png',\n", " 'job_id': 'fff0eaa9-d44a-4c46-9011-32be250821b1',\n", " 'original_file_path': './research/data/main.pdf',\n", " 'page_number': 4,\n", " 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png'},\n", " {'name': 'img_p5_1.png',\n", " 'height': 596,\n", " 'width': 675,\n", " 'x': 115.654,\n", " 'y': 385.58421200000004,\n", " 'original_width': 1304,\n", " 'original_height': 1151,\n", " 'path': '/tmp/img_p5_1.png',\n", " 'job_id': 'fff0eaa9-d44a-4c46-9011-32be250821b1',\n", " 'original_file_path': './research/data/main.pdf',\n", " 'page_number': 6,\n", " 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p5_1.png'},\n", " {'name': 'img_p7_1.png',\n", " 'height': 592,\n", " 'width': 767,\n", " 'x': 94.2803,\n", " 'y': 387.36891199999997,\n", " 'original_width': 1482,\n", " 'original_height': 1144,\n", " 'path': '/tmp/img_p7_1.png',\n", " 'job_id': 'fff0eaa9-d44a-4c46-9011-32be250821b1',\n", " 'original_file_path': './research/data/main.pdf',\n", " 'page_number': 8,\n", " 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png'},\n", " {'name': 'img_p8_1.png',\n", " 'height': 529,\n", " 'width': 767,\n", " 'x': 94.2803,\n", " 'y': 426.325992,\n", " 'original_width': 1482,\n", " 'original_height': 1021,\n", " 'path': '/tmp/img_p8_1.png',\n", " 'job_id': 'fff0eaa9-d44a-4c46-9011-32be250821b1',\n", " 'original_file_path': './research/data/main.pdf',\n", " 'page_number': 9,\n", " 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png'}]" ] }, "execution_count": 9, "metadata": {}, "output_type": "execute_result" } ], "source": [ "image_dicts" ] }, { "cell_type": "code", "execution_count": 20, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[{'page_number': 1,\n", " 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p0_1.png'},\n", " {'page_number': 3,\n", " 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png'},\n", " {'page_number': 4,\n", " 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png'},\n", " {'page_number': 6,\n", " 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p5_1.png'},\n", " {'page_number': 8,\n", " 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png'},\n", " {'page_number': 9,\n", " 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png'}]" ] }, "execution_count": 20, "metadata": {}, "output_type": "execute_result" } ], "source": [ "# Filter to keep only entries with an image link\n", "filtered_images = [{\"page_number\": img[\"page_number\"], \"image_link\": img[\"image_link\"]}\n", " for img in image_dicts if img[\"image_link\"] is not None]\n", "\n", "# Print the result\n", "filtered_images" ] }, { "cell_type": "code", "execution_count": 12, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "['https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p0_1.png', 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png', 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png', 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p5_1.png', 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png']\n" ] } ], "source": [ "# Extract just the 'link' values\n", "links = [image['image_link'] for image in image_dicts]\n", "\n", "# Print the result\n", "print(links)" ] }, { "cell_type": "code", "execution_count": 13, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "['https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p0_1.png',\n", " 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png',\n", " 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png',\n", " 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p5_1.png',\n", " 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png',\n", " 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png']" ] }, "execution_count": 13, "metadata": {}, "output_type": "execute_result" } ], "source": [ "links" ] }, { "cell_type": "markdown", "metadata": {}, "source": [ "# Version 3" ] }, { "cell_type": "code", "execution_count": 21, "metadata": {}, "outputs": [], "source": [ "from copy import deepcopy\n", "from llama_index.core import Document\n", "from script.get_metadata import Metadata\n", "\n", "\n", "# attach image metadata to the text nodes\n", "def get_text_documents(json_dicts=None, image_links=None):\n", " \"\"\"Split docs into nodes, by separator.\"\"\"\n", " text_documents = []\n", "\n", " # Preprocess metadata\n", " md_texts = [d[\"md\"] for d in json_dicts] if json_dicts is not None else None\n", "\n", " # Create a dictionary for quick lookup of image links by page number\n", " image_link_dict = {item[\"page_number\"]: item[\"image_link\"] for item in image_links} if image_links else {}\n", "\n", " # Split documents into chunks\n", " # doc_chunks = [c for d in docs for c in d.text.split(\"---\")]\n", " md_texts = [d[\"md\"] for d in json_dicts]\n", " \n", " for idx, md_text in enumerate(md_texts):\n", " page_number = idx + 1\n", " chunk_metadata = {\"page_number\": page_number}\n", "\n", " # Set the image link if it exists; otherwise, set it to None\n", " chunk_metadata[\"image_link\"] = image_link_dict.get(page_number, None)\n", " # chunk_metadata[\"parsed_text_markdown\"] = md_text\n", " \n", " # Add parsed text and create the TextNode\n", " # chunk_metadata[\"parsed_text\"] = md_text \n", " text_document = Document(\n", " text=md_text,\n", " metadata=chunk_metadata,\n", " )\n", " \n", " text_documents.append(text_document)\n", "\n", " return text_documents" ] }, { "cell_type": "code", "execution_count": 22, "metadata": {}, "outputs": [], "source": [ "parsed_documents = get_text_documents(md_json_list, filtered_images)\n", "\n", "reference = {\n", " \"title\": \"Jurnal Paru Paru\",\n", " \"author\": \"Hamzah\",\n", " \"category\": \"Pernapasan\",\n", " \"year\": 2023,\n", " \"publisher\": \"Multimedika\",\n", "}\n", "metadata_gen = Metadata(reference)\n", "documents_with_metadata = metadata_gen.apply_metadata(parsed_documents)" ] }, { "cell_type": "code", "execution_count": 47, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[Document(id_='d3de7f86-2aff-49ff-bffb-855068eb7bb4', embedding=None, metadata={'page_number': 1, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p0_1.png', 'page': 1, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='```markdown\\n# IL-22: A Key Inflammatory Mediator as a Biomarker and Potential Therapeutic Target for Lung Cancer\\n\\n**Authors:**\\nLing Xu, Peng Cao, Jianpeng Wang, Peng Zhang, Shuhui Hu, Chao Cheng, Hua Wang\\n**Affiliations:**\\n- Department of Interventional Pulmonary Diseases, The Anhui Chest Hospital, Hefei, China\\n- First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China\\n- Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China\\n\\n## Abstract\\n\\n**Keywords:**\\nLung cancer, IL-22, Biomarker, Inflammation immunology\\n\\nLung cancer, one of the most prevalent cancers worldwide, stands as the primary cause of cancer-related deaths. The utmost crucial risk factor contributing to lung cancer is smoking. In recent years, remarkable progress has been made in treating lung cancer, particularly non-small cell lung cancer (NSCLC). Nevertheless, the absence of effective and accurate biomarkers for diagnosing and treating lung cancer remains a pressing issue. Interleukin 22 (IL-22) is a member of the IL-10 cytokine family. It exerts biological functions (including induction of proliferation and anti-apoptotic signaling pathways, enhancement of tissue regeneration and immunity defense) by binding to heterodimeric receptors containing type 1 receptor chain (R1) and type 2 receptor chain (R2). IL-22 has been identified as a pro-cancer factor since dysregulation of the IL-22-IL-22R system has been implicated in the development of different cancers, including lung, breast, gastric, pancreatic, and colon cancers. In this review, we discuss the differential expression, regulatory role, and potential clinical significance of IL-22 in lung cancer, while shedding light on innovative approaches for the future.\\n\\n## 1. Introduction\\n\\nLung cancer is a heterogeneous disease in which cells in the lung grow aberrantly culminating in the formation of tumors. Typically, these tumors present as nodules or masses discernible through pulmonary imaging techniques. In the year 2020, the global incidence of lung cancer surpassed a staggering 2.2 million cases, leading to approximately 1.8 million tragic fatalities. When considering age-standardized rates, the morbidity and mortality figures stand at 22.4 and 18.0 per 100,000 individuals respectively. Generally, lung cancer is considered to be intricately linked to a multitude of factors including but not limited to smoking, genetic predisposition, occupational exposures, as well as the deleterious effects of air and environmental pollution. Among the risk factors for lung cancer, smoking dominates overwhelmingly, with about two-thirds of lung cancer deaths globally caused by it. In recent years, the drug resistance phenomenon of lung cancer to chemotherapy and targeted therapy has become more and more prominent. Therefore, it is of heightened importance to find new therapeutic targets.\\n\\n*Corresponding author. Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, China. E-mail address: wanghua@ahmu.edu.cn (H. Wang).*\\n\\n**DOI:** [10.1016/j.heliyon.2024.e35901](https://doi.org/10.1016/j.heliyon.2024.e35901)\\n**Received:** 13 August 2023; **Revised:** 5 August 2024; **Accepted:** 6 August 2024; **Available online:** 10 August 2024\\n**License:** This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).\\n```', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='115cd6cd-d63e-426e-b132-12bfaca5c2c5', embedding=None, metadata={'page_number': 2, 'image_link': None, 'page': 2, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='```markdown\\n# IL-22 and Lung Cancer\\n\\n## IL-22 Overview\\nIL-22 is an IL-10 family cytokine produced by T cells and innate lymphocytes. Like all other IL-10 family members, the IL-22 structure contains six α-helices (termed helices A to F). They are arranged in an antiparallel conformation and produce a single bundled protein. IL-22 coordinates mucosal immune defense and tissue regeneration through pleiotropic effects including pro-survival signaling, cell migration, dysplasia, and angiogenesis. These molecules act by targeting the heterodimeric transmembrane receptor complex composed of IL-22R1 and IL-10R2 and by activating subsequent signaling pathways (including JAK/STAT signaling pathway, p38 MAPK signaling pathway, and PI3K/AKT signaling pathway).\\n\\nIL-22 is widely expressed in human tissues and organs, including lung, liver, heart, kidney, pancreas, gastrointestinal tract, skin, blood, adipose, and synovial tissues. It is also found to be broadly expressed in pathological states such as cancer, infectious diseases, tissue injury, chronic inflammatory diseases, and Graft-Versus-Host Disease. In most cancer diseases, excessively elevated levels of IL-22 are considered to be detrimental. For instance, a recent study has demonstrated that IL-22 promotes extravasation of tumor cells in liver metastasis.\\n\\nOver the past few years, there has been a surge in research focusing on the relationship between IL-22 and lung cancer. Particularly in patients with NSCLC, researchers have discovered up-regulated expression of IL-22 in serum, malignant pleural effusion, and tumor tissues, and the levels of IL-22Rα1 in tumor cells and tissues are also increased. Although emerging studies have revealed that IL-22 is closely correlated with lung cancer in terms of tissue, cell, and pathological changes, the specific function and mechanism remain to be explored.\\n\\nIn the present review, we mainly summarized the regulatory function and clinical role of IL-22 in lung cancer. In addition, the feasibility of IL-22 as a biomarker for lung cancer and directions for future research were also discussed. It is reasonable to hypothesize that IL-22 may serve as a potential target in the treatment of lung cancer.\\n\\n## Overview of Lung Cancer\\nLung cancer is a malignant disease characterized by high morbidity and mortality. According to the data of GLOBOCAN, lung cancer is the second most common cancer in 2020 and the main cause of cancer death worldwide, with about one-tenth (11.4%) of cancer diagnoses and one-fifth (18.0%) of deaths. When it comes to gender, the incidence and mortality rates of lung cancer were on the rise in females but declining in males in most countries over the past decade. The 5-year survival rate of lung cancer patients varies by 4–17% in light of stage and region.\\n\\nAs predicted by the American Cancer Society, more than 120,000 people will die of lung cancer in the United States in 2023. The good news is that although the incidence is stable or increasing, the overall mortality is decreasing at an accelerated pace. From the perspective of histopathology and biological behavior, lung cancer can be divided into NSCLC and SCLC, among which the former mainly includes several common types such as adenocarcinoma, squamous cell carcinoma, and large cell carcinoma.\\n\\nThe pathogenesis of lung cancer primarily involves the following aspects: chromosome changes; abnormal immune response; abnormal activation of developmental pathways; dysregulation of tumor suppressor genes, proto-oncogenes, and signaling pathways; and the up-regulation of receptor tyrosine kinases, growth factors, and cell markers. These abnormal changes cause an imbalance between lung cell proliferation and apoptosis, which leads to lung cancer.\\n\\nFor example, when exposed to risk factors continuously, the production of ROS, chemokines, and cytokines increases in lung cells, which leads to DNA damage and gives rise to inflammation and other pathobiological changes that ultimately promote carcinogenesis. At the same time, the anti-tumor immune function of macrophages, T lymphocytes, B lymphocytes, and NK cells gets suppressed, failing recognition and clearance of malignant cells, and eventually bringing about the formation of tumors.\\n\\nIn the early stage of the disease, it is usually considered to be asymptomatic, while it may manifest as cough, dyspnea, chest pain, hemoptysis, hoarseness, and so on in the middle and advanced period. In principle, the treatment of lung cancer depends largely on the type, stage, and condition of the patient’s disease. Currently, the main treatment approaches for lung cancer include surgery, chemotherapy, and radiotherapy. Among them, platinum-containing double drugs are preferred for chemotherapy. Radiation therapy is mainly applied in the control of the local lesion.\\n\\nFurthermore, targeted therapy for EGFR, ALK, ROS1, and other gene mutations and immunotherapy to inhibit PD-1/PD-L1 also plays an irreplaceable role as emerging breakthrough therapeutic means. Compared with chemotherapy, targeted therapy can prominently enhance the survival rate and tolerance of patients with NSCLC. The combination of chemotherapy and immunotherapy has also shown a more notable curative effect over chemotherapy alone.\\n\\nAdditionally, there has been a growing body of research focusing on natural product therapy, local ablative therapy, and chimeric antigen receptor (CAR)-T-cell therapy lately. In principle, the treatments of lung cancer are individualized depending largely on the type, stage, and condition of patients. Unfortunately, the limited sensitivity of NSCLC patients to chemotherapy and immunotherapy drugs has proven to be a major obstacle to clinical treatment.\\n\\nDenk D et al. suggested that inflammation is ubiquitous in carcinogenesis. In his study, he noted that interfering with individual cytokines and their respective signaling pathways holds great promise for the development and improvement of current clinical cancer therapies. IL-22 is a new type of cytokine discovered in 2000 and has gradually attracted attention due to its role in tumor diseases. In recent years, multiple studies have reported the positive role of IL-22 in enhancing chemotherapy resistance in human lung cancer patients. This positive effect is related to the function of IL-22 in promoting lung cancer cell proliferation and inhibiting lung cancer cell apoptosis. Results showed that IL-22 activated the EGFR/AKT/ERK signaling pathway, STAT3, and ERK1/2 signaling pathways in drug-treated lung cancer cells, thereby attenuating the pro-apoptotic effect of the drug on lung cancer cells.\\n\\n## Function Role of IL-22 in Lung Cancer\\nIL-22 is a cytokine first identified by Dumoutier et al. in IL-9-induced murine T cells over 20 years ago and was once called IL-10-related T cell-derived inducible factor (IL-10-TIF).\\n```', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='d42bb730-5e18-40be-beaf-37066d405b5b', embedding=None, metadata={'page_number': 3, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png', 'page': 3, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='```markdown\\n## Page Content\\n\\nL. Xu et al. Heliyon 10 (2024) e35901\\n\\nWhen the body is in homeostasis, the most important source of IL-22 is Group 3 innate lymphoid cells (ILC3) [14]. Different from other common cytokines, IL-22 is generally thought to be produced only by hematopoietic origin immune cells, whereas it mainly acts on non-hematopoietic cells due to its receptor distribution [55]. Recently, researchers have found that non-hematopoietic cells represented by fibroblasts can also produce IL-22 under certain circumstances [11]. IL-22 is known to act by binding to its receptor (IL-22R), which is synthesized from the IL-22R1 and IL-10R2 subunits [56]. Thereinto, IL-22R1 expression is thought to be restricted to epithelial cells in organs such as the lung, liver, intestine, and skin, while the latter is universally expressed [11,57]. IL-22BP, also known as IL-22RA2, is a soluble IL-22 receptor that binds specifically to IL-22 and prevents it from binding to IL-22R1. All currently known functions of IL-22BP are achieved by inhibiting IL-22 [58,59]. Broadly speaking, the primary function of IL-22 in the body is to promote cell proliferation and tissue protection [60]. Sometimes, excessive activation of this function may lead to pathological results. This dual effect is reflected in both inflammatory and tumor-related diseases. In the short term, the production of IL-22 can play a protective role in anti-inflammatory and tumor prevention, while the uncontrolled generation of IL-22 may promote inflammation and tumor formation [13,18]. The duality of IL-22 reveals that it could be a potential drug target, and the tight regulation of IL-22 is crucial in the treatment of a variety of diseases.\\n\\nIn general, the expression levels of IL-22 in vivo are regulated by a variety of cytokines and genes. For instance, IL-1β and IL-23 can induce the production of IL-22 independently, and the two act synergistically [11]. What’s more, Cornelia Voigt described a novel mechanism whereby cancer cells promote tumor growth by releasing IL-1β to induce IL-22 production by memory CD4+ T cells [61]. According to an animal experiment, IL-1β can enhance the proliferation of epithelial cells and promote lung tumorigenesis [62]. IL-23 has been proven to promote proliferation in NSCLC by Anne-Marie Baird et al. [63]. Although IL-23 is thought to be able to induce macrophages to produce IL-22, this study by Anne-Marie Baird et al. cannot directly prove whether the proliferation-promoting effect of IL-23 on NSCLC cells is related to IL-23’s promotion of IL-22 production. IL-23 is also thought to promote the expression of IL-26 by macrophages. Like IL-22, IL-26 is part of the IL-10 family. Researchers demonstrated for the first time that IL-26 is involved in the generation of malignant pleural effusions [64]. They reported that IL-26 promotes the generation of malignant pleural effusion by mediating the infiltration of CD4+IL-22+T cells in malignant pleural effusion and stimulating CD4+ IL-22+ T cells to secrete IL-22. Recently, the Notch-AhR-IL-22 axis is thought to be involved in the pathogenesis of LUAD. It is corroborated that in LUAD patients, elevated Notch1 facilitates IL-22 generation by CD4+ T cells via aryl hydrocarbon receptors (AhR) [65]. In NSCLC, Notch signaling can both promote tumorigenesis and inhibit tumor progression, which mainly depends on its regulation of the.\\n\\n### Figure 1\\nIL-22 plays four main functions during the progression of lung cancer:\\n1. Promote lung cancer cell proliferation and invasion, and inhibit lung cancer cell apoptosis.\\n2. Regulate the abundance of immune cells in lung cancer tissues and activate the inflammatory microenvironment.\\n3. Promote cancer angiogenesis.\\n4. Activate lung cancer stem cells.\\n\\n**Summary of Figure 1**: The figure illustrates the multifaceted role of IL-22 in lung cancer, highlighting its involvement in cell proliferation, immune regulation, angiogenesis, and cancer stem cell activation. The diagram likely includes various cell types and signaling pathways associated with these functions.\\n\\n```', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='a0c7f4da-b86c-4fe1-8e2b-dd28a72c169c', embedding=None, metadata={'page_number': 4, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png', 'page': 4, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='```markdown\\n## Page Content\\n\\nL. Xu et al. Heliyon 10 (2024) e35901\\n\\nThe transformation between neuroendocrine and non-neuroendocrine. For patients with SCLC containing Notch active tumor cells, the application of Notch inhibitors may be an effective treatment [66]. Moreover, the expression of IL-22 is also regulated by miR-26. In cutaneous T-cell lymphoma (CTCL) cells, transfection of miR-26 resulted in a remarkable decrease in the expression levels of IL-22 and IL-22 mRNA [67]. In human NSCLC, Yi He et al. found that the expression levels of miR-26 were lower in tumor tissues compared to paracancerous tissue. As a functional miRNA, miR-26 was further proved by the team to inhibit autophagy and induce apoptosis of NSCLC cells both in vitro and in vivo [68]. On the other hand, IL-22 has also been shown to regulate other cytokines. Studies have shown that the production of IL-22 generally reduces Th1-type immune responses. This action may be coordinated with the protective effect of IL-22R-expressing tissue cells to reduce collateral damage in the context of infection and inflammation [69]. Besides, animal experiments have indicated that IL-22 can also promote B-cell responses by inducing CXCL13 in tertiary lymphoid follicles [70,71]. In the latest murine lung cancer model, IL-22 was discovered to induce NK cells to overexpress CD155, thus mediating the immune evasion of tumor cells [72]. As a transmembrane adhesive molecule, CD155 has been proven to inhibit T and NK cell-mediated anti-tumor immune responses, thereby promoting tumor progression (Fig. 2) [73–75].\\n\\nIn the occurrence and development of pulmonary diseases, IL-22 is considered to play an important role. As previously demonstrated in an epicutaneously sensitized mice experiment, IL-22 promotes the development of neutrophil and eosinophile-mediated airway inflammation and airway hyperresponsiveness stimulated by intranasal antigens [76]. The conclusion implies that blocking IL-22 may be helpful for the treatment of bronchial asthma. When it comes to chronic obstructive pulmonary disease (COPD), the expression levels of both IL-22 and its receptor in COPD patients were higher than those of healthy controls. This result was confirmed in mice with experimental COPD induced by cigarette smoke. What’s more, researchers also found that cigarette smoke-induced inappropriate activation of pulmonary neutrophils decreased in IL-22-deficient mice with COPD. This suggests that IL-22 may be involved in the pathogenesis of COPD. The research further manifested that IL-22 promotes cigarette smoke-induced airway remodeling, pulmonary neutrophil inflammation, and the impairment of pulmonary function, and is involved in the pathogenesis of COPD [77]. While in pulmonary infectious diseases such as pneumonia, tuberculosis, and pulmonary mycosis, it is thought that IL-22 appears to take a protective and preventive part [78–83]. For good measure, in the bleomycin-induced pulmonary fibrosis model, the degree of pulmonary fibrosis in IL-22 knockout mice was aggravated, and injection of recombinant IL-22 alleviated the severe fibrosis in IL-22 knockout mice. This latest research has suggested the potential antifibrotic effect of IL-22 [84].\\n\\nIn recent years, differential expression of IL-22 has also been discovered in various specimens of lung cancer (Table 1). In the first place, the mean levels of IL-22 in the plasma of NSCLC patients were significantly higher than that of the reference cohort [21,85]. The plasma levels of IL-22 were observed to elevate along with the increase in lung cancer staging [85]. In addition, Immunohistochemistry analysis showed that IL-22 expression was up-regulated in NSCLC tumor specimens in comparison to that in the adjacent tissues. RT-qPCR analysis also revealed similar differences in IL-22 mRNA expression between lung cancer tissues and normal tissues [24,86]. Interestingly, Yi Bi et al. compared IL-22 levels between tissues and serum of patients with primary NSCLC and their paired recurrent lung cancer specimens and the expression levels of IL-22 were found to be obviously up-regulated in the latter group [23]. Apart from this, IL-22 expression was also detected in bronchoalveolar lavage fluid (BALF). As reported by an article in 2016, IL-22 levels were .\\n\\n## Figure Description\\n\\n**Figure 2**: IL-22 induces NK cells to overexpress CD155, which binds to NK cell activation receptor CD226. Over-activation leads to a decrease in the amount of CD226 and impaired NK cell function, thereby mediating tumor cell immune escape.\\n\\n- **Summary**: This figure illustrates the mechanism by which IL-22 influences NK cell activity through the overexpression of CD155, leading to immune evasion by tumor cells. The diagram likely includes arrows indicating the interactions between IL-22, NK cells, and CD155, as well as the resulting effects on immune function.\\n```', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='10a6d7aa-971a-44ba-b153-1d0b7d766b0f', embedding=None, metadata={'page_number': 5, 'image_link': None, 'page': 5, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='```markdown\\n# Page Content\\n\\n## Table 1\\nDifferential expression of IL-22/IL-22 mRNA/IL-22R1 mRNA in various samples in lung cancer. +: Up-regulated.\\n\\n| Molecule | Samples | Expression | P value | Ref. (PMID) |\\n|---------------------|----------------------------------|------------|----------|--------------|\\n| IL-22 | Plasma | + | 0.0013 | 24956177 |\\n| IL-22 mRNA | Tissues | + | 0.0313 | 18927282 |\\n| IL-22 | Pleural effusion | + | 0.0051 | 18927282 |\\n| IL-22 mRNA, IL-22 | Tissues, serum | + | <0.01 | 26983629 |\\n| IL-22R1 mRNA | Tissues | + | <0.05 | 26983629 |\\n| IL-22 | BALF | + | <0.001 | 27388918 |\\n\\nIL-22 is significantly higher in BALF from lung cancer patients compared with the control group. The researchers expanded the cohort to patients with lung metastases from other malignancies and found that IL-22 concentrations remained higher than controls. These results implied that IL-22 in BALF may be a biomarker for lung cancer. Additionally, researchers found traces of IL-22 in pleural effusion. One study revealed that IL-22 levels were higher in malignant pleural effusion compared to tuberculous pleural effusion. These differential expressions suggest that IL-22 may participate in the occurrence and development of lung cancer (Table 2).\\n\\nThe link between inflammatory processes and cancer has long been recognized. Related studies indicate that inflammatory responses play a vital role in different phases of tumor occurrence, development, and metastasis. The function of IL-22 in cancer is extremely complicated. Initially, IL-22 may prevent tumorigenesis by reducing chronic inflammation, promoting barrier function, and inducing tissue regeneration. Conversely, if IL-22 is excessively expressed under persistent chronic inflammation, malignant cells may utilize this signal to facilitate its progression. In the lung tumor microenvironment, uncontrolled expression of IL-22 can amplify inflammation by inducing various inflammatory mediators alone or in concert with other cytokines.\\n\\nAs illustrated by a cellular experiment, IL-22 could promote the proliferation of A549 and H125 cells belonging to the NSCLC cell lines, thereby enhancing the ability of tumor cell migration and invasion. An in vitro experiment in 2018 confirmed that IL-22 can directly act on endothelial cells to stimulate tumor angiogenesis. This enhances the ability of tumor cells to absorb nutrients and facilitates distant metastasis. From another perspective, this provides new ideas for anti-angiogenic therapy of tumors.\\n\\nNasim Khosravi suggested that IL-22 promotes tumor progression by inducing a pro-tumor immune response and protective stem cell properties of tumor cells. It is reported that after 12 hours of serum starvation, the proportion of apoptotic lung cancer cells transfected with the IL-22 gene was significantly lower than that of control lung cancer cells. Additionally, the apoptosis-inducing and anti-proliferative effects of chemotherapeutic drugs on lung cancer cells were inhibited in IL-22 transgenic cell lines. Simultaneously, the apoptosis of lung cancer cells induced by gefitinib was significantly reduced 48 hours after IL-22 exposure. Conversely, exposure to IL-22R1 blocking antibodies or in vitro transfection of IL-22-RNA interference plasmid leads to apoptosis of lung cancer cells.\\n\\nZhiliang Huang et al. found that the apoptosis rate of paclitaxel-treated lung cancer cells in the IL-22 siRNA transfection group was significantly increased compared with the control group. Apart from this, IL-22 antibody treated mice and IL-22-deficient mice were found to be protected from the formation of pulmonary metastases caused by colon cancer, while IL-22 overexpression promoted metastases. In short, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and migration of lung cancer cells, the growth of tumor tissues, and the generation of lung metastatic cancer.\\n\\n## Regulatory role of IL-22 in lung cancer\\n\\nNumerous signaling pathways are involved in the regulation of IL-22 in lung cancer, including PI3K/AKT, JAK-STAT3, p38 MAPK signaling pathways, and so on. In the following, we will elaborate on the regulatory role of IL-22 in lung cancer from the point of view of each major signaling pathway (Figure 3).\\n\\n## Table 2\\nPotential clinical role of IL-22, its receptors and producing cells in lung cancer.\\n\\n| Sample | Clinical function | Conclusion | Ref. (PMID) |\\n|---------------|---------------------------|----------------------------------------------------------------------------------------------------------------|-----------------------------|\\n| Patients | Diagnosis | IL-22 levels were significantly higher in lung cancer patients than control group. | 24956177, 27388918 |\\n| Patients | Prognosis assessment | IL-22R1 levels were associated with poorer prognosis. | 26846835 |\\n| Patients | Disease assessment | The levels of IL-22-producing Th22 cells were positively correlated with TNM stage and lymph node metastasis. | 35669104 |\\n| Patients | Efficacy prediction | IL-22 expression levels were associated with EGFR-TKI efficacy. | 31750252 |\\n| Mice model | Treatment | IL-22-deficient mice had a lower metastatic load of lung cancer. | 36630913 |\\n| Mice model | Treatment | Gene ablation of IL-22 resulted in a marked reduction in the number and size of lung tumors. | 29764837 |\\n```', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='6fb5613b-d0aa-41d1-98dd-92415a3fcf4f', embedding=None, metadata={'page_number': 6, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p5_1.png', 'page': 6, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='```markdown\\n# Page Content\\n\\n## 4.1. PI3K/Akt Signaling Pathway\\n\\nThe PI3K/AKT signaling pathway is one of the core intracellular signaling pathways, which plays a critical role in regulating cell growth, survival, metabolism, movement, and proliferation [97]. As a downstream effector of receptor tyrosine kinases (RTKs) and G-protein-coupled receptors (GPCRs), PI3K is a group of lipid kinases consisting of three subunits. It can be divided into three categories according to various functions and structures. Class IA PI3K is a heterodimer of the p110 catalytic subunit and the p58 regulatory subunit, and it is primarily related to human tumors [98,99].\\n\\nAs we all know, PI3K can catalyze phosphatidylinositol [4, 5]-bisphosphate (PIP2) to phosphatidylinositol [3–5]-trisphosphate (PIP3). Serine/threonine protein kinase (AKT), as the main downstream molecule of the PI3K signaling pathway, is mainly activated by PIP3-driven plasma membrane recruitment and phosphorylation. The mammalian target of rapamycin (mTOR), a major downstream signaling molecule in the PI3K/AKT signaling pathway, is considered to be a modified protein kinase in the form of mTORC1 and mTORC2. The first is mainly activated by the PI3K/AKT signaling pathway, and mTORC2 further activates AKT by directly phosphorylating its hydrophobic motif (Ser473) [100].\\n\\nThe PI3K/Akt signaling pathway is considered to be the chief regulatory factor of idiopathic pulmonary fibrosis (IPF); it may directly participate in the formation of IPF or promote the occurrence and development of fibrosis in collaboration with other pathways [97]. Several studies have declared that certain natural products like resveratrol and Danhong injection can provide neuroprotective effects by activating the PI3K/AKT/mTOR signaling pathway [101,102]. Furthermore, the relationship between the PI3K/AKT/mTOR signaling pathway and cancer has been most intensively studied. Activation of the PI3K/AKT/mTOR signaling pathway is believed to promote the occurrence, proliferation, and progression of a variety of cancers, including breast cancer, ovarian cancer, prostate cancer, etc. [99,100,103]. In addition, it is also an important cause of tumor drug resistance [104].\\n\\nIn NSCLC, KRAS, EGFR, and PTEN mutations are believed to activate the PI3K/Akt/mTOR signaling pathway [105]. As demonstrated in a previous article, upregulation of the PI3K signaling pathway was identified as an early and reversible event in the pathogenesis of NSCLC [106]. One experiment has confirmed that the PI3K/AKT signaling pathway promotes the proliferation of LUAD cells mainly through anti-apoptosis [107]. Additionally, as revealed in a cellular study, IL-22 produced by CAFs markedly improves the proliferation and invasion of lung cancer cells and lessens apoptosis by activating the PI3K/Akt/mTOR signaling pathway [86].\\n\\nFor good measure, it has been found that AKT phosphorylation in NSCLC cells is facilitated by different concentrations of IL-22 in a time- and dose-dependent way [23]. Collectively, the PI3K/Akt/mTOR signaling pathway plays a significant role in the relationship between IL-22 and lung cancer. It is worth mentioning that IL-22 does not seem to always activate the PI3K/Akt/mTOR signaling pathway. Meng Yuxia et al. found that IL-22 inhibits the activity of the PI3K/AKT/mTOR signaling pathway in mouse liver fibrosis tissue [108]. This opposite finding may be related to the dual function of IL-22. Further study on the impact of IL-22 on the PI3K/AKT/mTOR signaling pathway in different disease processes will help us better understand the specific mechanism of IL-22’s function in the human body.\\n\\n### Diagram Description\\n\\n**Figure 3**: IL-22 promotes the proliferation, migration, and epithelial-mesenchymal transition of lung cancer cells through PI3K/AKT, JAK-STAT3, p38 MAPK, and other signaling pathways, and antagonizes the apoptosis of lung cancer cells induced by anti-tumor drugs.\\n\\n- The diagram illustrates the interaction of various signaling pathways (PI3K, JAK, P38 MAPK) with IL-22 and their effects on lung cancer cells, including proliferation, migration, epithelial-mesenchymal transition (EMT), and apoptosis.\\n- The diagram includes elements such as:\\n- **IL-22**: A cytokine involved in the signaling.\\n- **PI3K**: A key signaling molecule in the pathway.\\n- **AKT**: A downstream effector activated by PI3K.\\n- **mTOR**: Another downstream target involved in cell growth and metabolism.\\n- **Gene expression**: Indicates the outcome of the signaling pathways.\\n- **Nucleus**: Represents the site of gene expression.\\n- **Lung tumor cell**: The target cells affected by these pathways.\\n\\nThe diagram visually summarizes the complex interactions and outcomes of the signaling pathways in the context of lung cancer.\\n```', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='c2ee4432-a4ef-4bdc-9627-6091e3c635f2', embedding=None, metadata={'page_number': 7, 'image_link': None, 'page': 7, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='```markdown\\n# IL-22-related Clinical Drug Development\\n\\n## 4.2. JAK/STAT Signaling Pathway\\n\\nThe JAK/STAT signaling pathway is an important communication center for cell function, and aberrant alterations in its components are associated with numerous human diseases. JAK/STAT is an evolutionarily conserved signaling pathway consisting of JAKs, STATs, and ligand-receptor complexes. There are four major members of the JAK family, all of which are composed of non-receptor tyrosine protein kinases. The STAT family contains six members which consist of 750–900 amino acids. The JAK/STAT signaling pathway is mainly thought to mediate inflammation, apoptosis, hematopoiesis, tissue repair, immune regulation, and adipogenesis [109].\\n\\nIn autoimmune diseases such as rheumatoid arthritis (RA), activation of the JAK-STAT signaling pathway leads to the progression of joint injury through overexpression of the matrix metalloproteinase gene, apoptosis of chondrocytes, and apoptotic resistance in synovial tissue [110,111]. In addition, in a 2020 study by Meyer LK, the inhibition of the JAK-STAT signaling pathway was found to sensitize CD8+ T cells to dexamethasone-induced excessive inflammatory cell apoptosis [112]. Song et al. have long discovered that the lifespan of NSCLC cells was notably reduced after inhibiting STAT3 [113]. In a murine lung model, overexpression of STAT3 in alveolar type II cells led to severe lung inflammation and eventually to the formation of LUAD [114].\\n\\nFurther, down-regulation of STAT3 was found to result in enhanced NK cell immunity in both human and murine NSCLC cells, which suggests that STAT3 plays an inhibitory role against tumor NK cell immunity [115,116]. A study last year disclosed that IL-22 triggers JAK-STAT3 pathway phosphorylation in NSCLC cells in a time- and dose-dependent manner, thus promoting the proliferation and metastasis of tumor cells [23,96]. Another study demonstrated that the overexpression of IL-22 protected lung cancer cells against apoptosis induced by serum starvation and chemotherapy drugs by activating STAT3 and its downstream anti-apoptotic proteins [24].\\n\\n## 4.3. p38 MAPK Signaling Pathway\\n\\nThe p38 mitogen-activated protein kinases (MAPK) signaling pathway takes a crucial role in signaling cascades induced by various cellular stimuli. There are four p38 kinase members in the mammalian mitogen-activated protein (MAP) family, which play momentous roles in extracellular stimulation-mediated proliferation, inflammation, differentiation, apoptosis, senescence, and tumorigenesis [117].\\n\\nIn the classical pathway, the p38 MAPK signaling pathway is activated by cascade phosphorylation [118]. In a hepatitis C virus (HCV) experiment, researchers demonstrated that virus-induced activation of the p38 MAPK signaling pathway promotes viral infection, and blocking activation of this pathway may be an antiviral approach [117]. According to Dan He in 2020, mTORC1 drives intestinal stem cell aging via the p38 MAPK-p53 signaling pathway [119]. The p38 MAPK signaling pathway has long been demonstrated to exhibit a major oncogenic role in LUAD [120–122].\\n\\nYinan Guo et al. found evidence that the p38 MAPK signaling pathway can promote EMT and metastasis of NSCLC both in vitro and in vivo [123]. In addition, a study published in 2017 proposed that the p38 MAPK signaling pathway activates stem cell properties of LUAD cells by regulating GLI1 [124]. What’s more, in lung cancer models, researchers found that the p38 MAPK signaling pathway inhibited the stem cell properties of lung CSCs and promoted their proliferation and differentiation, thereby leading to tumorigenesis.\\n\\nMore importantly, they also elucidated that the p38 MAPK and PI3K/AKT signaling pathways have unique and synergistic roles in regulating lung CSCs self-renewal as carcinogenic and/or stem cell signaling pathways [107]. This provides a new idea for the stem cell-based treatment of lung cancer. In NSCLC, IL-22 in vivo and in vitro were both verified to activate the p38 MAPK signaling pathway. The collected evidence from this study confirmed the negative immunomodulatory role of IL-22 in the disease [96].\\n\\n## 5. Clinical Role of IL-22 in Lung Cancer\\n\\nCurrently, there is still a lack of efficient biomarkers for the diagnosis and treatment of lung cancer. In recent years, the value of the interleukin family as biomarkers and therapeutic targets of lung cancer has been deeply investigated [125–132]. Of these, IL-1 and IL-6 have been studied most extensively in lung cancer. Bo Yuan’s findings in mice experiments supported IL-1β as a potential target for the prevention and treatment of LUAD patients with Kras mutations [129].\\n\\nIn a clinical trial of the anti-IL-1β antibody canakinumab, researchers found that 300 mg canakinumab significantly reduced lung cancer mortality compared with the control group (HR 0.49 [95%CI 0.31–0.75]; p = 0.0009) [133]. In plasma samples or tumor tissues from NSCLC, researchers revealed that patients with lower baseline IL-6 concentrations benefited more from immunotherapy. The study elucidated the role of IL-6 in predicting the efficacy of immunotherapy in patients with NSCLC [128].\\n\\nFurthermore, in one lung cancer study, the survival hazard ratio before and after chemotherapy for high versus low IL-6 levels was 1.25 (95%CI 0.73–2.13) and 3.66 (95%CI 2.18–6.15), respectively. It is suggested that IL-6 may be a prognostic indicator of survival in patients with advanced NSCLC receiving chemotherapy [127]. Some scholars have also described the potential value of IL-11 as a biomarker for the diagnosis and prognosis of NSCLC [125].\\n\\nIn addition, another research has shown that changes in serum IL-8 levels in NSCLC patients could reflect and predict the response to immunotherapy [130]. Kaplan-Meier survival analysis showed that the overall survival outcome of NSCLC patients with high IL-22R1 expression was significantly lower than that of patients with low IL-22R1 expression (p = 0.022). Multivariate regression analysis also confirmed an association between IL-22R1 levels and poorer outcomes (HR 1.5, 95%CI 1.2–1.9; p = 0.0011). This suggested that high expression of IL-22R1 is an independent factor for low overall survival in NSCLC [134].\\n\\nWhat’s more, the levels of IL-22-producing Th22 cells in peripheral blood were positively correlated with TNM stage, lymph node metastasis, and clinical tumor markers of lung cancer (p < 0.01) [96]. The above indicates the significance of IL-22 as a biomarker in the diagnosis and disease assessment of lung cancer. Apart from this, Renhua Guo’s team found that the expression of IL-22 in the EGFR-TKI resistant group was higher than that in sensitive.\\n```', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='639e4d98-0b0c-4fd5-a8e3-02469c6a8a6f', embedding=None, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='```markdown\\n# Page Content\\n\\nL. Xu et al. Heliyon 10 (2024) e35901\\n\\nThe expression level was correlated with the efficacy of EGFR-TKI in plasma [135]. Therefore, it is reasonable to suspect that IL-22 may be a new biomarker to overcome EGFR-TKI resistance in NSCLC. In terms of animal models, some investigators implanted Line-1 lung cancer cells into wild-type and IL-22-deficient mice simultaneously, and found reduced intrapulmonary metastasis in the latter group, which is independent of primary tumor size. Besides, they performed forced metastasis by intravenous injection of lung cancer cells, and the results further confirmed the lower metastatic load in mice with IL-22 deletion [72]. In another model of Kras-mutated lung cancer in mice, gene ablation of IL-22 resulted in a marked reduction in tumor number and size. The authors also analyzed the association between IL-22R1 expression and survival in patients with KRAS mutant lung adenocarcinoma, the results showed that high expression of IL-22R1 was an independent indicator of poorer relapse-free survival [94]. Taken together, these pieces of evidence highlight the potential clinical role of IL-22, IL-22R, and IL-22-producing cells in the treatment of lung cancer (Table 2).\\n\\n## Future Perspectives\\n\\n### CRISPR-Cas13a Technical\\n\\nAt present, mounting clinical trials based on IL-22 are being carried out in full swing worldwide, mainly involving ulcerative colitis, alcoholic cirrhosis, GVHD, and psoriasis [12,14,54,60]. However, there are presently no clinical trials based on IL-22 in lung cancer. As described previously, reduced intrapulmonary metastasis was found in IL-22-deficient mice as well as in IL-22-suppressed NSCLC cells [20,72]. In addition, blocking IL-22R1 or knockout of the IL-22 gene both retarded the progression of lung cancer [24,94]. These findings provide a new train of thought for the down-regulation of IL-22 in treating lung cancer.\\n\\nIn recent years, the research on gene editing treatment for various diseases has become more and more popular [136–138]. CRISPR-Cas13a is an effective tool for knocking out specific RNA sequences, it has been shown to induce the death of glioma cells that overexpress EGFR, which is one of the subtypes of EGFR mutation in glioma. Apart from this, the CRISPR-Cas13a gene-editing system can also inhibit the formation of intracranial tumors in mice with glioma [139]. In a collagen-induced mouse model, injection of gene-edited human amniotic mesenchymal stem cells that overexpressed IL-10 increased proteoglycan expression in joint tissue and reduced the inflammatory response and production of various inflammatory cytokines [137]. In the world’s first human phase I clinical trial utilizing CRISPR-Cas9 in the treatment of advanced NSCLC, researchers have demonstrated the feasibility and safety of gene-edited T-cell therapy targeting the PD-1 gene [140]. Thus, genome editing strategies have the potential to treat lung cancer by altering IL-22 expression levels. In the future, the role of pulmonary precision delivery based on CRISPR-Cas13 gene-editing components targeting the IL-22 mRNA in lung cancer therapy should not be ignored. CRISPR-Cas13 is expected to be further integrated.\\n\\n## Figure 4\\n\\nCrispr-cas13-based IL-22 mRNA editing can be utilized for lung cancer therapy by combining with emerging technologies such as single-base editing and single-cell sequencing.\\n\\n![Crispr-cas13-based IL-22 mRNA editing]()\\n```', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='62b61341-476f-41e8-89c7-d0e5a632b766', embedding=None, metadata={'page_number': 9, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png', 'page': 9, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='```markdown\\n# Page Content\\n\\n## 6.2. Small interfering RNA\\n\\nSmall interfering RNA (siRNA) is a double-stranded RNA molecule composed of 21–23 nucleotides. In cells, siRNA forms functional complexes by binding to the RNA-induced silencing complex (RISC). RISC in the functional complex specifically recognizes and binds to the target mRNA, leading to degradation of the target mRNA and thereby silencing the expression of the target gene. Compared with traditional therapies such as small molecules and protein drugs, siRNA technology has many advantages:\\n\\n1. siRNA is highly specific. siRNA can only silence homologous genes, while unrelated genes are not affected.\\n2. siRNA can silence genes by using RISC.\\n3. siRNA can be designed to target different genes through sequence design, and can even target targets that were previously considered “undruggable”.\\n4. siRNA does not activate the innate immune system.\\n\\nTwenty years after the discovery of the RNA interference mechanism, the first siRNA drugs (including Patisiran, Givosiran, Lumasiran, Inclisiran, Vutrisiran) were approved for clinical use by the U.S. Food and Drug Administration (FDA) and the European Medicines Agency from 2018 to 2022 [141,142]. NFKBIZ is an upstream target of IL-23, IL-36, and IL-17A. In the study of Mandal A et al. [143], NFKBIZ-siRNA significantly reduces the mRNA levels of multiple pro-inflammatory cytokines, including IL-17, IL-19, IL-22, etc., in the skin tissue of psoriasis mice, thereby alleviating the condition of the mice. The safety evaluation results of NFKBIZ-siRNA preparations show that NFKBIZ-siRNA preparations can complex with nucleic acids without affecting biological activity and show no toxicity. TGF-β is a pleiotropic regulatory cytokine that can regulate a variety of ILs including IL-22 and IL-17 to affect the composition of the tumor microenvironment [144]. Currently, Sirnaomics has developed an siRNA drug that targets TGF-β (called STP705). Recently, the drug has completed phase II clinical trials in the United States and achieved positive results. The role of ILs in cancer has been extensively studied. In recent years, the positive role of IL-22 in lung cancer has received attention. The researchers believe that knocking down IL-22 mRNA levels in the lesions of lung cancer patients will help prolong the survival of lung cancer patients and improve the cure rate of lung cancer patients. For example, Zhang Wei et al. found that IL-22-siRNA slowed tumor growth in NSCLC model mice. In addition, they reported that the therapeutic effect of IL-22-siRNA combined with chemotherapy drugs (5-FU and carboplatin) on NSCLC mice was better than that of chemotherapy drugs alone [24]. In an in vitro assay [145], cell line PC9 cells (NSCLC) transfected with PDLIM5-siRNA targeting the PDLIM5 gene had reduced growth viability and exhibited higher apoptotic rates. In the chemotherapy drug gefitinib-resistant cell line PC9 cells, PDLIM5-siRNA still showed significant anti-tumor effects. These results indicate that siRNA-based therapy has good application in the clinical treatment of NSCLC, especially in drug-resistant patients. Based on these findings, we believe that the development of IL-22-siRNA drugs for lung cancer treatment has clinical potential and theoretical basis.\\n\\n## 6.3. Nanoparticle drug delivery systems\\n\\nOn the other hand, given the toxicity and erratic efficacy of current anti-tumor drugs, research on novel drug carriers in lung cancer is ongoing.\\n\\n### Figure 5\\n**Caption:** Precision delivery of various nanomaterials containing IL-22 related drugs for the treatment of lung cancer.\\n\\n**Description:** Figure 5 illustrates the precision delivery of various types of nanomaterials that are designed to carry IL-22 related drugs specifically for lung cancer treatment. The diagram likely includes different types of nanoparticles and their targeting mechanisms, emphasizing the advancements in drug delivery systems aimed at improving therapeutic outcomes in lung cancer patients.\\n```', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='cdc71132-045a-4494-80cf-e31978f89e4c', embedding=None, metadata={'page_number': 10, 'image_link': None, 'page': 10, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='```markdown\\n# Page Content\\n\\nL. Xu et al. Heliyon 10 (2024) e35901\\n\\nNanoparticles containing targeted drugs can be delivered to the intended site using carriers with affinity for various specific tissues or lesions [146,147]. In an in vivo mice lung model, combined delivery of sorafenib and crizotinib by polymer nanoparticles significantly reduced tumor progression and toxic side effects, and improved survival rate [148]. Moreover, Maofan Zhang demonstrated that the efficacy of dual-drug-loaded polymeric nanoparticles with etoposide and cisplatin was significantly superior to conventional chemotherapy modality without causing additional toxicity [149]. These imply that nanomaterials loaded with IL-22-related drugs may also have more unique advantages. Therefore, the utilization of novel nanomaterials loaded with IL-22 antibodies and IL-22 inhibitors like IL-22BP for targeted therapy of lung tumors is also a promising research direction (Figure 5).\\n\\n## 7. Conclusion\\n\\nIn this review, we provided a comprehensive analysis of the role of IL-22 in the immune microenvironment and its involvement in major signaling pathways in the context of lung cancer. Put in a nutshell, IL-22 not only antagonizes the induction of apoptosis and cell cycle arrest of lung cancer cells by anti-tumor drugs but also promotes the proliferation and metastasis of lung cancer cells and the growth of tumor tissues. Additionally, the potential clinical significance of IL-22 in the diagnosis, treatment, and prognosis evaluation of lung cancer was further confirmed. Next, the prospects of IL-22 in combination with gene editing and novel nanomaterials in the treatment of lung cancer have been discussed. With the general increase in drug resistance to chemotherapy, targeted therapy, and immunotherapy in lung cancer, it is also necessary to study in depth to discover the correlation between IL-22 and the mechanism of drug resistance. To sum up, the potential of IL-22 as a biomarker for lung cancer still remains to be explored. Further research on the molecular, physiological effects and mechanism of IL-22 in lung cancer as well as the conduction of standardized clinical trials are expected to inject fresh blood into the diagnosis and treatment of lung cancer.\\n\\n## Financial Support\\n\\nNone.\\n\\n## Data Availability Statement\\n\\nNot applicable.\\n\\n## CRediT Authorship Contribution Statement\\n\\n- Ling Xu: Writing – original draft.\\n- Peng Cao: Visualization.\\n- Jianpeng Wang: Writing – review & editing.\\n- Peng Zhang: Validation.\\n- Shuhui Hu: Validation.\\n- Chao Cheng: Writing – review & editing.\\n- Hua Wang: Writing – review & editing, Supervision, Conceptualization.\\n\\n## Declaration of Competing Interest\\n\\nThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\\n\\n## Acknowledgements\\n\\nNone.\\n\\n## Abbreviations\\n\\n- non-small cell lung cancer: NSCLC\\n- Interleukin-22: IL-22\\n- chimeric antigen receptor: CAR\\n- IL-10-related T cell-derived inducible factor: IL-10-TIF\\n- Group 3 innate lymphoid cells: ILC3\\n- IL-22 receptor: IL-22R\\n- aryl hydrocarbon receptors: AhR\\n- chronic obstructive pulmonary disease: COPD\\n- cutaneous T-cell lymphoma: CTCL\\n- bronchoalveolar lavage fluid: BALF\\n- receptor tyrosine kinases: RTKs\\n- G-protein-coupled receptors: GPCRs\\n- Mammalian target of rapamycin: mTOR\\n- idiopathic pulmonary fibrosis: IPF\\n- rheumatoid arthritis: RA\\n```', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='6ae836ff-d0eb-4749-8de0-f687c0c08d31', embedding=None, metadata={'page_number': 11, 'image_link': None, 'page': 11, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='```markdown\\n# Page Content\\n\\n## Abbreviations\\n- mitogen-activated protein kinases: MAPK\\n- mitogen-activated protein: MAP\\n- hepatitis C virus: HCV\\n\\n## References\\n1. S. Lareau, C. Slatore, R. Smyth, Lung cancer, *Am. J. Respir. Crit. Care Med.* 204 (12) (2021) P21–P22.\\n2. J. Huang, Y. Deng, M.S. Tin, V. Lok, C.H. Ngai, L. Zhang, et al., Distribution, risk factors, and temporal trends for lung cancer incidence and mortality: a global analysis, *Chest* 161 (4) (2022) 1101–1111.\\n3. B.C. Bade, C.S. Dela Cruz, Lung cancer 2020: epidemiology, etiology, and prevention, *Clin. Chest Med.* 41 (1) (2020) 1–24.\\n4. J. Malhotra, M. Malvezzi, E. Negri, C. La Vecchia, P. Boffetta, Risk factors for lung cancer worldwide, *Eur. Respir. J.* 48 (3) (2016) 889–902.\\n5. H. Sung, J. Ferlay, R.L. Siegel, M. Laversanne, I. Soerjomataram, A. 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Bashash, The PI3K/Akt/mTOR pathway in lung cancer; oncogenic alterations, therapeutic opportunities, challenges, and a glance at the application of nanoparticles, Transl Oncol 18 (2022) 101364.\\n18. A.M. Gustafson, R. Soldi, C. Anderlind, M.B. Scholand, J. Qian, X. Zhang, et al., Airway PI3K pathway activation is an early and reversible event in lung cancer development, Sci. Transl. Med. 2 (26) (2010) 26ra5.\\n19. J. Li, J. Wang, D. Xie, Q. Pei, X. Wan, H.R. Xing, et al., Characteristics of the PI3K/AKT and MAPK/ERK pathways involved in the maintenance of self-renewal in lung cancer stem-like cells, Int. J. Biol. Sci. 17 (5) (2021) 1191–1202.\\n20. Y.X. Meng, R. Zhao, L.J. Huo, Interleukin-22 alleviates alcohol-associated hepatic fibrosis, inhibits autophagy, and suppresses the PI3K/AKT/mTOR pathway in mice, Alcohol Clin. Exp. Res. 47 (3) (2023) 448–458.\\n21. X. Hu, J. Li, M. Fu, X. Zhao, W. Wang, The JAK/STAT signaling pathway: from bench to clinic, Signal Transduct. Targeted Ther. 6 (1) (2021) 402.\\n22. C. Baldini, F.R. Moriconi, S. Galimberti, P. Libby, R. De Caterina, The JAK-STAT pathway: an emerging target for cardiovascular disease in rheumatoid arthritis and myeloproliferative neoplasms, Eur. Heart J. 42 (42) (2021) 4389–4400.\\n23. L. Hu, R. Liu, L. Zhang, Advance in bone destruction participated by JAK/STAT in rheumatoid arthritis and therapeutic effect of JAK/STAT inhibitors, Int. Immunopharm. 111 (2022) 109095.\\n24. L.K. Meyer, K.C. Verbist, S. Albeituni, B.P. Scull, R.C. Bassett, A.N. Stroh, et al., JAK/STAT pathway inhibition sensitizes CD8 T cells to dexamethasone-induced apoptosis in hyperinflammation, Blood 136 (6) (2020) 657–668.\\n25. L. Song, J. Turkson, J.G. Karras, R. Jove, E.B. Haura, Activation of Stat3 by receptor tyrosine kinases and cytokines regulates survival in human non-small cell carcinoma cells, Oncogene 22 (27) (2003) 4150–4165.\\n26. Y. Li, H. Du, Y. Qin, J. Roberts, O.W. Cummings, C. Yan, Activation of the signal transducers and activators of the transcription 3 pathway in alveolar epithelial cells induces inflammation and adenocarcinomas in mouse lung, Cancer Res. 67 (18) (2007) 8494–8503.\\n27. S. Ihara, H. Kida, H. Arase, L.P. Tripathi, Y.A. Chen, T. Kimura, et al., Inhibitory roles of signal transducer and activator of transcription 3 in antitumor immunity during carcinogen-induced lung tumorigenesis, Cancer Res. 72 (12) (2012) 2990–2999.\\n28. J. Mohrherr, I.Z. Uras, H.P. Moll, E. Casanova, STAT3: versatile functions in non-small cell lung cancer, Cancers 12 (5) (2020).\\n29. Y. Cheng, F. Sun, L. Wang, M. Gao, Y. Xie, Y. Sun, et al., Virus-induced p38 MAPK activation facilitates viral infection, Theranostics 10 (26) (2020) 12223–12240.\\n30. Y. Xu, Q. Sun, F. Yuan, H. Dong, H. Zhang, R. Geng, et al., RND2 attenuates apoptosis and autophagy in glioblastoma cells by targeting the p38 MAPK signalling pathway, J. Exp. Clin. Cancer Res. : CR 39 (1) (2020) 174.\\n31. D. He, H. Wu, J. Xiang, X. Ruan, P. Peng, Y. Ruan, et al., Gut stem cell aging is driven by mTORC1 via a p38 MAPK-p53 pathway, Nat. Commun. 11 (1) (2020) 37.\\n32. O. Dreesen, A.H. Brivanlou, Signaling pathways in cancer and embryonic stem cells, Stem Cell Rev. 3 (1) (2007) 7–17.\\n33. X.M. Hou, T. Zhang, Z. Da, X.A. Wu, CHPF promotes lung adenocarcinoma proliferation and anti-apoptosis via the MAPK pathway, Pathol. Res. Pract. 215 (5) (2019) 988–994.\\n34. Y.C. Wang, D.W. Wu, T.C. Wu, L. Wang, C.Y. Chen, H. Lee, Dioscin overcome TKI resistance in EGFR-mutated lung adenocarcinoma cells via down-regulation of tyrosine phosphatase SHP2 expression, Int. J. Biol. Sci. 14 (1) (2018) 47–56.\\n35. Y. Guo, M. Jiang, X. Zhao, M. Gu, Z. Wang, S. Xu, et al., Cyclophilin A promotes non-small cell lung cancer metastasis via p38 MAPK, Thorac Cancer 9 (1) (2018) 120–128.\\n36. A. Po, M. Silvano, E. Miele, C. Capalbo, A. Eramo, V. Salvati, et al., Noncanonical GLI1 signaling promotes stemness features and in vivo growth in lung adenocarcinoma, Oncogene 36 (32) (2017) 4641–4652.\\n37. J.H. Leung, B. Ng, W.W. Lim, Interleukin-11: a potential biomarker and molecular therapeutic target in non-small cell lung cancer, Cells 11 (14) (2022).\\n38. H. Wang, F. Zhou, C. Zhao, L. Cheng, C. Zhou, M. Qiao, et al., Interleukin-10 is a promising marker for immune-related adverse events in patients with non-small cell lung cancer receiving immunotherapy, Front. Immunol. 13 (2022) 840313.\\n39. C.H. Chang, C.F. Hsiao, Y.M. Yeh, G.C. Chang, Y.H. Tsai, Y.M. Chen, et al., Circulating interleukin-6 level is a prognostic marker for survival in advanced nonsmall cell lung cancer patients treated with chemotherapy, Int. J. Cancer 132 (9) (2013) 1977–1985.\\n40. C. Liu, L. Yang, H. Xu, S. Zheng, Z. Wang, S. Wang, et al., Systematic analysis of IL-6 as a predictive biomarker and desensitizer of immunotherapy responses in patients with non-small cell lung cancer, BMC Med. 20 (1) (2022) 187.\\n41. B. Yuan, M.J. Clowers, W.V. Velasco, S. Peng, Q. Peng, Y. Shi, et al., Targeting IL-1beta as an immunopreventive and therapeutic modality for K-ras-mutant lung cancer, JCI Insight 7 (11) (2022).\\n42. M.F. Sanmamed, J.L. Perez-Gracia, K.A. Schalper, J.P. Fusco, A. Gonzalez, M.E. Rodriguez-Ruiz, et al., Changes in serum interleukin-8 (IL-8) levels reflect and predict response to anti-PD-1 treatment in melanoma and non-small-cell lung cancer patients, Ann. Oncol. 28 (8) (2017) 1988–1995.\\n43. M. Joerger, S.P. Finn, S. Cuffe, A.T. Byrne, S.G. Gray, The IL-17-Th1/Th17 pathway: an attractive target for lung cancer therapy? Expert Opin. Ther. Targets 20 (11) (2016) 1339–1356.\\n44. M.S. Kim, E. Kim, J.S. Heo, D.J. Bae, J.U. Lee, T.H. Lee, et al., Circulating IL-33 level is associated with the progression of lung cancer, Lung Cancer 90 (2) (2015) 346–351.\\n45. P.M. Ridker, J.G. MacFadyen, T. Thuren, B.M. Everett, P. Libby, R.J. Glynn, et al., Effect of interleukin-1beta inhibition with canakinumab on incident lung cancer in patients with atherosclerosis: exploratory results from a randomised, double-blind, placebo-controlled trial, Lancet 390 (10105) (2017) 1833–1842.\\n```', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'),\n", " Document(id_='87753374-b9f2-4911-9a56-1d19ad87010b', embedding=None, metadata={'page_number': 14, 'image_link': None, 'page': 14, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='```markdown\\n# References\\n\\n1. A. Guillon, F. Gueugnon, K. Mavridis, E. Dalloneau, Y. Jouan, P. Diot, et al., Interleukin-22 receptor is overexpressed in nonsmall cell lung cancer and portends a poor prognosis, Eur. Respir. J. 47 (4) (2016) 1277–1280.\\n2. X. Wang, J. Xu, J. Chen, S. Jin, J. Yao, T. Yu, et al., IL-22 confers EGFR-TKI resistance in NSCLC via the AKT and ERK signaling pathways, Front. Oncol. 9 (2019) 1167.\\n3. N. Zabaleta, L. Torella, N.D. Weber, G. Gonzalez-Aseguinolaza, mRNA and gene editing: late breaking therapies in liver diseases, Hepatology 76 (3) (2022) 869–887.\\n4. D.S. Chae, Y.J. Park, S.W. Kim, Anti-arthritogenic property of interleukin 10-expressing human amniotic MSCs generated by gene editing in collagen-induced arthritis, Int. J. Mol. Sci. 23 (14) (2022).\\n5. E. Vermersch, C. Jouve, J.S. Hulot, CRISPR/Cas9 gene-editing strategies in cardiovascular cells, Cardiovasc. Res. 116 (5) (2020) 894–907.\\n6. Q. Wang, X. Liu, J. Zhou, C. Yang, G. Wang, Y. Tan, et al., The CRISPR-Cas13a gene-editing system induces collateral cleavage of RNA in glioma cells, Adv. Sci. 6 (20) (2019) 1901299.\\n7. Y. Lu, J. Xue, T. Deng, X. Zhou, K. Yu, L. Deng, et al., Safety and feasibility of CRISPR-edited T cells in patients with refractory non-small-cell lung cancer, Nat. Med. 26 (5) (2020) 732–740.\\n8. S.M. Hoy, Patisiran: first global approval, Drugs 78 (15) (2018) 1625–1631.\\n9. H. Wood, FDA approves patisiran to treat hereditary transthyretin amyloidosis, Nat. Rev. Neurol. 14 (10) (2018) 570.\\n10. A. Mandal, N. Kumbhojkar, C. Reilly, V. Dharamdasani, A. Ukidve, D.E. Ingber, et al., Treatment of psoriasis with NFKBIZ siRNA using topical ionic liquid formulations, Sci. Adv. 6 (30) (2020) eabb6049.\\n11. T. Fabre, M.F. Molina, G. Soucy, J.P. Goulet, B. Willems, J.P. Villeneuve, et al., Type 3 cytokines IL-17A and IL-22 drive TGF-beta-dependent liver fibrosis, Sci Immunol. 3 (28) (2018).\\n12. C. Su, X. Ren, F. Yang, B. Li, H. Wu, H. Li, et al., Ultrasound-sensitive siRNA-loaded nanobubbles fabrication and antagonism in drug resistance for NSCLC, Drug Deliv. 29 (1) (2022) 99–110.\\n13. M.E. Aikins, C. Xu, J.J. Moon, Engineered nanoparticles for cancer vaccination and immunotherapy, Acc. Chem. Res. 53 (10) (2020) 2094–2105.\\n14. S. Li, S. Xu, X. Liang, Y. Xue, J. Mei, Y. Ma, et al., Nanotechnology: breaking the current treatment limits of lung cancer, Adv. Healthcare Mater. 10 (12) (2021) e2100078.\\n15. T. Zhong, X. Liu, H. Li, J. Zhang, Co-delivery of sorafenib and crizotinib encapsulated with polymeric nanoparticles for the treatment of in vivo lung cancer animal model, Drug Deliv. 28 (1) (2021) 2108–2118.\\n16. M. Zhang, CTt Hagan, H. Foley, X. Tian, F. Yang, K.M. Au, et al., Co-delivery of etoposide and cisplatin in dual-drug loaded nanoparticles synergistically improves chemoradiotherapy in non-small cell lung cancer models, Acta Biomater. 124 (2021) 327–335.\\n```', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n')]" ] }, "execution_count": 47, "metadata": {}, "output_type": "execute_result" } ], "source": [ "documents_with_metadata" ] }, { "cell_type": "code", "execution_count": 48, "metadata": {}, "outputs": [], "source": [ "from llama_index.llms.openai import OpenAI\n", "from llama_index.embeddings.openai import OpenAIEmbedding\n", "from llama_index.core.ingestion import IngestionPipeline\n", "from llama_index.core.node_parser import (\n", " SentenceSplitter,\n", " SemanticSplitterNodeParser,\n", ")\n", "\n", "embed_model = OpenAIEmbedding(model=\"text-embedding-3-large\")\n", "pipeline = IngestionPipeline(\n", " transformations=[\n", " SemanticSplitterNodeParser(\n", " buffer_size=1,\n", " breakpoint_percentile_threshold=95,\n", " embed_model=embed_model,\n", " ),\n", " # topic_extractor,\n", " ]\n", ")\n", "\n", "nodes_with_metadata = pipeline.run(documents=documents_with_metadata)" ] }, { "cell_type": "code", "execution_count": 93, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "page_number: 10\n", "image_link: None\n", "page: 10\n", "title: Jurnal Paru Paru\n", "author: Hamzah\n", "category: Pernapasan\n", "year: 2023\n", "publisher: Multimedika\n", "reference: Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.\n", "\n", "## Data Availability Statement\n", "\n", "Not applicable.\n", "\n", "## CRediT Authorship Contribution Statement\n", "\n", "- Ling Xu: Writing – original draft.\n", "- Peng Cao: Visualization.\n", "- Jianpeng Wang: Writing – review & editing.\n", "- Peng Zhang: Validation.\n", "- Shuhui Hu: Validation.\n", "- Chao Cheng: Writing – review & editing.\n", "- Hua Wang: Writing – review & editing, Supervision, Conceptualization.\n", "\n", "## Declaration of Competing Interest\n", "\n", "The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\n" ] } ], "source": [ "print(nodes_with_metadata[30].get_content(metadata_mode=\"all\"))" ] }, { "cell_type": "markdown", "metadata": {}, "source": [ "# Retriever" ] }, { "cell_type": "code", "execution_count": null, "metadata": {}, "outputs": [], "source": [ "from llama_index.core import Settings\n", "from llama_index.llms.openai import OpenAI\n", "from llama_index.embeddings.openai import OpenAIEmbedding\n", "\n", "embed_model = OpenAIEmbedding(model=\"text-embedding-3-large\")\n", "llm = OpenAI(model=\"gpt-4o-mini\")\n", "\n", "Settings.embed_model = embed_model\n", "Settings.llm = llm" ] }, { "cell_type": "markdown", "metadata": {}, "source": [ "# Vector Store" ] }, { "cell_type": "code", "execution_count": null, "metadata": {}, "outputs": [], "source": [ "import os\n", "from llama_index.core import (\n", " StorageContext,\n", " VectorStoreIndex,\n", " load_index_from_storage,\n", ")\n", "\n", "if not os.path.exists(\"storage_nodes\"):\n", " index = VectorStoreIndex(nodes_with_metadata)\n", " # save index to disk\n", " index.set_index_id(\"vector_index\")\n", " index.storage_context.persist(\"./storage_nodes\")\n", "else:\n", " # rebuild storage context\n", " storage_context = StorageContext.from_defaults(persist_dir=\"storage_nodes\")\n", " # load index\n", " index = load_index_from_storage(storage_context, index_id=\"vector_index\")\n", "\n", "retriever = index.as_retriever()" ] }, { "cell_type": "code", "execution_count": 97, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[NodeWithScore(node=TextNode(id_='0a02cf83-8abf-4649-8ed8-a5b122a84262', embedding=None, metadata={'page_number': 3, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png', 'page': 3, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='d42bb730-5e18-40be-beaf-37066d405b5b', node_type=, metadata={'page_number': 3, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png', 'page': 3, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='f4e4b57abf5f37e76eb424244ded870abf13d31e7e5933830035298e0109655b'), : RelatedNodeInfo(node_id='a0f4cfdc-bbb7-4d3a-9d44-6969a46db292', node_type=, metadata={'page_number': 3, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png', 'page': 3, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='17cd99487344119de2c777b0fc687c85702bd8d6e2231148b7360d7ee74b83f7')}, text='```', mimetype='text/plain', start_char_idx=0, end_char_idx=3, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.34021260990109614),\n", " NodeWithScore(node=TextNode(id_='d8f2b337-9824-457d-ab7a-44325756ef58', embedding=None, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='639e4d98-0b0c-4fd5-a8e3-02469c6a8a6f', node_type=, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='9ff8d774480d557a48cf7b1f0691d936cd820966803fba4a916c1a7002a5a56b'), : RelatedNodeInfo(node_id='76b22bea-51e0-4aba-9f7f-058cd8d76537', node_type=, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='dbdfe3399f77c148ce50e514b961e41f412d878993c1920f1ef2fb3013cd44ea')}, text='[Crispr-cas13-based IL-22 mRNA editing]()\\n```', mimetype='text/plain', start_char_idx=3416, end_char_idx=3485, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.3392627240703643)]" ] }, "execution_count": 97, "metadata": {}, "output_type": "execute_result" } ], "source": [ "nodes = retriever.retrieve('test image')\n", "nodes" ] }, { "cell_type": "code", "execution_count": 98, "metadata": {}, "outputs": [], "source": [ "from llama_index.core.schema import ImageNode, NodeWithScore, MetadataMode\n", "\n", "\n", "nodes = retriever.retrieve('test image')\n", "image_nodes = [\n", " NodeWithScore(node=ImageNode(image_url=n.metadata[\"image_link\"]))\n", " for n in nodes\n", " if \"image_link\" in n.metadata and n.metadata[\"image_link\"]\n", "]" ] }, { "cell_type": "code", "execution_count": 99, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[NodeWithScore(node=TextNode(id_='0a02cf83-8abf-4649-8ed8-a5b122a84262', embedding=None, metadata={'page_number': 3, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png', 'page': 3, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='d42bb730-5e18-40be-beaf-37066d405b5b', node_type=, metadata={'page_number': 3, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png', 'page': 3, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='f4e4b57abf5f37e76eb424244ded870abf13d31e7e5933830035298e0109655b'), : RelatedNodeInfo(node_id='a0f4cfdc-bbb7-4d3a-9d44-6969a46db292', node_type=, metadata={'page_number': 3, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png', 'page': 3, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='17cd99487344119de2c777b0fc687c85702bd8d6e2231148b7360d7ee74b83f7')}, text='```', mimetype='text/plain', start_char_idx=0, end_char_idx=3, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.34021260990109614),\n", " NodeWithScore(node=TextNode(id_='d8f2b337-9824-457d-ab7a-44325756ef58', embedding=None, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='639e4d98-0b0c-4fd5-a8e3-02469c6a8a6f', node_type=, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='9ff8d774480d557a48cf7b1f0691d936cd820966803fba4a916c1a7002a5a56b'), : RelatedNodeInfo(node_id='76b22bea-51e0-4aba-9f7f-058cd8d76537', node_type=, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='dbdfe3399f77c148ce50e514b961e41f412d878993c1920f1ef2fb3013cd44ea')}, text='[Crispr-cas13-based IL-22 mRNA editing]()\\n```', mimetype='text/plain', start_char_idx=3416, end_char_idx=3485, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.3392627240703643)]" ] }, "execution_count": 99, "metadata": {}, "output_type": "execute_result" } ], "source": [ "nodes" ] }, { "cell_type": "code", "execution_count": 100, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[NodeWithScore(node=ImageNode(id_='73e2b9a8-c21b-4e8c-b460-96a3578e722e', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n', image=None, image_path=None, image_url='https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png', image_mimetype=None, text_embedding=None), score=None),\n", " NodeWithScore(node=ImageNode(id_='10fb22d3-29af-4f76-9757-209c5d1562e3', embedding=None, metadata={}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={}, text='', mimetype='text/plain', start_char_idx=None, end_char_idx=None, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n', image=None, image_path=None, image_url='https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', image_mimetype=None, text_embedding=None), score=None)]" ] }, "execution_count": 100, "metadata": {}, "output_type": "execute_result" } ], "source": [ "image_nodes" ] }, { "cell_type": "markdown", "metadata": {}, "source": [ "# Build Multimodal Query Engine" ] }, { "cell_type": "code", "execution_count": null, "metadata": {}, "outputs": [], "source": [ "from llama_index.core.query_engine import CustomQueryEngine, SimpleMultiModalQueryEngine\n", "from llama_index.core.retrievers import BaseRetriever\n", "from llama_index.multi_modal_llms.openai import OpenAIMultiModal\n", "from llama_index.core.schema import ImageNode, NodeWithScore, MetadataMode\n", "from llama_index.core.prompts import PromptTemplate\n", "from llama_index.core.base.response.schema import Response\n", "from typing import Optional\n", "\n", "\n", "gpt_4o = OpenAIMultiModal(model=\"gpt-4o-mini\", max_new_tokens=4096)\n", "\n", "QA_PROMPT_TMPL = \"\"\"\\\n", "\n", "Below is parsed text from books, available in two formats: 'markdown' (which organizes relevant diagrams as tables) and 'raw text' (preserving the rough spatial layout of the original text). Additionally, image references from the book are provided.\n", "\n", "### Instructions:\n", "1. **Use image information as the primary source**: Reference the **image URL** to explain your answer, if possible.\n", "2. **Only use parsed text** (markdown or raw) **if the image does not provide a clear answer**.\n", "3. **Always cite the page number** for any information referenced.\n", "4. **Provide the image inline in the answer** by linking directly to the AWS S3 image URL provided for easy viewing.\n", "\n", "### Example:\n", "**Sources Provided:**\n", "\n", "**Source 1:**\n", "- Page number: 10\n", "- Image URL: `https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p9_1.png`\n", "- Text: \"The sky is red in the evening and blue in the morning. [p-10]\"\n", "\n", "**Source 2:**\n", "- Page number: 11\n", "- Image URL: `https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p10_1.png`\n", "- Text: \"Water is wet when the sky is red. [p-11]\"\n", "\n", "**Query:** When is water wet?\n", "\n", "**Answer:**\n", "Based on the images:\\n\n", "![figure-10](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p9_1.png)\\n\n", "and \\n\n", "![figure-11](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p10_1.png)\\n,\n", "water is wet when the sky is red in the evening [p-10, p-11].\n", "\n", "**Sources Provided:**\n", "Source 1:\n", "\n", "Page number: 15\n", "Image URL: https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p14_1.png\n", "Text: \"Plants grow best in blue light but struggle in red light.\"\n", "Source 2:\n", "\n", "Page number: 16\n", "Image URL: https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p15_1.png\n", "Text: \"Optimal light conditions for plant growth are illustrated in Figure 16.\"\n", "\n", "Query:\n", "What color of light is best for plant growth?\n", "\n", "Answer:\n", "When we look in the image :\\n\n", "![figure-15](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p14_1.png)\n", "\n", "\n", "Plants grow best under blue light, as shown in the color-coded illustration in the image [p-15].\n", "\n", "And the optimal light condition will be shown it the figure : \\n\n", "\n", "![figure-16](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p15_1.png)\n", "\n", "[p-16]\n", "---\n", "\n", "**Now, please answer the following query based on the sources provided:**\n", "\n", "---\n", "\n", "**Sources:**\n", "{context_str}\n", "\n", "**Query:**\n", "{query_str}\n", "\n", "**Answer:**\n", "\n", "\"\"\"\n", "\n", "QA_PROMPT = PromptTemplate(QA_PROMPT_TMPL)\n", "\n", "\n", "class MultimodalQueryEngine(CustomQueryEngine):\n", " \"\"\"Custom multimodal Query Engine.\n", "\n", " Takes in a retriever to retrieve a set of document nodes.\n", " Also takes in a prompt template and multimodal model.\n", "\n", " \"\"\"\n", "\n", " qa_prompt: PromptTemplate\n", " retriever: BaseRetriever\n", " multi_modal_llm: OpenAIMultiModal\n", "\n", " def __init__(self, qa_prompt: Optional[PromptTemplate] = None, **kwargs) -> None:\n", " \"\"\"Initialize.\"\"\"\n", " super().__init__(qa_prompt=qa_prompt or QA_PROMPT, **kwargs)\n", "\n", " def custom_query(self, query_str: str):\n", " # retrieve text nodes\n", " nodes = self.retriever.retrieve(query_str)\n", " # create ImageNode items from text nodes\n", " image_nodes = [\n", " NodeWithScore(node=ImageNode(image_url=n.metadata[\"image_link\"]))\n", " for n in nodes\n", " if \"image_link\" in n.metadata and n.metadata[\"image_link\"] != \"\"\n", " ]\n", " \n", " # image_nodes = [\n", " # NodeWithScore(node=ImageNode(image_url=n.metadata[\"image_link\"]))\n", " # for n in nodes\n", " # ]\n", "\n", " # create context string from text nodes, dump into the prompt\n", " context_str = \"\\n\\n\".join(\n", " [r.get_content(metadata_mode=MetadataMode.LLM) for r in nodes]\n", " )\n", " fmt_prompt = self.qa_prompt.format(context_str=context_str, query_str=query_str)\n", "\n", " # synthesize an answer from formatted text and images\n", " llm_response = self.multi_modal_llm.complete(\n", " prompt=fmt_prompt,\n", " image_documents=[image_node.node for image_node in image_nodes],\n", " )\n", " return Response(\n", " response=str(llm_response),\n", " source_nodes=nodes,\n", " metadata={\"text_nodes\": nodes, \"image_nodes\": image_nodes},\n", " )" ] }, { "cell_type": "code", "execution_count": 139, "metadata": {}, "outputs": [], "source": [ "query_engine = MultimodalQueryEngine(\n", " retriever=index.as_retriever(similarity_top_k=10), multi_modal_llm=gpt_4o\n", ")" ] }, { "cell_type": "markdown", "metadata": {}, "source": [ "# Build Agent" ] }, { "cell_type": "code", "execution_count": 140, "metadata": {}, "outputs": [], "source": [ "from llama_index.core.tools import QueryEngineTool\n", "from llama_index.core.agent import FunctionCallingAgentWorker\n", "\n", "\n", "vector_tool = QueryEngineTool.from_defaults(\n", " query_engine=query_engine,\n", " name=\"vector_tool\",\n", " description=(\n", " \"Useful for retrieving specific context from the data. Do NOT select if question asks for a summary of the data.\"\n", " ),\n", ")\n", "agent = FunctionCallingAgentWorker.from_tools(\n", " [vector_tool], llm=llm, verbose=True\n", ").as_agent()" ] }, { "cell_type": "markdown", "metadata": {}, "source": [ "# Try out Queries" ] }, { "cell_type": "code", "execution_count": 141, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "Added user message to memory: Jelaskan proses Crispr-cas13-based IL-22 mRNA pada figure 4 dengan bahasa indonesia, \n", " \n", " additional instruction:\n", " ** jika menjelaskan gambar, pastikan cantumkan link gambarnya yang ditampilkan di markdown** contoh :\n", " * Based on the images: \n", "\n", "![figure-10](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p9_1.png) --> kamu tetap harus menampilkan tampilan gambar yang di markdown sehingga menjadi : \n", " \n", " Dari gambar : \n", "\n", " ![figure-10](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p9_1.png)\n", "\n", " \n", " **jangan hilangkan halaman page numbernya seperti jika kamu ketemu teks , contoh :**\n", " \n", " * Water is wet when the sky is red. [p-11] --> kamu harus tetap cantumkan [p-11] pada jawaban yang kamu generate \n", " \n", " * source : \n", " page_number : 12\n", " The sky is red in the evening and blue in the morning. --> Kamu harus mengubahnya menjadi sesuai dengan page numbernya atau citationnya sehingga menjadi :\n", " The sky is red in the evening and blue in the morning. [p-12]\n", " \n", "=== Calling Function ===\n", "Calling function: vector_tool with args: {\"input\": \"Crispr-cas13-based IL-22 mRNA figure 4\"}\n", "=== Function Output ===\n", "Based on the provided sources, **Figure 4** illustrates the application of CRISPR-Cas13-based IL-22 mRNA editing for lung cancer therapy. It highlights the combination of CRISPR-Cas13a with emerging technologies such as single-base editing and single-cell sequencing.\n", "\n", "Here is the relevant image for **Figure 4**:\n", "\n", "![figure-4](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png)\n", "\n", "This figure emphasizes the potential of CRISPR-Cas13a in targeting IL-22 mRNA, which could play a significant role in developing therapeutic strategies for lung cancer [p-8].\n", "=== LLM Response ===\n", "Dari gambar:\n", "\n", "![figure-4](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png)\n", "\n", "Gambar ini menggambarkan penerapan pengeditan mRNA IL-22 berbasis CRISPR-Cas13 untuk terapi kanker paru-paru. Gambar ini menyoroti kombinasi CRISPR-Cas13a dengan teknologi baru seperti pengeditan basis tunggal dan pengurutan sel tunggal.\n", "\n", "Gambar ini menekankan potensi CRISPR-Cas13a dalam menargetkan mRNA IL-22, yang dapat memainkan peran penting dalam pengembangan strategi terapeutik untuk kanker paru-paru [p-8].\n" ] } ], "source": [ "prompt = \"Jelaskan proses Crispr-cas13-based IL-22 mRNA pada figure 4 dengan bahasa indonesia\"\n", "query = (\n", " f\"\"\" {prompt}, \n", " \n", " additional instruction:\n", " ** jika menjelaskan gambar, pastikan cantumkan link gambarnya yang ditampilkan di markdown** contoh :\n", " * Based on the images: \\n\n", "![figure-10](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p9_1.png) --> kamu tetap harus menampilkan tampilan gambar yang di markdown sehingga menjadi : \n", " \n", " Dari gambar : \\n\n", " ![figure-10](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p9_1.png)\\n\n", " \n", " **jangan hilangkan halaman page numbernya seperti jika kamu ketemu teks , contoh :**\n", " \n", " * Water is wet when the sky is red. [p-11] --> kamu harus tetap cantumkan [p-11] pada jawaban yang kamu generate \n", " \n", " * source : \n", " page_number : 12\n", " The sky is red in the evening and blue in the morning. --> Kamu harus mengubahnya menjadi sesuai dengan page numbernya atau citationnya sehingga menjadi :\n", " The sky is red in the evening and blue in the morning. [p-12]\n", " \"\"\"\n", ")\n", "response = agent.query(query)" ] }, { "cell_type": "code", "execution_count": 142, "metadata": {}, "outputs": [ { "data": { "text/markdown": [ "Dari gambar:\n", "\n", "![figure-4](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png)\n", "\n", "Gambar ini menggambarkan penerapan pengeditan mRNA IL-22 berbasis CRISPR-Cas13 untuk terapi kanker paru-paru. Gambar ini menyoroti kombinasi CRISPR-Cas13a dengan teknologi baru seperti pengeditan basis tunggal dan pengurutan sel tunggal.\n", "\n", "Gambar ini menekankan potensi CRISPR-Cas13a dalam menargetkan mRNA IL-22, yang dapat memainkan peran penting dalam pengembangan strategi terapeutik untuk kanker paru-paru [p-8]." ], "text/plain": [ "" ] }, "metadata": {}, "output_type": "display_data" } ], "source": [ "from IPython.display import Markdown, display\n", "display(Markdown(str(response)))\n", "# print(str(response))" ] }, { "cell_type": "code", "execution_count": 144, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[NodeWithScore(node=TextNode(id_='76b22bea-51e0-4aba-9f7f-058cd8d76537', embedding=None, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='639e4d98-0b0c-4fd5-a8e3-02469c6a8a6f', node_type=, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='9ff8d774480d557a48cf7b1f0691d936cd820966803fba4a916c1a7002a5a56b'), : RelatedNodeInfo(node_id='96f6e620-7086-4ce8-95b4-eb0bdc2833ae', node_type=, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='a73daf5ae99d39455d113b3f60f7cabdb5e463e1682b2618e617acae3aa5e2f4'), : RelatedNodeInfo(node_id='d8f2b337-9824-457d-ab7a-44325756ef58', node_type=, metadata={}, hash='6ee4b80f1be8e08ef95f66a51450a7420f4df70f201a511d1014c3b7b7e9ce52')}, text='As described previously, reduced intrapulmonary metastasis was found in IL-22-deficient mice as well as in IL-22-suppressed NSCLC cells [20,72]. In addition, blocking IL-22R1 or knockout of the IL-22 gene both retarded the progression of lung cancer [24,94]. These findings provide a new train of thought for the down-regulation of IL-22 in treating lung cancer.\\n\\nIn recent years, the research on gene editing treatment for various diseases has become more and more popular [136–138]. CRISPR-Cas13a is an effective tool for knocking out specific RNA sequences, it has been shown to induce the death of glioma cells that overexpress EGFR, which is one of the subtypes of EGFR mutation in glioma. Apart from this, the CRISPR-Cas13a gene-editing system can also inhibit the formation of intracranial tumors in mice with glioma [139]. In a collagen-induced mouse model, injection of gene-edited human amniotic mesenchymal stem cells that overexpressed IL-10 increased proteoglycan expression in joint tissue and reduced the inflammatory response and production of various inflammatory cytokines [137]. In the world’s first human phase I clinical trial utilizing CRISPR-Cas9 in the treatment of advanced NSCLC, researchers have demonstrated the feasibility and safety of gene-edited T-cell therapy targeting the PD-1 gene [140]. Thus, genome editing strategies have the potential to treat lung cancer by altering IL-22 expression levels. In the future, the role of pulmonary precision delivery based on CRISPR-Cas13 gene-editing components targeting the IL-22 mRNA in lung cancer therapy should not be ignored. CRISPR-Cas13 is expected to be further integrated.\\n\\n## Figure 4\\n\\nCrispr-cas13-based IL-22 mRNA editing can be utilized for lung cancer therapy by combining with emerging technologies such as single-base editing and single-cell sequencing.\\n\\n!', mimetype='text/plain', start_char_idx=1569, end_char_idx=3416, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.5523770514163773),\n", " NodeWithScore(node=TextNode(id_='96f6e620-7086-4ce8-95b4-eb0bdc2833ae', embedding=None, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='639e4d98-0b0c-4fd5-a8e3-02469c6a8a6f', node_type=, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='9ff8d774480d557a48cf7b1f0691d936cd820966803fba4a916c1a7002a5a56b'), : RelatedNodeInfo(node_id='76b22bea-51e0-4aba-9f7f-058cd8d76537', node_type=, metadata={}, hash='f5791dd81e986be09ff24e70b8ec5d1256475c958552409fd97d7c5e1c20590f')}, text='```markdown\\n# Page Content\\n\\nL. Xu et al. Heliyon 10 (2024) e35901\\n\\nThe expression level was correlated with the efficacy of EGFR-TKI in plasma [135]. Therefore, it is reasonable to suspect that IL-22 may be a new biomarker to overcome EGFR-TKI resistance in NSCLC. In terms of animal models, some investigators implanted Line-1 lung cancer cells into wild-type and IL-22-deficient mice simultaneously, and found reduced intrapulmonary metastasis in the latter group, which is independent of primary tumor size. Besides, they performed forced metastasis by intravenous injection of lung cancer cells, and the results further confirmed the lower metastatic load in mice with IL-22 deletion [72]. In another model of Kras-mutated lung cancer in mice, gene ablation of IL-22 resulted in a marked reduction in tumor number and size. The authors also analyzed the association between IL-22R1 expression and survival in patients with KRAS mutant lung adenocarcinoma, the results showed that high expression of IL-22R1 was an independent indicator of poorer relapse-free survival [94]. Taken together, these pieces of evidence highlight the potential clinical role of IL-22, IL-22R, and IL-22-producing cells in the treatment of lung cancer (Table 2).\\n\\n## Future Perspectives\\n\\n### CRISPR-Cas13a Technical\\n\\nAt present, mounting clinical trials based on IL-22 are being carried out in full swing worldwide, mainly involving ulcerative colitis, alcoholic cirrhosis, GVHD, and psoriasis [12,14,54,60]. However, there are presently no clinical trials based on IL-22 in lung cancer. ', mimetype='text/plain', start_char_idx=0, end_char_idx=1569, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.4992012810266958),\n", " NodeWithScore(node=TextNode(id_='d8f2b337-9824-457d-ab7a-44325756ef58', embedding=None, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='639e4d98-0b0c-4fd5-a8e3-02469c6a8a6f', node_type=, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='9ff8d774480d557a48cf7b1f0691d936cd820966803fba4a916c1a7002a5a56b'), : RelatedNodeInfo(node_id='76b22bea-51e0-4aba-9f7f-058cd8d76537', node_type=, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='dbdfe3399f77c148ce50e514b961e41f412d878993c1920f1ef2fb3013cd44ea')}, text='[Crispr-cas13-based IL-22 mRNA editing]()\\n```', mimetype='text/plain', start_char_idx=3416, end_char_idx=3485, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.4837079234927595),\n", " NodeWithScore(node=TextNode(id_='783e337e-c8d9-4ff6-8c99-9ca4d778c9cc', embedding=None, metadata={'page_number': 4, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png', 'page': 4, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='a0c7f4da-b86c-4fe1-8e2b-dd28a72c169c', node_type=, metadata={'page_number': 4, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png', 'page': 4, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='216973f6992af692845c18a0861c9a3b302693fa7306c27bedb54528bf3686c0'), : RelatedNodeInfo(node_id='187ed8b7-6729-479c-af3c-fcc830886498', node_type=, metadata={'page_number': 4, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png', 'page': 4, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='9956f4c5a7f72f0477d80a35fc505f8bdc6e8d336d1d7e298f366e4439e4fa30')}, text='In the occurrence and development of pulmonary diseases, IL-22 is considered to play an important role. As previously demonstrated in an epicutaneously sensitized mice experiment, IL-22 promotes the development of neutrophil and eosinophile-mediated airway inflammation and airway hyperresponsiveness stimulated by intranasal antigens [76]. The conclusion implies that blocking IL-22 may be helpful for the treatment of bronchial asthma. When it comes to chronic obstructive pulmonary disease (COPD), the expression levels of both IL-22 and its receptor in COPD patients were higher than those of healthy controls. This result was confirmed in mice with experimental COPD induced by cigarette smoke. What’s more, researchers also found that cigarette smoke-induced inappropriate activation of pulmonary neutrophils decreased in IL-22-deficient mice with COPD. This suggests that IL-22 may be involved in the pathogenesis of COPD. The research further manifested that IL-22 promotes cigarette smoke-induced airway remodeling, pulmonary neutrophil inflammation, and the impairment of pulmonary function, and is involved in the pathogenesis of COPD [77]. While in pulmonary infectious diseases such as pneumonia, tuberculosis, and pulmonary mycosis, it is thought that IL-22 appears to take a protective and preventive part [78–83]. For good measure, in the bleomycin-induced pulmonary fibrosis model, the degree of pulmonary fibrosis in IL-22 knockout mice was aggravated, and injection of recombinant IL-22 alleviated the severe fibrosis in IL-22 knockout mice. This latest research has suggested the potential antifibrotic effect of IL-22 [84].\\n\\nIn recent years, differential expression of IL-22 has also been discovered in various specimens of lung cancer (Table 1). In the first place, the mean levels of IL-22 in the plasma of NSCLC patients were significantly higher than that of the reference cohort [21,85]. The plasma levels of IL-22 were observed to elevate along with the increase in lung cancer staging [85]. In addition, Immunohistochemistry analysis showed that IL-22 expression was up-regulated in NSCLC tumor specimens in comparison to that in the adjacent tissues. RT-qPCR analysis also revealed similar differences in IL-22 mRNA expression between lung cancer tissues and normal tissues [24,86]. Interestingly, Yi Bi et al. compared IL-22 levels between tissues and serum of patients with primary NSCLC and their paired recurrent lung cancer specimens and the expression levels of IL-22 were found to be obviously up-regulated in the latter group [23]. Apart from this, IL-22 expression was also detected in bronchoalveolar lavage fluid (BALF). As reported by an article in 2016, IL-22 levels were .\\n\\n## Figure Description\\n\\n**Figure 2**: IL-22 induces NK cells to overexpress CD155, which binds to NK cell activation receptor CD226. Over-activation leads to a decrease in the amount of CD226 and impaired NK cell function, thereby mediating tumor cell immune escape.\\n\\n- **Summary**: This figure illustrates the mechanism by which IL-22 influences NK cell activity through the overexpression of CD155, leading to immune evasion by tumor cells. The diagram likely includes arrows indicating the interactions between IL-22, NK cells, and CD155, as well as the resulting effects on immune function.\\n```', mimetype='text/plain', start_char_idx=1588, end_char_idx=4926, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.46097483331812655),\n", " NodeWithScore(node=TextNode(id_='e3fb9d7f-09e7-468b-b277-bd64109763b1', embedding=None, metadata={'page_number': 9, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png', 'page': 9, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. 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Multimedika.'}, hash='02395df71225386b793eb870f51f5ff4d508a360bb6258e7fc5b565eb7faba87'), : RelatedNodeInfo(node_id='55d32031-0898-413b-b41c-06944850b55e', node_type=, metadata={}, hash='987928d388551bb87aaaa7fc84ccd48a139c6c9fad8823433ac48c8905de495a')}, text='NFKBIZ is an upstream target of IL-23, IL-36, and IL-17A. In the study of Mandal A et al. [143], NFKBIZ-siRNA significantly reduces the mRNA levels of multiple pro-inflammatory cytokines, including IL-17, IL-19, IL-22, etc., in the skin tissue of psoriasis mice, thereby alleviating the condition of the mice. The safety evaluation results of NFKBIZ-siRNA preparations show that NFKBIZ-siRNA preparations can complex with nucleic acids without affecting biological activity and show no toxicity. TGF-β is a pleiotropic regulatory cytokine that can regulate a variety of ILs including IL-22 and IL-17 to affect the composition of the tumor microenvironment [144]. Currently, Sirnaomics has developed an siRNA drug that targets TGF-β (called STP705). Recently, the drug has completed phase II clinical trials in the United States and achieved positive results. ', mimetype='text/plain', start_char_idx=1211, end_char_idx=2070, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.4601137006408929),\n", " NodeWithScore(node=TextNode(id_='73d1261c-5a36-494b-a8d1-82717662feb8', embedding=None, metadata={'page_number': 3, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p2_1.png', 'page': 3, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. 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Different from other common cytokines, IL-22 is generally thought to be produced only by hematopoietic origin immune cells, whereas it mainly acts on non-hematopoietic cells due to its receptor distribution [55]. Recently, researchers have found that non-hematopoietic cells represented by fibroblasts can also produce IL-22 under certain circumstances [11]. IL-22 is known to act by binding to its receptor (IL-22R), which is synthesized from the IL-22R1 and IL-10R2 subunits [56]. Thereinto, IL-22R1 expression is thought to be restricted to epithelial cells in organs such as the lung, liver, intestine, and skin, while the latter is universally expressed [11,57]. IL-22BP, also known as IL-22RA2, is a soluble IL-22 receptor that binds specifically to IL-22 and prevents it from binding to IL-22R1. All currently known functions of IL-22BP are achieved by inhibiting IL-22 [58,59]. Broadly speaking, the primary function of IL-22 in the body is to promote cell proliferation and tissue protection [60]. Sometimes, excessive activation of this function may lead to pathological results. This dual effect is reflected in both inflammatory and tumor-related diseases. In the short term, the production of IL-22 can play a protective role in anti-inflammatory and tumor prevention, while the uncontrolled generation of IL-22 may promote inflammation and tumor formation [13,18]. The duality of IL-22 reveals that it could be a potential drug target, and the tight regulation of IL-22 is crucial in the treatment of a variety of diseases.\\n\\nIn general, the expression levels of IL-22 in vivo are regulated by a variety of cytokines and genes. For instance, IL-1β and IL-23 can induce the production of IL-22 independently, and the two act synergistically [11]. What’s more, Cornelia Voigt described a novel mechanism whereby cancer cells promote tumor growth by releasing IL-1β to induce IL-22 production by memory CD4+ T cells [61]. According to an animal experiment, IL-1β can enhance the proliferation of epithelial cells and promote lung tumorigenesis [62]. IL-23 has been proven to promote proliferation in NSCLC by Anne-Marie Baird et al. [63]. Although IL-23 is thought to be able to induce macrophages to produce IL-22, this study by Anne-Marie Baird et al. cannot directly prove whether the proliferation-promoting effect of IL-23 on NSCLC cells is related to IL-23’s promotion of IL-22 production. IL-23 is also thought to promote the expression of IL-26 by macrophages. Like IL-22, IL-26 is part of the IL-10 family. Researchers demonstrated for the first time that IL-26 is involved in the generation of malignant pleural effusions [64]. They reported that IL-26 promotes the generation of malignant pleural effusion by mediating the infiltration of CD4+IL-22+T cells in malignant pleural effusion and stimulating CD4+ IL-22+ T cells to secrete IL-22. Recently, the Notch-AhR-IL-22 axis is thought to be involved in the pathogenesis of LUAD. It is corroborated that in LUAD patients, elevated Notch1 facilitates IL-22 generation by CD4+ T cells via aryl hydrocarbon receptors (AhR) [65]. In NSCLC, Notch signaling can both promote tumorigenesis and inhibit tumor progression, which mainly depends on its regulation of the.\\n\\n### Figure 1\\nIL-22 plays four main functions during the progression of lung cancer:\\n1. Promote lung cancer cell proliferation and invasion, and inhibit lung cancer cell apoptosis.\\n', mimetype='text/plain', start_char_idx=0, end_char_idx=3596, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.45988006131315323),\n", " NodeWithScore(node=TextNode(id_='187ed8b7-6729-479c-af3c-fcc830886498', embedding=None, metadata={'page_number': 4, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png', 'page': 4, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. 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Multimedika.'}, hash='2428241601979a6d78b483ea4173c0e34fb923b0ddbe59aa1299eeece05b58bd'), : RelatedNodeInfo(node_id='783e337e-c8d9-4ff6-8c99-9ca4d778c9cc', node_type=, metadata={}, hash='f5b67364dee5ac5ddee1e30aac44c8dc7b9ef598c0c9307ece44105c848954d1')}, text='Studies have shown that the production of IL-22 generally reduces Th1-type immune responses. This action may be coordinated with the protective effect of IL-22R-expressing tissue cells to reduce collateral damage in the context of infection and inflammation [69]. Besides, animal experiments have indicated that IL-22 can also promote B-cell responses by inducing CXCL13 in tertiary lymphoid follicles [70,71]. In the latest murine lung cancer model, IL-22 was discovered to induce NK cells to overexpress CD155, thus mediating the immune evasion of tumor cells [72]. As a transmembrane adhesive molecule, CD155 has been proven to inhibit T and NK cell-mediated anti-tumor immune responses, thereby promoting tumor progression (Fig. 2) [73–75].\\n\\n', mimetype='text/plain', start_char_idx=842, end_char_idx=1588, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.4485697801580606),\n", " NodeWithScore(node=TextNode(id_='55d32031-0898-413b-b41c-06944850b55e', embedding=None, metadata={'page_number': 9, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png', 'page': 9, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. 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Multimedika.'}, hash='3459a55e6e59cac0e62cfe57733ee9e86a8b2f0a90eddc289731bd56802680ea')}, text='The role of ILs in cancer has been extensively studied. In recent years, the positive role of IL-22 in lung cancer has received attention. The researchers believe that knocking down IL-22 mRNA levels in the lesions of lung cancer patients will help prolong the survival of lung cancer patients and improve the cure rate of lung cancer patients. For example, Zhang Wei et al. found that IL-22-siRNA slowed tumor growth in NSCLC model mice. In addition, they reported that the therapeutic effect of IL-22-siRNA combined with chemotherapy drugs (5-FU and carboplatin) on NSCLC mice was better than that of chemotherapy drugs alone [24]. In an in vitro assay [145], cell line PC9 cells (NSCLC) transfected with PDLIM5-siRNA targeting the PDLIM5 gene had reduced growth viability and exhibited higher apoptotic rates. In the chemotherapy drug gefitinib-resistant cell line PC9 cells, PDLIM5-siRNA still showed significant anti-tumor effects. These results indicate that siRNA-based therapy has good application in the clinical treatment of NSCLC, especially in drug-resistant patients. Based on these findings, we believe that the development of IL-22-siRNA drugs for lung cancer treatment has clinical potential and theoretical basis.\\n\\n## 6.3. Nanoparticle drug delivery systems\\n\\nOn the other hand, given the toxicity and erratic efficacy of current anti-tumor drugs, research on novel drug carriers in lung cancer is ongoing.\\n\\n### Figure 5\\n**Caption:** Precision delivery of various nanomaterials containing IL-22 related drugs for the treatment of lung cancer.\\n\\n**Description:** Figure 5 illustrates the precision delivery of various types of nanomaterials that are designed to carry IL-22 related drugs specifically for lung cancer treatment. The diagram likely includes different types of nanoparticles and their targeting mechanisms, emphasizing the advancements in drug delivery systems aimed at improving therapeutic outcomes in lung cancer patients.\\n```', mimetype='text/plain', start_char_idx=2070, end_char_idx=4027, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.4458408940616319),\n", " NodeWithScore(node=TextNode(id_='af550301-0a45-4410-bf98-98c0aea9b6b5', embedding=None, metadata={'page_number': 14, 'image_link': None, 'page': 14, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. 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Multimedika.'}, hash='e4b4a681c4570ef6a12eeda6104d0cafce5d8dfefdcab875f1a4c63bcbcf00cf'), : RelatedNodeInfo(node_id='5a1ee8cc-98b2-474c-ba55-105f40f0fa73', node_type=, metadata={}, hash='d04083ff1e928a5562b76a474b0fe752c289ddb7f52759e603a20c7fc56ede9a')}, text='D.S. Chae, Y.J. Park, S.W. Kim, Anti-arthritogenic property of interleukin 10-expressing human amniotic MSCs generated by gene editing in collagen-induced arthritis, Int. J. Mol. Sci. 23 (14) (2022).\\n5. E. Vermersch, C. Jouve, J.S. Hulot, CRISPR/Cas9 gene-editing strategies in cardiovascular cells, Cardiovasc. Res. 116 (5) (2020) 894–907.\\n6. Q. Wang, X. Liu, J. Zhou, C. Yang, G. Wang, Y. Tan, et al., The CRISPR-Cas13a gene-editing system induces collateral cleavage of RNA in glioma cells, Adv. Sci. 6 (20) (2019) 1901299.\\n7. Y. Lu, J. Xue, T. Deng, X. Zhou, K. Yu, L. Deng, et al., Safety and feasibility of CRISPR-edited T cells in patients with refractory non-small-cell lung cancer, Nat. Med. 26 (5) (2020) 732–740.\\n8. ', mimetype='text/plain', start_char_idx=590, end_char_idx=1317, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.43834732475104),\n", " NodeWithScore(node=TextNode(id_='61176e79-6d6c-412d-aaad-a4e15850fb5a', embedding=None, metadata={'page_number': 11, 'image_link': None, 'page': 11, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='6ae836ff-d0eb-4749-8de0-f687c0c08d31', node_type=, metadata={'page_number': 11, 'image_link': None, 'page': 11, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='c21d4417269c923110cf31f78ff89010c410b64858ffb462d3bc205f49c2184a'), : RelatedNodeInfo(node_id='3e659843-216a-44f8-8e3c-f40ecd9fa3f6', node_type=, metadata={'page_number': 11, 'image_link': None, 'page': 11, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='39296bd53f5e0af9a87a3b87512779716c4bf236d0ad8c0c0a59d911bf5d5b7d'), : RelatedNodeInfo(node_id='f67fb982-5053-46ed-a6d2-308b2246e621', node_type=, metadata={}, hash='cb6d8e77d1d809e3c4a4841700eaf1a9e88bfca9f30ce0e92db6a1bdc72e9222')}, text='R.A. Nagem, D. Colau, L. Dumoutier, J.C. Renauld, C. Ogata, I. Polikarpov, Crystal structure of recombinant human interleukin-22, *Structure* 10 (8) (2002) 1051–1062.\\n10. D. Lejeune, L. Dumoutier, S. Constantinescu, W. Kruijer, J.J. Schuringa, J.C. Renauld, Interleukin-22 (IL-22) activates the JAK/STAT, ERK, JNK, and p38 MAP kinase pathways in a rat hepatoma cell line. Pathways that are shared with and distinct from IL-10, *J. Biol. Chem.* 277 (37) (2002) 33676–33682.\\n11. J.A. Dudakov, A.M. Hanash, M.R. van den Brink, Interleukin-22: immunobiology and pathology, *Annu. Rev. Immunol.* 33 (2015) 747–785.\\n12. Lanfranca M. Perusina, Y. Lin, J. Fang, W. Zou, T. Frankel, Biological and pathological activities of interleukin-22, *J. Mol. Med. (Berl.)* 94 (5) (2016) 523–534.\\n13. L.A. Zenewicz, R.A. Flavell, Recent advances in IL-22 biology, *Int. Immunol.* 23 (3) (2011) 159–163.\\n14. Y. Wu, J. Min, C. Ge, J. Shu, D. Tian, Y. Yuan, et al., Interleukin 22 in liver injury, inflammation and cancer, *Int. J. Biol. Sci.* 16 (13) (2020) 2405–2413.\\n15. Y. Zhu, T. Shi, X. Lu, Z. Xu, J. Qu, Z. Zhang, et al., Fungal-induced glycolysis in macrophages promotes colon cancer by enhancing innate lymphoid cell secretion of IL-22, *EMBO J.* 40 (11) (2021) e105320.\\n16. A.D. Giannou, J. Lucke, D. Kleinschmidt, A.M. Shiri, B. Steglich, M. Nawrocki, et al., A critical role of the IL-22-IL-22 binding protein Axis in hepatocellular carcinoma, *Cancers* 14 (24) (2022).\\n17. X. Xuan, J. Zhou, Z. Tian, Y. Lin, J. Song, Z. Ruan, et al., ILC3 cells promote the proliferation and invasion of pancreatic cancer cells through IL-22/AKT signaling, *Clin. Transl. Oncol.* 22 (4) (2020) 563–575.\\n18. L.G. Perez, J. Kempski, H.M. McGee, P. Pelzcar, T. Agalioti, A. Giannou, et al., TGF-beta signaling in Th17 cells promotes IL-22 production and colitis-associated colon cancer, *Nat. Commun.', mimetype='text/plain', start_char_idx=1714, end_char_idx=3585, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.41315716968880384)]" ] }, "execution_count": 144, "metadata": {}, "output_type": "execute_result" } ], "source": [ "response.source_nodes" ] }, { "cell_type": "code", "execution_count": 145, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "page_number: 8\n", "image_link: https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png\n", "page: 8\n", "title: Jurnal Paru Paru\n", "author: Hamzah\n", "category: Pernapasan\n", "year: 2023\n", "publisher: Multimedika\n", "reference: Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.\n", "\n", "As described previously, reduced intrapulmonary metastasis was found in IL-22-deficient mice as well as in IL-22-suppressed NSCLC cells [20,72]. In addition, blocking IL-22R1 or knockout of the IL-22 gene both retarded the progression of lung cancer [24,94]. These findings provide a new train of thought for the down-regulation of IL-22 in treating lung cancer.\n", "\n", "In recent years, the research on gene editing treatment for various diseases has become more and more popular [136–138]. CRISPR-Cas13a is an effective tool for knocking out specific RNA sequences, it has been shown to induce the death of glioma cells that overexpress EGFR, which is one of the subtypes of EGFR mutation in glioma. Apart from this, the CRISPR-Cas13a gene-editing system can also inhibit the formation of intracranial tumors in mice with glioma [139]. In a collagen-induced mouse model, injection of gene-edited human amniotic mesenchymal stem cells that overexpressed IL-10 increased proteoglycan expression in joint tissue and reduced the inflammatory response and production of various inflammatory cytokines [137]. In the world’s first human phase I clinical trial utilizing CRISPR-Cas9 in the treatment of advanced NSCLC, researchers have demonstrated the feasibility and safety of gene-edited T-cell therapy targeting the PD-1 gene [140]. Thus, genome editing strategies have the potential to treat lung cancer by altering IL-22 expression levels. In the future, the role of pulmonary precision delivery based on CRISPR-Cas13 gene-editing components targeting the IL-22 mRNA in lung cancer therapy should not be ignored. CRISPR-Cas13 is expected to be further integrated.\n", "\n", "## Figure 4\n", "\n", "Crispr-cas13-based IL-22 mRNA editing can be utilized for lung cancer therapy by combining with emerging technologies such as single-base editing and single-cell sequencing.\n", "\n", "!\n" ] } ], "source": [ "print(response.source_nodes[0].get_content(metadata_mode=\"all\"))" ] }, { "cell_type": "code", "execution_count": 108, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "[NodeWithScore(node=TextNode(id_='76b22bea-51e0-4aba-9f7f-058cd8d76537', embedding=None, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='639e4d98-0b0c-4fd5-a8e3-02469c6a8a6f', node_type=, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='9ff8d774480d557a48cf7b1f0691d936cd820966803fba4a916c1a7002a5a56b'), : RelatedNodeInfo(node_id='96f6e620-7086-4ce8-95b4-eb0bdc2833ae', node_type=, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='a73daf5ae99d39455d113b3f60f7cabdb5e463e1682b2618e617acae3aa5e2f4'), : RelatedNodeInfo(node_id='d8f2b337-9824-457d-ab7a-44325756ef58', node_type=, metadata={}, hash='6ee4b80f1be8e08ef95f66a51450a7420f4df70f201a511d1014c3b7b7e9ce52')}, text='As described previously, reduced intrapulmonary metastasis was found in IL-22-deficient mice as well as in IL-22-suppressed NSCLC cells [20,72]. In addition, blocking IL-22R1 or knockout of the IL-22 gene both retarded the progression of lung cancer [24,94]. These findings provide a new train of thought for the down-regulation of IL-22 in treating lung cancer.\\n\\nIn recent years, the research on gene editing treatment for various diseases has become more and more popular [136–138]. CRISPR-Cas13a is an effective tool for knocking out specific RNA sequences, it has been shown to induce the death of glioma cells that overexpress EGFR, which is one of the subtypes of EGFR mutation in glioma. Apart from this, the CRISPR-Cas13a gene-editing system can also inhibit the formation of intracranial tumors in mice with glioma [139]. In a collagen-induced mouse model, injection of gene-edited human amniotic mesenchymal stem cells that overexpressed IL-10 increased proteoglycan expression in joint tissue and reduced the inflammatory response and production of various inflammatory cytokines [137]. In the world’s first human phase I clinical trial utilizing CRISPR-Cas9 in the treatment of advanced NSCLC, researchers have demonstrated the feasibility and safety of gene-edited T-cell therapy targeting the PD-1 gene [140]. Thus, genome editing strategies have the potential to treat lung cancer by altering IL-22 expression levels. In the future, the role of pulmonary precision delivery based on CRISPR-Cas13 gene-editing components targeting the IL-22 mRNA in lung cancer therapy should not be ignored. CRISPR-Cas13 is expected to be further integrated.\\n\\n## Figure 4\\n\\nCrispr-cas13-based IL-22 mRNA editing can be utilized for lung cancer therapy by combining with emerging technologies such as single-base editing and single-cell sequencing.\\n\\n!', mimetype='text/plain', start_char_idx=1569, end_char_idx=3416, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.6268507408328755), NodeWithScore(node=TextNode(id_='d8f2b337-9824-457d-ab7a-44325756ef58', embedding=None, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. 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Multimedika.'}, hash='dbdfe3399f77c148ce50e514b961e41f412d878993c1920f1ef2fb3013cd44ea')}, text='[Crispr-cas13-based IL-22 mRNA editing]()\\n```', mimetype='text/plain', start_char_idx=3416, end_char_idx=3485, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.5910267721934587), NodeWithScore(node=TextNode(id_='96f6e620-7086-4ce8-95b4-eb0bdc2833ae', embedding=None, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='639e4d98-0b0c-4fd5-a8e3-02469c6a8a6f', node_type=, metadata={'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p7_1.png', 'page': 8, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='9ff8d774480d557a48cf7b1f0691d936cd820966803fba4a916c1a7002a5a56b'), : RelatedNodeInfo(node_id='76b22bea-51e0-4aba-9f7f-058cd8d76537', node_type=, metadata={}, hash='f5791dd81e986be09ff24e70b8ec5d1256475c958552409fd97d7c5e1c20590f')}, text='```markdown\\n# Page Content\\n\\nL. Xu et al. Heliyon 10 (2024) e35901\\n\\nThe expression level was correlated with the efficacy of EGFR-TKI in plasma [135]. Therefore, it is reasonable to suspect that IL-22 may be a new biomarker to overcome EGFR-TKI resistance in NSCLC. In terms of animal models, some investigators implanted Line-1 lung cancer cells into wild-type and IL-22-deficient mice simultaneously, and found reduced intrapulmonary metastasis in the latter group, which is independent of primary tumor size. Besides, they performed forced metastasis by intravenous injection of lung cancer cells, and the results further confirmed the lower metastatic load in mice with IL-22 deletion [72]. In another model of Kras-mutated lung cancer in mice, gene ablation of IL-22 resulted in a marked reduction in tumor number and size. The authors also analyzed the association between IL-22R1 expression and survival in patients with KRAS mutant lung adenocarcinoma, the results showed that high expression of IL-22R1 was an independent indicator of poorer relapse-free survival [94]. Taken together, these pieces of evidence highlight the potential clinical role of IL-22, IL-22R, and IL-22-producing cells in the treatment of lung cancer (Table 2).\\n\\n## Future Perspectives\\n\\n### CRISPR-Cas13a Technical\\n\\nAt present, mounting clinical trials based on IL-22 are being carried out in full swing worldwide, mainly involving ulcerative colitis, alcoholic cirrhosis, GVHD, and psoriasis [12,14,54,60]. However, there are presently no clinical trials based on IL-22 in lung cancer. ', mimetype='text/plain', start_char_idx=0, end_char_idx=1569, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.5625273829466113), NodeWithScore(node=TextNode(id_='af550301-0a45-4410-bf98-98c0aea9b6b5', embedding=None, metadata={'page_number': 14, 'image_link': None, 'page': 14, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='87753374-b9f2-4911-9a56-1d19ad87010b', node_type=, metadata={'page_number': 14, 'image_link': None, 'page': 14, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='abfb1abe40d423232b7713fefe7591c79ab2d0243c8ade5185c59bd0d28a3244'), : RelatedNodeInfo(node_id='ad6a0525-d1cc-49ab-9f9b-0a209297241e', node_type=, metadata={'page_number': 14, 'image_link': None, 'page': 14, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='e4b4a681c4570ef6a12eeda6104d0cafce5d8dfefdcab875f1a4c63bcbcf00cf'), : RelatedNodeInfo(node_id='5a1ee8cc-98b2-474c-ba55-105f40f0fa73', node_type=, metadata={}, hash='d04083ff1e928a5562b76a474b0fe752c289ddb7f52759e603a20c7fc56ede9a')}, text='D.S. Chae, Y.J. Park, S.W. Kim, Anti-arthritogenic property of interleukin 10-expressing human amniotic MSCs generated by gene editing in collagen-induced arthritis, Int. J. Mol. Sci. 23 (14) (2022).\\n5. E. Vermersch, C. Jouve, J.S. Hulot, CRISPR/Cas9 gene-editing strategies in cardiovascular cells, Cardiovasc. Res. 116 (5) (2020) 894–907.\\n6. Q. Wang, X. Liu, J. Zhou, C. Yang, G. Wang, Y. Tan, et al., The CRISPR-Cas13a gene-editing system induces collateral cleavage of RNA in glioma cells, Adv. Sci. 6 (20) (2019) 1901299.\\n7. Y. Lu, J. Xue, T. Deng, X. Zhou, K. Yu, L. Deng, et al., Safety and feasibility of CRISPR-edited T cells in patients with refractory non-small-cell lung cancer, Nat. Med. 26 (5) (2020) 732–740.\\n8. ', mimetype='text/plain', start_char_idx=590, end_char_idx=1317, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.5416033343925973), NodeWithScore(node=TextNode(id_='187ed8b7-6729-479c-af3c-fcc830886498', embedding=None, metadata={'page_number': 4, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png', 'page': 4, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='a0c7f4da-b86c-4fe1-8e2b-dd28a72c169c', node_type=, metadata={'page_number': 4, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png', 'page': 4, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='216973f6992af692845c18a0861c9a3b302693fa7306c27bedb54528bf3686c0'), : RelatedNodeInfo(node_id='5e0c56bf-0b21-4551-ad51-1794e3b373d5', node_type=, metadata={'page_number': 4, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png', 'page': 4, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='2428241601979a6d78b483ea4173c0e34fb923b0ddbe59aa1299eeece05b58bd'), : RelatedNodeInfo(node_id='783e337e-c8d9-4ff6-8c99-9ca4d778c9cc', node_type=, metadata={}, hash='f5b67364dee5ac5ddee1e30aac44c8dc7b9ef598c0c9307ece44105c848954d1')}, text='Studies have shown that the production of IL-22 generally reduces Th1-type immune responses. This action may be coordinated with the protective effect of IL-22R-expressing tissue cells to reduce collateral damage in the context of infection and inflammation [69]. Besides, animal experiments have indicated that IL-22 can also promote B-cell responses by inducing CXCL13 in tertiary lymphoid follicles [70,71]. In the latest murine lung cancer model, IL-22 was discovered to induce NK cells to overexpress CD155, thus mediating the immune evasion of tumor cells [72]. As a transmembrane adhesive molecule, CD155 has been proven to inhibit T and NK cell-mediated anti-tumor immune responses, thereby promoting tumor progression (Fig. 2) [73–75].\\n\\n', mimetype='text/plain', start_char_idx=842, end_char_idx=1588, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.5393980773302611), NodeWithScore(node=TextNode(id_='783e337e-c8d9-4ff6-8c99-9ca4d778c9cc', embedding=None, metadata={'page_number': 4, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png', 'page': 4, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='a0c7f4da-b86c-4fe1-8e2b-dd28a72c169c', node_type=, metadata={'page_number': 4, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png', 'page': 4, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='216973f6992af692845c18a0861c9a3b302693fa7306c27bedb54528bf3686c0'), : RelatedNodeInfo(node_id='187ed8b7-6729-479c-af3c-fcc830886498', node_type=, metadata={'page_number': 4, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p3_1.png', 'page': 4, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='9956f4c5a7f72f0477d80a35fc505f8bdc6e8d336d1d7e298f366e4439e4fa30')}, text='In the occurrence and development of pulmonary diseases, IL-22 is considered to play an important role. As previously demonstrated in an epicutaneously sensitized mice experiment, IL-22 promotes the development of neutrophil and eosinophile-mediated airway inflammation and airway hyperresponsiveness stimulated by intranasal antigens [76]. The conclusion implies that blocking IL-22 may be helpful for the treatment of bronchial asthma. When it comes to chronic obstructive pulmonary disease (COPD), the expression levels of both IL-22 and its receptor in COPD patients were higher than those of healthy controls. This result was confirmed in mice with experimental COPD induced by cigarette smoke. What’s more, researchers also found that cigarette smoke-induced inappropriate activation of pulmonary neutrophils decreased in IL-22-deficient mice with COPD. This suggests that IL-22 may be involved in the pathogenesis of COPD. The research further manifested that IL-22 promotes cigarette smoke-induced airway remodeling, pulmonary neutrophil inflammation, and the impairment of pulmonary function, and is involved in the pathogenesis of COPD [77]. While in pulmonary infectious diseases such as pneumonia, tuberculosis, and pulmonary mycosis, it is thought that IL-22 appears to take a protective and preventive part [78–83]. For good measure, in the bleomycin-induced pulmonary fibrosis model, the degree of pulmonary fibrosis in IL-22 knockout mice was aggravated, and injection of recombinant IL-22 alleviated the severe fibrosis in IL-22 knockout mice. This latest research has suggested the potential antifibrotic effect of IL-22 [84].\\n\\nIn recent years, differential expression of IL-22 has also been discovered in various specimens of lung cancer (Table 1). In the first place, the mean levels of IL-22 in the plasma of NSCLC patients were significantly higher than that of the reference cohort [21,85]. The plasma levels of IL-22 were observed to elevate along with the increase in lung cancer staging [85]. In addition, Immunohistochemistry analysis showed that IL-22 expression was up-regulated in NSCLC tumor specimens in comparison to that in the adjacent tissues. RT-qPCR analysis also revealed similar differences in IL-22 mRNA expression between lung cancer tissues and normal tissues [24,86]. Interestingly, Yi Bi et al. compared IL-22 levels between tissues and serum of patients with primary NSCLC and their paired recurrent lung cancer specimens and the expression levels of IL-22 were found to be obviously up-regulated in the latter group [23]. Apart from this, IL-22 expression was also detected in bronchoalveolar lavage fluid (BALF). As reported by an article in 2016, IL-22 levels were .\\n\\n## Figure Description\\n\\n**Figure 2**: IL-22 induces NK cells to overexpress CD155, which binds to NK cell activation receptor CD226. Over-activation leads to a decrease in the amount of CD226 and impaired NK cell function, thereby mediating tumor cell immune escape.\\n\\n- **Summary**: This figure illustrates the mechanism by which IL-22 influences NK cell activity through the overexpression of CD155, leading to immune evasion by tumor cells. The diagram likely includes arrows indicating the interactions between IL-22, NK cells, and CD155, as well as the resulting effects on immune function.\\n```', mimetype='text/plain', start_char_idx=1588, end_char_idx=4926, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.5371243866376708), NodeWithScore(node=TextNode(id_='e3fb9d7f-09e7-468b-b277-bd64109763b1', embedding=None, metadata={'page_number': 9, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png', 'page': 9, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='62b61341-476f-41e8-89c7-d0e5a632b766', node_type=, metadata={'page_number': 9, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png', 'page': 9, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='bdbbf435b3450b76194aae12490d97b649499661b49c1c68811c3c488532cb1f'), : RelatedNodeInfo(node_id='b591759b-c221-4a7a-b0ca-2b5bec2d20e2', node_type=, metadata={'page_number': 9, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png', 'page': 9, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='02395df71225386b793eb870f51f5ff4d508a360bb6258e7fc5b565eb7faba87'), : RelatedNodeInfo(node_id='55d32031-0898-413b-b41c-06944850b55e', node_type=, metadata={}, hash='987928d388551bb87aaaa7fc84ccd48a139c6c9fad8823433ac48c8905de495a')}, text='NFKBIZ is an upstream target of IL-23, IL-36, and IL-17A. In the study of Mandal A et al. [143], NFKBIZ-siRNA significantly reduces the mRNA levels of multiple pro-inflammatory cytokines, including IL-17, IL-19, IL-22, etc., in the skin tissue of psoriasis mice, thereby alleviating the condition of the mice. The safety evaluation results of NFKBIZ-siRNA preparations show that NFKBIZ-siRNA preparations can complex with nucleic acids without affecting biological activity and show no toxicity. TGF-β is a pleiotropic regulatory cytokine that can regulate a variety of ILs including IL-22 and IL-17 to affect the composition of the tumor microenvironment [144]. Currently, Sirnaomics has developed an siRNA drug that targets TGF-β (called STP705). Recently, the drug has completed phase II clinical trials in the United States and achieved positive results. ', mimetype='text/plain', start_char_idx=1211, end_char_idx=2070, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.5333240759554043), NodeWithScore(node=TextNode(id_='55d32031-0898-413b-b41c-06944850b55e', embedding=None, metadata={'page_number': 9, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png', 'page': 9, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='62b61341-476f-41e8-89c7-d0e5a632b766', node_type=, metadata={'page_number': 9, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png', 'page': 9, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='bdbbf435b3450b76194aae12490d97b649499661b49c1c68811c3c488532cb1f'), : RelatedNodeInfo(node_id='e3fb9d7f-09e7-468b-b277-bd64109763b1', node_type=, metadata={'page_number': 9, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p8_1.png', 'page': 9, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='3459a55e6e59cac0e62cfe57733ee9e86a8b2f0a90eddc289731bd56802680ea')}, text='The role of ILs in cancer has been extensively studied. In recent years, the positive role of IL-22 in lung cancer has received attention. The researchers believe that knocking down IL-22 mRNA levels in the lesions of lung cancer patients will help prolong the survival of lung cancer patients and improve the cure rate of lung cancer patients. For example, Zhang Wei et al. found that IL-22-siRNA slowed tumor growth in NSCLC model mice. In addition, they reported that the therapeutic effect of IL-22-siRNA combined with chemotherapy drugs (5-FU and carboplatin) on NSCLC mice was better than that of chemotherapy drugs alone [24]. In an in vitro assay [145], cell line PC9 cells (NSCLC) transfected with PDLIM5-siRNA targeting the PDLIM5 gene had reduced growth viability and exhibited higher apoptotic rates. In the chemotherapy drug gefitinib-resistant cell line PC9 cells, PDLIM5-siRNA still showed significant anti-tumor effects. These results indicate that siRNA-based therapy has good application in the clinical treatment of NSCLC, especially in drug-resistant patients. Based on these findings, we believe that the development of IL-22-siRNA drugs for lung cancer treatment has clinical potential and theoretical basis.\\n\\n## 6.3. Nanoparticle drug delivery systems\\n\\nOn the other hand, given the toxicity and erratic efficacy of current anti-tumor drugs, research on novel drug carriers in lung cancer is ongoing.\\n\\n### Figure 5\\n**Caption:** Precision delivery of various nanomaterials containing IL-22 related drugs for the treatment of lung cancer.\\n\\n**Description:** Figure 5 illustrates the precision delivery of various types of nanomaterials that are designed to carry IL-22 related drugs specifically for lung cancer treatment. The diagram likely includes different types of nanoparticles and their targeting mechanisms, emphasizing the advancements in drug delivery systems aimed at improving therapeutic outcomes in lung cancer patients.\\n```', mimetype='text/plain', start_char_idx=2070, end_char_idx=4027, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.5239087235435067), NodeWithScore(node=TextNode(id_='61176e79-6d6c-412d-aaad-a4e15850fb5a', embedding=None, metadata={'page_number': 11, 'image_link': None, 'page': 11, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='6ae836ff-d0eb-4749-8de0-f687c0c08d31', node_type=, metadata={'page_number': 11, 'image_link': None, 'page': 11, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='c21d4417269c923110cf31f78ff89010c410b64858ffb462d3bc205f49c2184a'), : RelatedNodeInfo(node_id='3e659843-216a-44f8-8e3c-f40ecd9fa3f6', node_type=, metadata={'page_number': 11, 'image_link': None, 'page': 11, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='39296bd53f5e0af9a87a3b87512779716c4bf236d0ad8c0c0a59d911bf5d5b7d'), : RelatedNodeInfo(node_id='f67fb982-5053-46ed-a6d2-308b2246e621', node_type=, metadata={}, hash='cb6d8e77d1d809e3c4a4841700eaf1a9e88bfca9f30ce0e92db6a1bdc72e9222')}, text='R.A. Nagem, D. Colau, L. Dumoutier, J.C. Renauld, C. Ogata, I. Polikarpov, Crystal structure of recombinant human interleukin-22, *Structure* 10 (8) (2002) 1051–1062.\\n10. D. Lejeune, L. Dumoutier, S. Constantinescu, W. Kruijer, J.J. Schuringa, J.C. Renauld, Interleukin-22 (IL-22) activates the JAK/STAT, ERK, JNK, and p38 MAP kinase pathways in a rat hepatoma cell line. Pathways that are shared with and distinct from IL-10, *J. Biol. Chem.* 277 (37) (2002) 33676–33682.\\n11. J.A. Dudakov, A.M. Hanash, M.R. van den Brink, Interleukin-22: immunobiology and pathology, *Annu. Rev. Immunol.* 33 (2015) 747–785.\\n12. Lanfranca M. Perusina, Y. Lin, J. Fang, W. Zou, T. Frankel, Biological and pathological activities of interleukin-22, *J. Mol. Med. (Berl.)* 94 (5) (2016) 523–534.\\n13. L.A. Zenewicz, R.A. Flavell, Recent advances in IL-22 biology, *Int. Immunol.* 23 (3) (2011) 159–163.\\n14. Y. Wu, J. Min, C. Ge, J. Shu, D. Tian, Y. Yuan, et al., Interleukin 22 in liver injury, inflammation and cancer, *Int. J. Biol. Sci.* 16 (13) (2020) 2405–2413.\\n15. Y. Zhu, T. Shi, X. Lu, Z. Xu, J. Qu, Z. Zhang, et al., Fungal-induced glycolysis in macrophages promotes colon cancer by enhancing innate lymphoid cell secretion of IL-22, *EMBO J.* 40 (11) (2021) e105320.\\n16. A.D. Giannou, J. Lucke, D. Kleinschmidt, A.M. Shiri, B. Steglich, M. Nawrocki, et al., A critical role of the IL-22-IL-22 binding protein Axis in hepatocellular carcinoma, *Cancers* 14 (24) (2022).\\n17. X. Xuan, J. Zhou, Z. Tian, Y. Lin, J. Song, Z. Ruan, et al., ILC3 cells promote the proliferation and invasion of pancreatic cancer cells through IL-22/AKT signaling, *Clin. Transl. Oncol.* 22 (4) (2020) 563–575.\\n18. L.G. Perez, J. Kempski, H.M. McGee, P. Pelzcar, T. Agalioti, A. Giannou, et al., TGF-beta signaling in Th17 cells promotes IL-22 production and colitis-associated colon cancer, *Nat. Commun.', mimetype='text/plain', start_char_idx=1714, end_char_idx=3585, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.5227704212840784), NodeWithScore(node=TextNode(id_='47796562-3d1b-4eac-90e7-d2e05e8d602d', embedding=None, metadata={'page_number': 2, 'image_link': None, 'page': 2, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='115cd6cd-d63e-426e-b132-12bfaca5c2c5', node_type=, metadata={'page_number': 2, 'image_link': None, 'page': 2, 'title': 'Jurnal Paru Paru', 'author': 'Hamzah', 'category': 'Pernapasan', 'year': 2023, 'publisher': 'Multimedika', 'reference': 'Hamzah. (2023). *Jurnal Paru Paru*. Multimedika.'}, hash='b0eae5683edb5b409c5d4be2dc31c02ba2a71c3615c56db656146b14ee4c6205'), : RelatedNodeInfo(node_id='dabbee8e-57b6-4a0e-ae4c-539ffde790e9', node_type=, metadata={}, hash='02b33ea6bdd46ec305dcd3f6a3e76a24f60c07b1137229295ea026ec2b5ec69b')}, text='```markdown\\n# IL-22 and Lung Cancer\\n\\n## IL-22 Overview\\nIL-22 is an IL-10 family cytokine produced by T cells and innate lymphocytes. Like all other IL-10 family members, the IL-22 structure contains six α-helices (termed helices A to F). ', mimetype='text/plain', start_char_idx=0, end_char_idx=238, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.5056685971538695)]\n" ] } ], "source": [ "print(response.source_nodes)" ] }, { "cell_type": "markdown", "metadata": {}, "source": [ "# Open AI Agent" ] }, { "cell_type": "code", "execution_count": 26, "metadata": {}, "outputs": [], "source": [ "from script.vector_db import IndexManager\n", "from llama_index.multi_modal_llms.openai import OpenAIMultiModal\n", "from llama_index.core import Settings\n", "from core.multimodal import MultimodalQueryEngine\n", "from llama_index.embeddings.openai import OpenAIEmbedding\n", "\n", "\n", "embed_model = OpenAIEmbedding(model=\"text-embedding-3-large\")\n", "Settings.embed_model = embed_model\n", "\n", "index_manager = IndexManager()\n", "index = index_manager.load_existing_indexes()\n", "\n", "model_multimodal = OpenAIMultiModal(model=\"gpt-4o-mini\", max_new_tokens=4096)\n", "retriever = index.as_retriever(similarity_top_k=10)\n", "citation_engine = MultimodalQueryEngine(retriever=retriever, multi_modal_llm=model_multimodal)" ] }, { "cell_type": "code", "execution_count": 27, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[NodeWithScore(node=TextNode(id_='63b47a30-2d12-4937-8880-f92753abbb9f', embedding=[0.0420109704, 0.01012382, -0.0178423058, 0.0146049894, 0.0225705989, -0.0097696092, -0.0085504679, 0.0587165058, -0.0148685882, 0.0365083553, 0.0410883762, -0.00281102816, 0.0176116563, -0.00999202, -0.0219116025, 0.0041187224, -0.0192261972, -0.00427935272, -0.0244981609, -0.0312858149, -0.0309233684, -0.00372538436, -0.0498200655, -0.00805622153, -0.00406517927, 0.0113347238, -0.00875640381, 0.00945658702, -0.0249924082, 0.00530079566, 0.0198687166, 0.0102144312, -0.0213020332, -0.0148521131, 0.0128668891, 0.00879759155, 0.0233613942, 0.0239874385, -0.00792854093, -0.00643344456, 0.0586176589, -0.0271011945, 0.00240121526, 0.0201817397, -0.0465250872, -0.0115983225, 0.0113511989, -0.019044973, -0.00160527206, -0.00413519749, 0.0176940318, 0.0190120228, 0.00808505248, -0.0135423597, -0.0343336686, -0.0478101298, 0.0298689753, 0.0421427675, 0.0130069256, -0.00670528, -0.00556851272, -0.0147944512, 0.0503802113, 0.00773907965, 0.0174469091, -0.0336417258, 0.0263104, 0.0341359712, -0.00775967306, 0.0465580374, 0.00693592848, 0.0161206797, 0.0514346063, 0.0288145822, 0.0581893101, -0.0279908385, -0.0013272583, 0.00680412957, -0.0361788571, 0.0238885898, 0.0145555651, 0.018699, -0.0476453826, -0.00058228441, 0.0115983225, 0.0151816113, -0.030412646, -0.0800679624, -0.021862179, 0.021713905, -0.00695240358, 0.00701418426, -0.00444410136, 0.00338147115, -0.0130481124, 0.0282709114, 0.030116098, 0.00775967306, -0.039407935, -0.010996989, -0.0109146144, -0.0209395848, -0.00670528, -0.0581563599, 0.0321425088, 0.016689064, -0.00497953547, -0.00189667172, 0.0344984196, 0.0145967519, -0.00200066948, 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jurnal', 'author': 'tes jurnal', 'category': [], 'year': 2024, 'publisher': 'multimedika', 'reference': 'tes jurnal. (2024). *tes jurnal*. multimedika.'}, excluded_embed_metadata_keys=[], excluded_llm_metadata_keys=[], relationships={: RelatedNodeInfo(node_id='1f0094a6-e761-4139-ad5b-0819c9579bb4', node_type=, metadata={'page_number': 11, 'image_link': '', 'page': 11, 'title': 'tes jurnal', 'author': 'tes jurnal', 'category': [], 'year': 2024, 'publisher': 'multimedika', 'reference': 'tes jurnal. (2024). *tes jurnal*. multimedika.'}, hash='f141fa35364bb8712b95938ae39bcf723ad0a85fb2daf7da574be60edad6475d'), : RelatedNodeInfo(node_id='13a0edc6-c909-49fb-94cc-7c98b2561e3b', node_type=, metadata={'page_number': 11, 'image_link': '', 'page': 11, 'title': 'tes jurnal', 'author': 'tes jurnal', 'category': [], 'year': 2024, 'publisher': 'multimedika', 'reference': 'tes jurnal. (2024). *tes jurnal*. multimedika.'}, hash='f74ad4f5f16cc824b69bfee4ea3e00dad26d8fe7e26c21c60bdc9efde81a7136'), : RelatedNodeInfo(node_id='3fe91acb-d5bd-4693-b0e9-f8ffad885e8b', node_type=, metadata={}, hash='c53da4237b8bbe75eef46068172528ce9274f55875bc2fcbcb56291715eff7ed')}, text='A.D. ', mimetype='text/plain', start_char_idx=2976, end_char_idx=2981, text_template='{metadata_str}\\n\\n{content}', metadata_template='{key}: {value}', metadata_seperator='\\n'), score=0.360824227)]" ] }, "execution_count": 27, "metadata": {}, "output_type": "execute_result" } ], "source": [ "nodes = retriever.retrieve(\"test image\")\n", "nodes" ] }, { "cell_type": "code", "execution_count": 28, "metadata": {}, "outputs": [], "source": [ "from llama_index.agent.openai import OpenAIAgent\n", "from llama_index.llms.openai import OpenAI\n", "from config import GPTBOT_CONFIG\n", "from llama_index.core.tools import QueryEngineTool\n", "\n", "\n", "system_prompt = \"\"\"\n", "Kamu adalah Medbot yang selalu menggunakan tools untuk menjawab pertanyaan medis. Jika pengguna bertanya tentang topik non-medis, arahkan mereka untuk bertanya di bidang medis. Tugasmu adalah memberikan jawaban yang informatif dan akurat berdasarkan tools yang tersedia. Pastikan kamu hanya memberikan informasi dari buku yang telah disediakan, jangan sampai menjawab pertanyaan yang tidak terdapat dalam buku atau tools yang kamu gunakan. Jika setelah itu tidak ada informasi yang ditemukan, katakan bahwa kamu tidak mengetahuinya dan berikan informasi dari apa yang kamu ketahui kemudian arahkan pengguna untuk bertanya ke dokter yang lebih ahli. Selalu cantumkan citation halamannya dari konteks yang kamu ambil berdasarkan format yang ada. Yaitu menggunakan [p-no.halaman] di akhir kutipan yang kamu ambil.\n", "\n", "**Instruksi**:\n", "\n", " 1. **Jawaban Berdasarkan Tools**: Jika pengguna bertanya tentang topik kedokteran, gunakanlah tools yang tersedia untuk memberikan jawaban. Pastikan jawabanmu relevan dan sesuai dengan informasi dari tools tersebut. Jelaskan informasi dengan jelas dan lengkap. Jika ada tabel, boleh anda tampilkan tabel nya untuk menyampaikan data data yang jelas berdasarkan konteks buku. \n", "\n", " 2. **Referensi dan Kutipan**: \n", " - Jika menjelaskan gambar, pastikan cantumkan link gambarnya yang ditampilkan di markdown** contoh :\n", " * Based on the images: \\n\n", "![figure-10](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p9_1.png) --> kamu tetap harus menampilkan tampilan gambar yang di markdown sehingga menjadi : \n", "\n", " Pada gambar : \\n\n", " ![figure-10](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/test/img_p9_1.png)\\n\n", " \n", " - Jangan menghapus sumber kutipan baik berupa citasi atau halaman (page number) dari teks yang diberikan. Contohnya, jika teksnya adalah \"Ilmu kedokteran sangat dibutuhkan [p-2]\", pastikan untuk menyertakan kutipan sumbernya yaitu [p-2] dalam jawabanmu. Contoh lain: : \n", "\n", " * Water is wet when the sky is red [p-11]. --> kamu harus tetap cantumkan [p-11] pada jawaban yang kamu generate \n", " \n", " * source : \n", " page_number : 12\n", " The sky is red in the evening and blue in the morning. --> Kamu harus mengubahnya menjadi sesuai dengan page numbernya atau citationnya sehingga menjadi :\n", " The sky is red in the evening and blue in the morning [p-12].\n", "\n", " 3. **Ketika Tidak Tahu Jawaban**: Jika pertanyaan pengguna tidak dapat dijawab dengan menggunakan tools ini, sampaikan dengan sopan bahwa kamu tidak memiliki jawaban untuk pertanyaan tersebut. Arahkan pengguna untuk mencari informasi lebih lanjut atau bertanya pada ahli di bidang kedokteran.\n", "\n", " 4. **Gaya Jawaban**: Berikan jawaban dengan gaya yang ramah dan profesional. Sampaikan informasi secara naratif agar lebih mudah dipahami. Boleh menggunakan point point dan uraiannya agar bisa menjelaskan informasi yang kompleks sehingga mudah dipahami. Gunakan kata 'dok' atau 'dokter' untuk merujuk pada dokter, dan hindari kesan monoton dengan menambahkan emotikon jika sesuai seperti 😁, 😊, 🙌, 😉, 😀, 🤔, 😇.\n", "\n", " 5. **Penutup**: Akhiri komunikasi dengan kalimat yang friendly, seperti \"Semoga informasi ini bermanfaat, dok ✨\" atau \"Jika ada pertanyaan lain, jangan ragu untuk bertanya ya dok 😊\" dan sebagainya. \n", "\"\"\"\n", "\n", "llm = OpenAI(\n", " temperature=GPTBOT_CONFIG.temperature,\n", " model=GPTBOT_CONFIG.model,\n", " max_tokens=GPTBOT_CONFIG.max_tokens,\n", " api_key=GPTBOT_CONFIG.api_key,\n", ")\n", "vector_tool = QueryEngineTool.from_defaults(\n", " query_engine=citation_engine,\n", " name=\"vector_tool\",\n", " description=(\n", " \"Useful for retrieving specific context from the data. Do NOT select if question asks for a summary of the data.\"\n", " ),\n", ")\n", "chat_engine = OpenAIAgent.from_tools(\n", " tools=[vector_tool],\n", " llm=llm,\n", " system_prompt=system_prompt,\n", ")" ] }, { "cell_type": "code", "execution_count": 29, "metadata": {}, "outputs": [], "source": [ "prompt = \"Jelaskan proses Crispr-cas13-based IL-22 mRNA pada gambar 4 dengan bahasa indonesia\"\n", "response = chat_engine.chat(prompt)" ] }, { "cell_type": "code", "execution_count": 30, "metadata": {}, "outputs": [ { "data": { "text/markdown": [ "Proses pengeditan mRNA IL-22 berbasis Crispr-Cas13 adalah pendekatan yang menjanjikan untuk terapi kanker paru-paru, seperti yang ditunjukkan dalam gambar berikut:\n", "\n", "![Crispr-Cas13-based IL-22 mRNA editing](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/tes%20jurnal/img_p7_1.png)\n", "\n", "Dalam gambar tersebut, sistem Crispr-Cas13 dapat dikombinasikan dengan teknologi baru seperti pengeditan basis tunggal dan pengurutan sel tunggal untuk menargetkan mRNA IL-22. Pendekatan ini berpotensi meningkatkan strategi terapeutik dalam pengobatan kanker paru-paru [p-8].\n", "\n", "Proses ini melibatkan beberapa langkah, antara lain:\n", "1. **Targeting mRNA**: Crispr-Cas13 dirancang untuk mengenali dan mengikat mRNA IL-22.\n", "2. **Pengeditan**: Setelah mengikat, sistem ini dapat melakukan pengeditan pada mRNA, yang dapat memodulasi ekspresi gen IL-22.\n", "3. **Penerapan Teknologi Lanjutan**: Kombinasi dengan teknologi pengeditan basis tunggal dan pengurutan sel tunggal memungkinkan analisis yang lebih mendalam dan spesifik terhadap efek pengeditan ini.\n", "\n", "Semoga informasi ini bermanfaat, dok ✨ Jika ada pertanyaan lain, jangan ragu untuk bertanya ya dok 😊" ], "text/plain": [ "" ] }, "metadata": {}, "output_type": "display_data" } ], "source": [ "from IPython.display import Markdown, display\n", "display(Markdown(str(response)))" ] }, { "cell_type": "code", "execution_count": 31, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "'Proses pengeditan mRNA IL-22 berbasis Crispr-Cas13 adalah pendekatan yang menjanjikan untuk terapi kanker paru-paru, seperti yang ditunjukkan dalam gambar berikut:\\n\\n![Crispr-Cas13-based IL-22 mRNA editing](https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/tes%20jurnal/img_p7_1.png)\\n\\nDalam gambar tersebut, sistem Crispr-Cas13 dapat dikombinasikan dengan teknologi baru seperti pengeditan basis tunggal dan pengurutan sel tunggal untuk menargetkan mRNA IL-22. Pendekatan ini berpotensi meningkatkan strategi terapeutik dalam pengobatan kanker paru-paru [p-8].\\n\\nProses ini melibatkan beberapa langkah, antara lain:\\n1. **Targeting mRNA**: Crispr-Cas13 dirancang untuk mengenali dan mengikat mRNA IL-22.\\n2. **Pengeditan**: Setelah mengikat, sistem ini dapat melakukan pengeditan pada mRNA, yang dapat memodulasi ekspresi gen IL-22.\\n3. **Penerapan Teknologi Lanjutan**: Kombinasi dengan teknologi pengeditan basis tunggal dan pengurutan sel tunggal memungkinkan analisis yang lebih mendalam dan spesifik terhadap efek pengeditan ini.\\n\\nSemoga informasi ini bermanfaat, dok ✨ Jika ada pertanyaan lain, jangan ragu untuk bertanya ya dok 😊'" ] }, "execution_count": 31, "metadata": {}, "output_type": "execute_result" } ], "source": [ "str(response)" ] }, { "cell_type": "code", "execution_count": 41, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "content 1 : Studies have shown that the production of IL-22 generally reduces Th1-type immune responses. This action may be coordinated with the protective effect of IL-22R-expressing tissue cells to reduce collateral damage in the context of infection and inflammation [69]. Besides, animal experiments have indicated that IL-22 can also promote B-cell responses by inducing CXCL13 in tertiary lymphoid follicles [70,71]. In the latest murine lung cancer model, IL-22 was discovered to induce NK cells to overexpress CD155, thus mediating the immune evasion of tumor cells [72]. As a transmembrane adhesive molecule, CD155 has been proven to inhibit T and NK cell-mediated anti-tumor immune responses, thereby promoting tumor progression (Fig. 2) [73–75].\n", "\n", "\n", "metadata 1 : {'page_number': 4, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/tes%20jurnal/img_p3_1.png', 'page': 4, 'title': 'tes jurnal', 'author': 'tes jurnal', 'category': [], 'year': 2024, 'publisher': 'multimedika', 'reference': 'tes jurnal. (2024). *tes jurnal*. multimedika.'}\n", "score 1 : 0.406081557 \n", "\n", " =================================================================\n", "content 2 : As described previously, reduced intrapulmonary metastasis was found in IL-22-deficient mice as well as in IL-22-suppressed NSCLC cells [20,72]. In addition, blocking IL-22R1 or knockout of the IL-22 gene both retarded the progression of lung cancer [24,94]. These findings provide a new train of thought for the down-regulation of IL-22 in treating lung cancer.\n", "\n", "In recent years, the research on gene editing treatment for various diseases has become more and more popular [136–138]. CRISPR-Cas13a is an effective tool for knocking out specific RNA sequences, it has been shown to induce the death of glioma cells that overexpress EGFR, which is one of the subtypes of EGFR mutation in glioma. Apart from this, the CRISPR-Cas13a gene-editing system can also inhibit the formation of intracranial tumors in mice with glioma [139]. In a collagen-induced mouse model, injection of gene-edited human amniotic mesenchymal stem cells that overexpressed IL-10 increased proteoglycan expression in joint tissue and reduced the inflammatory response and production of various inflammatory cytokines [137]. In the world’s first human phase I clinical trial utilizing CRISPR-Cas9 in the treatment of advanced NSCLC, researchers have demonstrated the feasibility and safety of gene-edited T-cell therapy targeting the PD-1 gene [140]. Thus, genome editing strategies have the potential to treat lung cancer by altering IL-22 expression levels. In the future, the role of pulmonary precision delivery based on CRISPR-Cas13 gene-editing components targeting the IL-22 mRNA in lung cancer therapy should not be ignored. CRISPR-Cas13 is expected to be further integrated.\n", "\n", "## Figure 4\n", "\n", "Crispr-cas13-based IL-22 mRNA editing can be utilized for lung cancer therapy by combining with emerging technologies such as single-base editing and single-cell sequencing.\n", "\n", "!\n", "metadata 2 : {'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/tes%20jurnal/img_p7_1.png', 'page': 8, 'title': 'tes jurnal', 'author': 'tes jurnal', 'category': [], 'year': 2024, 'publisher': 'multimedika', 'reference': 'tes jurnal. (2024). *tes jurnal*. multimedika.'}\n", "score 2 : 0.550439537 \n", "\n", " =================================================================\n", "content 3 : ```markdown\n", "# Page Content\n", "\n", "L. Xu et al. Heliyon 10 (2024) e35901\n", "\n", "The expression level was correlated with the efficacy of EGFR-TKI in plasma [135]. Therefore, it is reasonable to suspect that IL-22 may be a new biomarker to overcome EGFR-TKI resistance in NSCLC. In terms of animal models, some investigators implanted Line-1 lung cancer cells into wild-type and IL-22-deficient mice simultaneously, and found reduced intrapulmonary metastasis in the latter group, which is independent of primary tumor size. Besides, they performed forced metastasis by intravenous injection of lung cancer cells, and the results further confirmed the lower metastatic load in mice with IL-22 deletion [72]. In another model of Kras-mutated lung cancer in mice, gene ablation of IL-22 resulted in a marked reduction in tumor number and size. The authors also analyzed the association between IL-22R1 expression and survival in patients with KRAS mutant lung adenocarcinoma, the results showed that high expression of IL-22R1 was an independent indicator of poorer relapse-free survival [94]. Taken together, these pieces of evidence highlight the potential clinical role of IL-22, IL-22R, and IL-22-producing cells in the treatment of lung cancer (Table 2).\n", "\n", "## Future Perspectives\n", "\n", "### CRISPR-Cas13a Technical\n", "\n", "At present, mounting clinical trials based on IL-22 are being carried out in full swing worldwide, mainly involving ulcerative colitis, alcoholic cirrhosis, GVHD, and psoriasis [12,14,54,60]. However, there are presently no clinical trials based on IL-22 in lung cancer. \n", "metadata 3 : {'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/tes%20jurnal/img_p7_1.png', 'page': 8, 'title': 'tes jurnal', 'author': 'tes jurnal', 'category': [], 'year': 2024, 'publisher': 'multimedika', 'reference': 'tes jurnal. (2024). *tes jurnal*. multimedika.'}\n", "score 3 : 0.510506392 \n", "\n", " =================================================================\n", "content 4 : [Crispr-cas13-based IL-22 mRNA editing]()\n", "```\n", "metadata 4 : {'page_number': 8, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/tes%20jurnal/img_p7_1.png', 'page': 8, 'title': 'tes jurnal', 'author': 'tes jurnal', 'category': [], 'year': 2024, 'publisher': 'multimedika', 'reference': 'tes jurnal. (2024). *tes jurnal*. multimedika.'}\n", "score 4 : 0.501743376 \n", "\n", " =================================================================\n", "content 5 : NFKBIZ is an upstream target of IL-23, IL-36, and IL-17A. In the study of Mandal A et al. [143], NFKBIZ-siRNA significantly reduces the mRNA levels of multiple pro-inflammatory cytokines, including IL-17, IL-19, IL-22, etc., in the skin tissue of psoriasis mice, thereby alleviating the condition of the mice. The safety evaluation results of NFKBIZ-siRNA preparations show that NFKBIZ-siRNA preparations can complex with nucleic acids without affecting biological activity and show no toxicity. TGF-β is a pleiotropic regulatory cytokine that can regulate a variety of ILs including IL-22 and IL-17 to affect the composition of the tumor microenvironment [144]. Currently, Sirnaomics has developed an siRNA drug that targets TGF-β (called STP705). Recently, the drug has completed phase II clinical trials in the United States and achieved positive results. \n", "metadata 5 : {'page_number': 9, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/tes%20jurnal/img_p8_1.png', 'page': 9, 'title': 'tes jurnal', 'author': 'tes jurnal', 'category': [], 'year': 2024, 'publisher': 'multimedika', 'reference': 'tes jurnal. (2024). *tes jurnal*. multimedika.'}\n", "score 5 : 0.474916041 \n", "\n", " =================================================================\n", "content 6 : D.S. Chae, Y.J. Park, S.W. Kim, Anti-arthritogenic property of interleukin 10-expressing human amniotic MSCs generated by gene editing in collagen-induced arthritis, Int. J. Mol. Sci. 23 (14) (2022).\n", "5. E. Vermersch, C. Jouve, J.S. Hulot, CRISPR/Cas9 gene-editing strategies in cardiovascular cells, Cardiovasc. Res. 116 (5) (2020) 894–907.\n", "6. Q. Wang, X. Liu, J. Zhou, C. Yang, G. Wang, Y. Tan, et al., The CRISPR-Cas13a gene-editing system induces collateral cleavage of RNA in glioma cells, Adv. Sci. 6 (20) (2019) 1901299.\n", "7. Y. Lu, J. Xue, T. Deng, X. Zhou, K. Yu, L. Deng, et al., Safety and feasibility of CRISPR-edited T cells in patients with refractory non-small-cell lung cancer, Nat. Med. 26 (5) (2020) 732–740.\n", "8. \n", "metadata 6 : {'page_number': 14, 'image_link': '', 'page': 14, 'title': 'tes jurnal', 'author': 'tes jurnal', 'category': [], 'year': 2024, 'publisher': 'multimedika', 'reference': 'tes jurnal. (2024). *tes jurnal*. multimedika.'}\n", "score 6 : 0.441436887 \n", "\n", " =================================================================\n", "content 7 : The role of ILs in cancer has been extensively studied. In recent years, the positive role of IL-22 in lung cancer has received attention. The researchers believe that knocking down IL-22 mRNA levels in the lesions of lung cancer patients will help prolong the survival of lung cancer patients and improve the cure rate of lung cancer patients. For example, Zhang Wei et al. found that IL-22-siRNA slowed tumor growth in NSCLC model mice. In addition, they reported that the therapeutic effect of IL-22-siRNA combined with chemotherapy drugs (5-FU and carboplatin) on NSCLC mice was better than that of chemotherapy drugs alone [24]. In an in vitro assay [145], cell line PC9 cells (NSCLC) transfected with PDLIM5-siRNA targeting the PDLIM5 gene had reduced growth viability and exhibited higher apoptotic rates. In the chemotherapy drug gefitinib-resistant cell line PC9 cells, PDLIM5-siRNA still showed significant anti-tumor effects. These results indicate that siRNA-based therapy has good application in the clinical treatment of NSCLC, especially in drug-resistant patients. Based on these findings, we believe that the development of IL-22-siRNA drugs for lung cancer treatment has clinical potential and theoretical basis.\n", "\n", "## 6.3. Nanoparticle drug delivery systems\n", "\n", "On the other hand, given the toxicity and erratic efficacy of current anti-tumor drugs, research on novel drug carriers in lung cancer is ongoing.\n", "\n", "### Figure 5\n", "**Caption:** Precision delivery of various nanomaterials containing IL-22 related drugs for the treatment of lung cancer.\n", "\n", "**Description:** Figure 5 illustrates the precision delivery of various types of nanomaterials that are designed to carry IL-22 related drugs specifically for lung cancer treatment. The diagram likely includes different types of nanoparticles and their targeting mechanisms, emphasizing the advancements in drug delivery systems aimed at improving therapeutic outcomes in lung cancer patients.\n", "```\n", "metadata 7 : {'page_number': 9, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/tes%20jurnal/img_p8_1.png', 'page': 9, 'title': 'tes jurnal', 'author': 'tes jurnal', 'category': [], 'year': 2024, 'publisher': 'multimedika', 'reference': 'tes jurnal. (2024). *tes jurnal*. multimedika.'}\n", "score 7 : 0.434656203 \n", "\n", " =================================================================\n", "content 8 : ```markdown\n", "## Page Content\n", "\n", "L. Xu et al. Heliyon 10 (2024) e35901\n", "\n", "When the body is in homeostasis, the most important source of IL-22 is Group 3 innate lymphoid cells (ILC3) [14]. Different from other common cytokines, IL-22 is generally thought to be produced only by hematopoietic origin immune cells, whereas it mainly acts on non-hematopoietic cells due to its receptor distribution [55]. Recently, researchers have found that non-hematopoietic cells represented by fibroblasts can also produce IL-22 under certain circumstances [11]. IL-22 is known to act by binding to its receptor (IL-22R), which is synthesized from the IL-22R1 and IL-10R2 subunits [56]. Thereinto, IL-22R1 expression is thought to be restricted to epithelial cells in organs such as the lung, liver, intestine, and skin, while the latter is universally expressed [11,57]. IL-22BP, also known as IL-22RA2, is a soluble IL-22 receptor that binds specifically to IL-22 and prevents it from binding to IL-22R1. All currently known functions of IL-22BP are achieved by inhibiting IL-22 [58,59]. Broadly speaking, the primary function of IL-22 in the body is to promote cell proliferation and tissue protection [60]. Sometimes, excessive activation of this function may lead to pathological results. This dual effect is reflected in both inflammatory and tumor-related diseases. In the short term, the production of IL-22 can play a protective role in anti-inflammatory and tumor prevention, while the uncontrolled generation of IL-22 may promote inflammation and tumor formation [13,18]. The duality of IL-22 reveals that it could be a potential drug target, and the tight regulation of IL-22 is crucial in the treatment of a variety of diseases.\n", "\n", "In general, the expression levels of IL-22 in vivo are regulated by a variety of cytokines and genes. For instance, IL-1β and IL-23 can induce the production of IL-22 independently, and the two act synergistically [11]. What’s more, Cornelia Voigt described a novel mechanism whereby cancer cells promote tumor growth by releasing IL-1β to induce IL-22 production by memory CD4+ T cells [61]. According to an animal experiment, IL-1β can enhance the proliferation of epithelial cells and promote lung tumorigenesis [62]. IL-23 has been proven to promote proliferation in NSCLC by Anne-Marie Baird et al. [63]. Although IL-23 is thought to be able to induce macrophages to produce IL-22, this study by Anne-Marie Baird et al. cannot directly prove whether the proliferation-promoting effect of IL-23 on NSCLC cells is related to IL-23’s promotion of IL-22 production. IL-23 is also thought to promote the expression of IL-26 by macrophages. Like IL-22, IL-26 is part of the IL-10 family. Researchers demonstrated for the first time that IL-26 is involved in the generation of malignant pleural effusions [64]. They reported that IL-26 promotes the generation of malignant pleural effusion by mediating the infiltration of CD4+IL-22+T cells in malignant pleural effusion and stimulating CD4+ IL-22+ T cells to secrete IL-22. Recently, the Notch-AhR-IL-22 axis is thought to be involved in the pathogenesis of LUAD. It is corroborated that in LUAD patients, elevated Notch1 facilitates IL-22 generation by CD4+ T cells via aryl hydrocarbon receptors (AhR) [65]. In NSCLC, Notch signaling can both promote tumorigenesis and inhibit tumor progression, which mainly depends on its regulation of the.\n", "\n", "### Figure 1\n", "IL-22 plays four main functions during the progression of lung cancer:\n", "1. Promote lung cancer cell proliferation and invasion, and inhibit lung cancer cell apoptosis.\n", "\n", "metadata 8 : {'page_number': 3, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/tes%20jurnal/img_p2_1.png', 'page': 3, 'title': 'tes jurnal', 'author': 'tes jurnal', 'category': [], 'year': 2024, 'publisher': 'multimedika', 'reference': 'tes jurnal. (2024). *tes jurnal*. multimedika.'}\n", "score 8 : 0.423405915 \n", "\n", " =================================================================\n", "content 9 : R.A. Nagem, D. Colau, L. Dumoutier, J.C. Renauld, C. Ogata, I. Polikarpov, Crystal structure of recombinant human interleukin-22, *Structure* 10 (8) (2002) 1051–1062.\n", "10. D. Lejeune, L. Dumoutier, S. Constantinescu, W. Kruijer, J.J. Schuringa, J.C. Renauld, Interleukin-22 (IL-22) activates the JAK/STAT, ERK, JNK, and p38 MAP kinase pathways in a rat hepatoma cell line. Pathways that are shared with and distinct from IL-10, *J. Biol. Chem.* 277 (37) (2002) 33676–33682.\n", "11. J.A. Dudakov, A.M. Hanash, M.R. van den Brink, Interleukin-22: immunobiology and pathology, *Annu. Rev. Immunol.* 33 (2015) 747–785.\n", "12. Lanfranca M. Perusina, Y. Lin, J. Fang, W. Zou, T. Frankel, Biological and pathological activities of interleukin-22, *J. Mol. Med. (Berl.)* 94 (5) (2016) 523–534.\n", "13. L.A. Zenewicz, R.A. Flavell, Recent advances in IL-22 biology, *Int. Immunol.* 23 (3) (2011) 159–163.\n", "14. Y. Wu, J. Min, C. Ge, J. Shu, D. Tian, Y. Yuan, et al., Interleukin 22 in liver injury, inflammation and cancer, *Int. J. Biol. Sci.* 16 (13) (2020) 2405–2413.\n", "15. Y. Zhu, T. Shi, X. Lu, Z. Xu, J. Qu, Z. Zhang, et al., Fungal-induced glycolysis in macrophages promotes colon cancer by enhancing innate lymphoid cell secretion of IL-22, *EMBO J.* 40 (11) (2021) e105320.\n", "16. A.D. Giannou, J. Lucke, D. Kleinschmidt, A.M. Shiri, B. Steglich, M. Nawrocki, et al., A critical role of the IL-22-IL-22 binding protein Axis in hepatocellular carcinoma, *Cancers* 14 (24) (2022).\n", "17. X. Xuan, J. Zhou, Z. Tian, Y. Lin, J. Song, Z. Ruan, et al., ILC3 cells promote the proliferation and invasion of pancreatic cancer cells through IL-22/AKT signaling, *Clin. Transl. Oncol.* 22 (4) (2020) 563–575.\n", "18. L.G. Perez, J. Kempski, H.M. McGee, P. Pelzcar, T. Agalioti, A. Giannou, et al., TGF-beta signaling in Th17 cells promotes IL-22 production and colitis-associated colon cancer, *Nat. Commun.\n", "metadata 9 : {'page_number': 11, 'image_link': '', 'page': 11, 'title': 'tes jurnal', 'author': 'tes jurnal', 'category': [], 'year': 2024, 'publisher': 'multimedika', 'reference': 'tes jurnal. (2024). *tes jurnal*. multimedika.'}\n", "score 9 : 0.418778956 \n", "\n", " =================================================================\n", "content 10 : In the occurrence and development of pulmonary diseases, IL-22 is considered to play an important role. As previously demonstrated in an epicutaneously sensitized mice experiment, IL-22 promotes the development of neutrophil and eosinophile-mediated airway inflammation and airway hyperresponsiveness stimulated by intranasal antigens [76]. The conclusion implies that blocking IL-22 may be helpful for the treatment of bronchial asthma. When it comes to chronic obstructive pulmonary disease (COPD), the expression levels of both IL-22 and its receptor in COPD patients were higher than those of healthy controls. This result was confirmed in mice with experimental COPD induced by cigarette smoke. What’s more, researchers also found that cigarette smoke-induced inappropriate activation of pulmonary neutrophils decreased in IL-22-deficient mice with COPD. This suggests that IL-22 may be involved in the pathogenesis of COPD. The research further manifested that IL-22 promotes cigarette smoke-induced airway remodeling, pulmonary neutrophil inflammation, and the impairment of pulmonary function, and is involved in the pathogenesis of COPD [77]. While in pulmonary infectious diseases such as pneumonia, tuberculosis, and pulmonary mycosis, it is thought that IL-22 appears to take a protective and preventive part [78–83]. For good measure, in the bleomycin-induced pulmonary fibrosis model, the degree of pulmonary fibrosis in IL-22 knockout mice was aggravated, and injection of recombinant IL-22 alleviated the severe fibrosis in IL-22 knockout mice. This latest research has suggested the potential antifibrotic effect of IL-22 [84].\n", "\n", "In recent years, differential expression of IL-22 has also been discovered in various specimens of lung cancer (Table 1). In the first place, the mean levels of IL-22 in the plasma of NSCLC patients were significantly higher than that of the reference cohort [21,85]. The plasma levels of IL-22 were observed to elevate along with the increase in lung cancer staging [85]. In addition, Immunohistochemistry analysis showed that IL-22 expression was up-regulated in NSCLC tumor specimens in comparison to that in the adjacent tissues. RT-qPCR analysis also revealed similar differences in IL-22 mRNA expression between lung cancer tissues and normal tissues [24,86]. Interestingly, Yi Bi et al. compared IL-22 levels between tissues and serum of patients with primary NSCLC and their paired recurrent lung cancer specimens and the expression levels of IL-22 were found to be obviously up-regulated in the latter group [23]. Apart from this, IL-22 expression was also detected in bronchoalveolar lavage fluid (BALF). As reported by an article in 2016, IL-22 levels were .\n", "\n", "## Figure Description\n", "\n", "**Figure 2**: IL-22 induces NK cells to overexpress CD155, which binds to NK cell activation receptor CD226. Over-activation leads to a decrease in the amount of CD226 and impaired NK cell function, thereby mediating tumor cell immune escape.\n", "\n", "- **Summary**: This figure illustrates the mechanism by which IL-22 influences NK cell activity through the overexpression of CD155, leading to immune evasion by tumor cells. The diagram likely includes arrows indicating the interactions between IL-22, NK cells, and CD155, as well as the resulting effects on immune function.\n", "```\n", "metadata 10 : {'page_number': 4, 'image_link': 'https://book-images-multimedika.s3.us-west-2.amazonaws.com/images/tes%20jurnal/img_p3_1.png', 'page': 4, 'title': 'tes jurnal', 'author': 'tes jurnal', 'category': [], 'year': 2024, 'publisher': 'multimedika', 'reference': 'tes jurnal. (2024). *tes jurnal*. multimedika.'}\n", "score 10 : 0.407066643 \n", "\n", " =================================================================\n" ] } ], "source": [ "sources = response.source_nodes\n", "for number in range (len(sources)):\n", " if sources and len(sources) > 0:\n", " content = sources[number - 1].node.get_text()\n", " print(f\"content {number+1} : \",content)\n", " metadata = dict(sources[number - 1].node.metadata)\n", " print(f\"metadata {number+1} : \", metadata)\n", " score = sources[number - 1].score\n", " print(f\"score {number+1} : \",score, \"\\n\\n =================================================================\")" ] }, { "cell_type": "markdown", "metadata": {}, "source": [ "# Check API Llamaparse" ] }, { "cell_type": "code", "execution_count": 8, "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "\n", "\n" ] } ], "source": [ "import os\n", "from contextlib import asynccontextmanager\n", "from typing import AsyncGenerator\n", "import httpx\n", "from dotenv import load_dotenv\n", "\n", "load_dotenv()\n", "\n", "job_id = \"688f7326-b8a0-4dea-8b84-9e6d7a72e258\"\n", "base_url = \"https://api.cloud.llamaindex.ai\"\n", "result_type = \"json\"\n", "\n", "result_url = f\"{base_url}/api/parsing/job/{job_id}/result/{result_type}\"\n", "status_url = f\"{base_url}/api/parsing/job/{job_id}\"\n", "api_key = os.getenv(\"LLAMA_PARSE_API_KEY\")\n", "headers = {\"Authorization\": f\"Bearer {api_key}\"}\n", "\n", "@asynccontextmanager\n", "async def client_context() -> AsyncGenerator[httpx.AsyncClient, None]:\n", " async with httpx.AsyncClient(timeout=2000) as client:\n", " yield client\n", "\n", "async with client_context() as client:\n", " result = await client.get(status_url, headers=headers)\n", " parsed_result = await client.get(result_url, headers=headers)\n", "\n", "print(result)\n", "print(parsed_result)\n", " \n" ] }, { "cell_type": "code", "execution_count": 9, "metadata": {}, "outputs": [], "source": [ "parsed_result_json = parsed_result.json()" ] }, { "cell_type": "code", "execution_count": 10, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "{'pages': [{'page': 1,\n", " 'text': \"SCHEIN'S COMMON SENSE\\nEMERGENCY\\nAbdominal Surgery\\n Fourth Edition\\n Moshe Schein\\n Paul N: Rogers\\n Ari Leppaniemi\\n Danny Rosin\\n Jonathan E. Efron\",\n", " 'md': \"```markdown\\n# Schein's Common Sense Emergency Abdominal Surgery\\n\\n**Fourth Edition**\\n\\n**Authors:**\\n- Moshe Schein\\n- Paul N. Rogers\\n- Ari Leppaniemi\\n- Danny Rosin\\n- Jonathan E. Efron\\n```\",\n", " 'images': [{'name': 'img_p0_1.png',\n", " 'height': 1602,\n", " 'width': 1238,\n", " 'x': 0,\n", " 'y': 0,\n", " 'original_width': 600,\n", " 'original_height': 876}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': \"Schein's Common Sense Emergency Abdominal Surgery\",\n", " 'md': \"# Schein's Common Sense Emergency Abdominal Surgery\",\n", " 'bBox': {'x': 20.29, 'y': 14.35, 'w': 252.41, 'h': 31.67}},\n", " {'type': 'text',\n", " 'value': '**Fourth Edition**\\n\\n**Authors:**\\n- Moshe Schein\\n- Paul N. Rogers\\n- Ari Leppaniemi\\n- Danny Rosin\\n- Jonathan E. Efron\\n```',\n", " 'md': '**Fourth Edition**\\n\\n**Authors:**\\n- Moshe Schein\\n- Paul N. Rogers\\n- Ari Leppaniemi\\n- Danny Rosin\\n- Jonathan E. Efron\\n```',\n", " 'bBox': {'x': 54.44, 'y': 102.92, 'w': 216.78, 'h': 14.84}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 2,\n", " 'text': \"SCHEIN'S COMMON SENSE\\n EMERGENCY\\n Abdominal SurgeryFourth Edition\\n Moshe Schein MD FACS\\n Attending Surgeon, Marshfield Clinic, Ladysmith, Wisconsin, USA\\n Paul N: Rogers MBChB MBA MD FRCS\\n Consultant General and Vascular Surgeon, Department of\\n Surgery, South Glasgow University Hospital, Glasgow; UK\\n Ari Leppaniemi MD\\n Chief of Emergency Surgery, Abdominal Center; University of\\n Helsinki, Finland\\n Danny Rosin MD FACS\\n Attending General and Advanced Laparoscopic Surgeon,\\n Sheba Medical Center; University of Tel Aviv, Israel\\n Jonathan E: Efron MD FACS FASCRS\\n Associate Professor ofSurgery, The Mark M. Ravitch Endowed\\n Professorship in Surgery; Chief; Ravitch Division, Johns Hopkins\\n University; Baltimore, Maryland, USA\",\n", " 'md': \"```markdown\\n# Schein's Common Sense Emergency Abdominal Surgery (Fourth Edition)\\n\\n**Authors:**\\n- Moshe Schein MD FACS\\nAttending Surgeon, Marshfield Clinic, Ladysmith, Wisconsin, USA\\n\\n- Paul N. Rogers MBChB MBA MD FRCS\\nConsultant General and Vascular Surgeon, Department of Surgery, South Glasgow University Hospital, Glasgow, UK\\n\\n- Ari Leppaniemi MD\\nChief of Emergency Surgery, Abdominal Center; University of Helsinki, Finland\\n\\n- Danny Rosin MD FACS\\nAttending General and Advanced Laparoscopic Surgeon, Sheba Medical Center; University of Tel Aviv, Israel\\n\\n- Jonathan E. Efron MD FACS FASCRS\\nAssociate Professor of Surgery, The Mark M. Ravitch Endowed Professorship in Surgery; Chief, Ravitch Division, Johns Hopkins University; Baltimore, Maryland, USA\\n```\",\n", " 'images': [{'name': 'img_p1_1.png',\n", " 'height': 1164,\n", " 'width': 789,\n", " 'x': 110.88,\n", " 'y': 72,\n", " 'original_width': 1084,\n", " 'original_height': 1600}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': \"Schein's Common Sense Emergency Abdominal Surgery (Fourth Edition)\",\n", " 'md': \"# Schein's Common Sense Emergency Abdominal Surgery (Fourth Edition)\",\n", " 'bBox': {'x': 132.15, 'y': 104.66, 'w': 338.31, 'h': 39.59}},\n", " {'type': 'text',\n", " 'value': '**Authors:**\\n- Moshe Schein MD FACS\\nAttending Surgeon, Marshfield Clinic, Ladysmith, Wisconsin, USA\\n\\n- Paul N. Rogers MBChB MBA MD FRCS\\nConsultant General and Vascular Surgeon, Department of Surgery, South Glasgow University Hospital, Glasgow, UK\\n\\n- Ari Leppaniemi MD\\nChief of Emergency Surgery, Abdominal Center; University of Helsinki, Finland\\n\\n- Danny Rosin MD FACS\\nAttending General and Advanced Laparoscopic Surgeon, Sheba Medical Center; University of Tel Aviv, Israel\\n\\n- Jonathan E. Efron MD FACS FASCRS\\nAssociate Professor of Surgery, The Mark M. Ravitch Endowed Professorship in Surgery; Chief, Ravitch Division, Johns Hopkins University; Baltimore, Maryland, USA\\n```',\n", " 'md': '**Authors:**\\n- Moshe Schein MD FACS\\nAttending Surgeon, Marshfield Clinic, Ladysmith, Wisconsin, USA\\n\\n- Paul N. Rogers MBChB MBA MD FRCS\\nConsultant General and Vascular Surgeon, Department of Surgery, South Glasgow University Hospital, Glasgow, UK\\n\\n- Ari Leppaniemi MD\\nChief of Emergency Surgery, Abdominal Center; University of Helsinki, Finland\\n\\n- Danny Rosin MD FACS\\nAttending General and Advanced Laparoscopic Surgeon, Sheba Medical Center; University of Tel Aviv, Israel\\n\\n- Jonathan E. Efron MD FACS FASCRS\\nAssociate Professor of Surgery, The Mark M. Ravitch Endowed Professorship in Surgery; Chief, Ravitch Division, Johns Hopkins University; Baltimore, Maryland, USA\\n```',\n", " 'bBox': {'x': 134.62, 'y': 138.8, 'w': 258.68, 'h': 39.59}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 3,\n", " 'text': 'tfm Publishing Limited, Castle ħill Barns, ħarley, Nr Shrewsbury, SY5\\n6LX, UK\\nTel: +44 (0)1952 510061; Fax: +44 (0)1952 510192\\nE-mail: info@tfmpublishing.com;\\nWeb site: www.tfmpublishing.com\\n\\nEditing, Design & Typesetting: Nikki Bramhill BSc (ħons) Dip Law\\nFourth edition: © 2016\\nCartoons: © 2016 Evgeniy E. (Perya) Perelygin, MD\\nFront cover painting: © 2011 Dan Schein (www.danschein.com)\\n“The thinking surgeon”: oil on canvas\\n\\n Paperback ISBN: 978-1-910079-11-9\\n\\nE-book editions: 2016\\n ePub ISBN: 978-1-910079-12-6\\n Mobi ISBN: 978-1-910079-13-3\\n Web pdf ISBN: 978-1-910079-14-0\\n\\nThe entire contents of Schein’s Common Sense Emergency Abdominal\\nSurgery is copyright tfm Publishing Ltd. Apart from any fair dealing for the\\npurposes of research or private study, or criticism or review, as permitted\\nunder the Copyright, Designs and Patents Act 1988, this publication may\\nnot be reproduced, stored in a retrieval system or transmitted in any form\\nor by any means, electronic, digital, mechanical, photocopying, recording\\nor otherwise, without the prior written permission of the publisher.\\n\\nNeither the authors, the editors nor the publisher can accept\\nresponsibility for any injury or damage to persons or property occasioned\\nthrough the implementation of any ideas or use of any product described\\nherein. Neither can they accept any responsibility for errors, omissions or\\nmisrepresentations, howsoever caused.\\n\\nWhilst every care is taken by the authors, the editors and the publisher to\\nensure that all information and data in this book are as accurate as\\npossible at the time of going to press, it is recommended that readers',\n", " 'md': '```markdown\\n# Page Information\\n\\n**Publisher Information:**\\n- tfm Publishing Limited, Castle Hill Barns, Harley, Nr Shrewsbury, SY5 6LX, UK\\n- Tel: +44 (0)1952 510061; Fax: +44 (0)1952 510192\\n- E-mail: [info@tfmpublishing.com](mailto:info@tfmpublishing.com)\\n- Web site: [www.tfmpublishing.com](http://www.tfmpublishing.com)\\n\\n**Editing, Design & Typesetting:**\\n- Nikki Bramhill BSc (Hons) Dip Law\\n\\n**Edition Information:**\\n- Fourth edition: © 2016\\n- Cartoons: © 2016 Evgeniy E. (Perya) Perelygin, MD\\n- Front cover painting: © 2011 Dan Schein ([www.danschein.com](http://www.danschein.com))\\n- “The thinking surgeon”: oil on canvas\\n\\n**ISBN Information:**\\n- Paperback ISBN: 978-1-910079-11-9\\n- E-book editions: 2016\\n- ePub ISBN: 978-1-910079-12-6\\n- Mobi ISBN: 978-1-910079-13-3\\n- Web pdf ISBN: 978-1-910079-14-0\\n\\n**Copyright Notice:**\\nThe entire contents of Schein’s Common Sense Emergency Abdominal Surgery is copyright tfm Publishing Ltd. Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may not be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, digital, mechanical, photocopying, recording or otherwise, without the prior written permission of the publisher.\\n\\n**Disclaimer:**\\nNeither the authors, the editors nor the publisher can accept responsibility for any injury or damage to persons or property occasioned through the implementation of any ideas or use of any product described herein. Neither can they accept any responsibility for errors, omissions or misrepresentations, howsoever caused.\\n\\n**Accuracy Notice:**\\nWhilst every care is taken by the authors, the editors and the publisher to ensure that all information and data in this book are as accurate as possible at the time of going to press, it is recommended that readers...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Information',\n", " 'md': '# Page Information',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Publisher Information:**\\n- tfm Publishing Limited, Castle Hill Barns, Harley, Nr Shrewsbury, SY5 6LX, UK\\n- Tel: +44 (0)1952 510061; Fax: +44 (0)1952 510192\\n- E-mail: [info@tfmpublishing.com](mailto:info@tfmpublishing.com)\\n- Web site: [www.tfmpublishing.com](http://www.tfmpublishing.com)\\n\\n**Editing, Design & Typesetting:**\\n- Nikki Bramhill BSc (Hons) Dip Law\\n\\n**Edition Information:**\\n- Fourth edition: © 2016\\n- Cartoons: © 2016 Evgeniy E. (Perya) Perelygin, MD\\n- Front cover painting: © 2011 Dan Schein ([www.danschein.com](http://www.danschein.com))\\n- “The thinking surgeon”: oil on canvas\\n\\n**ISBN Information:**\\n- Paperback ISBN: 978-1-910079-11-9\\n- E-book editions: 2016\\n- ePub ISBN: 978-1-910079-12-6\\n- Mobi ISBN: 978-1-910079-13-3\\n- Web pdf ISBN: 978-1-910079-14-0\\n\\n**Copyright Notice:**\\nThe entire contents of Schein’s Common Sense Emergency Abdominal Surgery is copyright tfm Publishing Ltd. Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may not be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, digital, mechanical, photocopying, recording or otherwise, without the prior written permission of the publisher.\\n\\n**Disclaimer:**\\nNeither the authors, the editors nor the publisher can accept responsibility for any injury or damage to persons or property occasioned through the implementation of any ideas or use of any product described herein. Neither can they accept any responsibility for errors, omissions or misrepresentations, howsoever caused.\\n\\n**Accuracy Notice:**\\nWhilst every care is taken by the authors, the editors and the publisher to ensure that all information and data in this book are as accurate as possible at the time of going to press, it is recommended that readers...\\n```',\n", " 'md': '**Publisher Information:**\\n- tfm Publishing Limited, Castle Hill Barns, Harley, Nr Shrewsbury, SY5 6LX, UK\\n- Tel: +44 (0)1952 510061; Fax: +44 (0)1952 510192\\n- E-mail: [info@tfmpublishing.com](mailto:info@tfmpublishing.com)\\n- Web site: [www.tfmpublishing.com](http://www.tfmpublishing.com)\\n\\n**Editing, Design & Typesetting:**\\n- Nikki Bramhill BSc (Hons) Dip Law\\n\\n**Edition Information:**\\n- Fourth edition: © 2016\\n- Cartoons: © 2016 Evgeniy E. (Perya) Perelygin, MD\\n- Front cover painting: © 2011 Dan Schein ([www.danschein.com](http://www.danschein.com))\\n- “The thinking surgeon”: oil on canvas\\n\\n**ISBN Information:**\\n- Paperback ISBN: 978-1-910079-11-9\\n- E-book editions: 2016\\n- ePub ISBN: 978-1-910079-12-6\\n- Mobi ISBN: 978-1-910079-13-3\\n- Web pdf ISBN: 978-1-910079-14-0\\n\\n**Copyright Notice:**\\nThe entire contents of Schein’s Common Sense Emergency Abdominal Surgery is copyright tfm Publishing Ltd. Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may not be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, digital, mechanical, photocopying, recording or otherwise, without the prior written permission of the publisher.\\n\\n**Disclaimer:**\\nNeither the authors, the editors nor the publisher can accept responsibility for any injury or damage to persons or property occasioned through the implementation of any ideas or use of any product described herein. Neither can they accept any responsibility for errors, omissions or misrepresentations, howsoever caused.\\n\\n**Accuracy Notice:**\\nWhilst every care is taken by the authors, the editors and the publisher to ensure that all information and data in this book are as accurate as possible at the time of going to press, it is recommended that readers...\\n```',\n", " 'bBox': {'x': 72, 'y': 116, 'w': 467.92, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'url': 'mailto:info@tfmpublishing.com',\n", " 'text': 'Web site: www.tfmpublishing.com'},\n", " {'url': 'http://www.tfmpublishing.com/', 'text': ''},\n", " {'url': 'http://www.danschein.com/', 'text': ''}]},\n", " {'page': 4,\n", " 'text': 'seek independent verification of advice on drug or other product usage,\\nsurgical techniques and clinical processes prior to their use.\\n\\nThe authors, editors and publisher gratefully acknowledge the permission\\ngranted to reproduce the copyright material where applicable in this book.\\nEvery effort has been made to trace copyright holders and to obtain their\\npermission for the use of copyright material. The publisher apologizes for\\nany errors or omissions and would be grateful if notified of any\\ncorrections that should be incorporated in future reprints or editions of\\nthis book.',\n", " 'md': '```markdown\\n# Page Content\\n\\nSeek independent verification of advice on drug or other product usage, surgical techniques, and clinical processes prior to their use.\\n\\nThe authors, editors, and publisher gratefully acknowledge the permission granted to reproduce the copyright material where applicable in this book. Every effort has been made to trace copyright holders and to obtain their permission for the use of copyright material. The publisher apologizes for any errors or omissions and would be grateful if notified of any corrections that should be incorporated in future reprints or editions of this book.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Seek independent verification of advice on drug or other product usage, surgical techniques, and clinical processes prior to their use.\\n\\nThe authors, editors, and publisher gratefully acknowledge the permission granted to reproduce the copyright material where applicable in this book. Every effort has been made to trace copyright holders and to obtain their permission for the use of copyright material. The publisher apologizes for any errors or omissions and would be grateful if notified of any corrections that should be incorporated in future reprints or editions of this book.\\n```',\n", " 'md': 'Seek independent verification of advice on drug or other product usage, surgical techniques, and clinical processes prior to their use.\\n\\nThe authors, editors, and publisher gratefully acknowledge the permission granted to reproduce the copyright material where applicable in this book. Every effort has been made to trace copyright holders and to obtain their permission for the use of copyright material. The publisher apologizes for any errors or omissions and would be grateful if notified of any corrections that should be incorporated in future reprints or editions of this book.\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.8, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 5,\n", " 'text': 'Contents\\nContributors\\n\\nEditors’ note\\n\\nPreface\\n\\nPART I — GENERAL CONSIDERATIONS\\n\\nChapter 1\\nGeneral philosophy\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and\\nJonathan E. Efron\\n\\nChapter 2\\nA brief history of emergency abdominal surgery\\nħarold Ellis\\n\\nPART II — BEFORE THE OPERATION\\n\\nChapter 3\\nThe acute abdomen\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and\\nJonathan E. Efron\\n\\nChapter 4\\nRational diagnostic procedures\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and',\n", " 'md': '```markdown\\n# Contents\\n\\n## Contributors\\n\\n## Editors’ note\\n\\n## Preface\\n\\n# PART I — GENERAL CONSIDERATIONS\\n\\n## Chapter 1\\n**General philosophy**\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n## Chapter 2\\n**A brief history of emergency abdominal surgery**\\nHarold Ellis\\n\\n# PART II — BEFORE THE OPERATION\\n\\n## Chapter 3\\n**The acute abdomen**\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n## Chapter 4\\n**Rational diagnostic procedures**\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Contents',\n", " 'md': '# Contents',\n", " 'bBox': {'x': 72, 'y': 129, 'w': 124.73, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Contributors',\n", " 'md': '## Contributors',\n", " 'bBox': {'x': 72, 'y': 180, 'w': 100.22, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Editors’ note',\n", " 'md': '## Editors’ note',\n", " 'bBox': {'x': 72, 'y': 216, 'w': 100.22, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Preface',\n", " 'md': '## Preface',\n", " 'bBox': {'x': 72, 'y': 251, 'w': 59.8, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'PART I — GENERAL CONSIDERATIONS',\n", " 'md': '# PART I — GENERAL CONSIDERATIONS',\n", " 'bBox': {'x': 72, 'y': 312, 'w': 312.66, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 1',\n", " 'md': '## Chapter 1',\n", " 'bBox': {'x': 72, 'y': 347, 'w': 76.34, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**General philosophy**\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron',\n", " 'md': '**General philosophy**\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron',\n", " 'bBox': {'x': 72, 'y': 366, 'w': 154.48, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 2',\n", " 'md': '## Chapter 2',\n", " 'bBox': {'x': 72, 'y': 438, 'w': 76.34, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**A brief history of emergency abdominal surgery**\\nHarold Ellis',\n", " 'md': '**A brief history of emergency abdominal surgery**\\nHarold Ellis',\n", " 'bBox': {'x': 72, 'y': 457, 'w': 376.38, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'PART II — BEFORE THE OPERATION',\n", " 'md': '# PART II — BEFORE THE OPERATION',\n", " 'bBox': {'x': 72, 'y': 536, 'w': 291.78, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 3',\n", " 'md': '## Chapter 3',\n", " 'bBox': {'x': 72, 'y': 571, 'w': 76.34, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**The acute abdomen**\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron',\n", " 'md': '**The acute abdomen**\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron',\n", " 'bBox': {'x': 72, 'y': 403, 'w': 155.42, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 4',\n", " 'md': '## Chapter 4',\n", " 'bBox': {'x': 72, 'y': 663, 'w': 76.34, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**Rational diagnostic procedures**\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n```',\n", " 'md': '**Rational diagnostic procedures**\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n```',\n", " 'bBox': {'x': 72, 'y': 403, 'w': 247.36, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Contributors'},\n", " {'text': 'Editors’ note'},\n", " {'text': 'Preface'},\n", " {'text': 'PART I — GENERAL CONSIDERATIONS'},\n", " {'text': 'Chapter 1 General philosophy'},\n", " {'text': 'General philosophy'},\n", " {'text': 'Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and Jonathan E. Efron'},\n", " {'text': 'Chapter 2 A brief history of emergency abdominal surgery'},\n", " {'text': 'A brief history of emergency abdominal surgery'},\n", " {'text': 'ħarold Ellis'},\n", " {'text': 'PART II — BEFORE THE OPERATION'},\n", " {'text': 'Chapter 3 The acute abdomen'},\n", " {'text': 'The acute abdomen'},\n", " {'text': 'Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and Jonathan E. Efron'},\n", " {'text': 'Chapter 4 Rational diagnostic procedures'},\n", " {'text': 'Rational diagnostic procedures'},\n", " {'text': 'Contents Contributors Editors’ note Preface PART I — GENERAL CONSIDERATIONS Chapter 1 General philosophy Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and Jonathan E. Efron Chapter 2 A brief history of emergency abdominal surgery ħarold Ellis PART II — BEFORE THE OPERATION Chapter 3 The acute abdomen Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and Jonathan E. Efron Chapter 4 Rational diagnostic procedures Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and'}]},\n", " {'page': 6,\n", " 'text': 'Jonathan E. Efron\\n\\nChapter 5\\nAbdominal imaging\\nMoshe Schein and ħans Ulrich Elben\\n\\nChapter 6\\nOptimizing the patient\\nJames C. Rucinski\\n\\nChapter 7\\nPre-operative antibiotics\\nMoshe Schein\\n\\nChapter 8\\nFamily, ethics, informed consent and medicolegal issues\\nJames C. Rucinski\\n\\nChapter 9\\nBefore the flight: pre-op checklist\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and\\nJonathan E. Efron\\n\\nPART III — THE OPERATION\\n\\nChapter 10\\nThe incision\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and\\nJonathan E. Efron\\n\\nChapter 11\\nAbdominal exploration: finding what is wrong\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and\\nJonathan E. Efron',\n", " 'md': '```markdown\\n# Table of Contents\\n\\n1. **Chapter 5**: Abdominal imaging\\nAuthors: Moshe Schein and Hans Ulrich Elben\\n\\n2. **Chapter 6**: Optimizing the patient\\nAuthor: James C. Rucinski\\n\\n3. **Chapter 7**: Pre-operative antibiotics\\nAuthor: Moshe Schein\\n\\n4. **Chapter 8**: Family, ethics, informed consent and medicolegal issues\\nAuthor: James C. Rucinski\\n\\n5. **Chapter 9**: Before the flight: pre-op checklist\\nAuthors: Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n----\\n\\n## PART III — THE OPERATION\\n\\n6. **Chapter 10**: The incision\\nAuthors: Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n7. **Chapter 11**: Abdominal exploration: finding what is wrong\\nAuthors: Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Table of Contents',\n", " 'md': '# Table of Contents',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. **Chapter 5**: Abdominal imaging\\nAuthors: Moshe Schein and Hans Ulrich Elben\\n\\n2. **Chapter 6**: Optimizing the patient\\nAuthor: James C. Rucinski\\n\\n3. **Chapter 7**: Pre-operative antibiotics\\nAuthor: Moshe Schein\\n\\n4. **Chapter 8**: Family, ethics, informed consent and medicolegal issues\\nAuthor: James C. Rucinski\\n\\n5. **Chapter 9**: Before the flight: pre-op checklist\\nAuthors: Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n----',\n", " 'md': '1. **Chapter 5**: Abdominal imaging\\nAuthors: Moshe Schein and Hans Ulrich Elben\\n\\n2. **Chapter 6**: Optimizing the patient\\nAuthor: James C. Rucinski\\n\\n3. **Chapter 7**: Pre-operative antibiotics\\nAuthor: Moshe Schein\\n\\n4. **Chapter 8**: Family, ethics, informed consent and medicolegal issues\\nAuthor: James C. Rucinski\\n\\n5. **Chapter 9**: Before the flight: pre-op checklist\\nAuthors: Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n----',\n", " 'bBox': {'x': 72, 'y': 87, 'w': 446.57, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'PART III — THE OPERATION',\n", " 'md': '## PART III — THE OPERATION',\n", " 'bBox': {'x': 72, 'y': 532, 'w': 222.8, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '6. **Chapter 10**: The incision\\nAuthors: Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n7. **Chapter 11**: Abdominal exploration: finding what is wrong\\nAuthors: Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n```',\n", " 'md': '6. **Chapter 10**: The incision\\nAuthors: Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n7. **Chapter 11**: Abdominal exploration: finding what is wrong\\nAuthors: Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n```',\n", " 'bBox': {'x': 72, 'y': 87, 'w': 359.45, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 5 Abdominal imaging'},\n", " {'text': 'Abdominal imaging'},\n", " {'text': 'Moshe Schein and ħans Ulrich Elben'},\n", " {'text': 'Chapter 6 Optimizing the patient'},\n", " {'text': 'Optimizing the patient'},\n", " {'text': 'James C. Rucinski'},\n", " {'text': 'Chapter 7 Pre-operative antibiotics'},\n", " {'text': 'Pre-operative antibiotics'},\n", " {'text': 'Moshe Schein'},\n", " {'text': 'Chapter 8 Family, ethics, informed consent and medicolegal issues'},\n", " {'text': 'Family, ethics, informed consent and medicolegal issues'},\n", " {'text': 'James C. Rucinski'},\n", " {'text': 'Chapter 9 Before the flight: pre-op checklist'},\n", " {'text': 'Before the flight: pre-op checklist'},\n", " {'text': 'Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and Jonathan E. Efron'},\n", " {'text': 'PART III — THE OPERATION'},\n", " {'text': 'Chapter 10 The incision'},\n", " {'text': 'The incision'},\n", " {'text': 'Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and Jonathan E. Efron'},\n", " {'text': 'Chapter 11 Abdominal exploration: finding what is wrong'},\n", " {'text': 'Abdominal exploration: finding what is wrong'},\n", " {'text': 'Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and Jonathan E. Efron'}]},\n", " {'page': 7,\n", " 'text': 'Chapter 12\\nThe laparoscopic approach to emergency abdominal\\nsurgery\\nDanny Rosin\\n\\nChapter 13\\nPeritonitis: classification and principles of treatment\\nMoshe Schein and Roger Saadia\\n\\nChapter 14\\nThe intestinal anastomosis (and stomata)\\nMark Cheetham, Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny\\nRosin and Jonathan E. Efron\\n\\nChapter 15\\nEsophageal emergencies\\nBrandon ħ. Tieu and John G. ħunter\\n\\nChapter 16\\nDiaphragmatic emergencies\\nDanny Rosin\\n\\nChapter 17\\nUpper gastrointestinal bleeding\\nMoshe Schein\\n\\nChapter 18\\nPerforated peptic ulcer\\nMoshe Schein\\n\\nChapter 19\\nAcute pancreatitis\\nAri Leppäniemi\\n\\nChapter 20',\n", " 'md': '```markdown\\n# Chapter 12\\n## The laparoscopic approach to emergency abdominal surgery\\n### Danny Rosin\\n\\n# Chapter 13\\n## Peritonitis: classification and principles of treatment\\n### Moshe Schein and Roger Saadia\\n\\n# Chapter 14\\n## The intestinal anastomosis (and stomata)\\n### Mark Cheetham, Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and Jonathan E. Efron\\n\\n# Chapter 15\\n## Esophageal emergencies\\n### Brandon ħ. Tieu and John G. ħunter\\n\\n# Chapter 16\\n## Diaphragmatic emergencies\\n### Danny Rosin\\n\\n# Chapter 17\\n## Upper gastrointestinal bleeding\\n### Moshe Schein\\n\\n# Chapter 18\\n## Perforated peptic ulcer\\n### Moshe Schein\\n\\n# Chapter 19\\n## Acute pancreatitis\\n### Ari Leppäniemi\\n\\n# Chapter 20\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 12',\n", " 'md': '# Chapter 12',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The laparoscopic approach to emergency abdominal surgery',\n", " 'md': '## The laparoscopic approach to emergency abdominal surgery',\n", " 'bBox': {'x': 72, 'y': 126, 'w': 60.71, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Danny Rosin',\n", " 'md': '### Danny Rosin',\n", " 'bBox': {'x': 72, 'y': 146, 'w': 82.38, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 13',\n", " 'md': '# Chapter 13',\n", " 'bBox': {'x': 72, 'y': 181, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Peritonitis: classification and principles of treatment',\n", " 'md': '## Peritonitis: classification and principles of treatment',\n", " 'bBox': {'x': 72, 'y': 201, 'w': 412.81, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Moshe Schein and Roger Saadia',\n", " 'md': '### Moshe Schein and Roger Saadia',\n", " 'bBox': {'x': 72, 'y': 220, 'w': 211.13, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 14',\n", " 'md': '# Chapter 14',\n", " 'bBox': {'x': 72, 'y': 255, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The intestinal anastomosis (and stomata)',\n", " 'md': '## The intestinal anastomosis (and stomata)',\n", " 'bBox': {'x': 72, 'y': 274, 'w': 325.51, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Mark Cheetham, Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and Jonathan E. Efron',\n", " 'md': '### Mark Cheetham, Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and Jonathan E. Efron',\n", " 'bBox': {'x': 72, 'y': 146, 'w': 467.76, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 15',\n", " 'md': '# Chapter 15',\n", " 'bBox': {'x': 72, 'y': 346, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Esophageal emergencies',\n", " 'md': '## Esophageal emergencies',\n", " 'bBox': {'x': 72, 'y': 366, 'w': 198.67, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Brandon ħ. Tieu and John G. ħunter',\n", " 'md': '### Brandon ħ. Tieu and John G. ħunter',\n", " 'bBox': {'x': 72, 'y': 385, 'w': 233.74, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 16',\n", " 'md': '# Chapter 16',\n", " 'bBox': {'x': 72, 'y': 420, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diaphragmatic emergencies',\n", " 'md': '## Diaphragmatic emergencies',\n", " 'bBox': {'x': 72, 'y': 439, 'w': 220.73, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Danny Rosin',\n", " 'md': '### Danny Rosin',\n", " 'bBox': {'x': 72, 'y': 146, 'w': 82.38, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 17',\n", " 'md': '# Chapter 17',\n", " 'bBox': {'x': 72, 'y': 494, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Upper gastrointestinal bleeding',\n", " 'md': '## Upper gastrointestinal bleeding',\n", " 'bBox': {'x': 72, 'y': 513, 'w': 248.26, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Moshe Schein',\n", " 'md': '### Moshe Schein',\n", " 'bBox': {'x': 72, 'y': 533, 'w': 91.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 18',\n", " 'md': '# Chapter 18',\n", " 'bBox': {'x': 72, 'y': 567, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Perforated peptic ulcer',\n", " 'md': '## Perforated peptic ulcer',\n", " 'bBox': {'x': 72, 'y': 587, 'w': 180.23, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Moshe Schein',\n", " 'md': '### Moshe Schein',\n", " 'bBox': {'x': 72, 'y': 533, 'w': 91.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 19',\n", " 'md': '# Chapter 19',\n", " 'bBox': {'x': 72, 'y': 641, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Acute pancreatitis',\n", " 'md': '## Acute pancreatitis',\n", " 'bBox': {'x': 72, 'y': 661, 'w': 143.46, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Ari Leppäniemi',\n", " 'md': '### Ari Leppäniemi',\n", " 'bBox': {'x': 72, 'y': 680, 'w': 95.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 20',\n", " 'md': '# Chapter 20',\n", " 'bBox': {'x': 72, 'y': 715, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 12 The '},\n", " {'text': 'The laparoscopic approach to emergency abdominal surgery'},\n", " {'text': 'Danny Rosin'},\n", " {'text': 'Chapter 13 Peritonitis: classification and principles of treatment'},\n", " {'text': 'Peritonitis: classification and principles of treatment'},\n", " {'text': 'Moshe Schein and Roger Saadia'},\n", " {'text': 'Chapter 14 The intestinal anastomosis (and stomata)'},\n", " {'text': 'The intestinal anastomosis (and stomata)'},\n", " {'text': 'Mark Cheetham, Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and Jonathan E. Efron'},\n", " {'text': 'Chapter 15 Esophageal emergencies'},\n", " {'text': 'Esophageal emergencies'},\n", " {'text': 'Brandon ħ. Tieu and John G. ħunter'},\n", " {'text': 'Chapter 16 Diaphragmatic emergencies'},\n", " {'text': 'Diaphragmatic emergencies'},\n", " {'text': 'Danny Rosin'},\n", " {'text': 'Chapter 17 Upper gastrointestinal bleeding'},\n", " {'text': 'Upper gastrointestinal bleeding'},\n", " {'text': 'Moshe Schein'},\n", " {'text': 'Chapter 18 Perforated peptic ulcer'},\n", " {'text': 'Perforated peptic ulcer'},\n", " {'text': 'Moshe Schein'},\n", " {'text': 'Chapter 19 Acute pancreatitis'},\n", " {'text': 'Acute pancreatitis'},\n", " {'text': 'Ari Leppäniemi'},\n", " {'text': 'Chapter 20'}]},\n", " {'page': 8,\n", " 'text': 'Gallbladder and biliary emergency surgery\\nDanny Rosin, Moshe Schein and B. Ramana\\n\\nChapter 21\\nSmall bowel obstruction\\nMoshe Schein and Danny Rosin\\n\\nChapter 22\\nAcute abdominal wall hernias\\nPaul N. Rogers\\n\\nChapter 23\\nAcute appendicitis\\nRoland E. Andersson\\n\\nChapter 24\\nAcute mesenteric ischemia\\nMoshe Schein and Paul N. Rogers\\n\\nChapter 25\\nHepatic emergencies\\nErik Schadde\\n\\nChapter 26\\nInflammatory bowel disease and other types of colitis\\nBashar Safar and Jonathan E. Efron\\n\\nChapter 27\\nColonic obstruction\\nJonathan E. Efron\\n\\nChapter 28\\nAcute diverticulitis\\nJonathan E. Efron',\n", " 'md': '```markdown\\n# Table of Contents\\n\\n1. **Gallbladder and biliary emergency surgery**\\nAuthors: Danny Rosin, Moshe Schein, and B. Ramana\\n\\n2. **Small bowel obstruction**\\nAuthors: Moshe Schein and Danny Rosin\\n\\n3. **Acute abdominal wall hernias**\\nAuthor: Paul N. Rogers\\n\\n4. **Acute appendicitis**\\nAuthor: Roland E. Andersson\\n\\n5. **Acute mesenteric ischemia**\\nAuthors: Moshe Schein and Paul N. Rogers\\n\\n6. **Hepatic emergencies**\\nAuthor: Erik Schadde\\n\\n7. **Inflammatory bowel disease and other types of colitis**\\nAuthors: Bashar Safar and Jonathan E. Efron\\n\\n8. **Colonic obstruction**\\nAuthor: Jonathan E. Efron\\n\\n9. **Acute diverticulitis**\\nAuthor: Jonathan E. Efron\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Table of Contents',\n", " 'md': '# Table of Contents',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. **Gallbladder and biliary emergency surgery**\\nAuthors: Danny Rosin, Moshe Schein, and B. Ramana\\n\\n2. **Small bowel obstruction**\\nAuthors: Moshe Schein and Danny Rosin\\n\\n3. **Acute abdominal wall hernias**\\nAuthor: Paul N. Rogers\\n\\n4. **Acute appendicitis**\\nAuthor: Roland E. Andersson\\n\\n5. **Acute mesenteric ischemia**\\nAuthors: Moshe Schein and Paul N. Rogers\\n\\n6. **Hepatic emergencies**\\nAuthor: Erik Schadde\\n\\n7. **Inflammatory bowel disease and other types of colitis**\\nAuthors: Bashar Safar and Jonathan E. Efron\\n\\n8. **Colonic obstruction**\\nAuthor: Jonathan E. Efron\\n\\n9. **Acute diverticulitis**\\nAuthor: Jonathan E. Efron\\n```',\n", " 'md': '1. **Gallbladder and biliary emergency surgery**\\nAuthors: Danny Rosin, Moshe Schein, and B. Ramana\\n\\n2. **Small bowel obstruction**\\nAuthors: Moshe Schein and Danny Rosin\\n\\n3. **Acute abdominal wall hernias**\\nAuthor: Paul N. Rogers\\n\\n4. **Acute appendicitis**\\nAuthor: Roland E. Andersson\\n\\n5. **Acute mesenteric ischemia**\\nAuthors: Moshe Schein and Paul N. Rogers\\n\\n6. **Hepatic emergencies**\\nAuthor: Erik Schadde\\n\\n7. **Inflammatory bowel disease and other types of colitis**\\nAuthors: Bashar Safar and Jonathan E. Efron\\n\\n8. **Colonic obstruction**\\nAuthor: Jonathan E. Efron\\n\\n9. **Acute diverticulitis**\\nAuthor: Jonathan E. Efron\\n```',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 421.11, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Gallbladder and biliary emergency surgery'},\n", " {'text': 'Danny Rosin, Moshe Schein and B. Ramana'},\n", " {'text': 'Chapter 21 Small bowel obstruction'},\n", " {'text': 'Small bowel obstruction'},\n", " {'text': 'Moshe Schein and Danny Rosin'},\n", " {'text': 'Chapter 22 Acute abdominal wall hernias'},\n", " {'text': 'Acute abdominal wall hernias'},\n", " {'text': 'Paul N. Rogers'},\n", " {'text': 'Chapter 23 Acute appendicitis'},\n", " {'text': 'Acute appendicitis'},\n", " {'text': 'Roland E. Andersson'},\n", " {'text': 'Chapter 24 Acute mesenteric ischemia'},\n", " {'text': 'Acute mesenteric ischemia'},\n", " {'text': 'Moshe Schein and Paul N. Rogers'},\n", " {'text': 'Chapter 25 Hepatic emergencies'},\n", " {'text': 'Hepatic emergencies'},\n", " {'text': 'Erik Schadde'},\n", " {'text': 'Chapter 26 Inflammatory bowel disease and other types of colitis'},\n", " {'text': 'Inflammatory bowel disease and other types of colitis'},\n", " {'text': 'Bashar Safar and Jonathan E. Efron'},\n", " {'text': 'Chapter 27 Colonic obstruction'},\n", " {'text': 'Colonic obstruction'},\n", " {'text': 'Jonathan E. Efron'},\n", " {'text': 'Chapter 28 Acute diverticulitis'},\n", " {'text': 'Acute diverticulitis'},\n", " {'text': 'Jonathan E. Efron'}]},\n", " {'page': 9,\n", " 'text': 'Chapter 29\\nMassive lower GI bleeding\\nJonathan E. Efron\\n\\nChapter 30\\nAnorectal emergencies\\nJonathan E. Efron\\n\\nChapter 31\\nSurgical complications of endoscopy\\nAhmad Assalia and Anat Ilivitzki\\n\\nChapter 32\\nAbdominal trauma\\nRoger Saadia\\n\\nChapter 33\\nThe abdominal compartment syndrome\\nAri Leppäniemi and Moshe Schein\\n\\nChapter 34\\nAbdominal aortic emergencies\\nPaul N. Rogers\\n\\nChapter 35\\nGynecological emergencies\\nMoshe Schein\\n\\nChapter 36\\nAbdominal emergencies in infancy and childhood\\nWojciech J. Górecki\\n\\nChapter 37\\nUrological emergencies\\nJack Baniel',\n", " 'md': '```markdown\\n# Table of Contents\\n\\n## Chapter 29\\n**Massive lower GI bleeding**\\n*Author: Jonathan E. Efron*\\n\\n## Chapter 30\\n**Anorectal emergencies**\\n*Author: Jonathan E. Efron*\\n\\n## Chapter 31\\n**Surgical complications of endoscopy**\\n*Authors: Ahmad Assalia and Anat Ilivitzki*\\n\\n## Chapter 32\\n**Abdominal trauma**\\n*Author: Roger Saadia*\\n\\n## Chapter 33\\n**The abdominal compartment syndrome**\\n*Authors: Ari Leppäniemi and Moshe Schein*\\n\\n## Chapter 34\\n**Abdominal aortic emergencies**\\n*Author: Paul N. Rogers*\\n\\n## Chapter 35\\n**Gynecological emergencies**\\n*Author: Moshe Schein*\\n\\n## Chapter 36\\n**Abdominal emergencies in infancy and childhood**\\n*Author: Wojciech J. Górecki*\\n\\n## Chapter 37\\n**Urological emergencies**\\n*Author: Jack Baniel*\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Table of Contents',\n", " 'md': '# Table of Contents',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 29',\n", " 'md': '## Chapter 29',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**Massive lower GI bleeding**\\n*Author: Jonathan E. Efron*',\n", " 'md': '**Massive lower GI bleeding**\\n*Author: Jonathan E. Efron*',\n", " 'bBox': {'x': 72, 'y': 107, 'w': 206.88, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 30',\n", " 'md': '## Chapter 30',\n", " 'bBox': {'x': 72, 'y': 162, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**Anorectal emergencies**\\n*Author: Jonathan E. Efron*',\n", " 'md': '**Anorectal emergencies**\\n*Author: Jonathan E. Efron*',\n", " 'bBox': {'x': 72, 'y': 126, 'w': 182.11, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 31',\n", " 'md': '## Chapter 31',\n", " 'bBox': {'x': 72, 'y': 235, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**Surgical complications of endoscopy**\\n*Authors: Ahmad Assalia and Anat Ilivitzki*',\n", " 'md': '**Surgical complications of endoscopy**\\n*Authors: Ahmad Assalia and Anat Ilivitzki*',\n", " 'bBox': {'x': 72, 'y': 255, 'w': 293.33, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 32',\n", " 'md': '## Chapter 32',\n", " 'bBox': {'x': 72, 'y': 309, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**Abdominal trauma**\\n*Author: Roger Saadia*',\n", " 'md': '**Abdominal trauma**\\n*Author: Roger Saadia*',\n", " 'bBox': {'x': 72, 'y': 329, 'w': 145.29, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 33',\n", " 'md': '## Chapter 33',\n", " 'bBox': {'x': 72, 'y': 383, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**The abdominal compartment syndrome**\\n*Authors: Ari Leppäniemi and Moshe Schein*',\n", " 'md': '**The abdominal compartment syndrome**\\n*Authors: Ari Leppäniemi and Moshe Schein*',\n", " 'bBox': {'x': 72, 'y': 402, 'w': 309.9, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 34',\n", " 'md': '## Chapter 34',\n", " 'bBox': {'x': 72, 'y': 457, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**Abdominal aortic emergencies**\\n*Author: Paul N. Rogers*',\n", " 'md': '**Abdominal aortic emergencies**\\n*Author: Paul N. Rogers*',\n", " 'bBox': {'x': 72, 'y': 476, 'w': 240.93, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 35',\n", " 'md': '## Chapter 35',\n", " 'bBox': {'x': 72, 'y': 530, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**Gynecological emergencies**\\n*Author: Moshe Schein*',\n", " 'md': '**Gynecological emergencies**\\n*Author: Moshe Schein*',\n", " 'bBox': {'x': 72, 'y': 550, 'w': 218.88, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 36',\n", " 'md': '## Chapter 36',\n", " 'bBox': {'x': 72, 'y': 605, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**Abdominal emergencies in infancy and childhood**\\n*Author: Wojciech J. Górecki*',\n", " 'md': '**Abdominal emergencies in infancy and childhood**\\n*Author: Wojciech J. Górecki*',\n", " 'bBox': {'x': 72, 'y': 624, 'w': 390.78, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 37',\n", " 'md': '## Chapter 37',\n", " 'bBox': {'x': 72, 'y': 678, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**Urological emergencies**\\n*Author: Jack Baniel*\\n```',\n", " 'md': '**Urological emergencies**\\n*Author: Jack Baniel*\\n```',\n", " 'bBox': {'x': 72, 'y': 697, 'w': 186.69, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 29 Massive lower GI bleeding'},\n", " {'text': 'Massive lower GI bleeding'},\n", " {'text': 'Jonathan E. Efron'},\n", " {'text': 'Chapter 30 Anorectal emergencies'},\n", " {'text': 'Anorectal emergencies'},\n", " {'text': 'Jonathan E. Efron'},\n", " {'text': 'Chapter 31 Surgical complications of endoscopy'},\n", " {'text': 'Surgical complications of endoscopy'},\n", " {'text': 'Ahmad Assalia and Anat Ilivitzki'},\n", " {'text': 'Chapter 32 Abdominal trauma'},\n", " {'text': 'Abdominal trauma'},\n", " {'text': 'Roger Saadia'},\n", " {'text': 'Chapter 33 The abdominal compartment syndrome'},\n", " {'text': 'The abdominal compartment syndrome'},\n", " {'text': 'Ari Leppäniemi and Moshe Schein'},\n", " {'text': 'Chapter 34 Abdominal aortic emergencies'},\n", " {'text': 'Abdominal aortic emergencies'},\n", " {'text': 'Paul N. Rogers'},\n", " {'text': 'Chapter 35 Gynecological emergencies'},\n", " {'text': 'Gynecological emergencies'},\n", " {'text': 'Moshe Schein'},\n", " {'text': 'Chapter 36 Abdominal emergencies in infancy and childhood'},\n", " {'text': 'Abdominal emergencies in infancy and childhood'},\n", " {'text': 'Wojciech J. Górecki'},\n", " {'text': 'Chapter 37 Urological emergencies'},\n", " {'text': 'Urological emergencies'},\n", " {'text': 'Jack Baniel'}]},\n", " {'page': 10,\n", " 'text': 'Chapter 38\\nAbdominal emergencies in the Third World\\nRobin Kaushik, Graeme Pitcher and Craig Joseph\\n\\nChapter 39\\nAbdominal drainage\\nMoshe Schein and Paul N. Rogers\\n\\nChapter 40\\nAbdominal closure\\nMoshe Schein and Danny Rosin\\n\\nChapter 41\\nBefore landing\\nMoshe Schein\\n\\nPART IV — AFTER THE OPERATION\\n\\nChapter 42\\nPostoperative care\\nMoshe Schein\\n\\nChapter 43\\nNutrition\\nJames C. Rucinski\\n\\nChapter 44\\nPostoperative antibiotics\\nMoshe Schein\\n\\nChapter 45\\nPostoperative ileus vs. intestinal obstruction',\n", " 'md': '```markdown\\n# Chapter 38\\n## Abdominal emergencies in the Third World\\n- Authors: Robin Kaushik, Graeme Pitcher, and Craig Joseph\\n\\n# Chapter 39\\n## Abdominal drainage\\n- Authors: Moshe Schein and Paul N. Rogers\\n\\n# Chapter 40\\n## Abdominal closure\\n- Authors: Moshe Schein and Danny Rosin\\n\\n# Chapter 41\\n## Before landing\\n- Author: Moshe Schein\\n\\n# PART IV — AFTER THE OPERATION\\n\\n# Chapter 42\\n## Postoperative care\\n- Author: Moshe Schein\\n\\n# Chapter 43\\n## Nutrition\\n- Author: James C. Rucinski\\n\\n# Chapter 44\\n## Postoperative antibiotics\\n- Author: Moshe Schein\\n\\n# Chapter 45\\n## Postoperative ileus vs. intestinal obstruction\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 38',\n", " 'md': '# Chapter 38',\n", " 'bBox': {'x': 72, 'y': 104, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal emergencies in the Third World',\n", " 'md': '## Abdominal emergencies in the Third World',\n", " 'bBox': {'x': 72, 'y': 124, 'w': 337.12, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Authors: Robin Kaushik, Graeme Pitcher, and Craig Joseph',\n", " 'md': '- Authors: Robin Kaushik, Graeme Pitcher, and Craig Joseph',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 39',\n", " 'md': '# Chapter 39',\n", " 'bBox': {'x': 72, 'y': 178, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal drainage',\n", " 'md': '## Abdominal drainage',\n", " 'bBox': {'x': 72, 'y': 197, 'w': 159.08, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Authors: Moshe Schein and Paul N. Rogers',\n", " 'md': '- Authors: Moshe Schein and Paul N. Rogers',\n", " 'bBox': {'x': 72, 'y': 216, 'w': 220.7, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 40',\n", " 'md': '# Chapter 40',\n", " 'bBox': {'x': 72, 'y': 252, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal closure',\n", " 'md': '## Abdominal closure',\n", " 'bBox': {'x': 72, 'y': 271, 'w': 148.97, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Authors: Moshe Schein and Danny Rosin',\n", " 'md': '- Authors: Moshe Schein and Danny Rosin',\n", " 'bBox': {'x': 72, 'y': 291, 'w': 205.53, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 41',\n", " 'md': '# Chapter 41',\n", " 'bBox': {'x': 72, 'y': 325, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Before landing',\n", " 'md': '## Before landing',\n", " 'bBox': {'x': 72, 'y': 345, 'w': 115.86, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Author: Moshe Schein',\n", " 'md': '- Author: Moshe Schein',\n", " 'bBox': {'x': 72, 'y': 364, 'w': 91.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'PART IV — AFTER THE OPERATION',\n", " 'md': '# PART IV — AFTER THE OPERATION',\n", " 'bBox': {'x': 72, 'y': 424, 'w': 284.43, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 42',\n", " 'md': '# Chapter 42',\n", " 'bBox': {'x': 72, 'y': 459, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Postoperative care',\n", " 'md': '## Postoperative care',\n", " 'bBox': {'x': 72, 'y': 479, 'w': 148.08, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Author: Moshe Schein',\n", " 'md': '- Author: Moshe Schein',\n", " 'bBox': {'x': 72, 'y': 364, 'w': 91.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 43',\n", " 'md': '# Chapter 43',\n", " 'bBox': {'x': 72, 'y': 533, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Nutrition',\n", " 'md': '## Nutrition',\n", " 'bBox': {'x': 72, 'y': 552, 'w': 68.94, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Author: James C. Rucinski',\n", " 'md': '- Author: James C. Rucinski',\n", " 'bBox': {'x': 72, 'y': 571, 'w': 119.15, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 44',\n", " 'md': '# Chapter 44',\n", " 'bBox': {'x': 72, 'y': 607, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Postoperative antibiotics',\n", " 'md': '## Postoperative antibiotics',\n", " 'bBox': {'x': 72, 'y': 626, 'w': 196.78, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Author: Moshe Schein',\n", " 'md': '- Author: Moshe Schein',\n", " 'bBox': {'x': 72, 'y': 364, 'w': 91.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 45',\n", " 'md': '# Chapter 45',\n", " 'bBox': {'x': 72, 'y': 680, 'w': 85.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Postoperative ileus vs. intestinal obstruction',\n", " 'md': '## Postoperative ileus vs. intestinal obstruction',\n", " 'bBox': {'x': 72, 'y': 700, 'w': 352.15, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 38 Abdominal emergencies in the Third World'},\n", " {'text': 'Abdominal emergencies in the Third World'},\n", " {'text': 'Robin Kaushik, Graeme Pitcher and Craig Joseph'},\n", " {'text': 'Chapter 39 Abdominal drainage'},\n", " {'text': 'Abdominal drainage'},\n", " {'text': 'Moshe Schein and Paul N. Rogers'},\n", " {'text': 'Chapter 40 Abdominal closure'},\n", " {'text': 'Abdominal closure'},\n", " {'text': 'Moshe Schein and Danny Rosin'},\n", " {'text': 'Chapter 41 Before landing'},\n", " {'text': 'Before landing'},\n", " {'text': 'Moshe Schein'},\n", " {'text': 'PART IV — AFTER THE OPERATION'},\n", " {'text': 'Chapter 42 Postoperative care'},\n", " {'text': 'Postoperative care'},\n", " {'text': 'Moshe Schein'},\n", " {'text': 'Chapter 43 Nutrition'},\n", " {'text': 'Nutrition'},\n", " {'text': 'James C. Rucinski'},\n", " {'text': 'Chapter 44 Postoperative antibiotics'},\n", " {'text': 'Postoperative antibiotics'},\n", " {'text': 'Moshe Schein'},\n", " {'text': 'Chapter 45 Postoperative ileus vs. intestinal obstruction'},\n", " {'text': 'Postoperative ileus vs. intestinal obstruction'}]},\n", " {'page': 11,\n", " 'text': 'Moshe Schein\\n\\nChapter 46\\nIntra-abdominal abscesses\\nMoshe Schein\\n\\nChapter 47\\nAnastomotic leaks and fistulas\\nMoshe Schein\\n\\nChapter 48\\nRelaparotomy and laparostomy for infection\\nRoger Saadia, Moshe Schein and Danny Rosin\\n\\nChapter 49\\nWound management\\nMoshe Schein\\n\\nChapter 50\\nIn the aftermath and the M & M meeting\\nMoshe Schein\\n\\nIndex',\n", " 'md': '```markdown\\n# Chapter Summaries\\n\\n## Chapter 46: Intra-abdominal abscesses\\n- Author: Moshe Schein\\n\\n## Chapter 47: Anastomotic leaks and fistulas\\n- Author: Moshe Schein\\n\\n## Chapter 48: Relaparotomy and laparostomy for infection\\n- Authors: Roger Saadia, Moshe Schein, and Danny Rosin\\n\\n## Chapter 49: Wound management\\n- Author: Moshe Schein\\n\\n## Chapter 50: In the aftermath and the M & M meeting\\n- Author: Moshe Schein\\n\\n## Index\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter Summaries',\n", " 'md': '# Chapter Summaries',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 46: Intra-abdominal abscesses',\n", " 'md': '## Chapter 46: Intra-abdominal abscesses',\n", " 'bBox': {'x': 72, 'y': 121, 'w': 212.45, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Author: Moshe Schein',\n", " 'md': '- Author: Moshe Schein',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 91.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 47: Anastomotic leaks and fistulas',\n", " 'md': '## Chapter 47: Anastomotic leaks and fistulas',\n", " 'bBox': {'x': 72, 'y': 195, 'w': 242.77, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Author: Moshe Schein',\n", " 'md': '- Author: Moshe Schein',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 91.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 48: Relaparotomy and laparostomy for infection',\n", " 'md': '## Chapter 48: Relaparotomy and laparostomy for infection',\n", " 'bBox': {'x': 72, 'y': 269, 'w': 347.57, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Authors: Roger Saadia, Moshe Schein, and Danny Rosin',\n", " 'md': '- Authors: Roger Saadia, Moshe Schein, and Danny Rosin',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 91.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 49: Wound management',\n", " 'md': '## Chapter 49: Wound management',\n", " 'bBox': {'x': 72, 'y': 342, 'w': 162.46, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Author: Moshe Schein',\n", " 'md': '- Author: Moshe Schein',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 91.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Chapter 50: In the aftermath and the M & M meeting',\n", " 'md': '## Chapter 50: In the aftermath and the M & M meeting',\n", " 'bBox': {'x': 72, 'y': 417, 'w': 308.92, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Author: Moshe Schein',\n", " 'md': '- Author: Moshe Schein',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 91.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Index',\n", " 'md': '## Index',\n", " 'bBox': {'x': 72, 'y': 490, 'w': 43.23, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Moshe Schein'},\n", " {'text': 'Chapter 46 Intra-abdominal abscesses'},\n", " {'text': 'Intra-abdominal abscesses'},\n", " {'text': 'Moshe Schein'},\n", " {'text': 'Chapter 47 Anastomotic leaks and fistulas'},\n", " {'text': 'Anastomotic leaks and fistulas'},\n", " {'text': 'Moshe Schein'},\n", " {'text': 'Chapter 48 Relaparotomy and laparostomy for infection'},\n", " {'text': 'Relaparotomy and laparostomy for infection'},\n", " {'text': 'Roger Saadia, Moshe Schein and Danny Rosin'},\n", " {'text': 'Chapter 49 Wound management'},\n", " {'text': 'Wound management'},\n", " {'text': 'Moshe Schein'},\n", " {'text': 'Chapter 50 In the aftermath and the M & M meeting'},\n", " {'text': 'In the aftermath and the M & M meeting'},\n", " {'text': 'Moshe Schein'},\n", " {'text': 'Index'}]},\n", " {'page': 12,\n", " 'text': 'Contributors\\nRoland E. Andersson MD PhD Associate Professor, Department of\\nClinical and Experimental Medicine, Linköping University, Linköping,\\nSweden; Consultant, Department of Surgery, County Hospital Ryhov,\\nJönköping, Sweden ( Chapter 23)\\nrolandersson@gmail.com\\n\\nAhmad Assalia MD Chief of Advanced and Bariatric Surgery, Rambam\\nHealth Care Campus, Haifa, Israel ( Chapter 31)\\nassaliaa@gmail.com\\n\\nJack Baniel MD Head, Urology Institute, Rabin Medical Center, Petach\\nTikva, Israel ( Chapter 37)\\nbaniel@netvision.net.il\\n\\nMark Cheetham BSc MD FRCS Consultant General and Colorectal\\nSurgeon, Royal Shrewsbury Hospital, Shrewsbury, Shropshire, UK (\\nChapter 14)\\nmarkcheets@aol.com\\n\\nJonathan E. Efron MD FACS FASCRS Associate Professor of Surgery,\\nThe Mark M. Ravitch MD Endowed Professorship in Surgery; Chief,\\nRavitch Division, Johns Hopkins University, Baltimore, Maryland, USA (\\nChapters 1, 3, 4, 9-11, 14 and 26-30)\\njefron1@jhmi.edu\\n\\nHans Ulrich Elben MD Leitender Artz der Radiologischen Abteilung,\\nKreisklinikum Schawrzwald-Barr GmbH, Donaueschingen, Germany (\\nChapter 5)\\nHansUlrich.Elben@swol.net\\n\\nHarold Ellis CBE MCh FRCS Professor, Applied Biomedical Research\\nGroup, Hodgkin Building, Guy’s Campus, London, UK ( Chapter 2)',\n", " 'md': '```markdown\\n# Contributors\\n\\n- **Roland E. Andersson MD PhD**\\nAssociate Professor, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Consultant, Department of Surgery, County Hospital Ryhov, Jönköping, Sweden (Chapter 23)\\nEmail: [rolandersson@gmail.com](mailto:rolandersson@gmail.com)\\n\\n- **Ahmad Assalia MD**\\nChief of Advanced and Bariatric Surgery, Rambam Health Care Campus, Haifa, Israel (Chapter 31)\\nEmail: [assaliaa@gmail.com](mailto:assaliaa@gmail.com)\\n\\n- **Jack Baniel MD**\\nHead, Urology Institute, Rabin Medical Center, Petach Tikva, Israel (Chapter 37)\\nEmail: [baniel@netvision.net.il](mailto:baniel@netvision.net.il)\\n\\n- **Mark Cheetham BSc MD FRCS**\\nConsultant General and Colorectal Surgeon, Royal Shrewsbury Hospital, Shrewsbury, Shropshire, UK (Chapter 14)\\nEmail: [markcheets@aol.com](mailto:markcheets@aol.com)\\n\\n- **Jonathan E. Efron MD FACS FASCRS**\\nAssociate Professor of Surgery, The Mark M. Ravitch MD Endowed Professorship in Surgery; Chief, Ravitch Division, Johns Hopkins University, Baltimore, Maryland, USA (Chapters 1, 3, 4, 9-11, 14 and 26-30)\\nEmail: [jefron1@jhmi.edu](mailto:jefron1@jhmi.edu)\\n\\n- **Hans Ulrich Elben MD**\\nLeitender Artz der Radiologischen Abteilung, Kreisklinikum Schawrzwald-Barr GmbH, Donaueschingen, Germany (Chapter 5)\\nEmail: [HansUlrich.Elben@swol.net](mailto:HansUlrich.Elben@swol.net)\\n\\n- **Harold Ellis CBE MCh FRCS**\\nProfessor, Applied Biomedical Research Group, Hodgkin Building, Guy’s Campus, London, UK (Chapter 2)\\n```',\n", " 'images': [{'name': 'img_p11_1.png',\n", " 'height': 19,\n", " 'width': 18,\n", " 'x': 206.64,\n", " 'y': 215.99999999999997},\n", " {'name': 'img_p11_1.png',\n", " 'height': 19,\n", " 'width': 18,\n", " 'x': 299.52,\n", " 'y': 284.4},\n", " {'name': 'img_p11_1.png',\n", " 'height': 19,\n", " 'width': 18,\n", " 'x': 157.68,\n", " 'y': 352.79999999999995},\n", " {'name': 'img_p11_1.png',\n", " 'height': 19,\n", " 'width': 18,\n", " 'x': 526.3199999999999,\n", " 'y': 421.2},\n", " {'name': 'img_p11_1.png',\n", " 'height': 19,\n", " 'width': 18,\n", " 'x': 526.3199999999999,\n", " 'y': 522.72},\n", " {'name': 'img_p11_1.png',\n", " 'height': 19,\n", " 'width': 18,\n", " 'x': 526.3199999999999,\n", " 'y': 607.6800000000001},\n", " {'name': 'img_p11_1.png',\n", " 'height': 19,\n", " 'width': 18,\n", " 'x': 422.64,\n", " 'y': 692.64}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Contributors',\n", " 'md': '# Contributors',\n", " 'bBox': {'x': 72, 'y': 129, 'w': 174.3, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '- **Roland E. Andersson MD PhD**\\nAssociate Professor, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Consultant, Department of Surgery, County Hospital Ryhov, Jönköping, Sweden (Chapter 23)\\nEmail: [rolandersson@gmail.com](mailto:rolandersson@gmail.com)\\n\\n- **Ahmad Assalia MD**\\nChief of Advanced and Bariatric Surgery, Rambam Health Care Campus, Haifa, Israel (Chapter 31)\\nEmail: [assaliaa@gmail.com](mailto:assaliaa@gmail.com)\\n\\n- **Jack Baniel MD**\\nHead, Urology Institute, Rabin Medical Center, Petach Tikva, Israel (Chapter 37)\\nEmail: [baniel@netvision.net.il](mailto:baniel@netvision.net.il)\\n\\n- **Mark Cheetham BSc MD FRCS**\\nConsultant General and Colorectal Surgeon, Royal Shrewsbury Hospital, Shrewsbury, Shropshire, UK (Chapter 14)\\nEmail: [markcheets@aol.com](mailto:markcheets@aol.com)\\n\\n- **Jonathan E. Efron MD FACS FASCRS**\\nAssociate Professor of Surgery, The Mark M. Ravitch MD Endowed Professorship in Surgery; Chief, Ravitch Division, Johns Hopkins University, Baltimore, Maryland, USA (Chapters 1, 3, 4, 9-11, 14 and 26-30)\\nEmail: [jefron1@jhmi.edu](mailto:jefron1@jhmi.edu)\\n\\n- **Hans Ulrich Elben MD**\\nLeitender Artz der Radiologischen Abteilung, Kreisklinikum Schawrzwald-Barr GmbH, Donaueschingen, Germany (Chapter 5)\\nEmail: [HansUlrich.Elben@swol.net](mailto:HansUlrich.Elben@swol.net)\\n\\n- **Harold Ellis CBE MCh FRCS**\\nProfessor, Applied Biomedical Research Group, Hodgkin Building, Guy’s Campus, London, UK (Chapter 2)\\n```',\n", " 'md': '- **Roland E. Andersson MD PhD**\\nAssociate Professor, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Consultant, Department of Surgery, County Hospital Ryhov, Jönköping, Sweden (Chapter 23)\\nEmail: [rolandersson@gmail.com](mailto:rolandersson@gmail.com)\\n\\n- **Ahmad Assalia MD**\\nChief of Advanced and Bariatric Surgery, Rambam Health Care Campus, Haifa, Israel (Chapter 31)\\nEmail: [assaliaa@gmail.com](mailto:assaliaa@gmail.com)\\n\\n- **Jack Baniel MD**\\nHead, Urology Institute, Rabin Medical Center, Petach Tikva, Israel (Chapter 37)\\nEmail: [baniel@netvision.net.il](mailto:baniel@netvision.net.il)\\n\\n- **Mark Cheetham BSc MD FRCS**\\nConsultant General and Colorectal Surgeon, Royal Shrewsbury Hospital, Shrewsbury, Shropshire, UK (Chapter 14)\\nEmail: [markcheets@aol.com](mailto:markcheets@aol.com)\\n\\n- **Jonathan E. Efron MD FACS FASCRS**\\nAssociate Professor of Surgery, The Mark M. Ravitch MD Endowed Professorship in Surgery; Chief, Ravitch Division, Johns Hopkins University, Baltimore, Maryland, USA (Chapters 1, 3, 4, 9-11, 14 and 26-30)\\nEmail: [jefron1@jhmi.edu](mailto:jefron1@jhmi.edu)\\n\\n- **Hans Ulrich Elben MD**\\nLeitender Artz der Radiologischen Abteilung, Kreisklinikum Schawrzwald-Barr GmbH, Donaueschingen, Germany (Chapter 5)\\nEmail: [HansUlrich.Elben@swol.net](mailto:HansUlrich.Elben@swol.net)\\n\\n- **Harold Ellis CBE MCh FRCS**\\nProfessor, Applied Biomedical Research Group, Hodgkin Building, Guy’s Campus, London, UK (Chapter 2)\\n```',\n", " 'bBox': {'x': 72, 'y': 227, 'w': 454.45, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'rolandersson@gmail.com'},\n", " {'url': 'mailto:rolandersson@gmail.com', 'text': 'rolandersson@gmail.com'},\n", " {'text': ''},\n", " {'url': 'mailto:assaliaa@gmail.com', 'text': 'assaliaa@gmail.com'},\n", " {'text': 'baniel@netvision.net.il'},\n", " {'url': 'mailto:baniel@netvision.net.il',\n", " 'text': 'baniel@netvision.net.il'},\n", " {'text': 'Chapter 14) markcheets@aol.com'},\n", " {'url': 'mailto:markcheets@aol.com', 'text': 'markcheets@aol.com'},\n", " {'text': 'Chapters 1, 3, 4, 9-11, 14 and 26-30) jefron1@jhmi.edu'},\n", " {'text': 'jefron1@jhmi.edu'},\n", " {'text': 'jefron1@jhmi.edu'},\n", " {'text': 'jefron1@jhmi.edu'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'url': 'mailto:jefron1@jhmi.edu', 'text': 'jefron1@jhmi.edu'},\n", " {'text': 'Chapter 5) HansUlrich.Elben@swol.net'},\n", " {'url': 'mailto:HansUlrich.Elben@swol.net',\n", " 'text': 'HansUlrich.Elben@swol.net'},\n", " {'text': ''}]},\n", " {'page': 13,\n", " 'text': 'harold.ellis@kcl.ac.uk\\n\\nWojciech J. Górecki MD PhD Associate Professor, Jagiellonian\\nUniversity Medical College; Chief, Department of Pediatric Surgery,\\nUniversity Children’s Hospital, Kraków, Poland ( Chapter 36)\\nmigoreck@cyf-kr.edu.pl\\n\\nJohn G. Hunter MD FACS Mackenzie Professor and Chairman of\\nSurgery, Oregon Health & Science University, Portland, Oregon, USA (\\nChapter 15)\\nhunterj@ohsu.edu\\n\\nAnat Ilivitzki MD Department of Radiology, Rambam Medical Center,\\nHaifa, Israel ( Chapter 31)\\na_ilivitzki@rambam.health.gov.il\\n\\nCraig Joseph MBBCh DA (SA) FCS(SA) Surgeon and\\nGastroenterologist, Witwatersrand Donald Gordon Medical Centre,\\nJohannesburg, South Africa ( Chapter 38)\\ncraigjos@mweb.co.za\\n\\nRobin Kaushik MD DNB Consultant Surgeon, General Surgery,\\nDepartment of Surgery, Government Medical College and Hospital,\\nChandigarh, India ( Chapter 38)\\nrobinkaushik@gmail.com\\n\\nAri Leppäniemi MD Chief of Emergency Surgery, Abdominal Center,\\nUniversity of Helsinki, Finland ( Chapters 1, 3, 4, 9-11, 14, 19 and 33)\\nari.leppaniemi@hus.fi\\n\\nEvgeniy E. Perelygin MD Attending Surgeon, Department of Urology,\\nPerm Clinical Center, Perm, Russia ( All chapters)\\nperya70@gmail.com\\n\\nGraeme Pitcher MBBCh FACS FCS(SA) Pediatric Surgeon, Associate\\nProfessor of Surgery, University of Iowa, Iowa City, USA ( Chapter 38)\\ngpitcher@healthcare.uiowa.edu',\n", " 'md': '```markdown\\n# Contact Information of Contributors\\n\\n- **Harold Ellis**\\nEmail: [harold.ellis@kcl.ac.uk](mailto:harold.ellis@kcl.ac.uk)\\n\\n- **Wojciech J. Górecki, MD, PhD**\\nAssociate Professor, Jagiellonian University Medical College; Chief, Department of Pediatric Surgery, University Children’s Hospital, Kraków, Poland\\n(Chapter 36)\\nEmail: [migoreck@cyf-kr.edu.pl](mailto:migoreck@cyf-kr.edu.pl)\\n\\n- **John G. Hunter, MD, FACS**\\nMackenzie Professor and Chairman of Surgery, Oregon Health & Science University, Portland, Oregon, USA\\n(Chapter 15)\\nEmail: [hunterj@ohsu.edu](mailto:hunterj@ohsu.edu)\\n\\n- **Anat Ilivitzki, MD**\\nDepartment of Radiology, Rambam Medical Center, Haifa, Israel\\n(Chapter 31)\\nEmail: [a_ilivitzki@rambam.health.gov.il](mailto:a_ilivitzki@rambam.health.gov.il)\\n\\n- **Craig Joseph, MBBCh, DA (SA), FCS(SA)**\\nSurgeon and Gastroenterologist, Witwatersrand Donald Gordon Medical Centre, Johannesburg, South Africa\\n(Chapter 38)\\nEmail: [craigjos@mweb.co.za](mailto:craigjos@mweb.co.za)\\n\\n- **Robin Kaushik, MD, DNB**\\nConsultant Surgeon, General Surgery, Department of Surgery, Government Medical College and Hospital, Chandigarh, India\\n(Chapter 38)\\nEmail: [robinkaushik@gmail.com](mailto:robinkaushik@gmail.com)\\n\\n- **Ari Leppäniemi, MD**\\nChief of Emergency Surgery, Abdominal Center, University of Helsinki, Finland\\n(Chapters 1, 3, 4, 9-11, 14, 19, and 33)\\nEmail: [ari.leppaniemi@hus.fi](mailto:ari.leppaniemi@hus.fi)\\n\\n- **Evgeniy E. Perelygin, MD**\\nAttending Surgeon, Department of Urology, Perm Clinical Center, Perm, Russia\\n(All chapters)\\nEmail: [perya70@gmail.com](mailto:perya70@gmail.com)\\n\\n- **Graeme Pitcher, MBBCh, FACS, FCS(SA)**\\nPediatric Surgeon, Associate Professor of Surgery, University of Iowa, Iowa City, USA\\n(Chapter 38)\\nEmail: [gpitcher@healthcare.uiowa.edu](mailto:gpitcher@healthcare.uiowa.edu)\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Contact Information of Contributors',\n", " 'md': '# Contact Information of Contributors',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Harold Ellis**\\nEmail: [harold.ellis@kcl.ac.uk](mailto:harold.ellis@kcl.ac.uk)\\n\\n- **Wojciech J. Górecki, MD, PhD**\\nAssociate Professor, Jagiellonian University Medical College; Chief, Department of Pediatric Surgery, University Children’s Hospital, Kraków, Poland\\n(Chapter 36)\\nEmail: [migoreck@cyf-kr.edu.pl](mailto:migoreck@cyf-kr.edu.pl)\\n\\n- **John G. Hunter, MD, FACS**\\nMackenzie Professor and Chairman of Surgery, Oregon Health & Science University, Portland, Oregon, USA\\n(Chapter 15)\\nEmail: [hunterj@ohsu.edu](mailto:hunterj@ohsu.edu)\\n\\n- **Anat Ilivitzki, MD**\\nDepartment of Radiology, Rambam Medical Center, Haifa, Israel\\n(Chapter 31)\\nEmail: [a_ilivitzki@rambam.health.gov.il](mailto:a_ilivitzki@rambam.health.gov.il)\\n\\n- **Craig Joseph, MBBCh, DA (SA), FCS(SA)**\\nSurgeon and Gastroenterologist, Witwatersrand Donald Gordon Medical Centre, Johannesburg, South Africa\\n(Chapter 38)\\nEmail: [craigjos@mweb.co.za](mailto:craigjos@mweb.co.za)\\n\\n- **Robin Kaushik, MD, DNB**\\nConsultant Surgeon, General Surgery, Department of Surgery, Government Medical College and Hospital, Chandigarh, India\\n(Chapter 38)\\nEmail: [robinkaushik@gmail.com](mailto:robinkaushik@gmail.com)\\n\\n- **Ari Leppäniemi, MD**\\nChief of Emergency Surgery, Abdominal Center, University of Helsinki, Finland\\n(Chapters 1, 3, 4, 9-11, 14, 19, and 33)\\nEmail: [ari.leppaniemi@hus.fi](mailto:ari.leppaniemi@hus.fi)\\n\\n- **Evgeniy E. Perelygin, MD**\\nAttending Surgeon, Department of Urology, Perm Clinical Center, Perm, Russia\\n(All chapters)\\nEmail: [perya70@gmail.com](mailto:perya70@gmail.com)\\n\\n- **Graeme Pitcher, MBBCh, FACS, FCS(SA)**\\nPediatric Surgeon, Associate Professor of Surgery, University of Iowa, Iowa City, USA\\n(Chapter 38)\\nEmail: [gpitcher@healthcare.uiowa.edu](mailto:gpitcher@healthcare.uiowa.edu)\\n```',\n", " 'md': '- **Harold Ellis**\\nEmail: [harold.ellis@kcl.ac.uk](mailto:harold.ellis@kcl.ac.uk)\\n\\n- **Wojciech J. Górecki, MD, PhD**\\nAssociate Professor, Jagiellonian University Medical College; Chief, Department of Pediatric Surgery, University Children’s Hospital, Kraków, Poland\\n(Chapter 36)\\nEmail: [migoreck@cyf-kr.edu.pl](mailto:migoreck@cyf-kr.edu.pl)\\n\\n- **John G. Hunter, MD, FACS**\\nMackenzie Professor and Chairman of Surgery, Oregon Health & Science University, Portland, Oregon, USA\\n(Chapter 15)\\nEmail: [hunterj@ohsu.edu](mailto:hunterj@ohsu.edu)\\n\\n- **Anat Ilivitzki, MD**\\nDepartment of Radiology, Rambam Medical Center, Haifa, Israel\\n(Chapter 31)\\nEmail: [a_ilivitzki@rambam.health.gov.il](mailto:a_ilivitzki@rambam.health.gov.il)\\n\\n- **Craig Joseph, MBBCh, DA (SA), FCS(SA)**\\nSurgeon and Gastroenterologist, Witwatersrand Donald Gordon Medical Centre, Johannesburg, South Africa\\n(Chapter 38)\\nEmail: [craigjos@mweb.co.za](mailto:craigjos@mweb.co.za)\\n\\n- **Robin Kaushik, MD, DNB**\\nConsultant Surgeon, General Surgery, Department of Surgery, Government Medical College and Hospital, Chandigarh, India\\n(Chapter 38)\\nEmail: [robinkaushik@gmail.com](mailto:robinkaushik@gmail.com)\\n\\n- **Ari Leppäniemi, MD**\\nChief of Emergency Surgery, Abdominal Center, University of Helsinki, Finland\\n(Chapters 1, 3, 4, 9-11, 14, 19, and 33)\\nEmail: [ari.leppaniemi@hus.fi](mailto:ari.leppaniemi@hus.fi)\\n\\n- **Evgeniy E. Perelygin, MD**\\nAttending Surgeon, Department of Urology, Perm Clinical Center, Perm, Russia\\n(All chapters)\\nEmail: [perya70@gmail.com](mailto:perya70@gmail.com)\\n\\n- **Graeme Pitcher, MBBCh, FACS, FCS(SA)**\\nPediatric Surgeon, Associate Professor of Surgery, University of Iowa, Iowa City, USA\\n(Chapter 38)\\nEmail: [gpitcher@healthcare.uiowa.edu](mailto:gpitcher@healthcare.uiowa.edu)\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 204.64, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'url': 'mailto:harold.ellis@kcl.ac.uk',\n", " 'text': 'harold.ellis@kcl.ac.uk'},\n", " {'text': ''},\n", " {'url': 'mailto:migoreck@cyf-kr.edu.pl', 'text': 'migoreck@cyf-kr.edu.pl'},\n", " {'text': 'Chapter 15) hunterj@ohsu.edu'},\n", " {'url': 'mailto:hunterj@ohsu.edu', 'text': 'hunterj@ohsu.edu'},\n", " {'text': 'a_ilivitzki@rambam.health.gov.il'},\n", " {'url': 'mailto:a_ilivitzki@rambam.health.gov.il',\n", " 'text': 'a_ilivitzki@rambam.health.gov.il'},\n", " {'text': ''},\n", " {'url': 'mailto:craigjos@mweb.co.za', 'text': 'craigjos@mweb.co.za'},\n", " {'text': 'robinkaushik@gmail.com'},\n", " {'url': 'mailto:robinkaushik@gmail.com', 'text': 'robinkaushik@gmail.com'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'url': 'mailto:ari.leppaniemi@hus.fi', 'text': 'ari.leppaniemi@hus.fi'},\n", " {'url': 'mailto:perya70@gmail.com', 'text': 'perya70@gmail.com'},\n", " {'text': ''},\n", " {'url': 'mailto:gpitcher@healthcare.uiowa.edu',\n", " 'text': 'gpitcher@healthcare.uiowa.edu'}]},\n", " {'page': 14,\n", " 'text': 'B. Ramana MS DNB FRCS Advanced Laparoscopic & Bariatric\\nSurgeon, Belle Vue Clinic, Kolkata, India ( Chapter 20)\\nrambodoc@gmail.com\\n\\nPaul N. Rogers MBChB MBA MD FRCS Consultant General and\\nVascular Surgeon, Department of Surgery, South Glasgow University\\nHospital, Glasgow, UK ( Chapters 1, 3, 4, 9-11, 14, 22, 24, 34 and 39)\\npn.rogers@btinternet.com\\n\\nDanny Rosin MD FACS Attending General and Advanced Laparoscopic\\nSurgeon, Department of General Surgery and Transplantation, Sackler\\nSchool of Medicine, Tel Aviv University, Sheba Medical Center, Tel\\nHashomer, Israel ( Chapters 1, 3, 4, 9-12, 14, 16, 20, 21, 40 and 48)\\ndrosin@mac.com\\n\\nJames C. Rucinski MD FACS Director of Surgical Education, New York\\nMethodist Hospital, Brooklyn, New York, USA ( Chapters 6, 8 and 43)\\njcrucinski@gmail.com\\n\\nRoger Saadia MD FRCS(Ed) Professor of Surgery, University of\\nManitoba and Health Sciences Centre, Winnipeg, Canada ( Chapters\\n13, 32 and 48)\\nrsaadia@shaw.ca\\n\\nBashar Safar MD FACS FRCS FASCRS Assistant Professor of Surgery,\\nJohns Hopkins Universtiy, Baltimore, Maryland, USA ( Chapter 26)\\nbsafar1@jhmi.edu\\n\\nErik Schadde MD FACS Director HPB Fellowship, Swiss HPB Center,\\nDepartment of Surgery, University Hospital Zurich, Zurich, Switzerland (\\nChapter 25)\\nerik.schadde@uzh.ch\\n\\nMoshe Schein MD FACS Attending Surgeon, Marshfield Clinic,\\nLadysmith, Wisconsin, USA ( Chapters 1, 3-5, 7, 9-11, 13, 14, 17, 18,\\n20, 21, 24, 33, 35, 39-42 and 44-50)\\nmosheschein@gmail.com',\n", " 'md': '```markdown\\n# Contributors\\n\\n## B. Ramana\\n- **Qualifications**: MS, DNB, FRCS\\n- **Position**: Advanced Laparoscopic & Bariatric Surgeon\\n- **Affiliation**: Belle Vue Clinic, Kolkata, India\\n- **Chapters**: 20\\n- **Email**: [rambodoc@gmail.com](mailto:rambodoc@gmail.com)\\n\\n## Paul N. Rogers\\n- **Qualifications**: MBChB, MBA, MD, FRCS\\n- **Position**: Consultant General and Vascular Surgeon\\n- **Affiliation**: Department of Surgery, South Glasgow University Hospital, Glasgow, UK\\n- **Chapters**: 1, 3, 4, 9-11, 14, 22, 24, 34, 39\\n- **Email**: [pn.rogers@btinternet.com](mailto:pn.rogers@btinternet.com)\\n\\n## Danny Rosin\\n- **Qualifications**: MD, FACS\\n- **Position**: Attending General and Advanced Laparoscopic Surgeon\\n- **Affiliation**: Department of General Surgery and Transplantation, Sackler School of Medicine, Tel Aviv University, Sheba Medical Center, Tel Hashomer, Israel\\n- **Chapters**: 1, 3, 4, 9-12, 14, 16, 20, 21, 40, 48\\n- **Email**: [drosin@mac.com](mailto:drosin@mac.com)\\n\\n## James C. Rucinski\\n- **Qualifications**: MD, FACS\\n- **Position**: Director of Surgical Education\\n- **Affiliation**: New York Methodist Hospital, Brooklyn, New York, USA\\n- **Chapters**: 6, 8, 43\\n- **Email**: [jcrucinski@gmail.com](mailto:jcrucinski@gmail.com)\\n\\n## Roger Saadia\\n- **Qualifications**: MD, FRCS(Ed)\\n- **Position**: Professor of Surgery\\n- **Affiliation**: University of Manitoba and Health Sciences Centre, Winnipeg, Canada\\n- **Chapters**: 13, 32, 48\\n- **Email**: [rsaadia@shaw.ca](mailto:rsaadia@shaw.ca)\\n\\n## Bashar Safar\\n- **Qualifications**: MD, FACS, FRCS, FASCRS\\n- **Position**: Assistant Professor of Surgery\\n- **Affiliation**: Johns Hopkins University, Baltimore, Maryland, USA\\n- **Chapters**: 26\\n- **Email**: [bsafar1@jhmi.edu](mailto:bsafar1@jhmi.edu)\\n\\n## Erik Schadde\\n- **Qualifications**: MD, FACS\\n- **Position**: Director HPB Fellowship\\n- **Affiliation**: Swiss HPB Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland\\n- **Chapters**: 25\\n- **Email**: [erik.schadde@uzh.ch](mailto:erik.schadde@uzh.ch)\\n\\n## Moshe Schein\\n- **Qualifications**: MD, FACS\\n- **Position**: Attending Surgeon\\n- **Affiliation**: Marshfield Clinic, Ladysmith, Wisconsin, USA\\n- **Chapters**: 1, 3-5, 7, 9-11, 13, 14, 17, 18, 20, 21, 24, 33, 35, 39-42, 44-50\\n- **Email**: [mosheschein@gmail.com](mailto:mosheschein@gmail.com)\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Contributors',\n", " 'md': '# Contributors',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'B. Ramana',\n", " 'md': '## B. Ramana',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 55.99, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Qualifications**: MS, DNB, FRCS\\n- **Position**: Advanced Laparoscopic & Bariatric Surgeon\\n- **Affiliation**: Belle Vue Clinic, Kolkata, India\\n- **Chapters**: 20\\n- **Email**: [rambodoc@gmail.com](mailto:rambodoc@gmail.com)',\n", " 'md': '- **Qualifications**: MS, DNB, FRCS\\n- **Position**: Advanced Laparoscopic & Bariatric Surgeon\\n- **Affiliation**: Belle Vue Clinic, Kolkata, India\\n- **Chapters**: 20\\n- **Email**: [rambodoc@gmail.com](mailto:rambodoc@gmail.com)',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 144.16, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Paul N. Rogers',\n", " 'md': '## Paul N. Rogers',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Qualifications**: MBChB, MBA, MD, FRCS\\n- **Position**: Consultant General and Vascular Surgeon\\n- **Affiliation**: Department of Surgery, South Glasgow University Hospital, Glasgow, UK\\n- **Chapters**: 1, 3, 4, 9-11, 14, 22, 24, 34, 39\\n- **Email**: [pn.rogers@btinternet.com](mailto:pn.rogers@btinternet.com)',\n", " 'md': '- **Qualifications**: MBChB, MBA, MD, FRCS\\n- **Position**: Consultant General and Vascular Surgeon\\n- **Affiliation**: Department of Surgery, South Glasgow University Hospital, Glasgow, UK\\n- **Chapters**: 1, 3, 4, 9-11, 14, 22, 24, 34, 39\\n- **Email**: [pn.rogers@btinternet.com](mailto:pn.rogers@btinternet.com)',\n", " 'bBox': {'x': 72, 'y': 204, 'w': 166.54, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Danny Rosin',\n", " 'md': '## Danny Rosin',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Qualifications**: MD, FACS\\n- **Position**: Attending General and Advanced Laparoscopic Surgeon\\n- **Affiliation**: Department of General Surgery and Transplantation, Sackler School of Medicine, Tel Aviv University, Sheba Medical Center, Tel Hashomer, Israel\\n- **Chapters**: 1, 3, 4, 9-12, 14, 16, 20, 21, 40, 48\\n- **Email**: [drosin@mac.com](mailto:drosin@mac.com)',\n", " 'md': '- **Qualifications**: MD, FACS\\n- **Position**: Attending General and Advanced Laparoscopic Surgeon\\n- **Affiliation**: Department of General Surgery and Transplantation, Sackler School of Medicine, Tel Aviv University, Sheba Medical Center, Tel Hashomer, Israel\\n- **Chapters**: 1, 3, 4, 9-12, 14, 16, 20, 21, 40, 48\\n- **Email**: [drosin@mac.com](mailto:drosin@mac.com)',\n", " 'bBox': {'x': 72, 'y': 305, 'w': 112.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'James C. Rucinski',\n", " 'md': '## James C. Rucinski',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Qualifications**: MD, FACS\\n- **Position**: Director of Surgical Education\\n- **Affiliation**: New York Methodist Hospital, Brooklyn, New York, USA\\n- **Chapters**: 6, 8, 43\\n- **Email**: [jcrucinski@gmail.com](mailto:jcrucinski@gmail.com)',\n", " 'md': '- **Qualifications**: MD, FACS\\n- **Position**: Director of Surgical Education\\n- **Affiliation**: New York Methodist Hospital, Brooklyn, New York, USA\\n- **Chapters**: 6, 8, 43\\n- **Email**: [jcrucinski@gmail.com](mailto:jcrucinski@gmail.com)',\n", " 'bBox': {'x': 72, 'y': 373, 'w': 139.36, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Roger Saadia',\n", " 'md': '## Roger Saadia',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Qualifications**: MD, FRCS(Ed)\\n- **Position**: Professor of Surgery\\n- **Affiliation**: University of Manitoba and Health Sciences Centre, Winnipeg, Canada\\n- **Chapters**: 13, 32, 48\\n- **Email**: [rsaadia@shaw.ca](mailto:rsaadia@shaw.ca)',\n", " 'md': '- **Qualifications**: MD, FRCS(Ed)\\n- **Position**: Professor of Surgery\\n- **Affiliation**: University of Manitoba and Health Sciences Centre, Winnipeg, Canada\\n- **Chapters**: 13, 32, 48\\n- **Email**: [rsaadia@shaw.ca](mailto:rsaadia@shaw.ca)',\n", " 'bBox': {'x': 72, 'y': 458, 'w': 113.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Bashar Safar',\n", " 'md': '## Bashar Safar',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Qualifications**: MD, FACS, FRCS, FASCRS\\n- **Position**: Assistant Professor of Surgery\\n- **Affiliation**: Johns Hopkins University, Baltimore, Maryland, USA\\n- **Chapters**: 26\\n- **Email**: [bsafar1@jhmi.edu](mailto:bsafar1@jhmi.edu)',\n", " 'md': '- **Qualifications**: MD, FACS, FRCS, FASCRS\\n- **Position**: Assistant Professor of Surgery\\n- **Affiliation**: Johns Hopkins University, Baltimore, Maryland, USA\\n- **Chapters**: 26\\n- **Email**: [bsafar1@jhmi.edu](mailto:bsafar1@jhmi.edu)',\n", " 'bBox': {'x': 72, 'y': 527, 'w': 116.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Erik Schadde',\n", " 'md': '## Erik Schadde',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Qualifications**: MD, FACS\\n- **Position**: Director HPB Fellowship\\n- **Affiliation**: Swiss HPB Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland\\n- **Chapters**: 25\\n- **Email**: [erik.schadde@uzh.ch](mailto:erik.schadde@uzh.ch)',\n", " 'md': '- **Qualifications**: MD, FACS\\n- **Position**: Director HPB Fellowship\\n- **Affiliation**: Swiss HPB Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland\\n- **Chapters**: 25\\n- **Email**: [erik.schadde@uzh.ch](mailto:erik.schadde@uzh.ch)',\n", " 'bBox': {'x': 72, 'y': 612, 'w': 138.59, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Moshe Schein',\n", " 'md': '## Moshe Schein',\n", " 'bBox': {'x': 72, 'y': 647, 'w': 47.17, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Qualifications**: MD, FACS\\n- **Position**: Attending Surgeon\\n- **Affiliation**: Marshfield Clinic, Ladysmith, Wisconsin, USA\\n- **Chapters**: 1, 3-5, 7, 9-11, 13, 14, 17, 18, 20, 21, 24, 33, 35, 39-42, 44-50\\n- **Email**: [mosheschein@gmail.com](mailto:mosheschein@gmail.com)\\n```',\n", " 'md': '- **Qualifications**: MD, FACS\\n- **Position**: Attending Surgeon\\n- **Affiliation**: Marshfield Clinic, Ladysmith, Wisconsin, USA\\n- **Chapters**: 1, 3-5, 7, 9-11, 13, 14, 17, 18, 20, 21, 24, 33, 35, 39-42, 44-50\\n- **Email**: [mosheschein@gmail.com](mailto:mosheschein@gmail.com)\\n```',\n", " 'bBox': {'x': 72, 'y': 647, 'w': 164.96, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'url': 'mailto:rambodoc@gmail.com', 'text': 'rambodoc@gmail.com'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'url': 'mailto:pn.rogers@btinternet.com',\n", " 'text': 'pn.rogers@btinternet.com'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'url': 'mailto:drosin@mac.com', 'text': 'drosin@mac.com'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'url': 'mailto:jcrucinski@gmail.com', 'text': 'jcrucinski@gmail.com'},\n", " {'text': 'Manitoba and Health Sciences Centre, Winnipeg, Canada ( Chapters 13, 32 and 48) rsaadia@shaw.ca'},\n", " {'text': 'rsaadia@shaw.ca'},\n", " {'text': 'rsaadia@shaw.ca'},\n", " {'url': 'mailto:rsaadia@shaw.ca', 'text': 'rsaadia@shaw.ca'},\n", " {'text': ''},\n", " {'url': 'mailto:bsafar1@jhmi.edu', 'text': 'bsafar1@jhmi.edu'},\n", " {'text': 'Chapter 25) erik.schadde@uzh.ch'},\n", " {'url': 'mailto:erik.schadde@uzh.ch', 'text': 'erik.schadde@uzh.ch'},\n", " {'text': '20, 21, 24, 33, 35, 39-42 and 44-50)'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '20, 21, 24, 33, 35, 39-42 and 44-50) mosheschein@gmail.com'},\n", " {'text': 'mosheschein@gmail.com'},\n", " {'text': 'mosheschein@gmail.com'},\n", " {'text': 'mosheschein@gmail.com'},\n", " {'text': 'mosheschein@gmail.com'},\n", " {'text': 'mosheschein@gmail.com'},\n", " {'text': 'mosheschein@gmail.com'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'url': 'mailto:mosheschein@gmail.com', 'text': 'mosheschein@gmail.com'}]},\n", " {'page': 15,\n", " 'text': 'Brandon H. Tieu MD Department of Cardiothoracic Surgery, Oregon\\nHealth & Science University Hospital, Portland, Oregon, USA ( Chapter\\n15)\\ntieub@ohsu.edu',\n", " 'md': '```markdown\\n# Chapter 15\\n\\n**Author:** Brandon H. Tieu, MD\\n**Affiliation:** Department of Cardiothoracic Surgery, Oregon Health & Science University Hospital, Portland, Oregon, USA\\n**Email:** [tieub@ohsu.edu](mailto:tieub@ohsu.edu)\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 15',\n", " 'md': '# Chapter 15',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Author:** Brandon H. Tieu, MD\\n**Affiliation:** Department of Cardiothoracic Surgery, Oregon Health & Science University Hospital, Portland, Oregon, USA\\n**Email:** [tieub@ohsu.edu](mailto:tieub@ohsu.edu)\\n```',\n", " 'md': '**Author:** Brandon H. Tieu, MD\\n**Affiliation:** Department of Cardiothoracic Surgery, Oregon Health & Science University Hospital, Portland, Oregon, USA\\n**Email:** [tieub@ohsu.edu](mailto:tieub@ohsu.edu)\\n```',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 104.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Health & Science University Hospital, Portland, Oregon, USA ( Chapter 15) tieub@ohsu.edu'},\n", " {'url': 'mailto:tieub@ohsu.edu', 'text': 'tieub@ohsu.edu'}]},\n", " {'page': 16,\n", " 'text': 'Editors’ note\\n This book has been assembled — in pieces — during long years of\\nintensive personal involvement, clinical and academic, urban and rural,\\nwith emergency abdominal surgery in South Africa, Israel, USA, UK,\\nAustralia, Finland, Nigeria, Kenya, Sudan, Pakistan, Thailand, Tuvalu and\\nAustralia.\\n\\n A long line of good old friends from all around the world were helpful in\\ngenerating this book and its three preceding editions. For the foundations\\nin this noble surgical field Moshe is indebted to the late George G.\\nDecker of Johannesburg. Drs. Asher Hirshberg and Adam Klipfel\\ncontributed to the first edition. Dr. Robert Lane, Ontario, Canada, helped\\nus with all the previous editions. Professor Ahmad Assalia has been part\\nof this book from its early days; he co-edited the third edition and\\ncontinues to share with us his wisdom.\\n\\n Dr. Alfredo Sepulveda of Santiago, Chile, edited the Spanish\\ntranslation (first edition), Dr. Francesco Vittorio Gammarota of Rome,\\nItaly, edited the Italian translation (second edition), Professor Wen-hao\\nTang, China, edited the Mandarin translation (third edition), Drs.\\nAlexander Ferko, Leo Klein, Eduard Havel, Dušan Šimkovic, Karel\\nŠmejkal, Czech Republic, edited the Czech translation (second edition),\\nDr. Wojciech Górecki, Poland, edited the Polish translation (third\\nedition), Dr. Teimuraz Kemoklidze and Professor Merab Kiladze,\\nGeorgia, edited the Georgian translation (third edition), Dr. Slava\\nRyndine, South Africa, helped to organize the Russian translation (third\\nedition) and we will always remember with affection the late Professor\\nBoris Savchuk of Moscow who edited the Russian translation (first\\nedition).\\n\\n We are grateful to the many members of SURGINET, who over the\\nyears have stimulated our brains with their constant international\\nfeedback. Thanks to Dr. Evgeniy (Perya) Perelygin who drew many new\\ncaricatures for this edition and to Dan Schein who painted the image on',\n", " 'md': '```markdown\\n# Editors’ Note\\n\\nThis book has been assembled — in pieces — during long years of intensive personal involvement, clinical and academic, urban and rural, with emergency abdominal surgery in South Africa, Israel, USA, UK, Australia, Finland, Nigeria, Kenya, Sudan, Pakistan, Thailand, Tuvalu, and Australia.\\n\\nA long line of good old friends from all around the world were helpful in generating this book and its three preceding editions. For the foundations in this noble surgical field, Moshe is indebted to the late George G. Decker of Johannesburg. Drs. Asher Hirshberg and Adam Klipfel contributed to the first edition. Dr. Robert Lane, Ontario, Canada, helped us with all the previous editions. Professor Ahmad Assalia has been part of this book from its early days; he co-edited the third edition and continues to share with us his wisdom.\\n\\nDr. Alfredo Sepulveda of Santiago, Chile, edited the Spanish translation (first edition), Dr. Francesco Vittorio Gammarota of Rome, Italy, edited the Italian translation (second edition), Professor Wen-hao Tang, China, edited the Mandarin translation (third edition), Drs. Alexander Ferko, Leo Klein, Eduard Havel, Dušan Šimkovic, Karel Šmejkal, Czech Republic, edited the Czech translation (second edition), Dr. Wojciech Górecki, Poland, edited the Polish translation (third edition), Dr. Teimuraz Kemoklidze and Professor Merab Kiladze, Georgia, edited the Georgian translation (third edition), Dr. Slava Ryndine, South Africa, helped to organize the Russian translation (third edition) and we will always remember with affection the late Professor Boris Savchuk of Moscow who edited the Russian translation (first edition).\\n\\nWe are grateful to the many members of SURGINET, who over the years have stimulated our brains with their constant international feedback. Thanks to Dr. Evgeniy (Perya) Perelygin who drew many new caricatures for this edition and to Dan Schein who painted the image on.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Editors’ Note',\n", " 'md': '# Editors’ Note',\n", " 'bBox': {'x': 72, 'y': 129, 'w': 174.35, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': 'This book has been assembled — in pieces — during long years of intensive personal involvement, clinical and academic, urban and rural, with emergency abdominal surgery in South Africa, Israel, USA, UK, Australia, Finland, Nigeria, Kenya, Sudan, Pakistan, Thailand, Tuvalu, and Australia.\\n\\nA long line of good old friends from all around the world were helpful in generating this book and its three preceding editions. For the foundations in this noble surgical field, Moshe is indebted to the late George G. Decker of Johannesburg. Drs. Asher Hirshberg and Adam Klipfel contributed to the first edition. Dr. Robert Lane, Ontario, Canada, helped us with all the previous editions. Professor Ahmad Assalia has been part of this book from its early days; he co-edited the third edition and continues to share with us his wisdom.\\n\\nDr. Alfredo Sepulveda of Santiago, Chile, edited the Spanish translation (first edition), Dr. Francesco Vittorio Gammarota of Rome, Italy, edited the Italian translation (second edition), Professor Wen-hao Tang, China, edited the Mandarin translation (third edition), Drs. Alexander Ferko, Leo Klein, Eduard Havel, Dušan Šimkovic, Karel Šmejkal, Czech Republic, edited the Czech translation (second edition), Dr. Wojciech Górecki, Poland, edited the Polish translation (third edition), Dr. Teimuraz Kemoklidze and Professor Merab Kiladze, Georgia, edited the Georgian translation (third edition), Dr. Slava Ryndine, South Africa, helped to organize the Russian translation (third edition) and we will always remember with affection the late Professor Boris Savchuk of Moscow who edited the Russian translation (first edition).\\n\\nWe are grateful to the many members of SURGINET, who over the years have stimulated our brains with their constant international feedback. Thanks to Dr. Evgeniy (Perya) Perelygin who drew many new caricatures for this edition and to Dan Schein who painted the image on.\\n```',\n", " 'md': 'This book has been assembled — in pieces — during long years of intensive personal involvement, clinical and academic, urban and rural, with emergency abdominal surgery in South Africa, Israel, USA, UK, Australia, Finland, Nigeria, Kenya, Sudan, Pakistan, Thailand, Tuvalu, and Australia.\\n\\nA long line of good old friends from all around the world were helpful in generating this book and its three preceding editions. For the foundations in this noble surgical field, Moshe is indebted to the late George G. Decker of Johannesburg. Drs. Asher Hirshberg and Adam Klipfel contributed to the first edition. Dr. Robert Lane, Ontario, Canada, helped us with all the previous editions. Professor Ahmad Assalia has been part of this book from its early days; he co-edited the third edition and continues to share with us his wisdom.\\n\\nDr. Alfredo Sepulveda of Santiago, Chile, edited the Spanish translation (first edition), Dr. Francesco Vittorio Gammarota of Rome, Italy, edited the Italian translation (second edition), Professor Wen-hao Tang, China, edited the Mandarin translation (third edition), Drs. Alexander Ferko, Leo Klein, Eduard Havel, Dušan Šimkovic, Karel Šmejkal, Czech Republic, edited the Czech translation (second edition), Dr. Wojciech Górecki, Poland, edited the Polish translation (third edition), Dr. Teimuraz Kemoklidze and Professor Merab Kiladze, Georgia, edited the Georgian translation (third edition), Dr. Slava Ryndine, South Africa, helped to organize the Russian translation (third edition) and we will always remember with affection the late Professor Boris Savchuk of Moscow who edited the Russian translation (first edition).\\n\\nWe are grateful to the many members of SURGINET, who over the years have stimulated our brains with their constant international feedback. Thanks to Dr. Evgeniy (Perya) Perelygin who drew many new caricatures for this edition and to Dan Schein who painted the image on.\\n```',\n", " 'bBox': {'x': 72, 'y': 244, 'w': 467.88, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 17,\n", " 'text': 'the front cover.\\n\\n Special thanks go to Nikki Bramhill who kindly agreed to produce this\\nbook which was previously published by Springer. Many of the aphorisms\\nand quotations used to decorate this book were retrieved from Aphorisms\\n& Quotations for the Surgeon (2002) and A Companion to Aphorisms &\\nQuotations for the Surgeon (2008), edited by Moshe and published by\\nNikki Bramhill’s tfm publishing Ltd, Shrewsbury, UK.\\n\\n The reader will find that there are not a few duplications scattered\\nthroughout the book. We did this on purpose, as repetition of important\\npoints is crucial in adult education.\\n\\n Any reader who has a question or a comment about anything to do\\nwith this book is invited to email any of us directly:\\n\\n • mosheschein@gmail.com;\\n • pn.rogers@btinternet.com;\\n • ari.leppaniemi@hus.fi;\\n • drosin@mac.com;\\n • jefron1@jhmi.edu.\\n We will reply!\\n\\n Finally, we are indebted to our loving wives, ħeidi, Jackie, Eija, Gilly,\\nand Jami, for their patience and sacrifice.',\n", " 'md': '```markdown\\n# Front Cover Acknowledgments\\n\\nSpecial thanks go to Nikki Bramhill who kindly agreed to produce this book which was previously published by Springer. Many of the aphorisms and quotations used to decorate this book were retrieved from *Aphorisms & Quotations for the Surgeon* (2002) and *A Companion to Aphorisms & Quotations for the Surgeon* (2008), edited by Moshe and published by Nikki Bramhill’s tfm publishing Ltd, Shrewsbury, UK.\\n\\nThe reader will find that there are not a few duplications scattered throughout the book. We did this on purpose, as repetition of important points is crucial in adult education.\\n\\nAny reader who has a question or a comment about anything to do with this book is invited to email any of us directly:\\n\\n- [mosheschein@gmail.com](mailto:mosheschein@gmail.com)\\n- [pn.rogers@btinternet.com](mailto:pn.rogers@btinternet.com)\\n- [ari.leppaniemi@hus.fi](mailto:ari.leppaniemi@hus.fi)\\n- [drosin@mac.com](mailto:drosin@mac.com)\\n- [jefron1@jhmi.edu](mailto:jefron1@jhmi.edu)\\n\\nWe will reply!\\n\\nFinally, we are indebted to our loving wives, Heidi, Jackie, Eija, Gilly, and Jami, for their patience and sacrifice.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Front Cover Acknowledgments',\n", " 'md': '# Front Cover Acknowledgments',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Special thanks go to Nikki Bramhill who kindly agreed to produce this book which was previously published by Springer. Many of the aphorisms and quotations used to decorate this book were retrieved from *Aphorisms & Quotations for the Surgeon* (2002) and *A Companion to Aphorisms & Quotations for the Surgeon* (2008), edited by Moshe and published by Nikki Bramhill’s tfm publishing Ltd, Shrewsbury, UK.\\n\\nThe reader will find that there are not a few duplications scattered throughout the book. We did this on purpose, as repetition of important points is crucial in adult education.\\n\\nAny reader who has a question or a comment about anything to do with this book is invited to email any of us directly:\\n\\n- [mosheschein@gmail.com](mailto:mosheschein@gmail.com)\\n- [pn.rogers@btinternet.com](mailto:pn.rogers@btinternet.com)\\n- [ari.leppaniemi@hus.fi](mailto:ari.leppaniemi@hus.fi)\\n- [drosin@mac.com](mailto:drosin@mac.com)\\n- [jefron1@jhmi.edu](mailto:jefron1@jhmi.edu)\\n\\nWe will reply!\\n\\nFinally, we are indebted to our loving wives, Heidi, Jackie, Eija, Gilly, and Jami, for their patience and sacrifice.\\n```',\n", " 'md': 'Special thanks go to Nikki Bramhill who kindly agreed to produce this book which was previously published by Springer. Many of the aphorisms and quotations used to decorate this book were retrieved from *Aphorisms & Quotations for the Surgeon* (2002) and *A Companion to Aphorisms & Quotations for the Surgeon* (2008), edited by Moshe and published by Nikki Bramhill’s tfm publishing Ltd, Shrewsbury, UK.\\n\\nThe reader will find that there are not a few duplications scattered throughout the book. We did this on purpose, as repetition of important points is crucial in adult education.\\n\\nAny reader who has a question or a comment about anything to do with this book is invited to email any of us directly:\\n\\n- [mosheschein@gmail.com](mailto:mosheschein@gmail.com)\\n- [pn.rogers@btinternet.com](mailto:pn.rogers@btinternet.com)\\n- [ari.leppaniemi@hus.fi](mailto:ari.leppaniemi@hus.fi)\\n- [drosin@mac.com](mailto:drosin@mac.com)\\n- [jefron1@jhmi.edu](mailto:jefron1@jhmi.edu)\\n\\nWe will reply!\\n\\nFinally, we are indebted to our loving wives, Heidi, Jackie, Eija, Gilly, and Jami, for their patience and sacrifice.\\n```',\n", " 'bBox': {'x': 72, 'y': 121, 'w': 467.63, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'url': 'mailto:mosheschein@gmail.com', 'text': ''},\n", " {'url': 'mailto:pn.rogers@btinternet.com', 'text': ''},\n", " {'url': 'mailto:ari.leppaniemi@hus.fi', 'text': ''},\n", " {'url': 'mailto:drosin@mac.com', 'text': ''},\n", " {'url': 'mailto:jefron1@jhmi.edu', 'text': ''}]},\n", " {'page': 18,\n", " 'text': ' Jon [ARI PAUL MOSHE] [DANNYI\\n Imik\\n PeR/A2O13_45\\nThe Editors.',\n", " 'md': '```markdown\\n# Page 1\\n\\n## Text\\n- Jon\\n- [ARI PAUL MOSHE] [DANNYI]\\n- Imik\\n- PeR/A2O13_45\\n- The Editors.\\n\\n## Images\\n- No identifiable images or graphs on this page.\\n\\n## Tables\\n- No tables present on this page.\\n```',\n", " 'images': [{'name': 'img_p17_1.png',\n", " 'height': 398,\n", " 'width': 601,\n", " 'x': 157.67999999999995,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1378,\n", " 'original_height': 912}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page 1',\n", " 'md': '# Page 1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Jon\\n- [ARI PAUL MOSHE] [DANNYI]\\n- Imik\\n- PeR/A2O13_45\\n- The Editors.',\n", " 'md': '- Jon\\n- [ARI PAUL MOSHE] [DANNYI]\\n- Imik\\n- PeR/A2O13_45\\n- The Editors.',\n", " 'bBox': {'x': 75, 'y': 181.08, 'w': 298.9, 'h': 12.84}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No identifiable images or graphs on this page.',\n", " 'md': '- No identifiable images or graphs on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No tables present on this page.\\n```',\n", " 'md': '- No tables present on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 19,\n", " 'text': 'Preface\\n Common things are common except common sense.\\n Yasser Mohsen\\n\\n Common sense and a sense of humor are the same thing,\\n moving at different speeds. A sense of humor is just\\n common sense, dancing. Those who lack humor are\\n without judgment and should be trusted with nothing.\\n Clive James\\n\\n We are pleased to present the fourth edition of this book, which, since\\nit first appeared 15 years ago, has become popular with surgeons having\\nto deal with emergency abdominal surgery.\\n\\n Is there anything new in this field that merits the revision and\\nupdate of such a book every 4-5 years? Yes. The way we practice\\nemergency surgery is constantly evolving. With almost unlimited access\\nto abdominal imaging, we can rapidly pinpoint the diagnosis and avoid an\\nunnecessary operation, or perform an indicated operation instead of\\nengaging in a prolonged period of uncertainty. We are gradually\\nbecoming more selective and cautious — understanding that everything\\nwe do involves wielding a double-edged sword and that in\\nemergency surgery usually doing less is better but occasionally\\ndoing more may be life-saving. At least — this is what we will want\\nyou to believe after reading this book…\\n\\n At the same time, changes in surgical education combined with the\\nexaggerated obsession with modern technology are producing a new\\ngeneration of general surgeons. In the new era super-specialization in\\n‘advanced lap’ procedures is considered profitable and ‘sexy’,\\nwhereas general surgical emergencies are left to the juniors or the\\nallegedly ‘less talented’ surgeons. So, while there are post-residency\\nfellowships in various fields, no such training is deemed necessary for',\n", " 'md': '```markdown\\n# Preface\\n\\n> Common things are common except common sense.\\n> — Yasser Mohsen\\n\\n> Common sense and a sense of humor are the same thing, moving at different speeds. A sense of humor is just common sense, dancing. Those who lack humor are without judgment and should be trusted with nothing.\\n> — Clive James\\n\\nWe are pleased to present the fourth edition of this book, which, since it first appeared 15 years ago, has become popular with surgeons having to deal with emergency abdominal surgery.\\n\\nIs there anything new in this field that merits the revision and update of such a book every 4-5 years? Yes. The way we practice emergency surgery is constantly evolving. With almost unlimited access to abdominal imaging, we can rapidly pinpoint the diagnosis and avoid an unnecessary operation, or perform an indicated operation instead of engaging in a prolonged period of uncertainty. We are gradually becoming more selective and cautious — understanding that everything we do involves wielding a double-edged sword and that in emergency surgery usually doing less is better but occasionally doing more may be life-saving. At least — this is what we will want you to believe after reading this book…\\n\\nAt the same time, changes in surgical education combined with the exaggerated obsession with modern technology are producing a new generation of general surgeons. In the new era super-specialization in ‘advanced lap’ procedures is considered profitable and ‘sexy’, whereas general surgical emergencies are left to the juniors or the allegedly ‘less talented’ surgeons. So, while there are post-residency fellowships in various fields, no such training is deemed necessary for...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Preface',\n", " 'md': '# Preface',\n", " 'bBox': {'x': 72, 'y': 129, 'w': 104.03, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '> Common things are common except common sense.\\n> — Yasser Mohsen\\n\\n> Common sense and a sense of humor are the same thing, moving at different speeds. A sense of humor is just common sense, dancing. Those who lack humor are without judgment and should be trusted with nothing.\\n> — Clive James\\n\\nWe are pleased to present the fourth edition of this book, which, since it first appeared 15 years ago, has become popular with surgeons having to deal with emergency abdominal surgery.\\n\\nIs there anything new in this field that merits the revision and update of such a book every 4-5 years? Yes. The way we practice emergency surgery is constantly evolving. With almost unlimited access to abdominal imaging, we can rapidly pinpoint the diagnosis and avoid an unnecessary operation, or perform an indicated operation instead of engaging in a prolonged period of uncertainty. We are gradually becoming more selective and cautious — understanding that everything we do involves wielding a double-edged sword and that in emergency surgery usually doing less is better but occasionally doing more may be life-saving. At least — this is what we will want you to believe after reading this book…\\n\\nAt the same time, changes in surgical education combined with the exaggerated obsession with modern technology are producing a new generation of general surgeons. In the new era super-specialization in ‘advanced lap’ procedures is considered profitable and ‘sexy’, whereas general surgical emergencies are left to the juniors or the allegedly ‘less talented’ surgeons. So, while there are post-residency fellowships in various fields, no such training is deemed necessary for...\\n```',\n", " 'md': '> Common things are common except common sense.\\n> — Yasser Mohsen\\n\\n> Common sense and a sense of humor are the same thing, moving at different speeds. A sense of humor is just common sense, dancing. Those who lack humor are without judgment and should be trusted with nothing.\\n> — Clive James\\n\\nWe are pleased to present the fourth edition of this book, which, since it first appeared 15 years ago, has become popular with surgeons having to deal with emergency abdominal surgery.\\n\\nIs there anything new in this field that merits the revision and update of such a book every 4-5 years? Yes. The way we practice emergency surgery is constantly evolving. With almost unlimited access to abdominal imaging, we can rapidly pinpoint the diagnosis and avoid an unnecessary operation, or perform an indicated operation instead of engaging in a prolonged period of uncertainty. We are gradually becoming more selective and cautious — understanding that everything we do involves wielding a double-edged sword and that in emergency surgery usually doing less is better but occasionally doing more may be life-saving. At least — this is what we will want you to believe after reading this book…\\n\\nAt the same time, changes in surgical education combined with the exaggerated obsession with modern technology are producing a new generation of general surgeons. In the new era super-specialization in ‘advanced lap’ procedures is considered profitable and ‘sexy’, whereas general surgical emergencies are left to the juniors or the allegedly ‘less talented’ surgeons. So, while there are post-residency fellowships in various fields, no such training is deemed necessary for...\\n```',\n", " 'bBox': {'x': 72, 'y': 178, 'w': 467.74, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 20,\n", " 'text': 'emergency surgery — which is considered a ‘bastard’ field, which\\neverybody can do… usually at the late hours when the ‘robots’ go to\\nsleep.\\n\\n In this brave new world we need to constantly updates ourselves. We have to relearn how to\\n deal with the old s**t — which is becoming rare — even when its odor is masked by the\\n perfume of modern practice. And this is what we continue to do in this new edition — reciting\\n the written-in-stone sacred, old basics but also showing how to integrate them with the\\n evolving modern world.\\n\\n What is new in the fourth edition? We added three new co-editors:\\nAri from the University of ħelsinki, Danny from the University of Tel Aviv\\nand Jon from Johns ħopkins ħospital, Baltimore — Jon took it upon\\nhimself to rewrite all the colorectal chapters. All the contributors are well\\nknown to us personally as experts in their field. All existing chapters have\\nbeen revised, expanded or rewritten by the old or new contributors and/or\\nthe Editors. Each chapter has been carefully scrutinized by us, its style\\nand tone tuned to conform to the overall ‘voice’ of the book. We have\\neliminated chapters from this edition (e.g. complications of bariatric\\nsurgery) or subchapters (e.g. complications of cholecystectomy) in order\\nnot to duplicate contents from our other recent book — Schein’s\\nCommon Sense Prevention and Management of Surgical Complications\\n(tfm publishing Ltd., UK 2013); we believe that these two ‘twin’ books\\ncomplement each other.\\n\\n From the beginning we knew that a book like this — written in a practical, colloquial, and direct\\n in-your-face style will be either loved or hated. And indeed, a few reviewers (of the first edition)\\n — appalled by dogmas that clashed with their own, and language not exactly conforming to\\n Strunk and White’s The Elements of Style — almost killed it, but many more loved it.\\n\\n Motivated by the enthusiasm with which the book is being received\\naround the world — particularly among those practicing ‘real surgery’ in\\nthe ‘real world’ — we set about enhancing it to produce a text that should\\nbe palatable to all of you — wherever you try to save lives — be it in',\n", " 'md': '```markdown\\n## Page Content\\n\\nEmergency surgery — which is considered a ‘bastard’ field, which everybody can do… usually at the late hours when the ‘robots’ go to sleep.\\n\\nIn this brave new world we need to constantly update ourselves. We have to relearn how to deal with the old s**t — which is becoming rare — even when its odor is masked by the perfume of modern practice. And this is what we continue to do in this new edition — reciting the written-in-stone sacred, old basics but also showing how to integrate them with the evolving modern world.\\n\\n### What is new in the fourth edition?\\n\\nWe added three new co-editors: Ari from the University of Helsinki, Danny from the University of Tel Aviv, and Jon from Johns Hopkins Hospital, Baltimore — Jon took it upon himself to rewrite all the colorectal chapters. All the contributors are well known to us personally as experts in their field. All existing chapters have been revised, expanded, or rewritten by the old or new contributors and/or the Editors. Each chapter has been carefully scrutinized by us, its style and tone tuned to conform to the overall ‘voice’ of the book. We have eliminated chapters from this edition (e.g. complications of bariatric surgery) or subchapters (e.g. complications of cholecystectomy) in order not to duplicate contents from our other recent book — Schein’s Common Sense Prevention and Management of Surgical Complications (tfm publishing Ltd., UK 2013); we believe that these two ‘twin’ books complement each other.\\n\\nFrom the beginning we knew that a book like this — written in a practical, colloquial, and direct in-your-face style will be either loved or hated. And indeed, a few reviewers (of the first edition) — appalled by dogmas that clashed with their own, and language not exactly conforming to Strunk and White’s The Elements of Style — almost killed it, but many more loved it.\\n\\nMotivated by the enthusiasm with which the book is being received around the world — particularly among those practicing ‘real surgery’ in the ‘real world’ — we set about enhancing it to produce a text that should be palatable to all of you — wherever you try to save lives — be it in...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas or hyperlinks present in the extracted text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Emergency surgery — which is considered a ‘bastard’ field, which everybody can do… usually at the late hours when the ‘robots’ go to sleep.\\n\\nIn this brave new world we need to constantly update ourselves. We have to relearn how to deal with the old s**t — which is becoming rare — even when its odor is masked by the perfume of modern practice. And this is what we continue to do in this new edition — reciting the written-in-stone sacred, old basics but also showing how to integrate them with the evolving modern world.',\n", " 'md': 'Emergency surgery — which is considered a ‘bastard’ field, which everybody can do… usually at the late hours when the ‘robots’ go to sleep.\\n\\nIn this brave new world we need to constantly update ourselves. We have to relearn how to deal with the old s**t — which is becoming rare — even when its odor is masked by the perfume of modern practice. And this is what we continue to do in this new edition — reciting the written-in-stone sacred, old basics but also showing how to integrate them with the evolving modern world.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 453.38, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'What is new in the fourth edition?',\n", " 'md': '### What is new in the fourth edition?',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'We added three new co-editors: Ari from the University of Helsinki, Danny from the University of Tel Aviv, and Jon from Johns Hopkins Hospital, Baltimore — Jon took it upon himself to rewrite all the colorectal chapters. All the contributors are well known to us personally as experts in their field. All existing chapters have been revised, expanded, or rewritten by the old or new contributors and/or the Editors. Each chapter has been carefully scrutinized by us, its style and tone tuned to conform to the overall ‘voice’ of the book. We have eliminated chapters from this edition (e.g. complications of bariatric surgery) or subchapters (e.g. complications of cholecystectomy) in order not to duplicate contents from our other recent book — Schein’s Common Sense Prevention and Management of Surgical Complications (tfm publishing Ltd., UK 2013); we believe that these two ‘twin’ books complement each other.\\n\\nFrom the beginning we knew that a book like this — written in a practical, colloquial, and direct in-your-face style will be either loved or hated. And indeed, a few reviewers (of the first edition) — appalled by dogmas that clashed with their own, and language not exactly conforming to Strunk and White’s The Elements of Style — almost killed it, but many more loved it.\\n\\nMotivated by the enthusiasm with which the book is being received around the world — particularly among those practicing ‘real surgery’ in the ‘real world’ — we set about enhancing it to produce a text that should be palatable to all of you — wherever you try to save lives — be it in...\\n```',\n", " 'md': 'We added three new co-editors: Ari from the University of Helsinki, Danny from the University of Tel Aviv, and Jon from Johns Hopkins Hospital, Baltimore — Jon took it upon himself to rewrite all the colorectal chapters. All the contributors are well known to us personally as experts in their field. All existing chapters have been revised, expanded, or rewritten by the old or new contributors and/or the Editors. Each chapter has been carefully scrutinized by us, its style and tone tuned to conform to the overall ‘voice’ of the book. We have eliminated chapters from this edition (e.g. complications of bariatric surgery) or subchapters (e.g. complications of cholecystectomy) in order not to duplicate contents from our other recent book — Schein’s Common Sense Prevention and Management of Surgical Complications (tfm publishing Ltd., UK 2013); we believe that these two ‘twin’ books complement each other.\\n\\nFrom the beginning we knew that a book like this — written in a practical, colloquial, and direct in-your-face style will be either loved or hated. And indeed, a few reviewers (of the first edition) — appalled by dogmas that clashed with their own, and language not exactly conforming to Strunk and White’s The Elements of Style — almost killed it, but many more loved it.\\n\\nMotivated by the enthusiasm with which the book is being received around the world — particularly among those practicing ‘real surgery’ in the ‘real world’ — we set about enhancing it to produce a text that should be palatable to all of you — wherever you try to save lives — be it in...\\n```',\n", " 'bBox': {'x': 72, 'y': 337, 'w': 467.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas or hyperlinks present in the extracted text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas or hyperlinks present in the extracted text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 21,\n", " 'text': 'Mumbai, Karachi, Cairo, Belgrade, Soweto, Mexico City, Kiev,\\nCopenhagen, Philadelphia, Glasgow, Krakow and, yes — even in Paris\\n(we hope there are a few French surgeons who can, and want to, read\\nEnglish…).\\n\\n If you are a surgeon who practices the way he was trained 20 or\\n30 years ago you will hate this book; if you are being trained by\\nsuch a surgeon then you desperately need to read this book.\\n\\n Dr. Anton Chekhov said: “Doctors are just the same as lawyers; the\\nonly difference is that lawyers merely rob you, whereas doctors rob you\\nand kill you, too.” Our chief aim in writing this book was to help you not\\nkill your patients. This non-orthodox book is not yet another tedious, full-\\nof-details textbook. We do not need more of these. It’s aimed at you, the\\nyoung practicing surgeon who desires a focused and friendly approach to\\nemergency abdominal surgery. We hope and believe that this modest\\nbook will be of some value to you.\\n\\n André Maurois said: “In literature, as in love, we are astonished at what\\nis chosen by others.” We hope you chose this book.\\n\\n The Editors\\n Northern Wisconsin/Glasgow/Helsinki/Tel Aviv/Baltimore',\n", " 'md': '```markdown\\n## Page Content\\n\\nMumbai, Karachi, Cairo, Belgrade, Soweto, Mexico City, Kiev, Copenhagen, Philadelphia, Glasgow, Krakow and, yes — even in Paris (we hope there are a few French surgeons who can, and want to, read English…).\\n\\nIf you are a surgeon who practices the way he was trained 20 or 30 years ago you will hate this book; if you are being trained by such a surgeon then you desperately need to read this book.\\n\\nDr. Anton Chekhov said: “Doctors are just the same as lawyers; the only difference is that lawyers merely rob you, whereas doctors rob you and kill you, too.” Our chief aim in writing this book was to help you not kill your patients. This non-orthodox book is not yet another tedious, full-of-details textbook. We do not need more of these. It’s aimed at you, the young practicing surgeon who desires a focused and friendly approach to emergency abdominal surgery. We hope and believe that this modest book will be of some value to you.\\n\\nAndré Maurois said: “In literature, as in love, we are astonished at what is chosen by others.” We hope you chose this book.\\n\\nThe Editors\\nNorthern Wisconsin/Glasgow/Helsinki/Tel Aviv/Baltimore\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted while excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Mumbai, Karachi, Cairo, Belgrade, Soweto, Mexico City, Kiev, Copenhagen, Philadelphia, Glasgow, Krakow and, yes — even in Paris (we hope there are a few French surgeons who can, and want to, read English…).\\n\\nIf you are a surgeon who practices the way he was trained 20 or 30 years ago you will hate this book; if you are being trained by such a surgeon then you desperately need to read this book.\\n\\nDr. Anton Chekhov said: “Doctors are just the same as lawyers; the only difference is that lawyers merely rob you, whereas doctors rob you and kill you, too.” Our chief aim in writing this book was to help you not kill your patients. This non-orthodox book is not yet another tedious, full-of-details textbook. We do not need more of these. It’s aimed at you, the young practicing surgeon who desires a focused and friendly approach to emergency abdominal surgery. We hope and believe that this modest book will be of some value to you.\\n\\nAndré Maurois said: “In literature, as in love, we are astonished at what is chosen by others.” We hope you chose this book.\\n\\nThe Editors\\nNorthern Wisconsin/Glasgow/Helsinki/Tel Aviv/Baltimore\\n```',\n", " 'md': 'Mumbai, Karachi, Cairo, Belgrade, Soweto, Mexico City, Kiev, Copenhagen, Philadelphia, Glasgow, Krakow and, yes — even in Paris (we hope there are a few French surgeons who can, and want to, read English…).\\n\\nIf you are a surgeon who practices the way he was trained 20 or 30 years ago you will hate this book; if you are being trained by such a surgeon then you desperately need to read this book.\\n\\nDr. Anton Chekhov said: “Doctors are just the same as lawyers; the only difference is that lawyers merely rob you, whereas doctors rob you and kill you, too.” Our chief aim in writing this book was to help you not kill your patients. This non-orthodox book is not yet another tedious, full-of-details textbook. We do not need more of these. It’s aimed at you, the young practicing surgeon who desires a focused and friendly approach to emergency abdominal surgery. We hope and believe that this modest book will be of some value to you.\\n\\nAndré Maurois said: “In literature, as in love, we are astonished at what is chosen by others.” We hope you chose this book.\\n\\nThe Editors\\nNorthern Wisconsin/Glasgow/Helsinki/Tel Aviv/Baltimore\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted while excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted while excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 22,\n", " 'text': ' Reviews of previous editions\\n\\n “This is written with short punchy chapters making it a very difficult\\nbook to put down…”.\\n\\n R. A. B. Wood\\n Journal of the Royal College of Surgeons of Edinburgh\\n\\n “Since Mondor’s times in the forties of the last century there was no\\nother book in surgery to be written so easy and witty …”.\\n\\n Boris D. Savchuk\\n World Journal of Surgery\\n\\n “By the end I was a total enthusiast… this is a text like no other I\\nread… Unreservedly recommended to old and young and alike.”\\n\\n M. Winslet, Royal Free Hospital, London\\n Colorectal Disease\\n\\n “The title describes this book perfectly. This is a no-nonsense approach\\nto the sometimes very difficult situations in general surgery.… The\\nauthors describe their experiences in tough situations of patient care for\\nresidents and young attendings.… the historical quotes add a good\\namount of insight and interest. I have not come across another book like\\nthis.… Focused on the real situations that surgeons come across, the\\nbook answers the questions that are not addressed in the major\\ntextbooks.”\\n\\n Robert A. Hanfland\\n Doody’s Review Service\\n\\n “This book covers emergency abdominal surgery in a useful and\\ninteresting way. [It is] a small and handy book yet the coverage is wide. It\\nwould be of interest to any general surgeon and should certainly be read\\nby surgical trainees. [It] allows mention of many things which would\\notherwise be excluded from a more rigidly structured work. I was also',\n", " 'md': '```markdown\\n# Reviews of Previous Editions\\n\\n- “This is written with short punchy chapters making it a very difficult book to put down…”.\\n- **R. A. B. Wood**, Journal of the Royal College of Surgeons of Edinburgh\\n\\n- “Since Mondor’s times in the forties of the last century there was no other book in surgery to be written so easy and witty …”.\\n- **Boris D. Savchuk**, World Journal of Surgery\\n\\n- “By the end I was a total enthusiast… this is a text like no other I read… Unreservedly recommended to old and young and alike.”\\n- **M. Winslet**, Royal Free Hospital, London, Colorectal Disease\\n\\n- “The title describes this book perfectly. This is a no-nonsense approach to the sometimes very difficult situations in general surgery.… The authors describe their experiences in tough situations of patient care for residents and young attendings.… the historical quotes add a good amount of insight and interest. I have not come across another book like this.… Focused on the real situations that surgeons come across, the book answers the questions that are not addressed in the major textbooks.”\\n- **Robert A. Hanfland**, Doody’s Review Service\\n\\n- “This book covers emergency abdominal surgery in a useful and interesting way. [It is] a small and handy book yet the coverage is wide. It would be of interest to any general surgeon and should certainly be read by surgical trainees. [It] allows mention of many things which would otherwise be excluded from a more rigidly structured work. I was also\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Reviews of Previous Editions',\n", " 'md': '# Reviews of Previous Editions',\n", " 'bBox': {'x': 86, 'y': 112, 'w': 228.04, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- “This is written with short punchy chapters making it a very difficult book to put down…”.\\n- **R. A. B. Wood**, Journal of the Royal College of Surgeons of Edinburgh\\n\\n- “Since Mondor’s times in the forties of the last century there was no other book in surgery to be written so easy and witty …”.\\n- **Boris D. Savchuk**, World Journal of Surgery\\n\\n- “By the end I was a total enthusiast… this is a text like no other I read… Unreservedly recommended to old and young and alike.”\\n- **M. Winslet**, Royal Free Hospital, London, Colorectal Disease\\n\\n- “The title describes this book perfectly. This is a no-nonsense approach to the sometimes very difficult situations in general surgery.… The authors describe their experiences in tough situations of patient care for residents and young attendings.… the historical quotes add a good amount of insight and interest. I have not come across another book like this.… Focused on the real situations that surgeons come across, the book answers the questions that are not addressed in the major textbooks.”\\n- **Robert A. Hanfland**, Doody’s Review Service\\n\\n- “This book covers emergency abdominal surgery in a useful and interesting way. [It is] a small and handy book yet the coverage is wide. It would be of interest to any general surgeon and should certainly be read by surgical trainees. [It] allows mention of many things which would otherwise be excluded from a more rigidly structured work. I was also\\n```',\n", " 'md': '- “This is written with short punchy chapters making it a very difficult book to put down…”.\\n- **R. A. B. Wood**, Journal of the Royal College of Surgeons of Edinburgh\\n\\n- “Since Mondor’s times in the forties of the last century there was no other book in surgery to be written so easy and witty …”.\\n- **Boris D. Savchuk**, World Journal of Surgery\\n\\n- “By the end I was a total enthusiast… this is a text like no other I read… Unreservedly recommended to old and young and alike.”\\n- **M. Winslet**, Royal Free Hospital, London, Colorectal Disease\\n\\n- “The title describes this book perfectly. This is a no-nonsense approach to the sometimes very difficult situations in general surgery.… The authors describe their experiences in tough situations of patient care for residents and young attendings.… the historical quotes add a good amount of insight and interest. I have not come across another book like this.… Focused on the real situations that surgeons come across, the book answers the questions that are not addressed in the major textbooks.”\\n- **Robert A. Hanfland**, Doody’s Review Service\\n\\n- “This book covers emergency abdominal surgery in a useful and interesting way. [It is] a small and handy book yet the coverage is wide. It would be of interest to any general surgeon and should certainly be read by surgical trainees. [It] allows mention of many things which would otherwise be excluded from a more rigidly structured work. I was also\\n```',\n", " 'bBox': {'x': 72, 'y': 165, 'w': 468, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 23,\n", " 'text': 'glad to be reminded of many things which I had known but forgotten. The\\nwriters clearly know what they are talking about.”\\n\\n David Evans\\n Annals of the Royal College of Surgeons of England\\n\\n A sample of testimonials posted on amazon...\\n By Donald Dupuis, MD, Lahey Clinic\\n “A Must Have Book. I am about to end my chief year in\\ngeneral surgery residency — my copy of the first edition shows the wear\\nof half a dozen total read throughs and probably hundreds of\\nreferencings. Newest edition is equally good. For the last 3 years I have\\ngiven this book to our interns if they finish their surgical internship. And\\nI’ve paid for this myself — if you know how little residents get paid you\\nwill know how important I think it is. If you are in surgical training DO NOT\\nWAIT ANOTHER DAY BEFORE YOU BUY THIS BOOK. I do agree with\\nanother reviewer who thought a bit of cool surgical technique would have\\nbeen good too. But, all in all, best, most useful little book on surgery ever.\\nNuff said.”\\n By Chet A. Morrison, Assistant Professor of Surgery, Director of Surgical Critical Care,\\n Michigan State University\\n “A very useful practical guide. This is a fine book in the\\ntradition of ‘guides to being on call’ — or maybe the ‘guide to the\\nperplexed’. I like the straightforward get to the point style, and the\\ndirectness of the book makes this a useful book to have handy when\\nconfronted with some of the emergency surgery problems. I would only\\nsay it could have had a bit more on surgical technique, and one or two\\nreferences would have been useful (instead there was almost a militant\\ninsistence on as few as possible). But I would recommend it for any\\nresident who is on call, and I find it useful as a staff sugeon as well.”\\n By K. M. Kemp\\n “Love it. I’m a big fan of this book, having just finished it a\\nmonth ago. It’s a good mix of the author’s own experience as well as\\nexpert commentary when indicated. Compared to a textbook, it’s much\\nmore engaging and easier to read. Also compared to a text, it seems',\n", " 'md': '```markdown\\n# Testimonials\\n\\n## David Evans\\n> \"Glad to be reminded of many things which I had known but forgotten. The writers clearly know what they are talking about.\"\\n>\\n> — Annals of the Royal College of Surgeons of England\\n\\n## By Donald Dupuis, MD, Lahey Clinic\\n> \"A Must Have Book. I am about to end my chief year in general surgery residency — my copy of the first edition shows the wear of half a dozen total read throughs and probably hundreds of referencings. Newest edition is equally good. For the last 3 years I have given this book to our interns if they finish their surgical internship. And I’ve paid for this myself — if you know how little residents get paid you will know how important I think it is. If you are in surgical training DO NOT WAIT ANOTHER DAY BEFORE YOU BUY THIS BOOK. I do agree with another reviewer who thought a bit of cool surgical technique would have been good too. But, all in all, best, most useful little book on surgery ever. Nuff said.\"\\n\\n## By Chet A. Morrison, Assistant Professor of Surgery, Director of Surgical Critical Care, Michigan State University\\n> \"A very useful practical guide. This is a fine book in the tradition of ‘guides to being on call’ — or maybe the ‘guide to the perplexed’. I like the straightforward get to the point style, and the directness of the book makes this a useful book to have handy when confronted with some of the emergency surgery problems. I would only say it could have had a bit more on surgical technique, and one or two references would have been useful (instead there was almost a militant insistence on as few as possible). But I would recommend it for any resident who is on call, and I find it useful as a staff surgeon as well.\"\\n\\n## By K. M. Kemp\\n> \"Love it. I’m a big fan of this book, having just finished it a month ago. It’s a good mix of the author’s own experience as well as expert commentary when indicated. Compared to a textbook, it’s much more engaging and easier to read. Also compared to a text, it seems .\"\\n```',\n", " 'images': [{'name': 'img_p22_1.png',\n", " 'height': 19,\n", " 'width': 95,\n", " 'x': 86.39999999999998,\n", " 'y': 234,\n", " 'original_width': 130,\n", " 'original_height': 27},\n", " {'name': 'img_p22_2.png',\n", " 'height': 19,\n", " 'width': 78,\n", " 'x': 86.39999999999998,\n", " 'y': 461.52,\n", " 'original_width': 106,\n", " 'original_height': 27},\n", " {'name': 'img_p22_1.png',\n", " 'height': 19,\n", " 'width': 95,\n", " 'x': 86.39999999999998,\n", " 'y': 643.68,\n", " 'original_width': 130,\n", " 'original_height': 27}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Testimonials',\n", " 'md': '# Testimonials',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'David Evans',\n", " 'md': '## David Evans',\n", " 'bBox': {'x': 454, 'y': 133, 'w': 85.55, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '> \"Glad to be reminded of many things which I had known but forgotten. The writers clearly know what they are talking about.\"\\n>\\n> — Annals of the Royal College of Surgeons of England',\n", " 'md': '> \"Glad to be reminded of many things which I had known but forgotten. The writers clearly know what they are talking about.\"\\n>\\n> — Annals of the Royal College of Surgeons of England',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.42, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'By Donald Dupuis, MD, Lahey Clinic',\n", " 'md': '## By Donald Dupuis, MD, Lahey Clinic',\n", " 'bBox': {'x': 82, 'y': 223, 'w': 185.19, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': '> \"A Must Have Book. I am about to end my chief year in general surgery residency — my copy of the first edition shows the wear of half a dozen total read throughs and probably hundreds of referencings. Newest edition is equally good. For the last 3 years I have given this book to our interns if they finish their surgical internship. And I’ve paid for this myself — if you know how little residents get paid you will know how important I think it is. If you are in surgical training DO NOT WAIT ANOTHER DAY BEFORE YOU BUY THIS BOOK. I do agree with another reviewer who thought a bit of cool surgical technique would have been good too. But, all in all, best, most useful little book on surgery ever. Nuff said.\"',\n", " 'md': '> \"A Must Have Book. I am about to end my chief year in general surgery residency — my copy of the first edition shows the wear of half a dozen total read throughs and probably hundreds of referencings. Newest edition is equally good. For the last 3 years I have given this book to our interns if they finish their surgical internship. And I’ve paid for this myself — if you know how little residents get paid you will know how important I think it is. If you are in surgical training DO NOT WAIT ANOTHER DAY BEFORE YOU BUY THIS BOOK. I do agree with another reviewer who thought a bit of cool surgical technique would have been good too. But, all in all, best, most useful little book on surgery ever. Nuff said.\"',\n", " 'bBox': {'x': 72, 'y': 260, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'By Chet A. Morrison, Assistant Professor of Surgery, Director of Surgical Critical Care, Michigan State University',\n", " 'md': '## By Chet A. Morrison, Assistant Professor of Surgery, Director of Surgical Critical Care, Michigan State University',\n", " 'bBox': {'x': 82, 'y': 438, 'w': 443.28, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': '> \"A very useful practical guide. This is a fine book in the tradition of ‘guides to being on call’ — or maybe the ‘guide to the perplexed’. I like the straightforward get to the point style, and the directness of the book makes this a useful book to have handy when confronted with some of the emergency surgery problems. I would only say it could have had a bit more on surgical technique, and one or two references would have been useful (instead there was almost a militant insistence on as few as possible). But I would recommend it for any resident who is on call, and I find it useful as a staff surgeon as well.\"',\n", " 'md': '> \"A very useful practical guide. This is a fine book in the tradition of ‘guides to being on call’ — or maybe the ‘guide to the perplexed’. I like the straightforward get to the point style, and the directness of the book makes this a useful book to have handy when confronted with some of the emergency surgery problems. I would only say it could have had a bit more on surgical technique, and one or two references would have been useful (instead there was almost a militant insistence on as few as possible). But I would recommend it for any resident who is on call, and I find it useful as a staff surgeon as well.\"',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'By K. M. Kemp',\n", " 'md': '## By K. M. Kemp',\n", " 'bBox': {'x': 82, 'y': 633, 'w': 75.53, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': '> \"Love it. I’m a big fan of this book, having just finished it a month ago. It’s a good mix of the author’s own experience as well as expert commentary when indicated. Compared to a textbook, it’s much more engaging and easier to read. Also compared to a text, it seems .\"\\n```',\n", " 'md': '> \"Love it. I’m a big fan of this book, having just finished it a month ago. It’s a good mix of the author’s own experience as well as expert commentary when indicated. Compared to a textbook, it’s much more engaging and easier to read. Also compared to a text, it seems .\"\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 24,\n", " 'text': 'much more practical in the advice it gives. As a brand new intern, I\\ngleaned a lot from this book. ħighly recommended for fellow trainees.”\\n By Jendri\\n “A surgical must have. This is a very well written and very\\npractical guide to emergency surgery. It covers virtually all aspects of\\nemergency general surgery and does it in a very interesting way. I think\\nthis is one of the best books on the subject. For me it certainly is a must\\nhave. In the next edition, probably the only thing that I would like to add\\nto this book would be the information about the military uniform worn by\\nDr. Karl Schein on the photograph on one of the first pages. Dr. Schein is\\nwearing a uniform of the 1st Polish Army formed in Soviet Union in 1943.\\nAltogether a great book.”\\n By andreromeo\\n “A must. Dr. Moshe Schein has a very personal view about\\nmedicine and about the art of surgery, and that is why this book is really a\\nmust for clinicians and surgeons.”\\n By Andy\\n “Simply perfect. The best choice in surgery for trainees! It\\nmakes the more difficult surgery areas very easy to understand. I\\nrecommend it to all surgeons.”\\n By maxim\\n “Worth every penny. Invaluable as a guide to assist in the\\nresolution of a broad range of abdominal problems. The book is well\\nstructured, running from opening chapters addressing pre-operative\\nissues, and on through a pretty complete spectrum of gut complaints\\nlikely to arise in the real world, and how best to sort them out. It’s not only\\nuseful, but very well written, and, for a text book, an absolute pleasure to\\nread. Short bite size chapters combined with the occasional cartoon\\nmake this 3rd edition of Schein well worth the investment. Blend with\\nCope’s Diagnosis of the Acute Abdomen for the ideal cocktail.”\\n By J. D. Wassner\\n “Well-written, easy to read. Should be required reading for\\nany general surgery resident, & anyone who does acute care & trauma.”',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Reviews\\n\\n1. **By Jendri**\\n“A surgical must have. This is a very well written and very practical guide to emergency surgery. It covers virtually all aspects of emergency general surgery and does it in a very interesting way. I think this is one of the best books on the subject. For me it certainly is a must have. In the next edition, probably the only thing that I would like to add to this book would be the information about the military uniform worn by Dr. Karl Schein on the photograph on one of the first pages. Dr. Schein is wearing a uniform of the 1st Polish Army formed in Soviet Union in 1943. Altogether a great book.”\\n\\n2. **By andreromeo**\\n“A must. Dr. Moshe Schein has a very personal view about medicine and about the art of surgery, and that is why this book is really a must for clinicians and surgeons.”\\n\\n3. **By Andy**\\n“Simply perfect. The best choice in surgery for trainees! It makes the more difficult surgery areas very easy to understand. I recommend it to all surgeons.”\\n\\n4. **By maxim**\\n“Worth every penny. Invaluable as a guide to assist in the resolution of a broad range of abdominal problems. The book is well structured, running from opening chapters addressing pre-operative issues, and on through a pretty complete spectrum of gut complaints likely to arise in the real world, and how best to sort them out. It’s not only useful, but very well written, and, for a text book, an absolute pleasure to read. Short bite size chapters combined with the occasional cartoon make this 3rd edition of Schein well worth the investment. Blend with Cope’s Diagnosis of the Acute Abdomen for the ideal cocktail.”\\n\\n5. **By J. D. Wassner**\\n“Well-written, easy to read. Should be required reading for any general surgery resident, & anyone who does acute care & trauma.”\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Reviews',\n", " 'md': '## Reviews',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. **By Jendri**\\n“A surgical must have. This is a very well written and very practical guide to emergency surgery. It covers virtually all aspects of emergency general surgery and does it in a very interesting way. I think this is one of the best books on the subject. For me it certainly is a must have. In the next edition, probably the only thing that I would like to add to this book would be the information about the military uniform worn by Dr. Karl Schein on the photograph on one of the first pages. Dr. Schein is wearing a uniform of the 1st Polish Army formed in Soviet Union in 1943. Altogether a great book.”\\n\\n2. **By andreromeo**\\n“A must. Dr. Moshe Schein has a very personal view about medicine and about the art of surgery, and that is why this book is really a must for clinicians and surgeons.”\\n\\n3. **By Andy**\\n“Simply perfect. The best choice in surgery for trainees! It makes the more difficult surgery areas very easy to understand. I recommend it to all surgeons.”\\n\\n4. **By maxim**\\n“Worth every penny. Invaluable as a guide to assist in the resolution of a broad range of abdominal problems. The book is well structured, running from opening chapters addressing pre-operative issues, and on through a pretty complete spectrum of gut complaints likely to arise in the real world, and how best to sort them out. It’s not only useful, but very well written, and, for a text book, an absolute pleasure to read. Short bite size chapters combined with the occasional cartoon make this 3rd edition of Schein well worth the investment. Blend with Cope’s Diagnosis of the Acute Abdomen for the ideal cocktail.”\\n\\n5. **By J. D. Wassner**\\n“Well-written, easy to read. Should be required reading for any general surgery resident, & anyone who does acute care & trauma.”\\n```',\n", " 'md': '1. **By Jendri**\\n“A surgical must have. This is a very well written and very practical guide to emergency surgery. It covers virtually all aspects of emergency general surgery and does it in a very interesting way. I think this is one of the best books on the subject. For me it certainly is a must have. In the next edition, probably the only thing that I would like to add to this book would be the information about the military uniform worn by Dr. Karl Schein on the photograph on one of the first pages. Dr. Schein is wearing a uniform of the 1st Polish Army formed in Soviet Union in 1943. Altogether a great book.”\\n\\n2. **By andreromeo**\\n“A must. Dr. Moshe Schein has a very personal view about medicine and about the art of surgery, and that is why this book is really a must for clinicians and surgeons.”\\n\\n3. **By Andy**\\n“Simply perfect. The best choice in surgery for trainees! It makes the more difficult surgery areas very easy to understand. I recommend it to all surgeons.”\\n\\n4. **By maxim**\\n“Worth every penny. Invaluable as a guide to assist in the resolution of a broad range of abdominal problems. The book is well structured, running from opening chapters addressing pre-operative issues, and on through a pretty complete spectrum of gut complaints likely to arise in the real world, and how best to sort them out. It’s not only useful, but very well written, and, for a text book, an absolute pleasure to read. Short bite size chapters combined with the occasional cartoon make this 3rd edition of Schein well worth the investment. Blend with Cope’s Diagnosis of the Acute Abdomen for the ideal cocktail.”\\n\\n5. **By J. D. Wassner**\\n“Well-written, easy to read. Should be required reading for any general surgery resident, & anyone who does acute care & trauma.”\\n```',\n", " 'bBox': {'x': 72, 'y': 132, 'w': 467.98, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 25,\n", " 'text': ' PART I\\n\\nGeneral considerations',\n", " 'md': '```markdown\\n# Part I\\n\\n## General Considerations\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Part I',\n", " 'md': '# Part I',\n", " 'bBox': {'x': 261, 'y': 172, 'w': 89.61, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'General Considerations',\n", " 'md': '## General Considerations',\n", " 'bBox': {'x': 146, 'y': 235, 'w': 319.97, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 26,\n", " 'text': 'Chapter 1\\nGeneral philosophy\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and\\nJonathan E. Efron\\n\\n Wisdom comes alone through suffering.\\n Aeschylus, Agamemnon\\n Good judgment comes from experience, experience comes\\n from bad judgment.\\n Surgeons are internists who operate…\\n\\n At this moment — just as you pick up this book and begin to browse\\nthrough its pages — there are many thousands of surgeons around the\\nworld facing a patient with an abdominal catastrophe. The platform on\\nwhich such an encounter occurs differs from place to place — a modern\\nemergency department in London, a shabby casualty room in the Bronx,\\nor a doctor’s tent in the African bush. But the scene itself is amazingly\\nuniform. It is always the same — you confronting a patient, he suffering,\\nin pain, and anxious. And you are anxious as well: anxious about the\\ndiagnosis, concerned about choosing the best management, troubled\\nabout your own abilities to do what is correct.\\n\\n We are in the 21st century but this universal scenario is not new. It is\\nas old as surgery itself. You are perhaps too young to know how little\\nsome things have changed — or how other things have changed,\\nand not always for the better — over the years. Yes, your hospital may\\nbe in the forefront of modern medicine; it has a team of subspecialists on',\n", " 'md': '```markdown\\n# Chapter 1: General Philosophy\\n\\n**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n> \"Wisdom comes alone through suffering.\"\\n> — Aeschylus, *Agamemnon*\\n\\n> \"Good judgment comes from experience, experience comes from bad judgment.\"\\n> — Surgeons are internists who operate…\\n\\nAt this moment — just as you pick up this book and begin to browse through its pages — there are many thousands of surgeons around the world facing a patient with an abdominal catastrophe. The platform on which such an encounter occurs differs from place to place — a modern emergency department in London, a shabby casualty room in the Bronx, or a doctor’s tent in the African bush. But the scene itself is amazingly uniform. It is always the same — you confronting a patient, he suffering, in pain, and anxious. And you are anxious as well: anxious about the diagnosis, concerned about choosing the best management, troubled about your own abilities to do what is correct.\\n\\nWe are in the 21st century but this universal scenario is not new. It is as old as surgery itself. You are perhaps too young to know how little some things have changed — or how other things have changed, and not always for the better — over the years. Yes, your hospital may be in the forefront of modern medicine; it has a team of subspecialists on...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 1: General Philosophy',\n", " 'md': '# Chapter 1: General Philosophy',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 173.61, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n> \"Wisdom comes alone through suffering.\"\\n> — Aeschylus, *Agamemnon*\\n\\n> \"Good judgment comes from experience, experience comes from bad judgment.\"\\n> — Surgeons are internists who operate…\\n\\nAt this moment — just as you pick up this book and begin to browse through its pages — there are many thousands of surgeons around the world facing a patient with an abdominal catastrophe. The platform on which such an encounter occurs differs from place to place — a modern emergency department in London, a shabby casualty room in the Bronx, or a doctor’s tent in the African bush. But the scene itself is amazingly uniform. It is always the same — you confronting a patient, he suffering, in pain, and anxious. And you are anxious as well: anxious about the diagnosis, concerned about choosing the best management, troubled about your own abilities to do what is correct.\\n\\nWe are in the 21st century but this universal scenario is not new. It is as old as surgery itself. You are perhaps too young to know how little some things have changed — or how other things have changed, and not always for the better — over the years. Yes, your hospital may be in the forefront of modern medicine; it has a team of subspecialists on...\\n```',\n", " 'md': '**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n> \"Wisdom comes alone through suffering.\"\\n> — Aeschylus, *Agamemnon*\\n\\n> \"Good judgment comes from experience, experience comes from bad judgment.\"\\n> — Surgeons are internists who operate…\\n\\nAt this moment — just as you pick up this book and begin to browse through its pages — there are many thousands of surgeons around the world facing a patient with an abdominal catastrophe. The platform on which such an encounter occurs differs from place to place — a modern emergency department in London, a shabby casualty room in the Bronx, or a doctor’s tent in the African bush. But the scene itself is amazingly uniform. It is always the same — you confronting a patient, he suffering, in pain, and anxious. And you are anxious as well: anxious about the diagnosis, concerned about choosing the best management, troubled about your own abilities to do what is correct.\\n\\nWe are in the 21st century but this universal scenario is not new. It is as old as surgery itself. You are perhaps too young to know how little some things have changed — or how other things have changed, and not always for the better — over the years. Yes, your hospital may be in the forefront of modern medicine; it has a team of subspecialists on...\\n```',\n", " 'bBox': {'x': 72, 'y': 260, 'w': 467.97, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 27,\n", " 'text': 'call to provide advice (it has an even larger administrative team of\\nfunctionaries to monitor you…), its emergency room has standby, state-\\nof-the-art spiral computed tomography and magnetic resonance imaging\\nmachines, but, practically, something has not changed: it is the patient\\nand you (often with the entire ‘system’ against you) — you who are\\nduty bound to provide a correct management plan and execute it.\\nAnd it often feels lonely out there; even we, experienced old farts, can\\nfeel the loneliness.\\n\\n The ‘best’ management of an abdominal emergency\\n\\n It is useful to compare the emergency abdominal surgeon to an infantry\\nsoldier ( Figure 1.1). Away from the limelight and glory that surrounds\\ncardiac or neurological surgeons, emergency abdominal surgery is closer\\nto infantry than it is to airborne action. A war cannot be won by remote\\ncontrol with cruise missiles, or robots, but with infantry on the\\nground. Likewise, technological gimmicks have a limited place in\\nemergency abdominal surgery, which is the domain of the surgeon’s\\nbrain and hands. To achieve the final ‘victory’ someone has to\\nagonize, sweat, bleed, and wet his hands — remember the bad smell\\nfrom your hands after operating on a perforated colon? Some\\nreaders may struggle with this military metaphor but the truth of the\\nmatter is that emergency abdominal surgery shares a few simple rules\\nwith infantry action — developed in the trenches and during offensives —\\nrules that are the key to survival and victory ( Table 1.1). Such a code of\\nbattle echoes the ‘best’ management of abdominal emergencies.',\n", " 'md': '```markdown\\n## Current Page Content\\n\\nCall to provide advice (it has an even larger administrative team of functionaries to monitor you…), its emergency room has standby, state-of-the-art spiral computed tomography and magnetic resonance imaging machines, but, practically, something has not changed: it is the patient and you (often with the entire ‘system’ against you) — you who are duty bound to provide a correct management plan and execute it. And it often feels lonely out there; even we, experienced old farts, can feel the loneliness.\\n\\n### The ‘Best’ Management of an Abdominal Emergency\\n\\nIt is useful to compare the emergency abdominal surgeon to an infantry soldier (Figure 1.1). Away from the limelight and glory that surrounds cardiac or neurological surgeons, emergency abdominal surgery is closer to infantry than it is to airborne action. A war cannot be won by remote control with cruise missiles, or robots, but with infantry on the ground. Likewise, technological gimmicks have a limited place in emergency abdominal surgery, which is the domain of the surgeon’s brain and hands. To achieve the final ‘victory’ someone has to agonize, sweat, bleed, and wet his hands — remember the bad smell from your hands after operating on a perforated colon? Some readers may struggle with this military metaphor but the truth of the matter is that emergency abdominal surgery shares a few simple rules with infantry action — developed in the trenches and during offensives — rules that are the key to survival and victory (Table 1.1). Such a code of battle echoes the ‘best’ management of abdominal emergencies.\\n\\n### Table 1.1: Key Rules for Emergency Abdominal Surgery\\n| Rule Number | Description |\\n|-------------|-------------|\\n| 1 | |\\n| 2 | |\\n| 3 | |\\n| 4 | |\\n\\n### Figure 1.1: Comparison of Emergency Abdominal Surgeon to Infantry Soldier\\n- **Description**: This figure illustrates the comparison between an emergency abdominal surgeon and an infantry soldier, emphasizing the hands-on nature of emergency surgery and the importance of direct involvement in patient care.\\n- **Summary**: The figure serves to highlight the similarities between the roles of a surgeon in emergency situations and that of a soldier in combat, focusing on the necessity of direct action and personal involvement in achieving successful outcomes.\\n```',\n", " 'images': [{'name': 'img_p26_1.png',\n", " 'height': 11,\n", " 'width': 11,\n", " 'x': 124.55999999999995,\n", " 'y': 288.71999999999997},\n", " {'name': 'img_p26_2.png',\n", " 'height': 12,\n", " 'width': 12,\n", " 'x': 358.55999999999995,\n", " 'y': 486.71999999999997}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Call to provide advice (it has an even larger administrative team of functionaries to monitor you…), its emergency room has standby, state-of-the-art spiral computed tomography and magnetic resonance imaging machines, but, practically, something has not changed: it is the patient and you (often with the entire ‘system’ against you) — you who are duty bound to provide a correct management plan and execute it. And it often feels lonely out there; even we, experienced old farts, can feel the loneliness.',\n", " 'md': 'Call to provide advice (it has an even larger administrative team of functionaries to monitor you…), its emergency room has standby, state-of-the-art spiral computed tomography and magnetic resonance imaging machines, but, practically, something has not changed: it is the patient and you (often with the entire ‘system’ against you) — you who are duty bound to provide a correct management plan and execute it. And it often feels lonely out there; even we, experienced old farts, can feel the loneliness.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The ‘Best’ Management of an Abdominal Emergency',\n", " 'md': '### The ‘Best’ Management of an Abdominal Emergency',\n", " 'bBox': {'x': 86, 'y': 245, 'w': 406.46, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'It is useful to compare the emergency abdominal surgeon to an infantry soldier (Figure 1.1). Away from the limelight and glory that surrounds cardiac or neurological surgeons, emergency abdominal surgery is closer to infantry than it is to airborne action. A war cannot be won by remote control with cruise missiles, or robots, but with infantry on the ground. Likewise, technological gimmicks have a limited place in emergency abdominal surgery, which is the domain of the surgeon’s brain and hands. To achieve the final ‘victory’ someone has to agonize, sweat, bleed, and wet his hands — remember the bad smell from your hands after operating on a perforated colon? Some readers may struggle with this military metaphor but the truth of the matter is that emergency abdominal surgery shares a few simple rules with infantry action — developed in the trenches and during offensives — rules that are the key to survival and victory (Table 1.1). Such a code of battle echoes the ‘best’ management of abdominal emergencies.',\n", " 'md': 'It is useful to compare the emergency abdominal surgeon to an infantry soldier (Figure 1.1). Away from the limelight and glory that surrounds cardiac or neurological surgeons, emergency abdominal surgery is closer to infantry than it is to airborne action. A war cannot be won by remote control with cruise missiles, or robots, but with infantry on the ground. Likewise, technological gimmicks have a limited place in emergency abdominal surgery, which is the domain of the surgeon’s brain and hands. To achieve the final ‘victory’ someone has to agonize, sweat, bleed, and wet his hands — remember the bad smell from your hands after operating on a perforated colon? Some readers may struggle with this military metaphor but the truth of the matter is that emergency abdominal surgery shares a few simple rules with infantry action — developed in the trenches and during offensives — rules that are the key to survival and victory (Table 1.1). Such a code of battle echoes the ‘best’ management of abdominal emergencies.',\n", " 'bBox': {'x': 72, 'y': 281, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 1.1: Key Rules for Emergency Abdominal Surgery',\n", " 'md': '### Table 1.1: Key Rules for Emergency Abdominal Surgery',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Rule Number', 'Description'],\n", " ['1', ''],\n", " ['2', ''],\n", " ['3', ''],\n", " ['4', '']],\n", " 'md': '| Rule Number | Description |\\n|-------------|-------------|\\n| 1 | |\\n| 2 | |\\n| 3 | |\\n| 4 | |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Rule Number\",\"Description\"\\n\"1\",\"\"\\n\"2\",\"\"\\n\"3\",\"\"\\n\"4\",\"\"',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 1.1: Comparison of Emergency Abdominal Surgeon to Infantry Soldier',\n", " 'md': '### Figure 1.1: Comparison of Emergency Abdominal Surgeon to Infantry Soldier',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure illustrates the comparison between an emergency abdominal surgeon and an infantry soldier, emphasizing the hands-on nature of emergency surgery and the importance of direct involvement in patient care.\\n- **Summary**: The figure serves to highlight the similarities between the roles of a surgeon in emergency situations and that of a soldier in combat, focusing on the necessity of direct action and personal involvement in achieving successful outcomes.\\n```',\n", " 'md': '- **Description**: This figure illustrates the comparison between an emergency abdominal surgeon and an infantry soldier, emphasizing the hands-on nature of emergency surgery and the importance of direct involvement in patient care.\\n- **Summary**: The figure serves to highlight the similarities between the roles of a surgeon in emergency situations and that of a soldier in combat, focusing on the necessity of direct action and personal involvement in achieving successful outcomes.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'cardiac or neurological surgeons, emergency abdominal surgery is closer'},\n", " {'text': 'battle echoes the ‘best’ management of abdominal emergencies.'}]},\n", " {'page': 28,\n", " 'text': ' OR\\n FerzA 2014\\nFigure 1.1. “Think as an infantry soldier...”',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\n- OR\\n- FerzA 2014\\n\\n## Figures\\n### Figure 1.1\\n- Caption: “Think as an infantry soldier...”\\n- Description: This figure likely illustrates a concept or idea related to infantry soldiers, possibly emphasizing a mindset or approach relevant to military strategy or tactics. The specific content of the figure is not provided in the text.\\n\\n```',\n", " 'images': [{'name': 'img_p27_1.png',\n", " 'height': 358,\n", " 'width': 502,\n", " 'x': 182.15999999999985,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1380,\n", " 'original_height': 985}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- OR\\n- FerzA 2014',\n", " 'md': '- OR\\n- FerzA 2014',\n", " 'bBox': {'x': 199.97, 'y': 96.65, 'w': 38.1, 'h': 15.83}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures',\n", " 'md': '## Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 1.1',\n", " 'md': '### Figure 1.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Caption: “Think as an infantry soldier...”\\n- Description: This figure likely illustrates a concept or idea related to infantry soldiers, possibly emphasizing a mindset or approach relevant to military strategy or tactics. The specific content of the figure is not provided in the text.\\n\\n```',\n", " 'md': '- Caption: “Think as an infantry soldier...”\\n- Description: This figure likely illustrates a concept or idea related to infantry soldiers, possibly emphasizing a mindset or approach relevant to military strategy or tactics. The specific content of the figure is not provided in the text.\\n\\n```',\n", " 'bBox': {'x': 199.97, 'y': 96.65, 'w': 18.8, 'h': 15.83}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 29,\n", " 'text': 'Table 1.1. The surgeon as an infantry soldier:\\n Rule Infantry action\\n Rule 1 Destroy your enemy before he\\n destroys you\\n Rule 2 Spare your own men\\n\\n Rule 3 Save ammunition\\n\\n Rule 4 Know your enemy\\n\\n Rule 5 Know your men\\n\\n\\n Rule 6 Attack at \\'soft\\' points\\n\\n\\n\\n Rule 7 Do not call for air force support\\n hand-to-hand battle\\n Rule 8 Conduct the battle from the\\n front line not from the rear\\n Rule 9 Take advice from the generals\\n but the decision is yours\\n\\n\\nRule 10 Avoid friendly fire\\n\\nRule 11 Consider using the drones\\n\\n\\n Rule 12 Maintain high morale among\\n your troops\\n Rule 13 Say \"follow mel\"\\n\\nEmergency abdominal surgery\\nOutmaneuver death (save life)\\n\\nReduce morbidity\\n(Handle tissues gently)\\nUse resources rationally\\n(Every stitch must count)\\nEstimate severity of disease\\n(Think how organs and cells are doing)\\nUnderstand the risk-benefit ratio of your therapy\\n(Don\\'t try to do too much in one operation, if the\\npatient will not tolerate it)\\nTailor your management to the disease and the\\npatient\\n(Mild disease, definitive surgery; severe disease;\\ndamage control)\\nDo not adopt useless gimmicks use your mind and\\nhands (and sutures)\\nDo not take and accept decisions over the phone\\n(When you are in charge you are in charge)\\nProcure and use consultation from \\\\\\'other specialties\"\\nselectively\\n(If the consultant gives wrong answer; change the\\nconsultant)\\nReduce iatrogenesis\\n(Don\\'t overdo it\\nAvoid suicidal missions\\n(e.g: when interventional radiology can help you in\\ndifficult anatomic locations)\\nBe proud providing the \\'best\\' management (but\\ngive the anesthetists and nurses some credit)\\nLead by examplel',\n", " 'md': '```markdown\\n# Table 1.1. The surgeon as an infantry soldier\\n\\n| Rule | Infantry action |\\n|--------|---------------------------------------------------------------------------------|\\n| Rule 1 | Destroy your enemy before he destroys you |\\n| Rule 2 | Spare your own men |\\n| Rule 3 | Save ammunition |\\n| Rule 4 | Know your enemy |\\n| Rule 5 | Know your men |\\n| Rule 6 | Attack at \\'soft\\' points |\\n| Rule 7 | Do not call for air force support hand-to-hand battle |\\n| Rule 8 | Conduct the battle from the front line not from the rear |\\n| Rule 9 | Take advice from the generals but the decision is yours |\\n| Rule 10| Avoid friendly fire |\\n| Rule 11| Consider using the drones |\\n| Rule 12| Maintain high morale among your troops |\\n| Rule 13| Say \"follow me!\" |\\n\\n## Emergency abdominal surgery\\n\\n- Outmaneuver death (save life)\\n- Reduce morbidity (Handle tissues gently)\\n- Use resources rationally (Every stitch must count)\\n- Estimate severity of disease (Think how organs and cells are doing)\\n- Understand the risk-benefit ratio of your therapy (Don\\'t try to do too much in one operation, if the patient will not tolerate it)\\n- Tailor your management to the disease and the patient (Mild disease, definitive surgery; severe disease; damage control)\\n- Do not adopt useless gimmicks; use your mind and hands (and sutures)\\n- Do not take and accept decisions over the phone (When you are in charge you are in charge)\\n- Procure and use consultation from \\'other specialties\\' selectively (If the consultant gives wrong answer; change the consultant)\\n- Reduce iatrogenesis (Don\\'t overdo it)\\n- Avoid suicidal missions (e.g: when interventional radiology can help you in difficult anatomic locations)\\n- Be proud providing the \\'best\\' management (but give the anesthetists and nurses some credit)\\n- Lead by example!\\n```',\n", " 'images': [{'name': 'img_p28_1.png',\n", " 'height': 1310,\n", " 'width': 811,\n", " 'x': 72,\n", " 'y': 72,\n", " 'original_width': 1392,\n", " 'original_height': 2432}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Table 1.1. The surgeon as an infantry soldier',\n", " 'md': '# Table 1.1. The surgeon as an infantry soldier',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Rule', 'Infantry action'],\n", " ['Rule 1', 'Destroy your enemy before he destroys you'],\n", " ['Rule 2', 'Spare your own men'],\n", " ['Rule 3', 'Save ammunition'],\n", " ['Rule 4', 'Know your enemy'],\n", " ['Rule 5', 'Know your men'],\n", " ['Rule 6', \"Attack at 'soft' points\"],\n", " ['Rule 7', 'Do not call for air force support hand-to-hand battle'],\n", " ['Rule 8', 'Conduct the battle from the front line not from the rear'],\n", " ['Rule 9', 'Take advice from the generals but the decision is yours'],\n", " ['Rule 10', 'Avoid friendly fire'],\n", " ['Rule 11', 'Consider using the drones'],\n", " ['Rule 12', 'Maintain high morale among your troops'],\n", " ['Rule 13', 'Say \"follow me!\"']],\n", " 'md': '| Rule | Infantry action |\\n|--------|---------------------------------------------------------------------------------|\\n| Rule 1 | Destroy your enemy before he destroys you |\\n| Rule 2 | Spare your own men |\\n| Rule 3 | Save ammunition |\\n| Rule 4 | Know your enemy |\\n| Rule 5 | Know your men |\\n| Rule 6 | Attack at \\'soft\\' points |\\n| Rule 7 | Do not call for air force support hand-to-hand battle |\\n| Rule 8 | Conduct the battle from the front line not from the rear |\\n| Rule 9 | Take advice from the generals but the decision is yours |\\n| Rule 10| Avoid friendly fire |\\n| Rule 11| Consider using the drones |\\n| Rule 12| Maintain high morale among your troops |\\n| Rule 13| Say \"follow me!\" |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Rule\",\"Infantry action\"\\n\"Rule 1\",\"Destroy your enemy before he destroys you\"\\n\"Rule 2\",\"Spare your own men\"\\n\"Rule 3\",\"Save ammunition\"\\n\"Rule 4\",\"Know your enemy\"\\n\"Rule 5\",\"Know your men\"\\n\"Rule 6\",\"Attack at \\'soft\\' points\"\\n\"Rule 7\",\"Do not call for air force support hand-to-hand battle\"\\n\"Rule 8\",\"Conduct the battle from the front line not from the rear\"\\n\"Rule 9\",\"Take advice from the generals but the decision is yours\"\\n\"Rule 10\",\"Avoid friendly fire\"\\n\"Rule 11\",\"Consider using the drones\"\\n\"Rule 12\",\"Maintain high morale among your troops\"\\n\"Rule 13\",\"Say \"\"follow me!\"\"\"',\n", " 'bBox': {'x': 75.46, 'y': 112.56, 'w': 121.15, 'h': 14.84}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Emergency abdominal surgery',\n", " 'md': '## Emergency abdominal surgery',\n", " 'bBox': {'x': 241.61, 'y': 113.06, 'w': 153.79, 'h': 15.83}},\n", " {'type': 'text',\n", " 'value': \"- Outmaneuver death (save life)\\n- Reduce morbidity (Handle tissues gently)\\n- Use resources rationally (Every stitch must count)\\n- Estimate severity of disease (Think how organs and cells are doing)\\n- Understand the risk-benefit ratio of your therapy (Don't try to do too much in one operation, if the patient will not tolerate it)\\n- Tailor your management to the disease and the patient (Mild disease, definitive surgery; severe disease; damage control)\\n- Do not adopt useless gimmicks; use your mind and hands (and sutures)\\n- Do not take and accept decisions over the phone (When you are in charge you are in charge)\\n- Procure and use consultation from 'other specialties' selectively (If the consultant gives wrong answer; change the consultant)\\n- Reduce iatrogenesis (Don't overdo it)\\n- Avoid suicidal missions (e.g: when interventional radiology can help you in difficult anatomic locations)\\n- Be proud providing the 'best' management (but give the anesthetists and nurses some credit)\\n- Lead by example!\\n```\",\n", " 'md': \"- Outmaneuver death (save life)\\n- Reduce morbidity (Handle tissues gently)\\n- Use resources rationally (Every stitch must count)\\n- Estimate severity of disease (Think how organs and cells are doing)\\n- Understand the risk-benefit ratio of your therapy (Don't try to do too much in one operation, if the patient will not tolerate it)\\n- Tailor your management to the disease and the patient (Mild disease, definitive surgery; severe disease; damage control)\\n- Do not adopt useless gimmicks; use your mind and hands (and sutures)\\n- Do not take and accept decisions over the phone (When you are in charge you are in charge)\\n- Procure and use consultation from 'other specialties' selectively (If the consultant gives wrong answer; change the consultant)\\n- Reduce iatrogenesis (Don't overdo it)\\n- Avoid suicidal missions (e.g: when interventional radiology can help you in difficult anatomic locations)\\n- Be proud providing the 'best' management (but give the anesthetists and nurses some credit)\\n- Lead by example!\\n```\",\n", " 'bBox': {'x': 240.62, 'y': 141.75, 'w': 197.8, 'h': 13.36}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 30,\n", " 'text': ' There are many ways to skin a cat and you know from your various\\nsurgical mentors that different clinical pathways may arrive at a similar\\noutcome. ħowever, one of the diverse pathways is the ‘best’ — thus, the\\n‘correct’ one!\\n\\n To be considered as such, the preferred pathway has to save life\\nand decrease morbidity in the most efficient way. Look at the\\nfollowing example.\\n\\n You can manage perforated acute appendicitis using two different\\npathways ( Chapter 23) — both leading to an eventual recovery and\\nboth considered absolutely appropriate ( Table 1.2).\\n Table 1.2. Two management pathways for a young male with\\n right lower quadrant peritonitis:\\n Step Pathway 1 Pathway 2\\n Step CT scan no:.(forget the debates for a moment_)\\n Step 2 Appendectomy for perforated Appendectomy for perforated acute\\n acute appendicitis appendicitis\\n Step 3 Peritoneal culture taken no_\\n Step Peritoneal cavity irrigated only sucked out and mopped\\n Step 5 Wound left open wound sutured\\n Step 6 Drain left in situ no drain\\n Step 7 i.v. antibiotics until WBC normal i.v. antibiotics until patient tolerates oral\\n diet. then home on oral antibiotics\\n Step 8 Secondary closure of wound wound completely healed',\n", " 'md': '```markdown\\nThere are many ways to skin a cat and you know from your various surgical mentors that different clinical pathways may arrive at a similar outcome. However, one of the diverse pathways is the ‘best’ — thus, the ‘correct’ one!\\n\\nTo be considered as such, the preferred pathway has to save life and decrease morbidity in the most efficient way. Look at the following example.\\n\\nYou can manage perforated acute appendicitis using two different pathways (Chapter 23) — both leading to an eventual recovery and both considered absolutely appropriate (Table 1.2).\\n\\n## Table 1.2. Two management pathways for a young male with right lower quadrant peritonitis:\\n\\n| Step | Pathway 1 | Pathway 2 |\\n|--------|------------------------------------------------|------------------------------------------------|\\n| Step 1 | CT scan | no: (forget the debates for a moment) |\\n| Step 2 | Appendectomy for perforated acute appendicitis | Appendectomy for perforated acute appendicitis |\\n| Step 3 | Peritoneal culture taken | no |\\n| Step 4 | Peritoneal cavity irrigated | only sucked out and mopped |\\n| Step 5 | Wound left open | wound sutured |\\n| Step 6 | Drain left in situ | no drain |\\n| Step 7 | i.v. antibiotics until WBC normal | i.v. antibiotics until patient tolerates oral diet, then home on oral antibiotics |\\n| Step 8 | Secondary closure of wound | wound completely healed |\\n```',\n", " 'images': [{'name': 'img_p29_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 143.27999999999997,\n", " 'y': 263.52000000000004},\n", " {'name': 'img_p29_3.png',\n", " 'height': 774,\n", " 'width': 815,\n", " 'x': 104.39999999999986,\n", " 'y': 304.56000000000006,\n", " 'original_width': 1401,\n", " 'original_height': 1330}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nThere are many ways to skin a cat and you know from your various surgical mentors that different clinical pathways may arrive at a similar outcome. However, one of the diverse pathways is the ‘best’ — thus, the ‘correct’ one!\\n\\nTo be considered as such, the preferred pathway has to save life and decrease morbidity in the most efficient way. Look at the following example.\\n\\nYou can manage perforated acute appendicitis using two different pathways (Chapter 23) — both leading to an eventual recovery and both considered absolutely appropriate (Table 1.2).',\n", " 'md': '```markdown\\nThere are many ways to skin a cat and you know from your various surgical mentors that different clinical pathways may arrive at a similar outcome. However, one of the diverse pathways is the ‘best’ — thus, the ‘correct’ one!\\n\\nTo be considered as such, the preferred pathway has to save life and decrease morbidity in the most efficient way. Look at the following example.\\n\\nYou can manage perforated acute appendicitis using two different pathways (Chapter 23) — both leading to an eventual recovery and both considered absolutely appropriate (Table 1.2).',\n", " 'bBox': {'x': 72, 'y': 104, 'w': 467.38, 'h': 15.84}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 1.2. Two management pathways for a young male with right lower quadrant peritonitis:',\n", " 'md': '## Table 1.2. Two management pathways for a young male with right lower quadrant peritonitis:',\n", " 'bBox': {'x': 108.85, 'y': 310.5, 'w': 401.72, 'h': 19.8}},\n", " {'type': 'table',\n", " 'rows': [['Step', 'Pathway 1', 'Pathway 2'],\n", " ['Step 1', 'CT scan', 'no: (forget the debates for a moment)'],\n", " ['Step 2',\n", " 'Appendectomy for perforated acute appendicitis',\n", " 'Appendectomy for perforated acute appendicitis'],\n", " ['Step 3', 'Peritoneal culture taken', 'no'],\n", " ['Step 4', 'Peritoneal cavity irrigated', 'only sucked out and mopped'],\n", " ['Step 5', 'Wound left open', 'wound sutured'],\n", " ['Step 6', 'Drain left in situ', 'no drain'],\n", " ['Step 7',\n", " 'i.v. antibiotics until WBC normal',\n", " 'i.v. antibiotics until patient tolerates oral diet, then home on oral antibiotics'],\n", " ['Step 8', 'Secondary closure of wound', 'wound completely healed']],\n", " 'md': '| Step | Pathway 1 | Pathway 2 |\\n|--------|------------------------------------------------|------------------------------------------------|\\n| Step 1 | CT scan | no: (forget the debates for a moment) |\\n| Step 2 | Appendectomy for perforated acute appendicitis | Appendectomy for perforated acute appendicitis |\\n| Step 3 | Peritoneal culture taken | no |\\n| Step 4 | Peritoneal cavity irrigated | only sucked out and mopped |\\n| Step 5 | Wound left open | wound sutured |\\n| Step 6 | Drain left in situ | no drain |\\n| Step 7 | i.v. antibiotics until WBC normal | i.v. antibiotics until patient tolerates oral diet, then home on oral antibiotics |\\n| Step 8 | Secondary closure of wound | wound completely healed |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Step\",\"Pathway 1\",\"Pathway 2\"\\n\"Step 1\",\"CT scan\",\"no: (forget the debates for a moment)\"\\n\"Step 2\",\"Appendectomy for perforated acute appendicitis\",\"Appendectomy for perforated acute appendicitis\"\\n\"Step 3\",\"Peritoneal culture taken\",\"no\"\\n\"Step 4\",\"Peritoneal cavity irrigated\",\"only sucked out and mopped\"\\n\"Step 5\",\"Wound left open\",\"wound sutured\"\\n\"Step 6\",\"Drain left in situ\",\"no drain\"\\n\"Step 7\",\"i.v. antibiotics until WBC normal\",\"i.v. antibiotics until patient tolerates oral diet, then home on oral antibiotics\"\\n\"Step 8\",\"Secondary closure of wound\",\"wound completely healed\"',\n", " 'bBox': {'x': 107.86, 'y': 349.59, 'w': 185.03, 'h': 18.31}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'both considered absolutely appropriate ('},\n", " {'text': ''}]},\n", " {'page': 31,\n", " 'text': ' Both the above pathways are ‘OK’, right? Yes, but pathway 2\\nclearly is the ‘best’ one: safer, faster and cheaper.\\n\\n Today many options exist to do almost anything. Any search on\\nGoogle or PubMed will overwhelm you with papers that can justify almost\\nany management pathway, with people practicing surgical acrobatics for\\nthe mere sake of doing so. Data and theory are everywhere: the sources\\nare numerous but what you really need is wisdom — to enable you to\\napply correctly the knowledge you already have and constantly gather.\\nAnd wisdom is what we are trying to provide. So please open your mind.\\n\\n General philosophy ( Figure 1.2)\\n CEO\\n ReFYA %o14\\nFigure 1.2. “Each of us has a different ‘general philosophy’…”\\n\\n “There is nothing new in the story…,” Winston Churchill said, “want of\\nforesight, unwillingness to act when action would be simple and effective,\\nlack of clear thinking, confusion of counsel until the emergency comes,\\nuntil self-preservation strikes its jarring gong…”. ħow true is this\\nChurchillian wisdom when applied to emergency surgery. ħow often do',\n", " 'md': '```markdown\\nBoth the above pathways are ‘OK’, right? Yes, but pathway 2 clearly is the ‘best’ one: safer, faster and cheaper.\\n\\nToday many options exist to do almost anything. Any search on Google or PubMed will overwhelm you with papers that can justify almost any management pathway, with people practicing surgical acrobatics for the mere sake of doing so. Data and theory are everywhere: the sources are numerous but what you really need is wisdom — to enable you to apply correctly the knowledge you already have and constantly gather. And wisdom is what we are trying to provide. So please open your mind.\\n\\n### General philosophy (Figure 1.2)\\n![Figure 1.2]()\\n**Caption:** “Each of us has a different ‘general philosophy’…”\\n\\n“There is nothing new in the story…,” Winston Churchill said, “want of foresight, unwillingness to act when action would be simple and effective, lack of clear thinking, confusion of counsel until the emergency comes, until self-preservation strikes its jarring gong…”. How true is this Churchillian wisdom when applied to emergency surgery. How often do...\\n```',\n", " 'images': [{'name': 'img_p30_2.png',\n", " 'height': 575,\n", " 'width': 803,\n", " 'x': 107.27999999999975,\n", " 'y': 294.48,\n", " 'original_width': 1380,\n", " 'original_height': 988}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nBoth the above pathways are ‘OK’, right? Yes, but pathway 2 clearly is the ‘best’ one: safer, faster and cheaper.\\n\\nToday many options exist to do almost anything. Any search on Google or PubMed will overwhelm you with papers that can justify almost any management pathway, with people practicing surgical acrobatics for the mere sake of doing so. Data and theory are everywhere: the sources are numerous but what you really need is wisdom — to enable you to apply correctly the knowledge you already have and constantly gather. And wisdom is what we are trying to provide. So please open your mind.',\n", " 'md': '```markdown\\nBoth the above pathways are ‘OK’, right? Yes, but pathway 2 clearly is the ‘best’ one: safer, faster and cheaper.\\n\\nToday many options exist to do almost anything. Any search on Google or PubMed will overwhelm you with papers that can justify almost any management pathway, with people practicing surgical acrobatics for the mere sake of doing so. Data and theory are everywhere: the sources are numerous but what you really need is wisdom — to enable you to apply correctly the knowledge you already have and constantly gather. And wisdom is what we are trying to provide. So please open your mind.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.85, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'General philosophy (Figure 1.2)',\n", " 'md': '### General philosophy (Figure 1.2)',\n", " 'bBox': {'x': 86, 'y': 280, 'w': 164.58, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '![Figure 1.2]()\\n**Caption:** “Each of us has a different ‘general philosophy’…”\\n\\n“There is nothing new in the story…,” Winston Churchill said, “want of foresight, unwillingness to act when action would be simple and effective, lack of clear thinking, confusion of counsel until the emergency comes, until self-preservation strikes its jarring gong…”. How true is this Churchillian wisdom when applied to emergency surgery. How often do...\\n```',\n", " 'md': '![Figure 1.2]()\\n**Caption:** “Each of us has a different ‘general philosophy’…”\\n\\n“There is nothing new in the story…,” Winston Churchill said, “want of foresight, unwillingness to act when action would be simple and effective, lack of clear thinking, confusion of counsel until the emergency comes, until self-preservation strikes its jarring gong…”. How true is this Churchillian wisdom when applied to emergency surgery. How often do...\\n```',\n", " 'bBox': {'x': 72, 'y': 646, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 32,\n", " 'text': 'we forget old — written in stone — principles while reinventing the\\nwheel?\\n\\n The ‘best’ management in each section of this book is based on\\nthe following elements.\\n\\n Old-established principles (don’t reinvent the wheel).\\n Modern-scientific understanding of inflammation and infection.\\n Evidence-based surgery (see below).\\n Personal experience.\\n\\n The inflamed patient\\n\\n Think about your patient as being INFLAMED by myriad inflammatory\\nmediators, generated by the primary disease process, whether\\ninflammatory, infectious or traumatic — so if you measure C-reactive\\nprotein (CRP) in these patients, in most it will be elevated! Local\\ninflammation (e.g. peritonitis) and systemic inflammatory response\\nsyndromes (SIRS) may lead to organ dysfunction or failure, and the\\neventual demise of your patient. The greater the inflammation — the\\nsicker the patient and the higher the expected morbidity and\\nmortality. Consider also that anything you do in attempting to halt\\nyour patient’s inflammation may in fact contribute to it — adding\\nfuel to the inflammatory fire. Excessive surgery, inappropriately\\nperformed, and too late, just adds nails to your patient’s coffin.\\nRemember also that SIRS is antagonized by the so-called compensatory\\nanti-inflammatory response syndrome (CARS), mediated by anti-\\ninflammatory cytokines, which in turn promotes immune suppression and\\nfacilitates infections that are so common after major operations and\\nsevere trauma ( Figure 1.3).',\n", " 'md': '```markdown\\n## Key Management Principles\\n\\nWe forget old — written in stone — principles while reinventing the wheel?\\n\\nThe ‘best’ management in each section of this book is based on the following elements:\\n\\n- Old-established principles (don’t reinvent the wheel).\\n- Modern-scientific understanding of inflammation and infection.\\n- Evidence-based surgery (see below).\\n- Personal experience.\\n\\n### The Inflamed Patient\\n\\nThink about your patient as being INFLAMED by myriad inflammatory mediators, generated by the primary disease process, whether inflammatory, infectious or traumatic — so if you measure C-reactive protein (CRP) in these patients, in most it will be elevated! Local inflammation (e.g. peritonitis) and systemic inflammatory response syndromes (SIRS) may lead to organ dysfunction or failure, and the eventual demise of your patient. The greater the inflammation — the sicker the patient and the higher the expected morbidity and mortality.\\n\\nConsider also that anything you do in attempting to halt your patient’s inflammation may in fact contribute to it — adding fuel to the inflammatory fire. Excessive surgery, inappropriately performed, and too late, just adds nails to your patient’s coffin. Remember also that SIRS is antagonized by the so-called compensatory anti-inflammatory response syndrome (CARS), mediated by anti-inflammatory cytokines, which in turn promotes immune suppression and facilitates infections that are so common after major operations and severe trauma.\\n\\n### Figure 1.3\\n- **Description**: This figure illustrates the relationship between systemic inflammatory response syndrome (SIRS) and compensatory anti-inflammatory response syndrome (CARS). It highlights how these two responses interact and affect patient outcomes, particularly in the context of major operations and severe trauma.\\n- **Summary**: The figure emphasizes the dual nature of inflammatory responses in patients, showing how SIRS can lead to complications while CARS may contribute to immune suppression and increased risk of infections.\\n```',\n", " 'images': [{'name': 'img_p31_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 189.35999999999999},\n", " {'name': 'img_p31_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 210.95999999999998},\n", " {'name': 'img_p31_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 232.55999999999997},\n", " {'name': 'img_p31_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 254.15999999999997}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Key Management Principles',\n", " 'md': '## Key Management Principles',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'We forget old — written in stone — principles while reinventing the wheel?\\n\\nThe ‘best’ management in each section of this book is based on the following elements:\\n\\n- Old-established principles (don’t reinvent the wheel).\\n- Modern-scientific understanding of inflammation and infection.\\n- Evidence-based surgery (see below).\\n- Personal experience.',\n", " 'md': 'We forget old — written in stone — principles while reinventing the wheel?\\n\\nThe ‘best’ management in each section of this book is based on the following elements:\\n\\n- Old-established principles (don’t reinvent the wheel).\\n- Modern-scientific understanding of inflammation and infection.\\n- Evidence-based surgery (see below).\\n- Personal experience.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 296.1, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Inflamed Patient',\n", " 'md': '### The Inflamed Patient',\n", " 'bBox': {'x': 86, 'y': 321, 'w': 160.9, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Think about your patient as being INFLAMED by myriad inflammatory mediators, generated by the primary disease process, whether inflammatory, infectious or traumatic — so if you measure C-reactive protein (CRP) in these patients, in most it will be elevated! Local inflammation (e.g. peritonitis) and systemic inflammatory response syndromes (SIRS) may lead to organ dysfunction or failure, and the eventual demise of your patient. The greater the inflammation — the sicker the patient and the higher the expected morbidity and mortality.\\n\\nConsider also that anything you do in attempting to halt your patient’s inflammation may in fact contribute to it — adding fuel to the inflammatory fire. Excessive surgery, inappropriately performed, and too late, just adds nails to your patient’s coffin. Remember also that SIRS is antagonized by the so-called compensatory anti-inflammatory response syndrome (CARS), mediated by anti-inflammatory cytokines, which in turn promotes immune suppression and facilitates infections that are so common after major operations and severe trauma.',\n", " 'md': 'Think about your patient as being INFLAMED by myriad inflammatory mediators, generated by the primary disease process, whether inflammatory, infectious or traumatic — so if you measure C-reactive protein (CRP) in these patients, in most it will be elevated! Local inflammation (e.g. peritonitis) and systemic inflammatory response syndromes (SIRS) may lead to organ dysfunction or failure, and the eventual demise of your patient. The greater the inflammation — the sicker the patient and the higher the expected morbidity and mortality.\\n\\nConsider also that anything you do in attempting to halt your patient’s inflammation may in fact contribute to it — adding fuel to the inflammatory fire. Excessive surgery, inappropriately performed, and too late, just adds nails to your patient’s coffin. Remember also that SIRS is antagonized by the so-called compensatory anti-inflammatory response syndrome (CARS), mediated by anti-inflammatory cytokines, which in turn promotes immune suppression and facilitates infections that are so common after major operations and severe trauma.',\n", " 'bBox': {'x': 72, 'y': 357, 'w': 467.38, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 1.3',\n", " 'md': '### Figure 1.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure illustrates the relationship between systemic inflammatory response syndrome (SIRS) and compensatory anti-inflammatory response syndrome (CARS). It highlights how these two responses interact and affect patient outcomes, particularly in the context of major operations and severe trauma.\\n- **Summary**: The figure emphasizes the dual nature of inflammatory responses in patients, showing how SIRS can lead to complications while CARS may contribute to immune suppression and increased risk of infections.\\n```',\n", " 'md': '- **Description**: This figure illustrates the relationship between systemic inflammatory response syndrome (SIRS) and compensatory anti-inflammatory response syndrome (CARS). It highlights how these two responses interact and affect patient outcomes, particularly in the context of major operations and severe trauma.\\n- **Summary**: The figure emphasizes the dual nature of inflammatory responses in patients, showing how SIRS can lead to complications while CARS may contribute to immune suppression and increased risk of infections.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 33,\n", " 'text': ' Disease Anti-inflammatory\\n Trauma mediators\\n Operations\\n Complications\\n Reoperations\\n CARS\\n Pro-inflammatory SIRS Multiple organ failure\\n mediators\\n Figure 1.3. The inflamed surgical patient. SIRS = systemic inflammatory response\\n syndrome; CARS = compensatory anti-inflammatory response syndrome. (Read the\\n classic by the late Roger Bone: Bone RC. Sir Isaac Newton, sepsis, SIRS, and CARS. Crit\\n Care Med 1996; 24: 1125-8.)\\n\\n The philosophy of treatment that we propose maintains that in order to\\ncure or minimize the inflammatory processes and the anti-inflammatory\\nresponse, management should be accurately tailored to the\\nindividual patient’s disease; as the punishment fits the crime, so\\nshould the remedy fit the disease. A well-trained foot soldier does not\\nfire indiscriminately in all directions. These days he can summon the\\ndrones for a surgical strike!\\n\\n Evidence\\n Economic considerations sometimes motivate the\\n physicians to accept that part of the scientific evidence that\\n best supports the method that gives him the most money.\\n George Crile\\n\\n A few words about what we mean when we talk about ‘evidence’. Many',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Figure 1.3\\n**Description:** This figure illustrates the relationship between various factors affecting the inflamed surgical patient. It categorizes the mediators into two groups: pro-inflammatory mediators and anti-inflammatory mediators. The pro-inflammatory mediators are linked to SIRS (Systemic Inflammatory Response Syndrome) and multiple organ failure, while the anti-inflammatory mediators are associated with CARS (Compensatory Anti-inflammatory Response Syndrome).\\n\\n**Caption:** The inflamed surgical patient. SIRS = systemic inflammatory response syndrome; CARS = compensatory anti-inflammatory response syndrome. (Read the classic by the late Roger Bone: Bone RC. Sir Isaac Newton, sepsis, SIRS, and CARS. Crit Care Med 1996; 24: 1125-8.)\\n\\n----\\n\\n## Text Content\\nThe philosophy of treatment that we propose maintains that in order to cure or minimize the inflammatory processes and the anti-inflammatory response, management should be accurately tailored to the individual patient’s disease; as the punishment fits the crime, so should the remedy fit the disease. A well-trained foot soldier does not fire indiscriminately in all directions. These days he can summon the drones for a surgical strike!\\n\\n### Evidence\\nEconomic considerations sometimes motivate the physicians to accept that part of the scientific evidence that best supports the method that gives him the most money.\\n*George Crile*\\n\\nA few words about what we mean when we talk about ‘evidence’.\\n```',\n", " 'images': [{'name': 'img_p32_1.png',\n", " 'height': 529,\n", " 'width': 811,\n", " 'x': 105.83999999999969,\n", " 'y': 82.79999999999995,\n", " 'original_width': 1392,\n", " 'original_height': 908}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 1.3',\n", " 'md': '## Figure 1.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure illustrates the relationship between various factors affecting the inflamed surgical patient. It categorizes the mediators into two groups: pro-inflammatory mediators and anti-inflammatory mediators. The pro-inflammatory mediators are linked to SIRS (Systemic Inflammatory Response Syndrome) and multiple organ failure, while the anti-inflammatory mediators are associated with CARS (Compensatory Anti-inflammatory Response Syndrome).\\n\\n**Caption:** The inflamed surgical patient. SIRS = systemic inflammatory response syndrome; CARS = compensatory anti-inflammatory response syndrome. (Read the classic by the late Roger Bone: Bone RC. Sir Isaac Newton, sepsis, SIRS, and CARS. Crit Care Med 1996; 24: 1125-8.)\\n\\n----',\n", " 'md': '**Description:** This figure illustrates the relationship between various factors affecting the inflamed surgical patient. It categorizes the mediators into two groups: pro-inflammatory mediators and anti-inflammatory mediators. The pro-inflammatory mediators are linked to SIRS (Systemic Inflammatory Response Syndrome) and multiple organ failure, while the anti-inflammatory mediators are associated with CARS (Compensatory Anti-inflammatory Response Syndrome).\\n\\n**Caption:** The inflamed surgical patient. SIRS = systemic inflammatory response syndrome; CARS = compensatory anti-inflammatory response syndrome. (Read the classic by the late Roger Bone: Bone RC. Sir Isaac Newton, sepsis, SIRS, and CARS. Crit Care Med 1996; 24: 1125-8.)\\n\\n----',\n", " 'bBox': {'x': 75, 'y': 138.63, 'w': 460.65, 'h': 15.32}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Content',\n", " 'md': '## Text Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The philosophy of treatment that we propose maintains that in order to cure or minimize the inflammatory processes and the anti-inflammatory response, management should be accurately tailored to the individual patient’s disease; as the punishment fits the crime, so should the remedy fit the disease. A well-trained foot soldier does not fire indiscriminately in all directions. These days he can summon the drones for a surgical strike!',\n", " 'md': 'The philosophy of treatment that we propose maintains that in order to cure or minimize the inflammatory processes and the anti-inflammatory response, management should be accurately tailored to the individual patient’s disease; as the punishment fits the crime, so should the remedy fit the disease. A well-trained foot soldier does not fire indiscriminately in all directions. These days he can summon the drones for a surgical strike!',\n", " 'bBox': {'x': 72, 'y': 138.63, 'w': 467.42, 'h': 15.32}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Evidence',\n", " 'md': '### Evidence',\n", " 'bBox': {'x': 86, 'y': 590, 'w': 72.67, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Economic considerations sometimes motivate the physicians to accept that part of the scientific evidence that best supports the method that gives him the most money.\\n*George Crile*\\n\\nA few words about what we mean when we talk about ‘evidence’.\\n```',\n", " 'md': 'Economic considerations sometimes motivate the physicians to accept that part of the scientific evidence that best supports the method that gives him the most money.\\n*George Crile*\\n\\nA few words about what we mean when we talk about ‘evidence’.\\n```',\n", " 'bBox': {'x': 86, 'y': 590, 'w': 381.5, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 34,\n", " 'text': 'formal classifications of scientific evidence are in circulation. ħere is one\\nversion along with what some people think about it ( Table 1.3).\\n Table 1.3. An example of a formal classification of scientific\\n evidence.\\n Level of Description Comments\\n evidence\\n Evidence from meta-analysis of Meta-analysis is to analysis as\\n randomized controlled trials metaphysics to physics. H: Harlan Stone\\n Ib Evidence from at least one Is it really randomized? Sometimes it is\\n randomized controlled trial hard to believe.\\n Ila Evidence from at least one Statistical numbers are like prisoners of\\n well-designed controlled trial war torture them enough and they\\n which is not randomized will admit to anything: Basil Pruitt\\n Ilb Evidence from at least one well- Hard to believe but humans are a little\\n designed experimental trial different from rats!\\n Evidence from case, As a general rule, results of\\n correlation, and comparative observational studies should be taken\\n studies with a grain of salt: Otherwise, one\\n might conclude that gray hair causes\\n heart attacks. Edward H. Livingstone\\n Evidence from a panel of An expert surgeon: someone more than\\n experts fifty miles from home with a Powerpoint\\n presentation\\n To the above ‘official’ classification we wish to add a few more\\ncategories frequently used by surgeons around the world.\\n\\n V — “In my personal series of X patients (never published) there were no',\n", " 'md': '```markdown\\n## Formal Classifications of Scientific Evidence\\n\\nThere are various formal classifications of scientific evidence in circulation. Here is one version along with some commentary on it.\\n\\n### Table 1.3: An Example of a Formal Classification of Scientific Evidence\\n\\n| Level of Evidence | Description | Comments |\\n|-------------------|-------------|----------|\\n| Ib | Evidence from meta-analysis of randomized controlled trials | Meta-analysis is to analysis as metaphysics is to physics. H: Harlan Stone |\\n| Ila | Evidence from at least one randomized controlled trial | Is it really randomized? Sometimes it is hard to believe. |\\n| Ilb | Evidence from at least one well-designed controlled trial which is not randomized | Statistical numbers are like prisoners of war: torture them enough and they will admit to anything. Basil Pruitt |\\n| IIb | Evidence from at least one well-designed experimental trial | Hard to believe but humans are a little different from rats! |\\n| | Evidence from case, correlation, and comparative studies | As a general rule, results of observational studies should be taken with a grain of salt: Otherwise, one might conclude that gray hair causes heart attacks. Edward H. Livingstone |\\n| | Evidence from a panel of experts | An expert surgeon: someone more than fifty miles from home with a PowerPoint presentation. |\\n\\nTo the above ‘official’ classification, we wish to add a few more categories frequently used by surgeons around the world.\\n\\nV — “In my personal series of X patients (never published) there were no .”\\n```',\n", " 'images': [{'name': 'img_p33_1.png',\n", " 'height': 990,\n", " 'width': 822,\n", " 'x': 102.96000000000004,\n", " 'y': 115.92000000000002,\n", " 'original_width': 1412,\n", " 'original_height': 1700}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formal Classifications of Scientific Evidence',\n", " 'md': '## Formal Classifications of Scientific Evidence',\n", " 'bBox': {'x': 109.89, 'y': 122.84, 'w': 228.64, 'h': 15.83}},\n", " {'type': 'text',\n", " 'value': 'There are various formal classifications of scientific evidence in circulation. Here is one version along with some commentary on it.',\n", " 'md': 'There are various formal classifications of scientific evidence in circulation. Here is one version along with some commentary on it.',\n", " 'bBox': {'x': 109.89, 'y': 122.84, 'w': 228.64, 'h': 15.83}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 1.3: An Example of a Formal Classification of Scientific Evidence',\n", " 'md': '### Table 1.3: An Example of a Formal Classification of Scientific Evidence',\n", " 'bBox': {'x': 109.89, 'y': 122.84, 'w': 140.55, 'h': 15.83}},\n", " {'type': 'table',\n", " 'rows': [['Level of Evidence', 'Description', 'Comments'],\n", " ['Ib',\n", " 'Evidence from meta-analysis of randomized controlled trials',\n", " 'Meta-analysis is to analysis as metaphysics is to physics. H: Harlan Stone'],\n", " ['Ila',\n", " 'Evidence from at least one randomized controlled trial',\n", " 'Is it really randomized? Sometimes it is hard to believe.'],\n", " ['Ilb',\n", " 'Evidence from at least one well-designed controlled trial which is not randomized',\n", " 'Statistical numbers are like prisoners of war: torture them enough and they will admit to anything. Basil Pruitt'],\n", " ['IIb',\n", " 'Evidence from at least one well-designed experimental trial',\n", " 'Hard to believe but humans are a little different from rats!'],\n", " ['',\n", " 'Evidence from case, correlation, and comparative studies',\n", " 'As a general rule, results of observational studies should be taken with a grain of salt: Otherwise, one might conclude that gray hair causes heart attacks. Edward H. Livingstone'],\n", " ['',\n", " 'Evidence from a panel of experts',\n", " 'An expert surgeon: someone more than fifty miles from home with a PowerPoint presentation.']],\n", " 'md': '| Level of Evidence | Description | Comments |\\n|-------------------|-------------|----------|\\n| Ib | Evidence from meta-analysis of randomized controlled trials | Meta-analysis is to analysis as metaphysics is to physics. H: Harlan Stone |\\n| Ila | Evidence from at least one randomized controlled trial | Is it really randomized? Sometimes it is hard to believe. |\\n| Ilb | Evidence from at least one well-designed controlled trial which is not randomized | Statistical numbers are like prisoners of war: torture them enough and they will admit to anything. Basil Pruitt |\\n| IIb | Evidence from at least one well-designed experimental trial | Hard to believe but humans are a little different from rats! |\\n| | Evidence from case, correlation, and comparative studies | As a general rule, results of observational studies should be taken with a grain of salt: Otherwise, one might conclude that gray hair causes heart attacks. Edward H. Livingstone |\\n| | Evidence from a panel of experts | An expert surgeon: someone more than fifty miles from home with a PowerPoint presentation. |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Level of Evidence\",\"Description\",\"Comments\"\\n\"Ib\",\"Evidence from meta-analysis of randomized controlled trials\",\"Meta-analysis is to analysis as metaphysics is to physics. H: Harlan Stone\"\\n\"Ila\",\"Evidence from at least one randomized controlled trial\",\"Is it really randomized? Sometimes it is hard to believe.\"\\n\"Ilb\",\"Evidence from at least one well-designed controlled trial which is not randomized\",\"Statistical numbers are like prisoners of war: torture them enough and they will admit to anything. Basil Pruitt\"\\n\"IIb\",\"Evidence from at least one well-designed experimental trial\",\"Hard to believe but humans are a little different from rats!\"\\n\"\",\"Evidence from case, correlation, and comparative studies\",\"As a general rule, results of observational studies should be taken with a grain of salt: Otherwise, one might conclude that gray hair causes heart attacks. Edward H. Livingstone\"\\n\"\",\"Evidence from a panel of experts\",\"An expert surgeon: someone more than fifty miles from home with a PowerPoint presentation.\"',\n", " 'bBox': {'x': 109.89, 'y': 122.84, 'w': 182.12, 'h': 15.83}},\n", " {'type': 'text',\n", " 'value': 'To the above ‘official’ classification, we wish to add a few more categories frequently used by surgeons around the world.\\n\\nV — “In my personal series of X patients (never published) there were no .”\\n```',\n", " 'md': 'To the above ‘official’ classification, we wish to add a few more categories frequently used by surgeons around the world.\\n\\nV — “In my personal series of X patients (never published) there were no .”\\n```',\n", " 'bBox': {'x': 72, 'y': 122.84, 'w': 397, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 35,\n", " 'text': ' complications.”\\n VI — “I remember that case… forty years ago…”\\n VII — “This is the way I do it and it is the best.”\\n VIII — “My grandmother thinks this is a good idea.”\\n\\n Note that level III retrospective case series form the main bulk of\\nsurgical literature dealing with abdominal emergencies, whereas levels V-\\nVIII are the main forms of evidence used by surgeons in general — think\\nabout your own departmental meetings! And level VIII evidence may\\nremind you of your chairman! To paraphrase a quote from Memoirs of\\nHadrian by Marguerite Yourcenar: “In any combat between fanaticism\\n(dogmatism) and common sense the latter has rarely the upper\\nhand.”\\n\\n We want to show you that this is not always the case! You should\\neducate yourself to think in terms of levels of evidence and resist\\nlocal dogmas. We believe that support for much of what we write\\nhere is available in the published literature, but we choose not to\\ncite it because it is not that kind of book. When high-level evidence\\nis not available, we have to use an individual approach and common\\nsense, and that is much of what this book is about.\\n\\n Evidence is the base of medicine but common sense is the\\n salt of it.\\n Slava Ryndine\\n\\n The absence of evidence isn’t the evidence of absence.\\n Henry Black\\n\\n As far as the surgical literature goes, use the ‘Texas\\n mockingbird approach’: eat everything in sight and vomit\\n what you can’t use.\\n Lew Flint\\n\\n Remember: You can get away with a lot… but not always. Most patients treated',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nNote that level III retrospective case series form the main bulk of surgical literature dealing with abdominal emergencies, whereas levels V-VIII are the main forms of evidence used by surgeons in general — think about your own departmental meetings! And level VIII evidence may remind you of your chairman! To paraphrase a quote from Memoirs of Hadrian by Marguerite Yourcenar: “In any combat between fanaticism (dogmatism) and common sense the latter has rarely the upper hand.”\\n\\nWe want to show you that this is not always the case! You should educate yourself to think in terms of levels of evidence and resist local dogmas. We believe that support for much of what we write here is available in the published literature, but we choose not to cite it because it is not that kind of book. When high-level evidence is not available, we have to use an individual approach and common sense, and that is much of what this book is about.\\n\\nEvidence is the base of medicine but common sense is the salt of it.\\n**Slava Ryndine**\\n\\nThe absence of evidence isn’t the evidence of absence.\\n**Henry Black**\\n\\nAs far as the surgical literature goes, use the ‘Texas mockingbird approach’: eat everything in sight and vomit what you can’t use.\\n**Lew Flint**\\n\\nRemember: You can get away with a lot… but not always. Most patients treated\\n\\n## Image Identification and Description\\n\\n*No images or graphs were identified on this page.*\\n\\n## Formulas\\n\\n*No formulas were identified on this page.*\\n\\n## Tables\\n\\n*No tables were identified on this page.*\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Note that level III retrospective case series form the main bulk of surgical literature dealing with abdominal emergencies, whereas levels V-VIII are the main forms of evidence used by surgeons in general — think about your own departmental meetings! And level VIII evidence may remind you of your chairman! To paraphrase a quote from Memoirs of Hadrian by Marguerite Yourcenar: “In any combat between fanaticism (dogmatism) and common sense the latter has rarely the upper hand.”\\n\\nWe want to show you that this is not always the case! You should educate yourself to think in terms of levels of evidence and resist local dogmas. We believe that support for much of what we write here is available in the published literature, but we choose not to cite it because it is not that kind of book. When high-level evidence is not available, we have to use an individual approach and common sense, and that is much of what this book is about.\\n\\nEvidence is the base of medicine but common sense is the salt of it.\\n**Slava Ryndine**\\n\\nThe absence of evidence isn’t the evidence of absence.\\n**Henry Black**\\n\\nAs far as the surgical literature goes, use the ‘Texas mockingbird approach’: eat everything in sight and vomit what you can’t use.\\n**Lew Flint**\\n\\nRemember: You can get away with a lot… but not always. Most patients treated',\n", " 'md': 'Note that level III retrospective case series form the main bulk of surgical literature dealing with abdominal emergencies, whereas levels V-VIII are the main forms of evidence used by surgeons in general — think about your own departmental meetings! And level VIII evidence may remind you of your chairman! To paraphrase a quote from Memoirs of Hadrian by Marguerite Yourcenar: “In any combat between fanaticism (dogmatism) and common sense the latter has rarely the upper hand.”\\n\\nWe want to show you that this is not always the case! You should educate yourself to think in terms of levels of evidence and resist local dogmas. We believe that support for much of what we write here is available in the published literature, but we choose not to cite it because it is not that kind of book. When high-level evidence is not available, we have to use an individual approach and common sense, and that is much of what this book is about.\\n\\nEvidence is the base of medicine but common sense is the salt of it.\\n**Slava Ryndine**\\n\\nThe absence of evidence isn’t the evidence of absence.\\n**Henry Black**\\n\\nAs far as the surgical literature goes, use the ‘Texas mockingbird approach’: eat everything in sight and vomit what you can’t use.\\n**Lew Flint**\\n\\nRemember: You can get away with a lot… but not always. Most patients treated',\n", " 'bBox': {'x': 72, 'y': 214, 'w': 468.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or graphs were identified on this page.*',\n", " 'md': '*No images or graphs were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formulas',\n", " 'md': '## Formulas',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No formulas were identified on this page.*',\n", " 'md': '*No formulas were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No tables were identified on this page.*\\n```',\n", " 'md': '*No tables were identified on this page.*\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 36,\n", " 'text': 'according to the above-mentioned pathway 1 will do just fine, but a few will not. The following\\npages will help you to develop your own judgment — pointing to the correct/preferred pathway\\nin any situation. This is obviously not a bible but it is based on a thorough knowledge of the\\nliterature and vast personal experience. So wherever you are — in India, Pakistan, Norway,\\nChile, Botswana, Canada or Palestine, and whatever your resources are — the general\\napproach to emergency abdominal surgery should be the same. So come and join us: to do it\\nwell, decrease morbidity, save lives, have fun — and attain glory!\\n\\n“The glory of surgeons is like that of actors, which lasts\\nonly for their own lifetime and can no longer be\\nappreciated once they have passed away. Actors and\\nsurgeons… are all heroes of the moment.”\\n Honoré de Balzac\\n“The operation is a silent confession to the surgeon’s\\ninadequacy.”\\n John Hunter',\n", " 'md': '```markdown\\n## Text\\n\\nAccording to the above-mentioned pathway, one will do just fine, but a few will not. The following pages will help you to develop your own judgment — pointing to the correct/preferred pathway in any situation. This is obviously not a bible but it is based on a thorough knowledge of the literature and vast personal experience. So wherever you are — in India, Pakistan, Norway, Chile, Botswana, Canada or Palestine, and whatever your resources are — the general approach to emergency abdominal surgery should be the same. So come and join us: to do it well, decrease morbidity, save lives, have fun — and attain glory!\\n\\n> “The glory of surgeons is like that of actors, which lasts only for their own lifetime and can no longer be appreciated once they have passed away. Actors and surgeons… are all heroes of the moment.”\\n> — Honoré de Balzac\\n\\n> “The operation is a silent confession to the surgeon’s inadequacy.”\\n> — John Hunter\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and formatted as per the instructions.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 211, 'y': 279, 'w': 33.1, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'According to the above-mentioned pathway, one will do just fine, but a few will not. The following pages will help you to develop your own judgment — pointing to the correct/preferred pathway in any situation. This is obviously not a bible but it is based on a thorough knowledge of the literature and vast personal experience. So wherever you are — in India, Pakistan, Norway, Chile, Botswana, Canada or Palestine, and whatever your resources are — the general approach to emergency abdominal surgery should be the same. So come and join us: to do it well, decrease morbidity, save lives, have fun — and attain glory!\\n\\n> “The glory of surgeons is like that of actors, which lasts only for their own lifetime and can no longer be appreciated once they have passed away. Actors and surgeons… are all heroes of the moment.”\\n> — Honoré de Balzac\\n\\n> “The operation is a silent confession to the surgeon’s inadequacy.”\\n> — John Hunter\\n```',\n", " 'md': 'According to the above-mentioned pathway, one will do just fine, but a few will not. The following pages will help you to develop your own judgment — pointing to the correct/preferred pathway in any situation. This is obviously not a bible but it is based on a thorough knowledge of the literature and vast personal experience. So wherever you are — in India, Pakistan, Norway, Chile, Botswana, Canada or Palestine, and whatever your resources are — the general approach to emergency abdominal surgery should be the same. So come and join us: to do it well, decrease morbidity, save lives, have fun — and attain glory!\\n\\n> “The glory of surgeons is like that of actors, which lasts only for their own lifetime and can no longer be appreciated once they have passed away. Actors and surgeons… are all heroes of the moment.”\\n> — Honoré de Balzac\\n\\n> “The operation is a silent confession to the surgeon’s inadequacy.”\\n> — John Hunter\\n```',\n", " 'bBox': {'x': 79, 'y': 106, 'w': 453.53, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 414, 'y': 279, 'w': 20.23, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and formatted as per the instructions.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and formatted as per the instructions.',\n", " 'bBox': {'x': 126, 'y': 279, 'w': 29.43, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 37,\n", " 'text': 'Chapter 2\\nA brief history of emergency abdominal surgery\\nHarold Ellis\\n\\n [We are proud to offer this chapter by Professor Ellis of London: a\\nrenowned surgeon, educator, writer, editor, anatomist, and surgical\\nhistorian. Among his many books, we would particularly recommend\\nOperations That Made History and A Brief History of Surgery. The\\nEditors.]\\n\\n In the study of some apparently new problems we often\\n make progress by reading the work of the great men of the\\n past.\\n Charles H. Mayo\\n\\n From the earliest days until comparatively modern times, surgeons\\nwere ignorant about the causes of the vast majority of acute abdominal\\nemergencies and equally ineffectual in their treatment. They were, of\\ncourse, well familiar with abdominal trauma and the dire consequences of\\nperforating injuries of the belly, the great majority of which would be fatal.\\nThus, in the Bible we read in the Book of Judges:\\n\\n But Ehud made him a dagger, which had two edges of a cubit length, and he did gird it under\\n the raiment of his right thigh. And he brought the present unto Eglon, King of Moab. And Eglon\\n was a very fat man... And Ehud put forth his left hsand and took the dagger from his right thigh,\\n and thrust it into his belly. And the haft went in after the blade and the fat closed over the blade,\\n so that he could not draw the blade out of his belly; and the dirt came out... And behold their',\n", " 'md': '```markdown\\n# Chapter 2\\n## A Brief History of Emergency Abdominal Surgery\\n### Harold Ellis\\n\\n> We are proud to offer this chapter by Professor Ellis of London: a renowned surgeon, educator, writer, editor, anatomist, and surgical historian. Among his many books, we would particularly recommend *Operations That Made History* and *A Brief History of Surgery*. The Editors.\\n\\n> In the study of some apparently new problems we often make progress by reading the work of the great men of the past.\\n> — Charles H. Mayo\\n\\nFrom the earliest days until comparatively modern times, surgeons were ignorant about the causes of the vast majority of acute abdominal emergencies and equally ineffectual in their treatment. They were, of course, well familiar with abdominal trauma and the dire consequences of perforating injuries of the belly, the great majority of which would be fatal.\\n\\nThus, in the Bible we read in the Book of Judges:\\n\\n> But Ehud made him a dagger, which had two edges of a cubit length, and he did gird it under the raiment of his right thigh. And he brought the present unto Eglon, King of Moab. And Eglon was a very fat man... And Ehud put forth his left hand and took the dagger from his right thigh, and thrust it into his belly. And the haft went in after the blade and the fat closed over the blade, so that he could not draw the blade out of his belly; and the dirt came out...\\n```\\n\\n### Notes:\\n- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- The biblical quote has been preserved as it is relevant to the context.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 2',\n", " 'md': '# Chapter 2',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 132.78, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'A Brief History of Emergency Abdominal Surgery',\n", " 'md': '## A Brief History of Emergency Abdominal Surgery',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 421.03, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Harold Ellis',\n", " 'md': '### Harold Ellis',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 72.75, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '> We are proud to offer this chapter by Professor Ellis of London: a renowned surgeon, educator, writer, editor, anatomist, and surgical historian. Among his many books, we would particularly recommend *Operations That Made History* and *A Brief History of Surgery*. The Editors.\\n\\n> In the study of some apparently new problems we often make progress by reading the work of the great men of the past.\\n> — Charles H. Mayo\\n\\nFrom the earliest days until comparatively modern times, surgeons were ignorant about the causes of the vast majority of acute abdominal emergencies and equally ineffectual in their treatment. They were, of course, well familiar with abdominal trauma and the dire consequences of perforating injuries of the belly, the great majority of which would be fatal.\\n\\nThus, in the Bible we read in the Book of Judges:\\n\\n> But Ehud made him a dagger, which had two edges of a cubit length, and he did gird it under the raiment of his right thigh. And he brought the present unto Eglon, King of Moab. And Eglon was a very fat man... And Ehud put forth his left hand and took the dagger from his right thigh, and thrust it into his belly. And the haft went in after the blade and the fat closed over the blade, so that he could not draw the blade out of his belly; and the dirt came out...\\n```',\n", " 'md': '> We are proud to offer this chapter by Professor Ellis of London: a renowned surgeon, educator, writer, editor, anatomist, and surgical historian. Among his many books, we would particularly recommend *Operations That Made History* and *A Brief History of Surgery*. The Editors.\\n\\n> In the study of some apparently new problems we often make progress by reading the work of the great men of the past.\\n> — Charles H. Mayo\\n\\nFrom the earliest days until comparatively modern times, surgeons were ignorant about the causes of the vast majority of acute abdominal emergencies and equally ineffectual in their treatment. They were, of course, well familiar with abdominal trauma and the dire consequences of perforating injuries of the belly, the great majority of which would be fatal.\\n\\nThus, in the Bible we read in the Book of Judges:\\n\\n> But Ehud made him a dagger, which had two edges of a cubit length, and he did gird it under the raiment of his right thigh. And he brought the present unto Eglon, King of Moab. And Eglon was a very fat man... And Ehud put forth his left hand and took the dagger from his right thigh, and thrust it into his belly. And the haft went in after the blade and the fat closed over the blade, so that he could not draw the blade out of his belly; and the dirt came out...\\n```',\n", " 'bBox': {'x': 72, 'y': 423, 'w': 467.76, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- The biblical quote has been preserved as it is relevant to the context.',\n", " 'md': '- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- The biblical quote has been preserved as it is relevant to the context.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 38,\n", " 'text': ' Lord was fallen down dead on the earth.\\n\\n Occasionally, a fecal fistula would form, and the patient survived. That\\ngreat 16th century French military surgeon, Ambroise Paré, recorded in\\nhis Case Reports and Autopsy Records:\\n\\n In time I have treated several who recovered after having had wounds by sword or pistol pass\\n through their bodies. One of these, in the town of Melun, was the steward of the Ambassador\\n of the King of Portugal. He was thrust through with a sword, by which his intestines were\\n wounded, so when he was dressed a great deal of fecal matter drained from the wound, yet\\n the steward was cured.\\n\\n Occasionally, a prolapsed loop of bowel, projecting through a lacerated\\nabdominal wound, might be successfully reduced. Still less often, an\\nenterprising surgeon might suture a laceration in such a loop and thus\\nsave the patient’s life.\\n\\n In 1676 Timothy Clark recorded the case of a butcher who attempted\\nsuicide with his butcher’s knife in the village of Wayford in the country of\\nSomerset, located in the southwest corner of England. Three days later,\\na surgeon who Clark does not name replaced the prolapsed gut,\\nremoved extruded omentum and prolapsed spleen and the patient\\nrecovered. Clark, himself, in 1633 had removed the spleen of a dog with\\nsurvival, thus showing that the organ was not essential to life and\\nconfirming an observation made by Vesalius a century beforehand.\\n\\n Strangulated hernias were also well known to ancients. Treatment\\nusually consisted of forcible manipulative reduction, which was aided by\\nhot baths, poultices, and the use of the head-down, feet-up position.\\nSometimes their efforts succeeded, but there was, of course, a dire risk\\nof rupture of the gut, especially in advanced cases. William Cheselden in\\n1723 reported the case of a woman in her 73rd year with a strangulated\\numbilical hernia. At operation, he resected 26 inches of gangrenous\\nintestine. She recovered with, of course, a persistent fecal fistula. The\\nextreme danger of strangulated hernia is well demonstrated by the fact',\n", " 'md': '# Page Content\\n\\nLord was fallen down dead on the earth.\\n\\nOccasionally, a fecal fistula would form, and the patient survived. That great 16th century French military surgeon, Ambroise Paré, recorded in his Case Reports and Autopsy Records:\\n\\nIn time I have treated several who recovered after having had wounds by sword or pistol pass through their bodies. One of these, in the town of Melun, was the steward of the Ambassador of the King of Portugal. He was thrust through with a sword, by which his intestines were wounded, so when he was dressed a great deal of fecal matter drained from the wound, yet the steward was cured.\\n\\nOccasionally, a prolapsed loop of bowel, projecting through a lacerated abdominal wound, might be successfully reduced. Still less often, an enterprising surgeon might suture a laceration in such a loop and thus save the patient’s life.\\n\\nIn 1676 Timothy Clark recorded the case of a butcher who attempted suicide with his butcher’s knife in the village of Wayford in the country of Somerset, located in the southwest corner of England. Three days later, a surgeon who Clark does not name replaced the prolapsed gut, removed extruded omentum and prolapsed spleen and the patient recovered. Clark, himself, in 1633 had removed the spleen of a dog with survival, thus showing that the organ was not essential to life and confirming an observation made by Vesalius a century beforehand.\\n\\nStrangulated hernias were also well known to ancients. Treatment usually consisted of forcible manipulative reduction, which was aided by hot baths, poultices, and the use of the head-down, feet-up position. Sometimes their efforts succeeded, but there was, of course, a dire risk of rupture of the gut, especially in advanced cases. William Cheselden in 1723 reported the case of a woman in her 73rd year with a strangulated umbilical hernia. At operation, he resected 26 inches of gangrenous intestine. She recovered with, of course, a persistent fecal fistula. The extreme danger of strangulated hernia is well demonstrated by the fact.\\n\\n----\\n\\n### Summary\\n\\n- The text discusses historical surgical cases and treatments related to severe abdominal injuries and conditions such as fecal fistulas, prolapsed bowel, and strangulated hernias.\\n- Notable figures mentioned include Ambroise Paré and Timothy Clark, highlighting their contributions to surgical practices and understanding of anatomy.\\n- The text emphasizes the risks associated with surgical interventions and the outcomes of various cases, illustrating the evolution of surgical techniques over time.',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Lord was fallen down dead on the earth.\\n\\nOccasionally, a fecal fistula would form, and the patient survived. That great 16th century French military surgeon, Ambroise Paré, recorded in his Case Reports and Autopsy Records:\\n\\nIn time I have treated several who recovered after having had wounds by sword or pistol pass through their bodies. One of these, in the town of Melun, was the steward of the Ambassador of the King of Portugal. He was thrust through with a sword, by which his intestines were wounded, so when he was dressed a great deal of fecal matter drained from the wound, yet the steward was cured.\\n\\nOccasionally, a prolapsed loop of bowel, projecting through a lacerated abdominal wound, might be successfully reduced. Still less often, an enterprising surgeon might suture a laceration in such a loop and thus save the patient’s life.\\n\\nIn 1676 Timothy Clark recorded the case of a butcher who attempted suicide with his butcher’s knife in the village of Wayford in the country of Somerset, located in the southwest corner of England. Three days later, a surgeon who Clark does not name replaced the prolapsed gut, removed extruded omentum and prolapsed spleen and the patient recovered. Clark, himself, in 1633 had removed the spleen of a dog with survival, thus showing that the organ was not essential to life and confirming an observation made by Vesalius a century beforehand.\\n\\nStrangulated hernias were also well known to ancients. Treatment usually consisted of forcible manipulative reduction, which was aided by hot baths, poultices, and the use of the head-down, feet-up position. Sometimes their efforts succeeded, but there was, of course, a dire risk of rupture of the gut, especially in advanced cases. William Cheselden in 1723 reported the case of a woman in her 73rd year with a strangulated umbilical hernia. At operation, he resected 26 inches of gangrenous intestine. She recovered with, of course, a persistent fecal fistula. The extreme danger of strangulated hernia is well demonstrated by the fact.\\n\\n----',\n", " 'md': 'Lord was fallen down dead on the earth.\\n\\nOccasionally, a fecal fistula would form, and the patient survived. That great 16th century French military surgeon, Ambroise Paré, recorded in his Case Reports and Autopsy Records:\\n\\nIn time I have treated several who recovered after having had wounds by sword or pistol pass through their bodies. One of these, in the town of Melun, was the steward of the Ambassador of the King of Portugal. He was thrust through with a sword, by which his intestines were wounded, so when he was dressed a great deal of fecal matter drained from the wound, yet the steward was cured.\\n\\nOccasionally, a prolapsed loop of bowel, projecting through a lacerated abdominal wound, might be successfully reduced. Still less often, an enterprising surgeon might suture a laceration in such a loop and thus save the patient’s life.\\n\\nIn 1676 Timothy Clark recorded the case of a butcher who attempted suicide with his butcher’s knife in the village of Wayford in the country of Somerset, located in the southwest corner of England. Three days later, a surgeon who Clark does not name replaced the prolapsed gut, removed extruded omentum and prolapsed spleen and the patient recovered. Clark, himself, in 1633 had removed the spleen of a dog with survival, thus showing that the organ was not essential to life and confirming an observation made by Vesalius a century beforehand.\\n\\nStrangulated hernias were also well known to ancients. Treatment usually consisted of forcible manipulative reduction, which was aided by hot baths, poultices, and the use of the head-down, feet-up position. Sometimes their efforts succeeded, but there was, of course, a dire risk of rupture of the gut, especially in advanced cases. William Cheselden in 1723 reported the case of a woman in her 73rd year with a strangulated umbilical hernia. At operation, he resected 26 inches of gangrenous intestine. She recovered with, of course, a persistent fecal fistula. The extreme danger of strangulated hernia is well demonstrated by the fact.\\n\\n----',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text discusses historical surgical cases and treatments related to severe abdominal injuries and conditions such as fecal fistulas, prolapsed bowel, and strangulated hernias.\\n- Notable figures mentioned include Ambroise Paré and Timothy Clark, highlighting their contributions to surgical practices and understanding of anatomy.\\n- The text emphasizes the risks associated with surgical interventions and the outcomes of various cases, illustrating the evolution of surgical techniques over time.',\n", " 'md': '- The text discusses historical surgical cases and treatments related to severe abdominal injuries and conditions such as fecal fistulas, prolapsed bowel, and strangulated hernias.\\n- Notable figures mentioned include Ambroise Paré and Timothy Clark, highlighting their contributions to surgical practices and understanding of anatomy.\\n- The text emphasizes the risks associated with surgical interventions and the outcomes of various cases, illustrating the evolution of surgical techniques over time.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 39,\n", " 'text': 'that Queen Caroline, wife of George II of England, died of a strangulated\\numbilical hernia at the age of 55 in 1736.\\n\\n Acute abdominal emergencies have no doubt affected humankind from\\nits earliest existence, yet it has only been in comparatively recent times\\n— the past couple of hundred years — that the pathology and then the\\ntreatment of these conditions were elucidated. This is because over\\nmany centuries post-mortem examinations were either forbidden or\\nfrowned upon in most societies. Operations on the abdomen were\\nperformed rarely, if at all, until the beginning of the 19th century. So, what\\nBerkeley Moynihan called “the pathology of the living”, the pathology of\\nthe abdominal cavity as revealed in the operating theater, awaited to a\\nlarge extent the development of anesthesia in the 1840s and antiseptic\\nsurgery in the 1870s.\\n\\n Knowledge of the causes of the acute abdomen advanced little in the\\n2000 years following the days of ħippocrates in the 5th century BC. The\\nGreek and Roman doctors were keen clinical observers. They recognized\\nthat, from time to time, a deep abdominal abscess might discharge\\nspontaneously or be amenable to surgical drainage with recovery of the\\npatient. Every other serious abdominal emergency was given the name\\nof ‘ileus’ or ‘iliac passion’ and was considered to be due to obstruction of\\nthe bowels. Of course, the fatal abdominal emergencies they were seeing\\nwere indeed due either to mechanical obstruction or to the paralytic ileus\\nof general peritonitis. Thus in ħippocrates we read:\\n\\n In ileus the belly becomes hard, there are no motions, the whole abdomen is painful, there are\\n fever and thirst and sometimes the patient is so tormented that he vomits bile... Medicines are\\n not retained and enemas do not penetrate. It is an acute and dangerous disease.\\n\\n Over the centuries there was little to offer the patient beyond poultices\\nto the abdomen, cupping, bleeding, purgation and enemas, all of which\\nprobably did more harm than good. It was not until 1776 that William\\nCullen, of Edinburgh, coined the term ‘peritonitis’ for inflammation of the\\nlining membrane of the abdominal cavity and its extensions to the\\nviscera. ħowever, he did not think the exact diagnosis of great\\nimportance since “when known, they do not require any remedies',\n", " 'md': '```markdown\\n# Page Content\\n\\nQueen Caroline, wife of George II of England, died of a strangulated umbilical hernia at the age of 55 in 1736.\\n\\nAcute abdominal emergencies have no doubt affected humankind from its earliest existence, yet it has only been in comparatively recent times — the past couple of hundred years — that the pathology and then the treatment of these conditions were elucidated. This is because over many centuries post-mortem examinations were either forbidden or frowned upon in most societies. Operations on the abdomen were performed rarely, if at all, until the beginning of the 19th century. So, what Berkeley Moynihan called “the pathology of the living”, the pathology of the abdominal cavity as revealed in the operating theater, awaited to a large extent the development of anesthesia in the 1840s and antiseptic surgery in the 1870s.\\n\\nKnowledge of the causes of the acute abdomen advanced little in the 2000 years following the days of Hippocrates in the 5th century BC. The Greek and Roman doctors were keen clinical observers. They recognized that, from time to time, a deep abdominal abscess might discharge spontaneously or be amenable to surgical drainage with recovery of the patient. Every other serious abdominal emergency was given the name of ‘ileus’ or ‘iliac passion’ and was considered to be due to obstruction of the bowels. Of course, the fatal abdominal emergencies they were seeing were indeed due either to mechanical obstruction or to the paralytic ileus of general peritonitis. Thus in Hippocrates we read:\\n\\n> In ileus the belly becomes hard, there are no motions, the whole abdomen is painful, there are fever and thirst and sometimes the patient is so tormented that he vomits bile... Medicines are not retained and enemas do not penetrate. It is an acute and dangerous disease.\\n\\nOver the centuries there was little to offer the patient beyond poultices to the abdomen, cupping, bleeding, purgation and enemas, all of which probably did more harm than good. It was not until 1776 that William Cullen, of Edinburgh, coined the term ‘peritonitis’ for inflammation of the lining membrane of the abdominal cavity and its extensions to the viscera. However, he did not think the exact diagnosis of great importance since “when known, they do not require any remedies”.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Queen Caroline, wife of George II of England, died of a strangulated umbilical hernia at the age of 55 in 1736.\\n\\nAcute abdominal emergencies have no doubt affected humankind from its earliest existence, yet it has only been in comparatively recent times — the past couple of hundred years — that the pathology and then the treatment of these conditions were elucidated. This is because over many centuries post-mortem examinations were either forbidden or frowned upon in most societies. Operations on the abdomen were performed rarely, if at all, until the beginning of the 19th century. So, what Berkeley Moynihan called “the pathology of the living”, the pathology of the abdominal cavity as revealed in the operating theater, awaited to a large extent the development of anesthesia in the 1840s and antiseptic surgery in the 1870s.\\n\\nKnowledge of the causes of the acute abdomen advanced little in the 2000 years following the days of Hippocrates in the 5th century BC. The Greek and Roman doctors were keen clinical observers. They recognized that, from time to time, a deep abdominal abscess might discharge spontaneously or be amenable to surgical drainage with recovery of the patient. Every other serious abdominal emergency was given the name of ‘ileus’ or ‘iliac passion’ and was considered to be due to obstruction of the bowels. Of course, the fatal abdominal emergencies they were seeing were indeed due either to mechanical obstruction or to the paralytic ileus of general peritonitis. Thus in Hippocrates we read:\\n\\n> In ileus the belly becomes hard, there are no motions, the whole abdomen is painful, there are fever and thirst and sometimes the patient is so tormented that he vomits bile... Medicines are not retained and enemas do not penetrate. It is an acute and dangerous disease.\\n\\nOver the centuries there was little to offer the patient beyond poultices to the abdomen, cupping, bleeding, purgation and enemas, all of which probably did more harm than good. It was not until 1776 that William Cullen, of Edinburgh, coined the term ‘peritonitis’ for inflammation of the lining membrane of the abdominal cavity and its extensions to the viscera. However, he did not think the exact diagnosis of great importance since “when known, they do not require any remedies”.\\n```',\n", " 'md': 'Queen Caroline, wife of George II of England, died of a strangulated umbilical hernia at the age of 55 in 1736.\\n\\nAcute abdominal emergencies have no doubt affected humankind from its earliest existence, yet it has only been in comparatively recent times — the past couple of hundred years — that the pathology and then the treatment of these conditions were elucidated. This is because over many centuries post-mortem examinations were either forbidden or frowned upon in most societies. Operations on the abdomen were performed rarely, if at all, until the beginning of the 19th century. So, what Berkeley Moynihan called “the pathology of the living”, the pathology of the abdominal cavity as revealed in the operating theater, awaited to a large extent the development of anesthesia in the 1840s and antiseptic surgery in the 1870s.\\n\\nKnowledge of the causes of the acute abdomen advanced little in the 2000 years following the days of Hippocrates in the 5th century BC. The Greek and Roman doctors were keen clinical observers. They recognized that, from time to time, a deep abdominal abscess might discharge spontaneously or be amenable to surgical drainage with recovery of the patient. Every other serious abdominal emergency was given the name of ‘ileus’ or ‘iliac passion’ and was considered to be due to obstruction of the bowels. Of course, the fatal abdominal emergencies they were seeing were indeed due either to mechanical obstruction or to the paralytic ileus of general peritonitis. Thus in Hippocrates we read:\\n\\n> In ileus the belly becomes hard, there are no motions, the whole abdomen is painful, there are fever and thirst and sometimes the patient is so tormented that he vomits bile... Medicines are not retained and enemas do not penetrate. It is an acute and dangerous disease.\\n\\nOver the centuries there was little to offer the patient beyond poultices to the abdomen, cupping, bleeding, purgation and enemas, all of which probably did more harm than good. It was not until 1776 that William Cullen, of Edinburgh, coined the term ‘peritonitis’ for inflammation of the lining membrane of the abdominal cavity and its extensions to the viscera. However, he did not think the exact diagnosis of great importance since “when known, they do not require any remedies”.\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.94, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 40,\n", " 'text': 'besides those of inflammation in general”.\\n\\n Appendicitis\\n\\n Lorenz ħeister, of ħelmstadt in Brunswig, must be given credit for the\\nfirst description of the appendix as the site of acute inflammation,\\nreporting this at an autopsy in 1755. For more than a century after this\\nthere were occasional autopsy reports, but most cases were\\nunrecognized or labelled ‘typhlitis’, ‘perityphlitis’ or ‘iliac passion’.\\n\\n In 1848, ħenry ħancock, of Charing Cross ħospital, London, reported\\nthe drainage of an appendix abscess in a young woman who was 8\\nmonths pregnant. She recovered, but in spite of ħancock’s plea, so fixed\\nwas the idea that it was useless to operate once peritonitis was\\nestablished that his advice was ignored for some 40 years. Indeed, it was\\na physician, not a surgeon, who advised appendicectomy and early\\ndiagnosis. This was Reginald Fitz, Professor of Medicine at ħarvard,\\nwho, in 1886, published a review of 257 cases, which clearly described\\nthe pathology and clinical features and advised removal of the acutely\\ninflamed organ or, in the presence of an abscess, surgical drainage.\\nFitz’s advice was taken up rapidly in the United States. Thomas Morton\\nof Philadelphia was the first to report, in 1887, the correct diagnosis and\\nsuccessful removal of a perforated appendix (although Robert Lawson\\nTait as early as 1880 had a similar case, he did not report this until 1890).\\nThe surge in early diagnosis and operative treatment was particularly\\npioneered by Charles McBurney of the Roosevelt ħospital, New York,\\nwho described ‘McBurney’s point’ and devised the muscle split incision,\\nand J.B. Murphy of Chicago, who emphasized the shift in pain in\\n‘Murphy’s sequence’. In 1902, Fredrick Treves, of the London ħospital,\\ndrained the appendix abscess of King Edward VII, 2 days before the\\ncoronation, and did much to raise the general public’s awareness of the\\ndisease.\\n\\n The ruptured spleen\\n\\n The spleen is the most commonly injured viscus in closed abdominal\\ntrauma, yet there was surprising diffidence among the pioneer abdominal',\n", " 'md': '```markdown\\n## Appendicitis\\n\\nLorenz Heister, of Helmstadt in Brunswig, must be given credit for the first description of the appendix as the site of acute inflammation, reporting this at an autopsy in 1755. For more than a century after this, there were occasional autopsy reports, but most cases were unrecognized or labelled ‘typhlitis’, ‘perityphlitis’ or ‘iliac passion’.\\n\\nIn 1848, Henry Hancock, of Charing Cross Hospital, London, reported the drainage of an appendix abscess in a young woman who was 8 months pregnant. She recovered, but in spite of Hancock’s plea, so fixed was the idea that it was useless to operate once peritonitis was established that his advice was ignored for some 40 years. Indeed, it was a physician, not a surgeon, who advised appendicectomy and early diagnosis. This was Reginald Fitz, Professor of Medicine at Harvard, who, in 1886, published a review of 257 cases, which clearly described the pathology and clinical features and advised removal of the acutely inflamed organ or, in the presence of an abscess, surgical drainage. Fitz’s advice was taken up rapidly in the United States. Thomas Morton of Philadelphia was the first to report, in 1887, the correct diagnosis and successful removal of a perforated appendix (although Robert Lawson Tait as early as 1880 had a similar case, he did not report this until 1890). The surge in early diagnosis and operative treatment was particularly pioneered by Charles McBurney of the Roosevelt Hospital, New York, who described ‘McBurney’s point’ and devised the muscle split incision, and J.B. Murphy of Chicago, who emphasized the shift in pain in ‘Murphy’s sequence’. In 1902, Fredrick Treves, of the London Hospital, drained the appendix abscess of King Edward VII, 2 days before the coronation, and did much to raise the general public’s awareness of the disease.\\n\\n## The Ruptured Spleen\\n\\nThe spleen is the most commonly injured viscus in closed abdominal trauma, yet there was surprising diffidence among the pioneer abdominal surgeons.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Appendicitis',\n", " 'md': '## Appendicitis',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 99.31, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Lorenz Heister, of Helmstadt in Brunswig, must be given credit for the first description of the appendix as the site of acute inflammation, reporting this at an autopsy in 1755. For more than a century after this, there were occasional autopsy reports, but most cases were unrecognized or labelled ‘typhlitis’, ‘perityphlitis’ or ‘iliac passion’.\\n\\nIn 1848, Henry Hancock, of Charing Cross Hospital, London, reported the drainage of an appendix abscess in a young woman who was 8 months pregnant. She recovered, but in spite of Hancock’s plea, so fixed was the idea that it was useless to operate once peritonitis was established that his advice was ignored for some 40 years. Indeed, it was a physician, not a surgeon, who advised appendicectomy and early diagnosis. This was Reginald Fitz, Professor of Medicine at Harvard, who, in 1886, published a review of 257 cases, which clearly described the pathology and clinical features and advised removal of the acutely inflamed organ or, in the presence of an abscess, surgical drainage. Fitz’s advice was taken up rapidly in the United States. Thomas Morton of Philadelphia was the first to report, in 1887, the correct diagnosis and successful removal of a perforated appendix (although Robert Lawson Tait as early as 1880 had a similar case, he did not report this until 1890). The surge in early diagnosis and operative treatment was particularly pioneered by Charles McBurney of the Roosevelt Hospital, New York, who described ‘McBurney’s point’ and devised the muscle split incision, and J.B. Murphy of Chicago, who emphasized the shift in pain in ‘Murphy’s sequence’. In 1902, Fredrick Treves, of the London Hospital, drained the appendix abscess of King Edward VII, 2 days before the coronation, and did much to raise the general public’s awareness of the disease.',\n", " 'md': 'Lorenz Heister, of Helmstadt in Brunswig, must be given credit for the first description of the appendix as the site of acute inflammation, reporting this at an autopsy in 1755. For more than a century after this, there were occasional autopsy reports, but most cases were unrecognized or labelled ‘typhlitis’, ‘perityphlitis’ or ‘iliac passion’.\\n\\nIn 1848, Henry Hancock, of Charing Cross Hospital, London, reported the drainage of an appendix abscess in a young woman who was 8 months pregnant. She recovered, but in spite of Hancock’s plea, so fixed was the idea that it was useless to operate once peritonitis was established that his advice was ignored for some 40 years. Indeed, it was a physician, not a surgeon, who advised appendicectomy and early diagnosis. This was Reginald Fitz, Professor of Medicine at Harvard, who, in 1886, published a review of 257 cases, which clearly described the pathology and clinical features and advised removal of the acutely inflamed organ or, in the presence of an abscess, surgical drainage. Fitz’s advice was taken up rapidly in the United States. Thomas Morton of Philadelphia was the first to report, in 1887, the correct diagnosis and successful removal of a perforated appendix (although Robert Lawson Tait as early as 1880 had a similar case, he did not report this until 1890). The surge in early diagnosis and operative treatment was particularly pioneered by Charles McBurney of the Roosevelt Hospital, New York, who described ‘McBurney’s point’ and devised the muscle split incision, and J.B. Murphy of Chicago, who emphasized the shift in pain in ‘Murphy’s sequence’. In 1902, Fredrick Treves, of the London Hospital, drained the appendix abscess of King Edward VII, 2 days before the coronation, and did much to raise the general public’s awareness of the disease.',\n", " 'bBox': {'x': 72, 'y': 214, 'w': 467.61, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Ruptured Spleen',\n", " 'md': '## The Ruptured Spleen',\n", " 'bBox': {'x': 86, 'y': 657, 'w': 159.08, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The spleen is the most commonly injured viscus in closed abdominal trauma, yet there was surprising diffidence among the pioneer abdominal surgeons.\\n```',\n", " 'md': 'The spleen is the most commonly injured viscus in closed abdominal trauma, yet there was surprising diffidence among the pioneer abdominal surgeons.\\n```',\n", " 'bBox': {'x': 72, 'y': 214, 'w': 467.89, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 41,\n", " 'text': 'surgeons to perform a splenectomy on these exsanguinating patients —\\nin spite of the fact that Jules Péan of Paris had performed a successful\\nsplenectomy on a girl with a massive splenic cyst in 1867. Two\\nunsuccessful attempts to save life in splenic rupture were reported in\\n1892 by Sir Arbuthnot Lane of Guy’s ħospital, London, and three more\\nfatal cases were recorded by Friedrich Trendelenburg in Leipzig the\\nfollowing year. The wording of these case reports strongly suggests that\\nhad blood transfusion been available, the patients might well have\\nsurvived.\\n\\n It fell to Oskar Riegner in Breslau to perform the first splenectomy for a\\npulped spleen with survival in 1893. The patient, a lad of 14, was found to\\nhave the spleen completely severed and there was 1.5L of blood in the\\nabdomen. Normal saline was given subcutaneously into all four limbs.\\nħis recovery was complicated by gangrene of the left foot, which required\\namputation, but he left the hospital, complete with artificial limb, 5 months\\nafter his splenectomy.\\n\\n Intestinal obstruction\\n\\n Not surprisingly, early attempts to deal with large bowel obstruction\\n(usually due to a left-sided colonic cancer) comprised performance of a\\ncolostomy. The first attempt to do this was made by Pillore of Rouen in\\n1776. ħe actually carried out a cecostomy on a wine merchant with gross\\nabdominal distension due to a rectosigmoid growth. The operation\\nproduced great relief, but the patient died on the 28th day because of\\nnecrosis of a loop of jejunum, brought about by the large amounts of\\nmercury given in the pre-operative attempts to overcome the obstruction.\\nIt remained for Pierre Fine of Geneva, in 1797, to perform a successful\\ntransverse colostomy. The patient, a lady of 63 with an obstructing\\nsigmoid growth, died 14 weeks later with ascites.\\n\\n Not until the introduction of anesthesia and antisepsis could routine\\nresection of bowel cancers be performed, the first success in this era\\nbeing reported by Vincent Czerny in ħeidelberg in 1879. It was soon\\nrealized that resection of the obstructed colon was very likely to result in\\na fatal anastomotic leak. Exteriorization of the growth, with formation of a\\ndouble-barrelled colostomy and its subsequent closure was introduced by',\n", " 'md': '```markdown\\n## Historical Surgical Procedures\\n\\nSurgeons faced significant challenges in performing splenectomies on exsanguinating patients, despite the successful splenectomy performed by Jules Péan of Paris on a girl with a massive splenic cyst in 1867. Two unsuccessful attempts to save lives in cases of splenic rupture were reported in 1892 by Sir Arbuthnot Lane of Guy’s Hospital, London, and three more fatal cases were recorded by Friedrich Trendelenburg in Leipzig the following year. The wording of these case reports strongly suggests that had blood transfusion been available, the patients might well have survived.\\n\\nIt fell to Oskar Riegner in Breslau to perform the first splenectomy for a pulped spleen with survival in 1893. The patient, a lad of 14, was found to have the spleen completely severed, and there was 1.5L of blood in the abdomen. Normal saline was given subcutaneously into all four limbs. His recovery was complicated by gangrene of the left foot, which required amputation, but he left the hospital, complete with an artificial limb, 5 months after his splenectomy.\\n\\n### Intestinal Obstruction\\n\\nNot surprisingly, early attempts to deal with large bowel obstruction (usually due to a left-sided colonic cancer) comprised the performance of a colostomy. The first attempt to do this was made by Pillore of Rouen in 1776. He actually carried out a cecostomy on a wine merchant with gross abdominal distension due to a rectosigmoid growth. The operation produced great relief, but the patient died on the 28th day because of necrosis of a loop of jejunum, brought about by the large amounts of mercury given in the pre-operative attempts to overcome the obstruction.\\n\\nIt remained for Pierre Fine of Geneva, in 1797, to perform a successful transverse colostomy. The patient, a lady of 63 with an obstructing sigmoid growth, died 14 weeks later with ascites.\\n\\nNot until the introduction of anesthesia and antisepsis could routine resection of bowel cancers be performed, the first success in this era being reported by Vincent Czerny in Heidelberg in 1879. It was soon realized that resection of the obstructed colon was very likely to result in a fatal anastomotic leak. Exteriorization of the growth, with formation of a double-barrelled colostomy and its subsequent closure was introduced by...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Historical Surgical Procedures',\n", " 'md': '## Historical Surgical Procedures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Surgeons faced significant challenges in performing splenectomies on exsanguinating patients, despite the successful splenectomy performed by Jules Péan of Paris on a girl with a massive splenic cyst in 1867. Two unsuccessful attempts to save lives in cases of splenic rupture were reported in 1892 by Sir Arbuthnot Lane of Guy’s Hospital, London, and three more fatal cases were recorded by Friedrich Trendelenburg in Leipzig the following year. The wording of these case reports strongly suggests that had blood transfusion been available, the patients might well have survived.\\n\\nIt fell to Oskar Riegner in Breslau to perform the first splenectomy for a pulped spleen with survival in 1893. The patient, a lad of 14, was found to have the spleen completely severed, and there was 1.5L of blood in the abdomen. Normal saline was given subcutaneously into all four limbs. His recovery was complicated by gangrene of the left foot, which required amputation, but he left the hospital, complete with an artificial limb, 5 months after his splenectomy.',\n", " 'md': 'Surgeons faced significant challenges in performing splenectomies on exsanguinating patients, despite the successful splenectomy performed by Jules Péan of Paris on a girl with a massive splenic cyst in 1867. Two unsuccessful attempts to save lives in cases of splenic rupture were reported in 1892 by Sir Arbuthnot Lane of Guy’s Hospital, London, and three more fatal cases were recorded by Friedrich Trendelenburg in Leipzig the following year. The wording of these case reports strongly suggests that had blood transfusion been available, the patients might well have survived.\\n\\nIt fell to Oskar Riegner in Breslau to perform the first splenectomy for a pulped spleen with survival in 1893. The patient, a lad of 14, was found to have the spleen completely severed, and there was 1.5L of blood in the abdomen. Normal saline was given subcutaneously into all four limbs. His recovery was complicated by gangrene of the left foot, which required amputation, but he left the hospital, complete with an artificial limb, 5 months after his splenectomy.',\n", " 'bBox': {'x': 72, 'y': 186, 'w': 467.75, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Intestinal Obstruction',\n", " 'md': '### Intestinal Obstruction',\n", " 'bBox': {'x': 86, 'y': 396, 'w': 168.25, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Not surprisingly, early attempts to deal with large bowel obstruction (usually due to a left-sided colonic cancer) comprised the performance of a colostomy. The first attempt to do this was made by Pillore of Rouen in 1776. He actually carried out a cecostomy on a wine merchant with gross abdominal distension due to a rectosigmoid growth. The operation produced great relief, but the patient died on the 28th day because of necrosis of a loop of jejunum, brought about by the large amounts of mercury given in the pre-operative attempts to overcome the obstruction.\\n\\nIt remained for Pierre Fine of Geneva, in 1797, to perform a successful transverse colostomy. The patient, a lady of 63 with an obstructing sigmoid growth, died 14 weeks later with ascites.\\n\\nNot until the introduction of anesthesia and antisepsis could routine resection of bowel cancers be performed, the first success in this era being reported by Vincent Czerny in Heidelberg in 1879. It was soon realized that resection of the obstructed colon was very likely to result in a fatal anastomotic leak. Exteriorization of the growth, with formation of a double-barrelled colostomy and its subsequent closure was introduced by...\\n```',\n", " 'md': 'Not surprisingly, early attempts to deal with large bowel obstruction (usually due to a left-sided colonic cancer) comprised the performance of a colostomy. The first attempt to do this was made by Pillore of Rouen in 1776. He actually carried out a cecostomy on a wine merchant with gross abdominal distension due to a rectosigmoid growth. The operation produced great relief, but the patient died on the 28th day because of necrosis of a loop of jejunum, brought about by the large amounts of mercury given in the pre-operative attempts to overcome the obstruction.\\n\\nIt remained for Pierre Fine of Geneva, in 1797, to perform a successful transverse colostomy. The patient, a lady of 63 with an obstructing sigmoid growth, died 14 weeks later with ascites.\\n\\nNot until the introduction of anesthesia and antisepsis could routine resection of bowel cancers be performed, the first success in this era being reported by Vincent Czerny in Heidelberg in 1879. It was soon realized that resection of the obstructed colon was very likely to result in a fatal anastomotic leak. Exteriorization of the growth, with formation of a double-barrelled colostomy and its subsequent closure was introduced by...\\n```',\n", " 'bBox': {'x': 72, 'y': 548, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 42,\n", " 'text': 'Frank Thomas Paul of Liverpool in 1895, and by Johannes von Mikulicz-\\nRadecki of Breslau a little later. This procedure, the Paul-Mikulicz\\noperation, was shown by the latter to reduce mortality in his own cases\\nfrom 43% with primary resection to 12.5% with the exteriorization\\nmethod.\\n\\n With its vivid clinical features of intestinal obstruction in a baby,\\npassage of redcurrant jelly stools, a palpable abdominal mass and\\nsometimes a prolapsing mass to be felt per rectum or even seen to\\nprotrude through the anal verge, it is not surprising that intussusception in\\nchildren was one of the earliest specific pathologies of the acute\\nabdomen to be recognized. Treatment was expectant, with the use of\\nenemas or rectal bougies, in attempts to reduce the mass. Surgeons\\nwere encouraged to do this by very occasional reports of success and\\nstill rarer accounts of recovery following the passage of the sloughed\\ngangrenous bowel per rectum. The first operative success was reported\\nby Sir Jonathan ħutchinson, of the London ħospital, in 1871. ħis patient,\\na girl aged 2, had her intussusception reduced through a short mid-line\\nincision, the operation requiring just a few minutes. ħutchinson’s\\nmeticulous report tabulated 131 previously recorded cases, which make\\nsad reading indeed.\\n\\n There was a downside to this new abdominal surgery. It was not long\\nafter this new era commenced that the first reports appeared of small\\nbowel obstruction due to postoperative adhesions. Thomas Bryant of\\nGuy’s ħospital recorded the first example in 1872 — a fatal case\\nfollowing an ovariotomy. A second fatality, 4 years after removal of an\\novarian mass, was reported in 1883 by William Battle of London. Today,\\npostoperative adhesions and bands account for some three-quarters of\\nall cases of small bowel obstructions in the Western World.\\n\\n Perforated peptic ulcer\\n\\n Untreated, a perforated peptic ulcer nearly always results in fatal\\nperitonitis. Unsuccessful attempts at repair were made by Mikulicz-\\nRadecki in 1884 and by Czerny in 1885 and subsequently by a number of\\nother surgeons. This depressing series came to an end under most\\ndifficult circumstances. In 1892, Ludwig ħeusner of Wuppertal, Germany,',\n", " 'md': '```markdown\\n## Page Content\\n\\nFrank Thomas Paul of Liverpool in 1895, and by Johannes von Mikulicz-Radecki of Breslau a little later. This procedure, the Paul-Mikulicz operation, was shown by the latter to reduce mortality in his own cases from 43% with primary resection to 12.5% with the exteriorization method.\\n\\nWith its vivid clinical features of intestinal obstruction in a baby, passage of redcurrant jelly stools, a palpable abdominal mass and sometimes a prolapsing mass to be felt per rectum or even seen to protrude through the anal verge, it is not surprising that intussusception in children was one of the earliest specific pathologies of the acute abdomen to be recognized. Treatment was expectant, with the use of enemas or rectal bougies, in attempts to reduce the mass. Surgeons were encouraged to do this by very occasional reports of success and still rarer accounts of recovery following the passage of the sloughed gangrenous bowel per rectum. The first operative success was reported by Sir Jonathan Hutchinson, of the London Hospital, in 1871. His patient, a girl aged 2, had her intussusception reduced through a short mid-line incision, the operation requiring just a few minutes. Hutchinson’s meticulous report tabulated 131 previously recorded cases, which make sad reading indeed.\\n\\nThere was a downside to this new abdominal surgery. It was not long after this new era commenced that the first reports appeared of small bowel obstruction due to postoperative adhesions. Thomas Bryant of Guy’s Hospital recorded the first example in 1872 — a fatal case following an ovariotomy. A second fatality, 4 years after removal of an ovarian mass, was reported in 1883 by William Battle of London. Today, postoperative adhesions and bands account for some three-quarters of all cases of small bowel obstructions in the Western World.\\n\\n### Perforated Peptic Ulcer\\n\\nUntreated, a perforated peptic ulcer nearly always results in fatal peritonitis. Unsuccessful attempts at repair were made by Mikulicz-Radecki in 1884 and by Czerny in 1885 and subsequently by a number of other surgeons. This depressing series came to an end under most difficult circumstances. In 1892, Ludwig Heusner of Wuppertal, Germany,\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Frank Thomas Paul of Liverpool in 1895, and by Johannes von Mikulicz-Radecki of Breslau a little later. This procedure, the Paul-Mikulicz operation, was shown by the latter to reduce mortality in his own cases from 43% with primary resection to 12.5% with the exteriorization method.\\n\\nWith its vivid clinical features of intestinal obstruction in a baby, passage of redcurrant jelly stools, a palpable abdominal mass and sometimes a prolapsing mass to be felt per rectum or even seen to protrude through the anal verge, it is not surprising that intussusception in children was one of the earliest specific pathologies of the acute abdomen to be recognized. Treatment was expectant, with the use of enemas or rectal bougies, in attempts to reduce the mass. Surgeons were encouraged to do this by very occasional reports of success and still rarer accounts of recovery following the passage of the sloughed gangrenous bowel per rectum. The first operative success was reported by Sir Jonathan Hutchinson, of the London Hospital, in 1871. His patient, a girl aged 2, had her intussusception reduced through a short mid-line incision, the operation requiring just a few minutes. Hutchinson’s meticulous report tabulated 131 previously recorded cases, which make sad reading indeed.\\n\\nThere was a downside to this new abdominal surgery. It was not long after this new era commenced that the first reports appeared of small bowel obstruction due to postoperative adhesions. Thomas Bryant of Guy’s Hospital recorded the first example in 1872 — a fatal case following an ovariotomy. A second fatality, 4 years after removal of an ovarian mass, was reported in 1883 by William Battle of London. Today, postoperative adhesions and bands account for some three-quarters of all cases of small bowel obstructions in the Western World.',\n", " 'md': 'Frank Thomas Paul of Liverpool in 1895, and by Johannes von Mikulicz-Radecki of Breslau a little later. This procedure, the Paul-Mikulicz operation, was shown by the latter to reduce mortality in his own cases from 43% with primary resection to 12.5% with the exteriorization method.\\n\\nWith its vivid clinical features of intestinal obstruction in a baby, passage of redcurrant jelly stools, a palpable abdominal mass and sometimes a prolapsing mass to be felt per rectum or even seen to protrude through the anal verge, it is not surprising that intussusception in children was one of the earliest specific pathologies of the acute abdomen to be recognized. Treatment was expectant, with the use of enemas or rectal bougies, in attempts to reduce the mass. Surgeons were encouraged to do this by very occasional reports of success and still rarer accounts of recovery following the passage of the sloughed gangrenous bowel per rectum. The first operative success was reported by Sir Jonathan Hutchinson, of the London Hospital, in 1871. His patient, a girl aged 2, had her intussusception reduced through a short mid-line incision, the operation requiring just a few minutes. Hutchinson’s meticulous report tabulated 131 previously recorded cases, which make sad reading indeed.\\n\\nThere was a downside to this new abdominal surgery. It was not long after this new era commenced that the first reports appeared of small bowel obstruction due to postoperative adhesions. Thomas Bryant of Guy’s Hospital recorded the first example in 1872 — a fatal case following an ovariotomy. A second fatality, 4 years after removal of an ovarian mass, was reported in 1883 by William Battle of London. Today, postoperative adhesions and bands account for some three-quarters of all cases of small bowel obstructions in the Western World.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.75, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Perforated Peptic Ulcer',\n", " 'md': '### Perforated Peptic Ulcer',\n", " 'bBox': {'x': 86, 'y': 613, 'w': 180.23, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Untreated, a perforated peptic ulcer nearly always results in fatal peritonitis. Unsuccessful attempts at repair were made by Mikulicz-Radecki in 1884 and by Czerny in 1885 and subsequently by a number of other surgeons. This depressing series came to an end under most difficult circumstances. In 1892, Ludwig Heusner of Wuppertal, Germany,\\n```',\n", " 'md': 'Untreated, a perforated peptic ulcer nearly always results in fatal peritonitis. Unsuccessful attempts at repair were made by Mikulicz-Radecki in 1884 and by Czerny in 1885 and subsequently by a number of other surgeons. This depressing series came to an end under most difficult circumstances. In 1892, Ludwig Heusner of Wuppertal, Germany,\\n```',\n", " 'bBox': {'x': 72, 'y': 613, 'w': 467.82, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 43,\n", " 'text': 'repaired a perforated gastric ulcer high up on the lesser curve in a 41-\\nyear-old businessman with a 16-hour history; the operation was\\nperformed in the middle of the night by candlelight! The convalescence\\nwas complicated by a left-sided empyema, which required drainage. Two\\nyears later, Thomas Morse, in Norwich, published the successful repair of\\na perforation near the cardia in a girl of 20. With these two successes,\\noperation for this condition became routine. Interestingly, gastric ulcer at\\nthe turn of the 20th century was far commoner than duodenal ulcer and\\nwas especially found in young women.\\n\\n Ruptured ectopic pregnancy\\n\\n Until 1883 a ruptured ectopic pregnancy was a death sentence. This is\\nsurprising because the early pioneers of abdominal surgery, going back\\nto pre-anesthetic era, were, in the main, concerned with removal of\\novarian masses. Indeed, the first elective abdominal operation for a\\nknown pathology was the removal of a massive ovarian cyst by Ephraim\\nMcDowell in Danville, Kentucky, in 1809. Yet, for some inexplicable\\nreason, the surgeon would stand helplessly by the bedside and watch a\\nyoung woman, in the most useful time of her existence, exsanguinate\\nfrom her ruptured tube. The first surgeon to perform successful surgery in\\nthis condition was Robert Lawson Tait, of Birmingham, whom we have\\nalready mentioned performing a successful appendicectomy in 1880. Tait\\nwas asked to see a girl with a ruptured ectopic pregnancy by Dr.\\nħallwright, a general practitioner. ħallwright suggested that Tait should\\nremove the ruptured tube. Tait recorded the following:\\n\\n The suggestion staggered me and I am afraid I did not receive it favourably. I declined to act\\n and a further haemorrhage killed the patient. A post-mortem examination revealed the perfect\\n accuracy of the diagnosis. I carefully inspected the specimen that was removed and found that\\n if I had tied the broad ligament and removed the tube I should have completely arrested the\\n haemorrhage, and I now believe that had I done this the patient’s life would have been saved.\\n\\n Eighteen months later, Tait operated on a clearly dying patient, the first\\noccasion in which such an operation was performed. The patient, in\\nthose pre-transfusion days, died of exsanguination. Finally, in March',\n", " 'md': '```markdown\\n## Historical Surgical Cases\\n\\n### Repaired Perforated Gastric Ulcer\\nA perforated gastric ulcer was repaired in a 41-year-old businessman who had a 16-hour history of the condition. The operation was performed in the middle of the night by candlelight. The convalescence was complicated by a left-sided empyema, which required drainage. Two years later, Thomas Morse, in Norwich, published the successful repair of a perforation near the cardia in a 20-year-old girl. With these two successes, the operation for this condition became routine. Interestingly, gastric ulcer at the turn of the 20th century was far more common than duodenal ulcer and was especially found in young women.\\n\\n### Ruptured Ectopic Pregnancy\\nUntil 1883, a ruptured ectopic pregnancy was considered a death sentence. This is surprising because the early pioneers of abdominal surgery, dating back to the pre-anesthetic era, were primarily concerned with the removal of ovarian masses. The first elective abdominal operation for a known pathology was the removal of a massive ovarian cyst by Ephraim McDowell in Danville, Kentucky, in 1809. Yet, for some inexplicable reason, surgeons would stand helplessly by the bedside and watch a young woman, in the most useful time of her existence, exsanguinate from her ruptured tube.\\n\\nThe first surgeon to perform successful surgery for this condition was Robert Lawson Tait of Birmingham, who had previously performed a successful appendicectomy in 1880. Tait was asked to see a girl with a ruptured ectopic pregnancy by Dr. Hallwright, a general practitioner. Hallwright suggested that Tait should remove the ruptured tube. Tait recorded the following:\\n\\n> \"The suggestion staggered me and I am afraid I did not receive it favourably. I declined to act and a further haemorrhage killed the patient. A post-mortem examination revealed the perfect accuracy of the diagnosis. I carefully inspected the specimen that was removed and found that if I had tied the broad ligament and removed the tube I should have completely arrested the haemorrhage, and I now believe that had I done this the patient’s life would have been saved.\"\\n\\nEighteen months later, Tait operated on a clearly dying patient, marking the first occasion in which such an operation was performed. The patient, in those pre-transfusion days, died of exsanguination.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Historical Surgical Cases',\n", " 'md': '## Historical Surgical Cases',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Repaired Perforated Gastric Ulcer',\n", " 'md': '### Repaired Perforated Gastric Ulcer',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A perforated gastric ulcer was repaired in a 41-year-old businessman who had a 16-hour history of the condition. The operation was performed in the middle of the night by candlelight. The convalescence was complicated by a left-sided empyema, which required drainage. Two years later, Thomas Morse, in Norwich, published the successful repair of a perforation near the cardia in a 20-year-old girl. With these two successes, the operation for this condition became routine. Interestingly, gastric ulcer at the turn of the 20th century was far more common than duodenal ulcer and was especially found in young women.',\n", " 'md': 'A perforated gastric ulcer was repaired in a 41-year-old businessman who had a 16-hour history of the condition. The operation was performed in the middle of the night by candlelight. The convalescence was complicated by a left-sided empyema, which required drainage. Two years later, Thomas Morse, in Norwich, published the successful repair of a perforation near the cardia in a 20-year-old girl. With these two successes, the operation for this condition became routine. Interestingly, gastric ulcer at the turn of the 20th century was far more common than duodenal ulcer and was especially found in young women.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Ruptured Ectopic Pregnancy',\n", " 'md': '### Ruptured Ectopic Pregnancy',\n", " 'bBox': {'x': 86, 'y': 261, 'w': 224.39, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Until 1883, a ruptured ectopic pregnancy was considered a death sentence. This is surprising because the early pioneers of abdominal surgery, dating back to the pre-anesthetic era, were primarily concerned with the removal of ovarian masses. The first elective abdominal operation for a known pathology was the removal of a massive ovarian cyst by Ephraim McDowell in Danville, Kentucky, in 1809. Yet, for some inexplicable reason, surgeons would stand helplessly by the bedside and watch a young woman, in the most useful time of her existence, exsanguinate from her ruptured tube.\\n\\nThe first surgeon to perform successful surgery for this condition was Robert Lawson Tait of Birmingham, who had previously performed a successful appendicectomy in 1880. Tait was asked to see a girl with a ruptured ectopic pregnancy by Dr. Hallwright, a general practitioner. Hallwright suggested that Tait should remove the ruptured tube. Tait recorded the following:\\n\\n> \"The suggestion staggered me and I am afraid I did not receive it favourably. I declined to act and a further haemorrhage killed the patient. A post-mortem examination revealed the perfect accuracy of the diagnosis. I carefully inspected the specimen that was removed and found that if I had tied the broad ligament and removed the tube I should have completely arrested the haemorrhage, and I now believe that had I done this the patient’s life would have been saved.\"\\n\\nEighteen months later, Tait operated on a clearly dying patient, marking the first occasion in which such an operation was performed. The patient, in those pre-transfusion days, died of exsanguination.\\n```',\n", " 'md': 'Until 1883, a ruptured ectopic pregnancy was considered a death sentence. This is surprising because the early pioneers of abdominal surgery, dating back to the pre-anesthetic era, were primarily concerned with the removal of ovarian masses. The first elective abdominal operation for a known pathology was the removal of a massive ovarian cyst by Ephraim McDowell in Danville, Kentucky, in 1809. Yet, for some inexplicable reason, surgeons would stand helplessly by the bedside and watch a young woman, in the most useful time of her existence, exsanguinate from her ruptured tube.\\n\\nThe first surgeon to perform successful surgery for this condition was Robert Lawson Tait of Birmingham, who had previously performed a successful appendicectomy in 1880. Tait was asked to see a girl with a ruptured ectopic pregnancy by Dr. Hallwright, a general practitioner. Hallwright suggested that Tait should remove the ruptured tube. Tait recorded the following:\\n\\n> \"The suggestion staggered me and I am afraid I did not receive it favourably. I declined to act and a further haemorrhage killed the patient. A post-mortem examination revealed the perfect accuracy of the diagnosis. I carefully inspected the specimen that was removed and found that if I had tied the broad ligament and removed the tube I should have completely arrested the haemorrhage, and I now believe that had I done this the patient’s life would have been saved.\"\\n\\nEighteen months later, Tait operated on a clearly dying patient, marking the first occasion in which such an operation was performed. The patient, in those pre-transfusion days, died of exsanguination.\\n```',\n", " 'bBox': {'x': 72, 'y': 261, 'w': 467.63, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 44,\n", " 'text': '1888, Tait performed a successful salpingectomy on such a case, who\\nsurvived even though, at operation, the abdomen was full of clot. Years\\nlater, he was able to report 39 cases, with but two deaths, including the\\nfirst.\\n\\n Envoi\\n\\n Even today, the acute abdomen presents a diagnostic and therapeutic\\nchallenge to the surgeon. This is in spite of the fact that we have the\\nancillary aids of radiology and other imaging, biochemical and\\nhaematological studies to help the diagnosis and blood transfusion, fluid\\nreplacement, nasogastric suction, antibiotics and skilled anesthetists to\\nassist with therapy.\\n\\n The study of surgical history shows that, occasionally, like the frog —\\nwe go one step forward, two steps back… ( Figure 2.1).\\n (00',\n", " 'md': '```markdown\\n### Text\\nIn 1888, Tait performed a successful salpingectomy on such a case, who survived even though, at operation, the abdomen was full of clot. Years later, he was able to report 39 cases, with but two deaths, including the first.\\n\\n#### Envoi\\nEven today, the acute abdomen presents a diagnostic and therapeutic challenge to the surgeon. This is in spite of the fact that we have the ancillary aids of radiology and other imaging, biochemical and haematological studies to help the diagnosis and blood transfusion, fluid replacement, nasogastric suction, antibiotics and skilled anesthetists to assist with therapy.\\n\\nThe study of surgical history shows that, occasionally, like the frog — we go one step forward, two steps back… (Figure 2.1).\\n\\n### Images\\n**Figure 2.1**: This figure likely illustrates a concept related to the challenges faced in diagnosing and treating acute abdomen cases, possibly depicting a historical perspective or a metaphorical representation (e.g., the frog analogy). The specific content of the image is not provided in the text, and thus cannot be described in detail.\\n\\n### Summary\\nThe text discusses the historical context of surgical procedures related to acute abdomen cases, highlighting the advancements and ongoing challenges in the field. It references a specific case from 1888 and emphasizes the importance of various medical aids in modern surgical practice.\\n```',\n", " 'images': [{'name': 'img_p43_1.png',\n", " 'height': 380,\n", " 'width': 574,\n", " 'x': 164.15999999999985,\n", " 'y': 362.88,\n", " 'original_width': 986,\n", " 'original_height': 652}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In 1888, Tait performed a successful salpingectomy on such a case, who survived even though, at operation, the abdomen was full of clot. Years later, he was able to report 39 cases, with but two deaths, including the first.',\n", " 'md': 'In 1888, Tait performed a successful salpingectomy on such a case, who survived even though, at operation, the abdomen was full of clot. Years later, he was able to report 39 cases, with but two deaths, including the first.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.5, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Envoi',\n", " 'md': '#### Envoi',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 45.07, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Even today, the acute abdomen presents a diagnostic and therapeutic challenge to the surgeon. This is in spite of the fact that we have the ancillary aids of radiology and other imaging, biochemical and haematological studies to help the diagnosis and blood transfusion, fluid replacement, nasogastric suction, antibiotics and skilled anesthetists to assist with therapy.\\n\\nThe study of surgical history shows that, occasionally, like the frog — we go one step forward, two steps back… (Figure 2.1).',\n", " 'md': 'Even today, the acute abdomen presents a diagnostic and therapeutic challenge to the surgeon. This is in spite of the fact that we have the ancillary aids of radiology and other imaging, biochemical and haematological studies to help the diagnosis and blood transfusion, fluid replacement, nasogastric suction, antibiotics and skilled anesthetists to assist with therapy.\\n\\nThe study of surgical history shows that, occasionally, like the frog — we go one step forward, two steps back… (Figure 2.1).',\n", " 'bBox': {'x': 72, 'y': 214, 'w': 467.55, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Images',\n", " 'md': '### Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 2.1**: This figure likely illustrates a concept related to the challenges faced in diagnosing and treating acute abdomen cases, possibly depicting a historical perspective or a metaphorical representation (e.g., the frog analogy). The specific content of the image is not provided in the text, and thus cannot be described in detail.',\n", " 'md': '**Figure 2.1**: This figure likely illustrates a concept related to the challenges faced in diagnosing and treating acute abdomen cases, possibly depicting a historical perspective or a metaphorical representation (e.g., the frog analogy). The specific content of the image is not provided in the text, and thus cannot be described in detail.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the historical context of surgical procedures related to acute abdomen cases, highlighting the advancements and ongoing challenges in the field. It references a specific case from 1888 and emphasizes the importance of various medical aids in modern surgical practice.\\n```',\n", " 'md': 'The text discusses the historical context of surgical procedures related to acute abdomen cases, highlighting the advancements and ongoing challenges in the field. It references a specific case from 1888 and emphasizes the importance of various medical aids in modern surgical practice.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 45,\n", " 'text': ' 0o0\\n (KakmeNiK\\n Oo\\nFigure 2.1. Great advance in surgery!\\n\\n“Let us therefore look back with a mélange of\\namazement, pride, and humility at the efforts of our\\nsurgical forefathers as they paved the way for us in the\\nmanagement of this fascinating group of diseases!”\\n Harold Ellis',\n", " 'md': '```markdown\\n# Page Content\\n\\n“Let us therefore look back with a mélange of amazement, pride, and humility at the efforts of our surgical forefathers as they paved the way for us in the management of this fascinating group of diseases!”\\n— Harold Ellis\\n\\n## Figure 2.1\\n**Title:** Great advance in surgery!\\n**Description:** This figure likely illustrates significant advancements in surgical techniques or technologies over time. The visual representation may include historical surgical instruments, notable figures in surgery, or a timeline of surgical milestones.\\n\\n**Summary:** The figure emphasizes the evolution of surgery and acknowledges the contributions of past surgeons, reflecting on the progress made in the field.\\n```',\n", " 'images': [{'name': 'img_p44_1.png',\n", " 'height': 419,\n", " 'width': 574,\n", " 'x': 164.15999999999985,\n", " 'y': 72.00000000000003,\n", " 'original_width': 986,\n", " 'original_height': 721}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 407, 'y': 358, 'w': 9.21, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 407, 'y': 358, 'w': 9.21, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '“Let us therefore look back with a mélange of amazement, pride, and humility at the efforts of our surgical forefathers as they paved the way for us in the management of this fascinating group of diseases!”\\n— Harold Ellis',\n", " 'md': '“Let us therefore look back with a mélange of amazement, pride, and humility at the efforts of our surgical forefathers as they paved the way for us in the management of this fascinating group of diseases!”\\n— Harold Ellis',\n", " 'bBox': {'x': 79, 'y': 273.42, 'w': 453.23, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 2.1',\n", " 'md': '## Figure 2.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Title:** Great advance in surgery!\\n**Description:** This figure likely illustrates significant advancements in surgical techniques or technologies over time. The visual representation may include historical surgical instruments, notable figures in surgery, or a timeline of surgical milestones.\\n\\n**Summary:** The figure emphasizes the evolution of surgery and acknowledges the contributions of past surgeons, reflecting on the progress made in the field.\\n```',\n", " 'md': '**Title:** Great advance in surgery!\\n**Description:** This figure likely illustrates significant advancements in surgical techniques or technologies over time. The visual representation may include historical surgical instruments, notable figures in surgery, or a timeline of surgical milestones.\\n\\n**Summary:** The figure emphasizes the evolution of surgery and acknowledges the contributions of past surgeons, reflecting on the progress made in the field.\\n```',\n", " 'bBox': {'x': 128, 'y': 358, 'w': 19.32, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 46,\n", " 'text': ' PART II\\n\\nBefore the operation',\n", " 'md': '# Part II\\n\\n## Before the Operation\\n\\n*No additional text or images were identified on this page.*',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Part II',\n", " 'md': '# Part II',\n", " 'bBox': {'x': 257, 'y': 172, 'w': 97.61, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Before the Operation',\n", " 'md': '## Before the Operation',\n", " 'bBox': {'x': 165, 'y': 235, 'w': 281.51, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '*No additional text or images were identified on this page.*',\n", " 'md': '*No additional text or images were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 47,\n", " 'text': 'Chapter 3\\nThe acute abdomen\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and\\nJonathan E. Efron 1\\n\\n For the abdominal surgeon it is a familiar experience to sit,\\n ready scrubbed, and gowned, in a corner of the quiet\\n theatre, with the clock pointing midnight. …In a few minutes\\n the patient will be wheeled in and another emergency\\n laparotomy will commence. This is the culmination of a\\n process which began a few hours previously with the\\n surgeon meeting with and examining the patient, reaching a\\n diagnosis, and making a plan of action.\\n Peter F. Jones\\n The general rule can be laid down that the majority of\\n severe abdominal pains which ensue in patients who have\\n been previously fairly well, and which last as long as six\\n hours, are caused by conditions of surgical import.\\n Zachary Cope\\n\\n Simply stated, the term ‘acute abdomen’ refers to abdominal pain\\nof short duration that requires a decision regarding whether an\\nurgent intervention is necessary. This clinical problem is the most\\ncommon cause for you to be called upon to provide a surgical\\nconsultation in the emergency room, and serves as a convenient\\ngateway for a discussion of the approach to abdominal surgical\\nemergencies.',\n", " 'md': '```markdown\\n# Chapter 3: The Acute Abdomen\\n\\n**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, Jonathan E. Efron\\n\\nFor the abdominal surgeon, it is a familiar experience to sit, ready scrubbed and gowned, in a corner of the quiet theatre, with the clock pointing midnight. In a few minutes, the patient will be wheeled in and another emergency laparotomy will commence. This is the culmination of a process which began a few hours previously with the surgeon meeting with and examining the patient, reaching a diagnosis, and making a plan of action.\\n— *Peter F. Jones*\\n\\nThe general rule can be laid down that the majority of severe abdominal pains which ensue in patients who have been previously fairly well, and which last as long as six hours, are caused by conditions of surgical import.\\n— *Zachary Cope*\\n\\nSimply stated, the term ‘acute abdomen’ refers to abdominal pain of short duration that requires a decision regarding whether an urgent intervention is necessary. This clinical problem is the most common cause for you to be called upon to provide a surgical consultation in the emergency room, and serves as a convenient gateway for a discussion of the approach to abdominal surgical emergencies.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 3: The Acute Abdomen',\n", " 'md': '# Chapter 3: The Acute Abdomen',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 179.21, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, Jonathan E. Efron\\n\\nFor the abdominal surgeon, it is a familiar experience to sit, ready scrubbed and gowned, in a corner of the quiet theatre, with the clock pointing midnight. In a few minutes, the patient will be wheeled in and another emergency laparotomy will commence. This is the culmination of a process which began a few hours previously with the surgeon meeting with and examining the patient, reaching a diagnosis, and making a plan of action.\\n— *Peter F. Jones*\\n\\nThe general rule can be laid down that the majority of severe abdominal pains which ensue in patients who have been previously fairly well, and which last as long as six hours, are caused by conditions of surgical import.\\n— *Zachary Cope*\\n\\nSimply stated, the term ‘acute abdomen’ refers to abdominal pain of short duration that requires a decision regarding whether an urgent intervention is necessary. This clinical problem is the most common cause for you to be called upon to provide a surgical consultation in the emergency room, and serves as a convenient gateway for a discussion of the approach to abdominal surgical emergencies.\\n```',\n", " 'md': '**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, Jonathan E. Efron\\n\\nFor the abdominal surgeon, it is a familiar experience to sit, ready scrubbed and gowned, in a corner of the quiet theatre, with the clock pointing midnight. In a few minutes, the patient will be wheeled in and another emergency laparotomy will commence. This is the culmination of a process which began a few hours previously with the surgeon meeting with and examining the patient, reaching a diagnosis, and making a plan of action.\\n— *Peter F. Jones*\\n\\nThe general rule can be laid down that the majority of severe abdominal pains which ensue in patients who have been previously fairly well, and which last as long as six hours, are caused by conditions of surgical import.\\n— *Zachary Cope*\\n\\nSimply stated, the term ‘acute abdomen’ refers to abdominal pain of short duration that requires a decision regarding whether an urgent intervention is necessary. This clinical problem is the most common cause for you to be called upon to provide a surgical consultation in the emergency room, and serves as a convenient gateway for a discussion of the approach to abdominal surgical emergencies.\\n```',\n", " 'bBox': {'x': 72, 'y': 430, 'w': 467.24, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Jonathan E. Efron 1'}]},\n", " {'page': 48,\n", " 'text': ' It is as much an intellectual exercise to tackle the problems\\n of belly ache as to work on the human genome.\\n Hugh Dudley\\n\\n The problem\\n\\n Most major textbooks contain a long list of possible causes of acute\\nabdominal pain. These ‘big lists’ usually go from perforated peptic ulcer\\ndown to such esoteric causes as porphyria and black widow spider bites.\\nThe lists are popular with medical students and residents in internal\\nmedicine, but are useless for practical guys like you.\\n\\n The experienced surgeon called upon to consult a patient with acute\\nabdominal pain in the emergency room (ER) in the middle of the night\\nsimply doesn’t work this way. ħe or she doesn’t consider the 50 or so\\n‘most likely’ causes of acute abdominal pain from the list, attempting to\\nrule them out one by one. Instead, the intelligent surgeon tries to\\nidentify a clinical pattern, and to decide upon a course of action\\nfrom a limited menu of management options. Below we will\\ndemonstrate how the multiple etiologies for acute abdominal pain actually\\nconverge into a small number of easily recognizable clinical patterns.\\nOnce recognized, each of these patterns dictates a specific course of\\naction.\\n\\n The acute abdomen: management menus and clinical\\n patterns\\n\\n The management options\\n\\n Seeing a patient with an acute abdomen in the ER ( Figure 3.1), you\\nhave only a few management options to choose from the following\\nmenu.\\n\\n Immediate operation (“surgery now… now… by now I mean now!”).',\n", " 'md': '```markdown\\n## The Problem\\n\\nMost major textbooks contain a long list of possible causes of acute abdominal pain. These ‘big lists’ usually go from perforated peptic ulcer down to such esoteric causes as porphyria and black widow spider bites. The lists are popular with medical students and residents in internal medicine, but are useless for practical guys like you.\\n\\nThe experienced surgeon called upon to consult a patient with acute abdominal pain in the emergency room (ER) in the middle of the night simply doesn’t work this way. He or she doesn’t consider the 50 or so ‘most likely’ causes of acute abdominal pain from the list, attempting to rule them out one by one. Instead, the intelligent surgeon tries to identify a clinical pattern, and to decide upon a course of action from a limited menu of management options. Below we will demonstrate how the multiple etiologies for acute abdominal pain actually converge into a small number of easily recognizable clinical patterns. Once recognized, each of these patterns dictates a specific course of action.\\n\\n## The Acute Abdomen: Management Menus and Clinical Patterns\\n\\n### The Management Options\\n\\nSeeing a patient with an acute abdomen in the ER (Figure 3.1), you have only a few management options to choose from the following menu.\\n\\n- Immediate operation (“surgery now… now… by now I mean now!”).\\n```\\n\\n### Image Identification and Description\\n- **Figure 3.1**: This figure likely depicts a scenario in the emergency room involving a patient with acute abdominal pain. The specific content of the image is not provided, but it is referenced in the context of management options for acute abdomen cases. The description of the image is .',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Problem',\n", " 'md': '## The Problem',\n", " 'bBox': {'x': 86, 'y': 169, 'w': 99.31, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Most major textbooks contain a long list of possible causes of acute abdominal pain. These ‘big lists’ usually go from perforated peptic ulcer down to such esoteric causes as porphyria and black widow spider bites. The lists are popular with medical students and residents in internal medicine, but are useless for practical guys like you.\\n\\nThe experienced surgeon called upon to consult a patient with acute abdominal pain in the emergency room (ER) in the middle of the night simply doesn’t work this way. He or she doesn’t consider the 50 or so ‘most likely’ causes of acute abdominal pain from the list, attempting to rule them out one by one. Instead, the intelligent surgeon tries to identify a clinical pattern, and to decide upon a course of action from a limited menu of management options. Below we will demonstrate how the multiple etiologies for acute abdominal pain actually converge into a small number of easily recognizable clinical patterns. Once recognized, each of these patterns dictates a specific course of action.',\n", " 'md': 'Most major textbooks contain a long list of possible causes of acute abdominal pain. These ‘big lists’ usually go from perforated peptic ulcer down to such esoteric causes as porphyria and black widow spider bites. The lists are popular with medical students and residents in internal medicine, but are useless for practical guys like you.\\n\\nThe experienced surgeon called upon to consult a patient with acute abdominal pain in the emergency room (ER) in the middle of the night simply doesn’t work this way. He or she doesn’t consider the 50 or so ‘most likely’ causes of acute abdominal pain from the list, attempting to rule them out one by one. Instead, the intelligent surgeon tries to identify a clinical pattern, and to decide upon a course of action from a limited menu of management options. Below we will demonstrate how the multiple etiologies for acute abdominal pain actually converge into a small number of easily recognizable clinical patterns. Once recognized, each of these patterns dictates a specific course of action.',\n", " 'bBox': {'x': 72, 'y': 238, 'w': 467.67, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Acute Abdomen: Management Menus and Clinical Patterns',\n", " 'md': '## The Acute Abdomen: Management Menus and Clinical Patterns',\n", " 'bBox': {'x': 86, 'y': 515, 'w': 452.09, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Management Options',\n", " 'md': '### The Management Options',\n", " 'bBox': {'x': 86, 'y': 578, 'w': 200.47, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Seeing a patient with an acute abdomen in the ER (Figure 3.1), you have only a few management options to choose from the following menu.\\n\\n- Immediate operation (“surgery now… now… by now I mean now!”).\\n```',\n", " 'md': 'Seeing a patient with an acute abdomen in the ER (Figure 3.1), you have only a few management options to choose from the following menu.\\n\\n- Immediate operation (“surgery now… now… by now I mean now!”).\\n```',\n", " 'bBox': {'x': 72, 'y': 647, 'w': 362.38, 'h': 15.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 3.1**: This figure likely depicts a scenario in the emergency room involving a patient with acute abdominal pain. The specific content of the image is not provided, but it is referenced in the context of management options for acute abdomen cases. The description of the image is .',\n", " 'md': '- **Figure 3.1**: This figure likely depicts a scenario in the emergency room involving a patient with acute abdominal pain. The specific content of the image is not provided, but it is referenced in the context of management options for acute abdomen cases. The description of the image is .',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ' to choose from the following'}]},\n", " {'page': 49,\n", " 'text': ' Emergency operation (“surgery within 2-3 hours… no need to run!”).\\n Urgent operation (“Let us take some time and optimize the patient and\\n operate tomorrow morning”).\\n Invasive non-surgical treatments (“Let’s embolize the bleeder”).\\n Conservative treatment — in the ICU if necessary (“I plan to\\n admit and treat with intravenous fluids, antibiotics, possibly image again. I may still\\n decide to operate later… The ICU is the best place for a sick patient who does not\\n need surgery now but has organ dysfunction”).\\n Discharge home.\\n PER1oz_ 14\\n Figure 3.1. “Which of them has an ‘acute abdomen’?”\\n\\n The clinical patterns\\n\\n The acute abdomen usually presents as one of the well-defined clinical\\npatterns listed below.\\n\\n Abdominal pain and shock.\\n Generalized peritonitis.\\n Localized peritonitis (confined to one quadrant of the abdomen).\\n Intestinal obstruction.',\n", " 'md': '```markdown\\n## Emergency Operations and Clinical Patterns\\n\\n### Text\\n- Emergency operation (“surgery within 2-3 hours… no need to run!”).\\n- Urgent operation (“Let us take some time and optimize the patient and operate tomorrow morning”).\\n- Invasive non-surgical treatments (“Let’s embolize the bleeder”).\\n- Conservative treatment — in the ICU if necessary (“I plan to admit and treat with intravenous fluids, antibiotics, possibly image again. I may still decide to operate later… The ICU is the best place for a sick patient who does not need surgery now but has organ dysfunction”).\\n- Discharge home.\\n\\n### Figure 3.1\\n**Caption:** “Which of them has an ‘acute abdomen’?”\\n\\n### The Clinical Patterns\\nThe acute abdomen usually presents as one of the well-defined clinical patterns listed below:\\n- Abdominal pain and shock.\\n- Generalized peritonitis.\\n- Localized peritonitis (confined to one quadrant of the abdomen).\\n- Intestinal obstruction.\\n```',\n", " 'images': [{'name': 'img_p48_1.png',\n", " 'height': 367,\n", " 'width': 511,\n", " 'x': 180,\n", " 'y': 286.56,\n", " 'original_width': 1404,\n", " 'original_height': 1008}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Emergency Operations and Clinical Patterns',\n", " 'md': '## Emergency Operations and Clinical Patterns',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Emergency operation (“surgery within 2-3 hours… no need to run!”).\\n- Urgent operation (“Let us take some time and optimize the patient and operate tomorrow morning”).\\n- Invasive non-surgical treatments (“Let’s embolize the bleeder”).\\n- Conservative treatment — in the ICU if necessary (“I plan to admit and treat with intravenous fluids, antibiotics, possibly image again. I may still decide to operate later… The ICU is the best place for a sick patient who does not need surgery now but has organ dysfunction”).\\n- Discharge home.',\n", " 'md': '- Emergency operation (“surgery within 2-3 hours… no need to run!”).\\n- Urgent operation (“Let us take some time and optimize the patient and operate tomorrow morning”).\\n- Invasive non-surgical treatments (“Let’s embolize the bleeder”).\\n- Conservative treatment — in the ICU if necessary (“I plan to admit and treat with intravenous fluids, antibiotics, possibly image again. I may still decide to operate later… The ICU is the best place for a sick patient who does not need surgery now but has organ dysfunction”).\\n- Discharge home.',\n", " 'bBox': {'x': 133, 'y': 85, 'w': 397.29, 'h': 16.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 3.1',\n", " 'md': '### Figure 3.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** “Which of them has an ‘acute abdomen’?”',\n", " 'md': '**Caption:** “Which of them has an ‘acute abdomen’?”',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Clinical Patterns',\n", " 'md': '### The Clinical Patterns',\n", " 'bBox': {'x': 86, 'y': 543, 'w': 159.99, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The acute abdomen usually presents as one of the well-defined clinical patterns listed below:\\n- Abdominal pain and shock.\\n- Generalized peritonitis.\\n- Localized peritonitis (confined to one quadrant of the abdomen).\\n- Intestinal obstruction.\\n```',\n", " 'md': 'The acute abdomen usually presents as one of the well-defined clinical patterns listed below:\\n- Abdominal pain and shock.\\n- Generalized peritonitis.\\n- Localized peritonitis (confined to one quadrant of the abdomen).\\n- Intestinal obstruction.\\n```',\n", " 'bBox': {'x': 86, 'y': 579, 'w': 453.13, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 50,\n", " 'text': ' Waste basket (‘non-specific’ abdominal pain or due to ‘medical causes’).\\n Gynecological.\\n Trauma.\\n\\n The last two patterns (gynecological and trauma) are addresed\\nelsewhere in this book. Occasionally a mixed picture of\\nobstruction/peritonitis may present. For each of these clinical patterns\\nyou have to choose a management option from the aforementioned\\nmenu — but your first task is to identify the specific pattern in order\\nto know how to proceed.\\n\\n Abdominal pain and shock\\n\\n This is the most dramatic and least common clinical pattern of the\\nacute abdomen. The patient typically presents pale and diaphoretic, in\\nsevere abdominal pain and with hypotension, the so-called abdominal\\napoplexy. The two most common etiologies of this clinical pattern are a\\nruptured abdominal aortic aneurysm and a ruptured ectopic\\npregnancy ( Chapters 34 and 35). ħere the only management option\\nis immediate surgery NOW! No time should be wasted on ‘preparation’\\nand on ancillary investigations. Losing a patient with abdominal apoplexy\\nin the CT scanner is a cardinal, and unfortunately not too rare, sin.\\n\\n Note however that other abdominal emergencies may also present with\\nabdominal pain and shock due to fluid loss into the ‘third space’. This\\nmay occur for example in patients with intestinal obstruction (\\nChapter 21), or severe acute pancreatitis ( Chapter 19) — particularly\\nif neglected or superimposed on a deficient cardiovascular system. In\\nmany of these situations an emergency operation is not necessary; and\\n— as we will be nagging you over and over again — operating on a\\npoorly resuscitated patient is like skating on thin ice.\\n\\n Generalized peritonitis\\n\\n The clinical picture of generalized peritonitis consists of diffuse, severe\\nabdominal pain in a patient who looks sick and toxic. The patient typically',\n", " 'md': '```markdown\\n## Abdominal Pain Management\\n\\n### Waste Basket of Abdominal Pain\\n- **Non-specific abdominal pain** or pain due to **medical causes**.\\n- **Gynecological** causes.\\n- **Trauma** related causes.\\n\\nThe last two patterns (gynecological and trauma) are addressed elsewhere in this book. Occasionally, a mixed picture of obstruction/peritonitis may present. For each of these clinical patterns, you have to choose a management option from the aforementioned menu — but your first task is to identify the specific pattern in order to know how to proceed.\\n\\n### Abdominal Pain and Shock\\nThis is the most dramatic and least common clinical pattern of the acute abdomen. The patient typically presents pale and diaphoretic, in severe abdominal pain and with hypotension, the so-called **abdominal apoplexy**. The two most common etiologies of this clinical pattern are a ruptured abdominal aortic aneurysm and a ruptured ectopic pregnancy (Chapters 34 and 35). Here, the only management option is immediate surgery **NOW!** No time should be wasted on ‘preparation’ and on ancillary investigations. Losing a patient with abdominal apoplexy in the CT scanner is a cardinal, and unfortunately not too rare, sin.\\n\\nNote, however, that other abdominal emergencies may also present with abdominal pain and shock due to fluid loss into the ‘third space’. This may occur, for example, in patients with intestinal obstruction (Chapter 21), or severe acute pancreatitis (Chapter 19) — particularly if neglected or superimposed on a deficient cardiovascular system. In many of these situations, an emergency operation is not necessary; and — as we will be nagging you over and over again — operating on a poorly resuscitated patient is like skating on thin ice.\\n\\n### Generalized Peritonitis\\nThe clinical picture of generalized peritonitis consists of diffuse, severe abdominal pain in a patient who looks sick and toxic. The patient typically...\\n```\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the provided content.*',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Pain Management',\n", " 'md': '## Abdominal Pain Management',\n", " 'bBox': {'x': 155, 'y': 192, 'w': 15.2, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Waste Basket of Abdominal Pain',\n", " 'md': '### Waste Basket of Abdominal Pain',\n", " 'bBox': {'x': 526, 'y': 192, 'w': 13.58, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Non-specific abdominal pain** or pain due to **medical causes**.\\n- **Gynecological** causes.\\n- **Trauma** related causes.\\n\\nThe last two patterns (gynecological and trauma) are addressed elsewhere in this book. Occasionally, a mixed picture of obstruction/peritonitis may present. For each of these clinical patterns, you have to choose a management option from the aforementioned menu — but your first task is to identify the specific pattern in order to know how to proceed.',\n", " 'md': '- **Non-specific abdominal pain** or pain due to **medical causes**.\\n- **Gynecological** causes.\\n- **Trauma** related causes.\\n\\nThe last two patterns (gynecological and trauma) are addressed elsewhere in this book. Occasionally, a mixed picture of obstruction/peritonitis may present. For each of these clinical patterns, you have to choose a management option from the aforementioned menu — but your first task is to identify the specific pattern in order to know how to proceed.',\n", " 'bBox': {'x': 72, 'y': 192, 'w': 467.63, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Abdominal Pain and Shock',\n", " 'md': '### Abdominal Pain and Shock',\n", " 'bBox': {'x': 86, 'y': 192, 'w': 210.57, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is the most dramatic and least common clinical pattern of the acute abdomen. The patient typically presents pale and diaphoretic, in severe abdominal pain and with hypotension, the so-called **abdominal apoplexy**. The two most common etiologies of this clinical pattern are a ruptured abdominal aortic aneurysm and a ruptured ectopic pregnancy (Chapters 34 and 35). Here, the only management option is immediate surgery **NOW!** No time should be wasted on ‘preparation’ and on ancillary investigations. Losing a patient with abdominal apoplexy in the CT scanner is a cardinal, and unfortunately not too rare, sin.\\n\\nNote, however, that other abdominal emergencies may also present with abdominal pain and shock due to fluid loss into the ‘third space’. This may occur, for example, in patients with intestinal obstruction (Chapter 21), or severe acute pancreatitis (Chapter 19) — particularly if neglected or superimposed on a deficient cardiovascular system. In many of these situations, an emergency operation is not necessary; and — as we will be nagging you over and over again — operating on a poorly resuscitated patient is like skating on thin ice.',\n", " 'md': 'This is the most dramatic and least common clinical pattern of the acute abdomen. The patient typically presents pale and diaphoretic, in severe abdominal pain and with hypotension, the so-called **abdominal apoplexy**. The two most common etiologies of this clinical pattern are a ruptured abdominal aortic aneurysm and a ruptured ectopic pregnancy (Chapters 34 and 35). Here, the only management option is immediate surgery **NOW!** No time should be wasted on ‘preparation’ and on ancillary investigations. Losing a patient with abdominal apoplexy in the CT scanner is a cardinal, and unfortunately not too rare, sin.\\n\\nNote, however, that other abdominal emergencies may also present with abdominal pain and shock due to fluid loss into the ‘third space’. This may occur, for example, in patients with intestinal obstruction (Chapter 21), or severe acute pancreatitis (Chapter 19) — particularly if neglected or superimposed on a deficient cardiovascular system. In many of these situations, an emergency operation is not necessary; and — as we will be nagging you over and over again — operating on a poorly resuscitated patient is like skating on thin ice.',\n", " 'bBox': {'x': 72, 'y': 192, 'w': 467.29, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Generalized Peritonitis',\n", " 'md': '### Generalized Peritonitis',\n", " 'bBox': {'x': 86, 'y': 664, 'w': 178.37, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The clinical picture of generalized peritonitis consists of diffuse, severe abdominal pain in a patient who looks sick and toxic. The patient typically...\\n```\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the provided content.*',\n", " 'md': 'The clinical picture of generalized peritonitis consists of diffuse, severe abdominal pain in a patient who looks sick and toxic. The patient typically...\\n```\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the provided content.*',\n", " 'bBox': {'x': 72, 'y': 192, 'w': 467.52, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'is immediate surgery NOW! No time should be wasted on ‘preparation’'},\n", " {'text': 'is immediate surgery NOW! No time should be wasted on ‘preparation’'},\n", " {'text': 'Chapter 21), or if neglected or superimposed on a deficient cardiovascular system. In'},\n", " {'text': 'if neglected or superimposed on a deficient cardiovascular system. In'}]},\n", " {'page': 51,\n", " 'text': 'lies motionless, and has an extremely tender abdomen with ‘peritoneal\\nsigns’ consisting of board-like rigidity, rebound-tenderness, and\\ninvoluntary defense-guarding. Surprisingly enough, less experienced\\nclinicians occasionally miss the diagnosis entirely. This is especially\\ncommon in the geriatric patient who may have weak abdominal\\nmusculature or may not exhibit the classical peritoneal signs. The most\\ncommon error in the physical examination of a patient with acute\\nabdominal pain is rough and ‘deep’ palpation of the abdomen, which may\\nelicit severe tenderness even in a patient without any abdominal\\npathology. Palpation of the abdomen should be very gentle, and should\\nnot hurt the patient. We appreciate that at this stage of your surgical\\ncareer you do not need a detailed lecture on the examination of the acute\\nabdomen. Forgive us, however, for emphasizing that the absence of\\nrebound tenderness means nothing and that a good way to elicit\\nperitoneal irritation is by asking the patient to cough, shaking (gently) his\\nbed, or by very gentle percussion of the abdomen — starting away from\\nthe painful area and slowly moving towards it. The deliberate\\ndemonstration of the clinical sign of rebound tenderness is cruel,\\nunnecessary and to be deplored.\\n\\n The three most common causes of generalized peritonitis in\\nadults are a perforated ulcer ( Chapter 18), colonic perforation (\\nChapter 28), and perforated appendicitis ( Chapter 23). Classically,\\nwith exceptions listed below and in the individual chapters, the\\nmanagement of a patient with diffuse peritonitis is an emergency\\noperation within a few hours (surgery tonight), after a brief period of pre-\\noperative optimization as outlined in Chapter 6.\\n\\n An important exception to this management option is the patient\\nwith acute pancreatitis. While most patients with acute pancreatitis\\npresent with mild epigastric tenderness, the occasional patient may\\npresent with a clinical picture mimicking diffuse peritonitis ( Chapter\\n19). As a precaution against misdiagnosing these patients, it is\\nessential practice always to measure the serum amylase (or lipase)\\nin any patient presenting with significant abdominal symptoms (\\nChapter 4). Note, however, that amylase/lipase levels are not completely\\nreliable but abdominal CT would establish the diagnosis in doubtful\\ncases. An exploratory laparotomy in a patient suffering from acute',\n", " 'md': '```markdown\\n## Page Content\\n\\nThe patient lies motionless and has an extremely tender abdomen with ‘peritoneal signs’ consisting of board-like rigidity, rebound tenderness, and involuntary defense-guarding. Surprisingly enough, less experienced clinicians occasionally miss the diagnosis entirely. This is especially common in the geriatric patient who may have weak abdominal musculature or may not exhibit the classical peritoneal signs.\\n\\nThe most common error in the physical examination of a patient with acute abdominal pain is rough and ‘deep’ palpation of the abdomen, which may elicit severe tenderness even in a patient without any abdominal pathology. Palpation of the abdomen should be very gentle and should not hurt the patient. We appreciate that at this stage of your surgical career you do not need a detailed lecture on the examination of the acute abdomen. Forgive us, however, for emphasizing that the absence of rebound tenderness means nothing and that a good way to elicit peritoneal irritation is by asking the patient to cough, shaking (gently) his bed, or by very gentle percussion of the abdomen — starting away from the painful area and slowly moving towards it. The deliberate demonstration of the clinical sign of rebound tenderness is cruel, unnecessary, and to be deplored.\\n\\nThe three most common causes of generalized peritonitis in adults are a perforated ulcer (Chapter 18), colonic perforation (Chapter 28), and perforated appendicitis (Chapter 23). Classically, with exceptions listed below and in the individual chapters, the management of a patient with diffuse peritonitis is an emergency operation within a few hours (surgery tonight), after a brief period of pre-operative optimization as outlined in Chapter 6.\\n\\nAn important exception to this management option is the patient with acute pancreatitis. While most patients with acute pancreatitis present with mild epigastric tenderness, the occasional patient may present with a clinical picture mimicking diffuse peritonitis (Chapter 19). As a precaution against misdiagnosing these patients, it is essential practice always to measure the serum amylase (or lipase) in any patient presenting with significant abdominal symptoms (Chapter 4). Note, however, that amylase/lipase levels are not completely reliable but abdominal CT would establish the diagnosis in doubtful cases. An exploratory laparotomy in a patient suffering from acute...\\n\\n## Figures and Images\\n\\n- **Figure 1**: \\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The patient lies motionless and has an extremely tender abdomen with ‘peritoneal signs’ consisting of board-like rigidity, rebound tenderness, and involuntary defense-guarding. Surprisingly enough, less experienced clinicians occasionally miss the diagnosis entirely. This is especially common in the geriatric patient who may have weak abdominal musculature or may not exhibit the classical peritoneal signs.\\n\\nThe most common error in the physical examination of a patient with acute abdominal pain is rough and ‘deep’ palpation of the abdomen, which may elicit severe tenderness even in a patient without any abdominal pathology. Palpation of the abdomen should be very gentle and should not hurt the patient. We appreciate that at this stage of your surgical career you do not need a detailed lecture on the examination of the acute abdomen. Forgive us, however, for emphasizing that the absence of rebound tenderness means nothing and that a good way to elicit peritoneal irritation is by asking the patient to cough, shaking (gently) his bed, or by very gentle percussion of the abdomen — starting away from the painful area and slowly moving towards it. The deliberate demonstration of the clinical sign of rebound tenderness is cruel, unnecessary, and to be deplored.\\n\\nThe three most common causes of generalized peritonitis in adults are a perforated ulcer (Chapter 18), colonic perforation (Chapter 28), and perforated appendicitis (Chapter 23). Classically, with exceptions listed below and in the individual chapters, the management of a patient with diffuse peritonitis is an emergency operation within a few hours (surgery tonight), after a brief period of pre-operative optimization as outlined in Chapter 6.\\n\\nAn important exception to this management option is the patient with acute pancreatitis. While most patients with acute pancreatitis present with mild epigastric tenderness, the occasional patient may present with a clinical picture mimicking diffuse peritonitis (Chapter 19). As a precaution against misdiagnosing these patients, it is essential practice always to measure the serum amylase (or lipase) in any patient presenting with significant abdominal symptoms (Chapter 4). Note, however, that amylase/lipase levels are not completely reliable but abdominal CT would establish the diagnosis in doubtful cases. An exploratory laparotomy in a patient suffering from acute...',\n", " 'md': 'The patient lies motionless and has an extremely tender abdomen with ‘peritoneal signs’ consisting of board-like rigidity, rebound tenderness, and involuntary defense-guarding. Surprisingly enough, less experienced clinicians occasionally miss the diagnosis entirely. This is especially common in the geriatric patient who may have weak abdominal musculature or may not exhibit the classical peritoneal signs.\\n\\nThe most common error in the physical examination of a patient with acute abdominal pain is rough and ‘deep’ palpation of the abdomen, which may elicit severe tenderness even in a patient without any abdominal pathology. Palpation of the abdomen should be very gentle and should not hurt the patient. We appreciate that at this stage of your surgical career you do not need a detailed lecture on the examination of the acute abdomen. Forgive us, however, for emphasizing that the absence of rebound tenderness means nothing and that a good way to elicit peritoneal irritation is by asking the patient to cough, shaking (gently) his bed, or by very gentle percussion of the abdomen — starting away from the painful area and slowly moving towards it. The deliberate demonstration of the clinical sign of rebound tenderness is cruel, unnecessary, and to be deplored.\\n\\nThe three most common causes of generalized peritonitis in adults are a perforated ulcer (Chapter 18), colonic perforation (Chapter 28), and perforated appendicitis (Chapter 23). Classically, with exceptions listed below and in the individual chapters, the management of a patient with diffuse peritonitis is an emergency operation within a few hours (surgery tonight), after a brief period of pre-operative optimization as outlined in Chapter 6.\\n\\nAn important exception to this management option is the patient with acute pancreatitis. While most patients with acute pancreatitis present with mild epigastric tenderness, the occasional patient may present with a clinical picture mimicking diffuse peritonitis (Chapter 19). As a precaution against misdiagnosing these patients, it is essential practice always to measure the serum amylase (or lipase) in any patient presenting with significant abdominal symptoms (Chapter 4). Note, however, that amylase/lipase levels are not completely reliable but abdominal CT would establish the diagnosis in doubtful cases. An exploratory laparotomy in a patient suffering from acute...',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures and Images',\n", " 'md': '## Figures and Images',\n", " 'bBox': {'x': 515, 'y': 103, 'w': 24, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: \\n```',\n", " 'md': '- **Figure 1**: \\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'perforated appendicitis'},\n", " {'text': 'Chapter 28), and with exceptions listed below and in the individual chapters, the'},\n", " {'text': 'with exceptions listed below and in the individual chapters, the'},\n", " {'text': ''},\n", " {'text': 'present with a clinical picture mimicking diffuse peritonitis ( Chapter 19). As a precaution against misdiagnosing these patients, it is essential practice always to measure the serum amylase (or lipase)'},\n", " {'text': 'Chapter 4). Note, however, that amylase/lipase levels are not completely reliable but abdominal CT would establish the diagnosis in doubtful'}]},\n", " {'page': 52,\n", " 'text': 'severe pancreatitis may lead to disaster; believe us — as we\\ndiscovered in the pre-imaging era, when we were young and\\naggressive. Remember: God put the pancreas in the back because\\nhe did not want surgeons messing with it.\\n\\n Localized peritonitis\\n\\n In the patient with localized peritonitis, the clinical signs are confined to\\none quadrant of the abdomen. Once you have decided which quadrant is\\nthe problem, there are only a few possible diagnoses from which to\\nchoose. Like the French Chief of Police said in the movie Casablanca:\\n“Round up the usual suspects.” In the right lower quadrant (RLQ) the\\nmost common cause of localized peritonitis is acute appendicitis (\\nChapter 23). In the right upper quadrant (RUQ) it is acute cholecystitis (\\n Chapter 20), and in the left lower quadrant (LLQ) it is acute\\ndiverticulitis ( Chapter 28). Peritonitis confined to the left upper\\nquadrant (LUQ) is uncommon, making this quadrant the ‘silent one’. Oh\\nwell, not always so silent: you can see the occasional colonic diverticulitis\\nor tumor perforation with abscess high in the descending colon, or the\\n‘funny’ splenic problems such as splenic infarct, but usually these are\\nonly discovered with CT.\\n\\n As a general rule, localized peritonitis is rarely an indication for\\nan emergency operation — ‘tonight!’. As you will learn from the\\nrelevant chapters most episodes of acute diverticulitis can be managed\\nwithout an operation ( Chapter 28). The majority of patients with acute\\ncholecystitis should undergo cholecystectomy ‘tomorrow’, or within 72\\nhours — but, in general, the sooner the better ( Chapter 20). Even\\nacute appendicitis is no longer considered a dire emergency — in most\\ncases the operation can be postponed until the morning ( Chapter 23).\\nBuy a copy of this book as a gift to your ER docs so that they too will\\nunderstand…\\n\\n What to do if the diagnosis is uncertain? Yes, even in this era of\\ninstant US or CT imaging this can happen! And, obviously, this situation\\nis not so rare if you practice away from modern imaging technology. You\\nshould then admit the patient for observation, hydrate him with\\nintravenous fluids, give antibiotics (e.g. if the diagnosis of acute',\n", " 'md': '```markdown\\n# Localized Peritonitis\\n\\nSevere pancreatitis may lead to disaster; believe us — as we discovered in the pre-imaging era, when we were young and aggressive. Remember: God put the pancreas in the back because he did not want surgeons messing with it.\\n\\n## Clinical Signs\\n\\nIn the patient with localized peritonitis, the clinical signs are confined to one quadrant of the abdomen. Once you have decided which quadrant is the problem, there are only a few possible diagnoses from which to choose. Like the French Chief of Police said in the movie Casablanca: “Round up the usual suspects.”\\n\\n- In the **right lower quadrant (RLQ)**, the most common cause of localized peritonitis is acute appendicitis (Chapter 23).\\n- In the **right upper quadrant (RUQ)**, it is acute cholecystitis (Chapter 20).\\n- In the **left lower quadrant (LLQ)**, it is acute diverticulitis (Chapter 28).\\n- Peritonitis confined to the **left upper quadrant (LUQ)** is uncommon, making this quadrant the ‘silent one’.\\n\\nOh well, not always so silent: you can see the occasional colonic diverticulitis or tumor perforation with abscess high in the descending colon, or the ‘funny’ splenic problems such as splenic infarct, but usually, these are only discovered with CT.\\n\\n## General Rule\\n\\nAs a general rule, localized peritonitis is rarely an indication for an emergency operation — ‘tonight!’. As you will learn from the relevant chapters, most episodes of acute diverticulitis can be managed without an operation (Chapter 28). The majority of patients with acute cholecystitis should undergo cholecystectomy ‘tomorrow’, or within 72 hours — but, in general, the sooner the better (Chapter 20). Even acute appendicitis is no longer considered a dire emergency — in most cases, the operation can be postponed until the morning (Chapter 23). Buy a copy of this book as a gift to your ER docs so that they too will understand…\\n\\n## Uncertain Diagnosis\\n\\nWhat to do if the diagnosis is uncertain? Yes, even in this era of instant US or CT imaging this can happen! And, obviously, this situation is not so rare if you practice away from modern imaging technology. You should then admit the patient for observation, hydrate him with intravenous fluids, give antibiotics (e.g. if the diagnosis of acute...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Localized Peritonitis',\n", " 'md': '# Localized Peritonitis',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 159.98, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Severe pancreatitis may lead to disaster; believe us — as we discovered in the pre-imaging era, when we were young and aggressive. Remember: God put the pancreas in the back because he did not want surgeons messing with it.',\n", " 'md': 'Severe pancreatitis may lead to disaster; believe us — as we discovered in the pre-imaging era, when we were young and aggressive. Remember: God put the pancreas in the back because he did not want surgeons messing with it.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.24, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Signs',\n", " 'md': '## Clinical Signs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In the patient with localized peritonitis, the clinical signs are confined to one quadrant of the abdomen. Once you have decided which quadrant is the problem, there are only a few possible diagnoses from which to choose. Like the French Chief of Police said in the movie Casablanca: “Round up the usual suspects.”\\n\\n- In the **right lower quadrant (RLQ)**, the most common cause of localized peritonitis is acute appendicitis (Chapter 23).\\n- In the **right upper quadrant (RUQ)**, it is acute cholecystitis (Chapter 20).\\n- In the **left lower quadrant (LLQ)**, it is acute diverticulitis (Chapter 28).\\n- Peritonitis confined to the **left upper quadrant (LUQ)** is uncommon, making this quadrant the ‘silent one’.\\n\\nOh well, not always so silent: you can see the occasional colonic diverticulitis or tumor perforation with abscess high in the descending colon, or the ‘funny’ splenic problems such as splenic infarct, but usually, these are only discovered with CT.',\n", " 'md': 'In the patient with localized peritonitis, the clinical signs are confined to one quadrant of the abdomen. Once you have decided which quadrant is the problem, there are only a few possible diagnoses from which to choose. Like the French Chief of Police said in the movie Casablanca: “Round up the usual suspects.”\\n\\n- In the **right lower quadrant (RLQ)**, the most common cause of localized peritonitis is acute appendicitis (Chapter 23).\\n- In the **right upper quadrant (RUQ)**, it is acute cholecystitis (Chapter 20).\\n- In the **left lower quadrant (LLQ)**, it is acute diverticulitis (Chapter 28).\\n- Peritonitis confined to the **left upper quadrant (LUQ)** is uncommon, making this quadrant the ‘silent one’.\\n\\nOh well, not always so silent: you can see the occasional colonic diverticulitis or tumor perforation with abscess high in the descending colon, or the ‘funny’ splenic problems such as splenic infarct, but usually, these are only discovered with CT.',\n", " 'bBox': {'x': 72, 'y': 178, 'w': 467.61, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'General Rule',\n", " 'md': '## General Rule',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'As a general rule, localized peritonitis is rarely an indication for an emergency operation — ‘tonight!’. As you will learn from the relevant chapters, most episodes of acute diverticulitis can be managed without an operation (Chapter 28). The majority of patients with acute cholecystitis should undergo cholecystectomy ‘tomorrow’, or within 72 hours — but, in general, the sooner the better (Chapter 20). Even acute appendicitis is no longer considered a dire emergency — in most cases, the operation can be postponed until the morning (Chapter 23). Buy a copy of this book as a gift to your ER docs so that they too will understand…',\n", " 'md': 'As a general rule, localized peritonitis is rarely an indication for an emergency operation — ‘tonight!’. As you will learn from the relevant chapters, most episodes of acute diverticulitis can be managed without an operation (Chapter 28). The majority of patients with acute cholecystitis should undergo cholecystectomy ‘tomorrow’, or within 72 hours — but, in general, the sooner the better (Chapter 20). Even acute appendicitis is no longer considered a dire emergency — in most cases, the operation can be postponed until the morning (Chapter 23). Buy a copy of this book as a gift to your ER docs so that they too will understand…',\n", " 'bBox': {'x': 72, 'y': 178, 'w': 467.39, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Uncertain Diagnosis',\n", " 'md': '## Uncertain Diagnosis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'What to do if the diagnosis is uncertain? Yes, even in this era of instant US or CT imaging this can happen! And, obviously, this situation is not so rare if you practice away from modern imaging technology. You should then admit the patient for observation, hydrate him with intravenous fluids, give antibiotics (e.g. if the diagnosis of acute...\\n```',\n", " 'md': 'What to do if the diagnosis is uncertain? Yes, even in this era of instant US or CT imaging this can happen! And, obviously, this situation is not so rare if you practice away from modern imaging technology. You should then admit the patient for observation, hydrate him with intravenous fluids, give antibiotics (e.g. if the diagnosis of acute...\\n```',\n", " 'bBox': {'x': 72, 'y': 666, 'w': 467.54, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 23). In the right upper quadrant (RUQ) it is '},\n", " {'text': 'diverticulitis'},\n", " {'text': 'quadrant (LUQ) is uncommon, making this quadrant the ‘silent one’. Oh'},\n", " {'text': ' should undergo cholecystectomy ‘tomorrow’, or within 72'},\n", " {'text': ' is no longer considered a dire emergency — in most'},\n", " {'text': 'Buy a copy of this book as a gift to your ER docs so that they too will'}]},\n", " {'page': 53,\n", " 'text': 'cholecystitis or diverticulitis is entertained), and conduct serial physical\\nexams. Do not omit analgesia! Condemning the patient to suffer\\nlong periods of untreated pain in order “not to mask signs and\\nsymptoms of an undiagnosed abdominal disaster” is an outdated\\npractice. Instead, provide small doses (1-4mg) of i.v. morphine.\\n\\n REMEMBER: ailments get better with time, true surgical problems\\nget worse with time. Thus time is a superb diagnostician; when you\\nreturn to the patient’s bedside after a few hours you may find all the\\npreviously missing clues. Of course, after you have consulted the\\nrelevant chapters in this book .\\n\\n In women of fertile age, lower abdominal peritonitis, on the right or left\\nside, commonly tends to be gynecological in origin, and is usually\\nmanaged conservatively ( Chapter 35).\\n\\n Intestinal obstruction\\n\\n The clinical pattern of intestinal obstruction consists of central,\\ncolicky abdominal pain, distension, vomiting and constipation (\\nChapters 21 and 27).\\n\\n As a general rule the earlier and more pronounced the vomiting, the\\nmore proximal the site of obstruction is likely to be. But the more marked\\nthe distension, the more distal is the site of obstruction. Thus, vomiting\\nand colicky pain are more characteristic of small bowel obstruction,\\nwhereas constipation and gross distension are typical of colonic\\nobstruction. ħowever, the distinction between these two kinds of\\nobstruction usually hinges on the plain abdominal X-ray — that is, if your\\nER doc still bothers obtaining it prior to the ‘obligatory CT’.\\n\\n There are two management options for these patients: a trial of\\nconservative treatment, or operative treatment after adequate\\npreparation. The major problem with intestinal obstruction is not in\\nmaking the diagnosis but in deciding on the appropriate course of action.\\nIf the patient has a history of previous abdominal surgery and presents\\nwith small bowel obstruction but without signs of peritonitis, the working',\n", " 'md': '```markdown\\n## Clinical Management of Abdominal Conditions\\n\\nCholecystitis or diverticulitis is entertained, and conduct serial physical exams. Do not omit analgesia! Condemning the patient to suffer long periods of untreated pain in order “not to mask signs and symptoms of an undiagnosed abdominal disaster” is an outdated practice. Instead, provide small doses (1-4mg) of i.v. morphine.\\n\\n**REMEMBER:** ailments get better with time, true surgical problems get worse with time. Thus time is a superb diagnostician; when you return to the patient’s bedside after a few hours you may find all the previously missing clues. Of course, after you have consulted the relevant chapters in this book.\\n\\nIn women of fertile age, lower abdominal peritonitis, on the right or left side, commonly tends to be gynecological in origin, and is usually managed conservatively (Chapter 35).\\n\\n### Intestinal Obstruction\\n\\nThe clinical pattern of intestinal obstruction consists of central, colicky abdominal pain, distension, vomiting, and constipation (Chapters 21 and 27).\\n\\nAs a general rule, the earlier and more pronounced the vomiting, the more proximal the site of obstruction is likely to be. But the more marked the distension, the more distal is the site of obstruction. Thus, vomiting and colicky pain are more characteristic of small bowel obstruction, whereas constipation and gross distension are typical of colonic obstruction. However, the distinction between these two kinds of obstruction usually hinges on the plain abdominal X-ray — that is, if your ER doc still bothers obtaining it prior to the ‘obligatory CT’.\\n\\nThere are two management options for these patients: a trial of conservative treatment, or operative treatment after adequate preparation. The major problem with intestinal obstruction is not in making the diagnosis but in deciding on the appropriate course of action. If the patient has a history of previous abdominal surgery and presents with small bowel obstruction but without signs of peritonitis, the working...\\n```\\n\\n### Notes:\\n- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been structured and formatted according to the markdown requirements.',\n", " 'images': [{'name': 'img_p52_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 262.7999999999997,\n", " 'y': 242.64}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Management of Abdominal Conditions',\n", " 'md': '## Clinical Management of Abdominal Conditions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Cholecystitis or diverticulitis is entertained, and conduct serial physical exams. Do not omit analgesia! Condemning the patient to suffer long periods of untreated pain in order “not to mask signs and symptoms of an undiagnosed abdominal disaster” is an outdated practice. Instead, provide small doses (1-4mg) of i.v. morphine.\\n\\n**REMEMBER:** ailments get better with time, true surgical problems get worse with time. Thus time is a superb diagnostician; when you return to the patient’s bedside after a few hours you may find all the previously missing clues. Of course, after you have consulted the relevant chapters in this book.\\n\\nIn women of fertile age, lower abdominal peritonitis, on the right or left side, commonly tends to be gynecological in origin, and is usually managed conservatively (Chapter 35).',\n", " 'md': 'Cholecystitis or diverticulitis is entertained, and conduct serial physical exams. Do not omit analgesia! Condemning the patient to suffer long periods of untreated pain in order “not to mask signs and symptoms of an undiagnosed abdominal disaster” is an outdated practice. Instead, provide small doses (1-4mg) of i.v. morphine.\\n\\n**REMEMBER:** ailments get better with time, true surgical problems get worse with time. Thus time is a superb diagnostician; when you return to the patient’s bedside after a few hours you may find all the previously missing clues. Of course, after you have consulted the relevant chapters in this book.\\n\\nIn women of fertile age, lower abdominal peritonitis, on the right or left side, commonly tends to be gynecological in origin, and is usually managed conservatively (Chapter 35).',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.64, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Intestinal Obstruction',\n", " 'md': '### Intestinal Obstruction',\n", " 'bBox': {'x': 86, 'y': 365, 'w': 168.25, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The clinical pattern of intestinal obstruction consists of central, colicky abdominal pain, distension, vomiting, and constipation (Chapters 21 and 27).\\n\\nAs a general rule, the earlier and more pronounced the vomiting, the more proximal the site of obstruction is likely to be. But the more marked the distension, the more distal is the site of obstruction. Thus, vomiting and colicky pain are more characteristic of small bowel obstruction, whereas constipation and gross distension are typical of colonic obstruction. However, the distinction between these two kinds of obstruction usually hinges on the plain abdominal X-ray — that is, if your ER doc still bothers obtaining it prior to the ‘obligatory CT’.\\n\\nThere are two management options for these patients: a trial of conservative treatment, or operative treatment after adequate preparation. The major problem with intestinal obstruction is not in making the diagnosis but in deciding on the appropriate course of action. If the patient has a history of previous abdominal surgery and presents with small bowel obstruction but without signs of peritonitis, the working...\\n```',\n", " 'md': 'The clinical pattern of intestinal obstruction consists of central, colicky abdominal pain, distension, vomiting, and constipation (Chapters 21 and 27).\\n\\nAs a general rule, the earlier and more pronounced the vomiting, the more proximal the site of obstruction is likely to be. But the more marked the distension, the more distal is the site of obstruction. Thus, vomiting and colicky pain are more characteristic of small bowel obstruction, whereas constipation and gross distension are typical of colonic obstruction. However, the distinction between these two kinds of obstruction usually hinges on the plain abdominal X-ray — that is, if your ER doc still bothers obtaining it prior to the ‘obligatory CT’.\\n\\nThere are two management options for these patients: a trial of conservative treatment, or operative treatment after adequate preparation. The major problem with intestinal obstruction is not in making the diagnosis but in deciding on the appropriate course of action. If the patient has a history of previous abdominal surgery and presents with small bowel obstruction but without signs of peritonitis, the working...\\n```',\n", " 'bBox': {'x': 72, 'y': 253, 'w': 467.94, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been structured and formatted according to the markdown requirements.',\n", " 'md': '- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been structured and formatted according to the markdown requirements.',\n", " 'bBox': {'x': 276, 'y': 253, 'w': 4, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': 'Chapters 21 and 27).'}, {'text': ''}]},\n", " {'page': 54,\n", " 'text': 'diagnosis is ‘simple’ adhesive small bowel obstruction. The initial\\nmanagement of these patients is conservative, with intravenous fluids\\nand nasogastric tube decompression. If the obstruction is complete (e.g.\\nno gas in the colon above the rectum), the chances of spontaneous\\nresolution are small and some surgeons would opt for an operative\\nintervention. In the presence of clinical features of intestinal compromise\\n— fever, peritonitis, and elevated white blood cell count, the indication for\\noperation is more persuasive. But, as always, in real life things are much\\nmore complicated so please read Chapter 21.\\n\\n There are a few classic pitfalls with small bowel obstruction:\\n\\n • The ‘virgin’ abdomen (no previous abdominal surgery): here,\\n typically adhesion may not be the underlying cause. Think outside\\n of the box and get a CT of the ‘black box’, i.e. the abdomen. In\\n these cases there is often a treatable cause for the obstruction, and\\n it makes you feel good at operation to have found it.\\n • The missed groin hernia. The elderly lady with no previous surgical\\n history who presents with small bowel obstruction due to an\\n incarcerated femoral hernia. Always examine the groin! Insist on\\n patients having their pants and underpants off. The fact that\\n modern ER docs tend to diagnose incarcerated inguinal hernias only\\n on CT is sad. But we want you to detect such hernias on\\n examination, prior to CT, which then becomes unnecessary.\\n • The silent cecal cancer. The patient with alleged ‘simple’ adhesive\\n small bowel obstruction who improves on conservative treatment\\n and is discharged, only to come back later with a large tumor mass\\n in the right colon. These cancers can act as a ball valve, causing\\n intermittent distal obstruction of the ileocecal valve.\\n • The gallstone ileus. The elderly lady whose partial small bowel\\n obstruction resolves and recurs intermittently and is finally\\n diagnosed as gallstone ileus. Always look for air in the bile ducts\\n on plain abdominal X-rays. If you don’t think about it you will\\n miss it!\\n • The post-gastric surgery patient, who presents with intermittent\\n episodes of obstruction originating from a bezoar in the terminal\\n ileum.',\n", " 'md': '```markdown\\n# Management of Simple Adhesive Small Bowel Obstruction\\n\\nThe diagnosis is ‘simple’ adhesive small bowel obstruction. The initial management of these patients is conservative, with intravenous fluids and nasogastric tube decompression. If the obstruction is complete (e.g. no gas in the colon above the rectum), the chances of spontaneous resolution are small and some surgeons would opt for an operative intervention. In the presence of clinical features of intestinal compromise — fever, peritonitis, and elevated white blood cell count, the indication for operation is more persuasive. But, as always, in real life things are much more complicated so please read [Chapter 21](#).\\n\\n## Classic Pitfalls with Small Bowel Obstruction\\n\\nThere are a few classic pitfalls with small bowel obstruction:\\n\\n- **The ‘virgin’ abdomen** (no previous abdominal surgery): Here, typically adhesion may not be the underlying cause. Think outside of the box and get a CT of the ‘black box’, i.e. the abdomen. In these cases, there is often a treatable cause for the obstruction, and it makes you feel good at operation to have found it.\\n\\n- **The missed groin hernia**: The elderly lady with no previous surgical history who presents with small bowel obstruction due to an incarcerated femoral hernia. Always examine the groin! Insist on patients having their pants and underpants off. The fact that modern ER docs tend to diagnose incarcerated inguinal hernias only on CT is sad. But we want you to detect such hernias on examination, prior to CT, which then becomes unnecessary.\\n\\n- **The silent cecal cancer**: The patient with alleged ‘simple’ adhesive small bowel obstruction who improves on conservative treatment and is discharged, only to come back later with a large tumor mass in the right colon. These cancers can act as a ball valve, causing intermittent distal obstruction of the ileocecal valve.\\n\\n- **The gallstone ileus**: The elderly lady whose partial small bowel obstruction resolves and recurs intermittently and is finally diagnosed as gallstone ileus. Always look for air in the bile ducts on plain abdominal X-rays. If you don’t think about it you will miss it!\\n\\n- **The post-gastric surgery patient**: Who presents with intermittent episodes of obstruction originating from a bezoar in the terminal ileum.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management of Simple Adhesive Small Bowel Obstruction',\n", " 'md': '# Management of Simple Adhesive Small Bowel Obstruction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The diagnosis is ‘simple’ adhesive small bowel obstruction. The initial management of these patients is conservative, with intravenous fluids and nasogastric tube decompression. If the obstruction is complete (e.g. no gas in the colon above the rectum), the chances of spontaneous resolution are small and some surgeons would opt for an operative intervention. In the presence of clinical features of intestinal compromise — fever, peritonitis, and elevated white blood cell count, the indication for operation is more persuasive. But, as always, in real life things are much more complicated so please read [Chapter 21](#).',\n", " 'md': 'The diagnosis is ‘simple’ adhesive small bowel obstruction. The initial management of these patients is conservative, with intravenous fluids and nasogastric tube decompression. If the obstruction is complete (e.g. no gas in the colon above the rectum), the chances of spontaneous resolution are small and some surgeons would opt for an operative intervention. In the presence of clinical features of intestinal compromise — fever, peritonitis, and elevated white blood cell count, the indication for operation is more persuasive. But, as always, in real life things are much more complicated so please read [Chapter 21](#).',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Classic Pitfalls with Small Bowel Obstruction',\n", " 'md': '## Classic Pitfalls with Small Bowel Obstruction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'There are a few classic pitfalls with small bowel obstruction:\\n\\n- **The ‘virgin’ abdomen** (no previous abdominal surgery): Here, typically adhesion may not be the underlying cause. Think outside of the box and get a CT of the ‘black box’, i.e. the abdomen. In these cases, there is often a treatable cause for the obstruction, and it makes you feel good at operation to have found it.\\n\\n- **The missed groin hernia**: The elderly lady with no previous surgical history who presents with small bowel obstruction due to an incarcerated femoral hernia. Always examine the groin! Insist on patients having their pants and underpants off. The fact that modern ER docs tend to diagnose incarcerated inguinal hernias only on CT is sad. But we want you to detect such hernias on examination, prior to CT, which then becomes unnecessary.\\n\\n- **The silent cecal cancer**: The patient with alleged ‘simple’ adhesive small bowel obstruction who improves on conservative treatment and is discharged, only to come back later with a large tumor mass in the right colon. These cancers can act as a ball valve, causing intermittent distal obstruction of the ileocecal valve.\\n\\n- **The gallstone ileus**: The elderly lady whose partial small bowel obstruction resolves and recurs intermittently and is finally diagnosed as gallstone ileus. Always look for air in the bile ducts on plain abdominal X-rays. If you don’t think about it you will miss it!\\n\\n- **The post-gastric surgery patient**: Who presents with intermittent episodes of obstruction originating from a bezoar in the terminal ileum.\\n```',\n", " 'md': 'There are a few classic pitfalls with small bowel obstruction:\\n\\n- **The ‘virgin’ abdomen** (no previous abdominal surgery): Here, typically adhesion may not be the underlying cause. Think outside of the box and get a CT of the ‘black box’, i.e. the abdomen. In these cases, there is often a treatable cause for the obstruction, and it makes you feel good at operation to have found it.\\n\\n- **The missed groin hernia**: The elderly lady with no previous surgical history who presents with small bowel obstruction due to an incarcerated femoral hernia. Always examine the groin! Insist on patients having their pants and underpants off. The fact that modern ER docs tend to diagnose incarcerated inguinal hernias only on CT is sad. But we want you to detect such hernias on examination, prior to CT, which then becomes unnecessary.\\n\\n- **The silent cecal cancer**: The patient with alleged ‘simple’ adhesive small bowel obstruction who improves on conservative treatment and is discharged, only to come back later with a large tumor mass in the right colon. These cancers can act as a ball valve, causing intermittent distal obstruction of the ileocecal valve.\\n\\n- **The gallstone ileus**: The elderly lady whose partial small bowel obstruction resolves and recurs intermittently and is finally diagnosed as gallstone ileus. Always look for air in the bile ducts on plain abdominal X-rays. If you don’t think about it you will miss it!\\n\\n- **The post-gastric surgery patient**: Who presents with intermittent episodes of obstruction originating from a bezoar in the terminal ileum.\\n```',\n", " 'bBox': {'x': 86, 'y': 253, 'w': 437.08, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 55,\n", " 'text': ' Unlike small bowel obstruction, colon obstruction is almost\\nalways an indication for surgery — ‘tonight’ or ‘tomorrow’ but usually\\n‘tomorrow’. A plain abdominal X-ray cannot reliably distinguish between\\nfunctional colonic pseudo-obstruction (Ogilvie’s syndrome) or chronic\\nmegacolon and a mechanical obstruction. Thus, these patients usually\\nneed additional imaging (contrast enema, CT) or fiberoptic colonoscopy\\nto clinch the diagnosis ( Chapter 27).\\n\\n The abdominal ‘waste basket’\\n\\n • Non-specific abdominal pain (NSAP). Many patients with acute\\n abdominal pain undergo a clinical examination and a limited work-up\\n — which today in many centers may include a CT scan — only to be\\n labeled as “non-specific abdominal pain” (NSAP), and then\\n discharged. NSAP is a clinical entity, albeit an ill-defined one. It is a\\n type of acute abdominal pain that is severe enough to bring a patient\\n to seek medical attention. The patient’s physical examination and\\n diagnostic work-up are negative, and the pain is self-limiting and\\n usually does not recur. It is important to keep in mind that in an\\n ER setting, more than half of patients presenting with acute\\n abdominal pain have NSAP, with acute appendicitis, acute\\n cholecystitis and ‘gynecological causes’, being the commonest\\n ‘specific’ conditions. But the exact pathology you see depends of\\n course on your geographical location and pattern of practice. Just\\n remember that patients discharged home labeled with a diagnosis of\\n NSAP have an increased probability of a subsequent diagnosis of\\n abdominal cancer or other lingering surprise pathologies. Therefore,\\n elective investigations may be indicated so try to follow-up these\\n patients.\\n • Important medical causes. While there is a large number of non-\\n surgical causes of acute abdominal pain, two must be kept\\n constantly in your mind: inferior wall myocardial infarction and\\n diabetic ketoacidosis. A laparotomy for porphyria or even basal\\n pneumonia is an unfortunate surgical (and medicolegal) occurrence,\\n but inadvertently operating on a patient with an undiagnosed inferior\\n wall MI or diabetic ketoacidosis may well be a lethal mistake. As a\\n surgeon you should strive to be a better physician than the\\n internists, and wouldn’t it be fun to show them a ‘medical’ diagnosis',\n", " 'md': '```markdown\\n## Abdominal Obstruction and Non-Specific Abdominal Pain\\n\\nUnlike small bowel obstruction, colon obstruction is almost always an indication for surgery — ‘tonight’ or ‘tomorrow’ but usually ‘tomorrow’. A plain abdominal X-ray cannot reliably distinguish between functional colonic pseudo-obstruction (Ogilvie’s syndrome) or chronic megacolon and a mechanical obstruction. Thus, these patients usually need additional imaging (contrast enema, CT) or fiberoptic colonoscopy to clinch the diagnosis (Chapter 27).\\n\\n### The Abdominal ‘Waste Basket’\\n\\n- **Non-specific abdominal pain (NSAP)**: Many patients with acute abdominal pain undergo a clinical examination and a limited work-up — which today in many centers may include a CT scan — only to be labeled as “non-specific abdominal pain” (NSAP), and then discharged. NSAP is a clinical entity, albeit an ill-defined one. It is a type of acute abdominal pain that is severe enough to bring a patient to seek medical attention. The patient’s physical examination and diagnostic work-up are negative, and the pain is self-limiting and usually does not recur. It is important to keep in mind that in an ER setting, more than half of patients presenting with acute abdominal pain have NSAP, with acute appendicitis, acute cholecystitis, and ‘gynecological causes’ being the commonest ‘specific’ conditions. But the exact pathology you see depends of course on your geographical location and pattern of practice. Just remember that patients discharged home labeled with a diagnosis of NSAP have an increased probability of a subsequent diagnosis of abdominal cancer or other lingering surprise pathologies. Therefore, elective investigations may be indicated so try to follow-up these patients.\\n\\n- **Important medical causes**: While there is a large number of non-surgical causes of acute abdominal pain, two must be kept constantly in your mind: inferior wall myocardial infarction and diabetic ketoacidosis. A laparotomy for porphyria or even basal pneumonia is an unfortunate surgical (and medicolegal) occurrence, but inadvertently operating on a patient with an undiagnosed inferior wall MI or diabetic ketoacidosis may well be a lethal mistake. As a surgeon, you should strive to be a better physician than the internists, and wouldn’t it be fun to show them a ‘medical’ diagnosis.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Obstruction and Non-Specific Abdominal Pain',\n", " 'md': '## Abdominal Obstruction and Non-Specific Abdominal Pain',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Unlike small bowel obstruction, colon obstruction is almost always an indication for surgery — ‘tonight’ or ‘tomorrow’ but usually ‘tomorrow’. A plain abdominal X-ray cannot reliably distinguish between functional colonic pseudo-obstruction (Ogilvie’s syndrome) or chronic megacolon and a mechanical obstruction. Thus, these patients usually need additional imaging (contrast enema, CT) or fiberoptic colonoscopy to clinch the diagnosis (Chapter 27).',\n", " 'md': 'Unlike small bowel obstruction, colon obstruction is almost always an indication for surgery — ‘tonight’ or ‘tomorrow’ but usually ‘tomorrow’. A plain abdominal X-ray cannot reliably distinguish between functional colonic pseudo-obstruction (Ogilvie’s syndrome) or chronic megacolon and a mechanical obstruction. Thus, these patients usually need additional imaging (contrast enema, CT) or fiberoptic colonoscopy to clinch the diagnosis (Chapter 27).',\n", " 'bBox': {'x': 72, 'y': 185, 'w': 150.33, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Abdominal ‘Waste Basket’',\n", " 'md': '### The Abdominal ‘Waste Basket’',\n", " 'bBox': {'x': 86, 'y': 228, 'w': 233.57, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- **Non-specific abdominal pain (NSAP)**: Many patients with acute abdominal pain undergo a clinical examination and a limited work-up — which today in many centers may include a CT scan — only to be labeled as “non-specific abdominal pain” (NSAP), and then discharged. NSAP is a clinical entity, albeit an ill-defined one. It is a type of acute abdominal pain that is severe enough to bring a patient to seek medical attention. The patient’s physical examination and diagnostic work-up are negative, and the pain is self-limiting and usually does not recur. It is important to keep in mind that in an ER setting, more than half of patients presenting with acute abdominal pain have NSAP, with acute appendicitis, acute cholecystitis, and ‘gynecological causes’ being the commonest ‘specific’ conditions. But the exact pathology you see depends of course on your geographical location and pattern of practice. Just remember that patients discharged home labeled with a diagnosis of NSAP have an increased probability of a subsequent diagnosis of abdominal cancer or other lingering surprise pathologies. Therefore, elective investigations may be indicated so try to follow-up these patients.\\n\\n- **Important medical causes**: While there is a large number of non-surgical causes of acute abdominal pain, two must be kept constantly in your mind: inferior wall myocardial infarction and diabetic ketoacidosis. A laparotomy for porphyria or even basal pneumonia is an unfortunate surgical (and medicolegal) occurrence, but inadvertently operating on a patient with an undiagnosed inferior wall MI or diabetic ketoacidosis may well be a lethal mistake. As a surgeon, you should strive to be a better physician than the internists, and wouldn’t it be fun to show them a ‘medical’ diagnosis.\\n```',\n", " 'md': '- **Non-specific abdominal pain (NSAP)**: Many patients with acute abdominal pain undergo a clinical examination and a limited work-up — which today in many centers may include a CT scan — only to be labeled as “non-specific abdominal pain” (NSAP), and then discharged. NSAP is a clinical entity, albeit an ill-defined one. It is a type of acute abdominal pain that is severe enough to bring a patient to seek medical attention. The patient’s physical examination and diagnostic work-up are negative, and the pain is self-limiting and usually does not recur. It is important to keep in mind that in an ER setting, more than half of patients presenting with acute abdominal pain have NSAP, with acute appendicitis, acute cholecystitis, and ‘gynecological causes’ being the commonest ‘specific’ conditions. But the exact pathology you see depends of course on your geographical location and pattern of practice. Just remember that patients discharged home labeled with a diagnosis of NSAP have an increased probability of a subsequent diagnosis of abdominal cancer or other lingering surprise pathologies. Therefore, elective investigations may be indicated so try to follow-up these patients.\\n\\n- **Important medical causes**: While there is a large number of non-surgical causes of acute abdominal pain, two must be kept constantly in your mind: inferior wall myocardial infarction and diabetic ketoacidosis. A laparotomy for porphyria or even basal pneumonia is an unfortunate surgical (and medicolegal) occurrence, but inadvertently operating on a patient with an undiagnosed inferior wall MI or diabetic ketoacidosis may well be a lethal mistake. As a surgeon, you should strive to be a better physician than the internists, and wouldn’t it be fun to show them a ‘medical’ diagnosis.\\n```',\n", " 'bBox': {'x': 100, 'y': 281, 'w': 437.03, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 56,\n", " 'text': ' they had missed!\\n\\n Exploratory laparotomy or laparoscopy for the acute\\n abdomen?\\n\\n Many of us, old farts, were raised on the dictum that clinical peritonitis\\nis an indication for abdominal exploration. Many of you, promising\\nemerging stars, are nurtured with the concept of “let us insert a camera\\nand see what’s going on”.\\n\\n The notions that “peritonitis is an indication for operation” and that “only\\nskin separates us from the diagnosis” developed before the days of\\nmodern abdominal imaging; but is this still true today, justifying opening\\nthe abdomen or inserting a scope, without resonable evidence of a\\nsurgical pathology necessitating an operation? We do not think so. We\\nbelieve that modern abdominal imaging has revolutionized\\nemergency abdominal surgery, and that if you have immediate\\naccess to abdominal CT and/or ultrasound you have to use it. This,\\nas will be discussed in many of the following chapters, will avoid an\\noperation in many patients, or make operative treatment less\\ninvasive and more specific. Thanks to the abdominal CT the\\nabdomen is no longer a black box. Use abdominal imaging liberally for\\nthe benefit of your patients — especially when the diagnosis is not clearly\\nevident. It is OK to operate on a young man with classcial features of\\nacute appendicitis without a pre-operative CT; but a woman of child-\\nbearing age needs abdominal imaging (to exclude gynecological\\nconditions) and so do elderly patients in whom other pathologies are\\nmore likely. This is all just common sense really.\\n The surgeon who strives for perfection\\n Needs some basis for patient selection\\n He would like to be sure\\n There’s a good chance for cure\\n Before he begins the resection.\\n Elwood G. Jensen\\n\\n Yes, what’s common is common and what’s rare is rare, but rare',\n", " 'md': '```markdown\\n## Exploratory Laparotomy or Laparoscopy for the Acute Abdomen?\\n\\nMany of us, old farts, were raised on the dictum that clinical peritonitis is an indication for abdominal exploration. Many of you, promising emerging stars, are nurtured with the concept of “let us insert a camera and see what’s going on”.\\n\\nThe notions that “peritonitis is an indication for operation” and that “only skin separates us from the diagnosis” developed before the days of modern abdominal imaging; but is this still true today, justifying opening the abdomen or inserting a scope, without reasonable evidence of a surgical pathology necessitating an operation? We do not think so. We believe that modern abdominal imaging has revolutionized emergency abdominal surgery, and that if you have immediate access to abdominal CT and/or ultrasound you have to use it. This, as will be discussed in many of the following chapters, will avoid an operation in many patients, or make operative treatment less invasive and more specific. Thanks to the abdominal CT the abdomen is no longer a black box. Use abdominal imaging liberally for the benefit of your patients — especially when the diagnosis is not clearly evident. It is OK to operate on a young man with classical features of acute appendicitis without a pre-operative CT; but a woman of child-bearing age needs abdominal imaging (to exclude gynecological conditions) and so do elderly patients in whom other pathologies are more likely. This is all just common sense really.\\n\\n> The surgeon who strives for perfection\\n> Needs some basis for patient selection\\n> He would like to be sure\\n> There’s a good chance for cure\\n> Before he begins the resection.\\n> — Elwood G. Jensen\\n\\nYes, what’s common is common and what’s rare is rare, but rare\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Exploratory Laparotomy or Laparoscopy for the Acute Abdomen?',\n", " 'md': '## Exploratory Laparotomy or Laparoscopy for the Acute Abdomen?',\n", " 'bBox': {'x': 86, 'y': 131, 'w': 97.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Many of us, old farts, were raised on the dictum that clinical peritonitis is an indication for abdominal exploration. Many of you, promising emerging stars, are nurtured with the concept of “let us insert a camera and see what’s going on”.\\n\\nThe notions that “peritonitis is an indication for operation” and that “only skin separates us from the diagnosis” developed before the days of modern abdominal imaging; but is this still true today, justifying opening the abdomen or inserting a scope, without reasonable evidence of a surgical pathology necessitating an operation? We do not think so. We believe that modern abdominal imaging has revolutionized emergency abdominal surgery, and that if you have immediate access to abdominal CT and/or ultrasound you have to use it. This, as will be discussed in many of the following chapters, will avoid an operation in many patients, or make operative treatment less invasive and more specific. Thanks to the abdominal CT the abdomen is no longer a black box. Use abdominal imaging liberally for the benefit of your patients — especially when the diagnosis is not clearly evident. It is OK to operate on a young man with classical features of acute appendicitis without a pre-operative CT; but a woman of child-bearing age needs abdominal imaging (to exclude gynecological conditions) and so do elderly patients in whom other pathologies are more likely. This is all just common sense really.\\n\\n> The surgeon who strives for perfection\\n> Needs some basis for patient selection\\n> He would like to be sure\\n> There’s a good chance for cure\\n> Before he begins the resection.\\n> — Elwood G. Jensen\\n\\nYes, what’s common is common and what’s rare is rare, but rare\\n```',\n", " 'md': 'Many of us, old farts, were raised on the dictum that clinical peritonitis is an indication for abdominal exploration. Many of you, promising emerging stars, are nurtured with the concept of “let us insert a camera and see what’s going on”.\\n\\nThe notions that “peritonitis is an indication for operation” and that “only skin separates us from the diagnosis” developed before the days of modern abdominal imaging; but is this still true today, justifying opening the abdomen or inserting a scope, without reasonable evidence of a surgical pathology necessitating an operation? We do not think so. We believe that modern abdominal imaging has revolutionized emergency abdominal surgery, and that if you have immediate access to abdominal CT and/or ultrasound you have to use it. This, as will be discussed in many of the following chapters, will avoid an operation in many patients, or make operative treatment less invasive and more specific. Thanks to the abdominal CT the abdomen is no longer a black box. Use abdominal imaging liberally for the benefit of your patients — especially when the diagnosis is not clearly evident. It is OK to operate on a young man with classical features of acute appendicitis without a pre-operative CT; but a woman of child-bearing age needs abdominal imaging (to exclude gynecological conditions) and so do elderly patients in whom other pathologies are more likely. This is all just common sense really.\\n\\n> The surgeon who strives for perfection\\n> Needs some basis for patient selection\\n> He would like to be sure\\n> There’s a good chance for cure\\n> Before he begins the resection.\\n> — Elwood G. Jensen\\n\\nYes, what’s common is common and what’s rare is rare, but rare\\n```',\n", " 'bBox': {'x': 72, 'y': 131, 'w': 467.96, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 57,\n", " 'text': 'things can be lethal — always keep them in mind!\\n\\n Who should look after the ‘acute abdomen’ and where?\\n Everybody’s business is nobody’s business.\\n\\n The majority of patients suspected of having an acute abdomen or\\nother abdominal emergency do not require an operation. Nevertheless,\\nit is you — the surgeon — who should take, or be granted, the\\nleadership in assessing, excluding or treating this condition, or at\\nleast play a major role in leading the managing team. To emphasize\\nhow crucial this issue is, we dedicate an entire section of this chapter to it\\n— although its scope would fit into a paragraph.\\n Wsw\\n \"0314\\n Figure 3.2. “Who is responsible?”\\n\\n Unfortunately, in real life, surgeons are often denied the primary\\nresponsibility. Too often we see patients with mesenteric ischemia\\nrotting away in medical wards, the surgeon being consulted “to evaluate\\nthe abdomen”, only when the bowel is dead, and the patient is soon to',\n", " 'md': '```markdown\\n## Acute Abdomen Management\\n\\nThings can be lethal — always keep them in mind!\\n\\n### Who should look after the ‘acute abdomen’ and where?\\nEverybody’s business is nobody’s business.\\n\\nThe majority of patients suspected of having an acute abdomen or other abdominal emergency do not require an operation. Nevertheless, it is you — the surgeon — who should take, or be granted, the leadership in assessing, excluding or treating this condition, or at least play a major role in leading the managing team. To emphasize how crucial this issue is, we dedicate an entire section of this chapter to it — although its scope would fit into a paragraph.\\n\\n**Figure 3.2.** “Who is responsible?”\\n\\nUnfortunately, in real life, surgeons are often denied the primary responsibility. Too often we see patients with mesenteric ischemia rotting away in medical wards, the surgeon being consulted “to evaluate the abdomen”, only when the bowel is dead, and the patient is soon to...\\n```\\n\\n### Image Description\\n- **Figure 3.2**: The image titled \"Who is responsible?\" likely illustrates the roles and responsibilities in managing acute abdomen cases. The content of the image is not provided, but it may depict a flowchart or organizational structure related to the management of acute abdomen, emphasizing the surgeon\\'s role. The exact details of the image are .',\n", " 'images': [{'name': 'img_p56_1.png',\n", " 'height': 581,\n", " 'width': 806,\n", " 'x': 106.55999999999949,\n", " 'y': 308.88,\n", " 'original_width': 1384,\n", " 'original_height': 996}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Acute Abdomen Management',\n", " 'md': '## Acute Abdomen Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Things can be lethal — always keep them in mind!',\n", " 'md': 'Things can be lethal — always keep them in mind!',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 338.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Who should look after the ‘acute abdomen’ and where?',\n", " 'md': '### Who should look after the ‘acute abdomen’ and where?',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 433.98, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Everybody’s business is nobody’s business.\\n\\nThe majority of patients suspected of having an acute abdomen or other abdominal emergency do not require an operation. Nevertheless, it is you — the surgeon — who should take, or be granted, the leadership in assessing, excluding or treating this condition, or at least play a major role in leading the managing team. To emphasize how crucial this issue is, we dedicate an entire section of this chapter to it — although its scope would fit into a paragraph.\\n\\n**Figure 3.2.** “Who is responsible?”\\n\\nUnfortunately, in real life, surgeons are often denied the primary responsibility. Too often we see patients with mesenteric ischemia rotting away in medical wards, the surgeon being consulted “to evaluate the abdomen”, only when the bowel is dead, and the patient is soon to...\\n```',\n", " 'md': 'Everybody’s business is nobody’s business.\\n\\nThe majority of patients suspected of having an acute abdomen or other abdominal emergency do not require an operation. Nevertheless, it is you — the surgeon — who should take, or be granted, the leadership in assessing, excluding or treating this condition, or at least play a major role in leading the managing team. To emphasize how crucial this issue is, we dedicate an entire section of this chapter to it — although its scope would fit into a paragraph.\\n\\n**Figure 3.2.** “Who is responsible?”\\n\\nUnfortunately, in real life, surgeons are often denied the primary responsibility. Too often we see patients with mesenteric ischemia rotting away in medical wards, the surgeon being consulted “to evaluate the abdomen”, only when the bowel is dead, and the patient is soon to...\\n```',\n", " 'bBox': {'x': 72, 'y': 160, 'w': 467.64, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 3.2**: The image titled \"Who is responsible?\" likely illustrates the roles and responsibilities in managing acute abdomen cases. The content of the image is not provided, but it may depict a flowchart or organizational structure related to the management of acute abdomen, emphasizing the surgeon\\'s role. The exact details of the image are .',\n", " 'md': '- **Figure 3.2**: The image titled \"Who is responsible?\" likely illustrates the roles and responsibilities in managing acute abdomen cases. The content of the image is not provided, but it may depict a flowchart or organizational structure related to the management of acute abdomen, emphasizing the surgeon\\'s role. The exact details of the image are .',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 58,\n", " 'text': 'be. A characteristic scenario is a patient with an abdominal surgical\\nemergency, admitted under the care of non-surgeons who undertake a\\nseries of unnecessary, potentially harmful and expensive diagnostic and\\ntherapeutic procedures. Typically, internists, gastroenterologists,\\ninfectious-disease specialists and radiologists are involved, each\\nprescribing his own wisdom in isolation (many treating the patient for\\n‘CRPitis’ or ECOUO — elevated CRP of unknown origin...) ( Figure\\n3.2). When, finally, the surgeon is called in, he finds the condition difficult\\nto diagnose, partially treated or maltreated. Eventually, the indicated\\noperation is performed, but too late and thus carries a higher morbidity\\nand mortality. The etiology of such chaos is not entirely clear. Motives of\\npower, ego and financial considerations are surely involved; it is politically\\ncorrect to call this a ‘system failure’.\\n\\n The team approach to the acutely ill surgical patient should not be\\ndiscarded. The team, however, should be led and coordinated by a\\ngeneral surgeon. ħe is the one who knows the abdomen from within and\\nwithout. ħe is the one qualified to call in consultants from other\\nspecialties, to order valuable tests, to veto those that are superfluous and\\nwasteful. And, above all, he is the one who will eventually decide that\\nenough is enough and the patient needs to be taken to the operating\\nroom.\\n\\n When you decided to become a general surgeon you became the\\ncaptain of the ship, navigating the deep ocean of the abdomen. Do\\nnot abandon your ship while the storm rages on!\\n\\n Continuity of care is a sine qua non in the optimal care of the\\nacute abdomen as the clinical picture, which may change rapidly, is a\\nmajor determinant in the choice of therapy and its timing. Such patients\\nneed to be frequently reassessed by the same clinician, who should be a\\nsurgeon. Any deviation from this may be hazardous to the patient; this is\\nour personal experience and that which is repeated ad nauseum in the\\nliterature. Why don’t we learn? The place for the patient with an acute\\nabdominal condition is on the surgical floor, surgical intensive care unit\\n(ICU), or in the operating room and under the care of a surgeon —\\nyourself. Don’t duck your responsibilities!',\n", " 'md': '```markdown\\n## Text\\n\\nA characteristic scenario is a patient with an abdominal surgical emergency, admitted under the care of non-surgeons who undertake a series of unnecessary, potentially harmful and expensive diagnostic and therapeutic procedures. Typically, internists, gastroenterologists, infectious-disease specialists, and radiologists are involved, each prescribing his own wisdom in isolation (many treating the patient for ‘CRPitis’ or ECOUO — elevated CRP of unknown origin...) (Figure 3.2). When, finally, the surgeon is called in, he finds the condition difficult to diagnose, partially treated or maltreated. Eventually, the indicated operation is performed, but too late and thus carries a higher morbidity and mortality. The etiology of such chaos is not entirely clear. Motives of power, ego, and financial considerations are surely involved; it is politically correct to call this a ‘system failure’.\\n\\nThe team approach to the acutely ill surgical patient should not be discarded. The team, however, should be led and coordinated by a general surgeon. He is the one who knows the abdomen from within and without. He is the one qualified to call in consultants from other specialties, to order valuable tests, to veto those that are superfluous and wasteful. And, above all, he is the one who will eventually decide that enough is enough and the patient needs to be taken to the operating room.\\n\\nWhen you decided to become a general surgeon you became the captain of the ship, navigating the deep ocean of the abdomen. Do not abandon your ship while the storm rages on!\\n\\nContinuity of care is a sine qua non in the optimal care of the acute abdomen as the clinical picture, which may change rapidly, is a major determinant in the choice of therapy and its timing. Such patients need to be frequently reassessed by the same clinician, who should be a surgeon. Any deviation from this may be hazardous to the patient; this is our personal experience and that which is repeated ad nauseum in the literature. Why don’t we learn? The place for the patient with an acute abdominal condition is on the surgical floor, surgical intensive care unit (ICU), or in the operating room and under the care of a surgeon — yourself. Don’t duck your responsibilities!\\n\\n## Figures\\n\\n### Figure 3.2\\n- **Description**: This figure likely illustrates the chaotic scenario described in the text, where multiple specialists are involved in the care of a patient with an acute abdominal condition, leading to delays and complications in treatment.\\n- **Summary**: The figure emphasizes the importance of a coordinated approach led by a general surgeon to avoid unnecessary procedures and ensure timely intervention for patients with abdominal emergencies.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A characteristic scenario is a patient with an abdominal surgical emergency, admitted under the care of non-surgeons who undertake a series of unnecessary, potentially harmful and expensive diagnostic and therapeutic procedures. Typically, internists, gastroenterologists, infectious-disease specialists, and radiologists are involved, each prescribing his own wisdom in isolation (many treating the patient for ‘CRPitis’ or ECOUO — elevated CRP of unknown origin...) (Figure 3.2). When, finally, the surgeon is called in, he finds the condition difficult to diagnose, partially treated or maltreated. Eventually, the indicated operation is performed, but too late and thus carries a higher morbidity and mortality. The etiology of such chaos is not entirely clear. Motives of power, ego, and financial considerations are surely involved; it is politically correct to call this a ‘system failure’.\\n\\nThe team approach to the acutely ill surgical patient should not be discarded. The team, however, should be led and coordinated by a general surgeon. He is the one who knows the abdomen from within and without. He is the one qualified to call in consultants from other specialties, to order valuable tests, to veto those that are superfluous and wasteful. And, above all, he is the one who will eventually decide that enough is enough and the patient needs to be taken to the operating room.\\n\\nWhen you decided to become a general surgeon you became the captain of the ship, navigating the deep ocean of the abdomen. Do not abandon your ship while the storm rages on!\\n\\nContinuity of care is a sine qua non in the optimal care of the acute abdomen as the clinical picture, which may change rapidly, is a major determinant in the choice of therapy and its timing. Such patients need to be frequently reassessed by the same clinician, who should be a surgeon. Any deviation from this may be hazardous to the patient; this is our personal experience and that which is repeated ad nauseum in the literature. Why don’t we learn? The place for the patient with an acute abdominal condition is on the surgical floor, surgical intensive care unit (ICU), or in the operating room and under the care of a surgeon — yourself. Don’t duck your responsibilities!',\n", " 'md': 'A characteristic scenario is a patient with an abdominal surgical emergency, admitted under the care of non-surgeons who undertake a series of unnecessary, potentially harmful and expensive diagnostic and therapeutic procedures. Typically, internists, gastroenterologists, infectious-disease specialists, and radiologists are involved, each prescribing his own wisdom in isolation (many treating the patient for ‘CRPitis’ or ECOUO — elevated CRP of unknown origin...) (Figure 3.2). When, finally, the surgeon is called in, he finds the condition difficult to diagnose, partially treated or maltreated. Eventually, the indicated operation is performed, but too late and thus carries a higher morbidity and mortality. The etiology of such chaos is not entirely clear. Motives of power, ego, and financial considerations are surely involved; it is politically correct to call this a ‘system failure’.\\n\\nThe team approach to the acutely ill surgical patient should not be discarded. The team, however, should be led and coordinated by a general surgeon. He is the one who knows the abdomen from within and without. He is the one qualified to call in consultants from other specialties, to order valuable tests, to veto those that are superfluous and wasteful. And, above all, he is the one who will eventually decide that enough is enough and the patient needs to be taken to the operating room.\\n\\nWhen you decided to become a general surgeon you became the captain of the ship, navigating the deep ocean of the abdomen. Do not abandon your ship while the storm rages on!\\n\\nContinuity of care is a sine qua non in the optimal care of the acute abdomen as the clinical picture, which may change rapidly, is a major determinant in the choice of therapy and its timing. Such patients need to be frequently reassessed by the same clinician, who should be a surgeon. Any deviation from this may be hazardous to the patient; this is our personal experience and that which is repeated ad nauseum in the literature. Why don’t we learn? The place for the patient with an acute abdominal condition is on the surgical floor, surgical intensive care unit (ICU), or in the operating room and under the care of a surgeon — yourself. Don’t duck your responsibilities!',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures',\n", " 'md': '## Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 3.2',\n", " 'md': '### Figure 3.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure likely illustrates the chaotic scenario described in the text, where multiple specialists are involved in the care of a patient with an acute abdominal condition, leading to delays and complications in treatment.\\n- **Summary**: The figure emphasizes the importance of a coordinated approach led by a general surgeon to avoid unnecessary procedures and ensure timely intervention for patients with abdominal emergencies.\\n```',\n", " 'md': '- **Description**: This figure likely illustrates the chaotic scenario described in the text, where multiple specialists are involved in the care of a patient with an acute abdominal condition, leading to delays and complications in treatment.\\n- **Summary**: The figure emphasizes the importance of a coordinated approach led by a general surgeon to avoid unnecessary procedures and ensure timely intervention for patients with abdominal emergencies.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '‘ CRPitis ’ or ECOUO — elevated CRP of unknown origin...) ( Figure 3.2). When, finally, the surgeon is called in, he finds the condition difficult to diagnose, partially treated or maltreated. Eventually, the indicated'}]},\n", " {'page': 59,\n", " 'text': ' Only 10 or 20 years ago, when we were residents, an ‘acute abdomen’\\nand clinical evidence of peritonitis mandated an operation. Today we are\\nsmarter. Judicious use of diagnostic modalities (see Chapter 4) and\\nbetter understanding of the natural history of various disease processes\\nallow us to decrease mortality and morbidity by being less invasive and\\nmore selective and, in general, to achieve more by doing less.\\n\\n The key for the ‘best’ outcome of the acute abdomen is:\\n\\n Operate only when necessary, and do the minimum possible.\\n Do not delay a necessary operation, and do the maximum when indicated.\\n\\n “The concept that one citizen will lay himself horizontal\\n and permit another to plunge a knife into him, take blood,\\n give blood, rearrange internal structures at will,\\n determine ultimate function, indeed, sometimes life itself\\n — that responsibility is awesome both in true and in the\\n currently debased meaning of that word.”\\n Alexander J. Walt\\n\\n1 Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.',\n", " 'md': '```markdown\\nOnly 10 or 20 years ago, when we were residents, an ‘acute abdomen’ and clinical evidence of peritonitis mandated an operation. Today we are smarter. Judicious use of diagnostic modalities (see Chapter 4) and better understanding of the natural history of various disease processes allow us to decrease mortality and morbidity by being less invasive and more selective and, in general, to achieve more by doing less.\\n\\nThe key for the ‘best’ outcome of the acute abdomen is:\\n\\n- Operate only when necessary, and do the minimum possible.\\n- Do not delay a necessary operation, and do the maximum when indicated.\\n\\n“The concept that one citizen will lay himself horizontal and permit another to plunge a knife into him, take blood, give blood, rearrange internal structures at will, determine ultimate function, indeed, sometimes life itself — that responsibility is awesome both in true and in the currently debased meaning of that word.”\\n— Alexander J. Walt\\n\\n1 Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nOnly 10 or 20 years ago, when we were residents, an ‘acute abdomen’ and clinical evidence of peritonitis mandated an operation. Today we are smarter. Judicious use of diagnostic modalities (see Chapter 4) and better understanding of the natural history of various disease processes allow us to decrease mortality and morbidity by being less invasive and more selective and, in general, to achieve more by doing less.\\n\\nThe key for the ‘best’ outcome of the acute abdomen is:\\n\\n- Operate only when necessary, and do the minimum possible.\\n- Do not delay a necessary operation, and do the maximum when indicated.\\n\\n“The concept that one citizen will lay himself horizontal and permit another to plunge a knife into him, take blood, give blood, rearrange internal structures at will, determine ultimate function, indeed, sometimes life itself — that responsibility is awesome both in true and in the currently debased meaning of that word.”\\n— Alexander J. Walt\\n\\n1 Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.\\n```',\n", " 'md': '```markdown\\nOnly 10 or 20 years ago, when we were residents, an ‘acute abdomen’ and clinical evidence of peritonitis mandated an operation. Today we are smarter. Judicious use of diagnostic modalities (see Chapter 4) and better understanding of the natural history of various disease processes allow us to decrease mortality and morbidity by being less invasive and more selective and, in general, to achieve more by doing less.\\n\\nThe key for the ‘best’ outcome of the acute abdomen is:\\n\\n- Operate only when necessary, and do the minimum possible.\\n- Do not delay a necessary operation, and do the maximum when indicated.\\n\\n“The concept that one citizen will lay himself horizontal and permit another to plunge a knife into him, take blood, give blood, rearrange internal structures at will, determine ultimate function, indeed, sometimes life itself — that responsibility is awesome both in true and in the currently debased meaning of that word.”\\n— Alexander J. Walt\\n\\n1 Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.69, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'better understanding of the natural history of various disease processes'},\n", " {'text': '1'}]},\n", " {'page': 60,\n", " 'text': 'Chapter 4\\nRational diagnostic procedures\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and\\nJonathan E. Efron 1\\n\\n To open an abdomen and search for a lesion as lightly as\\n one would open a bureau drawer to look for the laundry,\\n may mean lack of mental overwork to the surgeon, but it\\n means horror to the patient.\\n J. Chalmers Da Costa\\n To see what is in front of one’s nose needs a constant\\n struggle.\\n George Orwell\\n\\n The 21st century brought bad news to the surgical cowboys. In the\\ngood old days you examined the patient, observed the systemic signs of\\ninfection or inflammation, poked the abdomen with your delicate hands\\nand noted “peritonitis” and hurrah — “take him to the OR”, you exclaimed\\nwith gusto, bathing in the admiration of the nurses and the envy of the\\nnon-surgeons — Gee, what a clinician! But these days even the born\\ncowboys have to feign being tame farmers: in the vast majority of\\ncases one can now only go to the OR with an established diagnosis!\\n\\n When treating a patient with acute abdominal pain it is tempting to\\nmake extensive use of ancillary investigations. This leads to the\\nemergence of ‘routines’ in the emergency room (ER) whereby every\\npatient with acute abdominal pain undergoes a series of blood tests,',\n", " 'md': '```markdown\\n# Chapter 4: Rational Diagnostic Procedures\\n\\n**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n> \"To open an abdomen and search for a lesion as lightly as one would open a bureau drawer to look for the laundry, may mean lack of mental overwork to the surgeon, but it means horror to the patient.\"\\n> — J. Chalmers Da Costa\\n\\n> \"To see what is in front of one’s nose needs a constant struggle.\"\\n> — George Orwell\\n\\nThe 21st century brought bad news to the surgical cowboys. In the good old days, you examined the patient, observed the systemic signs of infection or inflammation, poked the abdomen with your delicate hands and noted “peritonitis” and hurrah — “take him to the OR”, you exclaimed with gusto, bathing in the admiration of the nurses and the envy of the non-surgeons — Gee, what a clinician! But these days even the born cowboys have to feign being tame farmers: in the vast majority of cases one can now only go to the OR with an established diagnosis!\\n\\nWhen treating a patient with acute abdominal pain, it is tempting to make extensive use of ancillary investigations. This leads to the emergence of ‘routines’ in the emergency room (ER) whereby every patient with acute abdominal pain undergoes a series of blood tests.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 4: Rational Diagnostic Procedures',\n", " 'md': '# Chapter 4: Rational Diagnostic Procedures',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 276.64, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n> \"To open an abdomen and search for a lesion as lightly as one would open a bureau drawer to look for the laundry, may mean lack of mental overwork to the surgeon, but it means horror to the patient.\"\\n> — J. Chalmers Da Costa\\n\\n> \"To see what is in front of one’s nose needs a constant struggle.\"\\n> — George Orwell\\n\\nThe 21st century brought bad news to the surgical cowboys. In the good old days, you examined the patient, observed the systemic signs of infection or inflammation, poked the abdomen with your delicate hands and noted “peritonitis” and hurrah — “take him to the OR”, you exclaimed with gusto, bathing in the admiration of the nurses and the envy of the non-surgeons — Gee, what a clinician! But these days even the born cowboys have to feign being tame farmers: in the vast majority of cases one can now only go to the OR with an established diagnosis!\\n\\nWhen treating a patient with acute abdominal pain, it is tempting to make extensive use of ancillary investigations. This leads to the emergence of ‘routines’ in the emergency room (ER) whereby every patient with acute abdominal pain undergoes a series of blood tests.\\n```',\n", " 'md': '**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n> \"To open an abdomen and search for a lesion as lightly as one would open a bureau drawer to look for the laundry, may mean lack of mental overwork to the surgeon, but it means horror to the patient.\"\\n> — J. Chalmers Da Costa\\n\\n> \"To see what is in front of one’s nose needs a constant struggle.\"\\n> — George Orwell\\n\\nThe 21st century brought bad news to the surgical cowboys. In the good old days, you examined the patient, observed the systemic signs of infection or inflammation, poked the abdomen with your delicate hands and noted “peritonitis” and hurrah — “take him to the OR”, you exclaimed with gusto, bathing in the admiration of the nurses and the envy of the non-surgeons — Gee, what a clinician! But these days even the born cowboys have to feign being tame farmers: in the vast majority of cases one can now only go to the OR with an established diagnosis!\\n\\nWhen treating a patient with acute abdominal pain, it is tempting to make extensive use of ancillary investigations. This leads to the emergence of ‘routines’ in the emergency room (ER) whereby every patient with acute abdominal pain undergoes a series of blood tests.\\n```',\n", " 'bBox': {'x': 72, 'y': 381, 'w': 467.53, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Jonathan E. Efron 1'}]},\n", " {'page': 61,\n", " 'text': 'which typically includes a complete blood count, routine blood chemistry\\nand serum amylase plus or minus whatever is fashionable, the soup de\\njour if you like, and a plain X-ray of the abdomen (AXR). As you know, in\\nmany centers the latter has been replaced with the knee jerk of a CT.\\nThese ‘routine’ tests have a very low diagnostic yield and are not cost\\neffective. However, they are also an unavoidable part of life in the ER\\nand are often, if not usually, obtained before the surgical\\nconsultation.\\n\\n For some surgeons the clinical finding of clear-cut diffuse peritonitis is\\nstill an indication to proceed with laparotomy or laparoscopy with no\\nfurther imaging. But what appears clear-cut to the experienced surgeon\\n— remember that he too may be wrong — may be less so for you. And\\nplease bear in mind the following caveats:\\n\\n • Intestinal distension associated with obstruction or inflammation\\n (e.g. enteritis or colitis) may produce diffuse abdominal tenderness\\n — mimicking ‘peritonitis’. The whole clinical picture as well as the\\n AXR will guide you toward the proper diagnosis ( Chapters 21 and\\n 27).\\n • Acute pancreatitis may present with clinical acute peritonitis. You\\n should always obtain a serum amylase or lipase level in every\\n patient with significant abdominal pain in order to avoid falling into\\n the not uncommon trap of unnecessarily and dangerously\\n operating on acute pancreatitis ( Chapter 19).\\n • Clostridium difficile enterocolitis should be considered in any\\n patient who receives, or has recently received, any quantity of\\n antibiotics. This may present — from the beginning — even as an\\n acute abdomen without diarrhea. ħere, the optimal initial\\n management is medical and not a laparotomy; sigmoidoscopy\\n and/or computed tomography (CT) may be diagnostic ( Chapter\\n 26).\\n\\n Blood tests\\n\\n As stated above, ‘routine labs’ are of minimal value. In addition to\\namylase level the only ‘routines’ that can be supported are white cell',\n", " 'md': '```markdown\\n## Clinical Considerations in Emergency Surgery\\n\\nIn emergency settings, routine tests typically include a complete blood count, routine blood chemistry, and serum amylase, along with a plain X-ray of the abdomen (AXR). In many centers, the AXR has been replaced by a CT scan. These ‘routine’ tests have a very low diagnostic yield and are not cost-effective. However, they are often obtained before the surgical consultation.\\n\\n### Key Points to Consider\\n\\n1. **Clinical Findings**:\\n- The clinical finding of clear-cut diffuse peritonitis may lead some surgeons to proceed with laparotomy or laparoscopy without further imaging. However, what seems clear to an experienced surgeon may not be as evident to others.\\n\\n2. **Caveats**:\\n- **Intestinal Distension**: Intestinal distension associated with obstruction or inflammation (e.g., enteritis or colitis) may produce diffuse abdominal tenderness, mimicking ‘peritonitis’. The entire clinical picture and the AXR will guide toward the proper diagnosis (refer to Chapters 21 and 27).\\n- **Acute Pancreatitis**: Acute pancreatitis may present with clinical acute peritonitis. Always obtain a serum amylase or lipase level in patients with significant abdominal pain to avoid unnecessary and dangerous operations (refer to Chapter 19).\\n- **Clostridium Difficile Enterocolitis**: Consider this in any patient who has received antibiotics. It may present as an acute abdomen without diarrhea. The optimal initial management is medical, not laparotomy; sigmoidoscopy and/or computed tomography (CT) may be diagnostic (refer to Chapter 26).\\n\\n### Blood Tests\\n\\nAs stated above, ‘routine labs’ are of minimal value. In addition to amylase level, the only ‘routines’ that can be supported are white cell counts.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Considerations in Emergency Surgery',\n", " 'md': '## Clinical Considerations in Emergency Surgery',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In emergency settings, routine tests typically include a complete blood count, routine blood chemistry, and serum amylase, along with a plain X-ray of the abdomen (AXR). In many centers, the AXR has been replaced by a CT scan. These ‘routine’ tests have a very low diagnostic yield and are not cost-effective. However, they are often obtained before the surgical consultation.',\n", " 'md': 'In emergency settings, routine tests typically include a complete blood count, routine blood chemistry, and serum amylase, along with a plain X-ray of the abdomen (AXR). In many centers, the AXR has been replaced by a CT scan. These ‘routine’ tests have a very low diagnostic yield and are not cost-effective. However, they are often obtained before the surgical consultation.',\n", " 'bBox': {'x': 72, 'y': 201, 'w': 89, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key Points to Consider',\n", " 'md': '### Key Points to Consider',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. **Clinical Findings**:\\n- The clinical finding of clear-cut diffuse peritonitis may lead some surgeons to proceed with laparotomy or laparoscopy without further imaging. However, what seems clear to an experienced surgeon may not be as evident to others.\\n\\n2. **Caveats**:\\n- **Intestinal Distension**: Intestinal distension associated with obstruction or inflammation (e.g., enteritis or colitis) may produce diffuse abdominal tenderness, mimicking ‘peritonitis’. The entire clinical picture and the AXR will guide toward the proper diagnosis (refer to Chapters 21 and 27).\\n- **Acute Pancreatitis**: Acute pancreatitis may present with clinical acute peritonitis. Always obtain a serum amylase or lipase level in patients with significant abdominal pain to avoid unnecessary and dangerous operations (refer to Chapter 19).\\n- **Clostridium Difficile Enterocolitis**: Consider this in any patient who has received antibiotics. It may present as an acute abdomen without diarrhea. The optimal initial management is medical, not laparotomy; sigmoidoscopy and/or computed tomography (CT) may be diagnostic (refer to Chapter 26).',\n", " 'md': '1. **Clinical Findings**:\\n- The clinical finding of clear-cut diffuse peritonitis may lead some surgeons to proceed with laparotomy or laparoscopy without further imaging. However, what seems clear to an experienced surgeon may not be as evident to others.\\n\\n2. **Caveats**:\\n- **Intestinal Distension**: Intestinal distension associated with obstruction or inflammation (e.g., enteritis or colitis) may produce diffuse abdominal tenderness, mimicking ‘peritonitis’. The entire clinical picture and the AXR will guide toward the proper diagnosis (refer to Chapters 21 and 27).\\n- **Acute Pancreatitis**: Acute pancreatitis may present with clinical acute peritonitis. Always obtain a serum amylase or lipase level in patients with significant abdominal pain to avoid unnecessary and dangerous operations (refer to Chapter 19).\\n- **Clostridium Difficile Enterocolitis**: Consider this in any patient who has received antibiotics. It may present as an acute abdomen without diarrhea. The optimal initial management is medical, not laparotomy; sigmoidoscopy and/or computed tomography (CT) may be diagnostic (refer to Chapter 26).',\n", " 'bBox': {'x': 100, 'y': 389, 'w': 437.08, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Blood Tests',\n", " 'md': '### Blood Tests',\n", " 'bBox': {'x': 86, 'y': 655, 'w': 90.12, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As stated above, ‘routine labs’ are of minimal value. In addition to amylase level, the only ‘routines’ that can be supported are white cell counts.\\n```',\n", " 'md': 'As stated above, ‘routine labs’ are of minimal value. In addition to amylase level, the only ‘routines’ that can be supported are white cell counts.\\n```',\n", " 'bBox': {'x': 408, 'y': 560, 'w': 23.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}, {'text': ''}, {'text': ' Chapter'}]},\n", " {'page': 62,\n", " 'text': 'count, hematocrit and baseline evaluation of renal function. An elevated\\nwhite cell count denotes an inflammatory response. Be aware that acute\\ncholecystitis or acute appendicitis can be present even when the white\\ncell count is within the normal range. Its elevation, however, supports the\\ndiagnosis. Many surgeons are convinced that C-reactive protein (CRP)\\nlevels are more sensitive in the diagnosis of an inflammatory response —\\nthey may be right. A low hematocrit in the emergency situation signifies a\\nchronic or subacute anemia; it poorly reflects on the magnitude of any\\nacute hemorrhage. However, in patients receiving i.v. fluids, a low\\nhematocrit commonly reflects hemodilution. Liver function tests are of\\nvalue in patients with right upper quadrant pain, diagnosed to have acute\\ncholecystitis (note: liver function tests may be normal or nearly normal in\\nacute cholecystitis; rely on clinical examination and ultrasound) or\\ncholangitis ( Chapter 20). Serum albumin on admission is a useful\\nmarker of the severity of the acute, or acute-on-chronic disease, and is\\nalso of proven prognostic value. When operating, for example, on\\nsomeone with albumin levels of 1.5g/dL you know that you have to do the\\nminimum and to expect trouble after the operation; and, as you will hear\\nrepeatedly below, to avoid an intestinal anastomosis.\\n\\n Remember: Whichever tests are ordered, either by you or by someone else on\\n your behalf (usually the ER doctor), be aware that the significance of the results should\\n never be judged in isolation but considered as part of the whole clinical picture.\\n\\n Chest X-ray (CXR)\\n\\n A CXR is routinely obtained to search for free air under the diaphragm,\\nas this is demonstrated in the majority of patients with perforated peptic\\nulcer ( Chapter 18) but less frequently seen when colonic perforation is\\nthe underlying problem. (With colonic perforation, the amount of free air\\nseen on an upright CXR can range from none to huge, from a few\\nbubbles of localized perforation of diverticulitis to the abdominal\\nballooning after a colonoscopic tear — Chapter 28.) Remember that\\nfree air is better seen on an erect CXR than AXR. Free intraperitoneal\\nair is not always caused by a perforated viscus and it is not always\\nan indication for a laparotomy. There is a long list of ‘non-operative’',\n", " 'md': '```markdown\\n## Clinical Evaluation of Inflammatory Response\\n\\nAn elevated white cell count denotes an inflammatory response. Be aware that acute cholecystitis or acute appendicitis can be present even when the white cell count is within the normal range. Its elevation, however, supports the diagnosis. Many surgeons are convinced that C-reactive protein (CRP) levels are more sensitive in the diagnosis of an inflammatory response — they may be right.\\n\\nA low hematocrit in the emergency situation signifies chronic or subacute anemia; it poorly reflects on the magnitude of any acute hemorrhage. However, in patients receiving intravenous (i.v.) fluids, a low hematocrit commonly reflects hemodilution. Liver function tests are of value in patients with right upper quadrant pain, diagnosed to have acute cholecystitis (note: liver function tests may be normal or nearly normal in acute cholecystitis; rely on clinical examination and ultrasound) or cholangitis (see Chapter 20).\\n\\nSerum albumin on admission is a useful marker of the severity of the acute, or acute-on-chronic disease, and is also of proven prognostic value. When operating, for example, on someone with albumin levels of 1.5 g/dL, you know that you have to do the minimum and to expect trouble after the operation; and, as you will hear repeatedly below, to avoid an intestinal anastomosis.\\n\\n**Remember:** Whichever tests are ordered, either by you or by someone else on your behalf (usually the ER doctor), be aware that the significance of the results should never be judged in isolation but considered as part of the whole clinical picture.\\n\\n### Chest X-ray (CXR)\\n\\nA CXR is routinely obtained to search for free air under the diaphragm, as this is demonstrated in the majority of patients with perforated peptic ulcer (see Chapter 18) but less frequently seen when colonic perforation is the underlying problem. (With colonic perforation, the amount of free air seen on an upright CXR can range from none to huge, from a few bubbles of localized perforation of diverticulitis to the abdominal ballooning after a colonoscopic tear — see Chapter 28.)\\n\\nRemember that free air is better seen on an erect CXR than an abdominal X-ray (AXR). Free intraperitoneal air is not always caused by a perforated viscus and it is not always an indication for a laparotomy. There is a long list of ‘non-operative’ conditions that can also lead to free air.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Evaluation of Inflammatory Response',\n", " 'md': '## Clinical Evaluation of Inflammatory Response',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'An elevated white cell count denotes an inflammatory response. Be aware that acute cholecystitis or acute appendicitis can be present even when the white cell count is within the normal range. Its elevation, however, supports the diagnosis. Many surgeons are convinced that C-reactive protein (CRP) levels are more sensitive in the diagnosis of an inflammatory response — they may be right.\\n\\nA low hematocrit in the emergency situation signifies chronic or subacute anemia; it poorly reflects on the magnitude of any acute hemorrhage. However, in patients receiving intravenous (i.v.) fluids, a low hematocrit commonly reflects hemodilution. Liver function tests are of value in patients with right upper quadrant pain, diagnosed to have acute cholecystitis (note: liver function tests may be normal or nearly normal in acute cholecystitis; rely on clinical examination and ultrasound) or cholangitis (see Chapter 20).\\n\\nSerum albumin on admission is a useful marker of the severity of the acute, or acute-on-chronic disease, and is also of proven prognostic value. When operating, for example, on someone with albumin levels of 1.5 g/dL, you know that you have to do the minimum and to expect trouble after the operation; and, as you will hear repeatedly below, to avoid an intestinal anastomosis.\\n\\n**Remember:** Whichever tests are ordered, either by you or by someone else on your behalf (usually the ER doctor), be aware that the significance of the results should never be judged in isolation but considered as part of the whole clinical picture.',\n", " 'md': 'An elevated white cell count denotes an inflammatory response. Be aware that acute cholecystitis or acute appendicitis can be present even when the white cell count is within the normal range. Its elevation, however, supports the diagnosis. Many surgeons are convinced that C-reactive protein (CRP) levels are more sensitive in the diagnosis of an inflammatory response — they may be right.\\n\\nA low hematocrit in the emergency situation signifies chronic or subacute anemia; it poorly reflects on the magnitude of any acute hemorrhage. However, in patients receiving intravenous (i.v.) fluids, a low hematocrit commonly reflects hemodilution. Liver function tests are of value in patients with right upper quadrant pain, diagnosed to have acute cholecystitis (note: liver function tests may be normal or nearly normal in acute cholecystitis; rely on clinical examination and ultrasound) or cholangitis (see Chapter 20).\\n\\nSerum albumin on admission is a useful marker of the severity of the acute, or acute-on-chronic disease, and is also of proven prognostic value. When operating, for example, on someone with albumin levels of 1.5 g/dL, you know that you have to do the minimum and to expect trouble after the operation; and, as you will hear repeatedly below, to avoid an intestinal anastomosis.\\n\\n**Remember:** Whichever tests are ordered, either by you or by someone else on your behalf (usually the ER doctor), be aware that the significance of the results should never be judged in isolation but considered as part of the whole clinical picture.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Chest X-ray (CXR)',\n", " 'md': '### Chest X-ray (CXR)',\n", " 'bBox': {'x': 86, 'y': 522, 'w': 142.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A CXR is routinely obtained to search for free air under the diaphragm, as this is demonstrated in the majority of patients with perforated peptic ulcer (see Chapter 18) but less frequently seen when colonic perforation is the underlying problem. (With colonic perforation, the amount of free air seen on an upright CXR can range from none to huge, from a few bubbles of localized perforation of diverticulitis to the abdominal ballooning after a colonoscopic tear — see Chapter 28.)\\n\\nRemember that free air is better seen on an erect CXR than an abdominal X-ray (AXR). Free intraperitoneal air is not always caused by a perforated viscus and it is not always an indication for a laparotomy. There is a long list of ‘non-operative’ conditions that can also lead to free air.\\n```',\n", " 'md': 'A CXR is routinely obtained to search for free air under the diaphragm, as this is demonstrated in the majority of patients with perforated peptic ulcer (see Chapter 18) but less frequently seen when colonic perforation is the underlying problem. (With colonic perforation, the amount of free air seen on an upright CXR can range from none to huge, from a few bubbles of localized perforation of diverticulitis to the abdominal ballooning after a colonoscopic tear — see Chapter 28.)\\n\\nRemember that free air is better seen on an erect CXR than an abdominal X-ray (AXR). Free intraperitoneal air is not always caused by a perforated viscus and it is not always an indication for a laparotomy. There is a long list of ‘non-operative’ conditions that can also lead to free air.\\n```',\n", " 'bBox': {'x': 72, 'y': 558, 'w': 467.72, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'marker of the severity of the acute, or acute-on-chronic disease, and is'},\n", " {'text': 'the underlying problem. (With '},\n", " {'text': 'free air is better seen on an erect CXR than AXR. '}]},\n", " {'page': 63,\n", " 'text': 'conditions that may produce free intraperitoneal air, such as a tension\\npneumothorax or even vigorous cunnilingus (oral sex). So, don’t\\ndiagnose in haste, look at the whole clinical picture.\\n\\n Any textbook tells you that lower lobe pneumonia may mimic an acute\\nabdomen, so think about it. Obviously, findings such as lung metastases\\nor pleural effusion may hint at the cause of the abdominal condition and\\ninfluence treatment and prognosis. Pneumothorax, pneumomediastinum\\nor pleural effusion may be associated with spontaneous esophageal\\nperforation — Boerhaave’s syndrome ( Chapter 15), which can present\\nas an acute abdomen. The value of a CXR in blunt or penetrating\\nabdominal injury is obvious — look at it carefully — a chest tube\\ninserted before the operation for a small pneumothorax would\\nprevent a life-threatening tension pneumothorax during the\\noperation; you surely understand why. A pre-operative CXR may also\\nbe requested by the anesthetists, especially after you have inserted a\\ncentral venous line, or indeed for no reason at all.\\n\\n Finally, and rarely, be aware that what looks to you on chest\\nradiography like free air under the right diaphragm is not free air but\\nbowel (usually the hepatic flexure of the colon) interposed between the\\nliver and diaphragm. This entity is named after the Austrian radiologist\\nwho described it, Dr. Chilaiditi. If asymptomatic it is termed the ‘Chilaiditi\\nsign’. When symptoms are attributed to it (subcostal pain, constipation,\\nrespiratory distress), it becomes the ‘Chilaiditi syndrome’. We have\\nnever encountered this ‘syndrome’, but others claim an occasional need\\nfor its operative treatment with ‘colopexy’ or colectomy! In uncertain\\ncases abdominal CT shows the ‘free air’ to be in the colon.\\n\\n Plain abdominal X-ray (AXR)\\n\\n This is the classical surgeon’s X-ray, as only surgeons know the true\\nvalue of these simple and cheap radiographs. Radiologists can look at\\nand talk about AXRs forever, searching for findings that could justify\\nadditional imaging studies. We surgeons need only a few seconds to\\ndecide whether the AXR is ‘non-specific’, namely, does not show any\\nobvious abnormality, or shows an abnormal gas pattern or abnormal\\nopacities. Unfortunately, in many of today’s ‘modern’ ERs the humble',\n", " 'md': '```markdown\\n## Page Content\\n\\nConditions that may produce free intraperitoneal air, such as a tension pneumothorax or even vigorous cunnilingus (oral sex). So, don’t diagnose in haste, look at the whole clinical picture.\\n\\nAny textbook tells you that lower lobe pneumonia may mimic an acute abdomen, so think about it. Obviously, findings such as lung metastases or pleural effusion may hint at the cause of the abdominal condition and influence treatment and prognosis. Pneumothorax, pneumomediastinum or pleural effusion may be associated with spontaneous esophageal perforation — Boerhaave’s syndrome (Chapter 15), which can present as an acute abdomen. The value of a CXR in blunt or penetrating abdominal injury is obvious — look at it carefully — a chest tube inserted before the operation for a small pneumothorax would prevent a life-threatening tension pneumothorax during the operation; you surely understand why. A pre-operative CXR may also be requested by the anesthetists, especially after you have inserted a central venous line, or indeed for no reason at all.\\n\\nFinally, and rarely, be aware that what looks to you on chest radiography like free air under the right diaphragm is not free air but bowel (usually the hepatic flexure of the colon) interposed between the liver and diaphragm. This entity is named after the Austrian radiologist who described it, Dr. Chilaiditi. If asymptomatic it is termed the ‘Chilaiditi sign’. When symptoms are attributed to it (subcostal pain, constipation, respiratory distress), it becomes the ‘Chilaiditi syndrome’. We have never encountered this ‘syndrome’, but others claim an occasional need for its operative treatment with ‘colopexy’ or colectomy! In uncertain cases abdominal CT shows the ‘free air’ to be in the colon.\\n\\n### Plain abdominal X-ray (AXR)\\n\\nThis is the classical surgeon’s X-ray, as only surgeons know the true value of these simple and cheap radiographs. Radiologists can look at and talk about AXRs forever, searching for findings that could justify additional imaging studies. We surgeons need only a few seconds to decide whether the AXR is ‘non-specific’, namely, does not show any obvious abnormality, or shows an abnormal gas pattern or abnormal opacities. Unfortunately, in many of today’s ‘modern’ ERs the humble\\n```\\n\\n### Image Identification and Description\\n- **Figure 1**: There is no image or graphical element identified on this page.\\n\\n### Summary\\nThe text discusses various medical conditions that can lead to the presence of free intraperitoneal air, emphasizing the importance of thorough clinical evaluation. It also highlights the significance of chest X-rays in diagnosing conditions that may present as acute abdomen and introduces the Chilaiditi sign and syndrome. The section on plain abdominal X-rays (AXR) underscores the practical approach surgeons take in interpreting these radiographs.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Conditions that may produce free intraperitoneal air, such as a tension pneumothorax or even vigorous cunnilingus (oral sex). So, don’t diagnose in haste, look at the whole clinical picture.\\n\\nAny textbook tells you that lower lobe pneumonia may mimic an acute abdomen, so think about it. Obviously, findings such as lung metastases or pleural effusion may hint at the cause of the abdominal condition and influence treatment and prognosis. Pneumothorax, pneumomediastinum or pleural effusion may be associated with spontaneous esophageal perforation — Boerhaave’s syndrome (Chapter 15), which can present as an acute abdomen. The value of a CXR in blunt or penetrating abdominal injury is obvious — look at it carefully — a chest tube inserted before the operation for a small pneumothorax would prevent a life-threatening tension pneumothorax during the operation; you surely understand why. A pre-operative CXR may also be requested by the anesthetists, especially after you have inserted a central venous line, or indeed for no reason at all.\\n\\nFinally, and rarely, be aware that what looks to you on chest radiography like free air under the right diaphragm is not free air but bowel (usually the hepatic flexure of the colon) interposed between the liver and diaphragm. This entity is named after the Austrian radiologist who described it, Dr. Chilaiditi. If asymptomatic it is termed the ‘Chilaiditi sign’. When symptoms are attributed to it (subcostal pain, constipation, respiratory distress), it becomes the ‘Chilaiditi syndrome’. We have never encountered this ‘syndrome’, but others claim an occasional need for its operative treatment with ‘colopexy’ or colectomy! In uncertain cases abdominal CT shows the ‘free air’ to be in the colon.',\n", " 'md': 'Conditions that may produce free intraperitoneal air, such as a tension pneumothorax or even vigorous cunnilingus (oral sex). So, don’t diagnose in haste, look at the whole clinical picture.\\n\\nAny textbook tells you that lower lobe pneumonia may mimic an acute abdomen, so think about it. Obviously, findings such as lung metastases or pleural effusion may hint at the cause of the abdominal condition and influence treatment and prognosis. Pneumothorax, pneumomediastinum or pleural effusion may be associated with spontaneous esophageal perforation — Boerhaave’s syndrome (Chapter 15), which can present as an acute abdomen. The value of a CXR in blunt or penetrating abdominal injury is obvious — look at it carefully — a chest tube inserted before the operation for a small pneumothorax would prevent a life-threatening tension pneumothorax during the operation; you surely understand why. A pre-operative CXR may also be requested by the anesthetists, especially after you have inserted a central venous line, or indeed for no reason at all.\\n\\nFinally, and rarely, be aware that what looks to you on chest radiography like free air under the right diaphragm is not free air but bowel (usually the hepatic flexure of the colon) interposed between the liver and diaphragm. This entity is named after the Austrian radiologist who described it, Dr. Chilaiditi. If asymptomatic it is termed the ‘Chilaiditi sign’. When symptoms are attributed to it (subcostal pain, constipation, respiratory distress), it becomes the ‘Chilaiditi syndrome’. We have never encountered this ‘syndrome’, but others claim an occasional need for its operative treatment with ‘colopexy’ or colectomy! In uncertain cases abdominal CT shows the ‘free air’ to be in the colon.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.74, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Plain abdominal X-ray (AXR)',\n", " 'md': '### Plain abdominal X-ray (AXR)',\n", " 'bBox': {'x': 86, 'y': 580, 'w': 223.43, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is the classical surgeon’s X-ray, as only surgeons know the true value of these simple and cheap radiographs. Radiologists can look at and talk about AXRs forever, searching for findings that could justify additional imaging studies. We surgeons need only a few seconds to decide whether the AXR is ‘non-specific’, namely, does not show any obvious abnormality, or shows an abnormal gas pattern or abnormal opacities. Unfortunately, in many of today’s ‘modern’ ERs the humble\\n```',\n", " 'md': 'This is the classical surgeon’s X-ray, as only surgeons know the true value of these simple and cheap radiographs. Radiologists can look at and talk about AXRs forever, searching for findings that could justify additional imaging studies. We surgeons need only a few seconds to decide whether the AXR is ‘non-specific’, namely, does not show any obvious abnormality, or shows an abnormal gas pattern or abnormal opacities. Unfortunately, in many of today’s ‘modern’ ERs the humble\\n```',\n", " 'bBox': {'x': 138, 'y': 303, 'w': 21.59, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: There is no image or graphical element identified on this page.',\n", " 'md': '- **Figure 1**: There is no image or graphical element identified on this page.',\n", " 'bBox': {'x': 518, 'y': 303, 'w': 21.59, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses various medical conditions that can lead to the presence of free intraperitoneal air, emphasizing the importance of thorough clinical evaluation. It also highlights the significance of chest X-rays in diagnosing conditions that may present as acute abdomen and introduces the Chilaiditi sign and syndrome. The section on plain abdominal X-rays (AXR) underscores the practical approach surgeons take in interpreting these radiographs.',\n", " 'md': 'The text discusses various medical conditions that can lead to the presence of free intraperitoneal air, emphasizing the importance of thorough clinical evaluation. It also highlights the significance of chest X-rays in diagnosing conditions that may present as acute abdomen and introduces the Chilaiditi sign and syndrome. The section on plain abdominal X-rays (AXR) underscores the practical approach surgeons take in interpreting these radiographs.',\n", " 'bBox': {'x': 518, 'y': 303, 'w': 21.59, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'The value of a CXR in blunt or penetrating'}]},\n", " {'page': 64,\n", " 'text': 'AXR is bypassed in favor of the high-tech CT. In fact now, for many (but\\nwe hope not for you), the CT supplants not only the AXR but also proper\\nhistory taking and physical examination. Do not forget that we operate\\non patients and not on CT abnormalities. Go to Chapter 5 to read\\nabout AXRs in detail.\\n\\n Abdominal ultrasound (US)\\n\\n Abdominal US is a readily available diagnostic modality in most places.\\nIts reliability is operator-dependent; the ideal situation is when the US is\\nperformed and interpreted by an experienced clinician — a surgeon. And,\\nin fact, many European surgeons are trained to use US as part of the\\nphysical examination. US is very accurate in the diagnosis of acute\\ncholecystitis ( Chapter 20); it is also used by gynecologists to rule out\\nacute pelvic pathology in female patients ( Chapter 35), and to\\ndemonstrate urological pathologies such as hydronephrosis ( Chapter\\n37). A non-compressible tubular structure (a ‘small sausage’) in the right\\nlower quadrant may be diagnostic of acute appendicitis, but as will be\\ndiscussed in Chapter 23, there are more accurate modes to reach this\\ndiagnosis. US is useful in demonstrating intra-abdominal fluid — be it\\nascites, pus, or blood, localized or diffuse. In blunt abdominal trauma,\\nFAST (focused abdominal sonography for trauma) has almost replaced\\nthe use of diagnostic peritoneal lavage. An US-guided aspiration of\\nunexplained intraperitoneal fluid can clarify the diagnosis: is it bile or pus\\nor feces? What is the level of amylase, bilirubin and creatinine in the\\nfluid? This gives you an idea of what’s going on. And this is our policy\\n(see Chapter 32).\\n\\n Abdominal computed tomography\\n\\n The use of the CT scan in the acute abdomen remains a subject of\\nsome controversy. While it is true that a CT scan should not be part of the\\nmanagement algorithm in all patients with acute abdominal pain, the\\nexisting spiral CT technology is nevertheless immediately available\\nand very powerful. The temptation to use it is strong, especially by\\nless experienced clinicians, but also by those experienced ones\\nwho wish to achieve an early and accurate diagnosis and avoid',\n", " 'md': '```markdown\\n# Abdominal Imaging Techniques\\n\\n## AXR and CT Scans\\nAXR is bypassed in favor of the high-tech CT. In fact, now, for many (but we hope not for you), the CT supplants not only the AXR but also proper history taking and physical examination. Do not forget that we operate on patients and not on CT abnormalities. Go to [Chapter 5](#) to read about AXRs in detail.\\n\\n## Abdominal Ultrasound (US)\\nAbdominal US is a readily available diagnostic modality in most places. Its reliability is operator-dependent; the ideal situation is when the US is performed and interpreted by an experienced clinician — a surgeon.\\n\\n- US is very accurate in the diagnosis of acute cholecystitis (see [Chapter 20](#)); it is also used by gynecologists to rule out acute pelvic pathology in female patients (see [Chapter 35](#)), and to demonstrate urological pathologies such as hydronephrosis (see [Chapter 37](#)).\\n- A non-compressible tubular structure (a ‘small sausage’) in the right lower quadrant may be diagnostic of acute appendicitis, but as will be discussed in [Chapter 23](#), there are more accurate modes to reach this diagnosis.\\n- US is useful in demonstrating intra-abdominal fluid — be it ascites, pus, or blood, localized or diffuse.\\n- In blunt abdominal trauma, FAST (focused abdominal sonography for trauma) has almost replaced the use of diagnostic peritoneal lavage.\\n- An US-guided aspiration of unexplained intraperitoneal fluid can clarify the diagnosis: is it bile or pus or feces? What is the level of amylase, bilirubin, and creatinine in the fluid? This gives you an idea of what’s going on. And this is our policy (see [Chapter 32](#)).\\n\\n## Abdominal Computed Tomography\\nThe use of the CT scan in the acute abdomen remains a subject of some controversy. While it is true that a CT scan should not be part of the management algorithm in all patients with acute abdominal pain, the existing spiral CT technology is nevertheless immediately available and very powerful. The temptation to use it is strong, especially by less experienced clinicians, but also by those experienced ones who wish to achieve an early and accurate diagnosis and avoid...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Abdominal Imaging Techniques',\n", " 'md': '# Abdominal Imaging Techniques',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'AXR and CT Scans',\n", " 'md': '## AXR and CT Scans',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'AXR is bypassed in favor of the high-tech CT. In fact, now, for many (but we hope not for you), the CT supplants not only the AXR but also proper history taking and physical examination. Do not forget that we operate on patients and not on CT abnormalities. Go to [Chapter 5](#) to read about AXRs in detail.',\n", " 'md': 'AXR is bypassed in favor of the high-tech CT. In fact, now, for many (but we hope not for you), the CT supplants not only the AXR but also proper history taking and physical examination. Do not forget that we operate on patients and not on CT abnormalities. Go to [Chapter 5](#) to read about AXRs in detail.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.4, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Ultrasound (US)',\n", " 'md': '## Abdominal Ultrasound (US)',\n", " 'bBox': {'x': 86, 'y': 195, 'w': 214.22, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Abdominal US is a readily available diagnostic modality in most places. Its reliability is operator-dependent; the ideal situation is when the US is performed and interpreted by an experienced clinician — a surgeon.\\n\\n- US is very accurate in the diagnosis of acute cholecystitis (see [Chapter 20](#)); it is also used by gynecologists to rule out acute pelvic pathology in female patients (see [Chapter 35](#)), and to demonstrate urological pathologies such as hydronephrosis (see [Chapter 37](#)).\\n- A non-compressible tubular structure (a ‘small sausage’) in the right lower quadrant may be diagnostic of acute appendicitis, but as will be discussed in [Chapter 23](#), there are more accurate modes to reach this diagnosis.\\n- US is useful in demonstrating intra-abdominal fluid — be it ascites, pus, or blood, localized or diffuse.\\n- In blunt abdominal trauma, FAST (focused abdominal sonography for trauma) has almost replaced the use of diagnostic peritoneal lavage.\\n- An US-guided aspiration of unexplained intraperitoneal fluid can clarify the diagnosis: is it bile or pus or feces? What is the level of amylase, bilirubin, and creatinine in the fluid? This gives you an idea of what’s going on. And this is our policy (see [Chapter 32](#)).',\n", " 'md': 'Abdominal US is a readily available diagnostic modality in most places. Its reliability is operator-dependent; the ideal situation is when the US is performed and interpreted by an experienced clinician — a surgeon.\\n\\n- US is very accurate in the diagnosis of acute cholecystitis (see [Chapter 20](#)); it is also used by gynecologists to rule out acute pelvic pathology in female patients (see [Chapter 35](#)), and to demonstrate urological pathologies such as hydronephrosis (see [Chapter 37](#)).\\n- A non-compressible tubular structure (a ‘small sausage’) in the right lower quadrant may be diagnostic of acute appendicitis, but as will be discussed in [Chapter 23](#), there are more accurate modes to reach this diagnosis.\\n- US is useful in demonstrating intra-abdominal fluid — be it ascites, pus, or blood, localized or diffuse.\\n- In blunt abdominal trauma, FAST (focused abdominal sonography for trauma) has almost replaced the use of diagnostic peritoneal lavage.\\n- An US-guided aspiration of unexplained intraperitoneal fluid can clarify the diagnosis: is it bile or pus or feces? What is the level of amylase, bilirubin, and creatinine in the fluid? This gives you an idea of what’s going on. And this is our policy (see [Chapter 32](#)).',\n", " 'bBox': {'x': 72, 'y': 231, 'w': 467.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Computed Tomography',\n", " 'md': '## Abdominal Computed Tomography',\n", " 'bBox': {'x': 86, 'y': 572, 'w': 269.42, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The use of the CT scan in the acute abdomen remains a subject of some controversy. While it is true that a CT scan should not be part of the management algorithm in all patients with acute abdominal pain, the existing spiral CT technology is nevertheless immediately available and very powerful. The temptation to use it is strong, especially by less experienced clinicians, but also by those experienced ones who wish to achieve an early and accurate diagnosis and avoid...\\n```',\n", " 'md': 'The use of the CT scan in the acute abdomen remains a subject of some controversy. While it is true that a CT scan should not be part of the management algorithm in all patients with acute abdominal pain, the existing spiral CT technology is nevertheless immediately available and very powerful. The temptation to use it is strong, especially by less experienced clinicians, but also by those experienced ones who wish to achieve an early and accurate diagnosis and avoid...\\n```',\n", " 'bBox': {'x': 72, 'y': 625, 'w': 467.65, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'acute pelvic pathology in female patients ('},\n", " {'text': 'demonstrate urological pathologies such as hydronephrosis ('},\n", " {'text': 'demonstrate urological pathologies such as hydronephrosis ( Chapter 37). A non-compressible tubular structure (a ‘small sausage’) in the right lower quadrant may be diagnostic of acute appendicitis, but as will be'},\n", " {'text': 'diagnosis. US is useful in demonstrating intra-abdominal fluid — be it'},\n", " {'text': ''}]},\n", " {'page': 65,\n", " 'text': 'unnecessary procedures.\\n\\n The major role of CT, where it can really make a critical difference, is\\nwith ‘clinical puzzles’. Not infrequently, the surgeon encounters a patient\\nwith acute abdominal pain that does not fit any of the clinical patterns\\ndescribed in Chapter 3. The patient is obviously sick, but the diagnosis\\nremains elusive. Occasionally there may be a suspicion of acute intra-\\nabdominal pathology in an unconscious patient. Under these\\ncircumstances, CT may be very helpful in identifying an intra-abdominal\\nproblem. It is even better in excluding the latter by being absolutely\\nnormal — letting you go home and pour an inch or so on the rocks. Know\\nthe feeling? Finally, the indespensible role of CT in abdominal trauma is\\ndiscussed later ( Chapter 32).\\n\\n The judicious and selective use of CT may help in avoiding\\nsurgery altogether — where previously ‘negative’, ‘exploratory’ or\\n‘non-therapeutic’ operations would have been performed. It may\\nsuggest that alternative percutaneous treatment is possible and, even if\\nan operation is still indicated, it may indicate the best incision and\\napproach ( Chapter 10). CT has a definite role in the post-laparotomy\\npatient as discussed in Part IV — “After the operation”. For a detailed\\ndiscussion on the interpretation of abdominal CT go to Chapter 5.\\n\\n A word of caution\\n\\n For most patients with acute abdominal pain, unnecessary ancillary\\ninvestigations are merely a resource problem and a waste of time. But for\\nsome surgical problems, unnecessary imaging can be lethal:\\n\\n • Acute mesenteric ischemia is the only life-threatening abdominal\\n condition that cannot be easily classified into one of the five clinical\\n patterns described in Chapter 3. Because of this, and because\\n your opportunity to salvage viable bowel is so limited, you must have\\n this diagnosis constantly embedded in the back of your mind. The\\n best chance to salvage these patients is to recognize the clinical\\n picture of severe abdominal pain with few objective findings in the\\n appropriate clinical context ( Chapter 24) and to proceed directly',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nThe major role of CT, where it can really make a critical difference, is with ‘clinical puzzles’. Not infrequently, the surgeon encounters a patient with acute abdominal pain that does not fit any of the clinical patterns described in Chapter 3. The patient is obviously sick, but the diagnosis remains elusive. Occasionally there may be a suspicion of acute intra-abdominal pathology in an unconscious patient. Under these circumstances, CT may be very helpful in identifying an intra-abdominal problem. It is even better in excluding the latter by being absolutely normal — letting you go home and pour an inch or so on the rocks. Know the feeling? Finally, the indispensable role of CT in abdominal trauma is discussed later (Chapter 32).\\n\\nThe judicious and selective use of CT may help in avoiding surgery altogether — where previously ‘negative’, ‘exploratory’ or ‘non-therapeutic’ operations would have been performed. It may suggest that alternative percutaneous treatment is possible and, even if an operation is still indicated, it may indicate the best incision and approach (Chapter 10). CT has a definite role in the post-laparotomy patient as discussed in Part IV — “After the operation”. For a detailed discussion on the interpretation of abdominal CT go to Chapter 5.\\n\\n### A word of caution\\n\\nFor most patients with acute abdominal pain, unnecessary ancillary investigations are merely a resource problem and a waste of time. But for some surgical problems, unnecessary imaging can be lethal:\\n\\n- Acute mesenteric ischemia is the only life-threatening abdominal condition that cannot be easily classified into one of the five clinical patterns described in Chapter 3. Because of this, and because your opportunity to salvage viable bowel is so limited, you must have this diagnosis constantly embedded in the back of your mind. The best chance to salvage these patients is to recognize the clinical picture of severe abdominal pain with few objective findings in the appropriate clinical context (Chapter 24) and to proceed directly.\\n\\n## Hyperlinks\\n\\n- Chapter 3\\n- Chapter 32\\n- Chapter 10\\n- Chapter 5\\n- Chapter 24\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The major role of CT, where it can really make a critical difference, is with ‘clinical puzzles’. Not infrequently, the surgeon encounters a patient with acute abdominal pain that does not fit any of the clinical patterns described in Chapter 3. The patient is obviously sick, but the diagnosis remains elusive. Occasionally there may be a suspicion of acute intra-abdominal pathology in an unconscious patient. Under these circumstances, CT may be very helpful in identifying an intra-abdominal problem. It is even better in excluding the latter by being absolutely normal — letting you go home and pour an inch or so on the rocks. Know the feeling? Finally, the indispensable role of CT in abdominal trauma is discussed later (Chapter 32).\\n\\nThe judicious and selective use of CT may help in avoiding surgery altogether — where previously ‘negative’, ‘exploratory’ or ‘non-therapeutic’ operations would have been performed. It may suggest that alternative percutaneous treatment is possible and, even if an operation is still indicated, it may indicate the best incision and approach (Chapter 10). CT has a definite role in the post-laparotomy patient as discussed in Part IV — “After the operation”. For a detailed discussion on the interpretation of abdominal CT go to Chapter 5.',\n", " 'md': 'The major role of CT, where it can really make a critical difference, is with ‘clinical puzzles’. Not infrequently, the surgeon encounters a patient with acute abdominal pain that does not fit any of the clinical patterns described in Chapter 3. The patient is obviously sick, but the diagnosis remains elusive. Occasionally there may be a suspicion of acute intra-abdominal pathology in an unconscious patient. Under these circumstances, CT may be very helpful in identifying an intra-abdominal problem. It is even better in excluding the latter by being absolutely normal — letting you go home and pour an inch or so on the rocks. Know the feeling? Finally, the indispensable role of CT in abdominal trauma is discussed later (Chapter 32).\\n\\nThe judicious and selective use of CT may help in avoiding surgery altogether — where previously ‘negative’, ‘exploratory’ or ‘non-therapeutic’ operations would have been performed. It may suggest that alternative percutaneous treatment is possible and, even if an operation is still indicated, it may indicate the best incision and approach (Chapter 10). CT has a definite role in the post-laparotomy patient as discussed in Part IV — “After the operation”. For a detailed discussion on the interpretation of abdominal CT go to Chapter 5.',\n", " 'bBox': {'x': 72, 'y': 121, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'A word of caution',\n", " 'md': '### A word of caution',\n", " 'bBox': {'x': 86, 'y': 481, 'w': 139.12, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'For most patients with acute abdominal pain, unnecessary ancillary investigations are merely a resource problem and a waste of time. But for some surgical problems, unnecessary imaging can be lethal:\\n\\n- Acute mesenteric ischemia is the only life-threatening abdominal condition that cannot be easily classified into one of the five clinical patterns described in Chapter 3. Because of this, and because your opportunity to salvage viable bowel is so limited, you must have this diagnosis constantly embedded in the back of your mind. The best chance to salvage these patients is to recognize the clinical picture of severe abdominal pain with few objective findings in the appropriate clinical context (Chapter 24) and to proceed directly.',\n", " 'md': 'For most patients with acute abdominal pain, unnecessary ancillary investigations are merely a resource problem and a waste of time. But for some surgical problems, unnecessary imaging can be lethal:\\n\\n- Acute mesenteric ischemia is the only life-threatening abdominal condition that cannot be easily classified into one of the five clinical patterns described in Chapter 3. Because of this, and because your opportunity to salvage viable bowel is so limited, you must have this diagnosis constantly embedded in the back of your mind. The best chance to salvage these patients is to recognize the clinical picture of severe abdominal pain with few objective findings in the appropriate clinical context (Chapter 24) and to proceed directly.',\n", " 'bBox': {'x': 72, 'y': 170, 'w': 467.58, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Hyperlinks',\n", " 'md': '## Hyperlinks',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Chapter 3\\n- Chapter 32\\n- Chapter 10\\n- Chapter 5\\n- Chapter 24\\n```',\n", " 'md': '- Chapter 3\\n- Chapter 32\\n- Chapter 10\\n- Chapter 5\\n- Chapter 24\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'remains elusive. Occasionally there may be a suspicion of acute intra-'},\n", " {'text': ''},\n", " {'text': 'patient as discussed in Part IV — “After the operation”. For a detailed'},\n", " {'text': ''},\n", " {'text': 'your opportunity to salvage viable bowel is so limited, you must have'},\n", " {'text': ''}]},\n", " {'page': 66,\n", " 'text': ' to ‘CT angio’ (mesenteric angiography). The tragedy in these\\n patients is the inability of even an experienced clinician to make his\\n or her mind up regarding the need for urgent imaging of the\\n mesenteric vasculature. As a result, the opportunity to salvage\\n viable bowel is lost. So, if you suspect mesenteric ischemia go\\n directly for a CT angio specifically to assess the patency of the\\n superior mesenteric artery as well as looking for possible bowel wall\\n thickening or gas bubbles in the bowel wall. There is no need to wait\\n for oral contrast to proceed. Along with CT angio, measurement of\\n blood lactate and D-dimer levels are helpful — high lactate levels\\n suggest ischemic bowel. Normal D-dimer levels speak against\\n thrombosis, high levels mean nothing.\\n • The second condition where the abuse of imaging may be lethal is\\n with a ruptured abdominal aortic aneurysm (AAA) ( Chapter\\n 34). The first scenario occurs in patients with a known aneurysm\\n presenting with features of acute rupture such as abdominal or back\\n pain associated with hypotension who are subjected to an\\n unnecessary CT that merely delays definitive treatment. The second\\n scenario arises as a result of the fact that a ruptured AAA may not\\n present as abdominal pain and shock but merely as severe\\n abdominal or back pain, and it may not be easily palpable in an\\n obese patient. When the possibility of a contained rupture is raised\\n in a hemodynamically stable patient, the one and only ancillary\\n investigation that is required is an urgent CT scan of the abdomen.\\n Unfortunately, too many times these patients spend several hours in\\n the ER, waiting for the results of non-relevant blood tests and\\n progressing slowly along the imaging path from AXRs, which are\\n usually non-diagnostic, to US, which shows the aneurysm but\\n usually cannot diagnose a rupture, to a long wait for unnecessary\\n contrast material to fill the bowel in preparation for a ‘technically\\n perfect’ CT scan. The tragic consequence of these delays is a\\n dramatic hemodynamic collapse either before or during an\\n abdominal CT scan.\\n\\n Contrast studies: barium vs. water-soluble contrast\\n\\n A caveat: in emergency situations do not use barium! Radiologists\\nprefer barium because of its superior imaging qualities, but for us —',\n", " 'md': '```markdown\\n## Key Points on Imaging in Emergency Situations\\n\\n- In cases of suspected mesenteric ischemia, it is crucial to proceed directly to a CT angiography (CT angio) to assess the patency of the superior mesenteric artery and to look for possible bowel wall thickening or gas bubbles in the bowel wall. There is no need to wait for oral contrast.\\n- Along with CT angio, measuring blood lactate and D-dimer levels can be helpful:\\n- High lactate levels suggest ischemic bowel.\\n- Normal D-dimer levels indicate against thrombosis, while high levels are inconclusive.\\n\\n### Conditions Where Imaging May Be Lethal\\n\\n1. **Ruptured Abdominal Aortic Aneurysm (AAA)**:\\n- Patients with a known aneurysm presenting with acute rupture features (abdominal or back pain with hypotension) may undergo unnecessary CT scans that delay definitive treatment.\\n- A ruptured AAA may present as severe abdominal or back pain without shock and may not be easily palpable in obese patients.\\n- In hemodynamically stable patients with a suspected contained rupture, the only necessary investigation is an urgent CT scan of the abdomen.\\n- Delays in treatment can lead to hemodynamic collapse before or during an abdominal CT scan.\\n\\n### Contrast Studies: Barium vs. Water-Soluble Contrast\\n\\n- **Caveat**: In emergency situations, do not use barium!\\n- Radiologists may prefer barium for its superior imaging qualities, but it is not suitable for emergency use.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Key Points on Imaging in Emergency Situations',\n", " 'md': '## Key Points on Imaging in Emergency Situations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- In cases of suspected mesenteric ischemia, it is crucial to proceed directly to a CT angiography (CT angio) to assess the patency of the superior mesenteric artery and to look for possible bowel wall thickening or gas bubbles in the bowel wall. There is no need to wait for oral contrast.\\n- Along with CT angio, measuring blood lactate and D-dimer levels can be helpful:\\n- High lactate levels suggest ischemic bowel.\\n- Normal D-dimer levels indicate against thrombosis, while high levels are inconclusive.',\n", " 'md': '- In cases of suspected mesenteric ischemia, it is crucial to proceed directly to a CT angiography (CT angio) to assess the patency of the superior mesenteric artery and to look for possible bowel wall thickening or gas bubbles in the bowel wall. There is no need to wait for oral contrast.\\n- Along with CT angio, measuring blood lactate and D-dimer levels can be helpful:\\n- High lactate levels suggest ischemic bowel.\\n- Normal D-dimer levels indicate against thrombosis, while high levels are inconclusive.',\n", " 'bBox': {'x': 100, 'y': 201, 'w': 437.04, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Conditions Where Imaging May Be Lethal',\n", " 'md': '### Conditions Where Imaging May Be Lethal',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. **Ruptured Abdominal Aortic Aneurysm (AAA)**:\\n- Patients with a known aneurysm presenting with acute rupture features (abdominal or back pain with hypotension) may undergo unnecessary CT scans that delay definitive treatment.\\n- A ruptured AAA may present as severe abdominal or back pain without shock and may not be easily palpable in obese patients.\\n- In hemodynamically stable patients with a suspected contained rupture, the only necessary investigation is an urgent CT scan of the abdomen.\\n- Delays in treatment can lead to hemodynamic collapse before or during an abdominal CT scan.',\n", " 'md': '1. **Ruptured Abdominal Aortic Aneurysm (AAA)**:\\n- Patients with a known aneurysm presenting with acute rupture features (abdominal or back pain with hypotension) may undergo unnecessary CT scans that delay definitive treatment.\\n- A ruptured AAA may present as severe abdominal or back pain without shock and may not be easily palpable in obese patients.\\n- In hemodynamically stable patients with a suspected contained rupture, the only necessary investigation is an urgent CT scan of the abdomen.\\n- Delays in treatment can lead to hemodynamic collapse before or during an abdominal CT scan.',\n", " 'bBox': {'x': 100, 'y': 618, 'w': 127.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Contrast Studies: Barium vs. Water-Soluble Contrast',\n", " 'md': '### Contrast Studies: Barium vs. Water-Soluble Contrast',\n", " 'bBox': {'x': 86, 'y': 664, 'w': 404.57, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- **Caveat**: In emergency situations, do not use barium!\\n- Radiologists may prefer barium for its superior imaging qualities, but it is not suitable for emergency use.\\n```',\n", " 'md': '- **Caveat**: In emergency situations, do not use barium!\\n- Radiologists may prefer barium for its superior imaging qualities, but it is not suitable for emergency use.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'ruptured abdominal aortic aneurysm (AAA) ( Chapter known aneurysm presenting with features of acute rupture such as abdominal or back'}]},\n", " {'page': 67,\n", " 'text': 'surgeons — barium is an enemy. Bacteria love barium, for it protects\\nthem from the peritoneal macrophages; a mixture of barium with feces is\\nthe best experimental recipe for the production of intractable peritonitis\\nand multiple intra-abdominal abscesses. Once barium leaks into the\\nperitoneal cavity it is very difficult to get rid of. Barium administered to the\\ngastrointestinal tract from above or below tends to stay there for days —\\ndistorting any subsequent CT or arteriography. And let us not forget the\\nrocks it forms in the rectum of constipated patients.\\n\\n A GI contrast study in the emergency situation has only two\\nqueries to answer:\\n\\n • Is there a leak and, if so, where? (Please note that the absence of\\n a contrast leak does not exclude a bowel perforation.)\\n • Is there an obstruction and, if so, where? (Please note that CT is\\n much better and more accurate in defining the obstruction site in\\n addition to giving other useful information about the condition of the\\n bowel.)\\n\\n For these purposes Gastrografin® is adequate. Use Gastrografin® in\\nupper gastrointestinal studies to document or exclude gastric outlet\\nobstruction, treat small bowel obstruction or postoperative ileus (\\nChapters 21 and 45) or order a Gastrografin® enema to diagnose colonic\\nobstruction or perforation. Unlike barium, Gastrografin® is harmless\\nshould it leak into the peritoneal cavity. Try to operate on a colon full of\\nbarium: a clamp slides off, a stapler misfires and you — not the\\nradiologist — are the one left to clean the s**t. Take some advice from\\nour bitter experience: ordering a Gastrografin® study is not enough;\\nyou must personally ensure that barium is not used. (The same, of\\ncourse, applies to an emergency CT: ask for Gastrografin®!)\\n A piece of general advice: do communicate with the radiologists and\\nradiographers. As Leo Gordon says: “The quality of the X-ray ordered\\nis directly proportional to the specificity of the clinical information\\nsupplied to the radiologist.” Talk to your radiologist, in person or on the\\nphone; often, once you express your questions and worries, what was\\npreviously missed becomes obvious!',\n", " 'md': '```markdown\\n# Page Content\\n\\nSurgeons — barium is an enemy. Bacteria love barium, for it protects them from the peritoneal macrophages; a mixture of barium with feces is the best experimental recipe for the production of intractable peritonitis and multiple intra-abdominal abscesses. Once barium leaks into the peritoneal cavity it is very difficult to get rid of. Barium administered to the gastrointestinal tract from above or below tends to stay there for days — distorting any subsequent CT or arteriography. And let us not forget the rocks it forms in the rectum of constipated patients.\\n\\nA GI contrast study in the emergency situation has only two queries to answer:\\n\\n- Is there a leak and, if so, where? (Please note that the absence of a contrast leak does not exclude a bowel perforation.)\\n- Is there an obstruction and, if so, where? (Please note that CT is much better and more accurate in defining the obstruction site in addition to giving other useful information about the condition of the bowel.)\\n\\nFor these purposes, Gastrografin® is adequate. Use Gastrografin® in upper gastrointestinal studies to document or exclude gastric outlet obstruction, treat small bowel obstruction or postoperative ileus (Chapters 21 and 45) or order a Gastrografin® enema to diagnose colonic obstruction or perforation. Unlike barium, Gastrografin® is harmless should it leak into the peritoneal cavity. Try to operate on a colon full of barium: a clamp slides off, a stapler misfires and you — not the radiologist — are the one left to clean the s**t. Take some advice from our bitter experience: ordering a Gastrografin® study is not enough; you must personally ensure that barium is not used. (The same, of course, applies to an emergency CT: ask for Gastrografin®!)\\n\\nA piece of general advice: do communicate with the radiologists and radiographers. As Leo Gordon says: “The quality of the X-ray ordered is directly proportional to the specificity of the clinical information supplied to the radiologist.” Talk to your radiologist, in person or on the phone; often, once you express your questions and worries, what was previously missed becomes obvious!\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the instructions.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Surgeons — barium is an enemy. Bacteria love barium, for it protects them from the peritoneal macrophages; a mixture of barium with feces is the best experimental recipe for the production of intractable peritonitis and multiple intra-abdominal abscesses. Once barium leaks into the peritoneal cavity it is very difficult to get rid of. Barium administered to the gastrointestinal tract from above or below tends to stay there for days — distorting any subsequent CT or arteriography. And let us not forget the rocks it forms in the rectum of constipated patients.\\n\\nA GI contrast study in the emergency situation has only two queries to answer:\\n\\n- Is there a leak and, if so, where? (Please note that the absence of a contrast leak does not exclude a bowel perforation.)\\n- Is there an obstruction and, if so, where? (Please note that CT is much better and more accurate in defining the obstruction site in addition to giving other useful information about the condition of the bowel.)\\n\\nFor these purposes, Gastrografin® is adequate. Use Gastrografin® in upper gastrointestinal studies to document or exclude gastric outlet obstruction, treat small bowel obstruction or postoperative ileus (Chapters 21 and 45) or order a Gastrografin® enema to diagnose colonic obstruction or perforation. Unlike barium, Gastrografin® is harmless should it leak into the peritoneal cavity. Try to operate on a colon full of barium: a clamp slides off, a stapler misfires and you — not the radiologist — are the one left to clean the s**t. Take some advice from our bitter experience: ordering a Gastrografin® study is not enough; you must personally ensure that barium is not used. (The same, of course, applies to an emergency CT: ask for Gastrografin®!)\\n\\nA piece of general advice: do communicate with the radiologists and radiographers. As Leo Gordon says: “The quality of the X-ray ordered is directly proportional to the specificity of the clinical information supplied to the radiologist.” Talk to your radiologist, in person or on the phone; often, once you express your questions and worries, what was previously missed becomes obvious!\\n```',\n", " 'md': 'Surgeons — barium is an enemy. Bacteria love barium, for it protects them from the peritoneal macrophages; a mixture of barium with feces is the best experimental recipe for the production of intractable peritonitis and multiple intra-abdominal abscesses. Once barium leaks into the peritoneal cavity it is very difficult to get rid of. Barium administered to the gastrointestinal tract from above or below tends to stay there for days — distorting any subsequent CT or arteriography. And let us not forget the rocks it forms in the rectum of constipated patients.\\n\\nA GI contrast study in the emergency situation has only two queries to answer:\\n\\n- Is there a leak and, if so, where? (Please note that the absence of a contrast leak does not exclude a bowel perforation.)\\n- Is there an obstruction and, if so, where? (Please note that CT is much better and more accurate in defining the obstruction site in addition to giving other useful information about the condition of the bowel.)\\n\\nFor these purposes, Gastrografin® is adequate. Use Gastrografin® in upper gastrointestinal studies to document or exclude gastric outlet obstruction, treat small bowel obstruction or postoperative ileus (Chapters 21 and 45) or order a Gastrografin® enema to diagnose colonic obstruction or perforation. Unlike barium, Gastrografin® is harmless should it leak into the peritoneal cavity. Try to operate on a colon full of barium: a clamp slides off, a stapler misfires and you — not the radiologist — are the one left to clean the s**t. Take some advice from our bitter experience: ordering a Gastrografin® study is not enough; you must personally ensure that barium is not used. (The same, of course, applies to an emergency CT: ask for Gastrografin®!)\\n\\nA piece of general advice: do communicate with the radiologists and radiographers. As Leo Gordon says: “The quality of the X-ray ordered is directly proportional to the specificity of the clinical information supplied to the radiologist.” Talk to your radiologist, in person or on the phone; often, once you express your questions and worries, what was previously missed becomes obvious!\\n```',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.91, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the instructions.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the instructions.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapters 21 and 45) or order a Gastrografin'},\n", " {'text': ''}]},\n", " {'page': 68,\n", " 'text': ' We simply cannot stand (the word ‘despise’ may not be too strong)\\nresidents, or doctors in general, who cite from radiological reports without\\never seeing themselves the actual iamges. Our method: check the\\nimages first, make a conclusion, and then check to see from the\\nradiology report if the radiologist agrees with your diagnosis.\\nViewing the images together with the radiologist is often a surprisingly\\nproductive exercise; you can accomplish it even on the phone — each of\\nyou looking at the images on your side of the fiberoptic cable.\\n\\n Unnecessary tests\\n\\n Dr. Lope Estevez Schwarz of Berlin shared with us this attractive\\nGerman phrase: “Wer viel misst, misst viel Mist” — free translation:\\npeople who test too much tend to get bullshit... Amen!\\n OR\\n fRom #Amly:E-mAi_\\n SECondobinion_ 0\\n Ferzo144\\nFigure 4.1. Rational diagnostic procedures. “Boss, get an MRI!”\\n\\n Unnecessary testing is plaguing modern medical practice',\n", " 'md': '```markdown\\n## Text\\n\\nWe simply cannot stand (the word ‘despise’ may not be too strong) residents, or doctors in general, who cite from radiological reports without ever seeing themselves the actual images. Our method: check the images first, make a conclusion, and then check to see from the radiology report if the radiologist agrees with your diagnosis. Viewing the images together with the radiologist is often a surprisingly productive exercise; you can accomplish it even on the phone — each of you looking at the images on your side of the fiberoptic cable.\\n\\nUnnecessary tests\\n\\nDr. Lope Estevez Schwarz of Berlin shared with us this attractive German phrase: “Wer viel misst, misst viel Mist” — free translation: people who test too much tend to get bullshit... Amen!\\n\\n## Figure\\n\\n**Figure 4.1.** Rational diagnostic procedures. “Boss, get an MRI!”\\n\\nUnnecessary testing is plaguing modern medical practice.\\n```',\n", " 'images': [{'name': 'img_p67_1.png',\n", " 'height': 601,\n", " 'width': 812,\n", " 'x': 105.11999999999989,\n", " 'y': 327.5999999999999,\n", " 'original_width': 1396,\n", " 'original_height': 1032}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'We simply cannot stand (the word ‘despise’ may not be too strong) residents, or doctors in general, who cite from radiological reports without ever seeing themselves the actual images. Our method: check the images first, make a conclusion, and then check to see from the radiology report if the radiologist agrees with your diagnosis. Viewing the images together with the radiologist is often a surprisingly productive exercise; you can accomplish it even on the phone — each of you looking at the images on your side of the fiberoptic cable.\\n\\nUnnecessary tests\\n\\nDr. Lope Estevez Schwarz of Berlin shared with us this attractive German phrase: “Wer viel misst, misst viel Mist” — free translation: people who test too much tend to get bullshit... Amen!',\n", " 'md': 'We simply cannot stand (the word ‘despise’ may not be too strong) residents, or doctors in general, who cite from radiological reports without ever seeing themselves the actual images. Our method: check the images first, make a conclusion, and then check to see from the radiology report if the radiologist agrees with your diagnosis. Viewing the images together with the radiologist is often a surprisingly productive exercise; you can accomplish it even on the phone — each of you looking at the images on your side of the fiberoptic cable.\\n\\nUnnecessary tests\\n\\nDr. Lope Estevez Schwarz of Berlin shared with us this attractive German phrase: “Wer viel misst, misst viel Mist” — free translation: people who test too much tend to get bullshit... Amen!',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.98, 'h': 17.81}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure',\n", " 'md': '## Figure',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 4.1.** Rational diagnostic procedures. “Boss, get an MRI!”\\n\\nUnnecessary testing is plaguing modern medical practice.\\n```',\n", " 'md': '**Figure 4.1.** Rational diagnostic procedures. “Boss, get an MRI!”\\n\\nUnnecessary testing is plaguing modern medical practice.\\n```',\n", " 'bBox': {'x': 79, 'y': 704, 'w': 453.35, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 69,\n", " 'text': ' ( Figure 4.1). Look around you and notice that the majority of investigations being ordered do\\n not add much to the quality of care. These unnecessary tests are expensive and potentially\\n harmful. In addition to the therapeutic delay they may cause, be familiar with the following\\n paradigm: the more non-indicated tests you order, the more false-positive results are\\n obtained, which in turn compel you to order more tests and lead to additional,\\n potentially harmful, diagnostic and therapeutic interventions. Eventually, you lose\\n control… and, sadly, you create VOMIT (victims of modern imaging technology).\\n\\n What are the reasons for unnecessary tests? The etiology is a\\ncombination of ignorance, lack of confidence, and laziness. When\\nabdominal emergencies are initially assessed by non-surgeons who do\\nnot ‘understand’ the abdomen, unnecessary imaging is requested to\\ncompensate for ignorance. Junior clinicians who lack confidence tend to\\norder tests “just to be sure — not to miss” a rare disorder. And\\nexperienced clinicians occasionally ask for an abdominal CT over the\\nphone in order to procrastinate. Isn’t it easier to ask for a CT rather than\\nto drive to the hospital in the middle of the night, or to interrupt the golf\\ngame, and examine the patient? (“Let’s do the CT and decide in the\\nmorning…”).\\n\\n An occasional surgical trainee finds it difficult to understand “what’s\\nwrong with excessive testing?” “Well,” we explain, “Why do we need you\\nat all? Let us all go home instead, and instruct our ER nurses to drive all\\npatients with abdominal pain through a predetermined line of tests and\\nimaging modalities.” But patients are not cars on a production line in\\nDetroit. They are individuals who need your continuous judgment and\\nselective use of tests.\\n\\n Be careful before adopting an investigation claimed to be ‘effective’ by\\nothers. You read, for example, that in a Boston ivory tower, routine CT of\\nthe abdomen has been proven cost-effective in the diagnosis of acute\\nappendicitis. Before succumbing to the temptation to order a CT for any\\nsuspected acute appendicitis, check whether the methods used in the\\noriginal study can be duplicated in your own environment. Do you have\\nsenior radiologists to read the CT at 3 a.m. — or would the CT be\\nreported only in the morning — after the appendix is, or should be, in the\\nformalin jar?',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Figure 4.1\\nLook around you and notice that the majority of investigations being ordered do not add much to the quality of care. These unnecessary tests are expensive and potentially harmful. In addition to the therapeutic delay they may cause, be familiar with the following paradigm: the more non-indicated tests you order, the more false-positive results are obtained, which in turn compel you to order more tests and lead to additional, potentially harmful, diagnostic and therapeutic interventions. Eventually, you lose control… and, sadly, you create VOMIT (victims of modern imaging technology).\\n\\nWhat are the reasons for unnecessary tests? The etiology is a combination of ignorance, lack of confidence, and laziness. When abdominal emergencies are initially assessed by non-surgeons who do not ‘understand’ the abdomen, unnecessary imaging is requested to compensate for ignorance. Junior clinicians who lack confidence tend to order tests “just to be sure — not to miss” a rare disorder. And experienced clinicians occasionally ask for an abdominal CT over the phone in order to procrastinate. Isn’t it easier to ask for a CT rather than to drive to the hospital in the middle of the night, or to interrupt the golf game, and examine the patient? (“Let’s do the CT and decide in the morning…”).\\n\\nAn occasional surgical trainee finds it difficult to understand “what’s wrong with excessive testing?” “Well,” we explain, “Why do we need you at all? Let us all go home instead, and instruct our ER nurses to drive all patients with abdominal pain through a predetermined line of tests and imaging modalities.” But patients are not cars on a production line in Detroit. They are individuals who need your continuous judgment and selective use of tests.\\n\\nBe careful before adopting an investigation claimed to be ‘effective’ by others. You read, for example, that in a Boston ivory tower, routine CT of the abdomen has been proven cost-effective in the diagnosis of acute appendicitis. Before succumbing to the temptation to order a CT for any suspected acute appendicitis, check whether the methods used in the original study can be duplicated in your own environment. Do you have senior radiologists to read the CT at 3 a.m. — or would the CT be reported only in the morning — after the appendix is, or should be, in the formalin jar?\\n```\\n\\n### Image Description\\n- **Figure 4.1**: The figure is referenced in the text but not visually present in the provided content. It likely illustrates the concept of unnecessary medical testing and its consequences, possibly depicting a flowchart or a diagram that emphasizes the cycle of ordering tests leading to false positives and further unnecessary interventions. The description of the figure is not available, but it is implied to be a critical visual aid in understanding the discussed paradigm.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 4.1',\n", " 'md': '### Figure 4.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Look around you and notice that the majority of investigations being ordered do not add much to the quality of care. These unnecessary tests are expensive and potentially harmful. In addition to the therapeutic delay they may cause, be familiar with the following paradigm: the more non-indicated tests you order, the more false-positive results are obtained, which in turn compel you to order more tests and lead to additional, potentially harmful, diagnostic and therapeutic interventions. Eventually, you lose control… and, sadly, you create VOMIT (victims of modern imaging technology).\\n\\nWhat are the reasons for unnecessary tests? The etiology is a combination of ignorance, lack of confidence, and laziness. When abdominal emergencies are initially assessed by non-surgeons who do not ‘understand’ the abdomen, unnecessary imaging is requested to compensate for ignorance. Junior clinicians who lack confidence tend to order tests “just to be sure — not to miss” a rare disorder. And experienced clinicians occasionally ask for an abdominal CT over the phone in order to procrastinate. Isn’t it easier to ask for a CT rather than to drive to the hospital in the middle of the night, or to interrupt the golf game, and examine the patient? (“Let’s do the CT and decide in the morning…”).\\n\\nAn occasional surgical trainee finds it difficult to understand “what’s wrong with excessive testing?” “Well,” we explain, “Why do we need you at all? Let us all go home instead, and instruct our ER nurses to drive all patients with abdominal pain through a predetermined line of tests and imaging modalities.” But patients are not cars on a production line in Detroit. They are individuals who need your continuous judgment and selective use of tests.\\n\\nBe careful before adopting an investigation claimed to be ‘effective’ by others. You read, for example, that in a Boston ivory tower, routine CT of the abdomen has been proven cost-effective in the diagnosis of acute appendicitis. Before succumbing to the temptation to order a CT for any suspected acute appendicitis, check whether the methods used in the original study can be duplicated in your own environment. Do you have senior radiologists to read the CT at 3 a.m. — or would the CT be reported only in the morning — after the appendix is, or should be, in the formalin jar?\\n```',\n", " 'md': 'Look around you and notice that the majority of investigations being ordered do not add much to the quality of care. These unnecessary tests are expensive and potentially harmful. In addition to the therapeutic delay they may cause, be familiar with the following paradigm: the more non-indicated tests you order, the more false-positive results are obtained, which in turn compel you to order more tests and lead to additional, potentially harmful, diagnostic and therapeutic interventions. Eventually, you lose control… and, sadly, you create VOMIT (victims of modern imaging technology).\\n\\nWhat are the reasons for unnecessary tests? The etiology is a combination of ignorance, lack of confidence, and laziness. When abdominal emergencies are initially assessed by non-surgeons who do not ‘understand’ the abdomen, unnecessary imaging is requested to compensate for ignorance. Junior clinicians who lack confidence tend to order tests “just to be sure — not to miss” a rare disorder. And experienced clinicians occasionally ask for an abdominal CT over the phone in order to procrastinate. Isn’t it easier to ask for a CT rather than to drive to the hospital in the middle of the night, or to interrupt the golf game, and examine the patient? (“Let’s do the CT and decide in the morning…”).\\n\\nAn occasional surgical trainee finds it difficult to understand “what’s wrong with excessive testing?” “Well,” we explain, “Why do we need you at all? Let us all go home instead, and instruct our ER nurses to drive all patients with abdominal pain through a predetermined line of tests and imaging modalities.” But patients are not cars on a production line in Detroit. They are individuals who need your continuous judgment and selective use of tests.\\n\\nBe careful before adopting an investigation claimed to be ‘effective’ by others. You read, for example, that in a Boston ivory tower, routine CT of the abdomen has been proven cost-effective in the diagnosis of acute appendicitis. Before succumbing to the temptation to order a CT for any suspected acute appendicitis, check whether the methods used in the original study can be duplicated in your own environment. Do you have senior radiologists to read the CT at 3 a.m. — or would the CT be reported only in the morning — after the appendix is, or should be, in the formalin jar?\\n```',\n", " 'bBox': {'x': 72, 'y': 164, 'w': 467.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 4.1**: The figure is referenced in the text but not visually present in the provided content. It likely illustrates the concept of unnecessary medical testing and its consequences, possibly depicting a flowchart or a diagram that emphasizes the cycle of ordering tests leading to false positives and further unnecessary interventions. The description of the figure is not available, but it is implied to be a critical visual aid in understanding the discussed paradigm.',\n", " 'md': '- **Figure 4.1**: The figure is referenced in the text but not visually present in the provided content. It likely illustrates the concept of unnecessary medical testing and its consequences, possibly depicting a flowchart or a diagram that emphasizes the cycle of ordering tests leading to false positives and further unnecessary interventions. The description of the figure is not available, but it is implied to be a critical visual aid in understanding the discussed paradigm.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 70,\n", " 'text': ' Perhaps the day is near when all patients on their way from the\\nambulance to the ER will be passed through a total body CT scanner —\\nread by a computer. But then luckily we will not be practicing surgery and\\nthis book will be long out of print. We do not believe, however, that\\npatients will fare better under such a system.\\n\\n Believe nobody — question everything… the more the\\n noise — the less the fact.\\n\\n Or, like Lenin said:\\n\\n Trust is good, control is better.\\n\\n Diagnostic laparoscopy\\n\\n This is an invasive diagnostic tool (some call it “controlled penetrating\\nabdominal trauma”) to be used in the operating room, after the decision\\nto intervene has been already taken. It has a selective role as discussed\\nin Chapter 12. Yes, frequently, it is tempting “just to have a peek” and\\nsolve the diagnostic dilemmas, at the small price of a few small scars and\\nthe advantage of avoiding the radiation associated with a CT scan. For\\nsome, diagnostic laparoscopy is conceived as an extension of the\\nimaging effort, and not as ‘real’ surgery. However, we should not forget\\nthat this is indeed a surgical procedure, for which we need a sound\\nindication. Complications, as well as unnecessary interventions\\n(like removing a normal appendix), are part of the package deal.\\n\\n Before ending we wish to cite yet again Leo Gordon: “The emergency\\nroom is the best place to evaluate an emergency.” Think about what\\ninvestigations you wish to order while the patient is still in the ER;\\nlogistically, in most hospitals, it will be more difficult to obtain all these\\ntests after the patient has been admitted.\\n\\n “God gave you ears, eyes, and hands; use them on the\\n patient in that order.”\\n William Kelsey Fry',\n", " 'md': '```markdown\\n## Text\\n\\nPerhaps the day is near when all patients on their way from the ambulance to the ER will be passed through a total body CT scanner — read by a computer. But then luckily we will not be practicing surgery and this book will be long out of print. We do not believe, however, that patients will fare better under such a system.\\n\\nBelieve nobody — question everything… the more the noise — the less the fact.\\n\\nOr, like Lenin said:\\n\\n> Trust is good, control is better.\\n\\n### Diagnostic Laparoscopy\\n\\nThis is an invasive diagnostic tool (some call it “controlled penetrating abdominal trauma”) to be used in the operating room, after the decision to intervene has been already taken. It has a selective role as discussed in Chapter 12. Yes, frequently, it is tempting “just to have a peek” and solve the diagnostic dilemmas, at the small price of a few small scars and the advantage of avoiding the radiation associated with a CT scan. For some, diagnostic laparoscopy is conceived as an extension of the imaging effort, and not as ‘real’ surgery. However, we should not forget that this is indeed a surgical procedure, for which we need a sound indication. Complications, as well as unnecessary interventions (like removing a normal appendix), are part of the package deal.\\n\\nBefore ending we wish to cite yet again Leo Gordon: “The emergency room is the best place to evaluate an emergency.” Think about what investigations you wish to order while the patient is still in the ER; logistically, in most hospitals, it will be more difficult to obtain all these tests after the patient has been admitted.\\n\\n> “God gave you ears, eyes, and hands; use them on the patient in that order.”\\n> — William Kelsey Fry\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Perhaps the day is near when all patients on their way from the ambulance to the ER will be passed through a total body CT scanner — read by a computer. But then luckily we will not be practicing surgery and this book will be long out of print. We do not believe, however, that patients will fare better under such a system.\\n\\nBelieve nobody — question everything… the more the noise — the less the fact.\\n\\nOr, like Lenin said:\\n\\n> Trust is good, control is better.',\n", " 'md': 'Perhaps the day is near when all patients on their way from the ambulance to the ER will be passed through a total body CT scanner — read by a computer. But then luckily we will not be practicing surgery and this book will be long out of print. We do not believe, however, that patients will fare better under such a system.\\n\\nBelieve nobody — question everything… the more the noise — the less the fact.\\n\\nOr, like Lenin said:\\n\\n> Trust is good, control is better.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diagnostic Laparoscopy',\n", " 'md': '### Diagnostic Laparoscopy',\n", " 'bBox': {'x': 86, 'y': 309, 'w': 186.69, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is an invasive diagnostic tool (some call it “controlled penetrating abdominal trauma”) to be used in the operating room, after the decision to intervene has been already taken. It has a selective role as discussed in Chapter 12. Yes, frequently, it is tempting “just to have a peek” and solve the diagnostic dilemmas, at the small price of a few small scars and the advantage of avoiding the radiation associated with a CT scan. For some, diagnostic laparoscopy is conceived as an extension of the imaging effort, and not as ‘real’ surgery. However, we should not forget that this is indeed a surgical procedure, for which we need a sound indication. Complications, as well as unnecessary interventions (like removing a normal appendix), are part of the package deal.\\n\\nBefore ending we wish to cite yet again Leo Gordon: “The emergency room is the best place to evaluate an emergency.” Think about what investigations you wish to order while the patient is still in the ER; logistically, in most hospitals, it will be more difficult to obtain all these tests after the patient has been admitted.\\n\\n> “God gave you ears, eyes, and hands; use them on the patient in that order.”\\n> — William Kelsey Fry\\n```',\n", " 'md': 'This is an invasive diagnostic tool (some call it “controlled penetrating abdominal trauma”) to be used in the operating room, after the decision to intervene has been already taken. It has a selective role as discussed in Chapter 12. Yes, frequently, it is tempting “just to have a peek” and solve the diagnostic dilemmas, at the small price of a few small scars and the advantage of avoiding the radiation associated with a CT scan. For some, diagnostic laparoscopy is conceived as an extension of the imaging effort, and not as ‘real’ surgery. However, we should not forget that this is indeed a surgical procedure, for which we need a sound indication. Complications, as well as unnecessary interventions (like removing a normal appendix), are part of the package deal.\\n\\nBefore ending we wish to cite yet again Leo Gordon: “The emergency room is the best place to evaluate an emergency.” Think about what investigations you wish to order while the patient is still in the ER; logistically, in most hospitals, it will be more difficult to obtain all these tests after the patient has been admitted.\\n\\n> “God gave you ears, eyes, and hands; use them on the patient in that order.”\\n> — William Kelsey Fry\\n```',\n", " 'bBox': {'x': 72, 'y': 309, 'w': 467.74, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'solve the diagnostic dilemmas, at the small price of a few small scars and'}]},\n", " {'page': 71,\n", " 'text': '1 Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.',\n", " 'md': '```markdown\\n# Page 1\\n\\nAsher Hirshberg, MD, contributed to this chapter in the first edition of this book.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page 1',\n", " 'md': '# Page 1',\n", " 'bBox': {'x': 73, 'y': 126, 'w': 4.8, 'h': 8.64}},\n", " {'type': 'text',\n", " 'value': 'Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.\\n```',\n", " 'md': 'Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.\\n```',\n", " 'bBox': {'x': 97, 'y': 129, 'w': 376.38, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 72,\n", " 'text': 'Chapter 5\\nAbdominal imaging\\nMoshe Schein and Hans Ulrich Elben\\n\\n The diagnostic problem of today\\n Has greatly changed — the changes have come to\\n stay;\\n We all have come to confess, though with a sigh\\n On complicated tests we much rely\\n And use too little hand and ear and eye.\\n Zachary Cope, The Acute Abdomen in Rhyme\\n\\n There are fundamental differences in how physicians, belonging to the\\ndifferent specialties involved in decision-making concerning the ‘acute\\nabdomen’, look at abdominal imaging. The radiologists’ sharp eyes see\\n‘everything’ but they tend to see ‘too much’, and do not always\\nunderstand the clinical significance of what they see. They describe all\\nkinds of ‘findings’, densities here, enhanced fat there, but what you\\nREALLY want to know is the diagnosis, right? Some (not all) ER\\nphysicians do not see much and do not understand the meaning of the\\nlittle they do see; all they care about is where to dump the patient. Some\\ndoctors (you surely know a few of them) even do not bother looking at the\\nactual images, finding it easier reading the radiologist’s report. This\\nleaves us with ourselves, the surgeons. Armed with a better\\nunderstanding of the natural history of the disease processes, and\\nable to correlate radiological imaging with the clinical scenario, or\\nprevious operative observations, we should be well positioned to\\ninterpret abdominal imaging — at least as well as the radiologists.\\nWe have already discussed ( Chapter 4) the role of abdominal imaging',\n", " 'md': '```markdown\\n# Chapter 5: Abdominal Imaging\\n**Authors:** Moshe Schein and Hans Ulrich Elben\\n\\n> \"The diagnostic problem of today has greatly changed — the changes have come to stay; We all have come to confess, though with a sigh On complicated tests we much rely And use too little hand and ear and eye.\"\\n> — Zachary Cope, *The Acute Abdomen in Rhyme*\\n\\nThere are fundamental differences in how physicians, belonging to the different specialties involved in decision-making concerning the ‘acute abdomen’, look at abdominal imaging. The radiologists’ sharp eyes see ‘everything’ but they tend to see ‘too much’, and do not always understand the clinical significance of what they see. They describe all kinds of ‘findings’, densities here, enhanced fat there, but what you REALLY want to know is the diagnosis, right? Some (not all) ER physicians do not see much and do not understand the meaning of the little they do see; all they care about is where to dump the patient. Some doctors (you surely know a few of them) even do not bother looking at the actual images, finding it easier reading the radiologist’s report. This leaves us with ourselves, the surgeons. Armed with a better understanding of the natural history of the disease processes, and able to correlate radiological imaging with the clinical scenario, or previous operative observations, we should be well positioned to interpret abdominal imaging — at least as well as the radiologists. We have already discussed (Chapter 4) the role of abdominal imaging.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 5: Abdominal Imaging',\n", " 'md': '# Chapter 5: Abdominal Imaging',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 171.36, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Moshe Schein and Hans Ulrich Elben\\n\\n> \"The diagnostic problem of today has greatly changed — the changes have come to stay; We all have come to confess, though with a sigh On complicated tests we much rely And use too little hand and ear and eye.\"\\n> — Zachary Cope, *The Acute Abdomen in Rhyme*\\n\\nThere are fundamental differences in how physicians, belonging to the different specialties involved in decision-making concerning the ‘acute abdomen’, look at abdominal imaging. The radiologists’ sharp eyes see ‘everything’ but they tend to see ‘too much’, and do not always understand the clinical significance of what they see. They describe all kinds of ‘findings’, densities here, enhanced fat there, but what you REALLY want to know is the diagnosis, right? Some (not all) ER physicians do not see much and do not understand the meaning of the little they do see; all they care about is where to dump the patient. Some doctors (you surely know a few of them) even do not bother looking at the actual images, finding it easier reading the radiologist’s report. This leaves us with ourselves, the surgeons. Armed with a better understanding of the natural history of the disease processes, and able to correlate radiological imaging with the clinical scenario, or previous operative observations, we should be well positioned to interpret abdominal imaging — at least as well as the radiologists. We have already discussed (Chapter 4) the role of abdominal imaging.\\n```',\n", " 'md': '**Authors:** Moshe Schein and Hans Ulrich Elben\\n\\n> \"The diagnostic problem of today has greatly changed — the changes have come to stay; We all have come to confess, though with a sigh On complicated tests we much rely And use too little hand and ear and eye.\"\\n> — Zachary Cope, *The Acute Abdomen in Rhyme*\\n\\nThere are fundamental differences in how physicians, belonging to the different specialties involved in decision-making concerning the ‘acute abdomen’, look at abdominal imaging. The radiologists’ sharp eyes see ‘everything’ but they tend to see ‘too much’, and do not always understand the clinical significance of what they see. They describe all kinds of ‘findings’, densities here, enhanced fat there, but what you REALLY want to know is the diagnosis, right? Some (not all) ER physicians do not see much and do not understand the meaning of the little they do see; all they care about is where to dump the patient. Some doctors (you surely know a few of them) even do not bother looking at the actual images, finding it easier reading the radiologist’s report. This leaves us with ourselves, the surgeons. Armed with a better understanding of the natural history of the disease processes, and able to correlate radiological imaging with the clinical scenario, or previous operative observations, we should be well positioned to interpret abdominal imaging — at least as well as the radiologists. We have already discussed (Chapter 4) the role of abdominal imaging.\\n```',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.82, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 73,\n", " 'text': 'in the evaluation of the patient with an acute abdomen. In this chapter we\\nwill try to provide you with practical tips on how to look at the images\\nand what to look for.\\n\\n Plain abdominal X-ray (AXR)\\n\\n Tragically, this simple, cheap and safe X-ray is increasingly bypassed\\nin favor of an immediate computed tomography (CT) scan — which\\ndelivers a much greater radiation dose. This is a pity because there is so\\nmuch that you can learn from a quick glance at the AXR.\\n\\n Look for abnormal gas patterns\\n\\n Gas outside the lumen of the bowel:\\n\\n • ‘Free air’ (pneumoperitoneum) is best seen on an erect chest X-ray\\n (CXR; Chapter 4) but may also be seen on an AXR ( Figure 5.1).\\n If the CXR and AXR are ‘normal’ and you suspect perforation of a\\n viscus, a left lateral decubitus abdominal film may show free gas in\\n the peritoneal cavity.\\n\\nFigure 5.1. Abdominal X-ray in the upright position demonstrating a pneumoperitoneum\\nwith air under both diaphragms (arrow).',\n", " 'md': '```markdown\\n# Evaluation of Acute Abdomen\\n\\nIn this chapter, we will try to provide you with practical tips on how to look at the images and what to look for.\\n\\n## Plain Abdominal X-ray (AXR)\\n\\nTragically, this simple, cheap, and safe X-ray is increasingly bypassed in favor of an immediate computed tomography (CT) scan — which delivers a much greater radiation dose. This is a pity because there is so much that you can learn from a quick glance at the AXR.\\n\\n### Look for Abnormal Gas Patterns\\n\\nGas outside the lumen of the bowel:\\n\\n- **Free air** (pneumoperitoneum) is best seen on an erect chest X-ray (CXR; Chapter 4) but may also be seen on an AXR (Figure 5.1). If the CXR and AXR are ‘normal’ and you suspect perforation of a viscus, a left lateral decubitus abdominal film may show free gas in the peritoneal cavity.\\n\\n### Figure 5.1\\n**Description:** Abdominal X-ray in the upright position demonstrating a pneumoperitoneum with air under both diaphragms (arrow).\\n**Summary:** This X-ray illustrates the presence of free air in the abdominal cavity, indicating potential perforation of a viscus.\\n```',\n", " 'images': [{'name': 'img_p72_1.png',\n", " 'height': 430,\n", " 'width': 402,\n", " 'x': 206.64,\n", " 'y': 451.44000000000005,\n", " 'original_width': 921,\n", " 'original_height': 985}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Evaluation of Acute Abdomen',\n", " 'md': '# Evaluation of Acute Abdomen',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In this chapter, we will try to provide you with practical tips on how to look at the images and what to look for.',\n", " 'md': 'In this chapter, we will try to provide you with practical tips on how to look at the images and what to look for.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.03, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Plain Abdominal X-ray (AXR)',\n", " 'md': '## Plain Abdominal X-ray (AXR)',\n", " 'bBox': {'x': 86, 'y': 162, 'w': 223.43, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Tragically, this simple, cheap, and safe X-ray is increasingly bypassed in favor of an immediate computed tomography (CT) scan — which delivers a much greater radiation dose. This is a pity because there is so much that you can learn from a quick glance at the AXR.',\n", " 'md': 'Tragically, this simple, cheap, and safe X-ray is increasingly bypassed in favor of an immediate computed tomography (CT) scan — which delivers a much greater radiation dose. This is a pity because there is so much that you can learn from a quick glance at the AXR.',\n", " 'bBox': {'x': 72, 'y': 231, 'w': 467.84, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Look for Abnormal Gas Patterns',\n", " 'md': '### Look for Abnormal Gas Patterns',\n", " 'bBox': {'x': 86, 'y': 291, 'w': 248.27, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Gas outside the lumen of the bowel:\\n\\n- **Free air** (pneumoperitoneum) is best seen on an erect chest X-ray (CXR; Chapter 4) but may also be seen on an AXR (Figure 5.1). If the CXR and AXR are ‘normal’ and you suspect perforation of a viscus, a left lateral decubitus abdominal film may show free gas in the peritoneal cavity.',\n", " 'md': 'Gas outside the lumen of the bowel:\\n\\n- **Free air** (pneumoperitoneum) is best seen on an erect chest X-ray (CXR; Chapter 4) but may also be seen on an AXR (Figure 5.1). If the CXR and AXR are ‘normal’ and you suspect perforation of a viscus, a left lateral decubitus abdominal film may show free gas in the peritoneal cavity.',\n", " 'bBox': {'x': 86, 'y': 327, 'w': 436.67, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 5.1',\n", " 'md': '### Figure 5.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** Abdominal X-ray in the upright position demonstrating a pneumoperitoneum with air under both diaphragms (arrow).\\n**Summary:** This X-ray illustrates the presence of free air in the abdominal cavity, indicating potential perforation of a viscus.\\n```',\n", " 'md': '**Description:** Abdominal X-ray in the upright position demonstrating a pneumoperitoneum with air under both diaphragms (arrow).\\n**Summary:** This X-ray illustrates the presence of free air in the abdominal cavity, indicating potential perforation of a viscus.\\n```',\n", " 'bBox': {'x': 75, 'y': 695, 'w': 203.75, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'If the CXR and AXR are ‘normal’ and you suspect perforation of a'},\n", " {'text': 'If the CXR and AXR are ‘normal’ and you suspect perforation of a'}]},\n", " {'page': 74,\n", " 'text': ' • Make a habit always to look for atypical gas patterns —\\n occasionally you may be rewarded with an eye-popping diagnosis:\\n gas in the biliary tree (pneumobilia) implies either a cholecysto-\\n enteric fistula (see gallstone ileus; Chapter 21) or a previous\\n enterobiliary bypass or, more commonly, a sphincterotomy of the\\n sphincter of Oddi (via endoscopic retrograde\\n cholangiopancreatography [ERCP]) ( Figure 5.2). Note that gas in\\n the intrahepatic biliary ducts is seen centrally, while gas in the\\n periphery of the liver suggests portal vein gas. The gas finds its\\n way into the portal venous system through a breach in the bowel\\n wall — usually associated with mesenteric ischemia or severe\\n colitis — and rarely with pylephlebitis. Commonly, gas in the portal\\n vein as a result of ischemic small or large bowel is associated with\\n pneumatosis intestinalis, i.e. the presence of intramural gas.\\n Abd SUPINE\\nFigure 5.2. Abdominal X-ray demonstrating air in the biliary tract (arrow).',\n", " 'md': '```markdown\\n### Text Extraction\\n\\n- Make a habit always to look for atypical gas patterns — occasionally you may be rewarded with an eye-popping diagnosis: gas in the biliary tree (pneumobilia) implies either a cholecysto-enteric fistula (see gallstone ileus; Chapter 21) or a previous enterobiliary bypass or, more commonly, a sphincterotomy of the sphincter of Oddi (via endoscopic retrograde cholangiopancreatography [ERCP]). Note that gas in the intrahepatic biliary ducts is seen centrally, while gas in the periphery of the liver suggests portal vein gas. The gas finds its way into the portal venous system through a breach in the bowel wall — usually associated with mesenteric ischemia or severe colitis — and rarely with pylephlebitis. Commonly, gas in the portal vein as a result of ischemic small or large bowel is associated with pneumatosis intestinalis, i.e. the presence of intramural gas.\\n\\n### Figure Description\\n\\n**Figure 5.2**: Abdominal X-ray demonstrating air in the biliary tract (arrow).\\n\\n- **Description**: The image shows an abdominal X-ray where air is present in the biliary tract, indicated by an arrow. This finding is significant as it suggests the presence of pneumobilia, which can be associated with various conditions such as cholecysto-enteric fistula or previous surgical interventions like sphincterotomy.\\n- **Summary**: The X-ray provides visual evidence of gas in the biliary tree, which is crucial for diagnosing potential underlying issues related to the biliary system.\\n```',\n", " 'images': [{'name': 'img_p73_1.png',\n", " 'height': 690,\n", " 'width': 543,\n", " 'x': 172.07999999999993,\n", " 'y': 336.24,\n", " 'original_width': 933,\n", " 'original_height': 1186}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text Extraction',\n", " 'md': '### Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Make a habit always to look for atypical gas patterns — occasionally you may be rewarded with an eye-popping diagnosis: gas in the biliary tree (pneumobilia) implies either a cholecysto-enteric fistula (see gallstone ileus; Chapter 21) or a previous enterobiliary bypass or, more commonly, a sphincterotomy of the sphincter of Oddi (via endoscopic retrograde cholangiopancreatography [ERCP]). Note that gas in the intrahepatic biliary ducts is seen centrally, while gas in the periphery of the liver suggests portal vein gas. The gas finds its way into the portal venous system through a breach in the bowel wall — usually associated with mesenteric ischemia or severe colitis — and rarely with pylephlebitis. Commonly, gas in the portal vein as a result of ischemic small or large bowel is associated with pneumatosis intestinalis, i.e. the presence of intramural gas.',\n", " 'md': '- Make a habit always to look for atypical gas patterns — occasionally you may be rewarded with an eye-popping diagnosis: gas in the biliary tree (pneumobilia) implies either a cholecysto-enteric fistula (see gallstone ileus; Chapter 21) or a previous enterobiliary bypass or, more commonly, a sphincterotomy of the sphincter of Oddi (via endoscopic retrograde cholangiopancreatography [ERCP]). Note that gas in the intrahepatic biliary ducts is seen centrally, while gas in the periphery of the liver suggests portal vein gas. The gas finds its way into the portal venous system through a breach in the bowel wall — usually associated with mesenteric ischemia or severe colitis — and rarely with pylephlebitis. Commonly, gas in the portal vein as a result of ischemic small or large bowel is associated with pneumatosis intestinalis, i.e. the presence of intramural gas.',\n", " 'bBox': {'x': 100, 'y': 170, 'w': 437.06, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Description',\n", " 'md': '### Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 5.2**: Abdominal X-ray demonstrating air in the biliary tract (arrow).\\n\\n- **Description**: The image shows an abdominal X-ray where air is present in the biliary tract, indicated by an arrow. This finding is significant as it suggests the presence of pneumobilia, which can be associated with various conditions such as cholecysto-enteric fistula or previous surgical interventions like sphincterotomy.\\n- **Summary**: The X-ray provides visual evidence of gas in the biliary tree, which is crucial for diagnosing potential underlying issues related to the biliary system.\\n```',\n", " 'md': '**Figure 5.2**: Abdominal X-ray demonstrating air in the biliary tract (arrow).\\n\\n- **Description**: The image shows an abdominal X-ray where air is present in the biliary tract, indicated by an arrow. This finding is significant as it suggests the presence of pneumobilia, which can be associated with various conditions such as cholecysto-enteric fistula or previous surgical interventions like sphincterotomy.\\n- **Summary**: The X-ray provides visual evidence of gas in the biliary tree, which is crucial for diagnosing potential underlying issues related to the biliary system.\\n```',\n", " 'bBox': {'x': 193, 'y': 170, 'w': 16, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'enterobiliary bypass or, more commonly, a sphincterotomy of the'},\n", " {'text': 'the intrahepatic biliary ducts is seen '}]},\n", " {'page': 75,\n", " 'text': ' • Gas in the gallbladder wall signifies a necrotizing infection (\\n Chapter 20). A soap-bubble appearance signifies free gas in the\\n retroperitoneum; in the epigastrium this is associated with infected\\n pancreatic necrosis ( Chapter 19), in the right upper quadrant with\\n a retroperitoneal perforation of the duodenum, and in either gutter it\\n is associated with retroperitoneal perforation of the colon.\\n\\n Note that all these types of pathological air pattern are much\\neasier to detect on CT images.\\n\\n Gas pattern within the lumen of the bowel:\\n\\n • Abnormal gaseous distension/dilatation of small bowel loops, with\\n or without fluid levels, implies a small bowel process — be it\\n obstructive (small bowel obstruction, Chapter 21), paralytic ileus\\n ( Chapter 45) or inflammatory (Crohn’s disease, Chapter 26).\\n Remember — acute gastroenteritis may produce small bowel\\n fluid levels; the diarrhea hints at the diagnosis.\\n • Abnormal gaseous distension/dilatation of the colon denotes colonic\\n obstruction or volvulus ( Chapter 27), colonic inflammation\\n (inflammatory bowel disease, Chapter 26) or colonic ileus\\n (pseudo-obstruction, Chapter 27).',\n", " 'md': '```markdown\\n## Gas Patterns in the Gallbladder and Bowel\\n\\n- Gas in the gallbladder wall signifies a necrotizing infection (Chapter 20). A soap-bubble appearance signifies free gas in the retroperitoneum; in the epigastrium, this is associated with infected pancreatic necrosis (Chapter 19), in the right upper quadrant with a retroperitoneal perforation of the duodenum, and in either gutter, it is associated with retroperitoneal perforation of the colon.\\n\\n- Note that all these types of pathological air patterns are much easier to detect on CT images.\\n\\n### Gas Pattern within the Lumen of the Bowel:\\n\\n- Abnormal gaseous distension/dilatation of small bowel loops, with or without fluid levels, implies a small bowel process — be it obstructive (small bowel obstruction, Chapter 21), paralytic ileus (Chapter 45), or inflammatory (Crohn’s disease, Chapter 26). Remember — acute gastroenteritis may produce small bowel fluid levels; the diarrhea hints at the diagnosis.\\n\\n- Abnormal gaseous distension/dilatation of the colon denotes colonic obstruction or volvulus (Chapter 27), colonic inflammation (inflammatory bowel disease, Chapter 26), or colonic ileus (pseudo-obstruction, Chapter 27).\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Gas Patterns in the Gallbladder and Bowel',\n", " 'md': '## Gas Patterns in the Gallbladder and Bowel',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Gas in the gallbladder wall signifies a necrotizing infection (Chapter 20). A soap-bubble appearance signifies free gas in the retroperitoneum; in the epigastrium, this is associated with infected pancreatic necrosis (Chapter 19), in the right upper quadrant with a retroperitoneal perforation of the duodenum, and in either gutter, it is associated with retroperitoneal perforation of the colon.\\n\\n- Note that all these types of pathological air patterns are much easier to detect on CT images.',\n", " 'md': '- Gas in the gallbladder wall signifies a necrotizing infection (Chapter 20). A soap-bubble appearance signifies free gas in the retroperitoneum; in the epigastrium, this is associated with infected pancreatic necrosis (Chapter 19), in the right upper quadrant with a retroperitoneal perforation of the duodenum, and in either gutter, it is associated with retroperitoneal perforation of the colon.\\n\\n- Note that all these types of pathological air patterns are much easier to detect on CT images.',\n", " 'bBox': {'x': 72, 'y': 137, 'w': 393, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Gas Pattern within the Lumen of the Bowel:',\n", " 'md': '### Gas Pattern within the Lumen of the Bowel:',\n", " 'bBox': {'x': 86, 'y': 260, 'w': 289, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- Abnormal gaseous distension/dilatation of small bowel loops, with or without fluid levels, implies a small bowel process — be it obstructive (small bowel obstruction, Chapter 21), paralytic ileus (Chapter 45), or inflammatory (Crohn’s disease, Chapter 26). Remember — acute gastroenteritis may produce small bowel fluid levels; the diarrhea hints at the diagnosis.\\n\\n- Abnormal gaseous distension/dilatation of the colon denotes colonic obstruction or volvulus (Chapter 27), colonic inflammation (inflammatory bowel disease, Chapter 26), or colonic ileus (pseudo-obstruction, Chapter 27).\\n```',\n", " 'md': '- Abnormal gaseous distension/dilatation of small bowel loops, with or without fluid levels, implies a small bowel process — be it obstructive (small bowel obstruction, Chapter 21), paralytic ileus (Chapter 45), or inflammatory (Crohn’s disease, Chapter 26). Remember — acute gastroenteritis may produce small bowel fluid levels; the diarrhea hints at the diagnosis.\\n\\n- Abnormal gaseous distension/dilatation of the colon denotes colonic obstruction or volvulus (Chapter 27), colonic inflammation (inflammatory bowel disease, Chapter 26), or colonic ileus (pseudo-obstruction, Chapter 27).\\n```',\n", " 'bBox': {'x': 100, 'y': 296, 'w': 437.02, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'retroperitoneum'},\n", " {'text': 'perforation of the duodenum'},\n", " {'text': ' (Crohn’s disease, '},\n", " {'text': 'Remember — acute gastroenteritis may produce small bowel'},\n", " {'text': 'Remember — acute gastroenteritis may produce small bowel'},\n", " {'text': '(inflammatory bowel disease, '},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 76,\n", " 'text': 'Figure 5.3. Abdominal X-ray: small bowel vs. large bowel. a) Small bowel obstruction.\\nNote the valvulae conniventes crossing the whole width of small bowel. b) Distal\\nobstruction of the colon. Note the haustra crossing a portion of bowel width.\\n\\n Distinguishing small bowel from colon on an AXR is easy: the\\n‘transverse lines’ go all the way across the diameter of the small bowel\\n(the valvulae conniventes) and only partly across the colon (the haustra).\\nIn general, loops of small bowel are situated centrally while large bowel\\noccupies the periphery ( Figure 5.3).\\n\\n Useful hints:\\n\\n Gaseous distension of small bowel + no gas in the colon = complete small\\n bowel obstruction.\\n Gaseous distension of small bowel + minimal quantity of colonic gas = partial\\n small bowel obstruction.\\n Significant gaseous distension of both the small bowel and the colon =\\n paralytic ileus.\\n Significant gaseous distension of the colon + minimal distension of the small',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Figure 5.3\\n**Abdominal X-ray: small bowel vs. large bowel.**\\na) Small bowel obstruction. Note the valvulae conniventes crossing the whole width of small bowel.\\nb) Distal obstruction of the colon. Note the haustra crossing a portion of bowel width.\\n\\nDistinguishing small bowel from colon on an AXR is easy: the ‘transverse lines’ go all the way across the diameter of the small bowel (the valvulae conniventes) and only partly across the colon (the haustra). In general, loops of small bowel are situated centrally while large bowel occupies the periphery (Figure 5.3).\\n\\n#### Useful hints:\\n- Gaseous distension of small bowel + no gas in the colon = complete small bowel obstruction.\\n- Gaseous distension of small bowel + minimal quantity of colonic gas = partial small bowel obstruction.\\n- Significant gaseous distension of both the small bowel and the colon = paralytic ileus.\\n- Significant gaseous distension of the colon + minimal distension of the small bowel = \\n```\\n\\n### Image Description\\n**Figure 5.3**: The image presents an abdominal X-ray comparing the small bowel and large bowel. It highlights two conditions: small bowel obstruction and distal obstruction of the colon. The small bowel is characterized by the valvulae conniventes, which are transverse lines that cross the entire width of the bowel, while the colon is identified by haustra, which only partially cross the bowel width. The image serves as a visual aid for distinguishing between these two types of bowel obstructions.',\n", " 'images': [{'name': 'img_p75_1.png',\n", " 'height': 556,\n", " 'width': 875,\n", " 'x': 90,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1503,\n", " 'original_height': 955}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 5.3',\n", " 'md': '### Figure 5.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Abdominal X-ray: small bowel vs. large bowel.**\\na) Small bowel obstruction. Note the valvulae conniventes crossing the whole width of small bowel.\\nb) Distal obstruction of the colon. Note the haustra crossing a portion of bowel width.\\n\\nDistinguishing small bowel from colon on an AXR is easy: the ‘transverse lines’ go all the way across the diameter of the small bowel (the valvulae conniventes) and only partly across the colon (the haustra). In general, loops of small bowel are situated centrally while large bowel occupies the periphery (Figure 5.3).',\n", " 'md': '**Abdominal X-ray: small bowel vs. large bowel.**\\na) Small bowel obstruction. Note the valvulae conniventes crossing the whole width of small bowel.\\nb) Distal obstruction of the colon. Note the haustra crossing a portion of bowel width.\\n\\nDistinguishing small bowel from colon on an AXR is easy: the ‘transverse lines’ go all the way across the diameter of the small bowel (the valvulae conniventes) and only partly across the colon (the haustra). In general, loops of small bowel are situated centrally while large bowel occupies the periphery (Figure 5.3).',\n", " 'bBox': {'x': 72, 'y': 402, 'w': 467.66, 'h': 16.4}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Useful hints:',\n", " 'md': '#### Useful hints:',\n", " 'bBox': {'x': 79, 'y': 561, 'w': 87.11, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- Gaseous distension of small bowel + no gas in the colon = complete small bowel obstruction.\\n- Gaseous distension of small bowel + minimal quantity of colonic gas = partial small bowel obstruction.\\n- Significant gaseous distension of both the small bowel and the colon = paralytic ileus.\\n- Significant gaseous distension of the colon + minimal distension of the small bowel = \\n```',\n", " 'md': '- Gaseous distension of small bowel + no gas in the colon = complete small bowel obstruction.\\n- Gaseous distension of small bowel + minimal quantity of colonic gas = partial small bowel obstruction.\\n- Significant gaseous distension of both the small bowel and the colon = paralytic ileus.\\n- Significant gaseous distension of the colon + minimal distension of the small bowel = \\n```',\n", " 'bBox': {'x': 133, 'y': 597, 'w': 390.18, 'h': 16.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 5.3**: The image presents an abdominal X-ray comparing the small bowel and large bowel. It highlights two conditions: small bowel obstruction and distal obstruction of the colon. The small bowel is characterized by the valvulae conniventes, which are transverse lines that cross the entire width of the bowel, while the colon is identified by haustra, which only partially cross the bowel width. The image serves as a visual aid for distinguishing between these two types of bowel obstructions.',\n", " 'md': '**Figure 5.3**: The image presents an abdominal X-ray comparing the small bowel and large bowel. It highlights two conditions: small bowel obstruction and distal obstruction of the colon. The small bowel is characterized by the valvulae conniventes, which are transverse lines that cross the entire width of the bowel, while the colon is identified by haustra, which only partially cross the bowel width. The image serves as a visual aid for distinguishing between these two types of bowel obstructions.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 77,\n", " 'text': ' bowel = colonic obstruction or pseudo-obstruction. (The\\n magnitude of small bowel distension proximal to large bowel obstruction depends\\n on the competence, or incompetence, of the ileocecal valve.)\\n\\n Abnormal opacities\\n\\n The opacities which you are able to spot on the AXR are the calcified\\nones: gallstones in the gallbladder (visible in about one-fifth of patients\\nwith cholelithiasis), ureteric stones (visible in some patients with ureteral\\ncolic), pancreatic calcifications (seen in some patients with chronic\\npancreatitis), and appendicular fecaliths (occasionally seen in patients\\nwith appendicitis) ( Figure 5.4). Clinically irrelevant calcified lesions that\\nare common include phleboliths in the pelvis and calcified lymph nodes in\\nthe right iliac fossa, usually associated with previous tuberculosis. Fecal\\nmatter may opacify the rectum and colon to a variable degree —\\nachieving extreme proportions in patients with fecal impaction. Note that\\na moderate amount of fecal material in the right colon is normal, while a\\ncolumn of feces on the left implies some abnormality, ranging in severity\\nfrom simple constipation to early malignant obstruction. Another opacity,\\nwhich may surprise you, is a forgotten surgical instrument or gauze swab.\\nAlso, massive ascites has a typical picture on AXR ( Figure 5.5).\\n\\n The simple abdominal X-ray is an extension of your clinical\\nevaluation, which is not complete without it.',\n", " 'md': '```markdown\\n## Abnormal Opacities\\n\\nThe opacities which you are able to spot on the AXR are the calcified ones: gallstones in the gallbladder (visible in about one-fifth of patients with cholelithiasis), ureteric stones (visible in some patients with ureteral colic), pancreatic calcifications (seen in some patients with chronic pancreatitis), and appendicular fecaliths (occasionally seen in patients with appendicitis) (Figure 5.4). Clinically irrelevant calcified lesions that are common include phleboliths in the pelvis and calcified lymph nodes in the right iliac fossa, usually associated with previous tuberculosis. Fecal matter may opacify the rectum and colon to a variable degree — achieving extreme proportions in patients with fecal impaction. Note that a moderate amount of fecal material in the right colon is normal, while a column of feces on the left implies some abnormality, ranging in severity from simple constipation to early malignant obstruction. Another opacity, which may surprise you, is a forgotten surgical instrument or gauze swab. Also, massive ascites has a typical picture on AXR (Figure 5.5).\\n\\nThe simple abdominal X-ray is an extension of your clinical evaluation, which is not complete without it.\\n\\n### Figures\\n\\n- **Figure 5.4**: Description of various calcified opacities visible on AXR, including gallstones, ureteric stones, pancreatic calcifications, and appendicular fecaliths.\\n- **Figure 5.5**: Typical appearance of massive ascites on AXR.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abnormal Opacities',\n", " 'md': '## Abnormal Opacities',\n", " 'bBox': {'x': 86, 'y': 191, 'w': 153.57, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The opacities which you are able to spot on the AXR are the calcified ones: gallstones in the gallbladder (visible in about one-fifth of patients with cholelithiasis), ureteric stones (visible in some patients with ureteral colic), pancreatic calcifications (seen in some patients with chronic pancreatitis), and appendicular fecaliths (occasionally seen in patients with appendicitis) (Figure 5.4). Clinically irrelevant calcified lesions that are common include phleboliths in the pelvis and calcified lymph nodes in the right iliac fossa, usually associated with previous tuberculosis. Fecal matter may opacify the rectum and colon to a variable degree — achieving extreme proportions in patients with fecal impaction. Note that a moderate amount of fecal material in the right colon is normal, while a column of feces on the left implies some abnormality, ranging in severity from simple constipation to early malignant obstruction. Another opacity, which may surprise you, is a forgotten surgical instrument or gauze swab. Also, massive ascites has a typical picture on AXR (Figure 5.5).\\n\\nThe simple abdominal X-ray is an extension of your clinical evaluation, which is not complete without it.',\n", " 'md': 'The opacities which you are able to spot on the AXR are the calcified ones: gallstones in the gallbladder (visible in about one-fifth of patients with cholelithiasis), ureteric stones (visible in some patients with ureteral colic), pancreatic calcifications (seen in some patients with chronic pancreatitis), and appendicular fecaliths (occasionally seen in patients with appendicitis) (Figure 5.4). Clinically irrelevant calcified lesions that are common include phleboliths in the pelvis and calcified lymph nodes in the right iliac fossa, usually associated with previous tuberculosis. Fecal matter may opacify the rectum and colon to a variable degree — achieving extreme proportions in patients with fecal impaction. Note that a moderate amount of fecal material in the right colon is normal, while a column of feces on the left implies some abnormality, ranging in severity from simple constipation to early malignant obstruction. Another opacity, which may surprise you, is a forgotten surgical instrument or gauze swab. Also, massive ascites has a typical picture on AXR (Figure 5.5).\\n\\nThe simple abdominal X-ray is an extension of your clinical evaluation, which is not complete without it.',\n", " 'bBox': {'x': 72, 'y': 227, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 5.4**: Description of various calcified opacities visible on AXR, including gallstones, ureteric stones, pancreatic calcifications, and appendicular fecaliths.\\n- **Figure 5.5**: Typical appearance of massive ascites on AXR.\\n```',\n", " 'md': '- **Figure 5.4**: Description of various calcified opacities visible on AXR, including gallstones, ureteric stones, pancreatic calcifications, and appendicular fecaliths.\\n- **Figure 5.5**: Typical appearance of massive ascites on AXR.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'are common include phleboliths in the pelvis and calcified lymph nodes in'},\n", " {'text': ''}]},\n", " {'page': 78,\n", " 'text': 'Figure 5.4. Abdominal X-ray demonstrating an appendicular fecalith (arrow); when\\nvisualized in a patient with symptoms and signs of acute appendicitis it is highly\\ndiagnostic.\\n\\nFigure 5.5. Abdominal X-ray demonstrating massive ascites. In the supine position the\\nbowel gas lies centrally and there is nothing peripherally. The lighter bowel loops are\\npractically floating on a lake of ascites in the abdominal cavity.\\n\\n Computed tomography in abdominal emergencies\\n\\n The road to the operating room does not always have to pass\\nthrough the CT scanner but an appropriately indicated CT may\\nobviate the need for a surgical journey.',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Text\\n- Computed tomography in abdominal emergencies\\n- The road to the operating room does not always have to pass through the CT scanner but an appropriately indicated CT may obviate the need for a surgical journey.\\n\\n### Figures\\n\\n#### Figure 5.4\\n- **Description**: Abdominal X-ray demonstrating an appendicular fecalith (arrow). This finding is highly diagnostic when visualized in a patient with symptoms and signs of acute appendicitis.\\n- **Summary**: The X-ray shows a clear indication of an appendicular fecalith, which is crucial for diagnosing acute appendicitis.\\n\\n#### Figure 5.5\\n- **Description**: Abdominal X-ray demonstrating massive ascites. In the supine position, the bowel gas lies centrally, and there is nothing peripherally. The lighter bowel loops appear to be floating on a lake of ascites in the abdominal cavity.\\n- **Summary**: The X-ray illustrates the presence of massive ascites, characterized by centrally located bowel gas and the appearance of bowel loops floating in fluid.\\n\\n```',\n", " 'images': [{'name': 'img_p77_1.png',\n", " 'height': 290,\n", " 'width': 400,\n", " 'x': 207.35999999999967,\n", " 'y': 82.79999999999998,\n", " 'original_width': 918,\n", " 'original_height': 664},\n", " {'name': 'img_p77_2.png',\n", " 'height': 501,\n", " 'width': 402,\n", " 'x': 206.63999999999987,\n", " 'y': 295.9200000000001,\n", " 'original_width': 920,\n", " 'original_height': 1148}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Computed tomography in abdominal emergencies\\n- The road to the operating room does not always have to pass through the CT scanner but an appropriately indicated CT may obviate the need for a surgical journey.',\n", " 'md': '- Computed tomography in abdominal emergencies\\n- The road to the operating room does not always have to pass through the CT scanner but an appropriately indicated CT may obviate the need for a surgical journey.',\n", " 'bBox': {'x': 72, 'y': 643, 'w': 408.49, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Figure 5.4',\n", " 'md': '#### Figure 5.4',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: Abdominal X-ray demonstrating an appendicular fecalith (arrow). This finding is highly diagnostic when visualized in a patient with symptoms and signs of acute appendicitis.\\n- **Summary**: The X-ray shows a clear indication of an appendicular fecalith, which is crucial for diagnosing acute appendicitis.',\n", " 'md': '- **Description**: Abdominal X-ray demonstrating an appendicular fecalith (arrow). This finding is highly diagnostic when visualized in a patient with symptoms and signs of acute appendicitis.\\n- **Summary**: The X-ray shows a clear indication of an appendicular fecalith, which is crucial for diagnosing acute appendicitis.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Figure 5.5',\n", " 'md': '#### Figure 5.5',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: Abdominal X-ray demonstrating massive ascites. In the supine position, the bowel gas lies centrally, and there is nothing peripherally. The lighter bowel loops appear to be floating on a lake of ascites in the abdominal cavity.\\n- **Summary**: The X-ray illustrates the presence of massive ascites, characterized by centrally located bowel gas and the appearance of bowel loops floating in fluid.\\n\\n```',\n", " 'md': '- **Description**: Abdominal X-ray demonstrating massive ascites. In the supine position, the bowel gas lies centrally, and there is nothing peripherally. The lighter bowel loops appear to be floating on a lake of ascites in the abdominal cavity.\\n- **Summary**: The X-ray illustrates the presence of massive ascites, characterized by centrally located bowel gas and the appearance of bowel loops floating in fluid.\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 79,\n", " 'text': ' The supremacy of CT in the imaging of the abdomen is not in dispute.\\nCT shows details that no other diagnostic method does: free gas, fluid,\\nmasses, tissue planes, inflammatory changes, opacities, blood vessels\\nand organ perfusion. So why should we object to the indiscriminate\\nuse of CT as practiced today in many countries around the world?\\n\\n We object for the simple reason that in many patients the diagnosis\\ncan be established without CT — the obtaining of which can delay\\ntreatment, and confuse the picture by showing non-significant findings\\n(see Chapter 4). Typically, whenever radiologists publish papers on the\\nuse of CT in various abdominal emergencies they always declare\\nsensitivity and specificity rates approaching 100%. When surgeons,\\nhowever, look objectively at the overall impact of CT on the diagnosis and\\ntreatment of specific conditions, the real impact of CT tends to be less\\nimpressive.\\n\\n In addition, remember that the radiation exposure of one abdominal CT\\nexamination can be several hundred times that of a chest X-ray.\\nAccording to the US Food and Drug Administration this amount of\\nradiation exposure may be associated with a small increase in\\nradiation-associated cancer in an individual. This is particularly\\nrelevant if people were to receive this examination repeatedly, starting at\\na young age — as in the young lady presenting with lower abdominal\\npain to an ER in Brooklyn, where CT shows an ovarian cyst. Two weeks\\nlater she shows up at another ER in the Bronx where another CT shows\\n(surprise!) the same cyst. And of course, somebody has to pay for the\\nCT, and radiologists have to possess the newest model of Mercedes.\\nDon’t they?\\n\\n The key word in the effective use of abdominal CT is ‘selectivity’.\\n Rather than indicating a need for exploration, CT is more useful in deciding when NOT to\\n operate — avoiding unnecessary ‘exploratory’ laparotomies or ‘diagnostic’ laparoscopies. Also,\\n a ‘normal CT’ can exclude surgical abdominal conditions — allowing the early discharge of\\n patients without the need for admission for observation.\\n\\n The recent introduction of fast scanners that image the abdomen from',\n", " 'md': '```markdown\\n# The Supremacy of CT in Abdominal Imaging\\n\\nThe supremacy of CT in the imaging of the abdomen is not in dispute. CT shows details that no other diagnostic method does: free gas, fluid, masses, tissue planes, inflammatory changes, opacities, blood vessels, and organ perfusion. So why should we object to the indiscriminate use of CT as practiced today in many countries around the world?\\n\\nWe object for the simple reason that in many patients the diagnosis can be established without CT — the obtaining of which can delay treatment, and confuse the picture by showing non-significant findings (see Chapter 4). Typically, whenever radiologists publish papers on the use of CT in various abdominal emergencies, they always declare sensitivity and specificity rates approaching 100%. When surgeons, however, look objectively at the overall impact of CT on the diagnosis and treatment of specific conditions, the real impact of CT tends to be less impressive.\\n\\nIn addition, remember that the radiation exposure of one abdominal CT examination can be several hundred times that of a chest X-ray. According to the US Food and Drug Administration, this amount of radiation exposure may be associated with a small increase in radiation-associated cancer in an individual. This is particularly relevant if people were to receive this examination repeatedly, starting at a young age — as in the young lady presenting with lower abdominal pain to an ER in Brooklyn, where CT shows an ovarian cyst. Two weeks later she shows up at another ER in the Bronx where another CT shows (surprise!) the same cyst. And of course, somebody has to pay for the CT, and radiologists have to possess the newest model of Mercedes. Don’t they?\\n\\nThe key word in the effective use of abdominal CT is ‘selectivity’. Rather than indicating a need for exploration, CT is more useful in deciding when NOT to operate — avoiding unnecessary ‘exploratory’ laparotomies or ‘diagnostic’ laparoscopies. Also, a ‘normal CT’ can exclude surgical abdominal conditions — allowing the early discharge of patients without the need for admission for observation.\\n\\nThe recent introduction of fast scanners that image the abdomen from...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present in the text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'The Supremacy of CT in Abdominal Imaging',\n", " 'md': '# The Supremacy of CT in Abdominal Imaging',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The supremacy of CT in the imaging of the abdomen is not in dispute. CT shows details that no other diagnostic method does: free gas, fluid, masses, tissue planes, inflammatory changes, opacities, blood vessels, and organ perfusion. So why should we object to the indiscriminate use of CT as practiced today in many countries around the world?\\n\\nWe object for the simple reason that in many patients the diagnosis can be established without CT — the obtaining of which can delay treatment, and confuse the picture by showing non-significant findings (see Chapter 4). Typically, whenever radiologists publish papers on the use of CT in various abdominal emergencies, they always declare sensitivity and specificity rates approaching 100%. When surgeons, however, look objectively at the overall impact of CT on the diagnosis and treatment of specific conditions, the real impact of CT tends to be less impressive.\\n\\nIn addition, remember that the radiation exposure of one abdominal CT examination can be several hundred times that of a chest X-ray. According to the US Food and Drug Administration, this amount of radiation exposure may be associated with a small increase in radiation-associated cancer in an individual. This is particularly relevant if people were to receive this examination repeatedly, starting at a young age — as in the young lady presenting with lower abdominal pain to an ER in Brooklyn, where CT shows an ovarian cyst. Two weeks later she shows up at another ER in the Bronx where another CT shows (surprise!) the same cyst. And of course, somebody has to pay for the CT, and radiologists have to possess the newest model of Mercedes. Don’t they?\\n\\nThe key word in the effective use of abdominal CT is ‘selectivity’. Rather than indicating a need for exploration, CT is more useful in deciding when NOT to operate — avoiding unnecessary ‘exploratory’ laparotomies or ‘diagnostic’ laparoscopies. Also, a ‘normal CT’ can exclude surgical abdominal conditions — allowing the early discharge of patients without the need for admission for observation.\\n\\nThe recent introduction of fast scanners that image the abdomen from...\\n```',\n", " 'md': 'The supremacy of CT in the imaging of the abdomen is not in dispute. CT shows details that no other diagnostic method does: free gas, fluid, masses, tissue planes, inflammatory changes, opacities, blood vessels, and organ perfusion. So why should we object to the indiscriminate use of CT as practiced today in many countries around the world?\\n\\nWe object for the simple reason that in many patients the diagnosis can be established without CT — the obtaining of which can delay treatment, and confuse the picture by showing non-significant findings (see Chapter 4). Typically, whenever radiologists publish papers on the use of CT in various abdominal emergencies, they always declare sensitivity and specificity rates approaching 100%. When surgeons, however, look objectively at the overall impact of CT on the diagnosis and treatment of specific conditions, the real impact of CT tends to be less impressive.\\n\\nIn addition, remember that the radiation exposure of one abdominal CT examination can be several hundred times that of a chest X-ray. According to the US Food and Drug Administration, this amount of radiation exposure may be associated with a small increase in radiation-associated cancer in an individual. This is particularly relevant if people were to receive this examination repeatedly, starting at a young age — as in the young lady presenting with lower abdominal pain to an ER in Brooklyn, where CT shows an ovarian cyst. Two weeks later she shows up at another ER in the Bronx where another CT shows (surprise!) the same cyst. And of course, somebody has to pay for the CT, and radiologists have to possess the newest model of Mercedes. Don’t they?\\n\\nThe key word in the effective use of abdominal CT is ‘selectivity’. Rather than indicating a need for exploration, CT is more useful in deciding when NOT to operate — avoiding unnecessary ‘exploratory’ laparotomies or ‘diagnostic’ laparoscopies. Also, a ‘normal CT’ can exclude surgical abdominal conditions — allowing the early discharge of patients without the need for admission for observation.\\n\\nThe recent introduction of fast scanners that image the abdomen from...\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.9, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present in the text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present in the text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'use of CT in various abdominal emergencies they always declare'}]},\n", " {'page': 80,\n", " 'text': 'the diaphragm to the pubis in a single breath has greatly improved the\\nimage quality and reduced the time required to obtain the images.\\nħowever, it does require that patients be transported to the CT suite and\\nexposes them to the risks of aspiration of oral contrast media and\\nadverse reactions to intravenous (i.v.) contrast media such as\\nanaphylaxis and nephrotoxicity. Unenhanced (no i.v. contrast) helical or\\nspiral CT scans are being increasingly used in suspected appendicitis,\\nwhile CTs without oral contrast have been reported as accurate in\\npatients suffering from blunt abdominal trauma. Whatever the CT\\nmethodology in your hospital, you — who know the abdomen inside\\nout and understand the natural history of abdominal diseases —\\nhave to be able to analyze the CT images better than the radiologist.\\n\\n As is the case with all imaging studies, interpretation of CT scan\\nimages requires a systematic approach, and it takes plenty of practice to\\nbecome confident in one’s own ability. One also needs to spend time,\\nand the more time you spend the more findings — both negative and\\npositive — you pick up. We are going to describe the way we look at a\\nCT scan of the abdomen; it is not ‘ideal’ or ‘perfect’ but it works for us,\\nespecially in the middle of the night when all the radiologists are snoring\\nin bed. In the morning they will, with latte in hand, dictate detailed reports.\\nThis is when you have to go over the images with them — you will\\nbe surprised how often, now, equipped with the accurate clinical\\ninformation you provide, they will see something that was missed at\\nnight.\\n\\n Spend a few hours on YouTube where you will find excellent clips on\\nhow to look at abdominal CT studies.\\n\\n It is important to pay attention to a few technical aspects of the\\nstudy before beginning to interpret it. While there is a lot of literature\\nto support the notion that there is no need for oral or intravenous contrast\\nmaterial, the use of contrast improves your own diagnostic yield. One\\nexception to this is when ureteric calculi are at the top of the differential\\ndiagnosis list and a non-contrast study gives almost all the information\\nrequired.',\n", " 'md': '```markdown\\n## CT Scan Interpretation\\n\\nThe diaphragm to the pubis in a single breath has greatly improved the image quality and reduced the time required to obtain the images. However, it does require that patients be transported to the CT suite and exposes them to the risks of aspiration of oral contrast media and adverse reactions to intravenous (i.v.) contrast media such as anaphylaxis and nephrotoxicity. Unenhanced (no i.v. contrast) helical or spiral CT scans are being increasingly used in suspected appendicitis, while CTs without oral contrast have been reported as accurate in patients suffering from blunt abdominal trauma. Whatever the CT methodology in your hospital, you — who know the abdomen inside out and understand the natural history of abdominal diseases — have to be able to analyze the CT images better than the radiologist.\\n\\nAs is the case with all imaging studies, interpretation of CT scan images requires a systematic approach, and it takes plenty of practice to become confident in one’s own ability. One also needs to spend time, and the more time you spend the more findings — both negative and positive — you pick up. We are going to describe the way we look at a CT scan of the abdomen; it is not ‘ideal’ or ‘perfect’ but it works for us, especially in the middle of the night when all the radiologists are snoring in bed. In the morning they will, with latte in hand, dictate detailed reports. This is when you have to go over the images with them — you will be surprised how often, now, equipped with the accurate clinical information you provide, they will see something that was missed at night.\\n\\nSpend a few hours on YouTube where you will find excellent clips on how to look at abdominal CT studies.\\n\\nIt is important to pay attention to a few technical aspects of the study before beginning to interpret it. While there is a lot of literature to support the notion that there is no need for oral or intravenous contrast material, the use of contrast improves your own diagnostic yield. One exception to this is when ureteric calculi are at the top of the differential diagnosis list and a non-contrast study gives almost all the information required.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'CT Scan Interpretation',\n", " 'md': '## CT Scan Interpretation',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The diaphragm to the pubis in a single breath has greatly improved the image quality and reduced the time required to obtain the images. However, it does require that patients be transported to the CT suite and exposes them to the risks of aspiration of oral contrast media and adverse reactions to intravenous (i.v.) contrast media such as anaphylaxis and nephrotoxicity. Unenhanced (no i.v. contrast) helical or spiral CT scans are being increasingly used in suspected appendicitis, while CTs without oral contrast have been reported as accurate in patients suffering from blunt abdominal trauma. Whatever the CT methodology in your hospital, you — who know the abdomen inside out and understand the natural history of abdominal diseases — have to be able to analyze the CT images better than the radiologist.\\n\\nAs is the case with all imaging studies, interpretation of CT scan images requires a systematic approach, and it takes plenty of practice to become confident in one’s own ability. One also needs to spend time, and the more time you spend the more findings — both negative and positive — you pick up. We are going to describe the way we look at a CT scan of the abdomen; it is not ‘ideal’ or ‘perfect’ but it works for us, especially in the middle of the night when all the radiologists are snoring in bed. In the morning they will, with latte in hand, dictate detailed reports. This is when you have to go over the images with them — you will be surprised how often, now, equipped with the accurate clinical information you provide, they will see something that was missed at night.\\n\\nSpend a few hours on YouTube where you will find excellent clips on how to look at abdominal CT studies.\\n\\nIt is important to pay attention to a few technical aspects of the study before beginning to interpret it. While there is a lot of literature to support the notion that there is no need for oral or intravenous contrast material, the use of contrast improves your own diagnostic yield. One exception to this is when ureteric calculi are at the top of the differential diagnosis list and a non-contrast study gives almost all the information required.\\n```',\n", " 'md': 'The diaphragm to the pubis in a single breath has greatly improved the image quality and reduced the time required to obtain the images. However, it does require that patients be transported to the CT suite and exposes them to the risks of aspiration of oral contrast media and adverse reactions to intravenous (i.v.) contrast media such as anaphylaxis and nephrotoxicity. Unenhanced (no i.v. contrast) helical or spiral CT scans are being increasingly used in suspected appendicitis, while CTs without oral contrast have been reported as accurate in patients suffering from blunt abdominal trauma. Whatever the CT methodology in your hospital, you — who know the abdomen inside out and understand the natural history of abdominal diseases — have to be able to analyze the CT images better than the radiologist.\\n\\nAs is the case with all imaging studies, interpretation of CT scan images requires a systematic approach, and it takes plenty of practice to become confident in one’s own ability. One also needs to spend time, and the more time you spend the more findings — both negative and positive — you pick up. We are going to describe the way we look at a CT scan of the abdomen; it is not ‘ideal’ or ‘perfect’ but it works for us, especially in the middle of the night when all the radiologists are snoring in bed. In the morning they will, with latte in hand, dictate detailed reports. This is when you have to go over the images with them — you will be surprised how often, now, equipped with the accurate clinical information you provide, they will see something that was missed at night.\\n\\nSpend a few hours on YouTube where you will find excellent clips on how to look at abdominal CT studies.\\n\\nIt is important to pay attention to a few technical aspects of the study before beginning to interpret it. While there is a lot of literature to support the notion that there is no need for oral or intravenous contrast material, the use of contrast improves your own diagnostic yield. One exception to this is when ureteric calculi are at the top of the differential diagnosis list and a non-contrast study gives almost all the information required.\\n```',\n", " 'bBox': {'x': 72, 'y': 168, 'w': 467.77, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 81,\n", " 'text': 'Contraindications to intravenous contrast medium:\\n\\n Impaired renal function (consult your hospital protocol, remember the\\n importance of pre-CT hydration).\\n History of prior allergic reaction to iodinated contrast medium.\\n Severe asthma or congestive heart failure.\\n Diabetic patient on metformin (if renal function is normal you can use\\n intravenous contrast but metformin should be stopped for 2 days thereafter).\\n Multiple myeloma or sickle-cell anemia.\\n Pheochromocytoma — i.v. contrast may precipitate a hypertensive crisis.\\n\\n Reviewing the abdominal CT\\n\\n• It is important to note the distance between two CT ‘slices’.\\n Usually the technicians use 5mm intervals between the slices but it\\n is sometimes helpful to request 3mm cuts of the appendiceal area in\\n a clinically difficult case. Also, it is essential to ensure that you have\\n all the images by looking at the image numbers. Many hospitals\\n have done away with hard copies and introduced instead Picture\\n Archiving and Communication Systems (PACS), which make access\\n to images easier. In the latter case, scrolling through the scan gives\\n information that is much easier to interpret than if individual films are\\n examined.\\n• With individual films we always begin with a good look at the scout\\n film; it provides similar information to a flatplate of the abdomen and\\n provides a ‘global view’.\\n• The visualized portions of the lower lung fields should also be\\n looked at in both mediastinal and lung windows. Pulmonary\\n infiltrates and pleural effusions can be easily identified and at times\\n are a reflection of an acute sub-diaphragmatic process. An\\n unsuspected pneumothorax in a trauma patient will also be obvious\\n in the lung windows.\\n• Whilst it is easier to concentrate on the area of interest (e.g. the\\n right lower quadrant in a patient with suspected appendicitis) and',\n", " 'md': '# Contraindications to Intravenous Contrast Medium\\n\\n- **Impaired renal function** (consult your hospital protocol, remember the importance of pre-CT hydration).\\n- **History of prior allergic reaction** to iodinated contrast medium.\\n- **Severe asthma** or **congestive heart failure**.\\n- **Diabetic patient on metformin** (if renal function is normal you can use intravenous contrast but metformin should be stopped for 2 days thereafter).\\n- **Multiple myeloma** or **sickle-cell anemia**.\\n- **Pheochromocytoma** — i.v. contrast may precipitate a hypertensive crisis.\\n\\n# Reviewing the Abdominal CT\\n\\n- It is important to note the distance between two CT ‘slices’. Usually, the technicians use 5mm intervals between the slices but it is sometimes helpful to request 3mm cuts of the appendiceal area in a clinically difficult case. Also, it is essential to ensure that you have all the images by looking at the image numbers. Many hospitals have done away with hard copies and introduced instead Picture Archiving and Communication Systems (PACS), which make access to images easier. In the latter case, scrolling through the scan gives information that is much easier to interpret than if individual films are examined.\\n- With individual films, we always begin with a good look at the scout film; it provides similar information to a flat plate of the abdomen and provides a ‘global view’.\\n- The visualized portions of the lower lung fields should also be looked at in both mediastinal and lung windows. Pulmonary infiltrates and pleural effusions can be easily identified and at times are a reflection of an acute sub-diaphragmatic process. An unsuspected pneumothorax in a trauma patient will also be obvious in the lung windows.\\n- Whilst it is easier to concentrate on the area of interest (e.g., the right lower quadrant in a patient with suspected appendicitis) and...\\n\\n(Note: The text appears to be truncated at the end.)',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Contraindications to Intravenous Contrast Medium',\n", " 'md': '# Contraindications to Intravenous Contrast Medium',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Impaired renal function** (consult your hospital protocol, remember the importance of pre-CT hydration).\\n- **History of prior allergic reaction** to iodinated contrast medium.\\n- **Severe asthma** or **congestive heart failure**.\\n- **Diabetic patient on metformin** (if renal function is normal you can use intravenous contrast but metformin should be stopped for 2 days thereafter).\\n- **Multiple myeloma** or **sickle-cell anemia**.\\n- **Pheochromocytoma** — i.v. contrast may precipitate a hypertensive crisis.',\n", " 'md': '- **Impaired renal function** (consult your hospital protocol, remember the importance of pre-CT hydration).\\n- **History of prior allergic reaction** to iodinated contrast medium.\\n- **Severe asthma** or **congestive heart failure**.\\n- **Diabetic patient on metformin** (if renal function is normal you can use intravenous contrast but metformin should be stopped for 2 days thereafter).\\n- **Multiple myeloma** or **sickle-cell anemia**.\\n- **Pheochromocytoma** — i.v. contrast may precipitate a hypertensive crisis.',\n", " 'bBox': {'x': 133, 'y': 147, 'w': 363.2, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Reviewing the Abdominal CT',\n", " 'md': '# Reviewing the Abdominal CT',\n", " 'bBox': {'x': 86, 'y': 335, 'w': 225.27, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- It is important to note the distance between two CT ‘slices’. Usually, the technicians use 5mm intervals between the slices but it is sometimes helpful to request 3mm cuts of the appendiceal area in a clinically difficult case. Also, it is essential to ensure that you have all the images by looking at the image numbers. Many hospitals have done away with hard copies and introduced instead Picture Archiving and Communication Systems (PACS), which make access to images easier. In the latter case, scrolling through the scan gives information that is much easier to interpret than if individual films are examined.\\n- With individual films, we always begin with a good look at the scout film; it provides similar information to a flat plate of the abdomen and provides a ‘global view’.\\n- The visualized portions of the lower lung fields should also be looked at in both mediastinal and lung windows. Pulmonary infiltrates and pleural effusions can be easily identified and at times are a reflection of an acute sub-diaphragmatic process. An unsuspected pneumothorax in a trauma patient will also be obvious in the lung windows.\\n- Whilst it is easier to concentrate on the area of interest (e.g., the right lower quadrant in a patient with suspected appendicitis) and...\\n\\n(Note: The text appears to be truncated at the end.)',\n", " 'md': '- It is important to note the distance between two CT ‘slices’. Usually, the technicians use 5mm intervals between the slices but it is sometimes helpful to request 3mm cuts of the appendiceal area in a clinically difficult case. Also, it is essential to ensure that you have all the images by looking at the image numbers. Many hospitals have done away with hard copies and introduced instead Picture Archiving and Communication Systems (PACS), which make access to images easier. In the latter case, scrolling through the scan gives information that is much easier to interpret than if individual films are examined.\\n- With individual films, we always begin with a good look at the scout film; it provides similar information to a flat plate of the abdomen and provides a ‘global view’.\\n- The visualized portions of the lower lung fields should also be looked at in both mediastinal and lung windows. Pulmonary infiltrates and pleural effusions can be easily identified and at times are a reflection of an acute sub-diaphragmatic process. An unsuspected pneumothorax in a trauma patient will also be obvious in the lung windows.\\n- Whilst it is easier to concentrate on the area of interest (e.g., the right lower quadrant in a patient with suspected appendicitis) and...\\n\\n(Note: The text appears to be truncated at the end.)',\n", " 'bBox': {'x': 100, 'y': 404, 'w': 437.03, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 82,\n", " 'text': ' look for findings to support or exclude the diagnosis, it is essential\\n to look at the rest of the abdomen. One needs to look specifically\\n for the presence of free gas and free fluid, and to see all the solid\\n organs (liver, spleen, kidneys, pancreas), the hollow ones (stomach,\\n small and large bowel), and blood vessels. One key point is to\\n follow the structure in question in serial images (stacking) to\\n obtain as much information as possible.\\n• It is important to visualize the abdominal contents both in the\\n transverse-axial (up-down) as well as the vertical-coronal plane\\n (front-back), as the images tend to supplement each other.\\n• Viewing the images with the PACS you can calculate the\\n Hounsfield Units (ħU) for the various structures you see. To remind\\n you take a look at Table 5.1 below.\\n Table 5.1. CT Hounsfield Units (HU) for various structures.\\n Structure HU\\n Bone 1000\\n Liver 40-60\\n Blood# 40\\n Muscle 10-40\\n Kidney 30\\n Water\\n Fat 550-100\\n Air 1000\\n #Afresh clot could measure over 70 Hounsfield Units; fresh blood measures about 40 HU,\\n but if you come back the nextday or two, it is as little as 20 HU.\\n A few additional tips:\\n\\n• Pneumoperitoneum. While an erect chest film can identify a\\n straightforward case of pneumoperitoneum, a CT scan is the most\\n sensitive means available for its detection. On a CT scan, gas\\n collects beneath the two rectus muscles around the falciform',\n", " 'md': '```markdown\\n## Findings in Abdominal Imaging\\n\\nTo support or exclude a diagnosis, it is essential to examine the entire abdomen. Specifically, one should look for the presence of free gas and free fluid, as well as assess all solid organs (liver, spleen, kidneys, pancreas), hollow organs (stomach, small and large bowel), and blood vessels. A key point is to follow the structure in question in serial images (stacking) to obtain as much information as possible.\\n\\nIt is important to visualize the abdominal contents in both the transverse-axial (up-down) and vertical-coronal (front-back) planes, as the images tend to supplement each other.\\n\\nWhen viewing the images with the PACS, you can calculate the Hounsfield Units (HU) for the various structures you see. To remind you, take a look at Table 5.1 below.\\n\\n### Table 5.1. CT Hounsfield Units (HU) for Various Structures\\n\\n| Structure | HU |\\n|-----------|------------|\\n| Bone | 1000 |\\n| Liver | 40-60 |\\n| Blood | 40 |\\n| Muscle | 10-40 |\\n| Kidney | 30 |\\n| Water | |\\n| Fat | 550-100 |\\n| Air | 1000 |\\n\\n> **Note:** A fresh clot could measure over 70 Hounsfield Units; fresh blood measures about 40 HU, but if you come back the next day or two, it is as little as 20 HU.\\n\\n### Additional Tips\\n\\n- **Pneumoperitoneum:** While an erect chest film can identify a straightforward case of pneumoperitoneum, a CT scan is the most sensitive means available for its detection. On a CT scan, gas collects beneath the two rectus muscles around the falciform.\\n```',\n", " 'images': [{'name': 'img_p81_1.png',\n", " 'height': 12,\n", " 'width': 12,\n", " 'x': 217.4399999999996,\n", " 'y': 280.8},\n", " {'name': 'img_p81_2.png',\n", " 'height': 568,\n", " 'width': 812,\n", " 'x': 105.11999999999989,\n", " 'y': 312.47999999999996,\n", " 'original_width': 1395,\n", " 'original_height': 976}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Findings in Abdominal Imaging',\n", " 'md': '## Findings in Abdominal Imaging',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'To support or exclude a diagnosis, it is essential to examine the entire abdomen. Specifically, one should look for the presence of free gas and free fluid, as well as assess all solid organs (liver, spleen, kidneys, pancreas), hollow organs (stomach, small and large bowel), and blood vessels. A key point is to follow the structure in question in serial images (stacking) to obtain as much information as possible.\\n\\nIt is important to visualize the abdominal contents in both the transverse-axial (up-down) and vertical-coronal (front-back) planes, as the images tend to supplement each other.\\n\\nWhen viewing the images with the PACS, you can calculate the Hounsfield Units (HU) for the various structures you see. To remind you, take a look at Table 5.1 below.',\n", " 'md': 'To support or exclude a diagnosis, it is essential to examine the entire abdomen. Specifically, one should look for the presence of free gas and free fluid, as well as assess all solid organs (liver, spleen, kidneys, pancreas), hollow organs (stomach, small and large bowel), and blood vessels. A key point is to follow the structure in question in serial images (stacking) to obtain as much information as possible.\\n\\nIt is important to visualize the abdominal contents in both the transverse-axial (up-down) and vertical-coronal (front-back) planes, as the images tend to supplement each other.\\n\\nWhen viewing the images with the PACS, you can calculate the Hounsfield Units (HU) for the various structures you see. To remind you, take a look at Table 5.1 below.',\n", " 'bBox': {'x': 100, 'y': 185, 'w': 275, 'h': 14.83}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 5.1. CT Hounsfield Units (HU) for Various Structures',\n", " 'md': '### Table 5.1. CT Hounsfield Units (HU) for Various Structures',\n", " 'bBox': {'x': 109.08, 'y': 356.97, 'w': 53.44, 'h': 13.84}},\n", " {'type': 'table',\n", " 'rows': [['Structure', 'HU'],\n", " ['Bone', '1000'],\n", " ['Liver', '40-60'],\n", " ['Blood', '40'],\n", " ['Muscle', '10-40'],\n", " ['Kidney', '30'],\n", " ['Water', ''],\n", " ['Fat', '550-100'],\n", " ['Air', '1000']],\n", " 'md': '| Structure | HU |\\n|-----------|------------|\\n| Bone | 1000 |\\n| Liver | 40-60 |\\n| Blood | 40 |\\n| Muscle | 10-40 |\\n| Kidney | 30 |\\n| Water | |\\n| Fat | 550-100 |\\n| Air | 1000 |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Structure\",\"HU\"\\n\"Bone\",\"1000\"\\n\"Liver\",\"40-60\"\\n\"Blood\",\"40\"\\n\"Muscle\",\"10-40\"\\n\"Kidney\",\"30\"\\n\"Water\",\"\"\\n\"Fat\",\"550-100\"\\n\"Air\",\"1000\"',\n", " 'bBox': {'x': 108.09, 'y': 356.97, 'w': 54.43, 'h': 14.83}},\n", " {'type': 'text',\n", " 'value': '> **Note:** A fresh clot could measure over 70 Hounsfield Units; fresh blood measures about 40 HU, but if you come back the next day or two, it is as little as 20 HU.',\n", " 'md': '> **Note:** A fresh clot could measure over 70 Hounsfield Units; fresh blood measures about 40 HU, but if you come back the next day or two, it is as little as 20 HU.',\n", " 'bBox': {'x': 109.08, 'y': 356.97, 'w': 286.97, 'h': 15.82}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Additional Tips',\n", " 'md': '### Additional Tips',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Pneumoperitoneum:** While an erect chest film can identify a straightforward case of pneumoperitoneum, a CT scan is the most sensitive means available for its detection. On a CT scan, gas collects beneath the two rectus muscles around the falciform.\\n```',\n", " 'md': '- **Pneumoperitoneum:** While an erect chest film can identify a straightforward case of pneumoperitoneum, a CT scan is the most sensitive means available for its detection. On a CT scan, gas collects beneath the two rectus muscles around the falciform.\\n```',\n", " 'bBox': {'x': 110.07, 'y': 442, 'w': 34.63, 'h': 11.86}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 83,\n", " 'text': ' ligament ( Figure 5.6). It also collects between the liver and anterior\\n abdominal wall and within the ‘leaves’ of the mesentery. The findings\\n are at times very subtle and only a few bubbles of extraluminal gas\\n are all that is required to make the diagnosis of pneumoperitoneum.\\n The key to the identification of extraluminal gas is inspection of\\n all the scans of the abdomen in lung windows. It is easier with\\n PACS as we can manipulate the window settings. Even if your\\n hospital belongs to the dark ages and does not have PACS, the CT\\n scan station will have the ability to do this.\\n\\nFigure 5.6. CT (lung window) demonstrating two pockets of extraluminal gas in the\\nepigastric region outlying the falciform ligament (arrow).\\n\\n • Free fluid. Free fluid from any source tends to accumulate in the\\n most dependent parts of the peritoneal cavity — Morrison’s\\n hepatorenal pouch and the pelvis. When there is a large amount of\\n fluid the bowel loops float to the midline. In addition to identifying\\n the presence of fluid, measurement of the fluid density offers some\\n clues regarding its nature: less than 15 ħU for transudative ascites,\\n and more than 30 ħU for exudative ascites or blood.\\n • Solid organs. While solid organ pathology is a rare cause of non-\\n traumatic acute abdominal conditions, CT is the modality of choice\\n in the investigation of the hemodynamically stable victim of blunt\\n abdominal trauma. Lacerations of the solid organs appear as linear\\n or branching low-attenuation areas. Subcapsular hematomas\\n appear as crescentic low-attenuation areas at the periphery.\\n Intraparenchymal hematomas appear as round or oval collections\\n of blood within the parenchyma.',\n", " 'md': '```markdown\\n## Page Content\\n\\nThe text discusses the identification of extraluminal gas in the abdomen, particularly in the context of pneumoperitoneum. It emphasizes the importance of inspecting all scans of the abdomen in lung windows for accurate diagnosis. The text also mentions the use of PACS (Picture Archiving and Communication System) for manipulating window settings to aid in diagnosis.\\n\\n### Figure 5.6\\n**Description:** CT (lung window) demonstrating two pockets of extraluminal gas in the epigastric region outlying the falciform ligament (arrow).\\n\\n**Summary:** This figure illustrates the presence of extraluminal gas, which is crucial for diagnosing pneumoperitoneum. The gas is located in the epigastric region, highlighting the importance of careful examination of CT scans.\\n\\n### Key Points\\n- **Free Fluid:** Free fluid tends to accumulate in the most dependent parts of the peritoneal cavity, such as Morrison’s hepatorenal pouch and the pelvis. The presence of fluid can cause bowel loops to float to the midline. Fluid density measurements can indicate its nature:\\n- Less than 15 ħU for transudative ascites\\n- More than 30 ħU for exudative ascites or blood\\n\\n- **Solid Organs:** While solid organ pathology is rare in non-traumatic acute abdominal conditions, CT is the preferred modality for investigating hemodynamically stable victims of blunt abdominal trauma.\\n- Lacerations of solid organs appear as linear or branching low-attenuation areas.\\n- Subcapsular hematomas appear as crescentic low-attenuation areas at the periphery.\\n- Intraparenchymal hematomas appear as round or oval collections of blood within the parenchyma.\\n```',\n", " 'images': [{'name': 'img_p82_1.png',\n", " 'height': 299,\n", " 'width': 339,\n", " 'x': 222.47999999999956,\n", " 'y': 251.28,\n", " 'original_width': 933,\n", " 'original_height': 820}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the identification of extraluminal gas in the abdomen, particularly in the context of pneumoperitoneum. It emphasizes the importance of inspecting all scans of the abdomen in lung windows for accurate diagnosis. The text also mentions the use of PACS (Picture Archiving and Communication System) for manipulating window settings to aid in diagnosis.',\n", " 'md': 'The text discusses the identification of extraluminal gas in the abdomen, particularly in the context of pneumoperitoneum. It emphasizes the importance of inspecting all scans of the abdomen in lung windows for accurate diagnosis. The text also mentions the use of PACS (Picture Archiving and Communication System) for manipulating window settings to aid in diagnosis.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 5.6',\n", " 'md': '### Figure 5.6',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** CT (lung window) demonstrating two pockets of extraluminal gas in the epigastric region outlying the falciform ligament (arrow).\\n\\n**Summary:** This figure illustrates the presence of extraluminal gas, which is crucial for diagnosing pneumoperitoneum. The gas is located in the epigastric region, highlighting the importance of careful examination of CT scans.',\n", " 'md': '**Description:** CT (lung window) demonstrating two pockets of extraluminal gas in the epigastric region outlying the falciform ligament (arrow).\\n\\n**Summary:** This figure illustrates the presence of extraluminal gas, which is crucial for diagnosing pneumoperitoneum. The gas is located in the epigastric region, highlighting the importance of careful examination of CT scans.',\n", " 'bBox': {'x': 75, 'y': 430, 'w': 289.42, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key Points',\n", " 'md': '### Key Points',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Free Fluid:** Free fluid tends to accumulate in the most dependent parts of the peritoneal cavity, such as Morrison’s hepatorenal pouch and the pelvis. The presence of fluid can cause bowel loops to float to the midline. Fluid density measurements can indicate its nature:\\n- Less than 15 ħU for transudative ascites\\n- More than 30 ħU for exudative ascites or blood\\n\\n- **Solid Organs:** While solid organ pathology is rare in non-traumatic acute abdominal conditions, CT is the preferred modality for investigating hemodynamically stable victims of blunt abdominal trauma.\\n- Lacerations of solid organs appear as linear or branching low-attenuation areas.\\n- Subcapsular hematomas appear as crescentic low-attenuation areas at the periphery.\\n- Intraparenchymal hematomas appear as round or oval collections of blood within the parenchyma.\\n```',\n", " 'md': '- **Free Fluid:** Free fluid tends to accumulate in the most dependent parts of the peritoneal cavity, such as Morrison’s hepatorenal pouch and the pelvis. The presence of fluid can cause bowel loops to float to the midline. Fluid density measurements can indicate its nature:\\n- Less than 15 ħU for transudative ascites\\n- More than 30 ħU for exudative ascites or blood\\n\\n- **Solid Organs:** While solid organ pathology is rare in non-traumatic acute abdominal conditions, CT is the preferred modality for investigating hemodynamically stable victims of blunt abdominal trauma.\\n- Lacerations of solid organs appear as linear or branching low-attenuation areas.\\n- Subcapsular hematomas appear as crescentic low-attenuation areas at the periphery.\\n- Intraparenchymal hematomas appear as round or oval collections of blood within the parenchyma.\\n```',\n", " 'bBox': {'x': 108, 'y': 713, 'w': 203.11, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'abdominal wall and within the ‘leaves’ of the mesentery. The findings'}]},\n", " {'page': 84,\n", " 'text': '• Hollow organs. The entire gastrointestinal tract from the stomach\\n to rectum can be traced in serial sections and abnormalities should\\n be sought. In the case of small bowel obstruction, the cause (e.g.\\n intussusception, tumor or inflammatory mass) and the site of\\n obstruction (the transition point) can be identified. The presence of\\n pneumatosis can be identified more readily with CT than a plain\\n film and, if present, suggests intestinal ischemia. (Remember,\\n however, that there are benign causes of pneumatosis and, as\\n always, correlation with the clinical picture is essential.) CT is also\\n sensitive for identifying inflammation, which is suggested by the\\n appearance of tissue infiltration or stranding. If i.v. contrast has\\n been administered, then reduced enhancement of loops of bowel\\n may signal ischemia. Similarly, the origins of the mesenteric\\n vessels may be inspected — best seen in the sagittal axis slices at\\n the abdominal aortic plane — to get some idea about patency.\\n Clots within the portal and/or mesenteric veins would provide\\n evidence for the diagnosis of venous mesenteric ischemia.\\n• Acute appendicitis. The various CT scan findings that are\\n associated with acute appendicitis are as follows:\\n appendiceal signs:\\n - appendix >6mm in diameter;\\n - failure of the appendix to fill with oral contrast or gas to its tip;\\n - enhancement of the appendix with i.v. contrast;\\n - appendicolith;\\n peri-appendiceal signs:\\n - increased fat attenuation (stranding) in the right lower\\n quadrant;\\n - cecal wall thickening;\\n - phlegmon in the right lower quadrant;\\n - abscess or extraluminal gas;\\n - fluid in the right lower quadrant or pelvis;',\n", " 'md': '```markdown\\n## Hollow Organs\\n\\nThe entire gastrointestinal tract from the stomach to rectum can be traced in serial sections and abnormalities should be sought. In the case of small bowel obstruction, the cause (e.g. intussusception, tumor or inflammatory mass) and the site of obstruction (the transition point) can be identified. The presence of pneumatosis can be identified more readily with CT than a plain film and, if present, suggests intestinal ischemia. (Remember, however, that there are benign causes of pneumatosis and, as always, correlation with the clinical picture is essential.) CT is also sensitive for identifying inflammation, which is suggested by the appearance of tissue infiltration or stranding. If i.v. contrast has been administered, then reduced enhancement of loops of bowel may signal ischemia. Similarly, the origins of the mesenteric vessels may be inspected — best seen in the sagittal axis slices at the abdominal aortic plane — to get some idea about patency. Clots within the portal and/or mesenteric veins would provide evidence for the diagnosis of venous mesenteric ischemia.\\n\\n## Acute Appendicitis\\n\\nThe various CT scan findings that are associated with acute appendicitis are as follows:\\n\\n### Appendiceal Signs:\\n- appendix >6mm in diameter;\\n- failure of the appendix to fill with oral contrast or gas to its tip;\\n- enhancement of the appendix with i.v. contrast;\\n- appendicolith;\\n\\n### Peri-appendiceal Signs:\\n- increased fat attenuation (stranding) in the right lower quadrant;\\n- cecal wall thickening;\\n- phlegmon in the right lower quadrant;\\n- abscess or extraluminal gas;\\n- fluid in the right lower quadrant or pelvis;\\n```',\n", " 'images': [{'name': 'img_p83_1.png',\n", " 'height': 8,\n", " 'width': 8,\n", " 'x': 108,\n", " 'y': 401.76},\n", " {'name': 'img_p83_1.png', 'height': 8, 'width': 8, 'x': 108, 'y': 497.52}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Hollow Organs',\n", " 'md': '## Hollow Organs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The entire gastrointestinal tract from the stomach to rectum can be traced in serial sections and abnormalities should be sought. In the case of small bowel obstruction, the cause (e.g. intussusception, tumor or inflammatory mass) and the site of obstruction (the transition point) can be identified. The presence of pneumatosis can be identified more readily with CT than a plain film and, if present, suggests intestinal ischemia. (Remember, however, that there are benign causes of pneumatosis and, as always, correlation with the clinical picture is essential.) CT is also sensitive for identifying inflammation, which is suggested by the appearance of tissue infiltration or stranding. If i.v. contrast has been administered, then reduced enhancement of loops of bowel may signal ischemia. Similarly, the origins of the mesenteric vessels may be inspected — best seen in the sagittal axis slices at the abdominal aortic plane — to get some idea about patency. Clots within the portal and/or mesenteric veins would provide evidence for the diagnosis of venous mesenteric ischemia.',\n", " 'md': 'The entire gastrointestinal tract from the stomach to rectum can be traced in serial sections and abnormalities should be sought. In the case of small bowel obstruction, the cause (e.g. intussusception, tumor or inflammatory mass) and the site of obstruction (the transition point) can be identified. The presence of pneumatosis can be identified more readily with CT than a plain film and, if present, suggests intestinal ischemia. (Remember, however, that there are benign causes of pneumatosis and, as always, correlation with the clinical picture is essential.) CT is also sensitive for identifying inflammation, which is suggested by the appearance of tissue infiltration or stranding. If i.v. contrast has been administered, then reduced enhancement of loops of bowel may signal ischemia. Similarly, the origins of the mesenteric vessels may be inspected — best seen in the sagittal axis slices at the abdominal aortic plane — to get some idea about patency. Clots within the portal and/or mesenteric veins would provide evidence for the diagnosis of venous mesenteric ischemia.',\n", " 'bBox': {'x': 108, 'y': 105, 'w': 429.71, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Acute Appendicitis',\n", " 'md': '## Acute Appendicitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The various CT scan findings that are associated with acute appendicitis are as follows:',\n", " 'md': 'The various CT scan findings that are associated with acute appendicitis are as follows:',\n", " 'bBox': {'x': 108, 'y': 389, 'w': 322.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Appendiceal Signs:',\n", " 'md': '### Appendiceal Signs:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- appendix >6mm in diameter;\\n- failure of the appendix to fill with oral contrast or gas to its tip;\\n- enhancement of the appendix with i.v. contrast;\\n- appendicolith;',\n", " 'md': '- appendix >6mm in diameter;\\n- failure of the appendix to fill with oral contrast or gas to its tip;\\n- enhancement of the appendix with i.v. contrast;\\n- appendicolith;',\n", " 'bBox': {'x': 130, 'y': 425, 'w': 389.34, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Peri-appendiceal Signs:',\n", " 'md': '### Peri-appendiceal Signs:',\n", " 'bBox': {'x': 130, 'y': 425, 'w': 3.6, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': '- increased fat attenuation (stranding) in the right lower quadrant;\\n- cecal wall thickening;\\n- phlegmon in the right lower quadrant;\\n- abscess or extraluminal gas;\\n- fluid in the right lower quadrant or pelvis;\\n```',\n", " 'md': '- increased fat attenuation (stranding) in the right lower quadrant;\\n- cecal wall thickening;\\n- phlegmon in the right lower quadrant;\\n- abscess or extraluminal gas;\\n- fluid in the right lower quadrant or pelvis;\\n```',\n", " 'bBox': {'x': 130, 'y': 425, 'w': 258.24, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 85,\n", " 'text': ' O2\\n WheRe\\n is TheCT?\\n PeRYA 1;\\nFigure 5.7. You do not need a CT ticket to enter the operating room!\\n\\n Non-visualization of the appendix (in the absence of secondary\\n local inflammatory changes), makes diagnosis of acute appendicitis\\n extremely unlikely!\\n • Colon. Similarly, stranding in the left lower quadrant, or thickening of\\n the sigmoid colon suggests diverticulitis. Diffuse thickening of the\\n colon suggests an inflammatory process like colitis whether\\n infectious or ischemic.\\n • The retroperitoneum including the pancreas should be looked at;\\n the presence of stranding and fluid collections around the pancreas\\n suggests pancreatitis ( Chapter 19). Retroperitoneal hematoma\\n next to an abdominal aortic aneurysm suggests a leak.\\n • Pelvic organs. It is also important to look at the pelvic organs in\\n female patients. Particular attention should be paid to any large\\n cystic masses in the adnexa, which may suggest a complicated cyst,\\n ovarian torsion or a tubo-ovarian abscess.\\n\\n Your patient doesn’t require a CT ticket to enter the OR ( Figure\\n5.7), but many times CT will change your operative plans or even\\ncancel the need for the operation.',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Text\\n- Non-visualization of the appendix (in the absence of secondary local inflammatory changes) makes diagnosis of acute appendicitis extremely unlikely!\\n- Colon. Similarly, stranding in the left lower quadrant, or thickening of the sigmoid colon suggests diverticulitis. Diffuse thickening of the colon suggests an inflammatory process like colitis whether infectious or ischemic.\\n- The retroperitoneum including the pancreas should be looked at; the presence of stranding and fluid collections around the pancreas suggests pancreatitis (Chapter 19). Retroperitoneal hematoma next to an abdominal aortic aneurysm suggests a leak.\\n- Pelvic organs. It is also important to look at the pelvic organs in female patients. Particular attention should be paid to any large cystic masses in the adnexa, which may suggest a complicated cyst, ovarian torsion or a tubo-ovarian abscess.\\n- Your patient doesn’t require a CT ticket to enter the OR (Figure 5.7), but many times CT will change your operative plans or even cancel the need for the operation.\\n\\n### Figure\\n**Figure 5.7**: You do not need a CT ticket to enter the operating room!\\n**Description**: This figure likely illustrates the context of CT ticket requirements for entering the operating room, emphasizing that a CT ticket is not necessary. The figure may also relate to the discussion of diagnostic imaging and its implications for surgical planning.\\n\\n### Summary\\nThe page discusses the importance of imaging in diagnosing various abdominal conditions, including appendicitis, diverticulitis, pancreatitis, and issues related to pelvic organs in female patients. It highlights that while a CT ticket is not required for operating room entry, CT scans can significantly influence surgical decisions.\\n```',\n", " 'images': [{'name': 'img_p84_1.png',\n", " 'height': 539,\n", " 'width': 802,\n", " 'x': 108,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1377,\n", " 'original_height': 925}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Non-visualization of the appendix (in the absence of secondary local inflammatory changes) makes diagnosis of acute appendicitis extremely unlikely!\\n- Colon. Similarly, stranding in the left lower quadrant, or thickening of the sigmoid colon suggests diverticulitis. Diffuse thickening of the colon suggests an inflammatory process like colitis whether infectious or ischemic.\\n- The retroperitoneum including the pancreas should be looked at; the presence of stranding and fluid collections around the pancreas suggests pancreatitis (Chapter 19). Retroperitoneal hematoma next to an abdominal aortic aneurysm suggests a leak.\\n- Pelvic organs. It is also important to look at the pelvic organs in female patients. Particular attention should be paid to any large cystic masses in the adnexa, which may suggest a complicated cyst, ovarian torsion or a tubo-ovarian abscess.\\n- Your patient doesn’t require a CT ticket to enter the OR (Figure 5.7), but many times CT will change your operative plans or even cancel the need for the operation.',\n", " 'md': '- Non-visualization of the appendix (in the absence of secondary local inflammatory changes) makes diagnosis of acute appendicitis extremely unlikely!\\n- Colon. Similarly, stranding in the left lower quadrant, or thickening of the sigmoid colon suggests diverticulitis. Diffuse thickening of the colon suggests an inflammatory process like colitis whether infectious or ischemic.\\n- The retroperitoneum including the pancreas should be looked at; the presence of stranding and fluid collections around the pancreas suggests pancreatitis (Chapter 19). Retroperitoneal hematoma next to an abdominal aortic aneurysm suggests a leak.\\n- Pelvic organs. It is also important to look at the pelvic organs in female patients. Particular attention should be paid to any large cystic masses in the adnexa, which may suggest a complicated cyst, ovarian torsion or a tubo-ovarian abscess.\\n- Your patient doesn’t require a CT ticket to enter the OR (Figure 5.7), but many times CT will change your operative plans or even cancel the need for the operation.',\n", " 'bBox': {'x': 72, 'y': 432, 'w': 465.2, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure',\n", " 'md': '### Figure',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 5.7**: You do not need a CT ticket to enter the operating room!\\n**Description**: This figure likely illustrates the context of CT ticket requirements for entering the operating room, emphasizing that a CT ticket is not necessary. The figure may also relate to the discussion of diagnostic imaging and its implications for surgical planning.',\n", " 'md': '**Figure 5.7**: You do not need a CT ticket to enter the operating room!\\n**Description**: This figure likely illustrates the context of CT ticket requirements for entering the operating room, emphasizing that a CT ticket is not necessary. The figure may also relate to the discussion of diagnostic imaging and its implications for surgical planning.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The page discusses the importance of imaging in diagnosing various abdominal conditions, including appendicitis, diverticulitis, pancreatitis, and issues related to pelvic organs in female patients. It highlights that while a CT ticket is not required for operating room entry, CT scans can significantly influence surgical decisions.\\n```',\n", " 'md': 'The page discusses the importance of imaging in diagnosing various abdominal conditions, including appendicitis, diverticulitis, pancreatitis, and issues related to pelvic organs in female patients. It highlights that while a CT ticket is not required for operating room entry, CT scans can significantly influence surgical decisions.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'next to an abdominal aortic aneurysm suggests a leak.'},\n", " {'text': 'Your patient doesn’t require a CT ticket to enter the OR ( Figure 5.7), but many times CT will change your operative plans or even cancel the need for the operation'}]},\n", " {'page': 86,\n", " 'text': ' And now, here are a few words from our radiologist friend, ħans Ulrich\\nElben.\\n\\n How to read and interpret the abdominal CT for an ‘acute\\n abdomen’\\n\\n How to order a CT examination\\n\\n Contrary to what you may think, some radiologists understand\\nsomething about medicine and surgery. And a few of us know something\\nabout CT scans. We therefore respectfully request that you please\\nprovide us with an accurate clinical picture and your tentative\\ndiagnosis when requesting a scan. You should tell us also about any\\nrelevant previous operations or injuries (like cholecystectomy,\\nappendectomy, hysterectomy).\\n\\n Technical state-of-the-art CT examination\\n\\n A good CT examination is performed with a spiral CT after i.v.\\nadministration of a contrast medium. If possible, we also like to use an\\noral diluted Gastrografin® medium. The latter can also be given rectally\\nespecially when suspecting an obstructing colonic lesion or colonic\\ntrauma. In women with suspected gynecological pathology, you could\\nmark the position of the vagina with a normal vaginal tampon. An\\nimportant exception: in cases of suspected ureteric colic the use of oral\\ncontrast is not necessary. ħaving said that, I admit that in some centers,\\nin order to save time, oral contrast is avoided in acute abdomen patients.\\n\\n Interpretation\\n\\n Start with a scout view, similar to a plain abdominal X-ray in a supine\\npatient. Look at the distribution of gas in the stomach and the small and\\nlarge intestine. Are there signs of free gas outside the intestinal lumen? It\\nis absolutely necessary to look at the CT images in a special window for\\nchest examination (center — 700 ħU, window width 2000 ħU) as well as',\n", " 'md': '```markdown\\n# How to Read and Interpret the Abdominal CT for an ‘Acute Abdomen’\\n\\n## Text\\n\\nAnd now, here are a few words from our radiologist friend, Hans Ulrich Elben.\\n\\nHow to order a CT examination\\n\\nContrary to what you may think, some radiologists understand something about medicine and surgery. And a few of us know something about CT scans. We therefore respectfully request that you please provide us with an accurate clinical picture and your tentative diagnosis when requesting a scan. You should tell us also about any relevant previous operations or injuries (like cholecystectomy, appendectomy, hysterectomy).\\n\\nTechnical state-of-the-art CT examination\\n\\nA good CT examination is performed with a spiral CT after i.v. administration of a contrast medium. If possible, we also like to use an oral diluted Gastrografin® medium. The latter can also be given rectally especially when suspecting an obstructing colonic lesion or colonic trauma. In women with suspected gynecological pathology, you could mark the position of the vagina with a normal vaginal tampon. An important exception: in cases of suspected ureteric colic the use of oral contrast is not necessary. Having said that, I admit that in some centers, in order to save time, oral contrast is avoided in acute abdomen patients.\\n\\nInterpretation\\n\\nStart with a scout view, similar to a plain abdominal X-ray in a supine patient. Look at the distribution of gas in the stomach and the small and large intestine. Are there signs of free gas outside the intestinal lumen? It is absolutely necessary to look at the CT images in a special window for chest examination (center — 700 HU, window width 2000 HU).\\n\\n## Figures\\n\\n*No images or figures were identified on this page.*\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'How to Read and Interpret the Abdominal CT for an ‘Acute Abdomen’',\n", " 'md': '# How to Read and Interpret the Abdominal CT for an ‘Acute Abdomen’',\n", " 'bBox': {'x': 86, 'y': 145, 'w': 452.58, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'And now, here are a few words from our radiologist friend, Hans Ulrich Elben.\\n\\nHow to order a CT examination\\n\\nContrary to what you may think, some radiologists understand something about medicine and surgery. And a few of us know something about CT scans. We therefore respectfully request that you please provide us with an accurate clinical picture and your tentative diagnosis when requesting a scan. You should tell us also about any relevant previous operations or injuries (like cholecystectomy, appendectomy, hysterectomy).\\n\\nTechnical state-of-the-art CT examination\\n\\nA good CT examination is performed with a spiral CT after i.v. administration of a contrast medium. If possible, we also like to use an oral diluted Gastrografin® medium. The latter can also be given rectally especially when suspecting an obstructing colonic lesion or colonic trauma. In women with suspected gynecological pathology, you could mark the position of the vagina with a normal vaginal tampon. An important exception: in cases of suspected ureteric colic the use of oral contrast is not necessary. Having said that, I admit that in some centers, in order to save time, oral contrast is avoided in acute abdomen patients.\\n\\nInterpretation\\n\\nStart with a scout view, similar to a plain abdominal X-ray in a supine patient. Look at the distribution of gas in the stomach and the small and large intestine. Are there signs of free gas outside the intestinal lumen? It is absolutely necessary to look at the CT images in a special window for chest examination (center — 700 HU, window width 2000 HU).',\n", " 'md': 'And now, here are a few words from our radiologist friend, Hans Ulrich Elben.\\n\\nHow to order a CT examination\\n\\nContrary to what you may think, some radiologists understand something about medicine and surgery. And a few of us know something about CT scans. We therefore respectfully request that you please provide us with an accurate clinical picture and your tentative diagnosis when requesting a scan. You should tell us also about any relevant previous operations or injuries (like cholecystectomy, appendectomy, hysterectomy).\\n\\nTechnical state-of-the-art CT examination\\n\\nA good CT examination is performed with a spiral CT after i.v. administration of a contrast medium. If possible, we also like to use an oral diluted Gastrografin® medium. The latter can also be given rectally especially when suspecting an obstructing colonic lesion or colonic trauma. In women with suspected gynecological pathology, you could mark the position of the vagina with a normal vaginal tampon. An important exception: in cases of suspected ureteric colic the use of oral contrast is not necessary. Having said that, I admit that in some centers, in order to save time, oral contrast is avoided in acute abdomen patients.\\n\\nInterpretation\\n\\nStart with a scout view, similar to a plain abdominal X-ray in a supine patient. Look at the distribution of gas in the stomach and the small and large intestine. Are there signs of free gas outside the intestinal lumen? It is absolutely necessary to look at the CT images in a special window for chest examination (center — 700 HU, window width 2000 HU).',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.9, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures',\n", " 'md': '## Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*\\n```',\n", " 'md': '*No images or figures were identified on this page.*\\n```',\n", " 'bBox': {'x': 295, 'y': 327, 'w': 16.79, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 87,\n", " 'text': 'in a normal window (center — 40 ħU, window width 400 ħU). Thus, you\\nwill recognize free gas outside the intestinal lumen much better.\\n\\n Step-by-step interpretation of images by organs\\n\\n Try to examine every organ from a cranial to caudal direction\\ncompletely. Especially note the limits and the structures of the tissues.\\n\\n Liver\\n Look at edges of the organ, homogeneous enhancement, and luminal\\ncontrast within the portal vein and its branches. Important diagnoses\\ninclude: blunt trauma with rupture of the liver, abscesses ( Figure 5.8),\\nand portal vein thrombosis.\\n\\nFigure 5.8. CT: liver abscess.\\n\\n Gallbladder and bile ducts\\n The intrahepatic bile ducts accompany the branches of the portal vein.\\nNormally they are hardly recognized unless dilated. If there is\\ncholangiectasis, follow the common bile duct down to the duodenal\\npapilla. Do you see any signs of tumor-associated obstruction or\\ncholedocholithiasis? Normally, the wall of the gallbladder is thin (about 2-\\n3mm). A distended gallbladder, thickened wall, a pericholecystic layer of\\nfluid, a ‘halo’ sign and intramural air are strong indications of cholecystitis\\n( Figure 5.9). But, of course, when it comes to the gallbladder and',\n", " 'md': '```markdown\\n## Step-by-step interpretation of images by organs\\n\\n### Liver\\nLook at edges of the organ, homogeneous enhancement, and luminal contrast within the portal vein and its branches. Important diagnoses include: blunt trauma with rupture of the liver, abscesses (Figure 5.8), and portal vein thrombosis.\\n\\n**Figure 5.8**: CT image showing a liver abscess.\\n\\n### Gallbladder and bile ducts\\nThe intrahepatic bile ducts accompany the branches of the portal vein. Normally they are hardly recognized unless dilated. If there is cholangiectasis, follow the common bile duct down to the duodenal papilla. Do you see any signs of tumor-associated obstruction or choledocholithiasis? Normally, the wall of the gallbladder is thin (about 2-3 mm). A distended gallbladder, thickened wall, a pericholecystic layer of fluid, a ‘halo’ sign, and intramural air are strong indications of cholecystitis (Figure 5.9). But, of course, when it comes to the gallbladder and...\\n```',\n", " 'images': [{'name': 'img_p86_1.png',\n", " 'height': 363,\n", " 'width': 405,\n", " 'x': 205.92000000000007,\n", " 'y': 321.12,\n", " 'original_width': 927,\n", " 'original_height': 829}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Step-by-step interpretation of images by organs',\n", " 'md': '## Step-by-step interpretation of images by organs',\n", " 'bBox': {'x': 86, 'y': 145, 'w': 376.99, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Liver',\n", " 'md': '### Liver',\n", " 'bBox': {'x': 86, 'y': 237, 'w': 34.38, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Look at edges of the organ, homogeneous enhancement, and luminal contrast within the portal vein and its branches. Important diagnoses include: blunt trauma with rupture of the liver, abscesses (Figure 5.8), and portal vein thrombosis.\\n\\n**Figure 5.8**: CT image showing a liver abscess.',\n", " 'md': 'Look at edges of the organ, homogeneous enhancement, and luminal contrast within the portal vein and its branches. Important diagnoses include: blunt trauma with rupture of the liver, abscesses (Figure 5.8), and portal vein thrombosis.\\n\\n**Figure 5.8**: CT image showing a liver abscess.',\n", " 'bBox': {'x': 72, 'y': 237, 'w': 467.1, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Gallbladder and bile ducts',\n", " 'md': '### Gallbladder and bile ducts',\n", " 'bBox': {'x': 86, 'y': 571, 'w': 179.83, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The intrahepatic bile ducts accompany the branches of the portal vein. Normally they are hardly recognized unless dilated. If there is cholangiectasis, follow the common bile duct down to the duodenal papilla. Do you see any signs of tumor-associated obstruction or choledocholithiasis? Normally, the wall of the gallbladder is thin (about 2-3 mm). A distended gallbladder, thickened wall, a pericholecystic layer of fluid, a ‘halo’ sign, and intramural air are strong indications of cholecystitis (Figure 5.9). But, of course, when it comes to the gallbladder and...\\n```',\n", " 'md': 'The intrahepatic bile ducts accompany the branches of the portal vein. Normally they are hardly recognized unless dilated. If there is cholangiectasis, follow the common bile duct down to the duodenal papilla. Do you see any signs of tumor-associated obstruction or choledocholithiasis? Normally, the wall of the gallbladder is thin (about 2-3 mm). A distended gallbladder, thickened wall, a pericholecystic layer of fluid, a ‘halo’ sign, and intramural air are strong indications of cholecystitis (Figure 5.9). But, of course, when it comes to the gallbladder and...\\n```',\n", " 'bBox': {'x': 72, 'y': 592, 'w': 467.71, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 88,\n", " 'text': 'gallstones, ultrasound is more accurate. Indeed, CT can miss\\ngallstones completely!\\n\\n Figure 5.9. CT: acute cholecystitis. Note the gallstones, thick wall of the gallbladder and\\n surrounding fluid.\\n\\n Spleen\\n Notice the size and form of the organ. Is there homogeneous\\nenhancement? Important diagnoses include traumatic or spontaneous\\nrupture with lack of contrast and fluid around the spleen, and infarct of\\nthe spleen with a hypoperfused wedge-like area. Look for extravasation\\nof i.v. contrast.\\n\\n Pancreas\\n The position of this organ is from the hilum of the spleen (cauda\\npancreatici), in front of the contrast-enhanced splenic artery and vein,\\nand superior mesenteric artery and vein, to the duodenal loop (caput\\npancreatici). Normally, the pancreas shows a uniform homogeneous\\nenhancement. In pancreatitis, the organ is enlarged diffusely. In\\npancreatic necrosis, parts of the gland do not light up with contrast. The\\nsurrounding fatty tissue is not dark and inconspicuous by comparison but\\nshows bright streaks. Fluid around the pancreas signifies inflammatory\\nexudate.',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Text\\n- Gallstones: Ultrasound is more accurate. Indeed, CT can miss gallstones completely!\\n\\n### Figure\\n- **Figure 5.9**: CT: acute cholecystitis. Note the gallstones, thick wall of the gallbladder, and surrounding fluid.\\n\\n### Spleen\\n- Notice the size and form of the organ. Is there homogeneous enhancement? Important diagnoses include traumatic or spontaneous rupture with lack of contrast and fluid around the spleen, and infarct of the spleen with a hypoperfused wedge-like area. Look for extravasation of i.v. contrast.\\n\\n### Pancreas\\n- The position of this organ is from the hilum of the spleen (cauda pancreatici), in front of the contrast-enhanced splenic artery and vein, and superior mesenteric artery and vein, to the duodenal loop (caput pancreatici). Normally, the pancreas shows a uniform homogeneous enhancement. In pancreatitis, the organ is enlarged diffusely. In pancreatic necrosis, parts of the gland do not light up with contrast. The surrounding fatty tissue is not dark and inconspicuous by comparison but shows bright streaks. Fluid around the pancreas signifies inflammatory exudate.\\n```',\n", " 'images': [{'name': 'img_p87_1.png',\n", " 'height': 408,\n", " 'width': 408,\n", " 'x': 205.19999999999982,\n", " 'y': 115.91999999999999,\n", " 'original_width': 936,\n", " 'original_height': 937}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Gallstones: Ultrasound is more accurate. Indeed, CT can miss gallstones completely!',\n", " 'md': '- Gallstones: Ultrasound is more accurate. Indeed, CT can miss gallstones completely!',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 155.07, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure',\n", " 'md': '### Figure',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 5.9**: CT: acute cholecystitis. Note the gallstones, thick wall of the gallbladder, and surrounding fluid.',\n", " 'md': '- **Figure 5.9**: CT: acute cholecystitis. Note the gallstones, thick wall of the gallbladder, and surrounding fluid.',\n", " 'bBox': {'x': 75, 'y': 350, 'w': 92.28, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Spleen',\n", " 'md': '### Spleen',\n", " 'bBox': {'x': 86, 'y': 400, 'w': 47.17, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- Notice the size and form of the organ. Is there homogeneous enhancement? Important diagnoses include traumatic or spontaneous rupture with lack of contrast and fluid around the spleen, and infarct of the spleen with a hypoperfused wedge-like area. Look for extravasation of i.v. contrast.',\n", " 'md': '- Notice the size and form of the organ. Is there homogeneous enhancement? Important diagnoses include traumatic or spontaneous rupture with lack of contrast and fluid around the spleen, and infarct of the spleen with a hypoperfused wedge-like area. Look for extravasation of i.v. contrast.',\n", " 'bBox': {'x': 72, 'y': 400, 'w': 92.47, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Pancreas',\n", " 'md': '### Pancreas',\n", " 'bBox': {'x': 86, 'y': 526, 'w': 63.99, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- The position of this organ is from the hilum of the spleen (cauda pancreatici), in front of the contrast-enhanced splenic artery and vein, and superior mesenteric artery and vein, to the duodenal loop (caput pancreatici). Normally, the pancreas shows a uniform homogeneous enhancement. In pancreatitis, the organ is enlarged diffusely. In pancreatic necrosis, parts of the gland do not light up with contrast. The surrounding fatty tissue is not dark and inconspicuous by comparison but shows bright streaks. Fluid around the pancreas signifies inflammatory exudate.\\n```',\n", " 'md': '- The position of this organ is from the hilum of the spleen (cauda pancreatici), in front of the contrast-enhanced splenic artery and vein, and superior mesenteric artery and vein, to the duodenal loop (caput pancreatici). Normally, the pancreas shows a uniform homogeneous enhancement. In pancreatitis, the organ is enlarged diffusely. In pancreatic necrosis, parts of the gland do not light up with contrast. The surrounding fatty tissue is not dark and inconspicuous by comparison but shows bright streaks. Fluid around the pancreas signifies inflammatory exudate.\\n```',\n", " 'bBox': {'x': 72, 'y': 400, 'w': 467.91, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 89,\n", " 'text': ' Kidneys, ureters, urinary bladder and urethra\\n Stones you will see best in a native (i.e. not contrasted) scan within the\\nrenal pelvis or one of the ureters. The ureters have to be examined along\\ntheir entire course from the renal pelvis to the bladder. Any dilatation?\\nAny tissue reaction surrounding calcification (rim sign)? Irregular spotty\\ncontrast of the renal tissue refers to nephritis, and wedge-shaped\\nabsence of contrast implies a renal infarct. In renal vein thrombosis, the\\nrenal vein does not enhance with contrast. Streaky changes in the\\nperirenal fatty tissue suggest inflammation.\\n\\n Organs of the pelvis\\n In women, examine the uterus and the adnexa positioned laterally to it.\\nDo you see cystic structures (ovarian cysts)? Do you recognize\\ninflammatory signs in the surrounding fatty tissue or is there a fluid\\nconcentration with enhancement of its wall (tubo-ovarian abscess)? Are\\nthere signs of bleeding? In men, identify the bladder, prostate gland and\\nseminal vesicles.\\n\\n Stomach, gut and peritoneal cavity\\n Examine the whole intestinal tract starting with the stomach and\\nfollowing the small bowel from duodenum to jejunum, ileum down to the\\nileocecal valve, the cecum and the ascending, transverse, descending\\nand pelvic colon to the rectum. CT features of obstruction and\\ninflammation and other specific conditions are discussed elsewhere in\\nthis book. An inflamed Meckel’s diverticulum can be identified by a\\ndiverticulation of the intestinal lumen with streaky reactions of the\\nsurrounding tissue ( Figure 5.10). In the right lower quadrant, look for\\nthe cecum and the vermiform appendix; signs of acute appendicitis are\\nwell described in the previous section. In active Crohn’s disease, you’ll\\noften recognize a considerably thickened wall of the terminal ileum (\\nFigure 5.11). In the descending and pelvic colon you should look for\\ndiverticula and signs of inflammation — a thickened wall and streaky\\nthickened structures in the pericolic fat. Complicated diverticulitis is\\nsuggested by extraluminal gas, leakage of contrast and an abscess.\\nAppendagitis is inflammation of an appendix epiploica and needs no\\noperation ( Figure 5.12). Colonic diverticula may perforate in the high\\npressure zone above an obstructing carcinoma. CT is not a good tool for',\n", " 'md': \"```markdown\\n# Examination of the Urinary and Pelvic Organs\\n\\n## Kidneys, Ureters, Urinary Bladder, and Urethra\\nStones are best visualized in a native (i.e., not contrasted) scan within the renal pelvis or one of the ureters. The ureters must be examined along their entire course from the renal pelvis to the bladder. Key points to consider include:\\n- Any dilatation?\\n- Any tissue reaction surrounding calcification (rim sign)?\\n- Irregular spotty contrast of the renal tissue indicates nephritis, while a wedge-shaped absence of contrast implies a renal infarct.\\n- In renal vein thrombosis, the renal vein does not enhance with contrast.\\n- Streaky changes in the perirenal fatty tissue suggest inflammation.\\n\\n## Organs of the Pelvis\\nIn women, examine the uterus and the adnexa positioned laterally to it. Key observations include:\\n- Presence of cystic structures (ovarian cysts)?\\n- Signs of inflammation in the surrounding fatty tissue or fluid concentration with enhancement of its wall (tubo-ovarian abscess)?\\n- Signs of bleeding?\\n\\nIn men, identify the bladder, prostate gland, and seminal vesicles.\\n\\n## Stomach, Gut, and Peritoneal Cavity\\nExamine the entire intestinal tract starting with the stomach and following the small bowel from the duodenum to jejunum, ileum down to the ileocecal valve, the cecum, and the ascending, transverse, descending, and pelvic colon to the rectum. Key features to look for include:\\n- CT features of obstruction and inflammation, which are discussed elsewhere in this book.\\n- An inflamed Meckel’s diverticulum can be identified by a diverticulation of the intestinal lumen with streaky reactions of the surrounding tissue (Figure 5.10).\\n- In the right lower quadrant, look for the cecum and the vermiform appendix; signs of acute appendicitis are well described in the previous section.\\n- In active Crohn’s disease, you’ll often recognize a considerably thickened wall of the terminal ileum (Figure 5.11).\\n- In the descending and pelvic colon, look for diverticula and signs of inflammation — a thickened wall and streaky thickened structures in the pericolic fat.\\n- Complicated diverticulitis is suggested by extraluminal gas, leakage of contrast, and an abscess.\\n- Appendagitis is inflammation of an appendix epiploica and does not require surgery (Figure 5.12).\\n- Colonic diverticula may perforate in the high-pressure zone above an obstructing carcinoma. CT is not a good tool for...\\n\\n## Figures\\n### Figure 5.10\\n- Description: An inflamed Meckel’s diverticulum identified by a diverticulation of the intestinal lumen with streaky reactions of the surrounding tissue.\\n- Summary: This figure illustrates the characteristic features of an inflamed Meckel's diverticulum.\\n\\n### Figure 5.11\\n- Description: A considerably thickened wall of the terminal ileum indicative of active Crohn’s disease.\\n- Summary: This figure highlights the typical appearance of the terminal ileum in Crohn's disease.\\n\\n### Figure 5.12\\n- Description: Inflammation of an appendix epiploica (appendagitis) which does not require surgical intervention.\\n- Summary: This figure depicts the condition of appendagitis, emphasizing its non-surgical management.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Examination of the Urinary and Pelvic Organs',\n", " 'md': '# Examination of the Urinary and Pelvic Organs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Kidneys, Ureters, Urinary Bladder, and Urethra',\n", " 'md': '## Kidneys, Ureters, Urinary Bladder, and Urethra',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Stones are best visualized in a native (i.e., not contrasted) scan within the renal pelvis or one of the ureters. The ureters must be examined along their entire course from the renal pelvis to the bladder. Key points to consider include:\\n- Any dilatation?\\n- Any tissue reaction surrounding calcification (rim sign)?\\n- Irregular spotty contrast of the renal tissue indicates nephritis, while a wedge-shaped absence of contrast implies a renal infarct.\\n- In renal vein thrombosis, the renal vein does not enhance with contrast.\\n- Streaky changes in the perirenal fatty tissue suggest inflammation.',\n", " 'md': 'Stones are best visualized in a native (i.e., not contrasted) scan within the renal pelvis or one of the ureters. The ureters must be examined along their entire course from the renal pelvis to the bladder. Key points to consider include:\\n- Any dilatation?\\n- Any tissue reaction surrounding calcification (rim sign)?\\n- Irregular spotty contrast of the renal tissue indicates nephritis, while a wedge-shaped absence of contrast implies a renal infarct.\\n- In renal vein thrombosis, the renal vein does not enhance with contrast.\\n- Streaky changes in the perirenal fatty tissue suggest inflammation.',\n", " 'bBox': {'x': 72, 'y': 223, 'w': 272.65, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Organs of the Pelvis',\n", " 'md': '## Organs of the Pelvis',\n", " 'bBox': {'x': 86, 'y': 262, 'w': 138.28, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'In women, examine the uterus and the adnexa positioned laterally to it. Key observations include:\\n- Presence of cystic structures (ovarian cysts)?\\n- Signs of inflammation in the surrounding fatty tissue or fluid concentration with enhancement of its wall (tubo-ovarian abscess)?\\n- Signs of bleeding?\\n\\nIn men, identify the bladder, prostate gland, and seminal vesicles.',\n", " 'md': 'In women, examine the uterus and the adnexa positioned laterally to it. Key observations include:\\n- Presence of cystic structures (ovarian cysts)?\\n- Signs of inflammation in the surrounding fatty tissue or fluid concentration with enhancement of its wall (tubo-ovarian abscess)?\\n- Signs of bleeding?\\n\\nIn men, identify the bladder, prostate gland, and seminal vesicles.',\n", " 'bBox': {'x': 72, 'y': 283, 'w': 466.8, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Stomach, Gut, and Peritoneal Cavity',\n", " 'md': '## Stomach, Gut, and Peritoneal Cavity',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Examine the entire intestinal tract starting with the stomach and following the small bowel from the duodenum to jejunum, ileum down to the ileocecal valve, the cecum, and the ascending, transverse, descending, and pelvic colon to the rectum. Key features to look for include:\\n- CT features of obstruction and inflammation, which are discussed elsewhere in this book.\\n- An inflamed Meckel’s diverticulum can be identified by a diverticulation of the intestinal lumen with streaky reactions of the surrounding tissue (Figure 5.10).\\n- In the right lower quadrant, look for the cecum and the vermiform appendix; signs of acute appendicitis are well described in the previous section.\\n- In active Crohn’s disease, you’ll often recognize a considerably thickened wall of the terminal ileum (Figure 5.11).\\n- In the descending and pelvic colon, look for diverticula and signs of inflammation — a thickened wall and streaky thickened structures in the pericolic fat.\\n- Complicated diverticulitis is suggested by extraluminal gas, leakage of contrast, and an abscess.\\n- Appendagitis is inflammation of an appendix epiploica and does not require surgery (Figure 5.12).\\n- Colonic diverticula may perforate in the high-pressure zone above an obstructing carcinoma. CT is not a good tool for...',\n", " 'md': 'Examine the entire intestinal tract starting with the stomach and following the small bowel from the duodenum to jejunum, ileum down to the ileocecal valve, the cecum, and the ascending, transverse, descending, and pelvic colon to the rectum. Key features to look for include:\\n- CT features of obstruction and inflammation, which are discussed elsewhere in this book.\\n- An inflamed Meckel’s diverticulum can be identified by a diverticulation of the intestinal lumen with streaky reactions of the surrounding tissue (Figure 5.10).\\n- In the right lower quadrant, look for the cecum and the vermiform appendix; signs of acute appendicitis are well described in the previous section.\\n- In active Crohn’s disease, you’ll often recognize a considerably thickened wall of the terminal ileum (Figure 5.11).\\n- In the descending and pelvic colon, look for diverticula and signs of inflammation — a thickened wall and streaky thickened structures in the pericolic fat.\\n- Complicated diverticulitis is suggested by extraluminal gas, leakage of contrast, and an abscess.\\n- Appendagitis is inflammation of an appendix epiploica and does not require surgery (Figure 5.12).\\n- Colonic diverticula may perforate in the high-pressure zone above an obstructing carcinoma. CT is not a good tool for...',\n", " 'bBox': {'x': 72, 'y': 707, 'w': 467.5, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures',\n", " 'md': '## Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 5.10',\n", " 'md': '### Figure 5.10',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- Description: An inflamed Meckel’s diverticulum identified by a diverticulation of the intestinal lumen with streaky reactions of the surrounding tissue.\\n- Summary: This figure illustrates the characteristic features of an inflamed Meckel's diverticulum.\",\n", " 'md': \"- Description: An inflamed Meckel’s diverticulum identified by a diverticulation of the intestinal lumen with streaky reactions of the surrounding tissue.\\n- Summary: This figure illustrates the characteristic features of an inflamed Meckel's diverticulum.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 5.11',\n", " 'md': '### Figure 5.11',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- Description: A considerably thickened wall of the terminal ileum indicative of active Crohn’s disease.\\n- Summary: This figure highlights the typical appearance of the terminal ileum in Crohn's disease.\",\n", " 'md': \"- Description: A considerably thickened wall of the terminal ileum indicative of active Crohn’s disease.\\n- Summary: This figure highlights the typical appearance of the terminal ileum in Crohn's disease.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 5.12',\n", " 'md': '### Figure 5.12',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Description: Inflammation of an appendix epiploica (appendagitis) which does not require surgical intervention.\\n- Summary: This figure depicts the condition of appendagitis, emphasizing its non-surgical management.\\n```',\n", " 'md': '- Description: Inflammation of an appendix epiploica (appendagitis) which does not require surgical intervention.\\n- Summary: This figure depicts the condition of appendagitis, emphasizing its non-surgical management.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'the cecum and the vermiform appendix; signs of acute appendicitis are'},\n", " {'text': 'Figure 5.11). In the descending and pelvic colon you should look for diverticula and signs of inflammation — a thickened wall and streaky'},\n", " {'text': 'pressure zone above an obstructing carcinoma. CT is not a good tool for'}]},\n", " {'page': 90,\n", " 'text': 'distinguishing a colonic inflammatory mass from a malignant one.\\n\\n Figure 5.10. CT: Meckel’s diverticulum (arrow).\\n\\n Figure 5.11. CT: Crohn’s disease. Note the thickened wall of the terminal ileum (arrow).',\n", " 'md': '```markdown\\n## Page Content\\n\\nThe text discusses the differentiation between a colonic inflammatory mass and a malignant one.\\n\\n### Figures\\n\\n- **Figure 5.10**: CT image showing Meckel’s diverticulum indicated by an arrow.\\n\\n- **Figure 5.11**: CT image illustrating Crohn’s disease, with a note on the thickened wall of the terminal ileum, also indicated by an arrow.\\n```',\n", " 'images': [{'name': 'img_p89_1.png',\n", " 'height': 411,\n", " 'width': 408,\n", " 'x': 205.1999999999989,\n", " 'y': 99.35999999999999,\n", " 'original_width': 933,\n", " 'original_height': 940},\n", " {'name': 'img_p89_2.png',\n", " 'height': 414,\n", " 'width': 408,\n", " 'x': 205.1999999999989,\n", " 'y': 347.76,\n", " 'original_width': 932,\n", " 'original_height': 946}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the differentiation between a colonic inflammatory mass and a malignant one.',\n", " 'md': 'The text discusses the differentiation between a colonic inflammatory mass and a malignant one.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 5.10**: CT image showing Meckel’s diverticulum indicated by an arrow.\\n\\n- **Figure 5.11**: CT image illustrating Crohn’s disease, with a note on the thickened wall of the terminal ileum, also indicated by an arrow.\\n```',\n", " 'md': '- **Figure 5.10**: CT image showing Meckel’s diverticulum indicated by an arrow.\\n\\n- **Figure 5.11**: CT image illustrating Crohn’s disease, with a note on the thickened wall of the terminal ileum, also indicated by an arrow.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 91,\n", " 'text': 'Figure 5.12. CT: Appendagitis epiploica (arrow).\\n\\n Free fluid\\n Watch for free fluid between the intestinal loops and elsewhere. The\\nfluid density gives a clue to its nature: for ascites it is like water, 0-20 ħU,\\nfor pus between 15 and 30 ħU, and for blood about 50 ħU, but be aware\\nthat these specifications don’t always allow an exact differentiation.\\n\\n Abscesses\\n An abscess shows an annular enhancement, and gas inclusions inside\\nwill prove it. Diffuse peritonitis is not easy to diagnose, but helpful signs\\ninclude fluid collections between intestinal loops and in the pouch of\\nDouglas, and a thickened base of the small bowel mesentery.\\n\\n Retroperitoneum, big vessels and abdominal wall\\n Look at the lumen of the aorta and the pelvic vessels in order to find a\\nruptured aneurysm. Look for free gas or a collection suggesting an\\nabscess due to retroperitoneal perforation of a viscus such as the colon\\nor duodenum. Looking at the abdominal wall, try to find pathological\\nchanges like subcutaneous abscesses, rectus sheath hematomas or\\nabdominal wall hernias.\\n\\n And be nice to your radiologists… they can be your best friends!',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Figure 5.12\\n**Description:** This figure illustrates appendagitis epiploica, indicated by an arrow. The image likely shows the affected area in a CT scan.\\n\\n### Free Fluid\\n- Watch for free fluid between the intestinal loops and elsewhere. The fluid density gives a clue to its nature:\\n- For ascites, it is like water, 0-20 ħU.\\n- For pus, between 15 and 30 ħU.\\n- For blood, about 50 ħU.\\n\\nBe aware that these specifications don’t always allow an exact differentiation.\\n\\n### Abscesses\\n- An abscess shows an annular enhancement, and gas inclusions inside will prove it.\\n- Diffuse peritonitis is not easy to diagnose, but helpful signs include:\\n- Fluid collections between intestinal loops.\\n- Fluid collections in the pouch of Douglas.\\n- A thickened base of the small bowel mesentery.\\n\\n### Retroperitoneum, Big Vessels, and Abdominal Wall\\n- Look at the lumen of the aorta and the pelvic vessels to find a ruptured aneurysm.\\n- Look for free gas or a collection suggesting an abscess due to retroperitoneal perforation of a viscus such as the colon or duodenum.\\n- When examining the abdominal wall, try to find pathological changes like:\\n- Subcutaneous abscesses.\\n- Rectus sheath hematomas.\\n- Abdominal wall hernias.\\n\\n### Note\\n- And be nice to your radiologists… they can be your best friends!\\n```',\n", " 'images': [{'name': 'img_p90_1.png',\n", " 'height': 350,\n", " 'width': 408,\n", " 'x': 205.1999999999989,\n", " 'y': 82.80000000000001,\n", " 'original_width': 927,\n", " 'original_height': 796}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 5.12',\n", " 'md': '### Figure 5.12',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure illustrates appendagitis epiploica, indicated by an arrow. The image likely shows the affected area in a CT scan.',\n", " 'md': '**Description:** This figure illustrates appendagitis epiploica, indicated by an arrow. The image likely shows the affected area in a CT scan.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Free Fluid',\n", " 'md': '### Free Fluid',\n", " 'bBox': {'x': 86, 'y': 326, 'w': 64.74, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- Watch for free fluid between the intestinal loops and elsewhere. The fluid density gives a clue to its nature:\\n- For ascites, it is like water, 0-20 ħU.\\n- For pus, between 15 and 30 ħU.\\n- For blood, about 50 ħU.\\n\\nBe aware that these specifications don’t always allow an exact differentiation.',\n", " 'md': '- Watch for free fluid between the intestinal loops and elsewhere. The fluid density gives a clue to its nature:\\n- For ascites, it is like water, 0-20 ħU.\\n- For pus, between 15 and 30 ħU.\\n- For blood, about 50 ħU.\\n\\nBe aware that these specifications don’t always allow an exact differentiation.',\n", " 'bBox': {'x': 72, 'y': 326, 'w': 425.92, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Abscesses',\n", " 'md': '### Abscesses',\n", " 'bBox': {'x': 86, 'y': 435, 'w': 75.18, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- An abscess shows an annular enhancement, and gas inclusions inside will prove it.\\n- Diffuse peritonitis is not easy to diagnose, but helpful signs include:\\n- Fluid collections between intestinal loops.\\n- Fluid collections in the pouch of Douglas.\\n- A thickened base of the small bowel mesentery.',\n", " 'md': '- An abscess shows an annular enhancement, and gas inclusions inside will prove it.\\n- Diffuse peritonitis is not easy to diagnose, but helpful signs include:\\n- Fluid collections between intestinal loops.\\n- Fluid collections in the pouch of Douglas.\\n- A thickened base of the small bowel mesentery.',\n", " 'bBox': {'x': 86, 'y': 456, 'w': 453.12, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Retroperitoneum, Big Vessels, and Abdominal Wall',\n", " 'md': '### Retroperitoneum, Big Vessels, and Abdominal Wall',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Look at the lumen of the aorta and the pelvic vessels to find a ruptured aneurysm.\\n- Look for free gas or a collection suggesting an abscess due to retroperitoneal perforation of a viscus such as the colon or duodenum.\\n- When examining the abdominal wall, try to find pathological changes like:\\n- Subcutaneous abscesses.\\n- Rectus sheath hematomas.\\n- Abdominal wall hernias.',\n", " 'md': '- Look at the lumen of the aorta and the pelvic vessels to find a ruptured aneurysm.\\n- Look for free gas or a collection suggesting an abscess due to retroperitoneal perforation of a viscus such as the colon or duodenum.\\n- When examining the abdominal wall, try to find pathological changes like:\\n- Subcutaneous abscesses.\\n- Rectus sheath hematomas.\\n- Abdominal wall hernias.',\n", " 'bBox': {'x': 72, 'y': 435, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Note',\n", " 'md': '### Note',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- And be nice to your radiologists… they can be your best friends!\\n```',\n", " 'md': '- And be nice to your radiologists… they can be your best friends!\\n```',\n", " 'bBox': {'x': 86, 'y': 684, 'w': 442.78, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 92,\n", " 'text': ' Final words from Moshe…\\n\\n Unfortunately or fortunately — depending on one’s viewpoint — in the\\nUSA, where I practice, the decision about whom and when to scan is no\\nlonger in our surgical hands. Aren’t we losing control? The fact of the\\nmatter is that most (if not all) patients have already undergone a CT\\nscan before we surgeons are called upon to assess them. Typically,\\nsuch scans are ordered by emergency room physicians or other\\nspecialists before consulting the surgeon. In most hospitals in the USA,\\neven the tiny rural ones, high-tech CT images are much easier to obtain\\nthan a gourmet meal or even a cup of real coffee. And radiologists are\\nalways readily available to interpret the images online. No wonder then\\nthat physicians and allied providers confronted with what they perceive to\\nbe an acute abdomen feel compelled to get a CT which is as easily\\nprocured as junk food. The general rule is: the more insecure one is —\\nthe more imaging (and other testing) is obtained…\\n\\n Is this practice of (almost) routine CT scanning, imposed on us by\\nothers, and impossible for us to modify or reverse, ‘good’ or ‘bad’ for our\\npatients? It is very difficult, if not impossible, to prove scientifically that\\nthis increased use of CT scanning is beneficial overall. But what about\\nthe individual patient?\\n\\n Luckily, gone are the days when the acute abdomen represented a\\ntotally black box — days I remember well from my training — when\\nperitoneal signs on examination mandated a laparotomy — which often\\nproved to be ‘negative’ or ‘non-therapeutic’, and therefore unnecessary.\\nThe gradual introduction of CT imaging (and ultrasound) has made that\\nabdominal black box much more penetrable and less mysterious. In the\\nindividual patient it helps us to be more selective and more\\nconservative; helps us to decide when not to operate, when to\\nchoose alternative modalities (e.g. percutaneous drainage) and\\nguides us to the choice of incision. Equally important — for those of\\nus who take emergency calls, those who do not yet work in shifts in the\\nmedical factories imposed on us — CT lets us sleep better and longer at\\nnight.\\n\\n So from the individual patient’s and surgeon’s perspective, I believe',\n", " 'md': '```markdown\\n## Final Words from Moshe\\n\\nUnfortunately or fortunately — depending on one’s viewpoint — in the USA, where I practice, the decision about whom and when to scan is no longer in our surgical hands. Aren’t we losing control? The fact of the matter is that most (if not all) patients have already undergone a CT scan before we surgeons are called upon to assess them. Typically, such scans are ordered by emergency room physicians or other specialists before consulting the surgeon. In most hospitals in the USA, even the tiny rural ones, high-tech CT images are much easier to obtain than a gourmet meal or even a cup of real coffee. And radiologists are always readily available to interpret the images online. No wonder then that physicians and allied providers confronted with what they perceive to be an acute abdomen feel compelled to get a CT which is as easily procured as junk food. The general rule is: the more insecure one is — the more imaging (and other testing) is obtained…\\n\\nIs this practice of (almost) routine CT scanning, imposed on us by others, and impossible for us to modify or reverse, ‘good’ or ‘bad’ for our patients? It is very difficult, if not impossible, to prove scientifically that this increased use of CT scanning is beneficial overall. But what about the individual patient?\\n\\nLuckily, gone are the days when the acute abdomen represented a totally black box — days I remember well from my training — when peritoneal signs on examination mandated a laparotomy — which often proved to be ‘negative’ or ‘non-therapeutic’, and therefore unnecessary. The gradual introduction of CT imaging (and ultrasound) has made that abdominal black box much more penetrable and less mysterious. In the individual patient it helps us to be more selective and more conservative; helps us to decide when not to operate, when to choose alternative modalities (e.g. percutaneous drainage) and guides us to the choice of incision. Equally important — for those of us who take emergency calls, those who do not yet work in shifts in the medical factories imposed on us — CT lets us sleep better and longer at night.\\n\\nSo from the individual patient’s and surgeon’s perspective, I believe...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Final Words from Moshe',\n", " 'md': '## Final Words from Moshe',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Unfortunately or fortunately — depending on one’s viewpoint — in the USA, where I practice, the decision about whom and when to scan is no longer in our surgical hands. Aren’t we losing control? The fact of the matter is that most (if not all) patients have already undergone a CT scan before we surgeons are called upon to assess them. Typically, such scans are ordered by emergency room physicians or other specialists before consulting the surgeon. In most hospitals in the USA, even the tiny rural ones, high-tech CT images are much easier to obtain than a gourmet meal or even a cup of real coffee. And radiologists are always readily available to interpret the images online. No wonder then that physicians and allied providers confronted with what they perceive to be an acute abdomen feel compelled to get a CT which is as easily procured as junk food. The general rule is: the more insecure one is — the more imaging (and other testing) is obtained…\\n\\nIs this practice of (almost) routine CT scanning, imposed on us by others, and impossible for us to modify or reverse, ‘good’ or ‘bad’ for our patients? It is very difficult, if not impossible, to prove scientifically that this increased use of CT scanning is beneficial overall. But what about the individual patient?\\n\\nLuckily, gone are the days when the acute abdomen represented a totally black box — days I remember well from my training — when peritoneal signs on examination mandated a laparotomy — which often proved to be ‘negative’ or ‘non-therapeutic’, and therefore unnecessary. The gradual introduction of CT imaging (and ultrasound) has made that abdominal black box much more penetrable and less mysterious. In the individual patient it helps us to be more selective and more conservative; helps us to decide when not to operate, when to choose alternative modalities (e.g. percutaneous drainage) and guides us to the choice of incision. Equally important — for those of us who take emergency calls, those who do not yet work in shifts in the medical factories imposed on us — CT lets us sleep better and longer at night.\\n\\nSo from the individual patient’s and surgeon’s perspective, I believe...\\n```',\n", " 'md': 'Unfortunately or fortunately — depending on one’s viewpoint — in the USA, where I practice, the decision about whom and when to scan is no longer in our surgical hands. Aren’t we losing control? The fact of the matter is that most (if not all) patients have already undergone a CT scan before we surgeons are called upon to assess them. Typically, such scans are ordered by emergency room physicians or other specialists before consulting the surgeon. In most hospitals in the USA, even the tiny rural ones, high-tech CT images are much easier to obtain than a gourmet meal or even a cup of real coffee. And radiologists are always readily available to interpret the images online. No wonder then that physicians and allied providers confronted with what they perceive to be an acute abdomen feel compelled to get a CT which is as easily procured as junk food. The general rule is: the more insecure one is — the more imaging (and other testing) is obtained…\\n\\nIs this practice of (almost) routine CT scanning, imposed on us by others, and impossible for us to modify or reverse, ‘good’ or ‘bad’ for our patients? It is very difficult, if not impossible, to prove scientifically that this increased use of CT scanning is beneficial overall. But what about the individual patient?\\n\\nLuckily, gone are the days when the acute abdomen represented a totally black box — days I remember well from my training — when peritoneal signs on examination mandated a laparotomy — which often proved to be ‘negative’ or ‘non-therapeutic’, and therefore unnecessary. The gradual introduction of CT imaging (and ultrasound) has made that abdominal black box much more penetrable and less mysterious. In the individual patient it helps us to be more selective and more conservative; helps us to decide when not to operate, when to choose alternative modalities (e.g. percutaneous drainage) and guides us to the choice of incision. Equally important — for those of us who take emergency calls, those who do not yet work in shifts in the medical factories imposed on us — CT lets us sleep better and longer at night.\\n\\nSo from the individual patient’s and surgeon’s perspective, I believe...\\n```',\n", " 'bBox': {'x': 72, 'y': 124, 'w': 467.87, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 93,\n", " 'text': 'that the liberal use of abdominal CT in the setting of the acute abdomen\\nsignals a positive trend. There are two caveats: first, we have to try and\\nprevent repeated exposures to CT radiation — particularly in younger\\npatients, and, most importantly, an experienced abdominal surgeon must\\nbe the one interpreting the CT images (together with the radiologist) and\\ndeciding how to proceed. An abdominal image without an abdominal\\nsurgeon is only an image — but together, the surgeon and the CT\\nrepresent the best modern surgical judgment — the human one\\nsupplemented and made more accurate.\\n\\n “Do not treat the image but the patient. A cliché? Yes. But\\n an important one.”',\n", " 'md': '```markdown\\n## Text\\n\\nThe liberal use of abdominal CT in the setting of the acute abdomen signals a positive trend. There are two caveats: first, we have to try and prevent repeated exposures to CT radiation — particularly in younger patients, and, most importantly, an experienced abdominal surgeon must be the one interpreting the CT images (together with the radiologist) and deciding how to proceed. An abdominal image without an abdominal surgeon is only an image — but together, the surgeon and the CT represent the best modern surgical judgment — the human one supplemented and made more accurate.\\n\\n“Do not treat the image but the patient. A cliché? Yes. But an important one.”\\n```\\n\\n### Notes\\n- No formulas, tables, or images were identified on this page.\\n- The text has been extracted without any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The liberal use of abdominal CT in the setting of the acute abdomen signals a positive trend. There are two caveats: first, we have to try and prevent repeated exposures to CT radiation — particularly in younger patients, and, most importantly, an experienced abdominal surgeon must be the one interpreting the CT images (together with the radiologist) and deciding how to proceed. An abdominal image without an abdominal surgeon is only an image — but together, the surgeon and the CT represent the best modern surgical judgment — the human one supplemented and made more accurate.\\n\\n“Do not treat the image but the patient. A cliché? Yes. But an important one.”\\n```',\n", " 'md': 'The liberal use of abdominal CT in the setting of the acute abdomen signals a positive trend. There are two caveats: first, we have to try and prevent repeated exposures to CT radiation — particularly in younger patients, and, most importantly, an experienced abdominal surgeon must be the one interpreting the CT images (together with the radiologist) and deciding how to proceed. An abdominal image without an abdominal surgeon is only an image — but together, the surgeon and the CT represent the best modern surgical judgment — the human one supplemented and made more accurate.\\n\\n“Do not treat the image but the patient. A cliché? Yes. But an important one.”\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.75, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No formulas, tables, or images were identified on this page.\\n- The text has been extracted without any headers, footers, or diagonal text.',\n", " 'md': '- No formulas, tables, or images were identified on this page.\\n- The text has been extracted without any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 94,\n", " 'text': 'Chapter 6\\nOptimizing the patient\\nJames C. Rucinski\\n\\n When physiology is disrupted, attempts at restoring\\n anatomy are futile.\\n The preparation of the patient for surgery may be as crucial\\n as the operation itself.\\n\\n It’s 4 a.m. and you assess your patient as having an ‘acute abdomen’\\n— probably due to a perforated viscus. Clearly your patient needs an\\nemergency laparotomy; what is left to decide is: what efforts and\\nhow much time should be invested in his optimization before the\\noperation?\\n\\n Optimization is a double-edged sword: wasting time trying to\\n‘stabilize’ an exsanguinating patient is an exercise in futility, for he will\\ndie. Conversely, rushing to surgery with a hypovolemic patient suffering\\nfrom intestinal obstruction is a recipe for disaster.\\n\\n The issues to be discussed are highlighted below.\\n\\n Why pre-operative optimization at all?\\n What are the goals of optimization?\\n Who needs optimization?\\n ħow to do it?',\n", " 'md': '```markdown\\n# Chapter 6: Optimizing the Patient\\n**Author:** James C. Rucinski\\n\\nWhen physiology is disrupted, attempts at restoring anatomy are futile. The preparation of the patient for surgery may be as crucial as the operation itself.\\n\\nIt’s 4 a.m. and you assess your patient as having an ‘acute abdomen’ — probably due to a perforated viscus. Clearly, your patient needs an emergency laparotomy; what is left to decide is: what efforts and how much time should be invested in his optimization before the operation?\\n\\nOptimization is a double-edged sword: wasting time trying to ‘stabilize’ an exsanguinating patient is an exercise in futility, for he will die. Conversely, rushing to surgery with a hypovolemic patient suffering from intestinal obstruction is a recipe for disaster.\\n\\nThe issues to be discussed are highlighted below:\\n\\n- Why pre-operative optimization at all?\\n- What are the goals of optimization?\\n- Who needs optimization?\\n- How to do it?\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 6: Optimizing the Patient',\n", " 'md': '# Chapter 6: Optimizing the Patient',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 194.85, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** James C. Rucinski\\n\\nWhen physiology is disrupted, attempts at restoring anatomy are futile. The preparation of the patient for surgery may be as crucial as the operation itself.\\n\\nIt’s 4 a.m. and you assess your patient as having an ‘acute abdomen’ — probably due to a perforated viscus. Clearly, your patient needs an emergency laparotomy; what is left to decide is: what efforts and how much time should be invested in his optimization before the operation?\\n\\nOptimization is a double-edged sword: wasting time trying to ‘stabilize’ an exsanguinating patient is an exercise in futility, for he will die. Conversely, rushing to surgery with a hypovolemic patient suffering from intestinal obstruction is a recipe for disaster.\\n\\nThe issues to be discussed are highlighted below:\\n\\n- Why pre-operative optimization at all?\\n- What are the goals of optimization?\\n- Who needs optimization?\\n- How to do it?\\n```',\n", " 'md': '**Author:** James C. Rucinski\\n\\nWhen physiology is disrupted, attempts at restoring anatomy are futile. The preparation of the patient for surgery may be as crucial as the operation itself.\\n\\nIt’s 4 a.m. and you assess your patient as having an ‘acute abdomen’ — probably due to a perforated viscus. Clearly, your patient needs an emergency laparotomy; what is left to decide is: what efforts and how much time should be invested in his optimization before the operation?\\n\\nOptimization is a double-edged sword: wasting time trying to ‘stabilize’ an exsanguinating patient is an exercise in futility, for he will die. Conversely, rushing to surgery with a hypovolemic patient suffering from intestinal obstruction is a recipe for disaster.\\n\\nThe issues to be discussed are highlighted below:\\n\\n- Why pre-operative optimization at all?\\n- What are the goals of optimization?\\n- Who needs optimization?\\n- How to do it?\\n```',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 453.3, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 95,\n", " 'text': ' Why is pre-operative optimization necessary?\\n\\n Simply, because volume-depleted patients do not tolerate\\nanesthesia and an operation. The induction of general anesthesia and\\nmuscle relaxation causes systemic vasodilatation, depressing the\\ncompensatory anti-shock physiologic mechanisms. On opening the\\nabdomen, intraperitoneal pressure suddenly declines, allowing pooling of\\nblood in the venous system, that, in turn, decreases venous return and\\nthus reduces cardiac output. An emergency laparotomy in an under-\\nresuscitated patient may result in cardiac arrest even before the\\noperation is started. In addition, the intra-operative fluid requirements\\nare unpredictable: do you want to start with a volume-depleted patient,\\nhaving to chase your tail?\\n\\n Remember: Operating on a poorly resuscitated patient is like driving (under the\\n influence of alcohol) a snow mobile on thin ice!\\n\\n What are the goals of optimization?\\n\\n Patients awaiting an emergency laparotomy need optimization for two\\nmain reasons: hypovolemia or sepsis. Both conditions cause under-\\nperfusion of the tissues and both are treated initially with volume\\nexpansion. The chief goal of pre-operative optimization is to improve\\nthe delivery of oxygen to the cells. There is a direct relationship\\nbetween cellular hypoxia and subsequent cellular dysfunction, SIRS,\\norgan failure and adverse outcome.\\n\\n In sick surgical patients, unlike medical ones, optimization means\\nVOLUME and more volume — a lot of i.v. fluids. (ħowever, this, as will\\nbe emphasized below, is not true in actively bleeding patients; here\\noptimization means immediate control of the hemorrhage — and until this\\nis achieved you should restrict fluids and keep the patient moderately\\nhypotensive.)\\n\\n Who needs optimization?',\n", " 'md': '```markdown\\n# Pre-operative Optimization\\n\\n## Why is pre-operative optimization necessary?\\n\\nSimply, because volume-depleted patients do not tolerate anesthesia and an operation. The induction of general anesthesia and muscle relaxation causes systemic vasodilatation, depressing the compensatory anti-shock physiologic mechanisms. On opening the abdomen, intraperitoneal pressure suddenly declines, allowing pooling of blood in the venous system, that, in turn, decreases venous return and thus reduces cardiac output. An emergency laparotomy in an under-resuscitated patient may result in cardiac arrest even before the operation is started. In addition, the intra-operative fluid requirements are unpredictable: do you want to start with a volume-depleted patient, having to chase your tail?\\n\\n**Remember:** Operating on a poorly resuscitated patient is like driving (under the influence of alcohol) a snow mobile on thin ice!\\n\\n## What are the goals of optimization?\\n\\nPatients awaiting an emergency laparotomy need optimization for two main reasons: hypovolemia or sepsis. Both conditions cause under-perfusion of the tissues and both are treated initially with volume expansion. The chief goal of pre-operative optimization is to improve the delivery of oxygen to the cells. There is a direct relationship between cellular hypoxia and subsequent cellular dysfunction, SIRS, organ failure, and adverse outcome.\\n\\nIn sick surgical patients, unlike medical ones, optimization means VOLUME and more volume — a lot of i.v. fluids. However, this, as will be emphasized below, is not true in actively bleeding patients; here optimization means immediate control of the hemorrhage — and until this is achieved you should restrict fluids and keep the patient moderately hypotensive.\\n\\n## Who needs optimization?\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Pre-operative Optimization',\n", " 'md': '# Pre-operative Optimization',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Why is pre-operative optimization necessary?',\n", " 'md': '## Why is pre-operative optimization necessary?',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 360.47, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Simply, because volume-depleted patients do not tolerate anesthesia and an operation. The induction of general anesthesia and muscle relaxation causes systemic vasodilatation, depressing the compensatory anti-shock physiologic mechanisms. On opening the abdomen, intraperitoneal pressure suddenly declines, allowing pooling of blood in the venous system, that, in turn, decreases venous return and thus reduces cardiac output. An emergency laparotomy in an under-resuscitated patient may result in cardiac arrest even before the operation is started. In addition, the intra-operative fluid requirements are unpredictable: do you want to start with a volume-depleted patient, having to chase your tail?\\n\\n**Remember:** Operating on a poorly resuscitated patient is like driving (under the influence of alcohol) a snow mobile on thin ice!',\n", " 'md': 'Simply, because volume-depleted patients do not tolerate anesthesia and an operation. The induction of general anesthesia and muscle relaxation causes systemic vasodilatation, depressing the compensatory anti-shock physiologic mechanisms. On opening the abdomen, intraperitoneal pressure suddenly declines, allowing pooling of blood in the venous system, that, in turn, decreases venous return and thus reduces cardiac output. An emergency laparotomy in an under-resuscitated patient may result in cardiac arrest even before the operation is started. In addition, the intra-operative fluid requirements are unpredictable: do you want to start with a volume-depleted patient, having to chase your tail?\\n\\n**Remember:** Operating on a poorly resuscitated patient is like driving (under the influence of alcohol) a snow mobile on thin ice!',\n", " 'bBox': {'x': 72, 'y': 140, 'w': 467.39, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'What are the goals of optimization?',\n", " 'md': '## What are the goals of optimization?',\n", " 'bBox': {'x': 86, 'y': 409, 'w': 279.49, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Patients awaiting an emergency laparotomy need optimization for two main reasons: hypovolemia or sepsis. Both conditions cause under-perfusion of the tissues and both are treated initially with volume expansion. The chief goal of pre-operative optimization is to improve the delivery of oxygen to the cells. There is a direct relationship between cellular hypoxia and subsequent cellular dysfunction, SIRS, organ failure, and adverse outcome.\\n\\nIn sick surgical patients, unlike medical ones, optimization means VOLUME and more volume — a lot of i.v. fluids. However, this, as will be emphasized below, is not true in actively bleeding patients; here optimization means immediate control of the hemorrhage — and until this is achieved you should restrict fluids and keep the patient moderately hypotensive.',\n", " 'md': 'Patients awaiting an emergency laparotomy need optimization for two main reasons: hypovolemia or sepsis. Both conditions cause under-perfusion of the tissues and both are treated initially with volume expansion. The chief goal of pre-operative optimization is to improve the delivery of oxygen to the cells. There is a direct relationship between cellular hypoxia and subsequent cellular dysfunction, SIRS, organ failure, and adverse outcome.\\n\\nIn sick surgical patients, unlike medical ones, optimization means VOLUME and more volume — a lot of i.v. fluids. However, this, as will be emphasized below, is not true in actively bleeding patients; here optimization means immediate control of the hemorrhage — and until this is achieved you should restrict fluids and keep the patient moderately hypotensive.',\n", " 'bBox': {'x': 72, 'y': 445, 'w': 467.58, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Who needs optimization?',\n", " 'md': '## Who needs optimization?',\n", " 'bBox': {'x': 86, 'y': 705, 'w': 200.43, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 96,\n", " 'text': ' Surgical patients often look ‘sick’. The appearance of the patient\\nusually gives an important first impression even before factoring in\\ntachycardia, tachypnea, hypotension, mental confusion, and poor\\nperipheral perfusion. So look at your patient — not only at his serum\\nlactate level!\\n\\n Only basic laboratory studies are necessary. Hemoconcentration,\\nreflected in an abnormally high hemoglobin and hematocrit, implies either\\nsevere dehydration or extracellular ‘third space’ fluid sequestration. Urine\\nanalysis showing a high specific gravity (>1.039) provides similar\\ninformation. Electrolyte imbalance and associated prerenal azotemia\\n(with a blood urea nitrogen [BUN]-to-creatinine ratio of >20:1) again imply\\nvolume depletion. Arterial blood gas measurement gives critical\\ninformation regarding respiratory function and tissue perfusion. Note that\\nin the emergency surgical patient, metabolic acidosis almost always\\nmeans lactic acidosis — associated with inadequate tissue\\noxygenation and anaerobic metabolism at the cellular level. Other\\ncauses of metabolic acidosis such as renal failure, diabetic ketoacidosis\\nor toxic poisoning are possible but extremely unlikely. A base deficit of\\nmore than 6 (BE less than minus 6) is a marker of significant metabolic\\nacidosis and adverse prognosis and indicates a need for aggressive\\nresuscitation. Of course, the ER doc or the nurse-hospitalist has already\\nmeasured the serum lactate...\\n\\n All patients with any degree of the above physiological\\nabnormalities need optimization. Naturally, the magnitude of your\\nefforts should correlate with the severity of the disturbances.\\n\\n Measurement of the severity of illness\\n\\n An experienced surgeon can ‘eye-ball’ his or her patient and estimate\\nhow sick they are by assessing the “gleam in his eye and the strength of\\nthe grip…”. But terms such as ‘very sick’, ‘critically ill’ or ‘moribund’ mean\\ndifferent things to different people. We recommend therefore that you\\nbecome familiar with a universal physiological scoring system which\\ngives an objective measure of ‘sickness’. One scoring system, which has\\nbeen validated in most emergency surgical situations, is the APACħE II\\n(Acute Physiological And Chronic ħealth Evaluation) — use one of the',\n", " 'md': '```markdown\\n# Surgical Patient Assessment\\n\\nSurgical patients often look ‘sick’. The appearance of the patient usually gives an important first impression even before factoring in tachycardia, tachypnea, hypotension, mental confusion, and poor peripheral perfusion. So look at your patient — not only at his serum lactate level!\\n\\nOnly basic laboratory studies are necessary. Hemoconcentration, reflected in an abnormally high hemoglobin and hematocrit, implies either severe dehydration or extracellular ‘third space’ fluid sequestration. Urine analysis showing a high specific gravity (>1.039) provides similar information. Electrolyte imbalance and associated prerenal azotemia (with a blood urea nitrogen [BUN]-to-creatinine ratio of >20:1) again imply volume depletion. Arterial blood gas measurement gives critical information regarding respiratory function and tissue perfusion. Note that in the emergency surgical patient, metabolic acidosis almost always means lactic acidosis — associated with inadequate tissue oxygenation and anaerobic metabolism at the cellular level. Other causes of metabolic acidosis such as renal failure, diabetic ketoacidosis or toxic poisoning are possible but extremely unlikely. A base deficit of more than 6 (BE less than minus 6) is a marker of significant metabolic acidosis and adverse prognosis and indicates a need for aggressive resuscitation. Of course, the ER doc or the nurse-hospitalist has already measured the serum lactate...\\n\\nAll patients with any degree of the above physiological abnormalities need optimization. Naturally, the magnitude of your efforts should correlate with the severity of the disturbances.\\n\\n## Measurement of the Severity of Illness\\n\\nAn experienced surgeon can ‘eye-ball’ his or her patient and estimate how sick they are by assessing the “gleam in his eye and the strength of the grip…”. But terms such as ‘very sick’, ‘critically ill’ or ‘moribund’ mean different things to different people. We recommend therefore that you become familiar with a universal physiological scoring system which gives an objective measure of ‘sickness’. One scoring system, which has been validated in most emergency surgical situations, is the APACHE II (Acute Physiological And Chronic Health Evaluation) — use one of the...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Surgical Patient Assessment',\n", " 'md': '# Surgical Patient Assessment',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Surgical patients often look ‘sick’. The appearance of the patient usually gives an important first impression even before factoring in tachycardia, tachypnea, hypotension, mental confusion, and poor peripheral perfusion. So look at your patient — not only at his serum lactate level!\\n\\nOnly basic laboratory studies are necessary. Hemoconcentration, reflected in an abnormally high hemoglobin and hematocrit, implies either severe dehydration or extracellular ‘third space’ fluid sequestration. Urine analysis showing a high specific gravity (>1.039) provides similar information. Electrolyte imbalance and associated prerenal azotemia (with a blood urea nitrogen [BUN]-to-creatinine ratio of >20:1) again imply volume depletion. Arterial blood gas measurement gives critical information regarding respiratory function and tissue perfusion. Note that in the emergency surgical patient, metabolic acidosis almost always means lactic acidosis — associated with inadequate tissue oxygenation and anaerobic metabolism at the cellular level. Other causes of metabolic acidosis such as renal failure, diabetic ketoacidosis or toxic poisoning are possible but extremely unlikely. A base deficit of more than 6 (BE less than minus 6) is a marker of significant metabolic acidosis and adverse prognosis and indicates a need for aggressive resuscitation. Of course, the ER doc or the nurse-hospitalist has already measured the serum lactate...\\n\\nAll patients with any degree of the above physiological abnormalities need optimization. Naturally, the magnitude of your efforts should correlate with the severity of the disturbances.',\n", " 'md': 'Surgical patients often look ‘sick’. The appearance of the patient usually gives an important first impression even before factoring in tachycardia, tachypnea, hypotension, mental confusion, and poor peripheral perfusion. So look at your patient — not only at his serum lactate level!\\n\\nOnly basic laboratory studies are necessary. Hemoconcentration, reflected in an abnormally high hemoglobin and hematocrit, implies either severe dehydration or extracellular ‘third space’ fluid sequestration. Urine analysis showing a high specific gravity (>1.039) provides similar information. Electrolyte imbalance and associated prerenal azotemia (with a blood urea nitrogen [BUN]-to-creatinine ratio of >20:1) again imply volume depletion. Arterial blood gas measurement gives critical information regarding respiratory function and tissue perfusion. Note that in the emergency surgical patient, metabolic acidosis almost always means lactic acidosis — associated with inadequate tissue oxygenation and anaerobic metabolism at the cellular level. Other causes of metabolic acidosis such as renal failure, diabetic ketoacidosis or toxic poisoning are possible but extremely unlikely. A base deficit of more than 6 (BE less than minus 6) is a marker of significant metabolic acidosis and adverse prognosis and indicates a need for aggressive resuscitation. Of course, the ER doc or the nurse-hospitalist has already measured the serum lactate...\\n\\nAll patients with any degree of the above physiological abnormalities need optimization. Naturally, the magnitude of your efforts should correlate with the severity of the disturbances.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Measurement of the Severity of Illness',\n", " 'md': '## Measurement of the Severity of Illness',\n", " 'bBox': {'x': 86, 'y': 564, 'w': 299.77, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'An experienced surgeon can ‘eye-ball’ his or her patient and estimate how sick they are by assessing the “gleam in his eye and the strength of the grip…”. But terms such as ‘very sick’, ‘critically ill’ or ‘moribund’ mean different things to different people. We recommend therefore that you become familiar with a universal physiological scoring system which gives an objective measure of ‘sickness’. One scoring system, which has been validated in most emergency surgical situations, is the APACHE II (Acute Physiological And Chronic Health Evaluation) — use one of the...\\n```',\n", " 'md': 'An experienced surgeon can ‘eye-ball’ his or her patient and estimate how sick they are by assessing the “gleam in his eye and the strength of the grip…”. But terms such as ‘very sick’, ‘critically ill’ or ‘moribund’ mean different things to different people. We recommend therefore that you become familiar with a universal physiological scoring system which gives an objective measure of ‘sickness’. One scoring system, which has been validated in most emergency surgical situations, is the APACHE II (Acute Physiological And Chronic Health Evaluation) — use one of the...\\n```',\n", " 'bBox': {'x': 72, 'y': 600, 'w': 467.62, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 97,\n", " 'text': 'online calculators, e.g:\\nhttp://clincalc.com/icumortality/apacheii.aspx#Mortality. It measures the\\nphysiological consequences of acute disease while taking into\\nconsideration the patient’s pre-morbid state and age. The scores are\\neasily measured from readily available basic clinical and laboratory\\nvariables and correlate with a prediction of morbidity and mortality.\\n\\n An adjunctive method of assessing pre-operative risk is now\\navailable through the American College of Surgeons NSQIP\\n(National Surgical Quality Improvement Program) Risk Calculator. The\\ncalculator is an online tool that can be used to determine an\\nindividualized risk profile for your specific patient. The calculator utilizes\\noutcome data from all of the hospitals that participate in the Program in\\norder to allow a statistical prediction of various outcomes (such as\\nsurgical site infection, respiratory infection or death) associated with the\\ncharacteristics of your patient. The tool is available at:\\nwww.riskcalculator.facs.org.\\n\\n How I do it? ( Figure 6.1)\\n Principles of optimization: air goes in and out; blood goes\\n ‘round and ‘round; oxygen is good.',\n", " 'md': '```markdown\\n## Page Content\\n\\nOnline calculators, e.g: [http://clincalc.com/icumortality/apacheii.aspx#Mortality](http://clincalc.com/icumortality/apacheii.aspx#Mortality). It measures the physiological consequences of acute disease while taking into consideration the patient’s pre-morbid state and age. The scores are easily measured from readily available basic clinical and laboratory variables and correlate with a prediction of morbidity and mortality.\\n\\nAn adjunctive method of assessing pre-operative risk is now available through the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) Risk Calculator. The calculator is an online tool that can be used to determine an individualized risk profile for your specific patient. The calculator utilizes outcome data from all of the hospitals that participate in the Program in order to allow a statistical prediction of various outcomes (such as surgical site infection, respiratory infection or death) associated with the characteristics of your patient. The tool is available at: [www.riskcalculator.facs.org](http://www.riskcalculator.facs.org).\\n\\n### How I do it? (Figure 6.1)\\nPrinciples of optimization: air goes in and out; blood goes ‘round and ‘round; oxygen is good.\\n\\n## Images and Graphs\\n\\n### Figure 6.1\\n- **Description**: This figure illustrates the principles of optimization in a medical context. It visually represents the flow of air and blood, emphasizing the importance of oxygen in the process.\\n- **Summary**: The image serves as a conceptual diagram that highlights the cyclical nature of air and blood flow in relation to patient care and optimization strategies.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Online calculators, e.g: [http://clincalc.com/icumortality/apacheii.aspx#Mortality](http://clincalc.com/icumortality/apacheii.aspx#Mortality). It measures the physiological consequences of acute disease while taking into consideration the patient’s pre-morbid state and age. The scores are easily measured from readily available basic clinical and laboratory variables and correlate with a prediction of morbidity and mortality.\\n\\nAn adjunctive method of assessing pre-operative risk is now available through the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) Risk Calculator. The calculator is an online tool that can be used to determine an individualized risk profile for your specific patient. The calculator utilizes outcome data from all of the hospitals that participate in the Program in order to allow a statistical prediction of various outcomes (such as surgical site infection, respiratory infection or death) associated with the characteristics of your patient. The tool is available at: [www.riskcalculator.facs.org](http://www.riskcalculator.facs.org).',\n", " 'md': 'Online calculators, e.g: [http://clincalc.com/icumortality/apacheii.aspx#Mortality](http://clincalc.com/icumortality/apacheii.aspx#Mortality). It measures the physiological consequences of acute disease while taking into consideration the patient’s pre-morbid state and age. The scores are easily measured from readily available basic clinical and laboratory variables and correlate with a prediction of morbidity and mortality.\\n\\nAn adjunctive method of assessing pre-operative risk is now available through the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) Risk Calculator. The calculator is an online tool that can be used to determine an individualized risk profile for your specific patient. The calculator utilizes outcome data from all of the hospitals that participate in the Program in order to allow a statistical prediction of various outcomes (such as surgical site infection, respiratory infection or death) associated with the characteristics of your patient. The tool is available at: [www.riskcalculator.facs.org](http://www.riskcalculator.facs.org).',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'How I do it? (Figure 6.1)',\n", " 'md': '### How I do it? (Figure 6.1)',\n", " 'bBox': {'x': 86, 'y': 396, 'w': 103.85, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Principles of optimization: air goes in and out; blood goes ‘round and ‘round; oxygen is good.',\n", " 'md': 'Principles of optimization: air goes in and out; blood goes ‘round and ‘round; oxygen is good.',\n", " 'bBox': {'x': 108, 'y': 119, 'w': 220.71, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images and Graphs',\n", " 'md': '## Images and Graphs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 6.1',\n", " 'md': '### Figure 6.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure illustrates the principles of optimization in a medical context. It visually represents the flow of air and blood, emphasizing the importance of oxygen in the process.\\n- **Summary**: The image serves as a conceptual diagram that highlights the cyclical nature of air and blood flow in relation to patient care and optimization strategies.\\n```',\n", " 'md': '- **Description**: This figure illustrates the principles of optimization in a medical context. It visually represents the flow of air and blood, emphasizing the importance of oxygen in the process.\\n- **Summary**: The image serves as a conceptual diagram that highlights the cyclical nature of air and blood flow in relation to patient care and optimization strategies.\\n```',\n", " 'bBox': {'x': 182, 'y': 119, 'w': 110, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'url': 'http://clincalc.com/icumortality/apacheii.aspx#Mortality',\n", " 'text': 'http://clincalc.com/icumortality/apacheii.aspx#Mortality. It measures the physiological '},\n", " {'url': 'http://www.riskcalculator.facs.org/',\n", " 'text': 'www.riskcalculator.facs.org .'},\n", " {'text': ''}]},\n", " {'page': 98,\n", " 'text': ' Figure 6.1. “Let me optimize you…”\\n\\n Despite the high-tech intensive care unit (ICU) environment, which may\\nor may not be available to you, optimization of the surgical patient is\\nsimple. It can be accomplished anywhere and requires minimal facilities.\\nAll you want is better oxygen delivery, i.e. increased oxygenation of\\narterial blood and enhanced tissue perfusion. You do not need a five-\\nstar ICU but you do have to stick around with the patient! Writing orders\\nand going to bed (until the operation) will unnecessarily prolong the\\noptimization and delay the operation. So stay with the patient, monitor\\nhis progress and be there to decide when enough is enough.\\n\\n Oxygenation\\n Hypoxia not only stops the motor, it wrecks the engine!\\n\\n Any patient who requires optimization should at least receive\\noxygen by mask. Look at the patient and his pulse oximetry or arterial\\nblood gases; evidence of severe hypoventilation or poor oxygenation',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Figure 6.1\\n“Let me optimize you…”\\n\\nDespite the high-tech intensive care unit (ICU) environment, which may or may not be available to you, optimization of the surgical patient is simple. It can be accomplished anywhere and requires minimal facilities. All you want is better oxygen delivery, i.e. increased oxygenation of arterial blood and enhanced tissue perfusion. You do not need a five-star ICU but you do have to stick around with the patient! Writing orders and going to bed (until the operation) will unnecessarily prolong the optimization and delay the operation. So stay with the patient, monitor his progress and be there to decide when enough is enough.\\n\\n### Oxygenation\\nHypoxia not only stops the motor, it wrecks the engine!\\n\\nAny patient who requires optimization should at least receive oxygen by mask. Look at the patient and his pulse oximetry or arterial blood gases; evidence of severe hypoventilation or poor oxygenation.\\n```',\n", " 'images': [{'name': 'img_p97_1.png',\n", " 'height': 572,\n", " 'width': 802,\n", " 'x': 108,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1377,\n", " 'original_height': 982}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 6.1',\n", " 'md': '## Figure 6.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '“Let me optimize you…”\\n\\nDespite the high-tech intensive care unit (ICU) environment, which may or may not be available to you, optimization of the surgical patient is simple. It can be accomplished anywhere and requires minimal facilities. All you want is better oxygen delivery, i.e. increased oxygenation of arterial blood and enhanced tissue perfusion. You do not need a five-star ICU but you do have to stick around with the patient! Writing orders and going to bed (until the operation) will unnecessarily prolong the optimization and delay the operation. So stay with the patient, monitor his progress and be there to decide when enough is enough.',\n", " 'md': '“Let me optimize you…”\\n\\nDespite the high-tech intensive care unit (ICU) environment, which may or may not be available to you, optimization of the surgical patient is simple. It can be accomplished anywhere and requires minimal facilities. All you want is better oxygen delivery, i.e. increased oxygenation of arterial blood and enhanced tissue perfusion. You do not need a five-star ICU but you do have to stick around with the patient! Writing orders and going to bed (until the operation) will unnecessarily prolong the optimization and delay the operation. So stay with the patient, monitor his progress and be there to decide when enough is enough.',\n", " 'bBox': {'x': 72, 'y': 432, 'w': 467.68, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Oxygenation',\n", " 'md': '### Oxygenation',\n", " 'bBox': {'x': 86, 'y': 608, 'w': 100.24, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Hypoxia not only stops the motor, it wrecks the engine!\\n\\nAny patient who requires optimization should at least receive oxygen by mask. Look at the patient and his pulse oximetry or arterial blood gases; evidence of severe hypoventilation or poor oxygenation.\\n```',\n", " 'md': 'Hypoxia not only stops the motor, it wrecks the engine!\\n\\nAny patient who requires optimization should at least receive oxygen by mask. Look at the patient and his pulse oximetry or arterial blood gases; evidence of severe hypoventilation or poor oxygenation.\\n```',\n", " 'bBox': {'x': 72, 'y': 608, 'w': 466.6, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 99,\n", " 'text': 'may be an indication for endotracheal intubation and mechanical\\nventilation. Do not temporize, the patient will need intubation\\nanyway, so why not now? Remember, pain and distension associated\\nwith any abdominal catastrophe impede ventilation. Effective analgesia\\nimpairs ventilation still further. If a nasogastric (NG) tube is not already in\\nsitu this may be the time to insert one. The advantages of NG tube\\ninsertion before intubation are to decompress the distended stomach and\\nreduce the risk of aspiration during the procedure. The disadvantage is\\nthat the presence of a tube through the cricopharyngeus may allow\\nregurgitation during rapid sequence induction of anesthesia.\\n\\n Restoration of volume\\n The major cause of shock is decreased circulatory volume.\\n Replace body fluids by the best means at hand.\\n Alfred Blalock\\n\\n Now after your patient is well oxygenated you must see to it that\\nthe oxygen arrives where it is needed, by restoring blood volume.\\nThis is accomplished by an intravenous infusion of crystalloids such as\\nnormal saline or Ringer’s lactate. Forget about the much more expensive\\ncolloids such as fresh frozen plasma, albumin or solutions containing\\nsynthetic organic macromolecules such as hetastarch or low-molecular-\\nweight dextran; their theoretical advantages have never been translated\\ninto better results — the opposite is true! ħypertonic saline resuscitation\\nmay theoretically be advantageous but it remains an investigational\\ntherapy at present. (It has been experimental since we finished medical\\nschool…). Blood and blood products are given if necessary, as discussed\\nbelow.\\n\\n ħow much crystalloid to infuse? An old rule of thumb was that the\\nhypovolemic surgical patient needs more volume than you think they\\nneed, and much more than the nursing staff think they need. But this rule\\nis now outdated — see the editorial comment at the end of the chapter.\\n\\n We assume that your patient already has a large-bore i.v. cannula in\\nsitu — so just hook it up to the solution and open the valve and let it run!',\n", " 'md': '```markdown\\n## Page Content\\n\\nmay be an indication for endotracheal intubation and mechanical ventilation. Do not temporize, the patient will need intubation anyway, so why not now? Remember, pain and distension associated with any abdominal catastrophe impede ventilation. Effective analgesia impairs ventilation still further. If a nasogastric (NG) tube is not already in situ this may be the time to insert one. The advantages of NG tube insertion before intubation are to decompress the distended stomach and reduce the risk of aspiration during the procedure. The disadvantage is that the presence of a tube through the cricopharyngeus may allow regurgitation during rapid sequence induction of anesthesia.\\n\\n### Restoration of Volume\\n\\nThe major cause of shock is decreased circulatory volume. Replace body fluids by the best means at hand.\\n**Alfred Blalock**\\n\\nNow after your patient is well oxygenated you must see to it that the oxygen arrives where it is needed, by restoring blood volume. This is accomplished by an intravenous infusion of crystalloids such as normal saline or Ringer’s lactate. Forget about the much more expensive colloids such as fresh frozen plasma, albumin or solutions containing synthetic organic macromolecules such as hetastarch or low-molecular-weight dextran; their theoretical advantages have never been translated into better results — the opposite is true! Hypertonic saline resuscitation may theoretically be advantageous but it remains an investigational therapy at present. (It has been experimental since we finished medical school…). Blood and blood products are given if necessary, as discussed below.\\n\\nHow much crystalloid to infuse? An old rule of thumb was that the hypovolemic surgical patient needs more volume than you think they need, and much more than the nursing staff think they need. But this rule is now outdated — see the editorial comment at the end of the chapter.\\n\\nWe assume that your patient already has a large-bore i.v. cannula in situ — so just hook it up to the solution and open the valve and let it run!\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'may be an indication for endotracheal intubation and mechanical ventilation. Do not temporize, the patient will need intubation anyway, so why not now? Remember, pain and distension associated with any abdominal catastrophe impede ventilation. Effective analgesia impairs ventilation still further. If a nasogastric (NG) tube is not already in situ this may be the time to insert one. The advantages of NG tube insertion before intubation are to decompress the distended stomach and reduce the risk of aspiration during the procedure. The disadvantage is that the presence of a tube through the cricopharyngeus may allow regurgitation during rapid sequence induction of anesthesia.',\n", " 'md': 'may be an indication for endotracheal intubation and mechanical ventilation. Do not temporize, the patient will need intubation anyway, so why not now? Remember, pain and distension associated with any abdominal catastrophe impede ventilation. Effective analgesia impairs ventilation still further. If a nasogastric (NG) tube is not already in situ this may be the time to insert one. The advantages of NG tube insertion before intubation are to decompress the distended stomach and reduce the risk of aspiration during the procedure. The disadvantage is that the presence of a tube through the cricopharyngeus may allow regurgitation during rapid sequence induction of anesthesia.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.55, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Restoration of Volume',\n", " 'md': '### Restoration of Volume',\n", " 'bBox': {'x': 86, 'y': 278, 'w': 174.71, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The major cause of shock is decreased circulatory volume. Replace body fluids by the best means at hand.\\n**Alfred Blalock**\\n\\nNow after your patient is well oxygenated you must see to it that the oxygen arrives where it is needed, by restoring blood volume. This is accomplished by an intravenous infusion of crystalloids such as normal saline or Ringer’s lactate. Forget about the much more expensive colloids such as fresh frozen plasma, albumin or solutions containing synthetic organic macromolecules such as hetastarch or low-molecular-weight dextran; their theoretical advantages have never been translated into better results — the opposite is true! Hypertonic saline resuscitation may theoretically be advantageous but it remains an investigational therapy at present. (It has been experimental since we finished medical school…). Blood and blood products are given if necessary, as discussed below.\\n\\nHow much crystalloid to infuse? An old rule of thumb was that the hypovolemic surgical patient needs more volume than you think they need, and much more than the nursing staff think they need. But this rule is now outdated — see the editorial comment at the end of the chapter.\\n\\nWe assume that your patient already has a large-bore i.v. cannula in situ — so just hook it up to the solution and open the valve and let it run!\\n```',\n", " 'md': 'The major cause of shock is decreased circulatory volume. Replace body fluids by the best means at hand.\\n**Alfred Blalock**\\n\\nNow after your patient is well oxygenated you must see to it that the oxygen arrives where it is needed, by restoring blood volume. This is accomplished by an intravenous infusion of crystalloids such as normal saline or Ringer’s lactate. Forget about the much more expensive colloids such as fresh frozen plasma, albumin or solutions containing synthetic organic macromolecules such as hetastarch or low-molecular-weight dextran; their theoretical advantages have never been translated into better results — the opposite is true! Hypertonic saline resuscitation may theoretically be advantageous but it remains an investigational therapy at present. (It has been experimental since we finished medical school…). Blood and blood products are given if necessary, as discussed below.\\n\\nHow much crystalloid to infuse? An old rule of thumb was that the hypovolemic surgical patient needs more volume than you think they need, and much more than the nursing staff think they need. But this rule is now outdated — see the editorial comment at the end of the chapter.\\n\\nWe assume that your patient already has a large-bore i.v. cannula in situ — so just hook it up to the solution and open the valve and let it run!\\n```',\n", " 'bBox': {'x': 72, 'y': 309, 'w': 467.82, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 100,\n", " 'text': 'You run in a liter and hang up another. But how much is enough? At\\nthis stage you need to assess the effectiveness of what you do.\\n\\n Measurement of effectiveness of treatment\\n\\n Again, the principal goal of non-operative treatment in the\\nemergency surgical patient is the restoration of adequate tissue\\noxygenation! This endpoint is recognized by physical examination\\nand measurement of urinary output, in conjunction with the\\ninformation provided by selective invasive monitoring and\\nlaboratory studies.\\n\\n With fluid resuscitation one hopes to see improvement of tissue\\noxygenation by normalization of vital signs and improvement in the visible\\nperipheral circulation. Resolution of hypotension, mental confusion,\\ntachypnea and tachycardia may be seen either partially or fully. Postural\\nhypotension reflects a significant deficit in the circulating blood volume.\\nRemember that the usual response to a change in position from supine to\\nupright is an increase in the systolic blood pressure — a widening of the\\npulse pressure. Consequently, if a narrowing of the pulse pressure is\\nseen when the patient sits up then postural hypotension is present.\\n\\n With fluid resuscitation, mottling of the skin and the palpable\\ntemperature of the fingers and toes may improve. Capillary refill is a\\nclinical test that observes the peripheral circulation in the nail bed. The\\nnail bed blanches when pressed and should return to its normal pink\\ncolor in less than 2 seconds. Fluid resuscitation aims to improve this\\nmeasure of the peripheral circulation as well.\\n\\n Urine output\\n Ventilate, perfuse, and piss is all that it is about!\\n Matt Oliver\\n\\n A Foley urinary bladder catheter is essential in any patient requiring optimization. It\\n allows an accurate, if indirect, measurement of tissue perfusion and adequacy of fluid',\n", " 'md': '```markdown\\n## Measurement of Effectiveness of Treatment\\n\\nAgain, the principal goal of non-operative treatment in the emergency surgical patient is the restoration of adequate tissue oxygenation! This endpoint is recognized by physical examination and measurement of urinary output, in conjunction with the information provided by selective invasive monitoring and laboratory studies.\\n\\nWith fluid resuscitation, one hopes to see improvement of tissue oxygenation by normalization of vital signs and improvement in the visible peripheral circulation. Resolution of hypotension, mental confusion, tachypnea, and tachycardia may be seen either partially or fully. Postural hypotension reflects a significant deficit in the circulating blood volume. Remember that the usual response to a change in position from supine to upright is an increase in the systolic blood pressure — a widening of the pulse pressure. Consequently, if a narrowing of the pulse pressure is seen when the patient sits up, then postural hypotension is present.\\n\\nWith fluid resuscitation, mottling of the skin and the palpable temperature of the fingers and toes may improve. Capillary refill is a clinical test that observes the peripheral circulation in the nail bed. The nail bed blanches when pressed and should return to its normal pink color in less than 2 seconds. Fluid resuscitation aims to improve this measure of the peripheral circulation as well.\\n\\n### Urine Output\\n> Ventilate, perfuse, and piss is all that it is about!\\n> — Matt Oliver\\n\\nA Foley urinary bladder catheter is essential in any patient requiring optimization. It allows an accurate, if indirect, measurement of tissue perfusion and adequacy of fluid.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Measurement of Effectiveness of Treatment',\n", " 'md': '## Measurement of Effectiveness of Treatment',\n", " 'bBox': {'x': 86, 'y': 145, 'w': 336.58, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Again, the principal goal of non-operative treatment in the emergency surgical patient is the restoration of adequate tissue oxygenation! This endpoint is recognized by physical examination and measurement of urinary output, in conjunction with the information provided by selective invasive monitoring and laboratory studies.\\n\\nWith fluid resuscitation, one hopes to see improvement of tissue oxygenation by normalization of vital signs and improvement in the visible peripheral circulation. Resolution of hypotension, mental confusion, tachypnea, and tachycardia may be seen either partially or fully. Postural hypotension reflects a significant deficit in the circulating blood volume. Remember that the usual response to a change in position from supine to upright is an increase in the systolic blood pressure — a widening of the pulse pressure. Consequently, if a narrowing of the pulse pressure is seen when the patient sits up, then postural hypotension is present.\\n\\nWith fluid resuscitation, mottling of the skin and the palpable temperature of the fingers and toes may improve. Capillary refill is a clinical test that observes the peripheral circulation in the nail bed. The nail bed blanches when pressed and should return to its normal pink color in less than 2 seconds. Fluid resuscitation aims to improve this measure of the peripheral circulation as well.',\n", " 'md': 'Again, the principal goal of non-operative treatment in the emergency surgical patient is the restoration of adequate tissue oxygenation! This endpoint is recognized by physical examination and measurement of urinary output, in conjunction with the information provided by selective invasive monitoring and laboratory studies.\\n\\nWith fluid resuscitation, one hopes to see improvement of tissue oxygenation by normalization of vital signs and improvement in the visible peripheral circulation. Resolution of hypotension, mental confusion, tachypnea, and tachycardia may be seen either partially or fully. Postural hypotension reflects a significant deficit in the circulating blood volume. Remember that the usual response to a change in position from supine to upright is an increase in the systolic blood pressure — a widening of the pulse pressure. Consequently, if a narrowing of the pulse pressure is seen when the patient sits up, then postural hypotension is present.\\n\\nWith fluid resuscitation, mottling of the skin and the palpable temperature of the fingers and toes may improve. Capillary refill is a clinical test that observes the peripheral circulation in the nail bed. The nail bed blanches when pressed and should return to its normal pink color in less than 2 seconds. Fluid resuscitation aims to improve this measure of the peripheral circulation as well.',\n", " 'bBox': {'x': 72, 'y': 247, 'w': 467.77, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Urine Output',\n", " 'md': '### Urine Output',\n", " 'bBox': {'x': 86, 'y': 593, 'w': 98.37, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '> Ventilate, perfuse, and piss is all that it is about!\\n> — Matt Oliver\\n\\nA Foley urinary bladder catheter is essential in any patient requiring optimization. It allows an accurate, if indirect, measurement of tissue perfusion and adequacy of fluid.\\n```',\n", " 'md': '> Ventilate, perfuse, and piss is all that it is about!\\n> — Matt Oliver\\n\\nA Foley urinary bladder catheter is essential in any patient requiring optimization. It allows an accurate, if indirect, measurement of tissue perfusion and adequacy of fluid.\\n```',\n", " 'bBox': {'x': 108, 'y': 247, 'w': 431.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 101,\n", " 'text': ' resuscitation, as reflected in the urine output.\\n\\n Your aim is at least 0.5 to 1ml urine/kg (patient’s weight) per hour. So from the ‘average’ 70kg\\n or 155lb patient (oh, how rare in our modern practice…), you would want between 30-50cc of\\n urine per hour. Adequate urine output is the single best sign of adequate tissue perfusion\\n associated with successful fluid resuscitation.\\n\\n Invasive monitoring\\n\\n The central venous catheter and the Swan-Ganz pulmonary arterial\\ncatheter are tools which permit ‘special studies’ to be carried out rapidly\\nand repeatedly. The downside of such devices is that they are invasive,\\nexpensive, often inaccurate, and associated with potentially life-\\nthreatening complications. Invasive hemodynamic monitoring could\\nprovide endpoint measurements that, in conjunction with urinary output,\\nindicate the adequacy of fluid resuscitation.\\n\\n The central venous catheter\\n\\n The central venous catheter measures central venous pressure\\n(CVP) which is a product of venous return (i.e. blood volume) and right\\nventricular function. Low CVP always means hypovolemia, but a high\\nCVP can signify either over-expansion of blood volume or cardiac\\nfailure. So aim for an adequate urinary output with a CVP in the normal\\nrange, up to 12cmħ2O. When the CVP rises above the normal range and\\nthe urinary output is still not adequate then either cardiac or renal\\nfunction is impaired or the measurement is an error. False elevations in\\nCVP are caused by abnormally high intra-thoracic or intra-abdominal\\npressure, which is directly transmitted to the great thoracic veins. The\\nmessage is clear — as long as the urine output is not adequate and\\nthe CVP is low — pour in the fluids. But remember: your patient may\\nbe far behind on fluid in the presence of a high or normal CVP. And\\nanother hint: the absolute CVP reading means less than its trend; it\\nis when a low or normal CVP suddenly jumps up that you have to\\nslow the fluids.',\n", " 'md': '```markdown\\n## Resuscitation and Urine Output\\n\\nYour aim is at least \\\\(0.5\\\\) to \\\\(1 \\\\, \\\\text{ml urine/kg}\\\\) (patient’s weight) per hour. For the ‘average’ \\\\(70 \\\\, \\\\text{kg}\\\\) or \\\\(155 \\\\, \\\\text{lb}\\\\) patient, you would want between \\\\(30-50 \\\\, \\\\text{cc}\\\\) of urine per hour. Adequate urine output is the single best sign of adequate tissue perfusion associated with successful fluid resuscitation.\\n\\n### Invasive Monitoring\\n\\nThe central venous catheter and the Swan-Ganz pulmonary arterial catheter are tools which permit ‘special studies’ to be carried out rapidly and repeatedly. The downside of such devices is that they are invasive, expensive, often inaccurate, and associated with potentially life-threatening complications. Invasive hemodynamic monitoring could provide endpoint measurements that, in conjunction with urinary output, indicate the adequacy of fluid resuscitation.\\n\\n#### The Central Venous Catheter\\n\\nThe central venous catheter measures central venous pressure (CVP) which is a product of venous return (i.e., blood volume) and right ventricular function. Low CVP always means hypovolemia, but a high CVP can signify either over-expansion of blood volume or cardiac failure. So aim for an adequate urinary output with a CVP in the normal range, up to \\\\(12 \\\\, \\\\text{cm} \\\\, \\\\text{H}_2\\\\text{O}\\\\).\\n\\nWhen the CVP rises above the normal range and the urinary output is still not adequate, then either cardiac or renal function is impaired or the measurement is an error. False elevations in CVP are caused by abnormally high intra-thoracic or intra-abdominal pressure, which is directly transmitted to the great thoracic veins.\\n\\nThe message is clear — as long as the urine output is not adequate and the CVP is low — pour in the fluids. But remember: your patient may be far behind on fluid in the presence of a high or normal CVP. And another hint: the absolute CVP reading means less than its trend; it is when a low or normal CVP suddenly jumps up that you have to slow the fluids.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Resuscitation and Urine Output',\n", " 'md': '## Resuscitation and Urine Output',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Your aim is at least \\\\(0.5\\\\) to \\\\(1 \\\\, \\\\text{ml urine/kg}\\\\) (patient’s weight) per hour. For the ‘average’ \\\\(70 \\\\, \\\\text{kg}\\\\) or \\\\(155 \\\\, \\\\text{lb}\\\\) patient, you would want between \\\\(30-50 \\\\, \\\\text{cc}\\\\) of urine per hour. Adequate urine output is the single best sign of adequate tissue perfusion associated with successful fluid resuscitation.',\n", " 'md': 'Your aim is at least \\\\(0.5\\\\) to \\\\(1 \\\\, \\\\text{ml urine/kg}\\\\) (patient’s weight) per hour. For the ‘average’ \\\\(70 \\\\, \\\\text{kg}\\\\) or \\\\(155 \\\\, \\\\text{lb}\\\\) patient, you would want between \\\\(30-50 \\\\, \\\\text{cc}\\\\) of urine per hour. Adequate urine output is the single best sign of adequate tissue perfusion associated with successful fluid resuscitation.',\n", " 'bBox': {'x': 79, 'y': 155, 'w': 452.5, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Invasive Monitoring',\n", " 'md': '### Invasive Monitoring',\n", " 'bBox': {'x': 86, 'y': 227, 'w': 156.31, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The central venous catheter and the Swan-Ganz pulmonary arterial catheter are tools which permit ‘special studies’ to be carried out rapidly and repeatedly. The downside of such devices is that they are invasive, expensive, often inaccurate, and associated with potentially life-threatening complications. Invasive hemodynamic monitoring could provide endpoint measurements that, in conjunction with urinary output, indicate the adequacy of fluid resuscitation.',\n", " 'md': 'The central venous catheter and the Swan-Ganz pulmonary arterial catheter are tools which permit ‘special studies’ to be carried out rapidly and repeatedly. The downside of such devices is that they are invasive, expensive, often inaccurate, and associated with potentially life-threatening complications. Invasive hemodynamic monitoring could provide endpoint measurements that, in conjunction with urinary output, indicate the adequacy of fluid resuscitation.',\n", " 'bBox': {'x': 72, 'y': 280, 'w': 467.51, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'The Central Venous Catheter',\n", " 'md': '#### The Central Venous Catheter',\n", " 'bBox': {'x': 86, 'y': 406, 'w': 219.8, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The central venous catheter measures central venous pressure (CVP) which is a product of venous return (i.e., blood volume) and right ventricular function. Low CVP always means hypovolemia, but a high CVP can signify either over-expansion of blood volume or cardiac failure. So aim for an adequate urinary output with a CVP in the normal range, up to \\\\(12 \\\\, \\\\text{cm} \\\\, \\\\text{H}_2\\\\text{O}\\\\).\\n\\nWhen the CVP rises above the normal range and the urinary output is still not adequate, then either cardiac or renal function is impaired or the measurement is an error. False elevations in CVP are caused by abnormally high intra-thoracic or intra-abdominal pressure, which is directly transmitted to the great thoracic veins.\\n\\nThe message is clear — as long as the urine output is not adequate and the CVP is low — pour in the fluids. But remember: your patient may be far behind on fluid in the presence of a high or normal CVP. And another hint: the absolute CVP reading means less than its trend; it is when a low or normal CVP suddenly jumps up that you have to slow the fluids.\\n```',\n", " 'md': 'The central venous catheter measures central venous pressure (CVP) which is a product of venous return (i.e., blood volume) and right ventricular function. Low CVP always means hypovolemia, but a high CVP can signify either over-expansion of blood volume or cardiac failure. So aim for an adequate urinary output with a CVP in the normal range, up to \\\\(12 \\\\, \\\\text{cm} \\\\, \\\\text{H}_2\\\\text{O}\\\\).\\n\\nWhen the CVP rises above the normal range and the urinary output is still not adequate, then either cardiac or renal function is impaired or the measurement is an error. False elevations in CVP are caused by abnormally high intra-thoracic or intra-abdominal pressure, which is directly transmitted to the great thoracic veins.\\n\\nThe message is clear — as long as the urine output is not adequate and the CVP is low — pour in the fluids. But remember: your patient may be far behind on fluid in the presence of a high or normal CVP. And another hint: the absolute CVP reading means less than its trend; it is when a low or normal CVP suddenly jumps up that you have to slow the fluids.\\n```',\n", " 'bBox': {'x': 72, 'y': 406, 'w': 467.58, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 102,\n", " 'text': ' Or you can give a bolus of fluid (300ml for example) rapidly and measure CVP. If it does not\\n increase, the patient appears to be hypovolemic. Ari\\n\\n The important message here is that it is the response of the CVP\\nmeasurement to a fluid challenge that best indicates the patient’s fluid\\nstatus.\\n\\n The Swan-Ganz pulmonary artery flotation catheter\\n\\n The Swan-Ganz measures pulmonary capillary wedge pressure, which\\nreflects the volume status and left cardiac function. Like the CVP\\ncatheter, the ‘Swan’ is used in conjunction with urinary output. We aim for\\na normal ‘wedge’ pressure (around 14mmħg) in conjunction with an\\nadequate urinary output. As with the CVP — a low wedge pressure\\nalways means hypovolemia; a high wedge pressure on the other hand,\\nmay indicate either volume overload, or dysfunction of the left heart. With\\nthe Swan-Ganz in situ, you can calculate and derive information about\\ncardiac function (cardiac output and cardiac index), adrenergic response\\nto injury or illness (peripheral vascular resistance) or tissue perfusion\\n(oxygen consumption and oxygen delivery). A normal cardiac index is a\\ngood confirmatory endpoint for resuscitation and, if pre-existing renal\\nfailure is present, is a good independent endpoint. When the wedge\\npressure is normal or high and the urinary output and cardiac index are\\nstill low then pharmacological intervention with inotropic agents may be\\nindicated.\\n\\n We know that intensivists and junior doctors like to insert central lines\\nand especially Swan-Ganz catheters. Being invasive and able to\\nmeasure sophisticated data is fun and clinically attractive. But invasive\\nmonitoring may be a panacea or a Pandora’s box. Wedge pressures are\\nnotoriously inaccurate in emergency surgical patients — prone to false\\nhigh readings similar to the CVP. Swan-Ganz catheters are expensive,\\npredisposed to complications and — above all — they rarely add\\nanything to the management of your patients. Consider this: when\\nwas the last time that your anesthetist really effectively used, intra-\\noperatively, the Swan-Ganz you placed pre-operatively? We cannot\\nremember such a case.',\n", " 'md': '```markdown\\n## Fluid Management and Monitoring\\n\\nOr you can give a bolus of fluid (300ml for example) rapidly and measure CVP. If it does not increase, the patient appears to be hypovolemic.\\n\\nThe important message here is that it is the response of the CVP measurement to a fluid challenge that best indicates the patient’s fluid status.\\n\\n### The Swan-Ganz Pulmonary Artery Flotation Catheter\\n\\nThe Swan-Ganz measures pulmonary capillary wedge pressure, which reflects the volume status and left cardiac function. Like the CVP catheter, the ‘Swan’ is used in conjunction with urinary output. We aim for a normal ‘wedge’ pressure (around 14 mmHg) in conjunction with an adequate urinary output.\\n\\nAs with the CVP — a low wedge pressure always means hypovolemia; a high wedge pressure, on the other hand, may indicate either volume overload or dysfunction of the left heart. With the Swan-Ganz in situ, you can calculate and derive information about cardiac function (cardiac output and cardiac index), adrenergic response to injury or illness (peripheral vascular resistance), or tissue perfusion (oxygen consumption and oxygen delivery). A normal cardiac index is a good confirmatory endpoint for resuscitation and, if pre-existing renal failure is present, is a good independent endpoint. When the wedge pressure is normal or high and the urinary output and cardiac index are still low, then pharmacological intervention with inotropic agents may be indicated.\\n\\nWe know that intensivists and junior doctors like to insert central lines and especially Swan-Ganz catheters. Being invasive and able to measure sophisticated data is fun and clinically attractive. But invasive monitoring may be a panacea or a Pandora’s box. Wedge pressures are notoriously inaccurate in emergency surgical patients — prone to false high readings similar to the CVP. Swan-Ganz catheters are expensive, predisposed to complications and — above all — they rarely add anything to the management of your patients. Consider this: when was the last time that your anesthetist really effectively used, intra-operatively, the Swan-Ganz you placed pre-operatively? We cannot remember such a case.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Fluid Management and Monitoring',\n", " 'md': '## Fluid Management and Monitoring',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Or you can give a bolus of fluid (300ml for example) rapidly and measure CVP. If it does not increase, the patient appears to be hypovolemic.\\n\\nThe important message here is that it is the response of the CVP measurement to a fluid challenge that best indicates the patient’s fluid status.',\n", " 'md': 'Or you can give a bolus of fluid (300ml for example) rapidly and measure CVP. If it does not increase, the patient appears to be hypovolemic.\\n\\nThe important message here is that it is the response of the CVP measurement to a fluid challenge that best indicates the patient’s fluid status.',\n", " 'bBox': {'x': 72, 'y': 187, 'w': 42.39, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Swan-Ganz Pulmonary Artery Flotation Catheter',\n", " 'md': '### The Swan-Ganz Pulmonary Artery Flotation Catheter',\n", " 'bBox': {'x': 86, 'y': 230, 'w': 401.82, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The Swan-Ganz measures pulmonary capillary wedge pressure, which reflects the volume status and left cardiac function. Like the CVP catheter, the ‘Swan’ is used in conjunction with urinary output. We aim for a normal ‘wedge’ pressure (around 14 mmHg) in conjunction with an adequate urinary output.\\n\\nAs with the CVP — a low wedge pressure always means hypovolemia; a high wedge pressure, on the other hand, may indicate either volume overload or dysfunction of the left heart. With the Swan-Ganz in situ, you can calculate and derive information about cardiac function (cardiac output and cardiac index), adrenergic response to injury or illness (peripheral vascular resistance), or tissue perfusion (oxygen consumption and oxygen delivery). A normal cardiac index is a good confirmatory endpoint for resuscitation and, if pre-existing renal failure is present, is a good independent endpoint. When the wedge pressure is normal or high and the urinary output and cardiac index are still low, then pharmacological intervention with inotropic agents may be indicated.\\n\\nWe know that intensivists and junior doctors like to insert central lines and especially Swan-Ganz catheters. Being invasive and able to measure sophisticated data is fun and clinically attractive. But invasive monitoring may be a panacea or a Pandora’s box. Wedge pressures are notoriously inaccurate in emergency surgical patients — prone to false high readings similar to the CVP. Swan-Ganz catheters are expensive, predisposed to complications and — above all — they rarely add anything to the management of your patients. Consider this: when was the last time that your anesthetist really effectively used, intra-operatively, the Swan-Ganz you placed pre-operatively? We cannot remember such a case.\\n```',\n", " 'md': 'The Swan-Ganz measures pulmonary capillary wedge pressure, which reflects the volume status and left cardiac function. Like the CVP catheter, the ‘Swan’ is used in conjunction with urinary output. We aim for a normal ‘wedge’ pressure (around 14 mmHg) in conjunction with an adequate urinary output.\\n\\nAs with the CVP — a low wedge pressure always means hypovolemia; a high wedge pressure, on the other hand, may indicate either volume overload or dysfunction of the left heart. With the Swan-Ganz in situ, you can calculate and derive information about cardiac function (cardiac output and cardiac index), adrenergic response to injury or illness (peripheral vascular resistance), or tissue perfusion (oxygen consumption and oxygen delivery). A normal cardiac index is a good confirmatory endpoint for resuscitation and, if pre-existing renal failure is present, is a good independent endpoint. When the wedge pressure is normal or high and the urinary output and cardiac index are still low, then pharmacological intervention with inotropic agents may be indicated.\\n\\nWe know that intensivists and junior doctors like to insert central lines and especially Swan-Ganz catheters. Being invasive and able to measure sophisticated data is fun and clinically attractive. But invasive monitoring may be a panacea or a Pandora’s box. Wedge pressures are notoriously inaccurate in emergency surgical patients — prone to false high readings similar to the CVP. Swan-Ganz catheters are expensive, predisposed to complications and — above all — they rarely add anything to the management of your patients. Consider this: when was the last time that your anesthetist really effectively used, intra-operatively, the Swan-Ganz you placed pre-operatively? We cannot remember such a case.\\n```',\n", " 'bBox': {'x': 72, 'y': 266, 'w': 467.92, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 103,\n", " 'text': ' A non-invasive equivalent of the Swan-Ganz catheter is currently available to measure cardiac\\n output — PICCO (peripherally inserted continuous cardiac output monitoring). Danny\\n\\n Laboratory\\n\\n The information provided by laboratory studies is easy to interpret. Aim\\nfor resolution of hemoconcentration, normalization of electrolyte, BUN\\nand creatinine levels, and resolution of metabolic acidosis. As mentioned\\npreviously, look at the base excess (BE) — if persistently negative, the\\noxygen deficit at the tissue level has not resolved.\\n\\n Blood and blood products\\n\\n Blood products, such as whole blood, packed red blood cells, fresh\\nfrozen plasma, cryoprecipitate or platelet concentrate, are indicated\\nselectively to restore oxygen-carrying capacity in actively bleeding or\\nchronically anemic patients, and to correct clotting abnormalities if\\npresent. Do not forget, however, the blood bank blood is a double-\\nedged sword. Beyond the usual and well-known complications of\\ntransfusion, blood is immunosuppressive and may be associated\\nwith an increased probability of postoperative infections. In\\naddition, the more blood you give the higher the risk of\\npostoperative organ system dysfunction, including the risk of\\ntransfusion-related acute lung injury (TRALI) and mortality.\\n\\n Do not forget that rehydration with crystalloids may unmask chronic\\nanemia as the hematocrit falls with volume expansion.\\n\\n Suggested steps in volume optimization\\n\\n • Institute intravenous fluid therapy and if signs of intestinal\\n dysfunction such as nausea, vomiting or abdominal distension are\\n present then designate nil per mouth (NPO) and, if necessary,\\n nasogastric suction. Intravenous crystalloid may be started at a\\n basic rate of 100 to 200ml per hour with the addition of boluses of',\n", " 'md': '```markdown\\n# Page Content\\n\\nA non-invasive equivalent of the Swan-Ganz catheter is currently available to measure cardiac output — PICCO (peripherally inserted continuous cardiac output monitoring).\\n\\n## Laboratory\\n\\nThe information provided by laboratory studies is easy to interpret. Aim for resolution of hemoconcentration, normalization of electrolyte, BUN and creatinine levels, and resolution of metabolic acidosis. As mentioned previously, look at the base excess (BE) — if persistently negative, the oxygen deficit at the tissue level has not resolved.\\n\\n## Blood and Blood Products\\n\\nBlood products, such as whole blood, packed red blood cells, fresh frozen plasma, cryoprecipitate or platelet concentrate, are indicated selectively to restore oxygen-carrying capacity in actively bleeding or chronically anemic patients, and to correct clotting abnormalities if present. Do not forget, however, that blood bank blood is a double-edged sword. Beyond the usual and well-known complications of transfusion, blood is immunosuppressive and may be associated with an increased probability of postoperative infections. In addition, the more blood you give the higher the risk of postoperative organ system dysfunction, including the risk of transfusion-related acute lung injury (TRALI) and mortality.\\n\\nDo not forget that rehydration with crystalloids may unmask chronic anemia as the hematocrit falls with volume expansion.\\n\\n## Suggested Steps in Volume Optimization\\n\\n- Institute intravenous fluid therapy and if signs of intestinal dysfunction such as nausea, vomiting or abdominal distension are present then designate nil per mouth (NPO) and, if necessary, nasogastric suction. Intravenous crystalloid may be started at a basic rate of 100 to 200 ml per hour with the addition of boluses.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured according to the provided guidelines.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A non-invasive equivalent of the Swan-Ganz catheter is currently available to measure cardiac output — PICCO (peripherally inserted continuous cardiac output monitoring).',\n", " 'md': 'A non-invasive equivalent of the Swan-Ganz catheter is currently available to measure cardiac output — PICCO (peripherally inserted continuous cardiac output monitoring).',\n", " 'bBox': {'x': 77, 'y': 91, 'w': 457.62, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Laboratory',\n", " 'md': '## Laboratory',\n", " 'bBox': {'x': 86, 'y': 162, 'w': 86.45, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The information provided by laboratory studies is easy to interpret. Aim for resolution of hemoconcentration, normalization of electrolyte, BUN and creatinine levels, and resolution of metabolic acidosis. As mentioned previously, look at the base excess (BE) — if persistently negative, the oxygen deficit at the tissue level has not resolved.',\n", " 'md': 'The information provided by laboratory studies is easy to interpret. Aim for resolution of hemoconcentration, normalization of electrolyte, BUN and creatinine levels, and resolution of metabolic acidosis. As mentioned previously, look at the base excess (BE) — if persistently negative, the oxygen deficit at the tissue level has not resolved.',\n", " 'bBox': {'x': 72, 'y': 162, 'w': 467.3, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Blood and Blood Products',\n", " 'md': '## Blood and Blood Products',\n", " 'bBox': {'x': 86, 'y': 307, 'w': 205.95, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Blood products, such as whole blood, packed red blood cells, fresh frozen plasma, cryoprecipitate or platelet concentrate, are indicated selectively to restore oxygen-carrying capacity in actively bleeding or chronically anemic patients, and to correct clotting abnormalities if present. Do not forget, however, that blood bank blood is a double-edged sword. Beyond the usual and well-known complications of transfusion, blood is immunosuppressive and may be associated with an increased probability of postoperative infections. In addition, the more blood you give the higher the risk of postoperative organ system dysfunction, including the risk of transfusion-related acute lung injury (TRALI) and mortality.\\n\\nDo not forget that rehydration with crystalloids may unmask chronic anemia as the hematocrit falls with volume expansion.',\n", " 'md': 'Blood products, such as whole blood, packed red blood cells, fresh frozen plasma, cryoprecipitate or platelet concentrate, are indicated selectively to restore oxygen-carrying capacity in actively bleeding or chronically anemic patients, and to correct clotting abnormalities if present. Do not forget, however, that blood bank blood is a double-edged sword. Beyond the usual and well-known complications of transfusion, blood is immunosuppressive and may be associated with an increased probability of postoperative infections. In addition, the more blood you give the higher the risk of postoperative organ system dysfunction, including the risk of transfusion-related acute lung injury (TRALI) and mortality.\\n\\nDo not forget that rehydration with crystalloids may unmask chronic anemia as the hematocrit falls with volume expansion.',\n", " 'bBox': {'x': 72, 'y': 509, 'w': 403, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Suggested Steps in Volume Optimization',\n", " 'md': '## Suggested Steps in Volume Optimization',\n", " 'bBox': {'x': 86, 'y': 603, 'w': 316.3, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Institute intravenous fluid therapy and if signs of intestinal dysfunction such as nausea, vomiting or abdominal distension are present then designate nil per mouth (NPO) and, if necessary, nasogastric suction. Intravenous crystalloid may be started at a basic rate of 100 to 200 ml per hour with the addition of boluses.\\n```',\n", " 'md': '- Institute intravenous fluid therapy and if signs of intestinal dysfunction such as nausea, vomiting or abdominal distension are present then designate nil per mouth (NPO) and, if necessary, nasogastric suction. Intravenous crystalloid may be started at a basic rate of 100 to 200 ml per hour with the addition of boluses.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured according to the provided guidelines.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured according to the provided guidelines.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 104,\n", " 'text': ' 250 to 500ml given over intervals of 15 to 30 minutes. We advise\\n you, however, to sit by your patient…\\n • Institute procedures for monitoring the effectiveness of treatment\\n including serial physical exam, Foley catheter placement and, in\\n more severe cases, central venous catheter placement.\\n • If the main underlying problem is hemorrhage, institute transfusion\\n of packed red blood cells — typed and cross-matched if there is\\n time, type-specific only if there is not. (Add blood components as\\n necessary.)\\n • Titrate the rate of fluid administration in light of the results of\\n monitoring. Increase or decrease the basic rate of fluid flow and give\\n additional bolus infusions as necessary.\\n • After the restoration of intravascular fluid volume, address any\\n residual signs of physiologic dysfunction with inotropic agents to\\n improve cardiac output and, possibly, an afterload-reducing agent to\\n improve myocardial oxygen supply and ease the workload of the\\n heart.\\n • Wheel the patient directly to the operating room yourself. Do not wait\\n for the porter — aren’t they usually late?\\n • If the basic problem is continuing hemorrhage then forget this\\n list and go directly to the operating room. The best resuscitation\\n in actively bleeding patients is surgical control of the source. In\\n addition, pre-operative over-resuscitation and transfusion\\n increase the blood loss.\\n\\n When is enough enough?\\n\\n The above steps in optimization are done with the aim of correcting\\nphysiologic derangement as much as possible but without unnecessarily\\ndelaying operative intervention. There is no magic formula for\\nachieving this balance. The disease process itself will determine the\\nduration of pre-operative optimization. At one end of the spectrum,\\nuncontrolled hemorrhage will require immediate operative intervention\\nafter only partial fluid resuscitation or none at all. At the other end of the\\nspectrum, intestinal obstruction that has been developing over several\\ndays will require a more complete resuscitation prior to operation. As in\\nlife in general, most cases will fall somewhere in between — which',\n", " 'md': '```markdown\\n## Page Content\\n\\n- 250 to 500 ml given over intervals of 15 to 30 minutes. We advise you, however, to sit by your patient…\\n- Institute procedures for monitoring the effectiveness of treatment including serial physical exam, Foley catheter placement and, in more severe cases, central venous catheter placement.\\n- If the main underlying problem is hemorrhage, institute transfusion of packed red blood cells — typed and cross-matched if there is time, type-specific only if there is not. (Add blood components as necessary.)\\n- Titrate the rate of fluid administration in light of the results of monitoring. Increase or decrease the basic rate of fluid flow and give additional bolus infusions as necessary.\\n- After the restoration of intravascular fluid volume, address any residual signs of physiologic dysfunction with inotropic agents to improve cardiac output and, possibly, an afterload-reducing agent to improve myocardial oxygen supply and ease the workload of the heart.\\n- Wheel the patient directly to the operating room yourself. Do not wait for the porter — aren’t they usually late?\\n- If the basic problem is continuing hemorrhage then forget this list and go directly to the operating room. The best resuscitation in actively bleeding patients is surgical control of the source. In addition, pre-operative over-resuscitation and transfusion increase the blood loss.\\n\\n### When is enough enough?\\n\\nThe above steps in optimization are done with the aim of correcting physiologic derangement as much as possible but without unnecessarily delaying operative intervention. There is no magic formula for achieving this balance. The disease process itself will determine the duration of pre-operative optimization. At one end of the spectrum, uncontrolled hemorrhage will require immediate operative intervention after only partial fluid resuscitation or none at all. At the other end of the spectrum, intestinal obstruction that has been developing over several days will require a more complete resuscitation prior to operation. As in life in general, most cases will fall somewhere in between — which\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 250 to 500 ml given over intervals of 15 to 30 minutes. We advise you, however, to sit by your patient…\\n- Institute procedures for monitoring the effectiveness of treatment including serial physical exam, Foley catheter placement and, in more severe cases, central venous catheter placement.\\n- If the main underlying problem is hemorrhage, institute transfusion of packed red blood cells — typed and cross-matched if there is time, type-specific only if there is not. (Add blood components as necessary.)\\n- Titrate the rate of fluid administration in light of the results of monitoring. Increase or decrease the basic rate of fluid flow and give additional bolus infusions as necessary.\\n- After the restoration of intravascular fluid volume, address any residual signs of physiologic dysfunction with inotropic agents to improve cardiac output and, possibly, an afterload-reducing agent to improve myocardial oxygen supply and ease the workload of the heart.\\n- Wheel the patient directly to the operating room yourself. Do not wait for the porter — aren’t they usually late?\\n- If the basic problem is continuing hemorrhage then forget this list and go directly to the operating room. The best resuscitation in actively bleeding patients is surgical control of the source. In addition, pre-operative over-resuscitation and transfusion increase the blood loss.',\n", " 'md': '- 250 to 500 ml given over intervals of 15 to 30 minutes. We advise you, however, to sit by your patient…\\n- Institute procedures for monitoring the effectiveness of treatment including serial physical exam, Foley catheter placement and, in more severe cases, central venous catheter placement.\\n- If the main underlying problem is hemorrhage, institute transfusion of packed red blood cells — typed and cross-matched if there is time, type-specific only if there is not. (Add blood components as necessary.)\\n- Titrate the rate of fluid administration in light of the results of monitoring. Increase or decrease the basic rate of fluid flow and give additional bolus infusions as necessary.\\n- After the restoration of intravascular fluid volume, address any residual signs of physiologic dysfunction with inotropic agents to improve cardiac output and, possibly, an afterload-reducing agent to improve myocardial oxygen supply and ease the workload of the heart.\\n- Wheel the patient directly to the operating room yourself. Do not wait for the porter — aren’t they usually late?\\n- If the basic problem is continuing hemorrhage then forget this list and go directly to the operating room. The best resuscitation in actively bleeding patients is surgical control of the source. In addition, pre-operative over-resuscitation and transfusion increase the blood loss.',\n", " 'bBox': {'x': 100, 'y': 102, 'w': 436.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'When is enough enough?',\n", " 'md': '### When is enough enough?',\n", " 'bBox': {'x': 86, 'y': 529, 'w': 202.28, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The above steps in optimization are done with the aim of correcting physiologic derangement as much as possible but without unnecessarily delaying operative intervention. There is no magic formula for achieving this balance. The disease process itself will determine the duration of pre-operative optimization. At one end of the spectrum, uncontrolled hemorrhage will require immediate operative intervention after only partial fluid resuscitation or none at all. At the other end of the spectrum, intestinal obstruction that has been developing over several days will require a more complete resuscitation prior to operation. As in life in general, most cases will fall somewhere in between — which\\n```',\n", " 'md': 'The above steps in optimization are done with the aim of correcting physiologic derangement as much as possible but without unnecessarily delaying operative intervention. There is no magic formula for achieving this balance. The disease process itself will determine the duration of pre-operative optimization. At one end of the spectrum, uncontrolled hemorrhage will require immediate operative intervention after only partial fluid resuscitation or none at all. At the other end of the spectrum, intestinal obstruction that has been developing over several days will require a more complete resuscitation prior to operation. As in life in general, most cases will fall somewhere in between — which\\n```',\n", " 'bBox': {'x': 72, 'y': 467, 'w': 467.86, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 105,\n", " 'text': 'means around 3 hours. Stubborn attempts to ‘improve’ a ‘non-responder’\\nbeyond 6 hours are usually counter-productive. That you, or your boss,\\ndo not feel like leaving your warm beds at 3 a.m. is not an excuse to\\n“continue aggressive resuscitation” until sunrise.\\n\\n But stop! Perhaps your patient does not need an operation? One\\nof the cleverest aphorisms in surgery was coined by the late Francis\\nD. Moore: “Never operate on a patient who is getting rapidly better\\nor rapidly worse.”\\n\\n So finally to recap…\\n\\n The key to pre-operative optimization in emergency surgery is\\noxygenation of the blood and intravenous fluid resuscitation with\\ncrystalloid solutions. The only goal of resuscitation is the restoration of\\nadequate tissue perfusion to supply oxygen to the suffocating\\nmitochondria. Accomplish it aggressively to reduce intra-operative and\\npostoperative complications.\\n\\n These old folks maintain a fragile system quite well… until it gets\\ndisturbed — like a house of cards.\\n\\n “Every operation is an experiment in physiology.”\\n Tid Kommer',\n", " 'md': '```markdown\\n## Key Points on Pre-operative Optimization in Emergency Surgery\\n\\n- The optimal duration for resuscitation efforts is around 3 hours.\\n- Continuing resuscitation beyond 6 hours is often counter-productive.\\n- Personal discomfort (e.g., not wanting to leave bed at 3 a.m.) is not a valid reason to prolong aggressive resuscitation.\\n\\n### Important Consideration\\n- Evaluate whether the patient truly requires surgery.\\n- A notable aphorism by Francis D. Moore states:\\n> “Never operate on a patient who is getting rapidly better or rapidly worse.”\\n\\n### Summary of Pre-operative Optimization\\n- The primary focus in emergency surgery should be on:\\n- Oxygenation of the blood.\\n- Intravenous fluid resuscitation using crystalloid solutions.\\n- The ultimate goal of resuscitation is to restore adequate tissue perfusion to supply oxygen to the mitochondria.\\n- Aggressive resuscitation is essential to minimize intra-operative and postoperative complications.\\n\\n### Final Thought\\n- Older patients often maintain a delicate physiological balance until it is disrupted, akin to a house of cards.\\n- Tid Kommer remarked:\\n> “Every operation is an experiment in physiology.”\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Key Points on Pre-operative Optimization in Emergency Surgery',\n", " 'md': '## Key Points on Pre-operative Optimization in Emergency Surgery',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The optimal duration for resuscitation efforts is around 3 hours.\\n- Continuing resuscitation beyond 6 hours is often counter-productive.\\n- Personal discomfort (e.g., not wanting to leave bed at 3 a.m.) is not a valid reason to prolong aggressive resuscitation.',\n", " 'md': '- The optimal duration for resuscitation efforts is around 3 hours.\\n- Continuing resuscitation beyond 6 hours is often counter-productive.\\n- Personal discomfort (e.g., not wanting to leave bed at 3 a.m.) is not a valid reason to prolong aggressive resuscitation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Important Consideration',\n", " 'md': '### Important Consideration',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Evaluate whether the patient truly requires surgery.\\n- A notable aphorism by Francis D. Moore states:\\n> “Never operate on a patient who is getting rapidly better or rapidly worse.”',\n", " 'md': '- Evaluate whether the patient truly requires surgery.\\n- A notable aphorism by Francis D. Moore states:\\n> “Never operate on a patient who is getting rapidly better or rapidly worse.”',\n", " 'bBox': {'x': 72, 'y': 220, 'w': 122.31, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary of Pre-operative Optimization',\n", " 'md': '### Summary of Pre-operative Optimization',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The primary focus in emergency surgery should be on:\\n- Oxygenation of the blood.\\n- Intravenous fluid resuscitation using crystalloid solutions.\\n- The ultimate goal of resuscitation is to restore adequate tissue perfusion to supply oxygen to the mitochondria.\\n- Aggressive resuscitation is essential to minimize intra-operative and postoperative complications.',\n", " 'md': '- The primary focus in emergency surgery should be on:\\n- Oxygenation of the blood.\\n- Intravenous fluid resuscitation using crystalloid solutions.\\n- The ultimate goal of resuscitation is to restore adequate tissue perfusion to supply oxygen to the mitochondria.\\n- Aggressive resuscitation is essential to minimize intra-operative and postoperative complications.',\n", " 'bBox': {'x': 72, 'y': 382, 'w': 181.53, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Final Thought',\n", " 'md': '### Final Thought',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Older patients often maintain a delicate physiological balance until it is disrupted, akin to a house of cards.\\n- Tid Kommer remarked:\\n> “Every operation is an experiment in physiology.”\\n```',\n", " 'md': '- Older patients often maintain a delicate physiological balance until it is disrupted, akin to a house of cards.\\n- Tid Kommer remarked:\\n> “Every operation is an experiment in physiology.”\\n```',\n", " 'bBox': {'x': 79, 'y': 481, 'w': 391.4, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 106,\n", " 'text': ' Table 6.1. How urgent is urgent?\\n Urgency Example(s) Meaning\\n Immediate Uncontrolled internal Run to the OR\\n hemorrhage; prolapse of cord\\n Life-threatening Leaking abdominal aortic Walk to the OR now\\n conditions aneurysm\\n Potentially life- Perforated viscus Take to the OR within 2-3 hours\\n threatening Torsion of testis\\n Should not be Acute appendicitis, intestinal Usually can wait 6 hours until\\n delayed obstruction the morning\\n Can be delayed Acute cholecystitis Most cases can wait until the\\n end of the weekend\\nFrom the Editors: a few more words on the dangers of over-\\nresuscitation\\nWe agree that restoring blood volume is a crucial step before any emergency operation but at\\nthe same time we have to warn you — as we’ll do again and again — not to drown your\\npatients in too much fluid. Pre-operative, intra-operative, or postoperative fluid\\nadministration can cut both ways. Equipped with huge-bore i.v. lines and fancy monitoring\\ndevices, enthusiastic surgeons and anesthetists commonly flood their patients with too much\\nwater and salt. We tend to ignore the ‘obligatory’ postoperative weight gain caused by over\\naggressive resuscitation with a shrug: “Well,” we say, “the patient is perfusing well and his urine\\noutput is excellent — he’ll diurese the excess fluids once he’s well.” But we are wrong!\\n\\nAccumulating evidence shows that the deleterious effect of excess fluid is not limited to patients\\nwho are actively bleeding (by increasing the rate of hemorrhage and the risk of rebleeding) but\\ncan, in fact, be demonstrated in all of our patients. Swollen, edematous cells are\\nbad news in each and every system. Edema contributes to',\n", " 'md': '```markdown\\n## Table 6.1. How urgent is urgent?\\n\\n| Urgency | Example(s) | Meaning |\\n|---------------------------|----------------------------------------|----------------------------------------------|\\n| Immediate | Uncontrolled internal hemorrhage; | Run to the OR |\\n| | prolapse of cord | |\\n| Life-threatening | Leaking abdominal aortic aneurysm | Walk to the OR now |\\n| Potentially life- | Perforated viscus | Take to the OR within 2-3 hours |\\n| threatening | Torsion of testis | |\\n| Should not be delayed | Acute appendicitis, intestinal | Usually can wait 6 hours until the morning |\\n| | obstruction | |\\n| Can be delayed | Acute cholecystitis | Most cases can wait until the end of the |\\n| | | weekend |\\n\\n----\\n\\nFrom the Editors: a few more words on the dangers of over-resuscitation\\n\\nWe agree that restoring blood volume is a crucial step before any emergency operation but at the same time we have to warn you — as we’ll do again and again — not to drown your patients in too much fluid. Pre-operative, intra-operative, or postoperative fluid administration can cut both ways. Equipped with huge-bore i.v. lines and fancy monitoring devices, enthusiastic surgeons and anesthetists commonly flood their patients with too much water and salt. We tend to ignore the ‘obligatory’ postoperative weight gain caused by over-aggressive resuscitation with a shrug: “Well,” we say, “the patient is perfusing well and his urine output is excellent — he’ll diurese the excess fluids once he’s well.” But we are wrong!\\n\\nAccumulating evidence shows that the deleterious effect of excess fluid is not limited to patients who are actively bleeding (by increasing the rate of hemorrhage and the risk of rebleeding) but can, in fact, be demonstrated in all of our patients. Swollen, edematous cells are bad news in each and every system. Edema contributes to...\\n```',\n", " 'images': [{'name': 'img_p105_1.png',\n", " 'height': 661,\n", " 'width': 814,\n", " 'x': 105.11999999999989,\n", " 'y': 72,\n", " 'original_width': 1398,\n", " 'original_height': 1135}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 6.1. How urgent is urgent?',\n", " 'md': '## Table 6.1. How urgent is urgent?',\n", " 'bBox': {'x': 110.56, 'y': 76.95, 'w': 203.22, 'h': 19.29}},\n", " {'type': 'table',\n", " 'rows': [['Urgency', 'Example(s)', 'Meaning'],\n", " ['Immediate', 'Uncontrolled internal hemorrhage;', 'Run to the OR'],\n", " ['', 'prolapse of cord', ''],\n", " ['Life-threatening',\n", " 'Leaking abdominal aortic aneurysm',\n", " 'Walk to the OR now'],\n", " ['Potentially life-',\n", " 'Perforated viscus',\n", " 'Take to the OR within 2-3 hours'],\n", " ['threatening', 'Torsion of testis', ''],\n", " ['Should not be delayed',\n", " 'Acute appendicitis, intestinal',\n", " 'Usually can wait 6 hours until the morning'],\n", " ['', 'obstruction', ''],\n", " ['Can be delayed',\n", " 'Acute cholecystitis',\n", " 'Most cases can wait until the end of the'],\n", " ['', '', 'weekend']],\n", " 'md': '| Urgency | Example(s) | Meaning |\\n|---------------------------|----------------------------------------|----------------------------------------------|\\n| Immediate | Uncontrolled internal hemorrhage; | Run to the OR |\\n| | prolapse of cord | |\\n| Life-threatening | Leaking abdominal aortic aneurysm | Walk to the OR now |\\n| Potentially life- | Perforated viscus | Take to the OR within 2-3 hours |\\n| threatening | Torsion of testis | |\\n| Should not be delayed | Acute appendicitis, intestinal | Usually can wait 6 hours until the morning |\\n| | obstruction | |\\n| Can be delayed | Acute cholecystitis | Most cases can wait until the end of the |\\n| | | weekend |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Urgency\",\"Example(s)\",\"Meaning\"\\n\"Immediate\",\"Uncontrolled internal hemorrhage;\",\"Run to the OR\"\\n\"\",\"prolapse of cord\",\"\"\\n\"Life-threatening\",\"Leaking abdominal aortic aneurysm\",\"Walk to the OR now\"\\n\"Potentially life-\",\"Perforated viscus\",\"Take to the OR within 2-3 hours\"\\n\"threatening\",\"Torsion of testis\",\"\"\\n\"Should not be delayed\",\"Acute appendicitis, intestinal\",\"Usually can wait 6 hours until the morning\"\\n\"\",\"obstruction\",\"\"\\n\"Can be delayed\",\"Acute cholecystitis\",\"Most cases can wait until the end of the\"\\n\"\",\"\",\"weekend\"',\n", " 'bBox': {'x': 109.57, 'y': 115.02, 'w': 145.37, 'h': 19.29}},\n", " {'type': 'text',\n", " 'value': '----\\n\\nFrom the Editors: a few more words on the dangers of over-resuscitation\\n\\nWe agree that restoring blood volume is a crucial step before any emergency operation but at the same time we have to warn you — as we’ll do again and again — not to drown your patients in too much fluid. Pre-operative, intra-operative, or postoperative fluid administration can cut both ways. Equipped with huge-bore i.v. lines and fancy monitoring devices, enthusiastic surgeons and anesthetists commonly flood their patients with too much water and salt. We tend to ignore the ‘obligatory’ postoperative weight gain caused by over-aggressive resuscitation with a shrug: “Well,” we say, “the patient is perfusing well and his urine output is excellent — he’ll diurese the excess fluids once he’s well.” But we are wrong!\\n\\nAccumulating evidence shows that the deleterious effect of excess fluid is not limited to patients who are actively bleeding (by increasing the rate of hemorrhage and the risk of rebleeding) but can, in fact, be demonstrated in all of our patients. Swollen, edematous cells are bad news in each and every system. Edema contributes to...\\n```',\n", " 'md': '----\\n\\nFrom the Editors: a few more words on the dangers of over-resuscitation\\n\\nWe agree that restoring blood volume is a crucial step before any emergency operation but at the same time we have to warn you — as we’ll do again and again — not to drown your patients in too much fluid. Pre-operative, intra-operative, or postoperative fluid administration can cut both ways. Equipped with huge-bore i.v. lines and fancy monitoring devices, enthusiastic surgeons and anesthetists commonly flood their patients with too much water and salt. We tend to ignore the ‘obligatory’ postoperative weight gain caused by over-aggressive resuscitation with a shrug: “Well,” we say, “the patient is perfusing well and his urine output is excellent — he’ll diurese the excess fluids once he’s well.” But we are wrong!\\n\\nAccumulating evidence shows that the deleterious effect of excess fluid is not limited to patients who are actively bleeding (by increasing the rate of hemorrhage and the risk of rebleeding) but can, in fact, be demonstrated in all of our patients. Swollen, edematous cells are bad news in each and every system. Edema contributes to...\\n```',\n", " 'bBox': {'x': 77, 'y': 430, 'w': 457.53, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 107,\n", " 'text': 'respiratory failure and cardiac dysfunction. It prevents tissue\\nhealing — adversely affecting intestinal anastomoses and\\nabdominal closure. It swells abdominal contents producing intra-\\nabdominal hypertension.\\n\\nSo do not go overboard! Give only as much fluid as is necessary\\nand, above all, monitor what the anesthetist is doing on his side of\\nthe screen. The old-fashioned formulas used to calculate how much fluid to administer\\nduring the operation are exaggerated and outdated. One has to replace blood loss and maintain\\nurine output at 0.5ml/kg per hour, which practically means between 30-50cc per hour — nothing\\nmore. The more unnecessary fluid given before and during the\\noperation — the more problems you’ll have with the patient in the\\nICU and on the floor (on the ward, for non-US surgeons!).\\n\\nResuscitation in the traumatized or bleeding patient\\nWe have to forget what the ATLS courses (and book) previously taught us — to flood the patient\\nwith crystalloids. Today we know that overly aggressive fluid resuscitation ‘washes’ out the clot,\\ndisturbs hemostasis, increases bleeding and decreases survival. Hence, the current\\nparadigm is ‘hypotensive resuscitation’ — keep the blood\\npressure just high enough to preserve vital organ perfusion. In\\npractical terms — do not aim for ‘normal’ blood pressure but keep systolic at around 90mmHg.\\n\\nIn actively bleeding patients start slowly with Ringer’s lactate (do not ‘pump’ it in) and then\\nswitch to blood. Recent studies suggest that whole fresh blood is better than component\\ntherapy. But if you have to transfuse more than two units of packed\\nred blood cells, growing evidence suggests that mortality and\\nmorbidity rates are improved by adding one unit of fresh frozen\\nplasma, and one unit of platelets for each unit of blood given.\\nThis is equally true for the injured patient, the one bleeding from his ulcer and the one with a\\nruptured aortic aneurysm!\\n\\nFor a ‘classification’ of the urgency of the case see Table 6.1. The Editors',\n", " 'md': '```markdown\\n## Page Content\\n\\nRespiratory failure and cardiac dysfunction. It prevents tissue healing — adversely affecting intestinal anastomoses and abdominal closure. It swells abdominal contents producing intra-abdominal hypertension.\\n\\nSo do not go overboard! Give only as much fluid as is necessary and, above all, monitor what the anesthetist is doing on his side of the screen. The old-fashioned formulas used to calculate how much fluid to administer during the operation are exaggerated and outdated. One has to replace blood loss and maintain urine output at \\\\(0.5 \\\\, \\\\text{ml/kg per hour}\\\\), which practically means between \\\\(30-50 \\\\, \\\\text{cc per hour}\\\\) — nothing more. The more unnecessary fluid given before and during the operation — the more problems you’ll have with the patient in the ICU and on the floor (on the ward, for non-US surgeons!).\\n\\n### Resuscitation in the Traumatized or Bleeding Patient\\n\\nWe have to forget what the ATLS courses (and book) previously taught us — to flood the patient with crystalloids. Today we know that overly aggressive fluid resuscitation ‘washes’ out the clot, disturbs hemostasis, increases bleeding and decreases survival. Hence, the current paradigm is ‘hypotensive resuscitation’ — keep the blood pressure just high enough to preserve vital organ perfusion. In practical terms — do not aim for ‘normal’ blood pressure but keep systolic at around \\\\(90 \\\\, \\\\text{mmHg}\\\\).\\n\\nIn actively bleeding patients start slowly with Ringer’s lactate (do not ‘pump’ it in) and then switch to blood. Recent studies suggest that whole fresh blood is better than component therapy. But if you have to transfuse more than two units of packed red blood cells, growing evidence suggests that mortality and morbidity rates are improved by adding one unit of fresh frozen plasma, and one unit of platelets for each unit of blood given. This is equally true for the injured patient, the one bleeding from his ulcer and the one with a ruptured aortic aneurysm!\\n\\nFor a ‘classification’ of the urgency of the case see Table 6.1. The Editors\\n\\n### Table 6.1\\n| Urgency Classification | Description |\\n|-----------------------|-------------|\\n| 1 | Immediate |\\n| 2 | Urgent |\\n| 3 | Semi-Urgent |\\n| 4 | Elective |\\n```\\n\\n### Image Identification and Description\\n- **Figure 6.1**: Table 6.1 is referenced in the text, which classifies the urgency of cases. The table includes columns for urgency classification and description.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Respiratory failure and cardiac dysfunction. It prevents tissue healing — adversely affecting intestinal anastomoses and abdominal closure. It swells abdominal contents producing intra-abdominal hypertension.\\n\\nSo do not go overboard! Give only as much fluid as is necessary and, above all, monitor what the anesthetist is doing on his side of the screen. The old-fashioned formulas used to calculate how much fluid to administer during the operation are exaggerated and outdated. One has to replace blood loss and maintain urine output at \\\\(0.5 \\\\, \\\\text{ml/kg per hour}\\\\), which practically means between \\\\(30-50 \\\\, \\\\text{cc per hour}\\\\) — nothing more. The more unnecessary fluid given before and during the operation — the more problems you’ll have with the patient in the ICU and on the floor (on the ward, for non-US surgeons!).',\n", " 'md': 'Respiratory failure and cardiac dysfunction. It prevents tissue healing — adversely affecting intestinal anastomoses and abdominal closure. It swells abdominal contents producing intra-abdominal hypertension.\\n\\nSo do not go overboard! Give only as much fluid as is necessary and, above all, monitor what the anesthetist is doing on his side of the screen. The old-fashioned formulas used to calculate how much fluid to administer during the operation are exaggerated and outdated. One has to replace blood loss and maintain urine output at \\\\(0.5 \\\\, \\\\text{ml/kg per hour}\\\\), which practically means between \\\\(30-50 \\\\, \\\\text{cc per hour}\\\\) — nothing more. The more unnecessary fluid given before and during the operation — the more problems you’ll have with the patient in the ICU and on the floor (on the ward, for non-US surgeons!).',\n", " 'bBox': {'x': 77, 'y': 87, 'w': 457.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Resuscitation in the Traumatized or Bleeding Patient',\n", " 'md': '### Resuscitation in the Traumatized or Bleeding Patient',\n", " 'bBox': {'x': 77, 'y': 87, 'w': 354.06, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'We have to forget what the ATLS courses (and book) previously taught us — to flood the patient with crystalloids. Today we know that overly aggressive fluid resuscitation ‘washes’ out the clot, disturbs hemostasis, increases bleeding and decreases survival. Hence, the current paradigm is ‘hypotensive resuscitation’ — keep the blood pressure just high enough to preserve vital organ perfusion. In practical terms — do not aim for ‘normal’ blood pressure but keep systolic at around \\\\(90 \\\\, \\\\text{mmHg}\\\\).\\n\\nIn actively bleeding patients start slowly with Ringer’s lactate (do not ‘pump’ it in) and then switch to blood. Recent studies suggest that whole fresh blood is better than component therapy. But if you have to transfuse more than two units of packed red blood cells, growing evidence suggests that mortality and morbidity rates are improved by adding one unit of fresh frozen plasma, and one unit of platelets for each unit of blood given. This is equally true for the injured patient, the one bleeding from his ulcer and the one with a ruptured aortic aneurysm!\\n\\nFor a ‘classification’ of the urgency of the case see Table 6.1. The Editors',\n", " 'md': 'We have to forget what the ATLS courses (and book) previously taught us — to flood the patient with crystalloids. Today we know that overly aggressive fluid resuscitation ‘washes’ out the clot, disturbs hemostasis, increases bleeding and decreases survival. Hence, the current paradigm is ‘hypotensive resuscitation’ — keep the blood pressure just high enough to preserve vital organ perfusion. In practical terms — do not aim for ‘normal’ blood pressure but keep systolic at around \\\\(90 \\\\, \\\\text{mmHg}\\\\).\\n\\nIn actively bleeding patients start slowly with Ringer’s lactate (do not ‘pump’ it in) and then switch to blood. Recent studies suggest that whole fresh blood is better than component therapy. But if you have to transfuse more than two units of packed red blood cells, growing evidence suggests that mortality and morbidity rates are improved by adding one unit of fresh frozen plasma, and one unit of platelets for each unit of blood given. This is equally true for the injured patient, the one bleeding from his ulcer and the one with a ruptured aortic aneurysm!\\n\\nFor a ‘classification’ of the urgency of the case see Table 6.1. The Editors',\n", " 'bBox': {'x': 77, 'y': 87, 'w': 457.76, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 6.1',\n", " 'md': '### Table 6.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Urgency Classification', 'Description'],\n", " ['1', 'Immediate'],\n", " ['2', 'Urgent'],\n", " ['3', 'Semi-Urgent'],\n", " ['4', 'Elective']],\n", " 'md': '| Urgency Classification | Description |\\n|-----------------------|-------------|\\n| 1 | Immediate |\\n| 2 | Urgent |\\n| 3 | Semi-Urgent |\\n| 4 | Elective |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Urgency Classification\",\"Description\"\\n\"1\",\"Immediate\"\\n\"2\",\"Urgent\"\\n\"3\",\"Semi-Urgent\"\\n\"4\",\"Elective\"',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 214, 'y': 87, 'w': 25.58, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Figure 6.1**: Table 6.1 is referenced in the text, which classifies the urgency of cases. The table includes columns for urgency classification and description.',\n", " 'md': '- **Figure 6.1**: Table 6.1 is referenced in the text, which classifies the urgency of cases. The table includes columns for urgency classification and description.',\n", " 'bBox': {'x': 154, 'y': 87, 'w': 85.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 108,\n", " 'text': 'Chapter 7\\nPre-operative antibiotics\\nMoshe Schein\\n\\n Most men die of their remedies, not of their diseases.\\n Molière\\n\\n Curmudgeon is the guy who gets up at the M & M meeting,\\n after you describe your brilliant save with an ER\\n thoracotomy for thoracoabdominal GSW and asks why you\\n did not give prophylactic antibiotics.\\n Albert I. Alexander\\n\\n It is common practice to administer broad-spectrum antibiotics before a\\nlaparotomy for an acute surgical condition or trauma. In this situation,\\nantibiotics are either therapeutic or prophylactic.\\n\\n Therapeutic antibiotics: given for an already established, tissue-invasive,\\n infection (e.g. perforated appendicitis).\\n\\n Prophylactic antibiotics: administered in the absence of infection, with the\\n objective of reducing the anticipated incidence of infections due to existing (e.g. penetrating\\n injury of the colon) or potential (e.g. gastrotomy to suture a bleeding ulcer) contamination\\n during the operative procedure.\\n\\n It is very important to distinguish between contamination and',\n", " 'md': '```markdown\\n# Chapter 7: Pre-operative Antibiotics\\n**Author:** Moshe Schein\\n\\n> \"Most men die of their remedies, not of their diseases.\"\\n> — Molière\\n\\n> \"Curmudgeon is the guy who gets up at the M & M meeting, after you describe your brilliant save with an ER thoracotomy for thoracoabdominal GSW and asks why you did not give prophylactic antibiotics.\"\\n> — Albert I. Alexander\\n\\nIt is common practice to administer broad-spectrum antibiotics before a laparotomy for an acute surgical condition or trauma. In this situation, antibiotics are either therapeutic or prophylactic.\\n\\n### Therapeutic Antibiotics\\nGiven for an already established, tissue-invasive infection (e.g., perforated appendicitis).\\n\\n### Prophylactic Antibiotics\\nAdministered in the absence of infection, with the objective of reducing the anticipated incidence of infections due to existing (e.g., penetrating injury of the colon) or potential (e.g., gastrotomy to suture a bleeding ulcer) contamination during the operative procedure.\\n\\nIt is very important to distinguish between contamination and...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 7: Pre-operative Antibiotics',\n", " 'md': '# Chapter 7: Pre-operative Antibiotics',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 216.12, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Moshe Schein\\n\\n> \"Most men die of their remedies, not of their diseases.\"\\n> — Molière\\n\\n> \"Curmudgeon is the guy who gets up at the M & M meeting, after you describe your brilliant save with an ER thoracotomy for thoracoabdominal GSW and asks why you did not give prophylactic antibiotics.\"\\n> — Albert I. Alexander\\n\\nIt is common practice to administer broad-spectrum antibiotics before a laparotomy for an acute surgical condition or trauma. In this situation, antibiotics are either therapeutic or prophylactic.',\n", " 'md': '**Author:** Moshe Schein\\n\\n> \"Most men die of their remedies, not of their diseases.\"\\n> — Molière\\n\\n> \"Curmudgeon is the guy who gets up at the M & M meeting, after you describe your brilliant save with an ER thoracotomy for thoracoabdominal GSW and asks why you did not give prophylactic antibiotics.\"\\n> — Albert I. Alexander\\n\\nIt is common practice to administer broad-spectrum antibiotics before a laparotomy for an acute surgical condition or trauma. In this situation, antibiotics are either therapeutic or prophylactic.',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 453.19, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Therapeutic Antibiotics',\n", " 'md': '### Therapeutic Antibiotics',\n", " 'bBox': {'x': 469, 'y': 381, 'w': 19.99, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Given for an already established, tissue-invasive infection (e.g., perforated appendicitis).',\n", " 'md': 'Given for an already established, tissue-invasive infection (e.g., perforated appendicitis).',\n", " 'bBox': {'x': 439, 'y': 381, 'w': 20, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Prophylactic Antibiotics',\n", " 'md': '### Prophylactic Antibiotics',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Administered in the absence of infection, with the objective of reducing the anticipated incidence of infections due to existing (e.g., penetrating injury of the colon) or potential (e.g., gastrotomy to suture a bleeding ulcer) contamination during the operative procedure.\\n\\nIt is very important to distinguish between contamination and...\\n```',\n", " 'md': 'Administered in the absence of infection, with the objective of reducing the anticipated incidence of infections due to existing (e.g., penetrating injury of the colon) or potential (e.g., gastrotomy to suture a bleeding ulcer) contamination during the operative procedure.\\n\\nIt is very important to distinguish between contamination and...\\n```',\n", " 'bBox': {'x': 79, 'y': 381, 'w': 350.59, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 109,\n", " 'text': 'infection ( Chapter 13), as only the latter requires postoperative\\nantibiotic administration, a topic to be discussed in the postoperative\\nsection ( Chapter 44).\\n\\n Therapeutic antibiotics assist the surgeon and the natural peritoneal\\ndefenses to eradicate an established infection.\\n\\n Prophylactic antibiotics prevent postoperative infections of the\\nlaparotomy wound; they do not prevent pulmonary or urinary infections\\nnor the occurrence of intra-abdominal abscesses, and should not be\\nadministered in an attempt to do any of these things.\\n\\n The overprescription of antibiotics is a modern curse for which our\\npatients pay the price in terms of morbidity and mortality from antibiotic-\\nassociated colitis and the emergence of resistant strains. All prescriptions\\nshould be provided with a clear purpose in mind and should be for as\\nshort a duration as possible. Finally, even dummies know that\\nantibiotics are only an adjunct to the proper surgical management\\nof contamination and infection ( Chapter 13).\\n\\n When should you start antibiotics?\\n\\n There are two schools of thought here. One says that if intra-abdominal\\ncontamination or infection is evident or strongly suspected pre-\\noperatively, administer antibiotics immediately — “the sooner the better”.\\nIn cases where there is delay in proceeding with the laparotomy, give a\\nsecond dose of pre-incisional antibiotics in the operating room. Pre-\\nincisional administration is best in cases where contamination is\\nexpected to occur intra-operatively. Some surgeons believe differently\\nand prefer to await the operative findings before giving antibiotics.\\nShould, for example, the acute appendicitis prove to be ‘simply\\nphlegmonous’ ( Chapter 23), or the blunt trauma not breach the lumen\\nof a hollow viscus ( Chapter 32), they would avoid antibiotics\\naltogether. Alternatively, if contamination or infection were encountered,\\nthey would start antibiotic therapy a few minutes after abdominal entry,\\napparently with no disadvantage. This will also allow proper cultures to\\nbe taken. Support for this second philosophy comes from the suggestion',\n", " 'md': '```markdown\\n# Chapter 13: Infection\\n\\nTherapeutic antibiotics assist the surgeon and the natural peritoneal defenses to eradicate an established infection.\\n\\nProphylactic antibiotics prevent postoperative infections of the laparotomy wound; they do not prevent pulmonary or urinary infections nor the occurrence of intra-abdominal abscesses, and should not be administered in an attempt to do any of these things.\\n\\nThe overprescription of antibiotics is a modern curse for which our patients pay the price in terms of morbidity and mortality from antibiotic-associated colitis and the emergence of resistant strains. All prescriptions should be provided with a clear purpose in mind and should be for as short a duration as possible. Finally, even dummies know that antibiotics are only an adjunct to the proper surgical management of contamination and infection.\\n\\n## When should you start antibiotics?\\n\\nThere are two schools of thought here. One says that if intra-abdominal contamination or infection is evident or strongly suspected pre-operatively, administer antibiotics immediately — “the sooner the better”. In cases where there is delay in proceeding with the laparotomy, give a second dose of pre-incisional antibiotics in the operating room. Pre-incisional administration is best in cases where contamination is expected to occur intra-operatively.\\n\\nSome surgeons believe differently and prefer to await the operative findings before giving antibiotics. Should, for example, the acute appendicitis prove to be ‘simply phlegmonous’, or the blunt trauma not breach the lumen of a hollow viscus, they would avoid antibiotics altogether. Alternatively, if contamination or infection were encountered, they would start antibiotic therapy a few minutes after abdominal entry, apparently with no disadvantage. This will also allow proper cultures to be taken. Support for this second philosophy comes from the suggestion.\\n```',\n", " 'images': [{'name': 'img_p108_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 145.43999999999994,\n", " 'y': 74.88000000000001},\n", " {'name': 'img_p108_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 126.72000000000003,\n", " 'y': 108},\n", " {'name': 'img_p108_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 290.15999999999997,\n", " 'y': 379.44},\n", " {'name': 'img_p108_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 170.64,\n", " 'y': 607.68},\n", " {'name': 'img_p108_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 221.76,\n", " 'y': 624.2399999999999}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 13: Infection',\n", " 'md': '# Chapter 13: Infection',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Therapeutic antibiotics assist the surgeon and the natural peritoneal defenses to eradicate an established infection.\\n\\nProphylactic antibiotics prevent postoperative infections of the laparotomy wound; they do not prevent pulmonary or urinary infections nor the occurrence of intra-abdominal abscesses, and should not be administered in an attempt to do any of these things.\\n\\nThe overprescription of antibiotics is a modern curse for which our patients pay the price in terms of morbidity and mortality from antibiotic-associated colitis and the emergence of resistant strains. All prescriptions should be provided with a clear purpose in mind and should be for as short a duration as possible. Finally, even dummies know that antibiotics are only an adjunct to the proper surgical management of contamination and infection.',\n", " 'md': 'Therapeutic antibiotics assist the surgeon and the natural peritoneal defenses to eradicate an established infection.\\n\\nProphylactic antibiotics prevent postoperative infections of the laparotomy wound; they do not prevent pulmonary or urinary infections nor the occurrence of intra-abdominal abscesses, and should not be administered in an attempt to do any of these things.\\n\\nThe overprescription of antibiotics is a modern curse for which our patients pay the price in terms of morbidity and mortality from antibiotic-associated colitis and the emergence of resistant strains. All prescriptions should be provided with a clear purpose in mind and should be for as short a duration as possible. Finally, even dummies know that antibiotics are only an adjunct to the proper surgical management of contamination and infection.',\n", " 'bBox': {'x': 72, 'y': 154, 'w': 467.86, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'When should you start antibiotics?',\n", " 'md': '## When should you start antibiotics?',\n", " 'bBox': {'x': 86, 'y': 433, 'w': 275.82, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'There are two schools of thought here. One says that if intra-abdominal contamination or infection is evident or strongly suspected pre-operatively, administer antibiotics immediately — “the sooner the better”. In cases where there is delay in proceeding with the laparotomy, give a second dose of pre-incisional antibiotics in the operating room. Pre-incisional administration is best in cases where contamination is expected to occur intra-operatively.\\n\\nSome surgeons believe differently and prefer to await the operative findings before giving antibiotics. Should, for example, the acute appendicitis prove to be ‘simply phlegmonous’, or the blunt trauma not breach the lumen of a hollow viscus, they would avoid antibiotics altogether. Alternatively, if contamination or infection were encountered, they would start antibiotic therapy a few minutes after abdominal entry, apparently with no disadvantage. This will also allow proper cultures to be taken. Support for this second philosophy comes from the suggestion.\\n```',\n", " 'md': 'There are two schools of thought here. One says that if intra-abdominal contamination or infection is evident or strongly suspected pre-operatively, administer antibiotics immediately — “the sooner the better”. In cases where there is delay in proceeding with the laparotomy, give a second dose of pre-incisional antibiotics in the operating room. Pre-incisional administration is best in cases where contamination is expected to occur intra-operatively.\\n\\nSome surgeons believe differently and prefer to await the operative findings before giving antibiotics. Should, for example, the acute appendicitis prove to be ‘simply phlegmonous’, or the blunt trauma not breach the lumen of a hollow viscus, they would avoid antibiotics altogether. Alternatively, if contamination or infection were encountered, they would start antibiotic therapy a few minutes after abdominal entry, apparently with no disadvantage. This will also allow proper cultures to be taken. Support for this second philosophy comes from the suggestion.\\n```',\n", " 'bBox': {'x': 72, 'y': 469, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'antibiotic administration, a topic to be discussed in the postoperative'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'of a hollow viscus ('},\n", " {'text': 'altogether. Alternatively, if contamination or infection were encountered,'}]},\n", " {'page': 110,\n", " 'text': 'that antibiotics liberate endotoxin from the killed bacteria; this leads some\\nsurgeons to believe that evacuation of pus (containing the source of\\nendotoxin) should be a prerequisite for commencing antimicrobial\\ntherapy.\\n\\n We, among many others, believe however, that antibiotics should\\npermeate the tissues at the time of the abdominal incision, because\\nimmediate vasoconstriction at the incision site would prevent antibiotics\\n— if given later — from reaching the operative wound. Thus, our\\nposition is to administer a dose of antibiotics prior to all emergency\\nabdominal operations. When infection or contamination is encountered,\\nor when contamination is expected to occur, the prophylactic or\\ntherapeutic value of antibiotics is obvious. In view of the beneficial effects\\nof prophylactic antibiotics in certain elective, clean procedures, we\\nassume that the same may be true in the acutely ill patient who is\\nsubjected to laparotomy, even in the absence of contamination or\\ninfection. The clinical significance of any antibiotic-generated\\nendotoxemia is presently unknown.\\n\\n Not uncommonly, we observe surgeons who, in the peri-operative\\nchaos, forget to administer antibiotics. To compensate for their failure,\\nthey order antibiotics after the operation. This is utterly futile. Are dirty\\nhands washed before or after the meal? The fate of the operative\\nwound is sealed by peri-operative events, including timely\\nadministration of antibiotics. Almost nothing done after the\\noperation can change the outcome of the wound ( Chapter 49).\\n\\n Which antibiotics to use?',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nAntibiotics liberate endotoxin from the killed bacteria; this leads some surgeons to believe that evacuation of pus (containing the source of endotoxin) should be a prerequisite for commencing antimicrobial therapy.\\n\\nWe, among many others, believe however, that antibiotics should permeate the tissues at the time of the abdominal incision, because immediate vasoconstriction at the incision site would prevent antibiotics — if given later — from reaching the operative wound. Thus, our position is to administer a dose of antibiotics prior to all emergency abdominal operations. When infection or contamination is encountered, or when contamination is expected to occur, the prophylactic or therapeutic value of antibiotics is obvious. In view of the beneficial effects of prophylactic antibiotics in certain elective, clean procedures, we assume that the same may be true in the acutely ill patient who is subjected to laparotomy, even in the absence of contamination or infection. The clinical significance of any antibiotic-generated endotoxemia is presently unknown.\\n\\nNot uncommonly, we observe surgeons who, in the peri-operative chaos, forget to administer antibiotics. To compensate for their failure, they order antibiotics after the operation. This is utterly futile. Are dirty hands washed before or after the meal? The fate of the operative wound is sealed by peri-operative events, including timely administration of antibiotics. Almost nothing done after the operation can change the outcome of the wound (Chapter 49).\\n\\n### Which antibiotics to use?\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- The text has been extracted without any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Antibiotics liberate endotoxin from the killed bacteria; this leads some surgeons to believe that evacuation of pus (containing the source of endotoxin) should be a prerequisite for commencing antimicrobial therapy.\\n\\nWe, among many others, believe however, that antibiotics should permeate the tissues at the time of the abdominal incision, because immediate vasoconstriction at the incision site would prevent antibiotics — if given later — from reaching the operative wound. Thus, our position is to administer a dose of antibiotics prior to all emergency abdominal operations. When infection or contamination is encountered, or when contamination is expected to occur, the prophylactic or therapeutic value of antibiotics is obvious. In view of the beneficial effects of prophylactic antibiotics in certain elective, clean procedures, we assume that the same may be true in the acutely ill patient who is subjected to laparotomy, even in the absence of contamination or infection. The clinical significance of any antibiotic-generated endotoxemia is presently unknown.\\n\\nNot uncommonly, we observe surgeons who, in the peri-operative chaos, forget to administer antibiotics. To compensate for their failure, they order antibiotics after the operation. This is utterly futile. Are dirty hands washed before or after the meal? The fate of the operative wound is sealed by peri-operative events, including timely administration of antibiotics. Almost nothing done after the operation can change the outcome of the wound (Chapter 49).',\n", " 'md': 'Antibiotics liberate endotoxin from the killed bacteria; this leads some surgeons to believe that evacuation of pus (containing the source of endotoxin) should be a prerequisite for commencing antimicrobial therapy.\\n\\nWe, among many others, believe however, that antibiotics should permeate the tissues at the time of the abdominal incision, because immediate vasoconstriction at the incision site would prevent antibiotics — if given later — from reaching the operative wound. Thus, our position is to administer a dose of antibiotics prior to all emergency abdominal operations. When infection or contamination is encountered, or when contamination is expected to occur, the prophylactic or therapeutic value of antibiotics is obvious. In view of the beneficial effects of prophylactic antibiotics in certain elective, clean procedures, we assume that the same may be true in the acutely ill patient who is subjected to laparotomy, even in the absence of contamination or infection. The clinical significance of any antibiotic-generated endotoxemia is presently unknown.\\n\\nNot uncommonly, we observe surgeons who, in the peri-operative chaos, forget to administer antibiotics. To compensate for their failure, they order antibiotics after the operation. This is utterly futile. Are dirty hands washed before or after the meal? The fate of the operative wound is sealed by peri-operative events, including timely administration of antibiotics. Almost nothing done after the operation can change the outcome of the wound (Chapter 49).',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Which antibiotics to use?',\n", " 'md': '### Which antibiotics to use?',\n", " 'bBox': {'x': 86, 'y': 547, 'w': 200.42, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted without any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted without any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 147, 'y': 353, 'w': 28.79, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 111,\n", " 'text': ' OR\\n ICcRiLA\\n IciLLinv\\n PRx%4\\n Figure 7.1. “Doctor, try our new Gorillacillin. Here is a recent paper published in the\\n Zimbabwean Journal of Surgery… in a study of 75 patients… it proved potent and safe!”\\n\\n Contrary to what is preached by drug companies ( Figure 7.1) and\\ntheir various beneficiaries or representatives — including certain\\nclinicians who function as ‘medical advisers’ (we have another name for\\nthem…) — the choice of drugs is straightforward. Many single drug or\\ncombination regimens are available and equally effective; the most\\nrecent and expensive not necessarily being better.\\n\\n The exact regimen of antibiotic to give depends on the pathology\\nyou are dealing with. Operating on different organs and disease\\nprocesses you are likely to encounter different sets of bugs. Therefore,\\nwhen considering which empiric antimicrobial agents to administer you\\nshould take into account:\\n\\n • The specific pathology (perforated colon vs. incarcerated hernia).\\n • Severity of disease (mild acute cholecystitis vs. emphysematous\\n cholecystitis with severe sepsis).',\n", " 'md': '```markdown\\n# Page Content\\n\\nFigure 7.1. “Doctor, try our new Gorillacillin. Here is a recent paper published in the Zimbabwean Journal of Surgery… in a study of 75 patients… it proved potent and safe!”\\n\\nContrary to what is preached by drug companies (Figure 7.1) and their various beneficiaries or representatives — including certain clinicians who function as ‘medical advisers’ (we have another name for them…) — the choice of drugs is straightforward. Many single drug or combination regimens are available and equally effective; the most recent and expensive not necessarily being better.\\n\\nThe exact regimen of antibiotic to give depends on the pathology you are dealing with. Operating on different organs and disease processes you are likely to encounter different sets of bugs. Therefore, when considering which empiric antimicrobial agents to administer you should take into account:\\n\\n- The specific pathology (perforated colon vs. incarcerated hernia).\\n- Severity of disease (mild acute cholecystitis vs. emphysematous cholecystitis with severe sepsis).\\n\\n# Image Identification and Description\\n\\n**Figure 7.1**: The image depicts a humorous advertisement for a fictional drug called \"Gorillacillin.\" It features a doctor promoting the drug, referencing a study published in the Zimbabwean Journal of Surgery. The caption suggests that the drug has been proven potent and safe in a study involving 75 patients. The image likely includes visual elements that convey a medical context, possibly with graphics related to the drug or the study mentioned.\\n\\n**Summary**: The image serves to illustrate the marketing tactics of pharmaceutical companies and the sometimes questionable endorsements by medical professionals. It highlights the importance of critically evaluating drug efficacy rather than relying solely on promotional claims.\\n\\n```',\n", " 'images': [{'name': 'img_p110_1.png',\n", " 'height': 575,\n", " 'width': 802,\n", " 'x': 108,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1377,\n", " 'original_height': 988}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 7.1. “Doctor, try our new Gorillacillin. Here is a recent paper published in the Zimbabwean Journal of Surgery… in a study of 75 patients… it proved potent and safe!”\\n\\nContrary to what is preached by drug companies (Figure 7.1) and their various beneficiaries or representatives — including certain clinicians who function as ‘medical advisers’ (we have another name for them…) — the choice of drugs is straightforward. Many single drug or combination regimens are available and equally effective; the most recent and expensive not necessarily being better.\\n\\nThe exact regimen of antibiotic to give depends on the pathology you are dealing with. Operating on different organs and disease processes you are likely to encounter different sets of bugs. Therefore, when considering which empiric antimicrobial agents to administer you should take into account:\\n\\n- The specific pathology (perforated colon vs. incarcerated hernia).\\n- Severity of disease (mild acute cholecystitis vs. emphysematous cholecystitis with severe sepsis).',\n", " 'md': 'Figure 7.1. “Doctor, try our new Gorillacillin. Here is a recent paper published in the Zimbabwean Journal of Surgery… in a study of 75 patients… it proved potent and safe!”\\n\\nContrary to what is preached by drug companies (Figure 7.1) and their various beneficiaries or representatives — including certain clinicians who function as ‘medical advisers’ (we have another name for them…) — the choice of drugs is straightforward. Many single drug or combination regimens are available and equally effective; the most recent and expensive not necessarily being better.\\n\\nThe exact regimen of antibiotic to give depends on the pathology you are dealing with. Operating on different organs and disease processes you are likely to encounter different sets of bugs. Therefore, when considering which empiric antimicrobial agents to administer you should take into account:\\n\\n- The specific pathology (perforated colon vs. incarcerated hernia).\\n- Severity of disease (mild acute cholecystitis vs. emphysematous cholecystitis with severe sepsis).',\n", " 'bBox': {'x': 72, 'y': 99.62, 'w': 467.49, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Image Identification and Description',\n", " 'md': '# Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 7.1**: The image depicts a humorous advertisement for a fictional drug called \"Gorillacillin.\" It features a doctor promoting the drug, referencing a study published in the Zimbabwean Journal of Surgery. The caption suggests that the drug has been proven potent and safe in a study involving 75 patients. The image likely includes visual elements that convey a medical context, possibly with graphics related to the drug or the study mentioned.\\n\\n**Summary**: The image serves to illustrate the marketing tactics of pharmaceutical companies and the sometimes questionable endorsements by medical professionals. It highlights the importance of critically evaluating drug efficacy rather than relying solely on promotional claims.\\n\\n```',\n", " 'md': '**Figure 7.1**: The image depicts a humorous advertisement for a fictional drug called \"Gorillacillin.\" It features a doctor promoting the drug, referencing a study published in the Zimbabwean Journal of Surgery. The caption suggests that the drug has been proven potent and safe in a study involving 75 patients. The image likely includes visual elements that convey a medical context, possibly with graphics related to the drug or the study mentioned.\\n\\n**Summary**: The image serves to illustrate the marketing tactics of pharmaceutical companies and the sometimes questionable endorsements by medical professionals. It highlights the importance of critically evaluating drug efficacy rather than relying solely on promotional claims.\\n\\n```',\n", " 'bBox': {'x': 441.4, 'y': 99.62, 'w': 28.69, 'h': 12.86}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'their various beneficiaries or representatives — including certain'}]},\n", " {'page': 112,\n", " 'text': ' • Other factors: Did the pathology develop during hospitalization?\\n Was the patient already on antibiotics? Is the patient\\n immunocompromised? Any of these factors could suggest that\\n unusual, opportunistic micro-organisms (e.g. fungi) could be\\n involved in the infection.\\n\\n In later chapters we will advise on which antibiotics to use when\\ntreating the specific pathologies. But here let us bring the gut as an\\nexample.\\n\\n The bacterial flora of the gut is predictable. When a drop of feces\\nleaks into the peritoneal cavity, it contains more than 400 different\\nspecies of bacteria; only a handful of these are involved in any ensuing\\ninfection. Thus, from the initial plethora of contaminating bacteria, the\\ninoculum is spontaneously reduced and simplified to include only a few\\norganisms that survive outside their natural environment. These are the\\nendotoxin-generating facultative anaerobes such as Escherichia coli and\\nobligate anaerobes, such as Bacteroides fragilis — which act in synergy.\\nAny agent or combination of agents that effectively kills these target\\nbacteria can be used.\\n\\n The once-popular ‘triple regimen’ of the 1970s (ampicillin, an\\naminoglycoside, and metronidazole or clindamycin) has become\\nobsolete. Enterococcus, frequently isolated in experimental and clinical\\nperitonitis, is clinically almost non-significant as a pathogen in the\\nperitoneal cavity and is not required to be ‘covered’ with ampicillin.\\nAminoglycosides are markedly nephrotoxic (especially in critically ill\\npatients), are inefficient in the low pħ of the infected peritoneal\\nenvironment, and are no longer the first choice of antibiotics in the initial\\ntreatment of intra-abdominal infection. Surgeons tend to be creatures of\\nhabit, desperately clinging to dogmas passed on by their mentors; the\\ntriple regimen is one such dogma that has been carried into the 21st\\ncentury through ignorance. (You may however, work in an environment\\nwhere these habits persist or have been reintroduced by decree. At least\\none of the editors does… A regrettable situation.)\\n\\n There are numerous agents on the market you can choose from. You\\nmay use whichever agent, as ‘monotherapy’ or in combination — as long',\n", " 'md': '```markdown\\n## Page Content\\n\\n- Other factors: Did the pathology develop during hospitalization? Was the patient already on antibiotics? Is the patient immunocompromised? Any of these factors could suggest that unusual, opportunistic micro-organisms (e.g. fungi) could be involved in the infection.\\n\\n- In later chapters we will advise on which antibiotics to use when treating the specific pathologies. But here let us bring the gut as an example.\\n\\n- The bacterial flora of the gut is predictable. When a drop of feces leaks into the peritoneal cavity, it contains more than 400 different species of bacteria; only a handful of these are involved in any ensuing infection. Thus, from the initial plethora of contaminating bacteria, the inoculum is spontaneously reduced and simplified to include only a few organisms that survive outside their natural environment. These are the endotoxin-generating facultative anaerobes such as \\\\( \\\\text{Escherichia coli} \\\\) and obligate anaerobes, such as \\\\( \\\\text{Bacteroides fragilis} \\\\) — which act in synergy. Any agent or combination of agents that effectively kills these target bacteria can be used.\\n\\n- The once-popular ‘triple regimen’ of the 1970s (ampicillin, an aminoglycoside, and metronidazole or clindamycin) has become obsolete. Enterococcus, frequently isolated in experimental and clinical peritonitis, is clinically almost non-significant as a pathogen in the peritoneal cavity and is not required to be ‘covered’ with ampicillin. Aminoglycosides are markedly nephrotoxic (especially in critically ill patients), are inefficient in the low pH of the infected peritoneal environment, and are no longer the first choice of antibiotics in the initial treatment of intra-abdominal infection. Surgeons tend to be creatures of habit, desperately clinging to dogmas passed on by their mentors; the triple regimen is one such dogma that has been carried into the 21st century through ignorance. (You may however, work in an environment where these habits persist or have been reintroduced by decree. At least one of the editors does… A regrettable situation.)\\n\\n- There are numerous agents on the market you can choose from. You may use whichever agent, as ‘monotherapy’ or in combination — as long...\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Other factors: Did the pathology develop during hospitalization? Was the patient already on antibiotics? Is the patient immunocompromised? Any of these factors could suggest that unusual, opportunistic micro-organisms (e.g. fungi) could be involved in the infection.\\n\\n- In later chapters we will advise on which antibiotics to use when treating the specific pathologies. But here let us bring the gut as an example.\\n\\n- The bacterial flora of the gut is predictable. When a drop of feces leaks into the peritoneal cavity, it contains more than 400 different species of bacteria; only a handful of these are involved in any ensuing infection. Thus, from the initial plethora of contaminating bacteria, the inoculum is spontaneously reduced and simplified to include only a few organisms that survive outside their natural environment. These are the endotoxin-generating facultative anaerobes such as \\\\( \\\\text{Escherichia coli} \\\\) and obligate anaerobes, such as \\\\( \\\\text{Bacteroides fragilis} \\\\) — which act in synergy. Any agent or combination of agents that effectively kills these target bacteria can be used.\\n\\n- The once-popular ‘triple regimen’ of the 1970s (ampicillin, an aminoglycoside, and metronidazole or clindamycin) has become obsolete. Enterococcus, frequently isolated in experimental and clinical peritonitis, is clinically almost non-significant as a pathogen in the peritoneal cavity and is not required to be ‘covered’ with ampicillin. Aminoglycosides are markedly nephrotoxic (especially in critically ill patients), are inefficient in the low pH of the infected peritoneal environment, and are no longer the first choice of antibiotics in the initial treatment of intra-abdominal infection. Surgeons tend to be creatures of habit, desperately clinging to dogmas passed on by their mentors; the triple regimen is one such dogma that has been carried into the 21st century through ignorance. (You may however, work in an environment where these habits persist or have been reintroduced by decree. At least one of the editors does… A regrettable situation.)\\n\\n- There are numerous agents on the market you can choose from. You may use whichever agent, as ‘monotherapy’ or in combination — as long...\\n\\n```',\n", " 'md': '- Other factors: Did the pathology develop during hospitalization? Was the patient already on antibiotics? Is the patient immunocompromised? Any of these factors could suggest that unusual, opportunistic micro-organisms (e.g. fungi) could be involved in the infection.\\n\\n- In later chapters we will advise on which antibiotics to use when treating the specific pathologies. But here let us bring the gut as an example.\\n\\n- The bacterial flora of the gut is predictable. When a drop of feces leaks into the peritoneal cavity, it contains more than 400 different species of bacteria; only a handful of these are involved in any ensuing infection. Thus, from the initial plethora of contaminating bacteria, the inoculum is spontaneously reduced and simplified to include only a few organisms that survive outside their natural environment. These are the endotoxin-generating facultative anaerobes such as \\\\( \\\\text{Escherichia coli} \\\\) and obligate anaerobes, such as \\\\( \\\\text{Bacteroides fragilis} \\\\) — which act in synergy. Any agent or combination of agents that effectively kills these target bacteria can be used.\\n\\n- The once-popular ‘triple regimen’ of the 1970s (ampicillin, an aminoglycoside, and metronidazole or clindamycin) has become obsolete. Enterococcus, frequently isolated in experimental and clinical peritonitis, is clinically almost non-significant as a pathogen in the peritoneal cavity and is not required to be ‘covered’ with ampicillin. Aminoglycosides are markedly nephrotoxic (especially in critically ill patients), are inefficient in the low pH of the infected peritoneal environment, and are no longer the first choice of antibiotics in the initial treatment of intra-abdominal infection. Surgeons tend to be creatures of habit, desperately clinging to dogmas passed on by their mentors; the triple regimen is one such dogma that has been carried into the 21st century through ignorance. (You may however, work in an environment where these habits persist or have been reintroduced by decree. At least one of the editors does… A regrettable situation.)\\n\\n- There are numerous agents on the market you can choose from. You may use whichever agent, as ‘monotherapy’ or in combination — as long...\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.94, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 113,\n", " 'text': 'as E. coli and B. fragilis are covered.\\n\\n A few more general points:\\n\\n • In abdominal emergencies, we advise that the same agent\\n should be used for prophylaxis and treatment. An initial dose of\\n the appropriate drug is given pre-operatively and, if indicated by the\\n intra-operative findings, can be continued following the operation\\n (see Chapter 44). The common (mal)practice of starting with a\\n ‘weak’ agent (e.g. cephazolin) before the operation and converting to\\n a ‘stronger’ regimen is baseless. But wait a minute, you may be\\n hollering, what about the results of intra-operative cultures? Well,\\n after finishing this book you will understand that routine\\n microbiological cultures often have no practical clinical value\\n — in many cases when the data on the cultured bacteria and its\\n sensitivity to antibiotics are available, the patient is at home and off\\n antibiotics. ħowever, while cultures are useless in ‘routine cases’\\n (e.g. acute appendicitis) they should be obtained in selective\\n situations as discussed in Chapter 13.\\n • Think about the dose. In the course of fluid resuscitation of\\n hypovolemic patients, antimicrobials may be ‘diluted’, reducing the\\n availability of antimicrobial drugs at sites of contamination or\\n infection. In these cases, especially in the trauma patient, higher\\n initial doses should be used: “sooner and more is better than less\\n and longer.” Don’t forget that fat people need higher doses!\\n • One might expect that the bacteriology of postoperative\\n infections at specific sites might be predicatble. Often, however,\\n this is not so. For example, the biliary system is typically\\n contaminated with Gram-negative bacteria but the post-\\n cholecystectomy wound infection is commonly caused by typical\\n skin bacteria — Staphylococcus aureus or even methicillin-resistant\\n Staphylococcus aureus (MRSA).\\n\\n To sum it up\\n\\n Start antibiotics prior to any emergency laparotomy/laparoscopy;\\nwhether you continue administration after the operation depends on the',\n", " 'md': '```markdown\\n## Key Points on Antibiotic Use in Abdominal Emergencies\\n\\n- In abdominal emergencies, the same agent should be used for prophylaxis and treatment. An initial dose of the appropriate drug is given pre-operatively and, if indicated by the intra-operative findings, can be continued following the operation (see Chapter 44). The common (mal)practice of starting with a ‘weak’ agent (e.g., cephazolin) before the operation and converting to a ‘stronger’ regimen is baseless.\\n\\n- While you may wonder about the results of intra-operative cultures, routine microbiological cultures often have no practical clinical value. In many cases, when the data on the cultured bacteria and its sensitivity to antibiotics are available, the patient is at home and off antibiotics. However, while cultures are useless in ‘routine cases’ (e.g., acute appendicitis), they should be obtained in selective situations as discussed in Chapter 13.\\n\\n- Consider the dose. In the course of fluid resuscitation of hypovolemic patients, antimicrobials may be ‘diluted’, reducing the availability of antimicrobial drugs at sites of contamination or infection. In these cases, especially in trauma patients, higher initial doses should be used: “sooner and more is better than less and longer.” Don’t forget that fat people need higher doses!\\n\\n- One might expect that the bacteriology of postoperative infections at specific sites might be predictable. Often, however, this is not the case. For example, the biliary system is typically contaminated with Gram-negative bacteria, but the post-cholecystectomy wound infection is commonly caused by typical skin bacteria — Staphylococcus aureus or even methicillin-resistant Staphylococcus aureus (MRSA).\\n\\n### Summary\\nStart antibiotics prior to any emergency laparotomy/laparoscopy; whether you continue administration after the operation depends on the clinical findings.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Key Points on Antibiotic Use in Abdominal Emergencies',\n", " 'md': '## Key Points on Antibiotic Use in Abdominal Emergencies',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- In abdominal emergencies, the same agent should be used for prophylaxis and treatment. An initial dose of the appropriate drug is given pre-operatively and, if indicated by the intra-operative findings, can be continued following the operation (see Chapter 44). The common (mal)practice of starting with a ‘weak’ agent (e.g., cephazolin) before the operation and converting to a ‘stronger’ regimen is baseless.\\n\\n- While you may wonder about the results of intra-operative cultures, routine microbiological cultures often have no practical clinical value. In many cases, when the data on the cultured bacteria and its sensitivity to antibiotics are available, the patient is at home and off antibiotics. However, while cultures are useless in ‘routine cases’ (e.g., acute appendicitis), they should be obtained in selective situations as discussed in Chapter 13.\\n\\n- Consider the dose. In the course of fluid resuscitation of hypovolemic patients, antimicrobials may be ‘diluted’, reducing the availability of antimicrobial drugs at sites of contamination or infection. In these cases, especially in trauma patients, higher initial doses should be used: “sooner and more is better than less and longer.” Don’t forget that fat people need higher doses!\\n\\n- One might expect that the bacteriology of postoperative infections at specific sites might be predictable. Often, however, this is not the case. For example, the biliary system is typically contaminated with Gram-negative bacteria, but the post-cholecystectomy wound infection is commonly caused by typical skin bacteria — Staphylococcus aureus or even methicillin-resistant Staphylococcus aureus (MRSA).',\n", " 'md': '- In abdominal emergencies, the same agent should be used for prophylaxis and treatment. An initial dose of the appropriate drug is given pre-operatively and, if indicated by the intra-operative findings, can be continued following the operation (see Chapter 44). The common (mal)practice of starting with a ‘weak’ agent (e.g., cephazolin) before the operation and converting to a ‘stronger’ regimen is baseless.\\n\\n- While you may wonder about the results of intra-operative cultures, routine microbiological cultures often have no practical clinical value. In many cases, when the data on the cultured bacteria and its sensitivity to antibiotics are available, the patient is at home and off antibiotics. However, while cultures are useless in ‘routine cases’ (e.g., acute appendicitis), they should be obtained in selective situations as discussed in Chapter 13.\\n\\n- Consider the dose. In the course of fluid resuscitation of hypovolemic patients, antimicrobials may be ‘diluted’, reducing the availability of antimicrobial drugs at sites of contamination or infection. In these cases, especially in trauma patients, higher initial doses should be used: “sooner and more is better than less and longer.” Don’t forget that fat people need higher doses!\\n\\n- One might expect that the bacteriology of postoperative infections at specific sites might be predictable. Often, however, this is not the case. For example, the biliary system is typically contaminated with Gram-negative bacteria, but the post-cholecystectomy wound infection is commonly caused by typical skin bacteria — Staphylococcus aureus or even methicillin-resistant Staphylococcus aureus (MRSA).',\n", " 'bBox': {'x': 100, 'y': 173, 'w': 437.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Start antibiotics prior to any emergency laparotomy/laparoscopy; whether you continue administration after the operation depends on the clinical findings.\\n```',\n", " 'md': 'Start antibiotics prior to any emergency laparotomy/laparoscopy; whether you continue administration after the operation depends on the clinical findings.\\n```',\n", " 'bBox': {'x': 468, 'y': 560, 'w': 23.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '‘weak’ agent (e.g. cephazolin) before the operation and converting to'},\n", " {'text': ''}]},\n", " {'page': 114,\n", " 'text': 'operative findings (see Chapter 44). Know the target flora, understand\\nthe host, be aware of exceptions, and use the cheapest and simplest\\nregimen. The bacteria cannot be confused, nor should you be!\\n\\n P.S.: Try to familiarise yourself with one or more of the many\\nguidelines on antimicrobial therapy for intra-abdominal infections\\navailable online. Choose the ones with an authors’ list which is shorter\\nthan the narrative. Avoid the ones with an ‘appendix’ which reads like the\\nphone directory of Manhattan. And remember: guidelines are written\\nby humans — use your common sense.\\n\\n “Patients can get well without antibiotics.”\\n Mark M. Ravitch',\n", " 'md': '```markdown\\n## Text\\n\\n- Operative findings (see Chapter 44). Know the target flora, understand the host, be aware of exceptions, and use the cheapest and simplest regimen. The bacteria cannot be confused, nor should you be!\\n\\n- P.S.: Try to familiarise yourself with one or more of the many guidelines on antimicrobial therapy for intra-abdominal infections available online. Choose the ones with an authors’ list which is shorter than the narrative. Avoid the ones with an ‘appendix’ which reads like the phone directory of Manhattan. And remember: guidelines are written by humans — use your common sense.\\n\\n- “Patients can get well without antibiotics.”\\nMark M. Ravitch\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Operative findings (see Chapter 44). Know the target flora, understand the host, be aware of exceptions, and use the cheapest and simplest regimen. The bacteria cannot be confused, nor should you be!\\n\\n- P.S.: Try to familiarise yourself with one or more of the many guidelines on antimicrobial therapy for intra-abdominal infections available online. Choose the ones with an authors’ list which is shorter than the narrative. Avoid the ones with an ‘appendix’ which reads like the phone directory of Manhattan. And remember: guidelines are written by humans — use your common sense.\\n\\n- “Patients can get well without antibiotics.”\\nMark M. Ravitch\\n```',\n", " 'md': '- Operative findings (see Chapter 44). Know the target flora, understand the host, be aware of exceptions, and use the cheapest and simplest regimen. The bacteria cannot be confused, nor should you be!\\n\\n- P.S.: Try to familiarise yourself with one or more of the many guidelines on antimicrobial therapy for intra-abdominal infections available online. Choose the ones with an authors’ list which is shorter than the narrative. Avoid the ones with an ‘appendix’ which reads like the phone directory of Manhattan. And remember: guidelines are written by humans — use your common sense.\\n\\n- “Patients can get well without antibiotics.”\\nMark M. Ravitch\\n```',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.3, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'the host, be aware of exceptions, and use the cheapest and simplest'}]},\n", " {'page': 115,\n", " 'text': 'Chapter 8\\nFamily, ethics, informed consent and medicolegal\\nissues\\nJames C. Rucinski\\n\\n Doctor, my doctor, what do you say…?\\n Philip Roth\\n\\n Stop lying! You know, and I know, that I am dying. So do at\\n least stop lying about it!\\n Lev Tolstoy\\n\\n (To understand the ‘dying man’ you have to read Tolstoy’s\\n The Death of Ivan Ilyich.)\\n\\n The wind whistles through the cracks in your on-call room window\\nwhen the emergency department (ED) calls and suddenly you find\\nyourself in the maelstrom of that environment, speaking to a small group\\nof extremely anxious strangers — having to explain that an immediate\\noperation will be required to save their beloved one. The operating room\\nis ready.\\n\\n Obtaining informed consent is a practical combination of\\nsalesmanship, ethical problem solving and psychological nurturing.\\nIt involves the rapid marketing of one’s own skills and plan for treatment.\\nIt requires the recruitment of the patient and the family as allies in the\\ndecision-making process. More than a legal requirement, however,\\ninformed consent requires an ethical commitment to the patient, your',\n", " 'md': '# Chapter 8: Family, Ethics, Informed Consent and Medicolegal Issues\\n**Author:** James C. Rucinski\\n\\n----\\n\\n> **Quote:** \"Doctor, my doctor, what do you say…?\" - Philip Roth\\n\\n> **Quote:** \"Stop lying! You know, and I know, that I am dying. So do at least stop lying about it!\" - Lev Tolstoy\\n\\n> *(To understand the ‘dying man’ you have to read Tolstoy’s The Death of Ivan Ilyich.)*\\n\\nThe wind whistles through the cracks in your on-call room window when the emergency department (ED) calls and suddenly you find yourself in the maelstrom of that environment, speaking to a small group of extremely anxious strangers — having to explain that an immediate operation will be required to save their beloved one. The operating room is ready.\\n\\nObtaining informed consent is a practical combination of salesmanship, ethical problem solving, and psychological nurturing. It involves the rapid marketing of one’s own skills and plan for treatment. It requires the recruitment of the patient and the family as allies in the decision-making process. More than a legal requirement, however, informed consent requires an ethical commitment to the patient.\\n\\n----\\n\\n*Note: No images, graphs, or tables were identified on this page.*',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 8: Family, Ethics, Informed Consent and Medicolegal Issues',\n", " 'md': '# Chapter 8: Family, Ethics, Informed Consent and Medicolegal Issues',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 439.7, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** James C. Rucinski\\n\\n----\\n\\n> **Quote:** \"Doctor, my doctor, what do you say…?\" - Philip Roth\\n\\n> **Quote:** \"Stop lying! You know, and I know, that I am dying. So do at least stop lying about it!\" - Lev Tolstoy\\n\\n> *(To understand the ‘dying man’ you have to read Tolstoy’s The Death of Ivan Ilyich.)*\\n\\nThe wind whistles through the cracks in your on-call room window when the emergency department (ED) calls and suddenly you find yourself in the maelstrom of that environment, speaking to a small group of extremely anxious strangers — having to explain that an immediate operation will be required to save their beloved one. The operating room is ready.\\n\\nObtaining informed consent is a practical combination of salesmanship, ethical problem solving, and psychological nurturing. It involves the rapid marketing of one’s own skills and plan for treatment. It requires the recruitment of the patient and the family as allies in the decision-making process. More than a legal requirement, however, informed consent requires an ethical commitment to the patient.\\n\\n----\\n\\n*Note: No images, graphs, or tables were identified on this page.*',\n", " 'md': '**Author:** James C. Rucinski\\n\\n----\\n\\n> **Quote:** \"Doctor, my doctor, what do you say…?\" - Philip Roth\\n\\n> **Quote:** \"Stop lying! You know, and I know, that I am dying. So do at least stop lying about it!\" - Lev Tolstoy\\n\\n> *(To understand the ‘dying man’ you have to read Tolstoy’s The Death of Ivan Ilyich.)*\\n\\nThe wind whistles through the cracks in your on-call room window when the emergency department (ED) calls and suddenly you find yourself in the maelstrom of that environment, speaking to a small group of extremely anxious strangers — having to explain that an immediate operation will be required to save their beloved one. The operating room is ready.\\n\\nObtaining informed consent is a practical combination of salesmanship, ethical problem solving, and psychological nurturing. It involves the rapid marketing of one’s own skills and plan for treatment. It requires the recruitment of the patient and the family as allies in the decision-making process. More than a legal requirement, however, informed consent requires an ethical commitment to the patient.\\n\\n----\\n\\n*Note: No images, graphs, or tables were identified on this page.*',\n", " 'bBox': {'x': 72, 'y': 263, 'w': 467.67, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 116,\n", " 'text': 'peers and to yourself.\\n\\n Salesmanship\\n\\n Begin by explaining the problem and your proposed treatment using\\nthe same words and language that you might use in speaking to one of\\nyour non-medical relatives. Describe the expected benefits of\\noperation and what the consequences of alternative treatment\\napproaches might be. (What happens if we do nothing…).\\n\\n Offer several scenarios; take a case of obstructing carcinoma of\\nthe sigmoid colon, for example. At one end of the spectrum is non-\\noperative management, which almost certainly will result in a slow and\\ndifficult death. At the other end of the spectrum is rapid recovery from\\noperation with long-term cure of the disease. In between lie the potential\\ndifficulties of peri-operative complications or death, recovery with\\ndisability or recurrent disease.\\n\\n It is crucial that you believe in the plan of treatment that you propose. If\\nthis is not the case, and the plan is not acceptable to you but dictated to\\nyou from above, then let the responsible surgeon (your boss) conduct his\\nown pre-operative ‘negotiations’ with the patient and/or his family.\\n\\n ‘Sell’ yourself to the patient and family as a scientific expert who\\nrecognizes the needs of another person, and is participating with\\nthem in solving a difficult problem. Include a description, with\\napproximate probabilities, of the most common ‘problems’\\n(complications) for the proposed procedure in your particular patient. You\\nwill need to make an estimate based on general and specific information.\\nFor example, the risk of mortality for elective colon resection may be\\nnegligible but in an elderly patient with acute colonic obstruction and\\nhypoalbuminemia the odds of dying may be one in four ( Chapter 6).\\nDiscuss general potential postoperative complications such as\\ninfection, hemorrhage (and risk of transfusion), poor healing and death.\\nThen mention the unique complications specific to the procedure you\\nare proposing to undertake, such as common bile duct injury or bile leak\\nin laparoscopic cholecystectomy.',\n", " 'md': '```markdown\\n## Salesmanship\\n\\nBegin by explaining the problem and your proposed treatment using the same words and language that you might use in speaking to one of your non-medical relatives. Describe the expected benefits of operation and what the consequences of alternative treatment approaches might be. (What happens if we do nothing…).\\n\\nOffer several scenarios; take a case of obstructing carcinoma of the sigmoid colon, for example. At one end of the spectrum is non-operative management, which almost certainly will result in a slow and difficult death. At the other end of the spectrum is rapid recovery from operation with long-term cure of the disease. In between lie the potential difficulties of peri-operative complications or death, recovery with disability or recurrent disease.\\n\\nIt is crucial that you believe in the plan of treatment that you propose. If this is not the case, and the plan is not acceptable to you but dictated to you from above, then let the responsible surgeon (your boss) conduct his own pre-operative ‘negotiations’ with the patient and/or his family.\\n\\n‘Sell’ yourself to the patient and family as a scientific expert who recognizes the needs of another person, and is participating with them in solving a difficult problem. Include a description, with approximate probabilities, of the most common ‘problems’ (complications) for the proposed procedure in your particular patient. You will need to make an estimate based on general and specific information. For example, the risk of mortality for elective colon resection may be negligible but in an elderly patient with acute colonic obstruction and hypoalbuminemia the odds of dying may be one in four (Chapter 6). Discuss general potential postoperative complications such as infection, hemorrhage (and risk of transfusion), poor healing and death. Then mention the unique complications specific to the procedure you are proposing to undertake, such as common bile duct injury or bile leak in laparoscopic cholecystectomy.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Salesmanship',\n", " 'md': '## Salesmanship',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 111.29, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Begin by explaining the problem and your proposed treatment using the same words and language that you might use in speaking to one of your non-medical relatives. Describe the expected benefits of operation and what the consequences of alternative treatment approaches might be. (What happens if we do nothing…).\\n\\nOffer several scenarios; take a case of obstructing carcinoma of the sigmoid colon, for example. At one end of the spectrum is non-operative management, which almost certainly will result in a slow and difficult death. At the other end of the spectrum is rapid recovery from operation with long-term cure of the disease. In between lie the potential difficulties of peri-operative complications or death, recovery with disability or recurrent disease.\\n\\nIt is crucial that you believe in the plan of treatment that you propose. If this is not the case, and the plan is not acceptable to you but dictated to you from above, then let the responsible surgeon (your boss) conduct his own pre-operative ‘negotiations’ with the patient and/or his family.\\n\\n‘Sell’ yourself to the patient and family as a scientific expert who recognizes the needs of another person, and is participating with them in solving a difficult problem. Include a description, with approximate probabilities, of the most common ‘problems’ (complications) for the proposed procedure in your particular patient. You will need to make an estimate based on general and specific information. For example, the risk of mortality for elective colon resection may be negligible but in an elderly patient with acute colonic obstruction and hypoalbuminemia the odds of dying may be one in four (Chapter 6). Discuss general potential postoperative complications such as infection, hemorrhage (and risk of transfusion), poor healing and death. Then mention the unique complications specific to the procedure you are proposing to undertake, such as common bile duct injury or bile leak in laparoscopic cholecystectomy.\\n```',\n", " 'md': 'Begin by explaining the problem and your proposed treatment using the same words and language that you might use in speaking to one of your non-medical relatives. Describe the expected benefits of operation and what the consequences of alternative treatment approaches might be. (What happens if we do nothing…).\\n\\nOffer several scenarios; take a case of obstructing carcinoma of the sigmoid colon, for example. At one end of the spectrum is non-operative management, which almost certainly will result in a slow and difficult death. At the other end of the spectrum is rapid recovery from operation with long-term cure of the disease. In between lie the potential difficulties of peri-operative complications or death, recovery with disability or recurrent disease.\\n\\nIt is crucial that you believe in the plan of treatment that you propose. If this is not the case, and the plan is not acceptable to you but dictated to you from above, then let the responsible surgeon (your boss) conduct his own pre-operative ‘negotiations’ with the patient and/or his family.\\n\\n‘Sell’ yourself to the patient and family as a scientific expert who recognizes the needs of another person, and is participating with them in solving a difficult problem. Include a description, with approximate probabilities, of the most common ‘problems’ (complications) for the proposed procedure in your particular patient. You will need to make an estimate based on general and specific information. For example, the risk of mortality for elective colon resection may be negligible but in an elderly patient with acute colonic obstruction and hypoalbuminemia the odds of dying may be one in four (Chapter 6). Discuss general potential postoperative complications such as infection, hemorrhage (and risk of transfusion), poor healing and death. Then mention the unique complications specific to the procedure you are proposing to undertake, such as common bile duct injury or bile leak in laparoscopic cholecystectomy.\\n```',\n", " 'bBox': {'x': 72, 'y': 181, 'w': 468.01, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'general potential postoperative complications'}]},\n", " {'page': 117,\n", " 'text': ' An adjunctive method of assessing pre-operative risk is now available\\nthrough the American College of Surgeons NSQIP (National Surgical\\nQuality Improvement Program) Risk Calculator. It utilizes outcome\\ndata to allow a statistical prediction of various outcomes associated with\\nthe characteristics of your patient. The tool is available without charge at:\\nwww.riskcalculator.facs.org.\\n\\n It is crucial that before any major emergency abdominal operation\\nyou emphasize that a reoperation may be necessary based on your\\noperative finding or if a problem subsequently develops. This will\\ndrastically facilitate the ‘confrontation’ with the family when a reoperation\\nis indeed indicated; they will understand that the reoperation\\nrepresents a ‘continued management effort’ rather than a\\n‘complication’. Minor complications, such as phlebitis arising from peri-\\noperative intravenous therapy, may contribute to information overload\\nand probably should be omitted.\\n\\n Try to conduct the above ‘script’ in a relatively quiet setting —\\naway from the usual chaos of the ER, SICU or the OR; find a quite\\ncorner and let everyone, including yourself, sit down! Use simple\\nlanguage and repeat yourself ad infinitum; stressed members of the\\nfamily may have difficulty in grasping what you say. Offer the opportunity\\nto ask questions and assess whether there is an understanding of your\\ndiscussion. The more they understand initially, the fewer ‘problems’ you’ll\\nhave if complications subsequently develop.\\n\\n Be ‘human’, friendly, empathetic but professional. A good trick is to\\nremind yourself from time to time that the family you are talking to\\ncould be yours. Finally, always leave open the possibilty that what you\\nthink the problem to be is not correct. Similarly, if you are asked to\\nprovide a prognosis always allow for the unexpected, both good and bad,\\nso that if a disaster or a miracle should occur this will not be ouside the\\nbounds of the possibilities you outlined earlier. Never mention specific\\ntimes; for example, if you say “3 to 6 months or so” the only thing\\nthat will be remembered is that you said “6 months”. Then, when\\nthe patient dies the following day of an MI… or is still alive a year\\nlater…',\n", " 'md': '```markdown\\n# Page Content\\n\\nAn adjunctive method of assessing pre-operative risk is now available through the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) Risk Calculator. It utilizes outcome data to allow a statistical prediction of various outcomes associated with the characteristics of your patient. The tool is available without charge at: [www.riskcalculator.facs.org](http://www.riskcalculator.facs.org).\\n\\nIt is crucial that before any major emergency abdominal operation you emphasize that a reoperation may be necessary based on your operative finding or if a problem subsequently develops. This will drastically facilitate the ‘confrontation’ with the family when a reoperation is indeed indicated; they will understand that the reoperation represents a ‘continued management effort’ rather than a ‘complication’. Minor complications, such as phlebitis arising from peri-operative intravenous therapy, may contribute to information overload and probably should be omitted.\\n\\nTry to conduct the above ‘script’ in a relatively quiet setting — away from the usual chaos of the ER, SICU or the OR; find a quiet corner and let everyone, including yourself, sit down! Use simple language and repeat yourself ad infinitum; stressed members of the family may have difficulty in grasping what you say. Offer the opportunity to ask questions and assess whether there is an understanding of your discussion. The more they understand initially, the fewer ‘problems’ you’ll have if complications subsequently develop.\\n\\nBe ‘human’, friendly, empathetic but professional. A good trick is to remind yourself from time to time that the family you are talking to could be yours. Finally, always leave open the possibility that what you think the problem to be is not correct. Similarly, if you are asked to provide a prognosis always allow for the unexpected, both good and bad, so that if a disaster or a miracle should occur this will not be outside the bounds of the possibilities you outlined earlier. Never mention specific times; for example, if you say “3 to 6 months or so” the only thing that will be remembered is that you said “6 months”. Then, when the patient dies the following day of an MI… or is still alive a year later…\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 531, 'y': 286, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 531, 'y': 286, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'An adjunctive method of assessing pre-operative risk is now available through the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) Risk Calculator. It utilizes outcome data to allow a statistical prediction of various outcomes associated with the characteristics of your patient. The tool is available without charge at: [www.riskcalculator.facs.org](http://www.riskcalculator.facs.org).\\n\\nIt is crucial that before any major emergency abdominal operation you emphasize that a reoperation may be necessary based on your operative finding or if a problem subsequently develops. This will drastically facilitate the ‘confrontation’ with the family when a reoperation is indeed indicated; they will understand that the reoperation represents a ‘continued management effort’ rather than a ‘complication’. Minor complications, such as phlebitis arising from peri-operative intravenous therapy, may contribute to information overload and probably should be omitted.\\n\\nTry to conduct the above ‘script’ in a relatively quiet setting — away from the usual chaos of the ER, SICU or the OR; find a quiet corner and let everyone, including yourself, sit down! Use simple language and repeat yourself ad infinitum; stressed members of the family may have difficulty in grasping what you say. Offer the opportunity to ask questions and assess whether there is an understanding of your discussion. The more they understand initially, the fewer ‘problems’ you’ll have if complications subsequently develop.\\n\\nBe ‘human’, friendly, empathetic but professional. A good trick is to remind yourself from time to time that the family you are talking to could be yours. Finally, always leave open the possibility that what you think the problem to be is not correct. Similarly, if you are asked to provide a prognosis always allow for the unexpected, both good and bad, so that if a disaster or a miracle should occur this will not be outside the bounds of the possibilities you outlined earlier. Never mention specific times; for example, if you say “3 to 6 months or so” the only thing that will be remembered is that you said “6 months”. Then, when the patient dies the following day of an MI… or is still alive a year later…\\n```',\n", " 'md': 'An adjunctive method of assessing pre-operative risk is now available through the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) Risk Calculator. It utilizes outcome data to allow a statistical prediction of various outcomes associated with the characteristics of your patient. The tool is available without charge at: [www.riskcalculator.facs.org](http://www.riskcalculator.facs.org).\\n\\nIt is crucial that before any major emergency abdominal operation you emphasize that a reoperation may be necessary based on your operative finding or if a problem subsequently develops. This will drastically facilitate the ‘confrontation’ with the family when a reoperation is indeed indicated; they will understand that the reoperation represents a ‘continued management effort’ rather than a ‘complication’. Minor complications, such as phlebitis arising from peri-operative intravenous therapy, may contribute to information overload and probably should be omitted.\\n\\nTry to conduct the above ‘script’ in a relatively quiet setting — away from the usual chaos of the ER, SICU or the OR; find a quiet corner and let everyone, including yourself, sit down! Use simple language and repeat yourself ad infinitum; stressed members of the family may have difficulty in grasping what you say. Offer the opportunity to ask questions and assess whether there is an understanding of your discussion. The more they understand initially, the fewer ‘problems’ you’ll have if complications subsequently develop.\\n\\nBe ‘human’, friendly, empathetic but professional. A good trick is to remind yourself from time to time that the family you are talking to could be yours. Finally, always leave open the possibility that what you think the problem to be is not correct. Similarly, if you are asked to provide a prognosis always allow for the unexpected, both good and bad, so that if a disaster or a miracle should occur this will not be outside the bounds of the possibilities you outlined earlier. Never mention specific times; for example, if you say “3 to 6 months or so” the only thing that will be remembered is that you said “6 months”. Then, when the patient dies the following day of an MI… or is still alive a year later…\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the requirements.',\n", " 'bBox': {'x': 531, 'y': 286, 'w': 8.01, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'url': 'http://www.riskcalculator.facs.org/',\n", " 'text': 'www.riskcalculator.facs.org.'}]},\n", " {'page': 118,\n", " 'text': ' Illustrate the problem\\n\\n When discussing the prospects of an operation with a patient or a\\nfamily we find that illustrating the problem and the planned\\nprocedure on a blank piece of paper greatly enhances the\\ncommunication. Draw, schematically, the obstructed colon: “here is the\\ncolon, this is the obstructing lesion and here is the segment we want to\\nremove; we hope to be able to join this piece of bowel to that one; a\\ncolostomy may, however, be needed; this is the place it will be brought\\nout.” Below the drawing write the diagnosis and the name of the planned\\noperation. At the end of the consultation you’ll be surprised to see how\\ncarefully members of the family restudy the piece of paper you left with\\nthem, explaining to each other the diagnosis and planned operation. Very\\noften patients and their relatives are very enthusiastic about keeping any\\ndrawings you make for them.\\n\\n The family\\n When it comes to an operation, you advise the patient and\\n his family and they decide…\\n\\n The patient’s family is your greatest ally in promoting your plan of\\naction. By involving them at an early point in the decision-making\\nprocess you may be able to make them partners in the relationship that\\nyou share with the patient. By avoiding the family you may alienate\\npotential allies or worsen an already ‘difficult’ group.\\n\\n The ‘difficult’ family is not uncommon. Long submerged conflicts and feelings of guilt tend\\n to surface when a member of the group becomes ill. Recruit them as allies by offering them a\\n chance to participate, by ‘reading’ the nuances of their relationships and by confidently and\\n continuously selling yourself as a knowledgeable and compassionate advisor. Use your first\\n meeting with the family to make a good impression and gain their trust so that you will continue\\n to be trusted when a complication arises or when further therapy becomes necessary.\\n Remember that if things turn out badly it will be the surviving family members that will want to\\n know “what went wrong?”',\n", " 'md': '```markdown\\n## Illustrate the Problem\\n\\nWhen discussing the prospects of an operation with a patient or a family, we find that illustrating the problem and the planned procedure on a blank piece of paper greatly enhances the communication. Draw, schematically, the obstructed colon: “here is the colon, this is the obstructing lesion and here is the segment we want to remove; we hope to be able to join this piece of bowel to that one; a colostomy may, however, be needed; this is the place it will be brought out.” Below the drawing write the diagnosis and the name of the planned operation. At the end of the consultation, you’ll be surprised to see how carefully members of the family restudy the piece of paper you left with them, explaining to each other the diagnosis and planned operation. Very often patients and their relatives are very enthusiastic about keeping any drawings you make for them.\\n\\n### The Family\\n\\nWhen it comes to an operation, you advise the patient and his family and they decide…\\n\\nThe patient’s family is your greatest ally in promoting your plan of action. By involving them at an early point in the decision-making process you may be able to make them partners in the relationship that you share with the patient. By avoiding the family you may alienate potential allies or worsen an already ‘difficult’ group.\\n\\nThe ‘difficult’ family is not uncommon. Long submerged conflicts and feelings of guilt tend to surface when a member of the group becomes ill. Recruit them as allies by offering them a chance to participate, by ‘reading’ the nuances of their relationships and by confidently and continuously selling yourself as a knowledgeable and compassionate advisor. Use your first meeting with the family to make a good impression and gain their trust so that you will continue to be trusted when a complication arises or when further therapy becomes necessary. Remember that if things turn out badly it will be the surviving family members that will want to know “what went wrong?”\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured appropriately.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Illustrate the Problem',\n", " 'md': '## Illustrate the Problem',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 168.25, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'When discussing the prospects of an operation with a patient or a family, we find that illustrating the problem and the planned procedure on a blank piece of paper greatly enhances the communication. Draw, schematically, the obstructed colon: “here is the colon, this is the obstructing lesion and here is the segment we want to remove; we hope to be able to join this piece of bowel to that one; a colostomy may, however, be needed; this is the place it will be brought out.” Below the drawing write the diagnosis and the name of the planned operation. At the end of the consultation, you’ll be surprised to see how carefully members of the family restudy the piece of paper you left with them, explaining to each other the diagnosis and planned operation. Very often patients and their relatives are very enthusiastic about keeping any drawings you make for them.',\n", " 'md': 'When discussing the prospects of an operation with a patient or a family, we find that illustrating the problem and the planned procedure on a blank piece of paper greatly enhances the communication. Draw, schematically, the obstructed colon: “here is the colon, this is the obstructing lesion and here is the segment we want to remove; we hope to be able to join this piece of bowel to that one; a colostomy may, however, be needed; this is the place it will be brought out.” Below the drawing write the diagnosis and the name of the planned operation. At the end of the consultation, you’ll be surprised to see how carefully members of the family restudy the piece of paper you left with them, explaining to each other the diagnosis and planned operation. Very often patients and their relatives are very enthusiastic about keeping any drawings you make for them.',\n", " 'bBox': {'x': 72, 'y': 124, 'w': 467.85, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Family',\n", " 'md': '### The Family',\n", " 'bBox': {'x': 86, 'y': 366, 'w': 81.84, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'When it comes to an operation, you advise the patient and his family and they decide…\\n\\nThe patient’s family is your greatest ally in promoting your plan of action. By involving them at an early point in the decision-making process you may be able to make them partners in the relationship that you share with the patient. By avoiding the family you may alienate potential allies or worsen an already ‘difficult’ group.\\n\\nThe ‘difficult’ family is not uncommon. Long submerged conflicts and feelings of guilt tend to surface when a member of the group becomes ill. Recruit them as allies by offering them a chance to participate, by ‘reading’ the nuances of their relationships and by confidently and continuously selling yourself as a knowledgeable and compassionate advisor. Use your first meeting with the family to make a good impression and gain their trust so that you will continue to be trusted when a complication arises or when further therapy becomes necessary. Remember that if things turn out badly it will be the surviving family members that will want to know “what went wrong?”\\n```',\n", " 'md': 'When it comes to an operation, you advise the patient and his family and they decide…\\n\\nThe patient’s family is your greatest ally in promoting your plan of action. By involving them at an early point in the decision-making process you may be able to make them partners in the relationship that you share with the patient. By avoiding the family you may alienate potential allies or worsen an already ‘difficult’ group.\\n\\nThe ‘difficult’ family is not uncommon. Long submerged conflicts and feelings of guilt tend to surface when a member of the group becomes ill. Recruit them as allies by offering them a chance to participate, by ‘reading’ the nuances of their relationships and by confidently and continuously selling yourself as a knowledgeable and compassionate advisor. Use your first meeting with the family to make a good impression and gain their trust so that you will continue to be trusted when a complication arises or when further therapy becomes necessary. Remember that if things turn out badly it will be the surviving family members that will want to know “what went wrong?”\\n```',\n", " 'bBox': {'x': 72, 'y': 366, 'w': 467.69, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured appropriately.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured appropriately.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 119,\n", " 'text': ' Ethical problem solving\\n\\n In order to sell a particular product or idea one must believe in it. In\\nother words, based on your knowledge and experience, the operation\\nyou offer should appear ethical to you. It is ethical if it is expected to\\nsave or prolong the patient’s life or palliate his symptoms, and can\\nachieve this goal with a reasonable risk-benefit ratio. At the same\\ntime you must also be convinced that there are no non-operative\\ntreatment modalities that are safer or as effective as your proposed\\noperation. The burden of proof is on you!\\n\\n Medicolegal considerations\\n Surgery is the most dangerous activity of legal society.\\n P. O. Nyström\\n\\n The medicolegal dangers associated with emergency abdominal\\nsurgery greatly depend on where you practice. In some countries\\nsurgeons can get away with almost anything; in other countries\\nemergency surgery is a legal minefield. There are a few simple but\\nwell-proven tactics to prevent lawsuits against you:\\n\\n • Have the patient and family ‘on your side’ (as mentioned above)\\n by being empathetic, caring, honest, open, informative, and at the\\n same time professional. Young surgeons tend to be over-optimistic,\\n trying to cheer up the family. A common scenario finds the surgeon\\n emerging from the operating room, assuming a ‘tired hero’ pose and\\n announcing: “It was smooth and easy, I removed the cancer from\\n the colon, relieving the obstruction. I was able to join the ends of the\\n bowel together, avoiding a colostomy. Yes, your father is stable, he\\n took the operation very well, let’s hope he’ll be home next week for\\n Easter… (or Passover or Ramadan).” Such a script is somewhat\\n misguided in that it may raise high hopes and expectations, with\\n subsequent anger and resentment if complications should develop.\\n The better script might be: “The operation was difficult, but we\\n managed to achieve our goals. The cancer is out and we avoided a\\n colostomy. Considering your father’s age and other illnesses he took',\n", " 'md': '```markdown\\n# Ethical Problem Solving\\n\\nIn order to sell a particular product or idea one must believe in it. In other words, based on your knowledge and experience, the operation you offer should appear ethical to you. It is ethical if it is expected to save or prolong the patient’s life or palliate his symptoms, and can achieve this goal with a reasonable risk-benefit ratio. At the same time, you must also be convinced that there are no non-operative treatment modalities that are safer or as effective as your proposed operation. The burden of proof is on you!\\n\\n## Medicolegal Considerations\\n\\n> Surgery is the most dangerous activity of legal society.\\n> — P. O. Nyström\\n\\nThe medicolegal dangers associated with emergency abdominal surgery greatly depend on where you practice. In some countries, surgeons can get away with almost anything; in other countries, emergency surgery is a legal minefield. There are a few simple but well-proven tactics to prevent lawsuits against you:\\n\\n- Have the patient and family ‘on your side’ (as mentioned above) by being empathetic, caring, honest, open, informative, and at the same time professional. Young surgeons tend to be over-optimistic, trying to cheer up the family. A common scenario finds the surgeon emerging from the operating room, assuming a ‘tired hero’ pose and announcing: “It was smooth and easy, I removed the cancer from the colon, relieving the obstruction. I was able to join the ends of the bowel together, avoiding a colostomy. Yes, your father is stable, he took the operation very well, let’s hope he’ll be home next week for Easter… (or Passover or Ramadan).” Such a script is somewhat misguided in that it may raise high hopes and expectations, with subsequent anger and resentment if complications should develop. The better script might be: “The operation was difficult, but we managed to achieve our goals. The cancer is out and we avoided a colostomy. Considering your father’s age and other illnesses he took...\\n```\\n\\n### Notes:\\n- No images or figures were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Ethical Problem Solving',\n", " 'md': '# Ethical Problem Solving',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 186.64, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In order to sell a particular product or idea one must believe in it. In other words, based on your knowledge and experience, the operation you offer should appear ethical to you. It is ethical if it is expected to save or prolong the patient’s life or palliate his symptoms, and can achieve this goal with a reasonable risk-benefit ratio. At the same time, you must also be convinced that there are no non-operative treatment modalities that are safer or as effective as your proposed operation. The burden of proof is on you!',\n", " 'md': 'In order to sell a particular product or idea one must believe in it. In other words, based on your knowledge and experience, the operation you offer should appear ethical to you. It is ethical if it is expected to save or prolong the patient’s life or palliate his symptoms, and can achieve this goal with a reasonable risk-benefit ratio. At the same time, you must also be convinced that there are no non-operative treatment modalities that are safer or as effective as your proposed operation. The burden of proof is on you!',\n", " 'bBox': {'x': 72, 'y': 157, 'w': 467.67, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Medicolegal Considerations',\n", " 'md': '## Medicolegal Considerations',\n", " 'bBox': {'x': 86, 'y': 283, 'w': 217.02, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '> Surgery is the most dangerous activity of legal society.\\n> — P. O. Nyström\\n\\nThe medicolegal dangers associated with emergency abdominal surgery greatly depend on where you practice. In some countries, surgeons can get away with almost anything; in other countries, emergency surgery is a legal minefield. There are a few simple but well-proven tactics to prevent lawsuits against you:\\n\\n- Have the patient and family ‘on your side’ (as mentioned above) by being empathetic, caring, honest, open, informative, and at the same time professional. Young surgeons tend to be over-optimistic, trying to cheer up the family. A common scenario finds the surgeon emerging from the operating room, assuming a ‘tired hero’ pose and announcing: “It was smooth and easy, I removed the cancer from the colon, relieving the obstruction. I was able to join the ends of the bowel together, avoiding a colostomy. Yes, your father is stable, he took the operation very well, let’s hope he’ll be home next week for Easter… (or Passover or Ramadan).” Such a script is somewhat misguided in that it may raise high hopes and expectations, with subsequent anger and resentment if complications should develop. The better script might be: “The operation was difficult, but we managed to achieve our goals. The cancer is out and we avoided a colostomy. Considering your father’s age and other illnesses he took...\\n```',\n", " 'md': '> Surgery is the most dangerous activity of legal society.\\n> — P. O. Nyström\\n\\nThe medicolegal dangers associated with emergency abdominal surgery greatly depend on where you practice. In some countries, surgeons can get away with almost anything; in other countries, emergency surgery is a legal minefield. There are a few simple but well-proven tactics to prevent lawsuits against you:\\n\\n- Have the patient and family ‘on your side’ (as mentioned above) by being empathetic, caring, honest, open, informative, and at the same time professional. Young surgeons tend to be over-optimistic, trying to cheer up the family. A common scenario finds the surgeon emerging from the operating room, assuming a ‘tired hero’ pose and announcing: “It was smooth and easy, I removed the cancer from the colon, relieving the obstruction. I was able to join the ends of the bowel together, avoiding a colostomy. Yes, your father is stable, he took the operation very well, let’s hope he’ll be home next week for Easter… (or Passover or Ramadan).” Such a script is somewhat misguided in that it may raise high hopes and expectations, with subsequent anger and resentment if complications should develop. The better script might be: “The operation was difficult, but we managed to achieve our goals. The cancer is out and we avoided a colostomy. Considering your father’s age and other illnesses he took...\\n```',\n", " 'bBox': {'x': 72, 'y': 314, 'w': 437.74, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images or figures were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 120,\n", " 'text': ' it well. Let us hope for the best but you must understand that the\\n road to recovery is long and, as I mentioned before the operation,\\n there are still many potential problems ahead.”\\n• Detailed informed consent ( Figure 8.1). This should be much\\n more than the standard, ‘shablonic’ sheet — listing in small print all\\n possible complications ever described in abdominal surgery. The\\n chart has to include evidence that you have met with the\\n patient before the operation and discussed with them the\\n planned procedure and its inherent risks — and alternatives of\\n management.\\n\\n• Documentation. This is crucial, as what has not been documented\\n in writing did not actually take place. Your notes can be brief but\\n must encompass the essentials. Prior to an emergency laparotomy\\n for colonic obstruction we would write: “78 YO male patient with\\n hypertension, diabetes and COPD. Three days of abdominal pain\\n plus distension. Abdominal X-ray — suggesting a distal large bowel\\n obstruction — confirmed on Gastrografin® study. APACħE II score\\n on admission 17 — making him a high risk. Therapeutic options,\\n risks and potential complications, including anastomotic leak, wound\\n infection, respiratory failure, explained in detail to the patient and\\n family who accept the need for an emergency laparotomy. They\\n understand that a colostomy may be needed and that further\\n operations may be necessary.” A year or so later, when you have\\n to defend a lawsuit, this short note will prove invaluable!',\n", " 'md': '```markdown\\n## Page Content\\n\\n- It is well. Let us hope for the best but you must understand that the road to recovery is long and, as I mentioned before the operation, there are still many potential problems ahead.\\n\\n- **Detailed informed consent** (Figure 8.1). This should be much more than the standard, ‘shablonic’ sheet — listing in small print all possible complications ever described in abdominal surgery. The chart has to include evidence that you have met with the patient before the operation and discussed with them the planned procedure and its inherent risks — and alternatives of management.\\n\\n- **Documentation**. This is crucial, as what has not been documented in writing did not actually take place. Your notes can be brief but must encompass the essentials. Prior to an emergency laparotomy for colonic obstruction we would write: “78 YO male patient with hypertension, diabetes and COPD. Three days of abdominal pain plus distension. Abdominal X-ray — suggesting a distal large bowel obstruction — confirmed on Gastrografin® study. APACHE II score on admission 17 — making him a high risk. Therapeutic options, risks and potential complications, including anastomotic leak, wound infection, respiratory failure, explained in detail to the patient and family who accept the need for an emergency laparotomy. They understand that a colostomy may be needed and that further operations may be necessary.” A year or so later, when you have to defend a lawsuit, this short note will prove invaluable!\\n\\n## Figures\\n\\n### Figure 8.1\\n- **Description**: This figure likely represents a detailed informed consent chart used in medical practice. It is designed to go beyond standard consent forms by including specific discussions about the procedure, risks, and alternatives with the patient.\\n- **Summary**: The chart serves as a comprehensive record of the informed consent process, ensuring that both the patient and the medical team are aligned on the treatment plan and its implications.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- It is well. Let us hope for the best but you must understand that the road to recovery is long and, as I mentioned before the operation, there are still many potential problems ahead.\\n\\n- **Detailed informed consent** (Figure 8.1). This should be much more than the standard, ‘shablonic’ sheet — listing in small print all possible complications ever described in abdominal surgery. The chart has to include evidence that you have met with the patient before the operation and discussed with them the planned procedure and its inherent risks — and alternatives of management.\\n\\n- **Documentation**. This is crucial, as what has not been documented in writing did not actually take place. Your notes can be brief but must encompass the essentials. Prior to an emergency laparotomy for colonic obstruction we would write: “78 YO male patient with hypertension, diabetes and COPD. Three days of abdominal pain plus distension. Abdominal X-ray — suggesting a distal large bowel obstruction — confirmed on Gastrografin® study. APACHE II score on admission 17 — making him a high risk. Therapeutic options, risks and potential complications, including anastomotic leak, wound infection, respiratory failure, explained in detail to the patient and family who accept the need for an emergency laparotomy. They understand that a colostomy may be needed and that further operations may be necessary.” A year or so later, when you have to defend a lawsuit, this short note will prove invaluable!',\n", " 'md': '- It is well. Let us hope for the best but you must understand that the road to recovery is long and, as I mentioned before the operation, there are still many potential problems ahead.\\n\\n- **Detailed informed consent** (Figure 8.1). This should be much more than the standard, ‘shablonic’ sheet — listing in small print all possible complications ever described in abdominal surgery. The chart has to include evidence that you have met with the patient before the operation and discussed with them the planned procedure and its inherent risks — and alternatives of management.\\n\\n- **Documentation**. This is crucial, as what has not been documented in writing did not actually take place. Your notes can be brief but must encompass the essentials. Prior to an emergency laparotomy for colonic obstruction we would write: “78 YO male patient with hypertension, diabetes and COPD. Three days of abdominal pain plus distension. Abdominal X-ray — suggesting a distal large bowel obstruction — confirmed on Gastrografin® study. APACHE II score on admission 17 — making him a high risk. Therapeutic options, risks and potential complications, including anastomotic leak, wound infection, respiratory failure, explained in detail to the patient and family who accept the need for an emergency laparotomy. They understand that a colostomy may be needed and that further operations may be necessary.” A year or so later, when you have to defend a lawsuit, this short note will prove invaluable!',\n", " 'bBox': {'x': 100, 'y': 155, 'w': 437.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures',\n", " 'md': '## Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 8.1',\n", " 'md': '### Figure 8.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure likely represents a detailed informed consent chart used in medical practice. It is designed to go beyond standard consent forms by including specific discussions about the procedure, risks, and alternatives with the patient.\\n- **Summary**: The chart serves as a comprehensive record of the informed consent process, ensuring that both the patient and the medical team are aligned on the treatment plan and its implications.\\n```',\n", " 'md': '- **Description**: This figure likely represents a detailed informed consent chart used in medical practice. It is designed to go beyond standard consent forms by including specific discussions about the procedure, risks, and alternatives with the patient.\\n- **Summary**: The chart serves as a comprehensive record of the informed consent process, ensuring that both the patient and the medical team are aligned on the treatment plan and its implications.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'more than the standard, ‘shablonic’ sheet — listing in small print all'}]},\n", " {'page': 121,\n", " 'text': \" WON'€ hehape _siah PLease 40 Sign!\\n Figure 8.1. “Is he going to sign?”\\n\\n Avoid selling autopsies under anesthesia (AUA)\\n\\n We compared you above to an astute salesman, interacting with\\nthe patient and his family. In this capacity, you, a respected clinician,\\ncan easily sell anything to the trusting clients. But be honest with yourself\\nand consider as objectively as possible the risk-benefit ratio of the\\nprocedure you are trying to ‘sell’. It may be easy to convince a worried\\nfamily that a (futile) operation is indeed necessary, and then at the\\ninevitable M & M (morbidity and mortality) meeting ( Chapter 50) to\\nexplain that the family forced the AUA on you. Easy and ethical don’t\\nalways coexist!\\n\\n One should advise surgery only if there is a reasonable\\n chance of success. To operate without having a chance\\n means to prostitute the beautiful art and science of surgery.\\n Theodor Billroth\",\n", " 'md': \"```markdown\\n# Page Content\\n\\n**Figure 8.1.** “Is he going to sign?”\\n\\nAvoid selling autopsies under anesthesia (AUA).\\n\\nWe compared you above to an astute salesman, interacting with the patient and his family. In this capacity, you, a respected clinician, can easily sell anything to the trusting clients. But be honest with yourself and consider as objectively as possible the risk-benefit ratio of the procedure you are trying to ‘sell’. It may be easy to convince a worried family that a (futile) operation is indeed necessary, and then at the inevitable M & M (morbidity and mortality) meeting to explain that the family forced the AUA on you. Easy and ethical don’t always coexist!\\n\\nOne should advise surgery only if there is a reasonable chance of success. To operate without having a chance means to prostitute the beautiful art and science of surgery.\\n— Theodor Billroth\\n```\\n\\n### Image Identification and Description\\n\\n**Figure 8.1**: The image depicts a thought-provoking scenario regarding the ethical considerations of surgery, particularly in the context of selling procedures to patients and their families. The caption suggests a moment of contemplation about whether a patient will agree to proceed with a surgical intervention. The image likely illustrates a clinician's dilemma in balancing ethical practice with the pressures from patients and families.\\n\\n**Summary**: The figure emphasizes the importance of ethical considerations in medical practice, particularly in surgical decision-making, and highlights the potential conflict between patient expectations and clinical judgment.\",\n", " 'images': [{'name': 'img_p120_1.png',\n", " 'height': 575,\n", " 'width': 800,\n", " 'x': 108,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1374,\n", " 'original_height': 988}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 8.1.** “Is he going to sign?”\\n\\nAvoid selling autopsies under anesthesia (AUA).\\n\\nWe compared you above to an astute salesman, interacting with the patient and his family. In this capacity, you, a respected clinician, can easily sell anything to the trusting clients. But be honest with yourself and consider as objectively as possible the risk-benefit ratio of the procedure you are trying to ‘sell’. It may be easy to convince a worried family that a (futile) operation is indeed necessary, and then at the inevitable M & M (morbidity and mortality) meeting to explain that the family forced the AUA on you. Easy and ethical don’t always coexist!\\n\\nOne should advise surgery only if there is a reasonable chance of success. To operate without having a chance means to prostitute the beautiful art and science of surgery.\\n— Theodor Billroth\\n```',\n", " 'md': '**Figure 8.1.** “Is he going to sign?”\\n\\nAvoid selling autopsies under anesthesia (AUA).\\n\\nWe compared you above to an astute salesman, interacting with the patient and his family. In this capacity, you, a respected clinician, can easily sell anything to the trusting clients. But be honest with yourself and consider as objectively as possible the risk-benefit ratio of the procedure you are trying to ‘sell’. It may be easy to convince a worried family that a (futile) operation is indeed necessary, and then at the inevitable M & M (morbidity and mortality) meeting to explain that the family forced the AUA on you. Easy and ethical don’t always coexist!\\n\\nOne should advise surgery only if there is a reasonable chance of success. To operate without having a chance means to prostitute the beautiful art and science of surgery.\\n— Theodor Billroth\\n```',\n", " 'bBox': {'x': 72, 'y': 442, 'w': 467.44, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"**Figure 8.1**: The image depicts a thought-provoking scenario regarding the ethical considerations of surgery, particularly in the context of selling procedures to patients and their families. The caption suggests a moment of contemplation about whether a patient will agree to proceed with a surgical intervention. The image likely illustrates a clinician's dilemma in balancing ethical practice with the pressures from patients and families.\\n\\n**Summary**: The figure emphasizes the importance of ethical considerations in medical practice, particularly in surgical decision-making, and highlights the potential conflict between patient expectations and clinical judgment.\",\n", " 'md': \"**Figure 8.1**: The image depicts a thought-provoking scenario regarding the ethical considerations of surgery, particularly in the context of selling procedures to patients and their families. The caption suggests a moment of contemplation about whether a patient will agree to proceed with a surgical intervention. The image likely illustrates a clinician's dilemma in balancing ethical practice with the pressures from patients and families.\\n\\n**Summary**: The figure emphasizes the importance of ethical considerations in medical practice, particularly in surgical decision-making, and highlights the potential conflict between patient expectations and clinical judgment.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'explain that the family forced the AUA on you. Easy and ethical don’t'}]},\n", " {'page': 122,\n", " 'text': ' Concluding remarks\\n\\n Not only is what you say important but also how it is said.\\nIntroduce yourself and all members of your team who are present. Shake\\nhands with all members of the family. Conduct the ‘session’ in a sitting\\nposition — you sitting at eye level, or lower, with the patient and his\\nfamily. Maintain constant eye contact with each of them — do not ignore\\nthe grumpy son hiding in the corner of the room — he may be the one\\nwho becomes your nemesis. Be ‘nice’ but not ‘too nice’ — this is not the\\ntime to smile or joke around. Just play the serious surgeon committed to\\nthe well-being of the patient. This surgeon is you, so play yourself!\\n\\n Nothing is truer than the cliché that should be constantly replayed\\n in your mind — would you recommend the same treatment to\\n your father, mother, wife or son? Studies show that surgeons are much less\\n likely to recommend operations on themselves or their loved ones. Do unto others as you\\n would have them do unto you — the golden rule. Even if your hands are so keen to\\n operate…\\n\\n I teach my residents: “Honesty and sensitivity in high doses is all it takes.” Ari\\n\\n “The patient’s family will never forgive a guarantee of\\n cure that failed and the patient will not let the physician\\n forget a pronouncement of incurability if he is so\\n fortunate as to survive.”\\n George T. Pack\\n\\n1 For much more about “Dealing with patients, families, lawyers and yourself” please consult\\n the so-named Chapter 10 in Schein’s Common Sense Prevention and Management of\\n Surgical Complications. Shrewsbury, UK: tfm publishing, 2013.',\n", " 'md': '```markdown\\n# Concluding Remarks\\n\\nNot only is what you say important but also how it is said. Introduce yourself and all members of your team who are present. Shake hands with all members of the family. Conduct the ‘session’ in a sitting position — you sitting at eye level, or lower, with the patient and his family. Maintain constant eye contact with each of them — do not ignore the grumpy son hiding in the corner of the room — he may be the one who becomes your nemesis. Be ‘nice’ but not ‘too nice’ — this is not the time to smile or joke around. Just play the serious surgeon committed to the well-being of the patient. This surgeon is you, so play yourself!\\n\\nNothing is truer than the cliché that should be constantly replayed in your mind — would you recommend the same treatment to your father, mother, wife or son? Studies show that surgeons are much less likely to recommend operations on themselves or their loved ones. Do unto others as you would have them do unto you — the golden rule. Even if your hands are so keen to operate…\\n\\nI teach my residents: “Honesty and sensitivity in high doses is all it takes.” Ari\\n\\n“The patient’s family will never forgive a guarantee of cure that failed and the patient will not let the physician forget a pronouncement of incurability if he is so fortunate as to survive.”\\n— George T. Pack\\n\\n1. For much more about “Dealing with patients, families, lawyers and yourself” please consult the so-named Chapter 10 in Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013. [Link to Chapter 10](#)\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 139, 'y': 545, 'w': 9.21, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Concluding Remarks',\n", " 'md': '# Concluding Remarks',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 160.01, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Not only is what you say important but also how it is said. Introduce yourself and all members of your team who are present. Shake hands with all members of the family. Conduct the ‘session’ in a sitting position — you sitting at eye level, or lower, with the patient and his family. Maintain constant eye contact with each of them — do not ignore the grumpy son hiding in the corner of the room — he may be the one who becomes your nemesis. Be ‘nice’ but not ‘too nice’ — this is not the time to smile or joke around. Just play the serious surgeon committed to the well-being of the patient. This surgeon is you, so play yourself!\\n\\nNothing is truer than the cliché that should be constantly replayed in your mind — would you recommend the same treatment to your father, mother, wife or son? Studies show that surgeons are much less likely to recommend operations on themselves or their loved ones. Do unto others as you would have them do unto you — the golden rule. Even if your hands are so keen to operate…\\n\\nI teach my residents: “Honesty and sensitivity in high doses is all it takes.” Ari\\n\\n“The patient’s family will never forgive a guarantee of cure that failed and the patient will not let the physician forget a pronouncement of incurability if he is so fortunate as to survive.”\\n— George T. Pack\\n\\n1. For much more about “Dealing with patients, families, lawyers and yourself” please consult the so-named Chapter 10 in Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013. [Link to Chapter 10](#)\\n```',\n", " 'md': 'Not only is what you say important but also how it is said. Introduce yourself and all members of your team who are present. Shake hands with all members of the family. Conduct the ‘session’ in a sitting position — you sitting at eye level, or lower, with the patient and his family. Maintain constant eye contact with each of them — do not ignore the grumpy son hiding in the corner of the room — he may be the one who becomes your nemesis. Be ‘nice’ but not ‘too nice’ — this is not the time to smile or joke around. Just play the serious surgeon committed to the well-being of the patient. This surgeon is you, so play yourself!\\n\\nNothing is truer than the cliché that should be constantly replayed in your mind — would you recommend the same treatment to your father, mother, wife or son? Studies show that surgeons are much less likely to recommend operations on themselves or their loved ones. Do unto others as you would have them do unto you — the golden rule. Even if your hands are so keen to operate…\\n\\nI teach my residents: “Honesty and sensitivity in high doses is all it takes.” Ari\\n\\n“The patient’s family will never forgive a guarantee of cure that failed and the patient will not let the physician forget a pronouncement of incurability if he is so fortunate as to survive.”\\n— George T. Pack\\n\\n1. For much more about “Dealing with patients, families, lawyers and yourself” please consult the so-named Chapter 10 in Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013. [Link to Chapter 10](#)\\n```',\n", " 'bBox': {'x': 72, 'y': 140, 'w': 467.97, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Surgical Complications'}]},\n", " {'page': 123,\n", " 'text': 'Chapter 9\\nBefore the flight: pre-op checklist\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and\\nJonathan E. Efron\\n\\n The pilot is by circumstances allowed only one serious\\n mistake, while the surgeon may commit many and not even\\n recognize his own errors as such.\\n John S. Lockwood\\n\\n Aren’t we all fed up of being compared to pilots? Richard C. Karl, a\\nsurgeon and pilot, has pointed out that the two professions are not\\nexactly the same:\\n\\n Pilots don’t fill out a form documenting that they put the\\n landing gear down. This is another fundamental difference\\n in the two professions. We (surgeons) obsess about\\n documentation; aviation worries about getting the wheels\\n down.\\n\\n I do know that it is harder to control bleeding from the back\\n side of the portal vein than it is to land a 737 with an engine\\n on fire.\\n\\n Neverthless, like any military or commercial pilot, prior to any flight, you\\nhave to go over a ‘checklist’ ( Figure 9.1). In fact, the need to check\\neverything obsessively is more crucial to you than to the pilot. For while a\\nteam of dedicated and well-trained maintenance professionals surround',\n", " 'md': '```markdown\\n# Chapter 9\\n## Before the flight: pre-op checklist\\n**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n> \"The pilot is by circumstances allowed only one serious mistake, while the surgeon may commit many and not even recognize his own errors as such.\"\\n> — John S. Lockwood\\n\\nAren’t we all fed up of being compared to pilots? Richard C. Karl, a surgeon and pilot, has pointed out that the two professions are not exactly the same:\\n\\n> \"Pilots don’t fill out a form documenting that they put the landing gear down. This is another fundamental difference in the two professions. We (surgeons) obsess about documentation; aviation worries about getting the wheels down.\"\\n> \"I do know that it is harder to control bleeding from the back side of the portal vein than it is to land a 737 with an engine on fire.\"\\n\\nNevertheless, like any military or commercial pilot, prior to any flight, you have to go over a ‘checklist’ (Figure 9.1). In fact, the need to check everything obsessively is more crucial to you than to the pilot. For while a team of dedicated and well-trained maintenance professionals surround...\\n```\\n\\n### Figure 9.1\\n- **Description:** The image referred to as Figure 9.1 is a checklist that pilots use before a flight. It likely includes various items that need to be verified to ensure safety and readiness for the flight.\\n- **Summary:** This checklist serves as a critical tool for ensuring that all necessary pre-flight procedures are completed, emphasizing the importance of thoroughness in surgical practice as well.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 9',\n", " 'md': '# Chapter 9',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 132.78, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Before the flight: pre-op checklist',\n", " 'md': '## Before the flight: pre-op checklist',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 293.38, 'h': 20.16}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n> \"The pilot is by circumstances allowed only one serious mistake, while the surgeon may commit many and not even recognize his own errors as such.\"\\n> — John S. Lockwood\\n\\nAren’t we all fed up of being compared to pilots? Richard C. Karl, a surgeon and pilot, has pointed out that the two professions are not exactly the same:\\n\\n> \"Pilots don’t fill out a form documenting that they put the landing gear down. This is another fundamental difference in the two professions. We (surgeons) obsess about documentation; aviation worries about getting the wheels down.\"\\n> \"I do know that it is harder to control bleeding from the back side of the portal vein than it is to land a 737 with an engine on fire.\"\\n\\nNevertheless, like any military or commercial pilot, prior to any flight, you have to go over a ‘checklist’ (Figure 9.1). In fact, the need to check everything obsessively is more crucial to you than to the pilot. For while a team of dedicated and well-trained maintenance professionals surround...\\n```',\n", " 'md': '**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n> \"The pilot is by circumstances allowed only one serious mistake, while the surgeon may commit many and not even recognize his own errors as such.\"\\n> — John S. Lockwood\\n\\nAren’t we all fed up of being compared to pilots? Richard C. Karl, a surgeon and pilot, has pointed out that the two professions are not exactly the same:\\n\\n> \"Pilots don’t fill out a form documenting that they put the landing gear down. This is another fundamental difference in the two professions. We (surgeons) obsess about documentation; aviation worries about getting the wheels down.\"\\n> \"I do know that it is harder to control bleeding from the back side of the portal vein than it is to land a 737 with an engine on fire.\"\\n\\nNevertheless, like any military or commercial pilot, prior to any flight, you have to go over a ‘checklist’ (Figure 9.1). In fact, the need to check everything obsessively is more crucial to you than to the pilot. For while a team of dedicated and well-trained maintenance professionals surround...\\n```',\n", " 'bBox': {'x': 72, 'y': 260, 'w': 467.5, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 9.1',\n", " 'md': '### Figure 9.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description:** The image referred to as Figure 9.1 is a checklist that pilots use before a flight. It likely includes various items that need to be verified to ensure safety and readiness for the flight.\\n- **Summary:** This checklist serves as a critical tool for ensuring that all necessary pre-flight procedures are completed, emphasizing the importance of thoroughness in surgical practice as well.',\n", " 'md': '- **Description:** The image referred to as Figure 9.1 is a checklist that pilots use before a flight. It likely includes various items that need to be verified to ensure safety and readiness for the flight.\\n- **Summary:** This checklist serves as a critical tool for ensuring that all necessary pre-flight procedures are completed, emphasizing the importance of thoroughness in surgical practice as well.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'everything obsessively is more crucial to you than to the pilot. For while a'}]},\n", " {'page': 124,\n", " 'text': \"the pilot — you are sometimes surrounded only by jerks. We do not want\\nto be abusive or rude or politically incorrect but let us be realistic: at 2\\na.m. your intern or junior resident is much more interested in his lost\\nsleep than your prospective operation. And the anesthetist? Your\\nemergency case is just a pain in his ass. The sooner he or she can\\nadminister the gases, and the sooner they can dump your ‘case’ in the\\nrecovery room, or intensive care unit, the sooner they can crawl under\\nthe comfort of their warm duvet. And the nursing staff? Forget them! Not\\nin vain today are they called OR technicians. (Lest we be accused of\\npainting with too wide a brush, there are always the wonderful exceptions\\n— some assist us better than any resident... in this scenario, let them\\nknow they are appreciated!).\\n .' '\\n . . `\\n : . ..\\n AeRxaAk\\n Figure 9.1. “Doctor, show me your pilot license and CME certificates!”\\n\\n So face it — you are alone; it is always a solo flight and you can\\ncount only on yourself. You are responsible for the success, failure,\\nmorbidity, mortality, and potential lawsuit. ħis or her fate is in your hands.\\nThis patient, regardless of how many people are buzzing around him, is\\nyours. So wake up and go over the checklist.\",\n", " 'md': '```markdown\\n## Page Content\\n\\nThe pilot — you are sometimes surrounded only by jerks. We do not want to be abusive or rude or politically incorrect but let us be realistic: at 2 a.m. your intern or junior resident is much more interested in his lost sleep than your prospective operation. And the anesthetist? Your emergency case is just a pain in his ass. The sooner he or she can administer the gases, and the sooner they can dump your ‘case’ in the recovery room, or intensive care unit, the sooner they can crawl under the comfort of their warm duvet. And the nursing staff? Forget them! Not in vain today are they called OR technicians. (Lest we be accused of painting with too wide a brush, there are always the wonderful exceptions — some assist us better than any resident... in this scenario, let them know they are appreciated!).\\n\\nSo face it — you are alone; it is always a solo flight and you can count only on yourself. You are responsible for the success, failure, morbidity, mortality, and potential lawsuit. His or her fate is in your hands. This patient, regardless of how many people are buzzing around him, is yours. So wake up and go over the checklist.\\n\\n### Figure 9.1\\n**Caption:** “Doctor, show me your pilot license and CME certificates!”\\n\\n**Description:** Figure 9.1 depicts a humorous illustration related to the medical profession, emphasizing the responsibilities of a doctor. The image likely portrays a doctor being asked for credentials in a light-hearted manner, highlighting the pressures and expectations placed on medical professionals.\\n\\n**Summary:** The figure serves to remind medical practitioners of their accountability and the often solitary nature of their work, especially in high-pressure situations.\\n```',\n", " 'images': [{'name': 'img_p123_1.png',\n", " 'height': 569,\n", " 'width': 802,\n", " 'x': 108,\n", " 'y': 281.52,\n", " 'original_width': 1377,\n", " 'original_height': 976}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The pilot — you are sometimes surrounded only by jerks. We do not want to be abusive or rude or politically incorrect but let us be realistic: at 2 a.m. your intern or junior resident is much more interested in his lost sleep than your prospective operation. And the anesthetist? Your emergency case is just a pain in his ass. The sooner he or she can administer the gases, and the sooner they can dump your ‘case’ in the recovery room, or intensive care unit, the sooner they can crawl under the comfort of their warm duvet. And the nursing staff? Forget them! Not in vain today are they called OR technicians. (Lest we be accused of painting with too wide a brush, there are always the wonderful exceptions — some assist us better than any resident... in this scenario, let them know they are appreciated!).\\n\\nSo face it — you are alone; it is always a solo flight and you can count only on yourself. You are responsible for the success, failure, morbidity, mortality, and potential lawsuit. His or her fate is in your hands. This patient, regardless of how many people are buzzing around him, is yours. So wake up and go over the checklist.',\n", " 'md': 'The pilot — you are sometimes surrounded only by jerks. We do not want to be abusive or rude or politically incorrect but let us be realistic: at 2 a.m. your intern or junior resident is much more interested in his lost sleep than your prospective operation. And the anesthetist? Your emergency case is just a pain in his ass. The sooner he or she can administer the gases, and the sooner they can dump your ‘case’ in the recovery room, or intensive care unit, the sooner they can crawl under the comfort of their warm duvet. And the nursing staff? Forget them! Not in vain today are they called OR technicians. (Lest we be accused of painting with too wide a brush, there are always the wonderful exceptions — some assist us better than any resident... in this scenario, let them know they are appreciated!).\\n\\nSo face it — you are alone; it is always a solo flight and you can count only on yourself. You are responsible for the success, failure, morbidity, mortality, and potential lawsuit. His or her fate is in your hands. This patient, regardless of how many people are buzzing around him, is yours. So wake up and go over the checklist.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.93, 'h': 27.21}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 9.1',\n", " 'md': '### Figure 9.1',\n", " 'bBox': {'x': 157.47, 'y': 317.14, 'w': 31.66, 'h': 7.92}},\n", " {'type': 'text',\n", " 'value': '**Caption:** “Doctor, show me your pilot license and CME certificates!”\\n\\n**Description:** Figure 9.1 depicts a humorous illustration related to the medical profession, emphasizing the responsibilities of a doctor. The image likely portrays a doctor being asked for credentials in a light-hearted manner, highlighting the pressures and expectations placed on medical professionals.\\n\\n**Summary:** The figure serves to remind medical practitioners of their accountability and the often solitary nature of their work, especially in high-pressure situations.\\n```',\n", " 'md': '**Caption:** “Doctor, show me your pilot license and CME certificates!”\\n\\n**Description:** Figure 9.1 depicts a humorous illustration related to the medical profession, emphasizing the responsibilities of a doctor. The image likely portrays a doctor being asked for credentials in a light-hearted manner, highlighting the pressures and expectations placed on medical professionals.\\n\\n**Summary:** The figure serves to remind medical practitioners of their accountability and the often solitary nature of their work, especially in high-pressure situations.\\n```',\n", " 'bBox': {'x': 157.47, 'y': 317.14, 'w': 31.66, 'h': 7.92}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 125,\n", " 'text': ' The formal ‘OR time out’, dictated by ‘big brother’ — that\\nmandated final review by the nursing team of the side, site and\\nnature of the procedure — cannot, and should not, come instead of\\nyour own checklist.\\n\\n The surgeon’s checklist\\n\\n • Does he really need the operation? The cliché that it is more\\n difficult to decide when not to operate than when to operate is\\n mentioned elsewhere in this book. Variations of this aphorism are\\n circulating around the world in many languages. But even more\\n difficult is to decide against the operation after the operation has\\n been scheduled. So you decided to book the patient for\\n appendectomy based on what the chief resident told you over the\\n phone — that “the CT is compatible with acute appendicitis” — and\\n now, when you arrive in the OR, you find the patient smiling and\\n sitting in bed with a soft and non-tender abdomen. Do you want to\\n operate on the CT or the patient? You do not need big balls (or\\n ovaries) to book a patient for the operation but you need large\\n balls to cancel the operation and order the patient back to the\\n floor (ward). You need huge balls to remove the patient from the\\n operating table and massive balls to tell the anesthetist to wake him\\n up… but if you palpate a large appendiceal mass (see Chapter\\n 23) after the induction of anesthesia and abdominal wall relaxation\\n — what is the point of continuing?\\n • Examine the patient before he is put to sleep. Never ever — we\\n repeat — never, never, never ever operate on a patient without\\n having examined him yourself; if you do then you are a frickin’\\n butcher! That the endoscopist visualized a ‘bleeding ulcer’ and the\\n patient continues to vomit blood may be an indication for operation,\\n but this is your chance to diagnose the large spleen and ascites,\\n which were hitherto overlooked by the others. You do not want to\\n operate on a Child’s C portal hypertension patient, or do you? (See\\n Chapter 25.)\\n • Look at the X-rays and imaging studies. Review all X-rays and\\n imaging studies by yourself. Do not rely only on what the radiologist\\n said or wrote. You may pick up findings, which may move you to',\n", " 'md': '```markdown\\n# The Surgeon’s Checklist\\n\\nThe formal ‘OR time out’, dictated by ‘big brother’ — that mandated final review by the nursing team of the side, site and nature of the procedure — cannot, and should not, come instead of your own checklist.\\n\\n## Checklist Items\\n\\n- **Does he really need the operation?** The cliché that it is more difficult to decide when not to operate than when to operate is mentioned elsewhere in this book. Variations of this aphorism are circulating around the world in many languages. But even more difficult is to decide against the operation after the operation has been scheduled. So you decided to book the patient for appendectomy based on what the chief resident told you over the phone — that “the CT is compatible with acute appendicitis” — and now, when you arrive in the OR, you find the patient smiling and sitting in bed with a soft and non-tender abdomen. Do you want to operate on the CT or the patient? You do not need big balls (or ovaries) to book a patient for the operation but you need large balls to cancel the operation and order the patient back to the floor (ward). You need huge balls to remove the patient from the operating table and massive balls to tell the anesthetist to wake him up… but if you palpate a large appendiceal mass (see Chapter 23) after the induction of anesthesia and abdominal wall relaxation — what is the point of continuing?\\n\\n- **Examine the patient before he is put to sleep.** Never ever — we repeat — never, never, never ever operate on a patient without having examined him yourself; if you do then you are a frickin’ butcher! That the endoscopist visualized a ‘bleeding ulcer’ and the patient continues to vomit blood may be an indication for operation, but this is your chance to diagnose the large spleen and ascites, which were hitherto overlooked by the others. You do not want to operate on a Child’s C portal hypertension patient, or do you? (See Chapter 25.)\\n\\n- **Look at the X-rays and imaging studies.** Review all X-rays and imaging studies by yourself. Do not rely only on what the radiologist said or wrote. You may pick up findings, which may move you to...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'The Surgeon’s Checklist',\n", " 'md': '# The Surgeon’s Checklist',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 187.9, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The formal ‘OR time out’, dictated by ‘big brother’ — that mandated final review by the nursing team of the side, site and nature of the procedure — cannot, and should not, come instead of your own checklist.',\n", " 'md': 'The formal ‘OR time out’, dictated by ‘big brother’ — that mandated final review by the nursing team of the side, site and nature of the procedure — cannot, and should not, come instead of your own checklist.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.45, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Checklist Items',\n", " 'md': '## Checklist Items',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Does he really need the operation?** The cliché that it is more difficult to decide when not to operate than when to operate is mentioned elsewhere in this book. Variations of this aphorism are circulating around the world in many languages. But even more difficult is to decide against the operation after the operation has been scheduled. So you decided to book the patient for appendectomy based on what the chief resident told you over the phone — that “the CT is compatible with acute appendicitis” — and now, when you arrive in the OR, you find the patient smiling and sitting in bed with a soft and non-tender abdomen. Do you want to operate on the CT or the patient? You do not need big balls (or ovaries) to book a patient for the operation but you need large balls to cancel the operation and order the patient back to the floor (ward). You need huge balls to remove the patient from the operating table and massive balls to tell the anesthetist to wake him up… but if you palpate a large appendiceal mass (see Chapter 23) after the induction of anesthesia and abdominal wall relaxation — what is the point of continuing?\\n\\n- **Examine the patient before he is put to sleep.** Never ever — we repeat — never, never, never ever operate on a patient without having examined him yourself; if you do then you are a frickin’ butcher! That the endoscopist visualized a ‘bleeding ulcer’ and the patient continues to vomit blood may be an indication for operation, but this is your chance to diagnose the large spleen and ascites, which were hitherto overlooked by the others. You do not want to operate on a Child’s C portal hypertension patient, or do you? (See Chapter 25.)\\n\\n- **Look at the X-rays and imaging studies.** Review all X-rays and imaging studies by yourself. Do not rely only on what the radiologist said or wrote. You may pick up findings, which may move you to...\\n```',\n", " 'md': '- **Does he really need the operation?** The cliché that it is more difficult to decide when not to operate than when to operate is mentioned elsewhere in this book. Variations of this aphorism are circulating around the world in many languages. But even more difficult is to decide against the operation after the operation has been scheduled. So you decided to book the patient for appendectomy based on what the chief resident told you over the phone — that “the CT is compatible with acute appendicitis” — and now, when you arrive in the OR, you find the patient smiling and sitting in bed with a soft and non-tender abdomen. Do you want to operate on the CT or the patient? You do not need big balls (or ovaries) to book a patient for the operation but you need large balls to cancel the operation and order the patient back to the floor (ward). You need huge balls to remove the patient from the operating table and massive balls to tell the anesthetist to wake him up… but if you palpate a large appendiceal mass (see Chapter 23) after the induction of anesthesia and abdominal wall relaxation — what is the point of continuing?\\n\\n- **Examine the patient before he is put to sleep.** Never ever — we repeat — never, never, never ever operate on a patient without having examined him yourself; if you do then you are a frickin’ butcher! That the endoscopist visualized a ‘bleeding ulcer’ and the patient continues to vomit blood may be an indication for operation, but this is your chance to diagnose the large spleen and ascites, which were hitherto overlooked by the others. You do not want to operate on a Child’s C portal hypertension patient, or do you? (See Chapter 25.)\\n\\n- **Look at the X-rays and imaging studies.** Review all X-rays and imaging studies by yourself. Do not rely only on what the radiologist said or wrote. You may pick up findings, which may move you to...\\n```',\n", " 'bBox': {'x': 100, 'y': 331, 'w': 437.43, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ' Chapter — what is the point of continuing?'},\n", " {'text': ''}]},\n", " {'page': 126,\n", " 'text': ' cancel the operation or to decide on a different incision. Fine details\\n on the CT may help you to plan the operation. It can show, for\\n example, the safest place to enter the abdomen and avoiding bowel\\n loops adherent to the anterior abdominal wall.\\n• Position the patient. Already before you start you have to have a\\n general idea what you are going to do or what you may have to do.\\n This has an impact on your patient’s position. For example — does\\n he need a Lloyd-Davies position, offering access to the anus and\\n rectum? This may be needed during colorectal procedures — to\\n insert a scope, to decompress the colon or to insert a stapler. You do\\n not want to have to stop the operation and place the patient in the\\n correct position or to send the intern crawling under soggy drapes\\n playing peak a boo with the anus. In whatever position your patient\\n is to be, check that all limbs are protected and well padded at\\n potential pressure sites. Poor positioning on the OR table may\\n result in damage to nerves, skin ulceration and compartment\\n syndrome of the extremities — and a lawsuit.\\n• Warm your patient. See that the patient is well covered and\\n warmed. ħypothermia increases the likelihood of postoperative\\n infections and contributes to intra-operative coagulopathy.\\n• Think about preventing deep vein thrombosis (DVT). Prevention\\n of DVT should be initiated before the patient is put to sleep — not\\n after the operation. Any abdominal procedure lasting longer than 30\\n minutes is associated with a moderate risk of DVT; you can add to\\n this specific risk factors such as smoking, the use of oral\\n contraceptives, a previous history of DVT, age, obesity, a cancer and\\n so forth. But instead of pondering too much — why don’t you\\n provide all your patients undergoing an emergency abdominal\\n operation with DVT prophylaxis? Whether it is in the form of\\n subcutaneous heparin or calf compression depends on what your\\n OR can offer. Bear in mind that anticoagulation is not good for an\\n exsanguinating patient! We have seen young patients dropping\\n dead from pulmonary embolism a few days after appendectomy and\\n young women developing intractable post-phlebitic syndromes\\n following appendectomy performed for pelvic inflammatory disease.\\n Always think about this.\\n• Is the bladder empty? Most patients undergoing major emergency\\n operations arrive at the OR with a urinary catheter in place; in the',\n", " 'md': '```markdown\\n## Surgical Preparation Guidelines\\n\\n- **Cancel the operation or decide on a different incision.** Fine details on the CT may help you to plan the operation. It can show, for example, the safest place to enter the abdomen and avoid bowel loops adherent to the anterior abdominal wall.\\n\\n- **Position the patient.** Before you start, you should have a general idea of what you are going to do or what you may have to do. This impacts your patient’s position. For example, does the patient need a Lloyd-Davies position, offering access to the anus and rectum? This may be needed during colorectal procedures — to insert a scope, decompress the colon, or insert a stapler. You do not want to have to stop the operation and place the patient in the correct position or to send the intern crawling under soggy drapes playing peek-a-boo with the anus. In whatever position your patient is to be, check that all limbs are protected and well padded at potential pressure sites. Poor positioning on the OR table may result in damage to nerves, skin ulceration, and compartment syndrome of the extremities — and a lawsuit.\\n\\n- **Warm your patient.** Ensure that the patient is well covered and warmed. Hypothermia increases the likelihood of postoperative infections and contributes to intra-operative coagulopathy.\\n\\n- **Think about preventing deep vein thrombosis (DVT).** Prevention of DVT should be initiated before the patient is put to sleep — not after the operation. Any abdominal procedure lasting longer than 30 minutes is associated with a moderate risk of DVT; you can add to this specific risk factors such as smoking, the use of oral contraceptives, a previous history of DVT, age, obesity, cancer, and so forth. Instead of pondering too much — why not provide all your patients undergoing an emergency abdominal operation with DVT prophylaxis? Whether it is in the form of subcutaneous heparin or calf compression depends on what your OR can offer. Bear in mind that anticoagulation is not good for an exsanguinating patient! We have seen young patients dropping dead from pulmonary embolism a few days after appendectomy and young women developing intractable post-phlebitic syndromes following appendectomy performed for pelvic inflammatory disease. Always think about this.\\n\\n- **Is the bladder empty?** Most patients undergoing major emergency operations arrive at the OR with a urinary catheter in place; in the...\\n```\\n\\n*Note: The text extraction is complete, but the content is truncated at the end. There are no images, graphs, or tables identified on this page.*',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Preparation Guidelines',\n", " 'md': '## Surgical Preparation Guidelines',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Cancel the operation or decide on a different incision.** Fine details on the CT may help you to plan the operation. It can show, for example, the safest place to enter the abdomen and avoid bowel loops adherent to the anterior abdominal wall.\\n\\n- **Position the patient.** Before you start, you should have a general idea of what you are going to do or what you may have to do. This impacts your patient’s position. For example, does the patient need a Lloyd-Davies position, offering access to the anus and rectum? This may be needed during colorectal procedures — to insert a scope, decompress the colon, or insert a stapler. You do not want to have to stop the operation and place the patient in the correct position or to send the intern crawling under soggy drapes playing peek-a-boo with the anus. In whatever position your patient is to be, check that all limbs are protected and well padded at potential pressure sites. Poor positioning on the OR table may result in damage to nerves, skin ulceration, and compartment syndrome of the extremities — and a lawsuit.\\n\\n- **Warm your patient.** Ensure that the patient is well covered and warmed. Hypothermia increases the likelihood of postoperative infections and contributes to intra-operative coagulopathy.\\n\\n- **Think about preventing deep vein thrombosis (DVT).** Prevention of DVT should be initiated before the patient is put to sleep — not after the operation. Any abdominal procedure lasting longer than 30 minutes is associated with a moderate risk of DVT; you can add to this specific risk factors such as smoking, the use of oral contraceptives, a previous history of DVT, age, obesity, cancer, and so forth. Instead of pondering too much — why not provide all your patients undergoing an emergency abdominal operation with DVT prophylaxis? Whether it is in the form of subcutaneous heparin or calf compression depends on what your OR can offer. Bear in mind that anticoagulation is not good for an exsanguinating patient! We have seen young patients dropping dead from pulmonary embolism a few days after appendectomy and young women developing intractable post-phlebitic syndromes following appendectomy performed for pelvic inflammatory disease. Always think about this.\\n\\n- **Is the bladder empty?** Most patients undergoing major emergency operations arrive at the OR with a urinary catheter in place; in the...\\n```\\n\\n*Note: The text extraction is complete, but the content is truncated at the end. There are no images, graphs, or tables identified on this page.*',\n", " 'md': '- **Cancel the operation or decide on a different incision.** Fine details on the CT may help you to plan the operation. It can show, for example, the safest place to enter the abdomen and avoid bowel loops adherent to the anterior abdominal wall.\\n\\n- **Position the patient.** Before you start, you should have a general idea of what you are going to do or what you may have to do. This impacts your patient’s position. For example, does the patient need a Lloyd-Davies position, offering access to the anus and rectum? This may be needed during colorectal procedures — to insert a scope, decompress the colon, or insert a stapler. You do not want to have to stop the operation and place the patient in the correct position or to send the intern crawling under soggy drapes playing peek-a-boo with the anus. In whatever position your patient is to be, check that all limbs are protected and well padded at potential pressure sites. Poor positioning on the OR table may result in damage to nerves, skin ulceration, and compartment syndrome of the extremities — and a lawsuit.\\n\\n- **Warm your patient.** Ensure that the patient is well covered and warmed. Hypothermia increases the likelihood of postoperative infections and contributes to intra-operative coagulopathy.\\n\\n- **Think about preventing deep vein thrombosis (DVT).** Prevention of DVT should be initiated before the patient is put to sleep — not after the operation. Any abdominal procedure lasting longer than 30 minutes is associated with a moderate risk of DVT; you can add to this specific risk factors such as smoking, the use of oral contraceptives, a previous history of DVT, age, obesity, cancer, and so forth. Instead of pondering too much — why not provide all your patients undergoing an emergency abdominal operation with DVT prophylaxis? Whether it is in the form of subcutaneous heparin or calf compression depends on what your OR can offer. Bear in mind that anticoagulation is not good for an exsanguinating patient! We have seen young patients dropping dead from pulmonary embolism a few days after appendectomy and young women developing intractable post-phlebitic syndromes following appendectomy performed for pelvic inflammatory disease. Always think about this.\\n\\n- **Is the bladder empty?** Most patients undergoing major emergency operations arrive at the OR with a urinary catheter in place; in the...\\n```\\n\\n*Note: The text extraction is complete, but the content is truncated at the end. There are no images, graphs, or tables identified on this page.*',\n", " 'bBox': {'x': 100, 'y': 135, 'w': 436.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 127,\n", " 'text': ' rest you will insert the catheter on the OR table. But if contemplating\\n a lower abdominal procedure on a non-catheterized patient you\\n have to check that the bladder is empty. When the bladder is full it\\n may look to you like the peritoneum — we have seen residents\\n opening the bladder in search of the appendix . Bladder distension\\n may also mimic a surgical abdominal condition, not rare in a\\n mentally challenged patient. It is your job to see that the nurses\\n insert the Foley properly. Even a senior RN is capable of inflating the\\n balloon in the urethra, causing massive hematuria. We have seen it\\n all.\\n • Think antibiotic prophylaxis (see Chapter 7).\\n • Document everything (see Chapter 8).\\n Now you can go and scrub. While doing so, continue to think and\\ncontemplate what you are going to do. Go through the anticipated phases\\nof the operation, refresh the different strategies and options available,\\nthink about additional equipment you might be needing, and finally, look\\nin the mirror and give yourself an encouraging nod — what a great\\nprofession this is! Don’t I look great with that mask covering my face?!\\n\\n Remember: Many lives have been saved by a moment\\n of reflection at the scrub sink.\\n Neal R. Reisman\\n\\n But do not behave like Tolstoy’s surgeon in War and Peace: “ħe…\\njoked… and chatted carelessly, as a famous surgeon confident that he\\nknows his job will often chat while he tucks up his sleeves and puts on\\nhis apron, and the patient is being strapped to the operating table. ‘I have\\nthe whole business at my finger-tips, and it’s all clear and definite in my\\nhead. When the time comes to set to work I shall do it as no one else\\ncould, but now I can jest, and the more I jest and the cooler I am the\\nmore hopeful and reassured you ought to feel, and the more you may\\nwonder at my genius.’”\\n\\n You are the captain of the ship — behave like one; the sight of a\\neuphoric surgeon dramatically entering the room with his scrubbed',\n", " 'md': '```markdown\\n## Page Content\\n\\nWhen contemplating a lower abdominal procedure on a non-catheterized patient, you have to check that the bladder is empty. When the bladder is full, it may look to you like the peritoneum — we have seen residents opening the bladder in search of the appendix. Bladder distension may also mimic a surgical abdominal condition, not rare in a mentally challenged patient. It is your job to see that the nurses insert the Foley properly. Even a senior RN is capable of inflating the balloon in the urethra, causing massive hematuria. We have seen it all.\\n\\n- Think antibiotic prophylaxis (see Chapter 7).\\n- Document everything (see Chapter 8).\\n\\nNow you can go and scrub. While doing so, continue to think and contemplate what you are going to do. Go through the anticipated phases of the operation, refresh the different strategies and options available, think about additional equipment you might be needing, and finally, look in the mirror and give yourself an encouraging nod — what a great profession this is! Don’t I look great with that mask covering my face?!\\n\\nRemember: Many lives have been saved by a moment of reflection at the scrub sink.\\n— Neal R. Reisman\\n\\nBut do not behave like Tolstoy’s surgeon in War and Peace: “He… joked… and chatted carelessly, as a famous surgeon confident that he knows his job will often chat while he tucks up his sleeves and puts on his apron, and the patient is being strapped to the operating table. ‘I have the whole business at my finger-tips, and it’s all clear and definite in my head. When the time comes to set to work I shall do it as no one else could, but now I can jest, and the more I jest and the cooler I am the more hopeful and reassured you ought to feel, and the more you may wonder at my genius.’”\\n\\nYou are the captain of the ship — behave like one; the sight of a euphoric surgeon dramatically entering the room with his scrubbed...\\n\\n## Notes\\n\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text includes references to chapters but does not provide hyperlinks or specific content from those chapters.\\n```',\n", " 'images': [{'name': 'img_p126_1.png',\n", " 'height': 19,\n", " 'width': 17,\n", " 'x': 398.15999999999985,\n", " 'y': 140.39999999999998}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'When contemplating a lower abdominal procedure on a non-catheterized patient, you have to check that the bladder is empty. When the bladder is full, it may look to you like the peritoneum — we have seen residents opening the bladder in search of the appendix. Bladder distension may also mimic a surgical abdominal condition, not rare in a mentally challenged patient. It is your job to see that the nurses insert the Foley properly. Even a senior RN is capable of inflating the balloon in the urethra, causing massive hematuria. We have seen it all.\\n\\n- Think antibiotic prophylaxis (see Chapter 7).\\n- Document everything (see Chapter 8).\\n\\nNow you can go and scrub. While doing so, continue to think and contemplate what you are going to do. Go through the anticipated phases of the operation, refresh the different strategies and options available, think about additional equipment you might be needing, and finally, look in the mirror and give yourself an encouraging nod — what a great profession this is! Don’t I look great with that mask covering my face?!\\n\\nRemember: Many lives have been saved by a moment of reflection at the scrub sink.\\n— Neal R. Reisman\\n\\nBut do not behave like Tolstoy’s surgeon in War and Peace: “He… joked… and chatted carelessly, as a famous surgeon confident that he knows his job will often chat while he tucks up his sleeves and puts on his apron, and the patient is being strapped to the operating table. ‘I have the whole business at my finger-tips, and it’s all clear and definite in my head. When the time comes to set to work I shall do it as no one else could, but now I can jest, and the more I jest and the cooler I am the more hopeful and reassured you ought to feel, and the more you may wonder at my genius.’”\\n\\nYou are the captain of the ship — behave like one; the sight of a euphoric surgeon dramatically entering the room with his scrubbed...',\n", " 'md': 'When contemplating a lower abdominal procedure on a non-catheterized patient, you have to check that the bladder is empty. When the bladder is full, it may look to you like the peritoneum — we have seen residents opening the bladder in search of the appendix. Bladder distension may also mimic a surgical abdominal condition, not rare in a mentally challenged patient. It is your job to see that the nurses insert the Foley properly. Even a senior RN is capable of inflating the balloon in the urethra, causing massive hematuria. We have seen it all.\\n\\n- Think antibiotic prophylaxis (see Chapter 7).\\n- Document everything (see Chapter 8).\\n\\nNow you can go and scrub. While doing so, continue to think and contemplate what you are going to do. Go through the anticipated phases of the operation, refresh the different strategies and options available, think about additional equipment you might be needing, and finally, look in the mirror and give yourself an encouraging nod — what a great profession this is! Don’t I look great with that mask covering my face?!\\n\\nRemember: Many lives have been saved by a moment of reflection at the scrub sink.\\n— Neal R. Reisman\\n\\nBut do not behave like Tolstoy’s surgeon in War and Peace: “He… joked… and chatted carelessly, as a famous surgeon confident that he knows his job will often chat while he tucks up his sleeves and puts on his apron, and the patient is being strapped to the operating table. ‘I have the whole business at my finger-tips, and it’s all clear and definite in my head. When the time comes to set to work I shall do it as no one else could, but now I can jest, and the more I jest and the cooler I am the more hopeful and reassured you ought to feel, and the more you may wonder at my genius.’”\\n\\nYou are the captain of the ship — behave like one; the sight of a euphoric surgeon dramatically entering the room with his scrubbed...',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Notes',\n", " 'md': '## Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text includes references to chapters but does not provide hyperlinks or specific content from those chapters.\\n```',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text includes references to chapters but does not provide hyperlinks or specific content from those chapters.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 128,\n", " 'text': 'hands held high in the air is pitiful.\\n\\n “Poor judgment is responsible for much bad surgery,\\n including the withholding of operations that are\\n necessary or advisable, the performance of unnecessary\\n and superfluous operations, and the performance of\\n inefficient, imperfect, and wrongly chosen ones.”\\n Charles F. M. Saint\\n “The surgeon, like the captain of the ship or a pilot of an\\n aircraft, is responsible for everything that happened. His\\n word is the only one that cannot be gainsaid.”\\n Francis D. Moore',\n", " 'md': '```markdown\\n## Page Content\\n\\n\"Poor judgment is responsible for much bad surgery, including the withholding of operations that are necessary or advisable, the performance of unnecessary and superfluous operations, and the performance of inefficient, imperfect, and wrongly chosen ones.\"\\n— Charles F. M. Saint\\n\\n\"The surgeon, like the captain of the ship or a pilot of an aircraft, is responsible for everything that happened. His word is the only one that cannot be gainsaid.\"\\n— Francis D. Moore\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '\"Poor judgment is responsible for much bad surgery, including the withholding of operations that are necessary or advisable, the performance of unnecessary and superfluous operations, and the performance of inefficient, imperfect, and wrongly chosen ones.\"\\n— Charles F. M. Saint\\n\\n\"The surgeon, like the captain of the ship or a pilot of an aircraft, is responsible for everything that happened. His word is the only one that cannot be gainsaid.\"\\n— Francis D. Moore\\n```',\n", " 'md': '\"Poor judgment is responsible for much bad surgery, including the withholding of operations that are necessary or advisable, the performance of unnecessary and superfluous operations, and the performance of inefficient, imperfect, and wrongly chosen ones.\"\\n— Charles F. M. Saint\\n\\n\"The surgeon, like the captain of the ship or a pilot of an aircraft, is responsible for everything that happened. His word is the only one that cannot be gainsaid.\"\\n— Francis D. Moore\\n```',\n", " 'bBox': {'x': 79, 'y': 152, 'w': 453.63, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 129,\n", " 'text': ' PART III\\n\\nThe operation',\n", " 'md': '# Part III\\n\\nThe operation',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Part III',\n", " 'md': '# Part III',\n", " 'bBox': {'x': 253, 'y': 172, 'w': 105.61, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': 'The operation',\n", " 'md': 'The operation',\n", " 'bBox': {'x': 210, 'y': 235, 'w': 190.33, 'h': 28.8}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 130,\n", " 'text': 'Chapter 10\\nThe incision\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and\\nJonathan E. Efron 1\\n\\n Incisions heal from side to side, not from end to end, but\\n length (as you may know) does matter.\\n When entering the abdomen, your finger is the best and\\n safest instrument.\\n\\n Have you ever heard about the novel concept of\\n‘macrolaparotomy’ — that it is possible and sometimes advisable to\\nenter the abdominal cavity by cutting into it directly? Yes, with a\\nknife, without inserting scopes or trocars! Did you know that this cutting-\\nedge method may be useful — particularly in emergency surgery? This\\nchapter is dedicated to this bold approach of open abdominal entry —\\nread about laparoscopic access in Chapter 12.\\n\\n The patient now lies on the table, anesthetized and ready for your\\nknife. Before you scrub, carefully examine the relaxed abdomen. Now\\nyou can feel things which were impossible to feel in the tense and tender\\nbelly. You may feel a distended gallbladder in a patient diagnosed as an\\nacute appendicitis, or an appendiceal mass in a patient booked for a\\ncholecystectomy. Yes, this can still occur in the era of ultrasound and CT,\\nespecially when and where imaging has been skirted or is not available.\\n\\n Traditionally, abdominal entry in an emergency situation or for\\nexploratory purposes has been through a generous and easily',\n", " 'md': '```markdown\\n# Chapter 10: The Incision\\n\\n**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\nIncisions heal from side to side, not from end to end, but length (as you may know) does matter. When entering the abdomen, your finger is the best and safest instrument.\\n\\nHave you ever heard about the novel concept of ‘macrolaparotomy’ — that it is possible and sometimes advisable to enter the abdominal cavity by cutting into it directly? Yes, with a knife, without inserting scopes or trocars! Did you know that this cutting-edge method may be useful — particularly in emergency surgery? This chapter is dedicated to this bold approach of open abdominal entry — read about laparoscopic access in [Chapter 12](#).\\n\\nThe patient now lies on the table, anesthetized and ready for your knife. Before you scrub, carefully examine the relaxed abdomen. Now you can feel things which were impossible to feel in the tense and tender belly. You may feel a distended gallbladder in a patient diagnosed as an acute appendicitis, or an appendiceal mass in a patient booked for a cholecystectomy. Yes, this can still occur in the era of ultrasound and CT, especially when and where imaging has been skirted or is not available.\\n\\nTraditionally, abdominal entry in an emergency situation or for exploratory purposes has been through a generous and easily...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 10: The Incision',\n", " 'md': '# Chapter 10: The Incision',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 148.79, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\nIncisions heal from side to side, not from end to end, but length (as you may know) does matter. When entering the abdomen, your finger is the best and safest instrument.\\n\\nHave you ever heard about the novel concept of ‘macrolaparotomy’ — that it is possible and sometimes advisable to enter the abdominal cavity by cutting into it directly? Yes, with a knife, without inserting scopes or trocars! Did you know that this cutting-edge method may be useful — particularly in emergency surgery? This chapter is dedicated to this bold approach of open abdominal entry — read about laparoscopic access in [Chapter 12](#).\\n\\nThe patient now lies on the table, anesthetized and ready for your knife. Before you scrub, carefully examine the relaxed abdomen. Now you can feel things which were impossible to feel in the tense and tender belly. You may feel a distended gallbladder in a patient diagnosed as an acute appendicitis, or an appendiceal mass in a patient booked for a cholecystectomy. Yes, this can still occur in the era of ultrasound and CT, especially when and where imaging has been skirted or is not available.\\n\\nTraditionally, abdominal entry in an emergency situation or for exploratory purposes has been through a generous and easily...\\n```',\n", " 'md': '**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\nIncisions heal from side to side, not from end to end, but length (as you may know) does matter. When entering the abdomen, your finger is the best and safest instrument.\\n\\nHave you ever heard about the novel concept of ‘macrolaparotomy’ — that it is possible and sometimes advisable to enter the abdominal cavity by cutting into it directly? Yes, with a knife, without inserting scopes or trocars! Did you know that this cutting-edge method may be useful — particularly in emergency surgery? This chapter is dedicated to this bold approach of open abdominal entry — read about laparoscopic access in [Chapter 12](#).\\n\\nThe patient now lies on the table, anesthetized and ready for your knife. Before you scrub, carefully examine the relaxed abdomen. Now you can feel things which were impossible to feel in the tense and tender belly. You may feel a distended gallbladder in a patient diagnosed as an acute appendicitis, or an appendiceal mass in a patient booked for a cholecystectomy. Yes, this can still occur in the era of ultrasound and CT, especially when and where imaging has been skirted or is not available.\\n\\nTraditionally, abdominal entry in an emergency situation or for exploratory purposes has been through a generous and easily...\\n```',\n", " 'bBox': {'x': 72, 'y': 348, 'w': 468.01, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Jonathan E. Efron 1'}, {'text': ''}]},\n", " {'page': 131,\n", " 'text': 'extensible vertical incision, especially a midline one. Generally\\nspeaking, the trans linea alba midline incision is swiftly effected and\\nrelatively bloodless. On the other hand, transverse incisions are a little\\nmore time- and blood-consuming but are associated with a lower\\nincidence of wound dehiscence and incisional hernia formation. In\\naddition, transverse incisions are known to be ‘easier’ on the patient and\\nhis lung function in the postoperative period, require less retraction, and\\nallow better exposure in the ‘wide and short’ patient. Vertical\\nparamedian incisions largely belong to history.\\n\\n Keeping this in mind, we should be pragmatic rather than dogmatic\\nand tailor the incision to the individual patient and his or her disease\\nprocess. We should take into consideration the urgency of the\\nsituation, the site and nature of the condition, the confidence in (or\\nuncertainty about) the pre-operative diagnosis, and the build of the\\npatient.\\n\\n Common sense dictates that the most direct access to the\\nspecific intra-abdominal pathology is preferable. Thus, the biliary\\nsystem is best approached through a right subcostal (‘Kocher’) incision.\\nTransverse incisions are easily extended to offer additional exposure; a\\nright subcostal incision can be extended into the left side (as a ‘chevron’),\\noffering an excellent view of the entire abdomen. When a normal\\nappendix is uncovered through a limited, transverse/oblique, muscle-\\nsplitting, right lower quadrant incision, one can extend it by cutting the\\nmuscles across the midline to deal with any intestinal or pelvic condition.\\nAlternatively, when an upper abdominal process is found, it is perfectly\\nreasonable to close the small right iliac fossa incision and place a new,\\nmore appropriate, one. Two good incisions are better than one,\\npoorly placed.\\n\\n Old Finnish surgical proverb: “Surgery is easier when the incision is placed over the organ to be\\n operated on.” Ari\\n\\n The midline incision is bloodless, rapid, and easily extended,\\naffording superior exposure and versatility; it remains the classic\\n‘incision of indecision’ — when the site of the abdominal catastrophe is',\n", " 'md': '```markdown\\n## Surgical Incisions\\n\\nAn extensible vertical incision, especially a midline one, is generally swift and relatively bloodless. In contrast, transverse incisions are more time-consuming and blood-consuming but are associated with a lower incidence of wound dehiscence and incisional hernia formation. Additionally, transverse incisions are known to be ‘easier’ on the patient and his lung function in the postoperative period, require less retraction, and allow better exposure in the ‘wide and short’ patient. Vertical paramedian incisions largely belong to history.\\n\\nKeeping this in mind, we should be pragmatic rather than dogmatic and tailor the incision to the individual patient and his or her disease process. Considerations should include the urgency of the situation, the site and nature of the condition, the confidence in (or uncertainty about) the pre-operative diagnosis, and the build of the patient.\\n\\nCommon sense dictates that the most direct access to the specific intra-abdominal pathology is preferable. Thus, the biliary system is best approached through a right subcostal (‘Kocher’) incision. Transverse incisions are easily extended to offer additional exposure; a right subcostal incision can be extended into the left side (as a ‘chevron’), offering an excellent view of the entire abdomen. When a normal appendix is uncovered through a limited, transverse/oblique, muscle-splitting, right lower quadrant incision, one can extend it by cutting the muscles across the midline to deal with any intestinal or pelvic condition. Alternatively, when an upper abdominal process is found, it is perfectly reasonable to close the small right iliac fossa incision and place a new, more appropriate one. Two good incisions are better than one poorly placed.\\n\\n> **Old Finnish surgical proverb:** “Surgery is easier when the incision is placed over the organ to be operated on.” - Ari\\n\\nThe midline incision is bloodless, rapid, and easily extended, affording superior exposure and versatility; it remains the classic ‘incision of indecision’ — when the site of the abdominal catastrophe is uncertain.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Incisions',\n", " 'md': '## Surgical Incisions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'An extensible vertical incision, especially a midline one, is generally swift and relatively bloodless. In contrast, transverse incisions are more time-consuming and blood-consuming but are associated with a lower incidence of wound dehiscence and incisional hernia formation. Additionally, transverse incisions are known to be ‘easier’ on the patient and his lung function in the postoperative period, require less retraction, and allow better exposure in the ‘wide and short’ patient. Vertical paramedian incisions largely belong to history.\\n\\nKeeping this in mind, we should be pragmatic rather than dogmatic and tailor the incision to the individual patient and his or her disease process. Considerations should include the urgency of the situation, the site and nature of the condition, the confidence in (or uncertainty about) the pre-operative diagnosis, and the build of the patient.\\n\\nCommon sense dictates that the most direct access to the specific intra-abdominal pathology is preferable. Thus, the biliary system is best approached through a right subcostal (‘Kocher’) incision. Transverse incisions are easily extended to offer additional exposure; a right subcostal incision can be extended into the left side (as a ‘chevron’), offering an excellent view of the entire abdomen. When a normal appendix is uncovered through a limited, transverse/oblique, muscle-splitting, right lower quadrant incision, one can extend it by cutting the muscles across the midline to deal with any intestinal or pelvic condition. Alternatively, when an upper abdominal process is found, it is perfectly reasonable to close the small right iliac fossa incision and place a new, more appropriate one. Two good incisions are better than one poorly placed.\\n\\n> **Old Finnish surgical proverb:** “Surgery is easier when the incision is placed over the organ to be operated on.” - Ari\\n\\nThe midline incision is bloodless, rapid, and easily extended, affording superior exposure and versatility; it remains the classic ‘incision of indecision’ — when the site of the abdominal catastrophe is uncertain.\\n```',\n", " 'md': 'An extensible vertical incision, especially a midline one, is generally swift and relatively bloodless. In contrast, transverse incisions are more time-consuming and blood-consuming but are associated with a lower incidence of wound dehiscence and incisional hernia formation. Additionally, transverse incisions are known to be ‘easier’ on the patient and his lung function in the postoperative period, require less retraction, and allow better exposure in the ‘wide and short’ patient. Vertical paramedian incisions largely belong to history.\\n\\nKeeping this in mind, we should be pragmatic rather than dogmatic and tailor the incision to the individual patient and his or her disease process. Considerations should include the urgency of the situation, the site and nature of the condition, the confidence in (or uncertainty about) the pre-operative diagnosis, and the build of the patient.\\n\\nCommon sense dictates that the most direct access to the specific intra-abdominal pathology is preferable. Thus, the biliary system is best approached through a right subcostal (‘Kocher’) incision. Transverse incisions are easily extended to offer additional exposure; a right subcostal incision can be extended into the left side (as a ‘chevron’), offering an excellent view of the entire abdomen. When a normal appendix is uncovered through a limited, transverse/oblique, muscle-splitting, right lower quadrant incision, one can extend it by cutting the muscles across the midline to deal with any intestinal or pelvic condition. Alternatively, when an upper abdominal process is found, it is perfectly reasonable to close the small right iliac fossa incision and place a new, more appropriate one. Two good incisions are better than one poorly placed.\\n\\n> **Old Finnish surgical proverb:** “Surgery is easier when the incision is placed over the organ to be operated on.” - Ari\\n\\nThe midline incision is bloodless, rapid, and easily extended, affording superior exposure and versatility; it remains the classic ‘incision of indecision’ — when the site of the abdominal catastrophe is uncertain.\\n```',\n", " 'bBox': {'x': 72, 'y': 185, 'w': 468, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 132,\n", " 'text': 'unknown, and is the safest approach in trauma. Sometimes even a long\\nmidline incision is not enough, and you need to make an additional\\ntransverse incision to gain exposure to the deep lateral or posterior\\nareas. If needed, don’t hesitate to do it. And conversely, a ‘chevron’\\nincision can be enlarged by a midline upper extension, creating a\\n‘Mercedes’ incision. (Ask your hepatic surgeon about his favourite\\nincision… and vehicle.)\\n\\n This is the time to mention that an emergency laparotomy without\\na diagnosis is not a sin! Yes, a patient can enter the operating theater\\nwithout a ticket from the CT scanner. A clinical acute abdomen — when\\nother diagnoses have been ruled out (see Chapters 3 and 4) —\\nremains an indication for laparotomy when the abdominal wall is the only\\nstructure separating the surgeon from an accurate diagnosis. ħaving said\\nthis — mainly to satisfy and pacify those of you who work under adverse\\ncircumstances (e.g. we have visited a city hospital in Eastern Europe\\nwhere patients had to travel by ambulance for a CT!) — we have to\\nstress that pre-operative abdominal imaging (see Chapter 5) not\\nonly pinpoints the diagnosis but also is of great help in choosing\\nthe correct incision. For example, in a patient needing splenectomy for\\na delayed rupture of the spleen we would place a left subcostal incision\\nrather than a midline one. The CT has shown us that this is an isolated\\nsplenic injury and there is no need to explore the rest of the abdomen.\\n\\n At what level must the midline incision start and how\\n long should it be? ( Figure 10.1)',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nunknown, and is the safest approach in trauma. Sometimes even a long midline incision is not enough, and you need to make an additional transverse incision to gain exposure to the deep lateral or posterior areas. If needed, don’t hesitate to do it. And conversely, a ‘chevron’ incision can be enlarged by a midline upper extension, creating a ‘Mercedes’ incision. (Ask your hepatic surgeon about his favourite incision… and vehicle.)\\n\\nThis is the time to mention that an emergency laparotomy without a diagnosis is not a sin! Yes, a patient can enter the operating theater without a ticket from the CT scanner. A clinical acute abdomen — when other diagnoses have been ruled out (see Chapters 3 and 4) — remains an indication for laparotomy when the abdominal wall is the only structure separating the surgeon from an accurate diagnosis. Having said this — mainly to satisfy and pacify those of you who work under adverse circumstances (e.g. we have visited a city hospital in Eastern Europe where patients had to travel by ambulance for a CT!) — we have to stress that pre-operative abdominal imaging (see Chapter 5) not only pinpoints the diagnosis but also is of great help in choosing the correct incision. For example, in a patient needing splenectomy for a delayed rupture of the spleen we would place a left subcostal incision rather than a midline one. The CT has shown us that this is an isolated splenic injury and there is no need to explore the rest of the abdomen.\\n\\nAt what level must the midline incision start and how long should it be? (Figure 10.1)\\n\\n## Image Identification and Description\\n\\n**Figure 10.1**: This figure likely illustrates the anatomical location and length of a midline incision in relation to the abdominal cavity. The image may include markings or annotations indicating the starting point and extent of the incision. The purpose of this figure is to provide a visual guide for surgeons on how to properly execute a midline incision during surgical procedures.\\n\\n**Summary**: The figure serves as a reference for surgical practice, emphasizing the importance of incision placement based on the specific clinical scenario.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'unknown, and is the safest approach in trauma. Sometimes even a long midline incision is not enough, and you need to make an additional transverse incision to gain exposure to the deep lateral or posterior areas. If needed, don’t hesitate to do it. And conversely, a ‘chevron’ incision can be enlarged by a midline upper extension, creating a ‘Mercedes’ incision. (Ask your hepatic surgeon about his favourite incision… and vehicle.)\\n\\nThis is the time to mention that an emergency laparotomy without a diagnosis is not a sin! Yes, a patient can enter the operating theater without a ticket from the CT scanner. A clinical acute abdomen — when other diagnoses have been ruled out (see Chapters 3 and 4) — remains an indication for laparotomy when the abdominal wall is the only structure separating the surgeon from an accurate diagnosis. Having said this — mainly to satisfy and pacify those of you who work under adverse circumstances (e.g. we have visited a city hospital in Eastern Europe where patients had to travel by ambulance for a CT!) — we have to stress that pre-operative abdominal imaging (see Chapter 5) not only pinpoints the diagnosis but also is of great help in choosing the correct incision. For example, in a patient needing splenectomy for a delayed rupture of the spleen we would place a left subcostal incision rather than a midline one. The CT has shown us that this is an isolated splenic injury and there is no need to explore the rest of the abdomen.\\n\\nAt what level must the midline incision start and how long should it be? (Figure 10.1)',\n", " 'md': 'unknown, and is the safest approach in trauma. Sometimes even a long midline incision is not enough, and you need to make an additional transverse incision to gain exposure to the deep lateral or posterior areas. If needed, don’t hesitate to do it. And conversely, a ‘chevron’ incision can be enlarged by a midline upper extension, creating a ‘Mercedes’ incision. (Ask your hepatic surgeon about his favourite incision… and vehicle.)\\n\\nThis is the time to mention that an emergency laparotomy without a diagnosis is not a sin! Yes, a patient can enter the operating theater without a ticket from the CT scanner. A clinical acute abdomen — when other diagnoses have been ruled out (see Chapters 3 and 4) — remains an indication for laparotomy when the abdominal wall is the only structure separating the surgeon from an accurate diagnosis. Having said this — mainly to satisfy and pacify those of you who work under adverse circumstances (e.g. we have visited a city hospital in Eastern Europe where patients had to travel by ambulance for a CT!) — we have to stress that pre-operative abdominal imaging (see Chapter 5) not only pinpoints the diagnosis but also is of great help in choosing the correct incision. For example, in a patient needing splenectomy for a delayed rupture of the spleen we would place a left subcostal incision rather than a midline one. The CT has shown us that this is an isolated splenic injury and there is no need to explore the rest of the abdomen.\\n\\nAt what level must the midline incision start and how long should it be? (Figure 10.1)',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.91, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 10.1**: This figure likely illustrates the anatomical location and length of a midline incision in relation to the abdominal cavity. The image may include markings or annotations indicating the starting point and extent of the incision. The purpose of this figure is to provide a visual guide for surgeons on how to properly execute a midline incision during surgical procedures.\\n\\n**Summary**: The figure serves as a reference for surgical practice, emphasizing the importance of incision placement based on the specific clinical scenario.\\n```',\n", " 'md': '**Figure 10.1**: This figure likely illustrates the anatomical location and length of a midline incision in relation to the abdominal cavity. The image may include markings or annotations indicating the starting point and extent of the incision. The purpose of this figure is to provide a visual guide for surgeons on how to properly execute a midline incision during surgical procedures.\\n\\n**Summary**: The figure serves as a reference for surgical practice, emphasizing the importance of incision placement based on the specific clinical scenario.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'remains an indication for laparotomy when the abdominal wall is the only'},\n", " {'text': 'remains an indication for laparotomy when the abdominal wall is the only'},\n", " {'text': 'only pinpoints the diagnosis but also is of great help in choosing'},\n", " {'text': ''}]},\n", " {'page': 133,\n", " 'text': ' Aerya\\n Figure 10.1. “Which incision?”\\n\\n The macho surgeons of previous generations often screamed: “Make it\\nlong. It heals from side to side, not from end to end.” Today, in the era of\\nminimal access surgery, we are familiar with the advantages of shorter\\nincisions. In the absence of any obvious urgency, enter the abdomen\\nthrough a short incision and then extend as necessary; but never\\naccept less than adequate exposure or strive for keyhole surgery.\\nBegin with an upper or lower midline incision, directed by your\\nclinical/imaging assessment; when in doubt, start near the level of the\\numbilicus and ‘sniff’ around from there, then extend towards the\\npathology. Just remember what the famous Swiss surgeon, Theodor\\nKocher, said more than 100 years ago: “The incision must be as long\\nas necessary and as short as possible.” Smart, eh? Before you\\ncontinue we want you to read a little about ħerr Kocher (go to\\nhttp://www.nobelprize.org/nobel_prizes/medicine/laureates/1909/kocher-\\nbio.html).\\n\\n When should you extend the incision into the thorax?',\n", " 'md': \"```markdown\\n# Page Content\\n\\n## Figure 10.1. “Which incision?”\\n\\nThe macho surgeons of previous generations often screamed: “Make it long. It heals from side to side, not from end to end.” Today, in the era of minimal access surgery, we are familiar with the advantages of shorter incisions. In the absence of any obvious urgency, enter the abdomen through a short incision and then extend as necessary; but never accept less than adequate exposure or strive for keyhole surgery. Begin with an upper or lower midline incision, directed by your clinical/imaging assessment; when in doubt, start near the level of the umbilicus and ‘sniff’ around from there, then extend towards the pathology. Just remember what the famous Swiss surgeon, Theodor Kocher, said more than 100 years ago: “The incision must be as long as necessary and as short as possible.” Smart, eh? Before you continue we want you to read a little about ħerr Kocher (go to [Nobel Prize - Kocher Bio](http://www.nobelprize.org/nobel_prizes/medicine/laureates/1909/kocher-bio.html)).\\n\\nWhen should you extend the incision into the thorax?\\n```\\n\\n### Image Description\\n- **Figure 10.1**: This figure likely illustrates different types of surgical incisions, emphasizing the contrast between traditional long incisions and modern shorter incisions used in minimal access surgery. The text discusses the philosophy behind incision length and provides guidance on when to extend an incision based on clinical assessment.\\n\\n### Summary\\nThe content emphasizes the evolution of surgical techniques, advocating for shorter incisions while maintaining adequate exposure. It references Theodor Kocher's famous quote on incision length, highlighting the balance between necessity and brevity in surgical practice. Additionally, it includes a hyperlink to further information about Kocher's contributions to medicine.\",\n", " 'images': [{'name': 'img_p132_1.png',\n", " 'height': 572,\n", " 'width': 789,\n", " 'x': 110.87999999999988,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1356,\n", " 'original_height': 982}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 10.1. “Which incision?”',\n", " 'md': '## Figure 10.1. “Which incision?”',\n", " 'bBox': {'x': 75, 'y': 386, 'w': 156.42, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': 'The macho surgeons of previous generations often screamed: “Make it long. It heals from side to side, not from end to end.” Today, in the era of minimal access surgery, we are familiar with the advantages of shorter incisions. In the absence of any obvious urgency, enter the abdomen through a short incision and then extend as necessary; but never accept less than adequate exposure or strive for keyhole surgery. Begin with an upper or lower midline incision, directed by your clinical/imaging assessment; when in doubt, start near the level of the umbilicus and ‘sniff’ around from there, then extend towards the pathology. Just remember what the famous Swiss surgeon, Theodor Kocher, said more than 100 years ago: “The incision must be as long as necessary and as short as possible.” Smart, eh? Before you continue we want you to read a little about ħerr Kocher (go to [Nobel Prize - Kocher Bio](http://www.nobelprize.org/nobel_prizes/medicine/laureates/1909/kocher-bio.html)).\\n\\nWhen should you extend the incision into the thorax?\\n```',\n", " 'md': 'The macho surgeons of previous generations often screamed: “Make it long. It heals from side to side, not from end to end.” Today, in the era of minimal access surgery, we are familiar with the advantages of shorter incisions. In the absence of any obvious urgency, enter the abdomen through a short incision and then extend as necessary; but never accept less than adequate exposure or strive for keyhole surgery. Begin with an upper or lower midline incision, directed by your clinical/imaging assessment; when in doubt, start near the level of the umbilicus and ‘sniff’ around from there, then extend towards the pathology. Just remember what the famous Swiss surgeon, Theodor Kocher, said more than 100 years ago: “The incision must be as long as necessary and as short as possible.” Smart, eh? Before you continue we want you to read a little about ħerr Kocher (go to [Nobel Prize - Kocher Bio](http://www.nobelprize.org/nobel_prizes/medicine/laureates/1909/kocher-bio.html)).\\n\\nWhen should you extend the incision into the thorax?\\n```',\n", " 'bBox': {'x': 72, 'y': 432, 'w': 467.92, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 10.1**: This figure likely illustrates different types of surgical incisions, emphasizing the contrast between traditional long incisions and modern shorter incisions used in minimal access surgery. The text discusses the philosophy behind incision length and provides guidance on when to extend an incision based on clinical assessment.',\n", " 'md': '- **Figure 10.1**: This figure likely illustrates different types of surgical incisions, emphasizing the contrast between traditional long incisions and modern shorter incisions used in minimal access surgery. The text discusses the philosophy behind incision length and provides guidance on when to extend an incision based on clinical assessment.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"The content emphasizes the evolution of surgical techniques, advocating for shorter incisions while maintaining adequate exposure. It references Theodor Kocher's famous quote on incision length, highlighting the balance between necessity and brevity in surgical practice. Additionally, it includes a hyperlink to further information about Kocher's contributions to medicine.\",\n", " 'md': \"The content emphasizes the evolution of surgical techniques, advocating for shorter incisions while maintaining adequate exposure. It references Theodor Kocher's famous quote on incision length, highlighting the balance between necessity and brevity in surgical practice. Additionally, it includes a hyperlink to further information about Kocher's contributions to medicine.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'url': 'http://www.nobelprize.org/nobel_prizes/medicine/laureates/1909/kocher-bio.html',\n", " 'text': 'http://www.nobelprize.org/nobel_prizes/medicine/laureates/1909/kocher- bio.html).'}]},\n", " {'page': 134,\n", " 'text': ' Very rarely! In the vast majority of cases, infra-diaphragmatic pathology\\nis approachable through abdominal incisions. The combination of a\\nsubcostal and upper midline incision offers an excellent exposure for\\nalmost all emergency hepatic procedures, with the exception of\\nretrohepatic venous injuries where insertion of a trans-atrial vena cava\\nshunt necessitates a median sternotomy — usually a futile exercise,\\nanyway. Thoracoabdominal incisions are mainly reserved for\\ncombined thoracoabdominal trauma (and rarely for tumors at the\\nesophagogastric junction which ‘climb’ up the esophagus). If not\\nabsolutely necessary, avoid extending the laparotomy incision to\\nthoracolaparotomy through the costal cartilage — it heals very poorly! In\\nmost cases, it is sufficient to do a separate anterolateral\\nthoracotomy incision. This can easily be extended to the other side for\\na ‘clamshell’ incision that offers an excellent view of all anterior thoracic\\nstructures. If you need to divide the diaphragm, do it laterally, curve-\\nshaped to avoid damage to the proximal branches of the phrenic\\nnerve. In some cases, rapid access to the pericardium during laparotomy\\n(suspected cardiac tamponade for example) is easily done through the\\ncentral tendon of the diaphragm by grasping the bare area of the\\npericardium with a Kocher’s clamp and opening the pericardium. If blood\\nis found, then extension of the laparotomy incision into a median\\nsternotomy is the best option.\\n\\n Knife or diathermy?\\n\\n A few studies suggest that the latter is a few minutes slower while the\\nformer sheds a few more drops of blood; otherwise results are\\ncomparable. We use either. In extreme urgency, gain immediate entry\\nwith a few swift strokes of the knife; otherwise, diathermy is convenient,\\nespecially when performing transverse muscle-cutting incisions.\\nAdequate hemostasis is a crucial surgical principle but do not go\\noverboard chasing individual erythrocytes and avoid reducing the\\nsubcutaneous fat or skin to charcoal. The hypothesis that “You can tell\\nhow bad the surgeon is by the stink of the Bovie (electrocautery) in his\\nOR” has not been proven by a double-blind randomized trial but makes\\nsense nonetheless.\\n\\n Subcutaneous hemostatic ligatures behave like a foreign body and are',\n", " 'md': '```markdown\\n## Surgical Approaches to Infra-Diaphragmatic Pathology\\n\\nVery rarely! In the vast majority of cases, infra-diaphragmatic pathology is approachable through abdominal incisions. The combination of a subcostal and upper midline incision offers an excellent exposure for almost all emergency hepatic procedures, with the exception of retrohepatic venous injuries where insertion of a trans-atrial vena cava shunt necessitates a median sternotomy — usually a futile exercise, anyway. Thoracoabdominal incisions are mainly reserved for combined thoracoabdominal trauma (and rarely for tumors at the esophagogastric junction which ‘climb’ up the esophagus). If not absolutely necessary, avoid extending the laparotomy incision to thoracolaparotomy through the costal cartilage — it heals very poorly! In most cases, it is sufficient to do a separate anterolateral thoracotomy incision. This can easily be extended to the other side for a ‘clamshell’ incision that offers an excellent view of all anterior thoracic structures. If you need to divide the diaphragm, do it laterally, curve-shaped to avoid damage to the proximal branches of the phrenic nerve. In some cases, rapid access to the pericardium during laparotomy (suspected cardiac tamponade for example) is easily done through the central tendon of the diaphragm by grasping the bare area of the pericardium with a Kocher’s clamp and opening the pericardium. If blood is found, then extension of the laparotomy incision into a median sternotomy is the best option.\\n\\n### Knife or Diathermy?\\n\\nA few studies suggest that the latter is a few minutes slower while the former sheds a few more drops of blood; otherwise, results are comparable. We use either. In extreme urgency, gain immediate entry with a few swift strokes of the knife; otherwise, diathermy is convenient, especially when performing transverse muscle-cutting incisions. Adequate hemostasis is a crucial surgical principle but do not go overboard chasing individual erythrocytes and avoid reducing the subcutaneous fat or skin to charcoal. The hypothesis that “You can tell how bad the surgeon is by the stink of the Bovie (electrocautery) in his OR” has not been proven by a double-blind randomized trial but makes sense nonetheless.\\n\\nSubcutaneous hemostatic ligatures behave like a foreign body and are\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Approaches to Infra-Diaphragmatic Pathology',\n", " 'md': '## Surgical Approaches to Infra-Diaphragmatic Pathology',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Very rarely! In the vast majority of cases, infra-diaphragmatic pathology is approachable through abdominal incisions. The combination of a subcostal and upper midline incision offers an excellent exposure for almost all emergency hepatic procedures, with the exception of retrohepatic venous injuries where insertion of a trans-atrial vena cava shunt necessitates a median sternotomy — usually a futile exercise, anyway. Thoracoabdominal incisions are mainly reserved for combined thoracoabdominal trauma (and rarely for tumors at the esophagogastric junction which ‘climb’ up the esophagus). If not absolutely necessary, avoid extending the laparotomy incision to thoracolaparotomy through the costal cartilage — it heals very poorly! In most cases, it is sufficient to do a separate anterolateral thoracotomy incision. This can easily be extended to the other side for a ‘clamshell’ incision that offers an excellent view of all anterior thoracic structures. If you need to divide the diaphragm, do it laterally, curve-shaped to avoid damage to the proximal branches of the phrenic nerve. In some cases, rapid access to the pericardium during laparotomy (suspected cardiac tamponade for example) is easily done through the central tendon of the diaphragm by grasping the bare area of the pericardium with a Kocher’s clamp and opening the pericardium. If blood is found, then extension of the laparotomy incision into a median sternotomy is the best option.',\n", " 'md': 'Very rarely! In the vast majority of cases, infra-diaphragmatic pathology is approachable through abdominal incisions. The combination of a subcostal and upper midline incision offers an excellent exposure for almost all emergency hepatic procedures, with the exception of retrohepatic venous injuries where insertion of a trans-atrial vena cava shunt necessitates a median sternotomy — usually a futile exercise, anyway. Thoracoabdominal incisions are mainly reserved for combined thoracoabdominal trauma (and rarely for tumors at the esophagogastric junction which ‘climb’ up the esophagus). If not absolutely necessary, avoid extending the laparotomy incision to thoracolaparotomy through the costal cartilage — it heals very poorly! In most cases, it is sufficient to do a separate anterolateral thoracotomy incision. This can easily be extended to the other side for a ‘clamshell’ incision that offers an excellent view of all anterior thoracic structures. If you need to divide the diaphragm, do it laterally, curve-shaped to avoid damage to the proximal branches of the phrenic nerve. In some cases, rapid access to the pericardium during laparotomy (suspected cardiac tamponade for example) is easily done through the central tendon of the diaphragm by grasping the bare area of the pericardium with a Kocher’s clamp and opening the pericardium. If blood is found, then extension of the laparotomy incision into a median sternotomy is the best option.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.66, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Knife or Diathermy?',\n", " 'md': '### Knife or Diathermy?',\n", " 'bBox': {'x': 86, 'y': 476, 'w': 156.31, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A few studies suggest that the latter is a few minutes slower while the former sheds a few more drops of blood; otherwise, results are comparable. We use either. In extreme urgency, gain immediate entry with a few swift strokes of the knife; otherwise, diathermy is convenient, especially when performing transverse muscle-cutting incisions. Adequate hemostasis is a crucial surgical principle but do not go overboard chasing individual erythrocytes and avoid reducing the subcutaneous fat or skin to charcoal. The hypothesis that “You can tell how bad the surgeon is by the stink of the Bovie (electrocautery) in his OR” has not been proven by a double-blind randomized trial but makes sense nonetheless.\\n\\nSubcutaneous hemostatic ligatures behave like a foreign body and are\\n```',\n", " 'md': 'A few studies suggest that the latter is a few minutes slower while the former sheds a few more drops of blood; otherwise, results are comparable. We use either. In extreme urgency, gain immediate entry with a few swift strokes of the knife; otherwise, diathermy is convenient, especially when performing transverse muscle-cutting incisions. Adequate hemostasis is a crucial surgical principle but do not go overboard chasing individual erythrocytes and avoid reducing the subcutaneous fat or skin to charcoal. The hypothesis that “You can tell how bad the surgeon is by the stink of the Bovie (electrocautery) in his OR” has not been proven by a double-blind randomized trial but makes sense nonetheless.\\n\\nSubcutaneous hemostatic ligatures behave like a foreign body and are\\n```',\n", " 'bBox': {'x': 72, 'y': 512, 'w': 467.82, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 135,\n", " 'text': 'almost never necessary. In practice, most incisional ‘oozers’ stop\\nspontaneously after a few minutes, under the pressure of a moist lap pad\\nor a temporary hemostat. If necessary, use well-directed diathermy to kill\\nthe bloody bleeder at the point where it emerges under the skin, and\\navoid burning blindly in a pool of blood. It is also unnecessary to ‘clean’\\nthe fascia by sweeping the fat laterally: the more you dissect and ‘burn’,\\nthe more inflammation and infection-generating dead tissue you\\ncreate!\\n\\n Keep in mind special circumstances:\\n\\n • If a stoma is anticipated then place the incision away from its\\n planned location. You don’t want the toilet in the kitchen!\\n • Abdominal re-entry into the ‘hostile abdomen’ of a previously\\n operated patient can be problematic. You may spend more time,\\n sweat and blood, but the real danger is creating inadvertent\\n enterotomies in intestine adherent to the previous incisional scar.\\n This is a common cause of postoperative external bowel fistula! (\\n Chapter 47). The prevailing opinion is to use the previous\\n incision for re-entry, if possible. When doing so, however, start a\\n few centimeters below or above the old incision and gain entry to the\\n abdomen through virgin territory. Then insert your finger into the\\n peritoneal cavity and navigate your way safely in, taking down\\n adhesions to the abdominal wall, which hamper the insertion of a\\n self-retaining retractor. Essentially, you are finished ‘getting in’ when\\n you are able to place a self-retaining retractor to open the abdomen\\n wide. In a dire emergency or when you expect the abdomen to be\\n exceptionally scarred, it may be prudent to stay away from trouble\\n and create an entirely fresh incision. In this situation beware of\\n parallel incisions in close proximity to one another because the\\n intervening skin may be at risk of necrosis, particularly if the first\\n incision is relatively recent.\\n\\n Remember: Sometimes, spending an hour to ‘get into the abdomen’ in order to do\\n a 5-minute procedure (e.g. release of an obstructing adhesion) is not a sign of a timid\\n surgeon but a judicious one! You may want to consider this mnemonic of abdominal entry\\n and exposure: ‘the 4 Ps’: patience, preservation, persistence, prudence. (Some surgeons may',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nIn practice, most incisional ‘oozers’ stop spontaneously after a few minutes, under the pressure of a moist lap pad or a temporary hemostat. If necessary, use well-directed diathermy to kill the bloody bleeder at the point where it emerges under the skin, and avoid burning blindly in a pool of blood. It is also unnecessary to ‘clean’ the fascia by sweeping the fat laterally: the more you dissect and ‘burn’, the more inflammation and infection-generating dead tissue you create!\\n\\nKeep in mind special circumstances:\\n\\n- If a stoma is anticipated then place the incision away from its planned location. You don’t want the toilet in the kitchen!\\n- Abdominal re-entry into the ‘hostile abdomen’ of a previously operated patient can be problematic. You may spend more time, sweat and blood, but the real danger is creating inadvertent enterotomies in intestine adherent to the previous incisional scar. This is a common cause of postoperative external bowel fistula! (Chapter 47). The prevailing opinion is to use the previous incision for re-entry, if possible. When doing so, however, start a few centimeters below or above the old incision and gain entry to the abdomen through virgin territory. Then insert your finger into the peritoneal cavity and navigate your way safely in, taking down adhesions to the abdominal wall, which hamper the insertion of a self-retaining retractor. Essentially, you are finished ‘getting in’ when you are able to place a self-retaining retractor to open the abdomen wide. In a dire emergency or when you expect the abdomen to be exceptionally scarred, it may be prudent to stay away from trouble and create an entirely fresh incision. In this situation beware of parallel incisions in close proximity to one another because the intervening skin may be at risk of necrosis, particularly if the first incision is relatively recent.\\n\\nRemember: Sometimes, spending an hour to ‘get into the abdomen’ in order to do a 5-minute procedure (e.g. release of an obstructing adhesion) is not a sign of a timid surgeon but a judicious one! You may want to consider this mnemonic of abdominal entry and exposure: ‘the 4 Ps’: patience, preservation, persistence, prudence.\\n\\n## Image Identification and Description\\n\\nNo images or graphs were identified on this page.\\n\\n## Summary\\n\\nThe text discusses surgical techniques and considerations for abdominal entry, emphasizing the importance of careful planning and execution to avoid complications. It highlights the need for patience and prudence in surgical practice, particularly in challenging cases.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In practice, most incisional ‘oozers’ stop spontaneously after a few minutes, under the pressure of a moist lap pad or a temporary hemostat. If necessary, use well-directed diathermy to kill the bloody bleeder at the point where it emerges under the skin, and avoid burning blindly in a pool of blood. It is also unnecessary to ‘clean’ the fascia by sweeping the fat laterally: the more you dissect and ‘burn’, the more inflammation and infection-generating dead tissue you create!\\n\\nKeep in mind special circumstances:\\n\\n- If a stoma is anticipated then place the incision away from its planned location. You don’t want the toilet in the kitchen!\\n- Abdominal re-entry into the ‘hostile abdomen’ of a previously operated patient can be problematic. You may spend more time, sweat and blood, but the real danger is creating inadvertent enterotomies in intestine adherent to the previous incisional scar. This is a common cause of postoperative external bowel fistula! (Chapter 47). The prevailing opinion is to use the previous incision for re-entry, if possible. When doing so, however, start a few centimeters below or above the old incision and gain entry to the abdomen through virgin territory. Then insert your finger into the peritoneal cavity and navigate your way safely in, taking down adhesions to the abdominal wall, which hamper the insertion of a self-retaining retractor. Essentially, you are finished ‘getting in’ when you are able to place a self-retaining retractor to open the abdomen wide. In a dire emergency or when you expect the abdomen to be exceptionally scarred, it may be prudent to stay away from trouble and create an entirely fresh incision. In this situation beware of parallel incisions in close proximity to one another because the intervening skin may be at risk of necrosis, particularly if the first incision is relatively recent.\\n\\nRemember: Sometimes, spending an hour to ‘get into the abdomen’ in order to do a 5-minute procedure (e.g. release of an obstructing adhesion) is not a sign of a timid surgeon but a judicious one! You may want to consider this mnemonic of abdominal entry and exposure: ‘the 4 Ps’: patience, preservation, persistence, prudence.',\n", " 'md': 'In practice, most incisional ‘oozers’ stop spontaneously after a few minutes, under the pressure of a moist lap pad or a temporary hemostat. If necessary, use well-directed diathermy to kill the bloody bleeder at the point where it emerges under the skin, and avoid burning blindly in a pool of blood. It is also unnecessary to ‘clean’ the fascia by sweeping the fat laterally: the more you dissect and ‘burn’, the more inflammation and infection-generating dead tissue you create!\\n\\nKeep in mind special circumstances:\\n\\n- If a stoma is anticipated then place the incision away from its planned location. You don’t want the toilet in the kitchen!\\n- Abdominal re-entry into the ‘hostile abdomen’ of a previously operated patient can be problematic. You may spend more time, sweat and blood, but the real danger is creating inadvertent enterotomies in intestine adherent to the previous incisional scar. This is a common cause of postoperative external bowel fistula! (Chapter 47). The prevailing opinion is to use the previous incision for re-entry, if possible. When doing so, however, start a few centimeters below or above the old incision and gain entry to the abdomen through virgin territory. Then insert your finger into the peritoneal cavity and navigate your way safely in, taking down adhesions to the abdominal wall, which hamper the insertion of a self-retaining retractor. Essentially, you are finished ‘getting in’ when you are able to place a self-retaining retractor to open the abdomen wide. In a dire emergency or when you expect the abdomen to be exceptionally scarred, it may be prudent to stay away from trouble and create an entirely fresh incision. In this situation beware of parallel incisions in close proximity to one another because the intervening skin may be at risk of necrosis, particularly if the first incision is relatively recent.\\n\\nRemember: Sometimes, spending an hour to ‘get into the abdomen’ in order to do a 5-minute procedure (e.g. release of an obstructing adhesion) is not a sign of a timid surgeon but a judicious one! You may want to consider this mnemonic of abdominal entry and exposure: ‘the 4 Ps’: patience, preservation, persistence, prudence.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.92, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'No images or graphs were identified on this page.',\n", " 'md': 'No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses surgical techniques and considerations for abdominal entry, emphasizing the importance of careful planning and execution to avoid complications. It highlights the need for patience and prudence in surgical practice, particularly in challenging cases.\\n```',\n", " 'md': 'The text discusses surgical techniques and considerations for abdominal entry, emphasizing the importance of careful planning and execution to avoid complications. It highlights the need for patience and prudence in surgical practice, particularly in challenging cases.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'incision for re-entry, '}]},\n", " {'page': 136,\n", " 'text': 'need a fifth p — Prozac®.)\\n\\n Pitfalls\\n\\n• When in haste, do not forget that the liver lies in the upper extremity\\n of the long midline incision, and the urinary bladder at its lowermost.\\n Be careful not to damage either.\\n• When approaching the upper abdomen divide and ligate the round\\n hepatic ligament. Leave it long: it could be used to elevate and\\n retract the liver or used as a patch for perforated duodenal ulcer if\\n the omentum is not available. Take the opportunity to divide the\\n bloodless falciform ligament, which runs from the anterior abdominal\\n wall and the diaphragm to the liver. If left intact it may ‘tear’ off the\\n liver causing irritating bleeding.\\n• When performing any transverse incision across the midline, do not\\n forget to ligate or transfix the epigastric vessels just behind the\\n rectus abdominis muscles. They may retract, be difficult to control,\\n and cause a delayed abdominal wall hematoma.\\n• In the very obese patient, in the upright position, the umbilicus\\n commonly reaches the level of the pubis. After elevating the fat\\n panniculus you can place a lower midline incision between the pubis\\n and umbilicus but after the operation it will be macerated by the\\n sweaty (and smelly) panniculus. Thus, in the super-fat, a supra-\\n umbilical midline incision would provide a better access into the\\n lower abdomen. (By the way, be careful with the fatty omentum, it\\n tears easily if pulled too hard, and bleeding from the torn omentum\\n is difficult to control except by resecting that part of the omentum\\n altogether.)\\n\\n“Pray before surgery, but remember God will not alter a\\nfaulty incision.”\\n Arthur H. Keeney\\n“When the doctor is in doubt and the patient in danger,\\nmake an exploratory incision and deal with what you find',\n", " 'md': '```markdown\\n## Pitfalls\\n\\n- When in haste, do not forget that the liver lies in the upper extremity of the long midline incision, and the urinary bladder at its lowermost. Be careful not to damage either.\\n- When approaching the upper abdomen, divide and ligate the round hepatic ligament. Leave it long; it could be used to elevate and retract the liver or used as a patch for perforated duodenal ulcer if the omentum is not available. Take the opportunity to divide the bloodless falciform ligament, which runs from the anterior abdominal wall and the diaphragm to the liver. If left intact, it may ‘tear’ off the liver causing irritating bleeding.\\n- When performing any transverse incision across the midline, do not forget to ligate or transfix the epigastric vessels just behind the rectus abdominis muscles. They may retract, be difficult to control, and cause a delayed abdominal wall hematoma.\\n- In the very obese patient, in the upright position, the umbilicus commonly reaches the level of the pubis. After elevating the fat panniculus, you can place a lower midline incision between the pubis and umbilicus, but after the operation, it will be macerated by the sweaty (and smelly) panniculus. Thus, in the super-fat, a supra-umbilical midline incision would provide better access into the lower abdomen. (By the way, be careful with the fatty omentum; it tears easily if pulled too hard, and bleeding from the torn omentum is difficult to control except by resecting that part of the omentum altogether.)\\n\\n> “Pray before surgery, but remember God will not alter a faulty incision.”\\n> — Arthur H. Keeney\\n\\n> “When the doctor is in doubt and the patient in danger, make an exploratory incision and deal with what you find.”\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Pitfalls',\n", " 'md': '## Pitfalls',\n", " 'bBox': {'x': 86, 'y': 139, 'w': 54.24, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- When in haste, do not forget that the liver lies in the upper extremity of the long midline incision, and the urinary bladder at its lowermost. Be careful not to damage either.\\n- When approaching the upper abdomen, divide and ligate the round hepatic ligament. Leave it long; it could be used to elevate and retract the liver or used as a patch for perforated duodenal ulcer if the omentum is not available. Take the opportunity to divide the bloodless falciform ligament, which runs from the anterior abdominal wall and the diaphragm to the liver. If left intact, it may ‘tear’ off the liver causing irritating bleeding.\\n- When performing any transverse incision across the midline, do not forget to ligate or transfix the epigastric vessels just behind the rectus abdominis muscles. They may retract, be difficult to control, and cause a delayed abdominal wall hematoma.\\n- In the very obese patient, in the upright position, the umbilicus commonly reaches the level of the pubis. After elevating the fat panniculus, you can place a lower midline incision between the pubis and umbilicus, but after the operation, it will be macerated by the sweaty (and smelly) panniculus. Thus, in the super-fat, a supra-umbilical midline incision would provide better access into the lower abdomen. (By the way, be careful with the fatty omentum; it tears easily if pulled too hard, and bleeding from the torn omentum is difficult to control except by resecting that part of the omentum altogether.)\\n\\n> “Pray before surgery, but remember God will not alter a faulty incision.”\\n> — Arthur H. Keeney\\n\\n> “When the doctor is in doubt and the patient in danger, make an exploratory incision and deal with what you find.”\\n```',\n", " 'md': '- When in haste, do not forget that the liver lies in the upper extremity of the long midline incision, and the urinary bladder at its lowermost. Be careful not to damage either.\\n- When approaching the upper abdomen, divide and ligate the round hepatic ligament. Leave it long; it could be used to elevate and retract the liver or used as a patch for perforated duodenal ulcer if the omentum is not available. Take the opportunity to divide the bloodless falciform ligament, which runs from the anterior abdominal wall and the diaphragm to the liver. If left intact, it may ‘tear’ off the liver causing irritating bleeding.\\n- When performing any transverse incision across the midline, do not forget to ligate or transfix the epigastric vessels just behind the rectus abdominis muscles. They may retract, be difficult to control, and cause a delayed abdominal wall hematoma.\\n- In the very obese patient, in the upright position, the umbilicus commonly reaches the level of the pubis. After elevating the fat panniculus, you can place a lower midline incision between the pubis and umbilicus, but after the operation, it will be macerated by the sweaty (and smelly) panniculus. Thus, in the super-fat, a supra-umbilical midline incision would provide better access into the lower abdomen. (By the way, be careful with the fatty omentum; it tears easily if pulled too hard, and bleeding from the torn omentum is difficult to control except by resecting that part of the omentum altogether.)\\n\\n> “Pray before surgery, but remember God will not alter a faulty incision.”\\n> — Arthur H. Keeney\\n\\n> “When the doctor is in doubt and the patient in danger, make an exploratory incision and deal with what you find.”\\n```',\n", " 'bBox': {'x': 79, 'y': 175, 'w': 458.09, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 137,\n", " 'text': ' as best as you can.”\\n Robert Lawson Tait\\n\\n1 Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.',\n", " 'md': '```markdown\\n# Page 1\\n\\n> \"as best as you can.”\\n> — Robert Lawson Tait\\n\\n1. Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page 1',\n", " 'md': '# Page 1',\n", " 'bBox': {'x': 73, 'y': 183, 'w': 4.8, 'h': 8.64}},\n", " {'type': 'text',\n", " 'value': '> \"as best as you can.”\\n> — Robert Lawson Tait\\n\\n1. Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.\\n```',\n", " 'md': '> \"as best as you can.”\\n> — Robert Lawson Tait\\n\\n1. Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.\\n```',\n", " 'bBox': {'x': 73, 'y': 88, 'w': 376.38, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 138,\n", " 'text': 'Chapter 11\\nAbdominal exploration: finding what is wrong\\nMoshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and\\nJonathan E. Efron 1\\n\\n In surgery, eyes first and most; fingers next and little;\\n tongue last and least.\\n Sir George Murray Humphry\\n\\n Never let the skin stand between you and the diagnosis.\\n\\n (We understand that this is an old and venerated surgical\\n aphorism but we think we don’t wish to encourage reckless\\n pursuit of diagnosis, do we?)\\n\\n Not uncommonly — especially with the increased use of diagnostic\\nimaging — when opening the abdomen, the surgeon knows what to\\nexpect inside; the clinical picture and/or ancillary tests direct him to the\\ndisease process. In some instances, however, he explores the unknown,\\nled on only by the signs of peritoneal irritation, assuming that the\\nperitoneal cavity is flooded by blood or pus. Usually the surgeon\\nspeculates about the predicted diagnosis but always remains ready for\\nthe unexpected (in some places ‘Big Brother’ compares our pre-op and\\npost-op diagnoses — we are expected always to be ‘correct’ whereas\\nthey are allowed to screw up the budget…). This is what makes\\nemergency abdominal surgery so exciting and demanding — the\\never looming catastrophe and the anxiety about whether or not you\\nare able to tackle it competently. Yes, even in the days of CT and MRI',\n", " 'md': '```markdown\\n# Chapter 11\\n## Abdominal exploration: finding what is wrong\\n**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n> \"In surgery, eyes first and most; fingers next and little; tongue last and least.\"\\n> — Sir George Murray Humphry\\n\\n> \"Never let the skin stand between you and the diagnosis.\"\\n> (We understand that this is an old and venerated surgical aphorism but we think we don’t wish to encourage reckless pursuit of diagnosis, do we?)\\n\\nNot uncommonly — especially with the increased use of diagnostic imaging — when opening the abdomen, the surgeon knows what to expect inside; the clinical picture and/or ancillary tests direct him to the disease process. In some instances, however, he explores the unknown, led on only by the signs of peritoneal irritation, assuming that the peritoneal cavity is flooded by blood or pus. Usually, the surgeon speculates about the predicted diagnosis but always remains ready for the unexpected (in some places ‘Big Brother’ compares our pre-op and post-op diagnoses — we are expected always to be ‘correct’ whereas they are allowed to screw up the budget…). This is what makes emergency abdominal surgery so exciting and demanding — the ever looming catastrophe and the anxiety about whether or not you are able to tackle it competently. Yes, even in the days of CT and MRI.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 11',\n", " 'md': '# Chapter 11',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 147.2, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal exploration: finding what is wrong',\n", " 'md': '## Abdominal exploration: finding what is wrong',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 398.68, 'h': 20.16}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n> \"In surgery, eyes first and most; fingers next and little; tongue last and least.\"\\n> — Sir George Murray Humphry\\n\\n> \"Never let the skin stand between you and the diagnosis.\"\\n> (We understand that this is an old and venerated surgical aphorism but we think we don’t wish to encourage reckless pursuit of diagnosis, do we?)\\n\\nNot uncommonly — especially with the increased use of diagnostic imaging — when opening the abdomen, the surgeon knows what to expect inside; the clinical picture and/or ancillary tests direct him to the disease process. In some instances, however, he explores the unknown, led on only by the signs of peritoneal irritation, assuming that the peritoneal cavity is flooded by blood or pus. Usually, the surgeon speculates about the predicted diagnosis but always remains ready for the unexpected (in some places ‘Big Brother’ compares our pre-op and post-op diagnoses — we are expected always to be ‘correct’ whereas they are allowed to screw up the budget…). This is what makes emergency abdominal surgery so exciting and demanding — the ever looming catastrophe and the anxiety about whether or not you are able to tackle it competently. Yes, even in the days of CT and MRI.\\n```',\n", " 'md': '**Authors:** Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\n> \"In surgery, eyes first and most; fingers next and little; tongue last and least.\"\\n> — Sir George Murray Humphry\\n\\n> \"Never let the skin stand between you and the diagnosis.\"\\n> (We understand that this is an old and venerated surgical aphorism but we think we don’t wish to encourage reckless pursuit of diagnosis, do we?)\\n\\nNot uncommonly — especially with the increased use of diagnostic imaging — when opening the abdomen, the surgeon knows what to expect inside; the clinical picture and/or ancillary tests direct him to the disease process. In some instances, however, he explores the unknown, led on only by the signs of peritoneal irritation, assuming that the peritoneal cavity is flooded by blood or pus. Usually, the surgeon speculates about the predicted diagnosis but always remains ready for the unexpected (in some places ‘Big Brother’ compares our pre-op and post-op diagnoses — we are expected always to be ‘correct’ whereas they are allowed to screw up the budget…). This is what makes emergency abdominal surgery so exciting and demanding — the ever looming catastrophe and the anxiety about whether or not you are able to tackle it competently. Yes, even in the days of CT and MRI.\\n```',\n", " 'bBox': {'x': 72, 'y': 348, 'w': 467.9, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Jonathan E. Efron 1'}]},\n", " {'page': 139,\n", " 'text': 'the abdomen can be full of surprises! If you don’t like surprises then go\\nand be a dermatologist.\\n\\n Abdominal exploration ( Figure 11.1)\\n\\n While the specific sequence and extent of abdominal exploration are to\\nbe tailored to the clinical circumstances, the two principal stages of any\\nexploration are:\\n\\n • Identification of the specific pathology which prompted the\\n laparotomy.\\n • Routine exploration of the peritoneal cavity.\\n Essentially, there is a sharp distinction between a laparotomy for non-\\ntraumatic conditions such as bowel obstruction, inflammation or\\nperitonitis, and laparotomy for trauma with intra-abdominal hemorrhage,\\nthe latter rarely being due to spontaneous, non-traumatic intra-abdominal\\ncauses.',\n", " 'md': '```markdown\\n# Abdominal Exploration\\n\\nThe abdomen can be full of surprises! If you don’t like surprises then go and be a dermatologist.\\n\\n## Abdominal Exploration (Figure 11.1)\\n\\nWhile the specific sequence and extent of abdominal exploration are to be tailored to the clinical circumstances, the two principal stages of any exploration are:\\n\\n- Identification of the specific pathology which prompted the laparotomy.\\n- Routine exploration of the peritoneal cavity.\\n\\nEssentially, there is a sharp distinction between a laparotomy for non-traumatic conditions such as bowel obstruction, inflammation or peritonitis, and laparotomy for trauma with intra-abdominal hemorrhage, the latter rarely being due to spontaneous, non-traumatic intra-abdominal causes.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Abdominal Exploration',\n", " 'md': '# Abdominal Exploration',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The abdomen can be full of surprises! If you don’t like surprises then go and be a dermatologist.',\n", " 'md': 'The abdomen can be full of surprises! If you don’t like surprises then go and be a dermatologist.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.45, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Exploration (Figure 11.1)',\n", " 'md': '## Abdominal Exploration (Figure 11.1)',\n", " 'bBox': {'x': 86, 'y': 145, 'w': 189.4, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'While the specific sequence and extent of abdominal exploration are to be tailored to the clinical circumstances, the two principal stages of any exploration are:\\n\\n- Identification of the specific pathology which prompted the laparotomy.\\n- Routine exploration of the peritoneal cavity.\\n\\nEssentially, there is a sharp distinction between a laparotomy for non-traumatic conditions such as bowel obstruction, inflammation or peritonitis, and laparotomy for trauma with intra-abdominal hemorrhage, the latter rarely being due to spontaneous, non-traumatic intra-abdominal causes.\\n```',\n", " 'md': 'While the specific sequence and extent of abdominal exploration are to be tailored to the clinical circumstances, the two principal stages of any exploration are:\\n\\n- Identification of the specific pathology which prompted the laparotomy.\\n- Routine exploration of the peritoneal cavity.\\n\\nEssentially, there is a sharp distinction between a laparotomy for non-traumatic conditions such as bowel obstruction, inflammation or peritonitis, and laparotomy for trauma with intra-abdominal hemorrhage, the latter rarely being due to spontaneous, non-traumatic intra-abdominal causes.\\n```',\n", " 'bBox': {'x': 72, 'y': 181, 'w': 467.6, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 140,\n", " 'text': ' Reryh\\n Figure 11.1. “Hey Doc, did you find anything?”\\n\\n So you incise the peritoneum, what now? Your action depends on\\nthe urgency of the situation (condition of the patient), the mechanism of\\nthe abdominal pathology (spontaneous versus trauma), and the initial\\nfindings (blood, enteric content, bile or pus). Whatever you find, follow the\\nmain priorities:\\n\\n • Identify and arrest active bleeding.\\n • Identify and control continuing contamination.\\n At the same time — do not be distracted by trivia. Do not chase\\nisolated red blood cells or bacteria in a patient who is bleeding to death.\\nFor example, do not repair minor mesenteric tears in a patient who is\\nbusy exsanguinating from a torn inferior vena cava. This is not a joke —\\nsurgeons are easily distracted.',\n", " 'md': '```markdown\\n# Page Content\\n\\n**Figure 11.1.** “Hey Doc, did you find anything?”\\n\\nSo you incise the peritoneum, what now? Your action depends on the urgency of the situation (condition of the patient), the mechanism of the abdominal pathology (spontaneous versus trauma), and the initial findings (blood, enteric content, bile or pus). Whatever you find, follow the main priorities:\\n\\n- Identify and arrest active bleeding.\\n- Identify and control continuing contamination.\\n\\nAt the same time — do not be distracted by trivia. Do not chase isolated red blood cells or bacteria in a patient who is bleeding to death. For example, do not repair minor mesenteric tears in a patient who is busy exsanguinating from a torn inferior vena cava. This is not a joke — surgeons are easily distracted.\\n\\n## Image Description\\n\\n**Figure 11.1**: This image likely depicts a surgical scenario or a humorous illustration related to the text. The caption suggests a dialogue that emphasizes the urgency and seriousness of surgical procedures. The image serves to highlight the critical decision-making process in surgery, particularly in emergency situations.\\n\\n### Summary\\nThe text discusses the priorities a surgeon must follow when faced with an urgent abdominal situation, emphasizing the importance of addressing life-threatening issues over minor concerns. The accompanying figure adds a visual element to this discussion, reinforcing the message about the seriousness of surgical distractions.\\n```',\n", " 'images': [{'name': 'img_p139_1.png',\n", " 'height': 576,\n", " 'width': 805,\n", " 'x': 107.27999999999997,\n", " 'y': 82.79999999999995,\n", " 'original_width': 1383,\n", " 'original_height': 991}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 11.1.** “Hey Doc, did you find anything?”\\n\\nSo you incise the peritoneum, what now? Your action depends on the urgency of the situation (condition of the patient), the mechanism of the abdominal pathology (spontaneous versus trauma), and the initial findings (blood, enteric content, bile or pus). Whatever you find, follow the main priorities:\\n\\n- Identify and arrest active bleeding.\\n- Identify and control continuing contamination.\\n\\nAt the same time — do not be distracted by trivia. Do not chase isolated red blood cells or bacteria in a patient who is bleeding to death. For example, do not repair minor mesenteric tears in a patient who is busy exsanguinating from a torn inferior vena cava. This is not a joke — surgeons are easily distracted.',\n", " 'md': '**Figure 11.1.** “Hey Doc, did you find anything?”\\n\\nSo you incise the peritoneum, what now? Your action depends on the urgency of the situation (condition of the patient), the mechanism of the abdominal pathology (spontaneous versus trauma), and the initial findings (blood, enteric content, bile or pus). Whatever you find, follow the main priorities:\\n\\n- Identify and arrest active bleeding.\\n- Identify and control continuing contamination.\\n\\nAt the same time — do not be distracted by trivia. Do not chase isolated red blood cells or bacteria in a patient who is bleeding to death. For example, do not repair minor mesenteric tears in a patient who is busy exsanguinating from a torn inferior vena cava. This is not a joke — surgeons are easily distracted.',\n", " 'bBox': {'x': 72, 'y': 451, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Description',\n", " 'md': '## Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 11.1**: This image likely depicts a surgical scenario or a humorous illustration related to the text. The caption suggests a dialogue that emphasizes the urgency and seriousness of surgical procedures. The image serves to highlight the critical decision-making process in surgery, particularly in emergency situations.',\n", " 'md': '**Figure 11.1**: This image likely depicts a surgical scenario or a humorous illustration related to the text. The caption suggests a dialogue that emphasizes the urgency and seriousness of surgical procedures. The image serves to highlight the critical decision-making process in surgery, particularly in emergency situations.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the priorities a surgeon must follow when faced with an urgent abdominal situation, emphasizing the importance of addressing life-threatening issues over minor concerns. The accompanying figure adds a visual element to this discussion, reinforcing the message about the seriousness of surgical distractions.\\n```',\n", " 'md': 'The text discusses the priorities a surgeon must follow when faced with an urgent abdominal situation, emphasizing the importance of addressing life-threatening issues over minor concerns. The accompanying figure adds a visual element to this discussion, reinforcing the message about the seriousness of surgical distractions.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 141,\n", " 'text': ' Intraperitoneal blood\\n\\n The patient may have suffered a blunt or penetrating injury or no injury\\nat all; in the latter case he is suffering from spontaneous intra-\\nabdominal hemorrhage (abdominal apoplexy), an uncommon entity\\nthe etiology of which is summarized in Table 11.1.\\n\\n You may have been expecting the presence of free intraperitoneal\\nblood from the clinical findings of hypovolemic shock, or the results of CT,\\nultrasound or peritoneal lavage. Your action depends on the magnitude of\\nhemorrhage and the degree of resulting hemodynamic compromise.\\nWhen the abdomen is full of blood, and the patient unstable, you\\nshould act swiftly.\\n\\n Control the situation:\\n Enlarge your initial incision generously (avoid the liver and bladder).\\n Lift out the small bowel completely (not hysterically… tearing the mesentery).\\n Evacuate the blood as fast as possible — always have two large suckers ready.\\n However, in massive hemoperitoneum it is better to scoop\\n out the blood with hand/towels/kidney dish, because\\n suckers get easily blocked.\\n Pack the four quadrants tightly with laparotomy pads.',\n", " 'md': '```markdown\\n# Intraperitoneal Blood\\n\\nThe patient may have suffered a blunt or penetrating injury or no injury at all; in the latter case, he is suffering from spontaneous intra-abdominal hemorrhage (abdominal apoplexy), an uncommon entity the etiology of which is summarized in Table 11.1.\\n\\nYou may have been expecting the presence of free intraperitoneal blood from the clinical findings of hypovolemic shock, or the results of CT, ultrasound, or peritoneal lavage. Your action depends on the magnitude of hemorrhage and the degree of resulting hemodynamic compromise. When the abdomen is full of blood, and the patient unstable, you should act swiftly.\\n\\n## Control the Situation:\\n- Enlarge your initial incision generously (avoid the liver and bladder).\\n- Lift out the small bowel completely (not hysterically… tearing the mesentery).\\n- Evacuate the blood as fast as possible — always have two large suckers ready.\\n- However, in massive hemoperitoneum it is better to scoop out the blood with hand/towels/kidney dish, because suckers get easily blocked.\\n- Pack the four quadrants tightly with laparotomy pads.\\n\\n**Note:** Table 11.1 is referenced but not included in the text.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Intraperitoneal Blood',\n", " 'md': '# Intraperitoneal Blood',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 164.57, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The patient may have suffered a blunt or penetrating injury or no injury at all; in the latter case, he is suffering from spontaneous intra-abdominal hemorrhage (abdominal apoplexy), an uncommon entity the etiology of which is summarized in Table 11.1.\\n\\nYou may have been expecting the presence of free intraperitoneal blood from the clinical findings of hypovolemic shock, or the results of CT, ultrasound, or peritoneal lavage. Your action depends on the magnitude of hemorrhage and the degree of resulting hemodynamic compromise. When the abdomen is full of blood, and the patient unstable, you should act swiftly.',\n", " 'md': 'The patient may have suffered a blunt or penetrating injury or no injury at all; in the latter case, he is suffering from spontaneous intra-abdominal hemorrhage (abdominal apoplexy), an uncommon entity the etiology of which is summarized in Table 11.1.\\n\\nYou may have been expecting the presence of free intraperitoneal blood from the clinical findings of hypovolemic shock, or the results of CT, ultrasound, or peritoneal lavage. Your action depends on the magnitude of hemorrhage and the degree of resulting hemodynamic compromise. When the abdomen is full of blood, and the patient unstable, you should act swiftly.',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.65, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Control the Situation:',\n", " 'md': '## Control the Situation:',\n", " 'bBox': {'x': 79, 'y': 339, 'w': 167.31, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Enlarge your initial incision generously (avoid the liver and bladder).\\n- Lift out the small bowel completely (not hysterically… tearing the mesentery).\\n- Evacuate the blood as fast as possible — always have two large suckers ready.\\n- However, in massive hemoperitoneum it is better to scoop out the blood with hand/towels/kidney dish, because suckers get easily blocked.\\n- Pack the four quadrants tightly with laparotomy pads.\\n\\n**Note:** Table 11.1 is referenced but not included in the text.\\n```',\n", " 'md': '- Enlarge your initial incision generously (avoid the liver and bladder).\\n- Lift out the small bowel completely (not hysterically… tearing the mesentery).\\n- Evacuate the blood as fast as possible — always have two large suckers ready.\\n- However, in massive hemoperitoneum it is better to scoop out the blood with hand/towels/kidney dish, because suckers get easily blocked.\\n- Pack the four quadrants tightly with laparotomy pads.\\n\\n**Note:** Table 11.1 is referenced but not included in the text.\\n```',\n", " 'bBox': {'x': 132, 'y': 371, 'w': 398.09, 'h': 15.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 142,\n", " 'text': \" Table 11.1. Causes of spontaneous intra-abdominal hemorrhage\\n ('abdominal apoplexy'.\\n Vascular\\n Ruptured abdominal aortic aneurysm\\n Ruptured arterial visceral aneurysm (hepatic, gastroduodenal, splenic,\\n pancreaticoduodenal, renal, gastroepiploic, middle colic, inferior mesenteric, left\\n gastric, ileocolic) (may be associated with Ehlers-Danlos syndrome or other\\n connective tissue disorders)\\n Intraperitoneal rupture of varices associated with portal hypertension\\n Spontaneous rupture of the iliac vein\\nESpontaneous rupture of the pregnant uterus with placenta percreta\\n Spontaneous ovarian hemorrhage (idiopathic, ruptured follicular cyst or corpus\\n Ruptured ectopic pregnancy\\n Postpartum ovarian artery rupture\\n luteum, ovarian cancer)\\n Pancreatitis\\n Erosion of adjacent vessels involved in the process of severe acute pancreatitis,\\n chronic pancreatitis or pancreatic pseudocyst\\n Liver\\n Rupture of benign (typically adenomas) or malignant hepatic tumors\\n Spleen\\n Spontaneous rupture\\n AdrenalSpontaneous hemorrhage: normal gland or secondary to tumor\\n KidneySpontaneous rupture: normal kidney or secondary to tumor\\n Anticoagulation\\n Patients on anticoagulation are prone to spontaneous retroperitoneal or\\n intraperitoneal bleeding often prompted by unrecognized minor trauma\\n Unrecognized or denied traumaPatient 'forgot' the kick to the LUQ, which broke his spleen\",\n", " 'md': \"```markdown\\n## Table 11.1. Causes of Spontaneous Intra-Abdominal Hemorrhage\\n\\n| Cause |\\n|------------------------------------------------------------------------------------------------|\\n| **Vascular** |\\n| - Ruptured abdominal aortic aneurysm |\\n| - Ruptured arterial visceral aneurysm (hepatic, gastroduodenal, splenic, pancreaticoduodenal, renal, gastroepiploic, middle colic, inferior mesenteric, left gastric, ileocolic) (may be associated with Ehlers-Danlos syndrome or other connective tissue disorders) |\\n| - Intraperitoneal rupture of varices associated with portal hypertension |\\n| - Spontaneous rupture of the iliac vein |\\n| - Spontaneous rupture of the pregnant uterus with placenta percreta |\\n| - Spontaneous ovarian hemorrhage (idiopathic, ruptured follicular cyst or corpus luteum, ovarian cancer) |\\n| - Ruptured ectopic pregnancy |\\n| - Postpartum ovarian artery rupture |\\n| **Pancreatitis** |\\n| - Erosion of adjacent vessels involved in the process of severe acute pancreatitis, chronic pancreatitis or pancreatic pseudocyst |\\n| **Liver** |\\n| - Rupture of benign (typically adenomas) or malignant hepatic tumors |\\n| **Spleen** |\\n| - Spontaneous rupture |\\n| **Adrenal** |\\n| - Spontaneous hemorrhage: normal gland or secondary to tumor |\\n| **Kidney** |\\n| - Spontaneous rupture: normal kidney or secondary to tumor |\\n| **Anticoagulation** |\\n| - Patients on anticoagulation are prone to spontaneous retroperitoneal or intraperitoneal bleeding often prompted by unrecognized minor trauma |\\n| **Unrecognized or denied trauma** |\\n| - Patient 'forgot' the kick to the LUQ, which broke his spleen |\\n```\",\n", " 'images': [{'name': 'img_p141_1.png',\n", " 'height': 1310,\n", " 'width': 815,\n", " 'x': 72,\n", " 'y': 72,\n", " 'original_width': 1400,\n", " 'original_height': 2388}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 11.1. Causes of Spontaneous Intra-Abdominal Hemorrhage',\n", " 'md': '## Table 11.1. Causes of Spontaneous Intra-Abdominal Hemorrhage',\n", " 'bBox': {'x': 72, 'y': 77.44, 'w': 376.48, 'h': 83.1}},\n", " {'type': 'table',\n", " 'rows': [['Cause'],\n", " ['**Vascular**'],\n", " ['- Ruptured abdominal aortic aneurysm'],\n", " ['- Ruptured arterial visceral aneurysm (hepatic, gastroduodenal, splenic, pancreaticoduodenal, renal, gastroepiploic, middle colic, inferior mesenteric, left gastric, ileocolic) (may be associated with Ehlers-Danlos syndrome or other connective tissue disorders)'],\n", " ['- Intraperitoneal rupture of varices associated with portal hypertension'],\n", " ['- Spontaneous rupture of the iliac vein'],\n", " ['- Spontaneous rupture of the pregnant uterus with placenta percreta'],\n", " ['- Spontaneous ovarian hemorrhage (idiopathic, ruptured follicular cyst or corpus luteum, ovarian cancer)'],\n", " ['- Ruptured ectopic pregnancy'],\n", " ['- Postpartum ovarian artery rupture'],\n", " ['**Pancreatitis**'],\n", " ['- Erosion of adjacent vessels involved in the process of severe acute pancreatitis, chronic pancreatitis or pancreatic pseudocyst'],\n", " ['**Liver**'],\n", " ['- Rupture of benign (typically adenomas) or malignant hepatic tumors'],\n", " ['**Spleen**'],\n", " ['- Spontaneous rupture'],\n", " ['**Adrenal**'],\n", " ['- Spontaneous hemorrhage: normal gland or secondary to tumor'],\n", " ['**Kidney**'],\n", " ['- Spontaneous rupture: normal kidney or secondary to tumor'],\n", " ['**Anticoagulation**'],\n", " ['- Patients on anticoagulation are prone to spontaneous retroperitoneal or intraperitoneal bleeding often prompted by unrecognized minor trauma'],\n", " ['**Unrecognized or denied trauma**'],\n", " [\"- Patient 'forgot' the kick to the LUQ, which broke his spleen\"]],\n", " 'md': \"| Cause |\\n|------------------------------------------------------------------------------------------------|\\n| **Vascular** |\\n| - Ruptured abdominal aortic aneurysm |\\n| - Ruptured arterial visceral aneurysm (hepatic, gastroduodenal, splenic, pancreaticoduodenal, renal, gastroepiploic, middle colic, inferior mesenteric, left gastric, ileocolic) (may be associated with Ehlers-Danlos syndrome or other connective tissue disorders) |\\n| - Intraperitoneal rupture of varices associated with portal hypertension |\\n| - Spontaneous rupture of the iliac vein |\\n| - Spontaneous rupture of the pregnant uterus with placenta percreta |\\n| - Spontaneous ovarian hemorrhage (idiopathic, ruptured follicular cyst or corpus luteum, ovarian cancer) |\\n| - Ruptured ectopic pregnancy |\\n| - Postpartum ovarian artery rupture |\\n| **Pancreatitis** |\\n| - Erosion of adjacent vessels involved in the process of severe acute pancreatitis, chronic pancreatitis or pancreatic pseudocyst |\\n| **Liver** |\\n| - Rupture of benign (typically adenomas) or malignant hepatic tumors |\\n| **Spleen** |\\n| - Spontaneous rupture |\\n| **Adrenal** |\\n| - Spontaneous hemorrhage: normal gland or secondary to tumor |\\n| **Kidney** |\\n| - Spontaneous rupture: normal kidney or secondary to tumor |\\n| **Anticoagulation** |\\n| - Patients on anticoagulation are prone to spontaneous retroperitoneal or intraperitoneal bleeding often prompted by unrecognized minor trauma |\\n| **Unrecognized or denied trauma** |\\n| - Patient 'forgot' the kick to the LUQ, which broke his spleen |\",\n", " 'isPerfectTable': True,\n", " 'csv': '\"Cause\"\\n\"**Vascular**\"\\n\"- Ruptured abdominal aortic aneurysm\"\\n\"- Ruptured arterial visceral aneurysm (hepatic, gastroduodenal, splenic, pancreaticoduodenal, renal, gastroepiploic, middle colic, inferior mesenteric, left gastric, ileocolic) (may be associated with Ehlers-Danlos syndrome or other connective tissue disorders)\"\\n\"- Intraperitoneal rupture of varices associated with portal hypertension\"\\n\"- Spontaneous rupture of the iliac vein\"\\n\"- Spontaneous rupture of the pregnant uterus with placenta percreta\"\\n\"- Spontaneous ovarian hemorrhage (idiopathic, ruptured follicular cyst or corpus luteum, ovarian cancer)\"\\n\"- Ruptured ectopic pregnancy\"\\n\"- Postpartum ovarian artery rupture\"\\n\"**Pancreatitis**\"\\n\"- Erosion of adjacent vessels involved in the process of severe acute pancreatitis, chronic pancreatitis or pancreatic pseudocyst\"\\n\"**Liver**\"\\n\"- Rupture of benign (typically adenomas) or malignant hepatic tumors\"\\n\"**Spleen**\"\\n\"- Spontaneous rupture\"\\n\"**Adrenal**\"\\n\"- Spontaneous hemorrhage: normal gland or secondary to tumor\"\\n\"**Kidney**\"\\n\"- Spontaneous rupture: normal kidney or secondary to tumor\"\\n\"**Anticoagulation**\"\\n\"- Patients on anticoagulation are prone to spontaneous retroperitoneal or intraperitoneal bleeding often prompted by unrecognized minor trauma\"\\n\"**Unrecognized or denied trauma**\"\\n\"- Patient \\'forgot\\' the kick to the LUQ, which broke his spleen\"',\n", " 'bBox': {'x': 72, 'y': 122.45, 'w': 342.35, 'h': 211.71}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 143,\n", " 'text': ' Evacuation of massive hemoperitoneum temporarily aggravates\\nhypovolemia. It releases the tamponade effect and relieves intra-\\nabdominal hypertension ( Chapter 33), resulting in sudden pooling of\\nblood in the venous circulation. At this stage, compress the aorta at its\\ndiaphragmatic hiatus, or through the lesser omentum, and let the\\nanesthetist catch up with fluid and blood requirements.\\n\\n Be patient, do not rush; with your hand or a Deever retractor\\n(carefully!) compressing the aorta, the abdomen tightly packed, and\\nthe patient’s vital organ perfusion improving, you have almost all\\nthe time in the world. Do not be tempted at this stage to continue\\nwith the operation, which can result in successful hemostasis in a\\ndead patient. Relax and plan the next move, remembering that from now\\non you can afford to lose only a limited amount of blood before the\\nvicious cycle of hypothermia, acidosis, and coagulopathy — the ‘triangle\\nof death’ — will further frustrate efforts to achieve hemostasis.\\n\\n Primary survey (see also Chapter 32)\\n\\n Now you are ready to identify and treat the life-threatening injuries. The\\ninitial direction of your search will be guided by the causative\\nmechanisms. In penetrating injury the bleeding source should be in\\nthe vicinity of the missile or knife track; in blunt trauma, bleeding\\nwill probably originate from a ruptured solid organ — the liver or\\nspleen, the pelvic retroperitoneum or a tear in the mesentery.\\n\\n Unpack, suck and repack each quadrant consecutively noting where\\nthere is blood reaccumulation (active bleeding) or hematoma. ħaving\\naccurately identified the source (or sources) of bleeding, start definitive\\nhemostasis, the rest of the abdomen being packed away. Simultaneously,\\nif the situation permits, control contamination from injured bowel using\\nclamps, staplers or tapes, or repacking in desperate situations.\\n\\n Stay tuned constantly to events behind the blood-brain barrier\\n(BBB) — which is the screen between you and the anesthetists. Wake\\nthem up from time to time and ask how the patient is doing. Take this',\n", " 'md': '```markdown\\n## Evacuation of Massive Hemoperitoneum\\n\\nEvacuation of massive hemoperitoneum temporarily aggravates hypovolemia. It releases the tamponade effect and relieves intra-abdominal hypertension (Chapter 33), resulting in sudden pooling of blood in the venous circulation. At this stage, compress the aorta at its diaphragmatic hiatus, or through the lesser omentum, and let the anesthetist catch up with fluid and blood requirements.\\n\\nBe patient, do not rush; with your hand or a Deever retractor (carefully!) compressing the aorta, the abdomen tightly packed, and the patient’s vital organ perfusion improving, you have almost all the time in the world. Do not be tempted at this stage to continue with the operation, which can result in successful hemostasis in a dead patient. Relax and plan the next move, remembering that from now on you can afford to lose only a limited amount of blood before the vicious cycle of hypothermia, acidosis, and coagulopathy — the ‘triangle of death’ — will further frustrate efforts to achieve hemostasis.\\n\\n### Primary Survey\\n\\nNow you are ready to identify and treat the life-threatening injuries. The initial direction of your search will be guided by the causative mechanisms. In penetrating injury, the bleeding source should be in the vicinity of the missile or knife track; in blunt trauma, bleeding will probably originate from a ruptured solid organ — the liver or spleen, the pelvic retroperitoneum, or a tear in the mesentery.\\n\\nUnpack, suck, and repack each quadrant consecutively noting where there is blood reaccumulation (active bleeding) or hematoma. Having accurately identified the source (or sources) of bleeding, start definitive hemostasis, the rest of the abdomen being packed away. Simultaneously, if the situation permits, control contamination from injured bowel using clamps, staplers, or tapes, or repacking in desperate situations.\\n\\nStay tuned constantly to events behind the blood-brain barrier (BBB) — which is the screen between you and the anesthetists. Wake them up from time to time and ask how the patient is doing. Take this.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Evacuation of Massive Hemoperitoneum',\n", " 'md': '## Evacuation of Massive Hemoperitoneum',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Evacuation of massive hemoperitoneum temporarily aggravates hypovolemia. It releases the tamponade effect and relieves intra-abdominal hypertension (Chapter 33), resulting in sudden pooling of blood in the venous circulation. At this stage, compress the aorta at its diaphragmatic hiatus, or through the lesser omentum, and let the anesthetist catch up with fluid and blood requirements.\\n\\nBe patient, do not rush; with your hand or a Deever retractor (carefully!) compressing the aorta, the abdomen tightly packed, and the patient’s vital organ perfusion improving, you have almost all the time in the world. Do not be tempted at this stage to continue with the operation, which can result in successful hemostasis in a dead patient. Relax and plan the next move, remembering that from now on you can afford to lose only a limited amount of blood before the vicious cycle of hypothermia, acidosis, and coagulopathy — the ‘triangle of death’ — will further frustrate efforts to achieve hemostasis.',\n", " 'md': 'Evacuation of massive hemoperitoneum temporarily aggravates hypovolemia. It releases the tamponade effect and relieves intra-abdominal hypertension (Chapter 33), resulting in sudden pooling of blood in the venous circulation. At this stage, compress the aorta at its diaphragmatic hiatus, or through the lesser omentum, and let the anesthetist catch up with fluid and blood requirements.\\n\\nBe patient, do not rush; with your hand or a Deever retractor (carefully!) compressing the aorta, the abdomen tightly packed, and the patient’s vital organ perfusion improving, you have almost all the time in the world. Do not be tempted at this stage to continue with the operation, which can result in successful hemostasis in a dead patient. Relax and plan the next move, remembering that from now on you can afford to lose only a limited amount of blood before the vicious cycle of hypothermia, acidosis, and coagulopathy — the ‘triangle of death’ — will further frustrate efforts to achieve hemostasis.',\n", " 'bBox': {'x': 72, 'y': 187, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Primary Survey',\n", " 'md': '### Primary Survey',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Now you are ready to identify and treat the life-threatening injuries. The initial direction of your search will be guided by the causative mechanisms. In penetrating injury, the bleeding source should be in the vicinity of the missile or knife track; in blunt trauma, bleeding will probably originate from a ruptured solid organ — the liver or spleen, the pelvic retroperitoneum, or a tear in the mesentery.\\n\\nUnpack, suck, and repack each quadrant consecutively noting where there is blood reaccumulation (active bleeding) or hematoma. Having accurately identified the source (or sources) of bleeding, start definitive hemostasis, the rest of the abdomen being packed away. Simultaneously, if the situation permits, control contamination from injured bowel using clamps, staplers, or tapes, or repacking in desperate situations.\\n\\nStay tuned constantly to events behind the blood-brain barrier (BBB) — which is the screen between you and the anesthetists. Wake them up from time to time and ask how the patient is doing. Take this.\\n```',\n", " 'md': 'Now you are ready to identify and treat the life-threatening injuries. The initial direction of your search will be guided by the causative mechanisms. In penetrating injury, the bleeding source should be in the vicinity of the missile or knife track; in blunt trauma, bleeding will probably originate from a ruptured solid organ — the liver or spleen, the pelvic retroperitoneum, or a tear in the mesentery.\\n\\nUnpack, suck, and repack each quadrant consecutively noting where there is blood reaccumulation (active bleeding) or hematoma. Having accurately identified the source (or sources) of bleeding, start definitive hemostasis, the rest of the abdomen being packed away. Simultaneously, if the situation permits, control contamination from injured bowel using clamps, staplers, or tapes, or repacking in desperate situations.\\n\\nStay tuned constantly to events behind the blood-brain barrier (BBB) — which is the screen between you and the anesthetists. Wake them up from time to time and ask how the patient is doing. Take this.\\n```',\n", " 'bBox': {'x': 72, 'y': 434, 'w': 467.98, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'blood in the venous circulation. At this stage, compress the aorta at its'},\n", " {'text': ''}]},\n", " {'page': 144,\n", " 'text': 'opportunity also to explain how and what you are doing. Communication\\namong members of the medical team in this situation is vital. While you\\nare busy repairing the iliac vein the patient may be developing a\\npericardial tamponade or pneumothorax. So avoid tunnel vision and\\nkeep your antennas up all the time!\\n\\n Secondary survey\\n\\n Now the exsanguinating lesion is permanently or temporarily controlled\\nand the patient’s hemodynamics have stabilized. With less adrenaline\\nfloating around you and the patient, you can divert your attention to all\\nthe rest, and look around more precisely. With growing experience your\\nabdominal exploration will become more efficient but never less\\nthorough, as ‘missed’ abdominal injuries continue to be a common\\nsource of preventable morbidity. The practicalities of systemic\\nabdominal exploration are described below.\\n\\n Intraperitoneal contamination or infection\\n\\n • First you register the offensive fecal smell or fecal-looking fluid\\n that denotes the abundance of anaerobic bacteria and usually an\\n infective source in the bowel. Note, however, that neglected\\n infections from any source can be pseudofeculant due to the\\n predominance of anaerobes.\\n • When, on opening the peritoneum gas escapes with a hiss, be\\n aware that a viscus has perforated. In the non-trauma situation this\\n usually implies perforated peptic ulcer or sigmoid diverticulitis.\\n • Bile-staining of the exudate points to pathology in the biliary tract,\\n gastroduodenum or proximal small bowel.\\n • Dark stout-beer fluid and fat necrosis hints at pancreatic necrosis\\n or infection in the lesser sac. John ħunter (no, not the author of\\n Chapter 15) observed that “the gastric juice is a fluid somewhat\\n transparent, and a little saltish or brackish to the taste” but we do not\\n suggest you go that far! Whatever the nature of contamination or\\n pus, suck and mop it away as soon as possible.',\n", " 'md': '```markdown\\n## Secondary Survey\\n\\nCommunication among members of the medical team in this situation is vital. While you are busy repairing the iliac vein, the patient may be developing a pericardial tamponade or pneumothorax. So avoid tunnel vision and keep your antennas up all the time!\\n\\n### Intraperitoneal Contamination or Infection\\n\\n- First, you register the offensive fecal smell or fecal-looking fluid that denotes the abundance of anaerobic bacteria and usually an infective source in the bowel. Note, however, that neglected infections from any source can be pseudofeculant due to the predominance of anaerobes.\\n- When, on opening the peritoneum, gas escapes with a hiss, be aware that a viscus has perforated. In the non-trauma situation, this usually implies perforated peptic ulcer or sigmoid diverticulitis.\\n- Bile-staining of the exudate points to pathology in the biliary tract, gastroduodenum, or proximal small bowel.\\n- Dark stout-beer fluid and fat necrosis hints at pancreatic necrosis or infection in the lesser sac. John Hunter (no, not the author of Chapter 15) observed that “the gastric juice is a fluid somewhat transparent, and a little saltish or brackish to the taste” but we do not suggest you go that far! Whatever the nature of contamination or pus, suck and mop it away as soon as possible.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Secondary Survey',\n", " 'md': '## Secondary Survey',\n", " 'bBox': {'x': 86, 'y': 195, 'w': 142.58, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Communication among members of the medical team in this situation is vital. While you are busy repairing the iliac vein, the patient may be developing a pericardial tamponade or pneumothorax. So avoid tunnel vision and keep your antennas up all the time!',\n", " 'md': 'Communication among members of the medical team in this situation is vital. While you are busy repairing the iliac vein, the patient may be developing a pericardial tamponade or pneumothorax. So avoid tunnel vision and keep your antennas up all the time!',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 466.66, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Intraperitoneal Contamination or Infection',\n", " 'md': '### Intraperitoneal Contamination or Infection',\n", " 'bBox': {'x': 86, 'y': 390, 'w': 327.3, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- First, you register the offensive fecal smell or fecal-looking fluid that denotes the abundance of anaerobic bacteria and usually an infective source in the bowel. Note, however, that neglected infections from any source can be pseudofeculant due to the predominance of anaerobes.\\n- When, on opening the peritoneum, gas escapes with a hiss, be aware that a viscus has perforated. In the non-trauma situation, this usually implies perforated peptic ulcer or sigmoid diverticulitis.\\n- Bile-staining of the exudate points to pathology in the biliary tract, gastroduodenum, or proximal small bowel.\\n- Dark stout-beer fluid and fat necrosis hints at pancreatic necrosis or infection in the lesser sac. John Hunter (no, not the author of Chapter 15) observed that “the gastric juice is a fluid somewhat transparent, and a little saltish or brackish to the taste” but we do not suggest you go that far! Whatever the nature of contamination or pus, suck and mop it away as soon as possible.\\n```',\n", " 'md': '- First, you register the offensive fecal smell or fecal-looking fluid that denotes the abundance of anaerobic bacteria and usually an infective source in the bowel. Note, however, that neglected infections from any source can be pseudofeculant due to the predominance of anaerobes.\\n- When, on opening the peritoneum, gas escapes with a hiss, be aware that a viscus has perforated. In the non-trauma situation, this usually implies perforated peptic ulcer or sigmoid diverticulitis.\\n- Bile-staining of the exudate points to pathology in the biliary tract, gastroduodenum, or proximal small bowel.\\n- Dark stout-beer fluid and fat necrosis hints at pancreatic necrosis or infection in the lesser sac. John Hunter (no, not the author of Chapter 15) observed that “the gastric juice is a fluid somewhat transparent, and a little saltish or brackish to the taste” but we do not suggest you go that far! Whatever the nature of contamination or pus, suck and mop it away as soon as possible.\\n```',\n", " 'bBox': {'x': 100, 'y': 493, 'w': 437.28, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'transparent, and a little saltish or brackish to the taste” but we do not'}]},\n", " {'page': 145,\n", " 'text': ' Generally, bile directs you proximally and feces distally, but ‘simple’ pus\\ncan come from anywhere. When its source remains elusive, start a\\nsystematic search keeping in mind all potential intraperitoneal and\\nretroperitoneal sources ‘from the esophagus to the rectum’. Be persistent\\nwith your search. We recall a case of spontaneous perforation of the\\nrectum in a young male, twice explored by experienced surgeons who\\nfailed to appreciate the minute hole deep in the rectovesical pouch. It was\\nfound (by a lowly resident) during a third operation.\\n\\n Occasionally, however, the origin of contamination or secondary\\nperitonitis is not found. A Gram stain disclosing a solitary bacterium — as\\nopposed to a few — suggests the diagnosis of primary peritonitis, since\\nsecondary peritonitis (e.g. secondary to a visceral pathology) is always\\npolymicrobial. More about this in Chapter 13.\\n\\n The direction and practicalities of exploration\\n\\n This depends on the reason for the laparotomy; let’s start with a\\ngeneral plan.\\n\\n The peritoneal cavity comprises two compartments: the supracolic\\nand the infracolic compartment. The dividing line is the transverse\\n(meso)colon, which in a xipho-pubic midline incision is located\\napproximately in the center of the incision (a little above the bauchnabel\\nor the belly button). It is important to develop and adhere to a fixed\\nroutine of abdominal exploration, which will include both compartments.\\nOur preference is to begin with the infracolic compartment: the transverse\\ncolon is being retracted upwards, the small bowel eviscerated, and the\\nrectosigmoid identified. Exploration begins with the pelvic reproductive\\norgans in the female, and then attention is turned to a systematic\\ninspection and palpation of the rectosigmoid, progressing in a retrograde\\nfashion to the left, transverse and then right colon and cecum, including\\ninspection of the mesocolon. The assistant follows the exploration with\\nsuccessive movements of a hand-held retractor to retract the edge of the\\nsurgical incision and to enable good visualization of whichever abdominal\\nstructure is the focus of attention. Exploration then proceeds in a\\nretrograde fashion from the ileocecal valve to the ligament of Treitz, with\\nspecial care being taken to inspect both ‘anterior’ and ‘posterior’ aspects',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nGenerally, bile directs you proximally and feces distally, but ‘simple’ pus can come from anywhere. When its source remains elusive, start a systematic search keeping in mind all potential intraperitoneal and retroperitoneal sources ‘from the esophagus to the rectum’. Be persistent with your search. We recall a case of spontaneous perforation of the rectum in a young male, twice explored by experienced surgeons who failed to appreciate the minute hole deep in the rectovesical pouch. It was found (by a lowly resident) during a third operation.\\n\\nOccasionally, however, the origin of contamination or secondary peritonitis is not found. A Gram stain disclosing a solitary bacterium — as opposed to a few — suggests the diagnosis of primary peritonitis, since secondary peritonitis (e.g. secondary to a visceral pathology) is always polymicrobial. More about this in Chapter 13.\\n\\nThe direction and practicalities of exploration\\n\\nThis depends on the reason for the laparotomy; let’s start with a general plan.\\n\\nThe peritoneal cavity comprises two compartments: the supracolic and the infracolic compartment. The dividing line is the transverse (meso)colon, which in a xipho-pubic midline incision is located approximately in the center of the incision (a little above the bauchnabel or the belly button). It is important to develop and adhere to a fixed routine of abdominal exploration, which will include both compartments. Our preference is to begin with the infracolic compartment: the transverse colon is being retracted upwards, the small bowel eviscerated, and the rectosigmoid identified. Exploration begins with the pelvic reproductive organs in the female, and then attention is turned to a systematic inspection and palpation of the rectosigmoid, progressing in a retrograde fashion to the left, transverse and then right colon and cecum, including inspection of the mesocolon. The assistant follows the exploration with successive movements of a hand-held retractor to retract the edge of the surgical incision and to enable good visualization of whichever abdominal structure is the focus of attention. Exploration then proceeds in a retrograde fashion from the ileocecal valve to the ligament of Treitz, with special care being taken to inspect both ‘anterior’ and ‘posterior’ aspects.\\n\\n## Image Identification and Description\\n\\n*No images or figures were identified on this page.*\\n\\n## Summary\\n\\nThis page discusses the systematic approach to exploring the abdominal cavity during laparotomy, emphasizing the importance of thoroughness in identifying potential sources of contamination or peritonitis. It outlines the anatomical compartments of the peritoneal cavity and the preferred method of exploration, starting from the infracolic compartment and moving through various structures in a retrograde manner.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Generally, bile directs you proximally and feces distally, but ‘simple’ pus can come from anywhere. When its source remains elusive, start a systematic search keeping in mind all potential intraperitoneal and retroperitoneal sources ‘from the esophagus to the rectum’. Be persistent with your search. We recall a case of spontaneous perforation of the rectum in a young male, twice explored by experienced surgeons who failed to appreciate the minute hole deep in the rectovesical pouch. It was found (by a lowly resident) during a third operation.\\n\\nOccasionally, however, the origin of contamination or secondary peritonitis is not found. A Gram stain disclosing a solitary bacterium — as opposed to a few — suggests the diagnosis of primary peritonitis, since secondary peritonitis (e.g. secondary to a visceral pathology) is always polymicrobial. More about this in Chapter 13.\\n\\nThe direction and practicalities of exploration\\n\\nThis depends on the reason for the laparotomy; let’s start with a general plan.\\n\\nThe peritoneal cavity comprises two compartments: the supracolic and the infracolic compartment. The dividing line is the transverse (meso)colon, which in a xipho-pubic midline incision is located approximately in the center of the incision (a little above the bauchnabel or the belly button). It is important to develop and adhere to a fixed routine of abdominal exploration, which will include both compartments. Our preference is to begin with the infracolic compartment: the transverse colon is being retracted upwards, the small bowel eviscerated, and the rectosigmoid identified. Exploration begins with the pelvic reproductive organs in the female, and then attention is turned to a systematic inspection and palpation of the rectosigmoid, progressing in a retrograde fashion to the left, transverse and then right colon and cecum, including inspection of the mesocolon. The assistant follows the exploration with successive movements of a hand-held retractor to retract the edge of the surgical incision and to enable good visualization of whichever abdominal structure is the focus of attention. Exploration then proceeds in a retrograde fashion from the ileocecal valve to the ligament of Treitz, with special care being taken to inspect both ‘anterior’ and ‘posterior’ aspects.',\n", " 'md': 'Generally, bile directs you proximally and feces distally, but ‘simple’ pus can come from anywhere. When its source remains elusive, start a systematic search keeping in mind all potential intraperitoneal and retroperitoneal sources ‘from the esophagus to the rectum’. Be persistent with your search. We recall a case of spontaneous perforation of the rectum in a young male, twice explored by experienced surgeons who failed to appreciate the minute hole deep in the rectovesical pouch. It was found (by a lowly resident) during a third operation.\\n\\nOccasionally, however, the origin of contamination or secondary peritonitis is not found. A Gram stain disclosing a solitary bacterium — as opposed to a few — suggests the diagnosis of primary peritonitis, since secondary peritonitis (e.g. secondary to a visceral pathology) is always polymicrobial. More about this in Chapter 13.\\n\\nThe direction and practicalities of exploration\\n\\nThis depends on the reason for the laparotomy; let’s start with a general plan.\\n\\nThe peritoneal cavity comprises two compartments: the supracolic and the infracolic compartment. The dividing line is the transverse (meso)colon, which in a xipho-pubic midline incision is located approximately in the center of the incision (a little above the bauchnabel or the belly button). It is important to develop and adhere to a fixed routine of abdominal exploration, which will include both compartments. Our preference is to begin with the infracolic compartment: the transverse colon is being retracted upwards, the small bowel eviscerated, and the rectosigmoid identified. Exploration begins with the pelvic reproductive organs in the female, and then attention is turned to a systematic inspection and palpation of the rectosigmoid, progressing in a retrograde fashion to the left, transverse and then right colon and cecum, including inspection of the mesocolon. The assistant follows the exploration with successive movements of a hand-held retractor to retract the edge of the surgical incision and to enable good visualization of whichever abdominal structure is the focus of attention. Exploration then proceeds in a retrograde fashion from the ileocecal valve to the ligament of Treitz, with special care being taken to inspect both ‘anterior’ and ‘posterior’ aspects.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 468, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*',\n", " 'md': '*No images or figures were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the systematic approach to exploring the abdominal cavity during laparotomy, emphasizing the importance of thoroughness in identifying potential sources of contamination or peritonitis. It outlines the anatomical compartments of the peritoneal cavity and the preferred method of exploration, starting from the infracolic compartment and moving through various structures in a retrograde manner.\\n```',\n", " 'md': 'This page discusses the systematic approach to exploring the abdominal cavity during laparotomy, emphasizing the importance of thoroughness in identifying potential sources of contamination or peritonitis. It outlines the anatomical compartments of the peritoneal cavity and the preferred method of exploration, starting from the infracolic compartment and moving through various structures in a retrograde manner.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 146,\n", " 'text': 'of each loop of bowel as well as its mesentery.\\n\\n Attention is then turned to the supracolic compartment. The\\ntransverse colon is pulled down, and the surgeon inspects and palpates\\nthe liver, gallbladder, stomach (including the proper placement of a\\nnasogastric tube), and spleen. Special care should be taken to avoid\\niatrogenic damage to the spleen caused by pulling hard on the body\\nof the stomach or the greater omentum. A complete abdominal\\nexploration also includes entry into the lesser peritoneal sac, which is\\nbest undertaken through the gastrocolic omentum. This omentum is\\nusually only a thin avascular membrane on the left side, and this should\\ntherefore be the preferred entry route into the lesser sac. Take care to\\navoid injury to the transverse mesocolon which may be adherent to the\\ngastrocolic omentum. A misdirected surgeon can be convinced that he is\\nentering the lesser sac when in fact he or she is cutting a hole in the\\ntransverse mesocolon. If ‘vascular’, the gastrocolic omentum is divided\\nbetween ligatures (or Ligasure™, if you like and can afford...), bringing\\nthe body and tail of the pancreas into full view. Should you decide to\\nenter the lesser sac through the lesser omentum be careful to not\\ndivide any pulsatile vessel coursing within the lesser sac as it may\\nbe the aberrant left hepatic artery originating from the left gastric\\nartery!\\n\\n Exploration of retroperitoneal structures involves two key\\nmobilization maneuvers, which should be employed whenever access to\\nthe retroperitoneum is deemed necessary:\\n\\n • ‘Kocher’s maneuver’ is mobilization of the duodenal loop and the\\n head of the pancreas by incising the thin peritoneal membrane\\n (posterior peritoneum) overlying the lateral aspect of the duodenum\\n and gradually lifting the duodenum and pancreatic head medially.\\n This maneuver is also the key to surgical exposure of the right\\n kidney and its hilum and the right adrenal gland. Kocher’s maneuver\\n may be extended further lateral and caudad, around the hepatic\\n flexure and along the ‘white line’ on the lateral aspect of the right\\n colon all the way down to the cecum. This extension allows medial\\n rotation of the right colon and affords good exposure of the right-\\n sided retroperitoneal structures such as the inferior vena cava, iliac',\n", " 'md': '```markdown\\n## Surgical Exploration of the Abdomen\\n\\nAttention is then turned to the supracolic compartment. The transverse colon is pulled down, and the surgeon inspects and palpates the liver, gallbladder, stomach (including the proper placement of a nasogastric tube), and spleen. Special care should be taken to avoid iatrogenic damage to the spleen caused by pulling hard on the body of the stomach or the greater omentum. A complete abdominal exploration also includes entry into the lesser peritoneal sac, which is best undertaken through the gastrocolic omentum. This omentum is usually only a thin avascular membrane on the left side, and this should therefore be the preferred entry route into the lesser sac. Take care to avoid injury to the transverse mesocolon which may be adherent to the gastrocolic omentum. A misdirected surgeon can be convinced that he is entering the lesser sac when in fact he or she is cutting a hole in the transverse mesocolon. If ‘vascular’, the gastrocolic omentum is divided between ligatures (or Ligasure™, if you like and can afford...), bringing the body and tail of the pancreas into full view. Should you decide to enter the lesser sac through the lesser omentum be careful to not divide any pulsatile vessel coursing within the lesser sac as it may be the aberrant left hepatic artery originating from the left gastric artery!\\n\\nExploration of retroperitoneal structures involves two key mobilization maneuvers, which should be employed whenever access to the retroperitoneum is deemed necessary:\\n\\n- **Kocher’s maneuver** is mobilization of the duodenal loop and the head of the pancreas by incising the thin peritoneal membrane (posterior peritoneum) overlying the lateral aspect of the duodenum and gradually lifting the duodenum and pancreatic head medially. This maneuver is also the key to surgical exposure of the right kidney and its hilum and the right adrenal gland. Kocher’s maneuver may be extended further lateral and caudad, around the hepatic flexure and along the ‘white line’ on the lateral aspect of the right colon all the way down to the cecum. This extension allows medial rotation of the right colon and affords good exposure of the right-sided retroperitoneal structures such as the inferior vena cava, iliac.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Exploration of the Abdomen',\n", " 'md': '## Surgical Exploration of the Abdomen',\n", " 'bBox': {'x': 86, 'y': 471, 'w': 83.12, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Attention is then turned to the supracolic compartment. The transverse colon is pulled down, and the surgeon inspects and palpates the liver, gallbladder, stomach (including the proper placement of a nasogastric tube), and spleen. Special care should be taken to avoid iatrogenic damage to the spleen caused by pulling hard on the body of the stomach or the greater omentum. A complete abdominal exploration also includes entry into the lesser peritoneal sac, which is best undertaken through the gastrocolic omentum. This omentum is usually only a thin avascular membrane on the left side, and this should therefore be the preferred entry route into the lesser sac. Take care to avoid injury to the transverse mesocolon which may be adherent to the gastrocolic omentum. A misdirected surgeon can be convinced that he is entering the lesser sac when in fact he or she is cutting a hole in the transverse mesocolon. If ‘vascular’, the gastrocolic omentum is divided between ligatures (or Ligasure™, if you like and can afford...), bringing the body and tail of the pancreas into full view. Should you decide to enter the lesser sac through the lesser omentum be careful to not divide any pulsatile vessel coursing within the lesser sac as it may be the aberrant left hepatic artery originating from the left gastric artery!\\n\\nExploration of retroperitoneal structures involves two key mobilization maneuvers, which should be employed whenever access to the retroperitoneum is deemed necessary:\\n\\n- **Kocher’s maneuver** is mobilization of the duodenal loop and the head of the pancreas by incising the thin peritoneal membrane (posterior peritoneum) overlying the lateral aspect of the duodenum and gradually lifting the duodenum and pancreatic head medially. This maneuver is also the key to surgical exposure of the right kidney and its hilum and the right adrenal gland. Kocher’s maneuver may be extended further lateral and caudad, around the hepatic flexure and along the ‘white line’ on the lateral aspect of the right colon all the way down to the cecum. This extension allows medial rotation of the right colon and affords good exposure of the right-sided retroperitoneal structures such as the inferior vena cava, iliac.\\n```',\n", " 'md': 'Attention is then turned to the supracolic compartment. The transverse colon is pulled down, and the surgeon inspects and palpates the liver, gallbladder, stomach (including the proper placement of a nasogastric tube), and spleen. Special care should be taken to avoid iatrogenic damage to the spleen caused by pulling hard on the body of the stomach or the greater omentum. A complete abdominal exploration also includes entry into the lesser peritoneal sac, which is best undertaken through the gastrocolic omentum. This omentum is usually only a thin avascular membrane on the left side, and this should therefore be the preferred entry route into the lesser sac. Take care to avoid injury to the transverse mesocolon which may be adherent to the gastrocolic omentum. A misdirected surgeon can be convinced that he is entering the lesser sac when in fact he or she is cutting a hole in the transverse mesocolon. If ‘vascular’, the gastrocolic omentum is divided between ligatures (or Ligasure™, if you like and can afford...), bringing the body and tail of the pancreas into full view. Should you decide to enter the lesser sac through the lesser omentum be careful to not divide any pulsatile vessel coursing within the lesser sac as it may be the aberrant left hepatic artery originating from the left gastric artery!\\n\\nExploration of retroperitoneal structures involves two key mobilization maneuvers, which should be employed whenever access to the retroperitoneum is deemed necessary:\\n\\n- **Kocher’s maneuver** is mobilization of the duodenal loop and the head of the pancreas by incising the thin peritoneal membrane (posterior peritoneum) overlying the lateral aspect of the duodenum and gradually lifting the duodenum and pancreatic head medially. This maneuver is also the key to surgical exposure of the right kidney and its hilum and the right adrenal gland. Kocher’s maneuver may be extended further lateral and caudad, around the hepatic flexure and along the ‘white line’ on the lateral aspect of the right colon all the way down to the cecum. This extension allows medial rotation of the right colon and affords good exposure of the right-sided retroperitoneal structures such as the inferior vena cava, iliac.\\n```',\n", " 'bBox': {'x': 72, 'y': 137, 'w': 467.88, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 147,\n", " 'text': ' vessels and the right ureter. Further extension of this incision angles\\n around the cecum and continues in a superomedial direction along\\n the line of fusion of the small bowel mesentery to the posterior\\n abdominal wall. Thus it is possible to mobilize and reflect the small\\n bowel upwards, the so-called Cattell-Braasch maneuver. This\\n affords optimal exposure of the entire inframesocolic\\n retroperitoneum, including the aorta and its infrarenal branches.\\n • The second key mobilization maneuver is called the ‘left-sided\\n Kocher’ or ‘medial visceral rotation’ (also called by some the\\n ‘Mattox maneuver’) and is used especially to gain access to the\\n entire length of the abdominal aorta and to the left-sided\\n retroperitoneal viscera. Depending on the structures to be exposed\\n this maneuver begins either lateral to the spleen (splenophrenic and\\n splenorenal ligament) working caudally or in the ‘white line’ of Toldt\\n lateral to the junction of the descending and sigmoid colon, working\\n upwards. The peritoneum is incised and the viscera, including the\\n left colon, spleen and tail of pancreas are gradually mobilized\\n medially. The left kidney can either be mobilized or left in situ,\\n depending on the surgical target of the exploration.\\n\\n In cases of spontaneous hemoperitoneum, you’ll have to look for a\\nruptured aortic, iliac or visceral arterial aneurysm, ectopic pregnancy,\\nbleeding hepatic tumor, spontaneous rupture of an enlarged spleen, or\\nany of the other causes listed in Table 11.1.\\n\\n In penetrating trauma you’ll follow the entry-exit track, taking into\\nconsideration the missile’s energy, velocity and potential to fragment.\\nWherever there is an entry wound in a viscus or blood vessel look\\nfor the exit one! The latter may lie concealed on the lesser sac wall of\\nthe stomach, the retroperitoneal surface of the duodenum, or the\\nmesenteric edge of the small bowel. Missing an exit wound is often a\\ndeath sentence to your patient!\\n\\n It is the blunt abdominal injury, however, that requires the most\\nextensive and less directed search, from the surface of both hemi-\\ndiaphragms to the pelvis, from gutter to gutter, on all solid organs, along\\nthe whole length of the gastrointestinal tract, and in the retroperitoneum\\n(as discussed in Chapter 32). The exact sequence of exploration is',\n", " 'md': '```markdown\\n## Surgical Techniques for Abdominal Access\\n\\nThe text discusses key surgical maneuvers for accessing the abdominal cavity, particularly in cases of trauma or hemoperitoneum.\\n\\n### Key Mobilization Maneuvers\\n\\n1. **Cattell-Braasch Maneuver**:\\n- This maneuver involves an incision that angles around the cecum and continues in a superomedial direction along the line of fusion of the small bowel mesentery to the posterior abdominal wall.\\n- It allows for the mobilization and reflection of the small bowel upwards, providing optimal exposure of the entire inframesocolic retroperitoneum, including the aorta and its infrarenal branches.\\n\\n2. **Left-Sided Kocher (Medial Visceral Rotation)**:\\n- Also known as the Mattox maneuver, this technique is used to access the abdominal aorta and left-sided retroperitoneal viscera.\\n- The maneuver can begin either lateral to the spleen or in the ‘white line’ of Toldt, depending on the structures to be exposed.\\n- The peritoneum is incised, and the left colon, spleen, and tail of the pancreas are gradually mobilized medially. The left kidney can be mobilized or left in situ based on the surgical target.\\n\\n### Considerations in Trauma Cases\\n\\n- In cases of spontaneous hemoperitoneum, it is crucial to look for potential sources of bleeding such as:\\n- Ruptured aortic, iliac, or visceral arterial aneurysm\\n- Ectopic pregnancy\\n- Bleeding hepatic tumor\\n- Spontaneous rupture of an enlarged spleen\\n- Other causes listed in Table 11.1.\\n\\n- For penetrating trauma, it is important to follow the entry-exit track, considering the missile’s energy, velocity, and potential to fragment.\\n- Always check for an exit wound, which may be concealed in various locations such as the lesser sac wall of the stomach or the retroperitoneal surface of the duodenum.\\n\\n- Blunt abdominal injury requires a comprehensive search from the surface of both hemi-diaphragms to the pelvis, covering all solid organs and the gastrointestinal tract, as well as the retroperitoneum.\\n\\n### Table Reference\\n- Refer to **Table 11.1** for a list of potential causes of spontaneous hemoperitoneum.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Techniques for Abdominal Access',\n", " 'md': '## Surgical Techniques for Abdominal Access',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses key surgical maneuvers for accessing the abdominal cavity, particularly in cases of trauma or hemoperitoneum.',\n", " 'md': 'The text discusses key surgical maneuvers for accessing the abdominal cavity, particularly in cases of trauma or hemoperitoneum.',\n", " 'bBox': {'x': 313, 'y': 168, 'w': 23.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key Mobilization Maneuvers',\n", " 'md': '### Key Mobilization Maneuvers',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. **Cattell-Braasch Maneuver**:\\n- This maneuver involves an incision that angles around the cecum and continues in a superomedial direction along the line of fusion of the small bowel mesentery to the posterior abdominal wall.\\n- It allows for the mobilization and reflection of the small bowel upwards, providing optimal exposure of the entire inframesocolic retroperitoneum, including the aorta and its infrarenal branches.\\n\\n2. **Left-Sided Kocher (Medial Visceral Rotation)**:\\n- Also known as the Mattox maneuver, this technique is used to access the abdominal aorta and left-sided retroperitoneal viscera.\\n- The maneuver can begin either lateral to the spleen or in the ‘white line’ of Toldt, depending on the structures to be exposed.\\n- The peritoneum is incised, and the left colon, spleen, and tail of the pancreas are gradually mobilized medially. The left kidney can be mobilized or left in situ based on the surgical target.',\n", " 'md': '1. **Cattell-Braasch Maneuver**:\\n- This maneuver involves an incision that angles around the cecum and continues in a superomedial direction along the line of fusion of the small bowel mesentery to the posterior abdominal wall.\\n- It allows for the mobilization and reflection of the small bowel upwards, providing optimal exposure of the entire inframesocolic retroperitoneum, including the aorta and its infrarenal branches.\\n\\n2. **Left-Sided Kocher (Medial Visceral Rotation)**:\\n- Also known as the Mattox maneuver, this technique is used to access the abdominal aorta and left-sided retroperitoneal viscera.\\n- The maneuver can begin either lateral to the spleen or in the ‘white line’ of Toldt, depending on the structures to be exposed.\\n- The peritoneum is incised, and the left colon, spleen, and tail of the pancreas are gradually mobilized medially. The left kidney can be mobilized or left in situ based on the surgical target.',\n", " 'bBox': {'x': 100, 'y': 102, 'w': 436.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Considerations in Trauma Cases',\n", " 'md': '### Considerations in Trauma Cases',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- In cases of spontaneous hemoperitoneum, it is crucial to look for potential sources of bleeding such as:\\n- Ruptured aortic, iliac, or visceral arterial aneurysm\\n- Ectopic pregnancy\\n- Bleeding hepatic tumor\\n- Spontaneous rupture of an enlarged spleen\\n- Other causes listed in Table 11.1.\\n\\n- For penetrating trauma, it is important to follow the entry-exit track, considering the missile’s energy, velocity, and potential to fragment.\\n- Always check for an exit wound, which may be concealed in various locations such as the lesser sac wall of the stomach or the retroperitoneal surface of the duodenum.\\n\\n- Blunt abdominal injury requires a comprehensive search from the surface of both hemi-diaphragms to the pelvis, covering all solid organs and the gastrointestinal tract, as well as the retroperitoneum.',\n", " 'md': '- In cases of spontaneous hemoperitoneum, it is crucial to look for potential sources of bleeding such as:\\n- Ruptured aortic, iliac, or visceral arterial aneurysm\\n- Ectopic pregnancy\\n- Bleeding hepatic tumor\\n- Spontaneous rupture of an enlarged spleen\\n- Other causes listed in Table 11.1.\\n\\n- For penetrating trauma, it is important to follow the entry-exit track, considering the missile’s energy, velocity, and potential to fragment.\\n- Always check for an exit wound, which may be concealed in various locations such as the lesser sac wall of the stomach or the retroperitoneal surface of the duodenum.\\n\\n- Blunt abdominal injury requires a comprehensive search from the surface of both hemi-diaphragms to the pelvis, covering all solid organs and the gastrointestinal tract, as well as the retroperitoneum.',\n", " 'bBox': {'x': 313, 'y': 168, 'w': 23.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table Reference',\n", " 'md': '### Table Reference',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Refer to **Table 11.1** for a list of potential causes of spontaneous hemoperitoneum.\\n\\n```',\n", " 'md': '- Refer to **Table 11.1** for a list of potential causes of spontaneous hemoperitoneum.\\n\\n```',\n", " 'bBox': {'x': 313, 'y': 168, 'w': 16, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 148,\n", " 'text': 'less important than its thoroughness.\\n\\n Use your common sense\\n\\n Are you already snoring? A little boring, eh? So wake up and listen:\\nbecause this book is aimed also at trainees we had to be complete and\\ndescribe the ‘classical abdominal exploration’. But frankly, if the patient is\\nbleeding from a ruptured liver we would explore the upper abdomen, but\\nif the infracolic compartment looks pristine and dry we would leave it\\nalone. So use your common sense: do not look for ovarian cysts in a\\npatient with a bleeding spleen. Like Dr. Leo Gordon said: “When\\ncommon sense interferes with a protocol, follow common sense.”\\n\\n What about retractors?\\n\\n Use whatever is available at your institution. In most circumstances we\\nprefer one of the hand-held retractors in the hands of the assistant. But\\nnot all assistants are as passive or active as you wish them to be. As\\nArthur E. ħertzler wrote: “If I ever deliberately commit murder I shall\\nselect an inattentive and awkward assistant as my victim. I shall select\\none who has assisted enough to delude himself into thinking he could\\nhimself do the work better than the surgeon who is operating. This\\nusually reaches the high point at about the third week of the intern’s\\nexperiences.”\\n\\n In some situations a ‘passive’ fixed retractor (a.k.a. a ‘mute intern’)\\nshould be used — especially when operating in the pelvis or upper\\nabdomen. The good old Balfour retractor is useful when doing a midline\\nlaparotomy. Of course, your hospital may have one of those fancy multi-\\narm retractors (called the Omni-Tract® or whatever) or the ingenious\\nBookwalter® ring retractor; some surgeons like to use them — particularly\\nthose who do not have residents but have to rely on sleepy nurses. We\\ntry to use those types of mechnical retractors selectively: often the time\\nneeded to place them is longer than the operation and we hate operating\\nwith a sharp metal frame piercing our paunch. But when you expect a\\ndeep and long dissection — a fixed, smart retractor can change your\\noperation from a struggle to pure fun.',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nLess important than its thoroughness.\\n\\nUse your common sense.\\n\\nAre you already snoring? A little boring, eh? So wake up and listen: because this book is aimed also at trainees we had to be complete and describe the ‘classical abdominal exploration’. But frankly, if the patient is bleeding from a ruptured liver we would explore the upper abdomen, but if the infracolic compartment looks pristine and dry we would leave it alone. So use your common sense: do not look for ovarian cysts in a patient with a bleeding spleen. Like Dr. Leo Gordon said: “When common sense interferes with a protocol, follow common sense.”\\n\\nWhat about retractors?\\n\\nUse whatever is available at your institution. In most circumstances we prefer one of the hand-held retractors in the hands of the assistant. But not all assistants are as passive or active as you wish them to be. As Arthur E. Hertzler wrote: “If I ever deliberately commit murder I shall select an inattentive and awkward assistant as my victim. I shall select one who has assisted enough to delude himself into thinking he could himself do the work better than the surgeon who is operating. This usually reaches the high point at about the third week of the intern’s experiences.”\\n\\nIn some situations a ‘passive’ fixed retractor (a.k.a. a ‘mute intern’) should be used — especially when operating in the pelvis or upper abdomen. The good old Balfour retractor is useful when doing a midline laparotomy. Of course, your hospital may have one of those fancy multi-arm retractors (called the Omni-Tract® or whatever) or the ingenious Bookwalter® ring retractor; some surgeons like to use them — particularly those who do not have residents but have to rely on sleepy nurses. We try to use those types of mechanical retractors selectively: often the time needed to place them is longer than the operation and we hate operating with a sharp metal frame piercing our paunch. But when you expect a deep and long dissection — a fixed, smart retractor can change your operation from a struggle to pure fun.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and formatted as per the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Less important than its thoroughness.\\n\\nUse your common sense.\\n\\nAre you already snoring? A little boring, eh? So wake up and listen: because this book is aimed also at trainees we had to be complete and describe the ‘classical abdominal exploration’. But frankly, if the patient is bleeding from a ruptured liver we would explore the upper abdomen, but if the infracolic compartment looks pristine and dry we would leave it alone. So use your common sense: do not look for ovarian cysts in a patient with a bleeding spleen. Like Dr. Leo Gordon said: “When common sense interferes with a protocol, follow common sense.”\\n\\nWhat about retractors?\\n\\nUse whatever is available at your institution. In most circumstances we prefer one of the hand-held retractors in the hands of the assistant. But not all assistants are as passive or active as you wish them to be. As Arthur E. Hertzler wrote: “If I ever deliberately commit murder I shall select an inattentive and awkward assistant as my victim. I shall select one who has assisted enough to delude himself into thinking he could himself do the work better than the surgeon who is operating. This usually reaches the high point at about the third week of the intern’s experiences.”\\n\\nIn some situations a ‘passive’ fixed retractor (a.k.a. a ‘mute intern’) should be used — especially when operating in the pelvis or upper abdomen. The good old Balfour retractor is useful when doing a midline laparotomy. Of course, your hospital may have one of those fancy multi-arm retractors (called the Omni-Tract® or whatever) or the ingenious Bookwalter® ring retractor; some surgeons like to use them — particularly those who do not have residents but have to rely on sleepy nurses. We try to use those types of mechanical retractors selectively: often the time needed to place them is longer than the operation and we hate operating with a sharp metal frame piercing our paunch. But when you expect a deep and long dissection — a fixed, smart retractor can change your operation from a struggle to pure fun.\\n```',\n", " 'md': 'Less important than its thoroughness.\\n\\nUse your common sense.\\n\\nAre you already snoring? A little boring, eh? So wake up and listen: because this book is aimed also at trainees we had to be complete and describe the ‘classical abdominal exploration’. But frankly, if the patient is bleeding from a ruptured liver we would explore the upper abdomen, but if the infracolic compartment looks pristine and dry we would leave it alone. So use your common sense: do not look for ovarian cysts in a patient with a bleeding spleen. Like Dr. Leo Gordon said: “When common sense interferes with a protocol, follow common sense.”\\n\\nWhat about retractors?\\n\\nUse whatever is available at your institution. In most circumstances we prefer one of the hand-held retractors in the hands of the assistant. But not all assistants are as passive or active as you wish them to be. As Arthur E. Hertzler wrote: “If I ever deliberately commit murder I shall select an inattentive and awkward assistant as my victim. I shall select one who has assisted enough to delude himself into thinking he could himself do the work better than the surgeon who is operating. This usually reaches the high point at about the third week of the intern’s experiences.”\\n\\nIn some situations a ‘passive’ fixed retractor (a.k.a. a ‘mute intern’) should be used — especially when operating in the pelvis or upper abdomen. The good old Balfour retractor is useful when doing a midline laparotomy. Of course, your hospital may have one of those fancy multi-arm retractors (called the Omni-Tract® or whatever) or the ingenious Bookwalter® ring retractor; some surgeons like to use them — particularly those who do not have residents but have to rely on sleepy nurses. We try to use those types of mechanical retractors selectively: often the time needed to place them is longer than the operation and we hate operating with a sharp metal frame piercing our paunch. But when you expect a deep and long dissection — a fixed, smart retractor can change your operation from a struggle to pure fun.\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.91, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and formatted as per the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and formatted as per the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 149,\n", " 'text': ' Additional points: grading the severity of injury\\n\\n Abdominal exploration for trauma ends with a strategic decision about\\nthe subsequent steps. Forget at this stage the many available organ\\ninjury scales, which are of academic value only; from the operating\\nsurgeon’s point of view there are essentially two patterns of visceral\\ndamage: ‘minor trouble’ and ‘major trouble’:\\n\\n • ‘Minor trouble’ involves easily fixable injuries, either because the\\n injured organ is accessible or the surgical solution is straightforward\\n (e.g. splenectomy, suture of mesenteric bleeders, or a colon\\n perforation). There is no immediate danger of exsanguination or loss\\n of surgical control. Under these circumstances you can immediately\\n proceed with definitive repair.\\n • ‘Major trouble’ is when the spontaneous condition or injury is not\\n easily rectified because of complexity or inaccessibility (e.g. a high-\\n grade liver injury, a major retroperitoneal vascular injury in the\\n supracolic compartment, or destruction of the pancreatoduodenal\\n complex). ħere the secret of success is to STOP the operation when\\n temporary (usually digital or manual) control of bleeding is achieved.\\n Take time to optimize the surgical attack on the injured organ.\\n Update all members of the operating and anesthesia teams on the\\n operative plan. Allow your anesthetist to use the time to stabilize the\\n patient hemodynamically and to obtain more blood products. Usually\\n you have to think for your team — don’t assume that all are awake.\\n ħowever, bear in mind that just as you are a ‘modern’ surgeon there\\n are now ‘modern’ anesthetists, and they are an invaluable resource\\n in the management of such patients. Take care not to alienate these\\n excellent practitioners! Order an autotransfusion device and a full\\n range of vascular and thoracotomy instruments to be brought in.\\n This is also the appropriate time to seek more competent help, and\\n to plan the operative strategy, including additional exposure and\\n mobilization. Such preparation is crucial for the survival of your\\n patient.\\n\\n Remember: Very often the initial exploration of the abdomen in the trauma patient is\\n incomplete, because the patient’s critical condition creates a situation where every minute',\n", " 'md': '```markdown\\n# Additional Points: Grading the Severity of Injury\\n\\nAbdominal exploration for trauma ends with a strategic decision about the subsequent steps. Forget at this stage the many available organ injury scales, which are of academic value only; from the operating surgeon’s point of view there are essentially two patterns of visceral damage: ‘minor trouble’ and ‘major trouble’:\\n\\n- **‘Minor trouble’** involves easily fixable injuries, either because the injured organ is accessible or the surgical solution is straightforward (e.g. splenectomy, suture of mesenteric bleeders, or a colon perforation). There is no immediate danger of exsanguination or loss of surgical control. Under these circumstances, you can immediately proceed with definitive repair.\\n\\n- **‘Major trouble’** is when the spontaneous condition or injury is not easily rectified because of complexity or inaccessibility (e.g. a high-grade liver injury, a major retroperitoneal vascular injury in the supracolic compartment, or destruction of the pancreatoduodenal complex). Here the secret of success is to STOP the operation when temporary (usually digital or manual) control of bleeding is achieved. Take time to optimize the surgical attack on the injured organ. Update all members of the operating and anesthesia teams on the operative plan. Allow your anesthetist to use the time to stabilize the patient hemodynamically and to obtain more blood products. Usually, you have to think for your team — don’t assume that all are awake.\\n\\nHowever, bear in mind that just as you are a ‘modern’ surgeon there are now ‘modern’ anesthetists, and they are an invaluable resource in the management of such patients. Take care not to alienate these excellent practitioners! Order an autotransfusion device and a full range of vascular and thoracotomy instruments to be brought in. This is also the appropriate time to seek more competent help, and to plan the operative strategy, including additional exposure and mobilization. Such preparation is crucial for the survival of your patient.\\n\\n**Remember:** Very often the initial exploration of the abdomen in the trauma patient is incomplete, because the patient’s critical condition creates a situation where every minute...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Additional Points: Grading the Severity of Injury',\n", " 'md': '# Additional Points: Grading the Severity of Injury',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 372.33, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Abdominal exploration for trauma ends with a strategic decision about the subsequent steps. Forget at this stage the many available organ injury scales, which are of academic value only; from the operating surgeon’s point of view there are essentially two patterns of visceral damage: ‘minor trouble’ and ‘major trouble’:\\n\\n- **‘Minor trouble’** involves easily fixable injuries, either because the injured organ is accessible or the surgical solution is straightforward (e.g. splenectomy, suture of mesenteric bleeders, or a colon perforation). There is no immediate danger of exsanguination or loss of surgical control. Under these circumstances, you can immediately proceed with definitive repair.\\n\\n- **‘Major trouble’** is when the spontaneous condition or injury is not easily rectified because of complexity or inaccessibility (e.g. a high-grade liver injury, a major retroperitoneal vascular injury in the supracolic compartment, or destruction of the pancreatoduodenal complex). Here the secret of success is to STOP the operation when temporary (usually digital or manual) control of bleeding is achieved. Take time to optimize the surgical attack on the injured organ. Update all members of the operating and anesthesia teams on the operative plan. Allow your anesthetist to use the time to stabilize the patient hemodynamically and to obtain more blood products. Usually, you have to think for your team — don’t assume that all are awake.\\n\\nHowever, bear in mind that just as you are a ‘modern’ surgeon there are now ‘modern’ anesthetists, and they are an invaluable resource in the management of such patients. Take care not to alienate these excellent practitioners! Order an autotransfusion device and a full range of vascular and thoracotomy instruments to be brought in. This is also the appropriate time to seek more competent help, and to plan the operative strategy, including additional exposure and mobilization. Such preparation is crucial for the survival of your patient.\\n\\n**Remember:** Very often the initial exploration of the abdomen in the trauma patient is incomplete, because the patient’s critical condition creates a situation where every minute...\\n```',\n", " 'md': 'Abdominal exploration for trauma ends with a strategic decision about the subsequent steps. Forget at this stage the many available organ injury scales, which are of academic value only; from the operating surgeon’s point of view there are essentially two patterns of visceral damage: ‘minor trouble’ and ‘major trouble’:\\n\\n- **‘Minor trouble’** involves easily fixable injuries, either because the injured organ is accessible or the surgical solution is straightforward (e.g. splenectomy, suture of mesenteric bleeders, or a colon perforation). There is no immediate danger of exsanguination or loss of surgical control. Under these circumstances, you can immediately proceed with definitive repair.\\n\\n- **‘Major trouble’** is when the spontaneous condition or injury is not easily rectified because of complexity or inaccessibility (e.g. a high-grade liver injury, a major retroperitoneal vascular injury in the supracolic compartment, or destruction of the pancreatoduodenal complex). Here the secret of success is to STOP the operation when temporary (usually digital or manual) control of bleeding is achieved. Take time to optimize the surgical attack on the injured organ. Update all members of the operating and anesthesia teams on the operative plan. Allow your anesthetist to use the time to stabilize the patient hemodynamically and to obtain more blood products. Usually, you have to think for your team — don’t assume that all are awake.\\n\\nHowever, bear in mind that just as you are a ‘modern’ surgeon there are now ‘modern’ anesthetists, and they are an invaluable resource in the management of such patients. Take care not to alienate these excellent practitioners! Order an autotransfusion device and a full range of vascular and thoracotomy instruments to be brought in. This is also the appropriate time to seek more competent help, and to plan the operative strategy, including additional exposure and mobilization. Such preparation is crucial for the survival of your patient.\\n\\n**Remember:** Very often the initial exploration of the abdomen in the trauma patient is incomplete, because the patient’s critical condition creates a situation where every minute...\\n```',\n", " 'bBox': {'x': 72, 'y': 124, 'w': 467.81, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 150,\n", " 'text': ' counts and injuries are simply repaired as they are encountered. Under these circumstances\\n you must complete the exploration before terminating the procedure.\\n\\n Finally, primum non nocere (first do no harm). This applies\\neverywhere in medicine but is of paramount importance during abdominal\\nexploration. The injured or infected contents of the peritoneal cavity may\\nbe inflamed, swollen, adherent, friable and brittle. Careless and sloppy\\nmanipulation and separation of viscera during exploration commonly\\ninduce additional bleeding and may produce additional bowel defects, or\\nenlarge the existing ones. And as always, new problems translate into\\nadditional therapies and morbidity.\\n\\n This is what makes emergency abdominal surgery so exciting and\\ndemanding: the ever looming catastrophe and the anxiety about\\nwhether you are able, or not, to tackle it competently.\\n\\n “When the doctor is in doubt and the patient in danger,\\n make an exploratory incision and deal with what you find\\n as best as you can.”\\n Robert Lawson Tait\\n\\n1 Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nCounts and injuries are simply repaired as they are encountered. Under these circumstances, you must complete the exploration before terminating the procedure.\\n\\nFinally, primum non nocere (first do no harm). This applies everywhere in medicine but is of paramount importance during abdominal exploration. The injured or infected contents of the peritoneal cavity may be inflamed, swollen, adherent, friable, and brittle. Careless and sloppy manipulation and separation of viscera during exploration commonly induce additional bleeding and may produce additional bowel defects, or enlarge the existing ones. And as always, new problems translate into additional therapies and morbidity.\\n\\nThis is what makes emergency abdominal surgery so exciting and demanding: the ever-looming catastrophe and the anxiety about whether you are able, or not, to tackle it competently.\\n\\n“When the doctor is in doubt and the patient in danger, make an exploratory incision and deal with what you find as best as you can.”\\n— Robert Lawson Tait\\n\\n1. Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.\\n```\\n\\n## Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Counts and injuries are simply repaired as they are encountered. Under these circumstances, you must complete the exploration before terminating the procedure.\\n\\nFinally, primum non nocere (first do no harm). This applies everywhere in medicine but is of paramount importance during abdominal exploration. The injured or infected contents of the peritoneal cavity may be inflamed, swollen, adherent, friable, and brittle. Careless and sloppy manipulation and separation of viscera during exploration commonly induce additional bleeding and may produce additional bowel defects, or enlarge the existing ones. And as always, new problems translate into additional therapies and morbidity.\\n\\nThis is what makes emergency abdominal surgery so exciting and demanding: the ever-looming catastrophe and the anxiety about whether you are able, or not, to tackle it competently.\\n\\n“When the doctor is in doubt and the patient in danger, make an exploratory incision and deal with what you find as best as you can.”\\n— Robert Lawson Tait\\n\\n1. Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.\\n```',\n", " 'md': 'Counts and injuries are simply repaired as they are encountered. Under these circumstances, you must complete the exploration before terminating the procedure.\\n\\nFinally, primum non nocere (first do no harm). This applies everywhere in medicine but is of paramount importance during abdominal exploration. The injured or infected contents of the peritoneal cavity may be inflamed, swollen, adherent, friable, and brittle. Careless and sloppy manipulation and separation of viscera during exploration commonly induce additional bleeding and may produce additional bowel defects, or enlarge the existing ones. And as always, new problems translate into additional therapies and morbidity.\\n\\nThis is what makes emergency abdominal surgery so exciting and demanding: the ever-looming catastrophe and the anxiety about whether you are able, or not, to tackle it competently.\\n\\n“When the doctor is in doubt and the patient in danger, make an exploratory incision and deal with what you find as best as you can.”\\n— Robert Lawson Tait\\n\\n1. Asher Hirshberg, MD, contributed to this chapter in the first edition of this book.\\n```',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.77, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Notes',\n", " 'md': '## Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 151,\n", " 'text': 'Chapter 12\\nThe laparoscopic approach to emergency\\nabdominal surgery\\nDanny Rosin\\n\\n Laparoscopy shares many similarities with the emperor’s\\n new clothes. If you do not join in the choir of praise you are\\n considered either stupid or unfit for the job. But someone\\n has to tell the truth.\\n Roland Andersson\\n\\n General principles\\n\\n Laparoscopy has long ago become part of our daily routine, and even if\\nwe still argue about its value in certain procedures, you surely feel\\nfamiliar and confident, after getting some training and experience, to\\nenter the abdomen and use the relevant instruments. So, what is so\\nspecial and different in emergency laparoscopy, compared to your\\nusual laparoscopic cholecystectomy?\\n\\n Well, quite a lot…\\n\\n Diagnosis may be elusive.\\n The patient’s physiology may be deranged.\\n Abdominal conditions may be unfavorable.',\n", " 'md': '```markdown\\n# Chapter 12: The Laparoscopic Approach to Emergency Abdominal Surgery\\n**Author:** Danny Rosin\\n\\n> \"Laparoscopy shares many similarities with the emperor’s new clothes. If you do not join in the choir of praise you are considered either stupid or unfit for the job. But someone has to tell the truth.\"\\n> — Roland Andersson\\n\\n## General Principles\\n\\nLaparoscopy has long ago become part of our daily routine, and even if we still argue about its value in certain procedures, you surely feel familiar and confident, after getting some training and experience, to enter the abdomen and use the relevant instruments. So, what is so special and different in emergency laparoscopy, compared to your usual laparoscopic cholecystectomy?\\n\\nWell, quite a lot…\\n\\n- Diagnosis may be elusive.\\n- The patient’s physiology may be deranged.\\n- Abdominal conditions may be unfavorable.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 12: The Laparoscopic Approach to Emergency Abdominal Surgery',\n", " 'md': '# Chapter 12: The Laparoscopic Approach to Emergency Abdominal Surgery',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 370.7, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Danny Rosin\\n\\n> \"Laparoscopy shares many similarities with the emperor’s new clothes. If you do not join in the choir of praise you are considered either stupid or unfit for the job. But someone has to tell the truth.\"\\n> — Roland Andersson',\n", " 'md': '**Author:** Danny Rosin\\n\\n> \"Laparoscopy shares many similarities with the emperor’s new clothes. If you do not join in the choir of praise you are considered either stupid or unfit for the job. But someone has to tell the truth.\"\\n> — Roland Andersson',\n", " 'bBox': {'x': 72, 'y': 263, 'w': 381.47, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'General Principles',\n", " 'md': '## General Principles',\n", " 'bBox': {'x': 86, 'y': 450, 'w': 144.36, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Laparoscopy has long ago become part of our daily routine, and even if we still argue about its value in certain procedures, you surely feel familiar and confident, after getting some training and experience, to enter the abdomen and use the relevant instruments. So, what is so special and different in emergency laparoscopy, compared to your usual laparoscopic cholecystectomy?\\n\\nWell, quite a lot…\\n\\n- Diagnosis may be elusive.\\n- The patient’s physiology may be deranged.\\n- Abdominal conditions may be unfavorable.\\n```',\n", " 'md': 'Laparoscopy has long ago become part of our daily routine, and even if we still argue about its value in certain procedures, you surely feel familiar and confident, after getting some training and experience, to enter the abdomen and use the relevant instruments. So, what is so special and different in emergency laparoscopy, compared to your usual laparoscopic cholecystectomy?\\n\\nWell, quite a lot…\\n\\n- Diagnosis may be elusive.\\n- The patient’s physiology may be deranged.\\n- Abdominal conditions may be unfavorable.\\n```',\n", " 'bBox': {'x': 72, 'y': 486, 'w': 467.4, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 152,\n", " 'text': ' Speed may be critical.\\n Timing is usually inconvenient: experienced staff may be lacking, available staff\\n may be tired, and you may need to handle unfamiliar situations, with less\\n assistance.\\n\\n So in general, both decision making and operating technique are\\nmore complicated in a surgical emergency. Even procedures you are\\nconfident with (laparoscopic cholecystectomy) may become a challenge\\n— for example, in acute gangrenous cholecystitis. But, as you know from\\nelective surgery, reducing surgical trauma to the abdominal wall is\\nbeneficial, maybe even more so in a patient with an acute condition who\\nneeds his ‘healing energy’ to overcome the disease itself. The usual\\npotential advantages of laparoscopy — less pain, shorter ileus, enhanced\\nmobilization — are relevant in the acute setting. On the other hand, the\\nlist above makes it obvious that emergency laparoscopy is not a walk\\nin the park, and the risk of complications is increased.\\n\\n So, before you decide to use this excellent tool, you have to realize its\\nlimitations, and even more important — you have to realize YOUR\\nlimitations. Selectivity, dexterity, and clinical judgment must guide\\nyour decisions when and if to use laparoscopy, how to carry it out\\nsafely, when to convert, and when to avoid it altogether.\\n\\n Potential advantages\\n\\n • Diagnosis. Despite modern imaging, we still operate on patients\\n that may surprise us. The use of CT scans has not completely\\n eliminated surgery for the non-inflamed appendix. The free air may\\n come from perforation of a viscus we did not suspect. The bowel\\n obstruction in a metastatic patient can be the result of a single\\n adhesive band. These situations and others can of course be\\n detected and treated by a large, ‘formal’ laparotomy, but what if\\n we could reduce the price of exploration by limiting the\\n abdominal wall trauma? Laparoscopic exploration can establish\\n the diagnosis, and direct us to the required intervention. And even if\\n open surgery is required — it may be done in a more directed',\n", " 'md': '```markdown\\n# Surgical Emergencies and Laparoscopy\\n\\nSpeed may be critical. Timing is usually inconvenient: experienced staff may be lacking, available staff may be tired, and you may need to handle unfamiliar situations, with less assistance.\\n\\nSo in general, both decision making and operating technique are more complicated in a surgical emergency. Even procedures you are confident with (laparoscopic cholecystectomy) may become a challenge — for example, in acute gangrenous cholecystitis. But, as you know from elective surgery, reducing surgical trauma to the abdominal wall is beneficial, maybe even more so in a patient with an acute condition who needs his ‘healing energy’ to overcome the disease itself. The usual potential advantages of laparoscopy — less pain, shorter ileus, enhanced mobilization — are relevant in the acute setting. On the other hand, the list above makes it obvious that emergency laparoscopy is not a walk in the park, and the risk of complications is increased.\\n\\nSo, before you decide to use this excellent tool, you have to realize its limitations, and even more important — you have to realize YOUR limitations. Selectivity, dexterity, and clinical judgment must guide your decisions when and if to use laparoscopy, how to carry it out safely, when to convert, and when to avoid it altogether.\\n\\n## Potential Advantages\\n\\n- **Diagnosis**: Despite modern imaging, we still operate on patients that may surprise us. The use of CT scans has not completely eliminated surgery for the non-inflamed appendix. The free air may come from perforation of a viscus we did not suspect. The bowel obstruction in a metastatic patient can be the result of a single adhesive band. These situations and others can of course be detected and treated by a large, ‘formal’ laparotomy, but what if we could reduce the price of exploration by limiting the abdominal wall trauma? Laparoscopic exploration can establish the diagnosis, and direct us to the required intervention. And even if open surgery is required — it may be done in a more directed manner.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Surgical Emergencies and Laparoscopy',\n", " 'md': '# Surgical Emergencies and Laparoscopy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Speed may be critical. Timing is usually inconvenient: experienced staff may be lacking, available staff may be tired, and you may need to handle unfamiliar situations, with less assistance.\\n\\nSo in general, both decision making and operating technique are more complicated in a surgical emergency. Even procedures you are confident with (laparoscopic cholecystectomy) may become a challenge — for example, in acute gangrenous cholecystitis. But, as you know from elective surgery, reducing surgical trauma to the abdominal wall is beneficial, maybe even more so in a patient with an acute condition who needs his ‘healing energy’ to overcome the disease itself. The usual potential advantages of laparoscopy — less pain, shorter ileus, enhanced mobilization — are relevant in the acute setting. On the other hand, the list above makes it obvious that emergency laparoscopy is not a walk in the park, and the risk of complications is increased.\\n\\nSo, before you decide to use this excellent tool, you have to realize its limitations, and even more important — you have to realize YOUR limitations. Selectivity, dexterity, and clinical judgment must guide your decisions when and if to use laparoscopy, how to carry it out safely, when to convert, and when to avoid it altogether.',\n", " 'md': 'Speed may be critical. Timing is usually inconvenient: experienced staff may be lacking, available staff may be tired, and you may need to handle unfamiliar situations, with less assistance.\\n\\nSo in general, both decision making and operating technique are more complicated in a surgical emergency. Even procedures you are confident with (laparoscopic cholecystectomy) may become a challenge — for example, in acute gangrenous cholecystitis. But, as you know from elective surgery, reducing surgical trauma to the abdominal wall is beneficial, maybe even more so in a patient with an acute condition who needs his ‘healing energy’ to overcome the disease itself. The usual potential advantages of laparoscopy — less pain, shorter ileus, enhanced mobilization — are relevant in the acute setting. On the other hand, the list above makes it obvious that emergency laparoscopy is not a walk in the park, and the risk of complications is increased.\\n\\nSo, before you decide to use this excellent tool, you have to realize its limitations, and even more important — you have to realize YOUR limitations. Selectivity, dexterity, and clinical judgment must guide your decisions when and if to use laparoscopy, how to carry it out safely, when to convert, and when to avoid it altogether.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.85, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Potential Advantages',\n", " 'md': '## Potential Advantages',\n", " 'bBox': {'x': 86, 'y': 502, 'w': 165.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- **Diagnosis**: Despite modern imaging, we still operate on patients that may surprise us. The use of CT scans has not completely eliminated surgery for the non-inflamed appendix. The free air may come from perforation of a viscus we did not suspect. The bowel obstruction in a metastatic patient can be the result of a single adhesive band. These situations and others can of course be detected and treated by a large, ‘formal’ laparotomy, but what if we could reduce the price of exploration by limiting the abdominal wall trauma? Laparoscopic exploration can establish the diagnosis, and direct us to the required intervention. And even if open surgery is required — it may be done in a more directed manner.\\n```',\n", " 'md': '- **Diagnosis**: Despite modern imaging, we still operate on patients that may surprise us. The use of CT scans has not completely eliminated surgery for the non-inflamed appendix. The free air may come from perforation of a viscus we did not suspect. The bowel obstruction in a metastatic patient can be the result of a single adhesive band. These situations and others can of course be detected and treated by a large, ‘formal’ laparotomy, but what if we could reduce the price of exploration by limiting the abdominal wall trauma? Laparoscopic exploration can establish the diagnosis, and direct us to the required intervention. And even if open surgery is required — it may be done in a more directed manner.\\n```',\n", " 'bBox': {'x': 100, 'y': 571, 'w': 436.95, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 153,\n", " 'text': ' way, through a limited incision sited where the pathology lies.\\n • Surgical trauma. In a patient suffering from an acute abdominal\\n condition, reducing the additional physiologic burden of a large\\n abdominal wound is a highly desired objective. Pain, ileus,\\n immobilization, respiratory dysfunction — are all expected in a\\n patient with an inflammatory or obstructive abdominal condition —\\n why add to that a long incision which can further stoke the fire of the\\n SIRS? Reducing tissue trauma contributes to enhanced\\n recovery.\\n • Wound-related problems. In acute conditions, the risk of wound\\n infection is increased, and so are the chances of wound healing\\n disorders, wound dehiscence and eventual incisional hernia.\\n Laparoscopy may prevent these conditions, or at least diminish\\n them by allowing the use of smaller, directed incisions.\\n\\n Potential flaws\\n\\n The significant advantages listed above should be balanced against\\nmany potential difficulties and risks expected in a patient with an acute\\nabdomen. These relate both to the general condition of the patient, and\\nthe specific conditions found inside the abdomen. The resulting\\ncomplications, or even mortality, may be fully preventable by an\\nopen approach or a timely conversion. ħere are a few drawbacks of\\nlaparoscopy:\\n\\n • Hemodynamic stability. Inflating the abdomen with CO2 is well\\n tolerated by most patients in elective conditions, despite the known\\n effects on the cardiovascular and respiratory system. This may not\\n be the case in the septic patient, suffering from a distended\\n abdomen and respiratory insufficiency. The delicate physiological\\n balance, if still maintained before surgery, may be easily lost by\\n the added insult of increased abdominal pressure and\\n decreased perfusion. In fact, an open abdomen may actually be\\n required as part of the treatment…\\n • Need for speed. Procrastination is certainly not something a\\n bleeding patient needs. A trauma patient in shock is not the correct\\n patient on whom to practice your hand-eye coordination skills. Open',\n", " 'md': '```markdown\\n## Text Extraction\\n\\n- Surgical trauma. In a patient suffering from an acute abdominal condition, reducing the additional physiologic burden of a large abdominal wound is a highly desired objective. Pain, ileus, immobilization, respiratory dysfunction — are all expected in a patient with an inflammatory or obstructive abdominal condition — why add to that a long incision which can further stoke the fire of the SIRS? Reducing tissue trauma contributes to enhanced recovery.\\n- Wound-related problems. In acute conditions, the risk of wound infection is increased, and so are the chances of wound healing disorders, wound dehiscence and eventual incisional hernia. Laparoscopy may prevent these conditions, or at least diminish them by allowing the use of smaller, directed incisions.\\n\\n### Potential Flaws\\n\\nThe significant advantages listed above should be balanced against many potential difficulties and risks expected in a patient with an acute abdomen. These relate both to the general condition of the patient, and the specific conditions found inside the abdomen. The resulting complications, or even mortality, may be fully preventable by an open approach or a timely conversion. Here are a few drawbacks of laparoscopy:\\n\\n- Hemodynamic stability. Inflating the abdomen with CO2 is well tolerated by most patients in elective conditions, despite the known effects on the cardiovascular and respiratory system. This may not be the case in the septic patient, suffering from a distended abdomen and respiratory insufficiency. The delicate physiological balance, if still maintained before surgery, may be easily lost by the added insult of increased abdominal pressure and decreased perfusion. In fact, an open abdomen may actually be required as part of the treatment…\\n- Need for speed. Procrastination is certainly not something a bleeding patient needs. A trauma patient in shock is not the correct patient on whom to practice your hand-eye coordination skills. Open\\n\\n## Image Identification and Description\\n\\n*No images or graphs were identified on this page.*\\n\\n## Summary\\n\\nThis page discusses the advantages and potential drawbacks of laparoscopic surgery in patients with acute abdominal conditions. It emphasizes the importance of minimizing surgical trauma and wound-related problems while also addressing the risks associated with hemodynamic stability and the urgency required in trauma situations.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Surgical trauma. In a patient suffering from an acute abdominal condition, reducing the additional physiologic burden of a large abdominal wound is a highly desired objective. Pain, ileus, immobilization, respiratory dysfunction — are all expected in a patient with an inflammatory or obstructive abdominal condition — why add to that a long incision which can further stoke the fire of the SIRS? Reducing tissue trauma contributes to enhanced recovery.\\n- Wound-related problems. In acute conditions, the risk of wound infection is increased, and so are the chances of wound healing disorders, wound dehiscence and eventual incisional hernia. Laparoscopy may prevent these conditions, or at least diminish them by allowing the use of smaller, directed incisions.',\n", " 'md': '- Surgical trauma. In a patient suffering from an acute abdominal condition, reducing the additional physiologic burden of a large abdominal wound is a highly desired objective. Pain, ileus, immobilization, respiratory dysfunction — are all expected in a patient with an inflammatory or obstructive abdominal condition — why add to that a long incision which can further stoke the fire of the SIRS? Reducing tissue trauma contributes to enhanced recovery.\\n- Wound-related problems. In acute conditions, the risk of wound infection is increased, and so are the chances of wound healing disorders, wound dehiscence and eventual incisional hernia. Laparoscopy may prevent these conditions, or at least diminish them by allowing the use of smaller, directed incisions.',\n", " 'bBox': {'x': 100, 'y': 188, 'w': 436.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Potential Flaws',\n", " 'md': '### Potential Flaws',\n", " 'bBox': {'x': 86, 'y': 352, 'w': 115.85, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The significant advantages listed above should be balanced against many potential difficulties and risks expected in a patient with an acute abdomen. These relate both to the general condition of the patient, and the specific conditions found inside the abdomen. The resulting complications, or even mortality, may be fully preventable by an open approach or a timely conversion. Here are a few drawbacks of laparoscopy:\\n\\n- Hemodynamic stability. Inflating the abdomen with CO2 is well tolerated by most patients in elective conditions, despite the known effects on the cardiovascular and respiratory system. This may not be the case in the septic patient, suffering from a distended abdomen and respiratory insufficiency. The delicate physiological balance, if still maintained before surgery, may be easily lost by the added insult of increased abdominal pressure and decreased perfusion. In fact, an open abdomen may actually be required as part of the treatment…\\n- Need for speed. Procrastination is certainly not something a bleeding patient needs. A trauma patient in shock is not the correct patient on whom to practice your hand-eye coordination skills. Open',\n", " 'md': 'The significant advantages listed above should be balanced against many potential difficulties and risks expected in a patient with an acute abdomen. These relate both to the general condition of the patient, and the specific conditions found inside the abdomen. The resulting complications, or even mortality, may be fully preventable by an open approach or a timely conversion. Here are a few drawbacks of laparoscopy:\\n\\n- Hemodynamic stability. Inflating the abdomen with CO2 is well tolerated by most patients in elective conditions, despite the known effects on the cardiovascular and respiratory system. This may not be the case in the septic patient, suffering from a distended abdomen and respiratory insufficiency. The delicate physiological balance, if still maintained before surgery, may be easily lost by the added insult of increased abdominal pressure and decreased perfusion. In fact, an open abdomen may actually be required as part of the treatment…\\n- Need for speed. Procrastination is certainly not something a bleeding patient needs. A trauma patient in shock is not the correct patient on whom to practice your hand-eye coordination skills. Open',\n", " 'bBox': {'x': 72, 'y': 421, 'w': 467.68, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or graphs were identified on this page.*',\n", " 'md': '*No images or graphs were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the advantages and potential drawbacks of laparoscopic surgery in patients with acute abdominal conditions. It emphasizes the importance of minimizing surgical trauma and wound-related problems while also addressing the risks associated with hemodynamic stability and the urgency required in trauma situations.\\n```',\n", " 'md': 'This page discusses the advantages and potential drawbacks of laparoscopic surgery in patients with acute abdominal conditions. It emphasizes the importance of minimizing surgical trauma and wound-related problems while also addressing the risks associated with hemodynamic stability and the urgency required in trauma situations.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 154,\n", " 'text': ' up and stop the bleeding!\\n • Need for space. This is a pre-requisite for safe and successful\\n laparoscopy. Colonic obstruction will not leave you enough working\\n space and is almost out of the question for laparoscopy. A thick,\\n edematous abdominal wall (common after aggressive resuscitation)\\n with limited compliance will hardly let you create a working space or\\n will mandate high (and dangerous) insufflation pressures.\\n Obstructed small bowel may still leave you enough working space\\n but will not make your life easy… extreme carefulness and a high\\n degree of expertise are needed to avoid catastrophic injuries\\n like major spillage of obstructed contents — we have seen\\n mortality from this.\\n • Technical limitations. The local conditions found in the acute\\n abdomen may limit the ability to handle the situation\\n laparoscopically. Adhesions, tissue edema, bowel distension — all\\n of these can interfere with the handling, retraction,\\n manipulation and mobilization needed to complete the\\n procedure promptly and safely.\\n • Missed pathology. The limited palpation, limited access to\\n retroperitoneal structures and sometimes limited visibility may result\\n in missing the actual pathology. Conversion is a good solution but\\n only if the surgeon realizes that something is missing…\\n\\n Remember: I have never seen a patient dying because he was converted to open; I saw\\n them dying because they were not converted in a timely manner. Moshe\\n\\n A small scar doesn’t matter in the coffin. Ari\\n\\n Setting the scene\\n\\n Laparoscopy is a team procedure, even more so than open surgery.\\nYou rely on equipment and technology that should be familiar to your OR\\nstaff, who should help you operate and trouble-shoot them. You also rely\\non good assistance, for holding the camera and additional instruments.\\nAnd you certainly rely on the anesthetist and his muscle-relaxing potions.',\n", " 'md': '```markdown\\n## Text Extraction\\n\\n- Up and stop the bleeding!\\n- Need for space. This is a pre-requisite for safe and successful laparoscopy. Colonic obstruction will not leave you enough working space and is almost out of the question for laparoscopy. A thick, edematous abdominal wall (common after aggressive resuscitation) with limited compliance will hardly let you create a working space or will mandate high (and dangerous) insufflation pressures. Obstructed small bowel may still leave you enough working space but will not make your life easy… extreme carefulness and a high degree of expertise are needed to avoid catastrophic injuries like major spillage of obstructed contents — we have seen mortality from this.\\n- Technical limitations. The local conditions found in the acute abdomen may limit the ability to handle the situation laparoscopically. Adhesions, tissue edema, bowel distension — all of these can interfere with the handling, retraction, manipulation and mobilization needed to complete the procedure promptly and safely.\\n- Missed pathology. The limited palpation, limited access to retroperitoneal structures and sometimes limited visibility may result in missing the actual pathology. Conversion is a good solution but only if the surgeon realizes that something is missing…\\n\\nRemember: I have never seen a patient dying because he was converted to open; I saw them dying because they were not converted in a timely manner. Moshe\\n\\nA small scar doesn’t matter in the coffin. Ari\\n\\n### Setting the Scene\\n\\nLaparoscopy is a team procedure, even more so than open surgery. You rely on equipment and technology that should be familiar to your OR staff, who should help you operate and trouble-shoot them. You also rely on good assistance, for holding the camera and additional instruments. And you certainly rely on the anesthetist and his muscle-relaxing potions.\\n```\\n\\n## Image Identification and Description\\n\\n- **No images or graphs were identified on this page.**',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Up and stop the bleeding!\\n- Need for space. This is a pre-requisite for safe and successful laparoscopy. Colonic obstruction will not leave you enough working space and is almost out of the question for laparoscopy. A thick, edematous abdominal wall (common after aggressive resuscitation) with limited compliance will hardly let you create a working space or will mandate high (and dangerous) insufflation pressures. Obstructed small bowel may still leave you enough working space but will not make your life easy… extreme carefulness and a high degree of expertise are needed to avoid catastrophic injuries like major spillage of obstructed contents — we have seen mortality from this.\\n- Technical limitations. The local conditions found in the acute abdomen may limit the ability to handle the situation laparoscopically. Adhesions, tissue edema, bowel distension — all of these can interfere with the handling, retraction, manipulation and mobilization needed to complete the procedure promptly and safely.\\n- Missed pathology. The limited palpation, limited access to retroperitoneal structures and sometimes limited visibility may result in missing the actual pathology. Conversion is a good solution but only if the surgeon realizes that something is missing…\\n\\nRemember: I have never seen a patient dying because he was converted to open; I saw them dying because they were not converted in a timely manner. Moshe\\n\\nA small scar doesn’t matter in the coffin. Ari',\n", " 'md': '- Up and stop the bleeding!\\n- Need for space. This is a pre-requisite for safe and successful laparoscopy. Colonic obstruction will not leave you enough working space and is almost out of the question for laparoscopy. A thick, edematous abdominal wall (common after aggressive resuscitation) with limited compliance will hardly let you create a working space or will mandate high (and dangerous) insufflation pressures. Obstructed small bowel may still leave you enough working space but will not make your life easy… extreme carefulness and a high degree of expertise are needed to avoid catastrophic injuries like major spillage of obstructed contents — we have seen mortality from this.\\n- Technical limitations. The local conditions found in the acute abdomen may limit the ability to handle the situation laparoscopically. Adhesions, tissue edema, bowel distension — all of these can interfere with the handling, retraction, manipulation and mobilization needed to complete the procedure promptly and safely.\\n- Missed pathology. The limited palpation, limited access to retroperitoneal structures and sometimes limited visibility may result in missing the actual pathology. Conversion is a good solution but only if the surgeon realizes that something is missing…\\n\\nRemember: I have never seen a patient dying because he was converted to open; I saw them dying because they were not converted in a timely manner. Moshe\\n\\nA small scar doesn’t matter in the coffin. Ari',\n", " 'bBox': {'x': 77, 'y': 86, 'w': 460.25, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Setting the Scene',\n", " 'md': '### Setting the Scene',\n", " 'bBox': {'x': 86, 'y': 306, 'w': 204.58, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Laparoscopy is a team procedure, even more so than open surgery. You rely on equipment and technology that should be familiar to your OR staff, who should help you operate and trouble-shoot them. You also rely on good assistance, for holding the camera and additional instruments. And you certainly rely on the anesthetist and his muscle-relaxing potions.\\n```',\n", " 'md': 'Laparoscopy is a team procedure, even more so than open surgery. You rely on equipment and technology that should be familiar to your OR staff, who should help you operate and trouble-shoot them. You also rely on good assistance, for holding the camera and additional instruments. And you certainly rely on the anesthetist and his muscle-relaxing potions.\\n```',\n", " 'bBox': {'x': 72, 'y': 306, 'w': 467.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 205, 'y': 356, 'w': 29.57, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **No images or graphs were identified on this page.**',\n", " 'md': '- **No images or graphs were identified on this page.**',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 155,\n", " 'text': ' Achieving smooth laparoscopic procedures out-of-hours, for non-\\nroutine cases, performed on patients in non-optimal conditions, in\\nnot an easy task. The tired anesthetist and the thirsty scrub nurse may\\nnot be eager to join you in what is conceived to be a longer and more\\ndifficult procedure. To become an emergency surgery laparoscopist\\nyou should train your OR team to function in these conditions, and\\nit starts by realizing that laparoscopy is possible, and that it’s in the\\npatient’s best interest to have the procedure done laparoscopically,\\neven at 2 a.m.\\n\\n You should start with simple procedures, like appendectomy or maybe\\ncholecystectomy for acute cholecystitis if you feel proficient enough, and\\nmake sure the system functions well. Only then can you embark on more\\nchallenging conditions like duodenal perforation or small bowel\\nobstruction. And don’t buy all that is described in the literature — we\\nwill forgive you if you continue to remove the shattered spleen via a\\nmidline laparotomy.\\n\\n You should also make sure you are well equipped for completing the\\ntask in front of you. You may know how to suture laparoscopically (you\\nshould!) but you need a suture holder. You may need to work in more\\nthan one quadrant so better have another monitor ready. You may need\\nto aspirate infected fluid so make sure your suction is connected and\\nfunctioning. Energy sources, staplers — think about your possible needs\\nin advance, while you think about your impending procedure and plan it,\\nand make sure you have what you need to make the operation safe and\\nsuccessful — your elegant hands are important but not enough on their\\nown.\\n\\n Technique\\n\\n Planning the procedure\\n\\n The beauty of emergency surgery is in the surprises it holds for you.\\nAnd yet, try to minimize surprises and be ready. If you plan to tackle an\\nincarcerated hernia laparoscopically — think about the possible\\nscenarios and how you will handle them: what will you do if you find',\n", " 'md': '```markdown\\n## Achieving Smooth Laparoscopic Procedures\\n\\nAchieving smooth laparoscopic procedures out-of-hours, for non-routine cases, performed on patients in non-optimal conditions, is not an easy task. The tired anesthetist and the thirsty scrub nurse may not be eager to join you in what is conceived to be a longer and more difficult procedure. To become an emergency surgery laparoscopist, you should train your OR team to function in these conditions, and it starts by realizing that laparoscopy is possible, and that it’s in the patient’s best interest to have the procedure done laparoscopically, even at 2 a.m.\\n\\nYou should start with simple procedures, like appendectomy or maybe cholecystectomy for acute cholecystitis if you feel proficient enough, and make sure the system functions well. Only then can you embark on more challenging conditions like duodenal perforation or small bowel obstruction. And don’t buy all that is described in the literature — we will forgive you if you continue to remove the shattered spleen via a midline laparotomy.\\n\\nYou should also make sure you are well equipped for completing the task in front of you. You may know how to suture laparoscopically (you should!) but you need a suture holder. You may need to work in more than one quadrant so better have another monitor ready. You may need to aspirate infected fluid so make sure your suction is connected and functioning. Energy sources, staplers — think about your possible needs in advance, while you think about your impending procedure and plan it, and make sure you have what you need to make the operation safe and successful — your elegant hands are important but not enough on their own.\\n\\n### Technique\\n\\n#### Planning the Procedure\\n\\nThe beauty of emergency surgery is in the surprises it holds for you. And yet, try to minimize surprises and be ready. If you plan to tackle an incarcerated hernia laparoscopically — think about the possible scenarios and how you will handle them: what will you do if you find...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Achieving Smooth Laparoscopic Procedures',\n", " 'md': '## Achieving Smooth Laparoscopic Procedures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Achieving smooth laparoscopic procedures out-of-hours, for non-routine cases, performed on patients in non-optimal conditions, is not an easy task. The tired anesthetist and the thirsty scrub nurse may not be eager to join you in what is conceived to be a longer and more difficult procedure. To become an emergency surgery laparoscopist, you should train your OR team to function in these conditions, and it starts by realizing that laparoscopy is possible, and that it’s in the patient’s best interest to have the procedure done laparoscopically, even at 2 a.m.\\n\\nYou should start with simple procedures, like appendectomy or maybe cholecystectomy for acute cholecystitis if you feel proficient enough, and make sure the system functions well. Only then can you embark on more challenging conditions like duodenal perforation or small bowel obstruction. And don’t buy all that is described in the literature — we will forgive you if you continue to remove the shattered spleen via a midline laparotomy.\\n\\nYou should also make sure you are well equipped for completing the task in front of you. You may know how to suture laparoscopically (you should!) but you need a suture holder. You may need to work in more than one quadrant so better have another monitor ready. You may need to aspirate infected fluid so make sure your suction is connected and functioning. Energy sources, staplers — think about your possible needs in advance, while you think about your impending procedure and plan it, and make sure you have what you need to make the operation safe and successful — your elegant hands are important but not enough on their own.',\n", " 'md': 'Achieving smooth laparoscopic procedures out-of-hours, for non-routine cases, performed on patients in non-optimal conditions, is not an easy task. The tired anesthetist and the thirsty scrub nurse may not be eager to join you in what is conceived to be a longer and more difficult procedure. To become an emergency surgery laparoscopist, you should train your OR team to function in these conditions, and it starts by realizing that laparoscopy is possible, and that it’s in the patient’s best interest to have the procedure done laparoscopically, even at 2 a.m.\\n\\nYou should start with simple procedures, like appendectomy or maybe cholecystectomy for acute cholecystitis if you feel proficient enough, and make sure the system functions well. Only then can you embark on more challenging conditions like duodenal perforation or small bowel obstruction. And don’t buy all that is described in the literature — we will forgive you if you continue to remove the shattered spleen via a midline laparotomy.\\n\\nYou should also make sure you are well equipped for completing the task in front of you. You may know how to suture laparoscopically (you should!) but you need a suture holder. You may need to work in more than one quadrant so better have another monitor ready. You may need to aspirate infected fluid so make sure your suction is connected and functioning. Energy sources, staplers — think about your possible needs in advance, while you think about your impending procedure and plan it, and make sure you have what you need to make the operation safe and successful — your elegant hands are important but not enough on their own.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Technique',\n", " 'md': '### Technique',\n", " 'bBox': {'x': 86, 'y': 580, 'w': 81.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Planning the Procedure',\n", " 'md': '#### Planning the Procedure',\n", " 'bBox': {'x': 86, 'y': 624, 'w': 184.82, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The beauty of emergency surgery is in the surprises it holds for you. And yet, try to minimize surprises and be ready. If you plan to tackle an incarcerated hernia laparoscopically — think about the possible scenarios and how you will handle them: what will you do if you find...\\n```',\n", " 'md': 'The beauty of emergency surgery is in the surprises it holds for you. And yet, try to minimize surprises and be ready. If you plan to tackle an incarcerated hernia laparoscopically — think about the possible scenarios and how you will handle them: what will you do if you find...\\n```',\n", " 'bBox': {'x': 72, 'y': 677, 'w': 467.96, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 156,\n", " 'text': 'necrotic bowel? If you go in for small bowel obstruction, try to identify the\\nlocation of the obstruction in the pre-op CT scan: this will help you plan\\nthe trocar placement for your scope and instruments, and the location of\\nthe monitor at a convenient spot in front of you.\\n\\n Getting in\\n\\n We are not here to solve the eternal debate — Veress or ħasson? You\\nmay have your own preferences for elective surgery, and it’s fine by us.\\nBut we expect you to be familiar with both techniques, because in\\nemergency conditions selectivity is the key, and the closed, blind\\nentry may be more dangerous in certain conditions. For example,\\nwith bowel obstruction — both the distended bowel and the\\nadhesions from previous operations mandate that you choose the\\nopen entry to avoid inadvertent bowel injury.\\n\\n Choosing the camera\\n\\n As you have probably realized by now, a 30° scope will increase your\\nfield of view and your overall versatility, and is recommended as a\\nstandard. It may be even more valuable in emergency operations, where\\nthe need ‘to look behind’, due to adhesions or bowel distension, is even\\nmore pronounced. Provided you have a good optical system with a good\\nlight source, a 5mm scope may allow you to easily move the camera\\nbetween different trocars, providing different viewing angles. A second\\nmonitor on the other side of the table may be a good adjunct for this\\ncondition. But if you don’t have a high-quality 5mm optical system, and\\nespecially when you know you are going to work in a single quadrant\\n(appendectomy, cholecystectomy), don’t compromise, and get the best\\nviewing conditions you can, using a 10mm scope. This will keep\\nyour illumination maximal, even in harsh conditions like blood\\npooling in your field.\\n\\n Placing the working trocars\\n\\n You should have a general working plan, to achieve your surgical task',\n", " 'md': '```markdown\\n## Surgical Techniques for Bowel Obstruction\\n\\n### Identifying the Location of Obstruction\\nIf you go in for small bowel obstruction, try to identify the location of the obstruction in the pre-op CT scan: this will help you plan the trocar placement for your scope and instruments, and the location of the monitor at a convenient spot in front of you.\\n\\n### Getting In\\nWe are not here to solve the eternal debate — Veress or Hasson? You may have your own preferences for elective surgery, and it’s fine by us. But we expect you to be familiar with both techniques, because in emergency conditions selectivity is the key, and the closed, blind entry may be more dangerous in certain conditions. For example, with bowel obstruction — both the distended bowel and the adhesions from previous operations mandate that you choose the open entry to avoid inadvertent bowel injury.\\n\\n### Choosing the Camera\\nAs you have probably realized by now, a 30° scope will increase your field of view and your overall versatility, and is recommended as a standard. It may be even more valuable in emergency operations, where the need ‘to look behind’, due to adhesions or bowel distension, is even more pronounced. Provided you have a good optical system with a good light source, a 5mm scope may allow you to easily move the camera between different trocars, providing different viewing angles. A second monitor on the other side of the table may be a good adjunct for this condition. But if you don’t have a high-quality 5mm optical system, and especially when you know you are going to work in a single quadrant (appendectomy, cholecystectomy), don’t compromise, and get the best viewing conditions you can, using a 10mm scope. This will keep your illumination maximal, even in harsh conditions like blood pooling in your field.\\n\\n### Placing the Working Trocars\\nYou should have a general working plan, to achieve your surgical task.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Techniques for Bowel Obstruction',\n", " 'md': '## Surgical Techniques for Bowel Obstruction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Identifying the Location of Obstruction',\n", " 'md': '### Identifying the Location of Obstruction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'If you go in for small bowel obstruction, try to identify the location of the obstruction in the pre-op CT scan: this will help you plan the trocar placement for your scope and instruments, and the location of the monitor at a convenient spot in front of you.',\n", " 'md': 'If you go in for small bowel obstruction, try to identify the location of the obstruction in the pre-op CT scan: this will help you plan the trocar placement for your scope and instruments, and the location of the monitor at a convenient spot in front of you.',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Getting In',\n", " 'md': '### Getting In',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 77.21, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'We are not here to solve the eternal debate — Veress or Hasson? You may have your own preferences for elective surgery, and it’s fine by us. But we expect you to be familiar with both techniques, because in emergency conditions selectivity is the key, and the closed, blind entry may be more dangerous in certain conditions. For example, with bowel obstruction — both the distended bowel and the adhesions from previous operations mandate that you choose the open entry to avoid inadvertent bowel injury.',\n", " 'md': 'We are not here to solve the eternal debate — Veress or Hasson? You may have your own preferences for elective surgery, and it’s fine by us. But we expect you to be familiar with both techniques, because in emergency conditions selectivity is the key, and the closed, blind entry may be more dangerous in certain conditions. For example, with bowel obstruction — both the distended bowel and the adhesions from previous operations mandate that you choose the open entry to avoid inadvertent bowel injury.',\n", " 'bBox': {'x': 72, 'y': 231, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Choosing the Camera',\n", " 'md': '### Choosing the Camera',\n", " 'bBox': {'x': 86, 'y': 373, 'w': 168.29, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As you have probably realized by now, a 30° scope will increase your field of view and your overall versatility, and is recommended as a standard. It may be even more valuable in emergency operations, where the need ‘to look behind’, due to adhesions or bowel distension, is even more pronounced. Provided you have a good optical system with a good light source, a 5mm scope may allow you to easily move the camera between different trocars, providing different viewing angles. A second monitor on the other side of the table may be a good adjunct for this condition. But if you don’t have a high-quality 5mm optical system, and especially when you know you are going to work in a single quadrant (appendectomy, cholecystectomy), don’t compromise, and get the best viewing conditions you can, using a 10mm scope. This will keep your illumination maximal, even in harsh conditions like blood pooling in your field.',\n", " 'md': 'As you have probably realized by now, a 30° scope will increase your field of view and your overall versatility, and is recommended as a standard. It may be even more valuable in emergency operations, where the need ‘to look behind’, due to adhesions or bowel distension, is even more pronounced. Provided you have a good optical system with a good light source, a 5mm scope may allow you to easily move the camera between different trocars, providing different viewing angles. A second monitor on the other side of the table may be a good adjunct for this condition. But if you don’t have a high-quality 5mm optical system, and especially when you know you are going to work in a single quadrant (appendectomy, cholecystectomy), don’t compromise, and get the best viewing conditions you can, using a 10mm scope. This will keep your illumination maximal, even in harsh conditions like blood pooling in your field.',\n", " 'bBox': {'x': 72, 'y': 409, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Placing the Working Trocars',\n", " 'md': '### Placing the Working Trocars',\n", " 'bBox': {'x': 86, 'y': 667, 'w': 216.99, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'You should have a general working plan, to achieve your surgical task.\\n```',\n", " 'md': 'You should have a general working plan, to achieve your surgical task.\\n```',\n", " 'bBox': {'x': 86, 'y': 703, 'w': 453.44, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 157,\n", " 'text': 'in hand. Some of the surgical emergencies are ‘straightforward’, and\\nhave a standard scheme: laparoscopic cholecystectomy or\\nappendectomy are usually done the same way (with some minor\\nvariations), and are limited to one abdominal quadrant. Bowel\\nobstruction, on the other hand, can have its ‘transition point’ in an\\nunexpected abdominal location. Analyzing the CT scan and\\nunderstanding where the obstruction point is, even approximately, will\\nhelp you to plan the trocars’ location in the most effective way ( Figure\\n12.1).\\n OLD\\n Zcm J0oo\"FArT\\n EMeRitus\\n (PRoFessoR\\n PeRMA 244\\nFigure 12.1. Surgeon: “I had to insert a few more trocars for exposure.” Assistant: “But\\nSir, SILS would have been more minimally invasive...”\\n\\n Tissue handling\\n\\n Dealing with swollen, edematous and inflamed tissues, or\\nobstructed, distended bowel, is a surgical challenge, requiring both\\ndelicacy and firmness in the exact amounts. ħolding too delicately or\\ntoo aggressively — you can rip softened tissue. Manipulating a distended',\n", " 'md': '```markdown\\nSome of the surgical emergencies are ‘straightforward’, and have a standard scheme: laparoscopic cholecystectomy or appendectomy are usually done the same way (with some minor variations), and are limited to one abdominal quadrant. Bowel obstruction, on the other hand, can have its ‘transition point’ in an unexpected abdominal location. Analyzing the CT scan and understanding where the obstruction point is, even approximately, will help you to plan the trocars’ location in the most effective way (Figure 12.1).\\n\\n**Figure 12.1**: Surgeon: “I had to insert a few more trocars for exposure.” Assistant: “But Sir, SILS would have been more minimally invasive...”\\n\\n### Tissue handling\\n\\nDealing with swollen, edematous and inflamed tissues, or obstructed, distended bowel, is a surgical challenge, requiring both delicacy and firmness in the exact amounts. Holding too delicately or too aggressively — you can rip softened tissue. Manipulating a distended...\\n```\\n\\n### Image Description\\n- **Figure 12.1**: This image likely depicts a surgical scenario involving a surgeon and an assistant discussing the insertion of trocars during a procedure. The caption suggests a conversation about the surgical approach, indicating a preference for a more minimally invasive technique (SILS - Single Incision Laparoscopic Surgery). The image captures the essence of surgical decision-making in real-time.\\n\\n### Note\\n- The text contains a section that is cut off: \"Manipulating a distended...\" which may indicate further discussion on tissue handling techniques.',\n", " 'images': [{'name': 'img_p156_1.png',\n", " 'height': 610,\n", " 'width': 796,\n", " 'x': 109.44000000000005,\n", " 'y': 231.83999999999997,\n", " 'original_width': 1368,\n", " 'original_height': 1048}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nSome of the surgical emergencies are ‘straightforward’, and have a standard scheme: laparoscopic cholecystectomy or appendectomy are usually done the same way (with some minor variations), and are limited to one abdominal quadrant. Bowel obstruction, on the other hand, can have its ‘transition point’ in an unexpected abdominal location. Analyzing the CT scan and understanding where the obstruction point is, even approximately, will help you to plan the trocars’ location in the most effective way (Figure 12.1).\\n\\n**Figure 12.1**: Surgeon: “I had to insert a few more trocars for exposure.” Assistant: “But Sir, SILS would have been more minimally invasive...”',\n", " 'md': '```markdown\\nSome of the surgical emergencies are ‘straightforward’, and have a standard scheme: laparoscopic cholecystectomy or appendectomy are usually done the same way (with some minor variations), and are limited to one abdominal quadrant. Bowel obstruction, on the other hand, can have its ‘transition point’ in an unexpected abdominal location. Analyzing the CT scan and understanding where the obstruction point is, even approximately, will help you to plan the trocars’ location in the most effective way (Figure 12.1).\\n\\n**Figure 12.1**: Surgeon: “I had to insert a few more trocars for exposure.” Assistant: “But Sir, SILS would have been more minimally invasive...”',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 275.7, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Tissue handling',\n", " 'md': '### Tissue handling',\n", " 'bBox': {'x': 86, 'y': 168, 'w': 453, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Dealing with swollen, edematous and inflamed tissues, or obstructed, distended bowel, is a surgical challenge, requiring both delicacy and firmness in the exact amounts. Holding too delicately or too aggressively — you can rip softened tissue. Manipulating a distended...\\n```',\n", " 'md': 'Dealing with swollen, edematous and inflamed tissues, or obstructed, distended bowel, is a surgical challenge, requiring both delicacy and firmness in the exact amounts. Holding too delicately or too aggressively — you can rip softened tissue. Manipulating a distended...\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.7, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 12.1**: This image likely depicts a surgical scenario involving a surgeon and an assistant discussing the insertion of trocars during a procedure. The caption suggests a conversation about the surgical approach, indicating a preference for a more minimally invasive technique (SILS - Single Incision Laparoscopic Surgery). The image captures the essence of surgical decision-making in real-time.',\n", " 'md': '- **Figure 12.1**: This image likely depicts a surgical scenario involving a surgeon and an assistant discussing the insertion of trocars during a procedure. The caption suggests a conversation about the surgical approach, indicating a preference for a more minimally invasive technique (SILS - Single Incision Laparoscopic Surgery). The image captures the essence of surgical decision-making in real-time.',\n", " 'bBox': {'x': 122, 'y': 102, 'w': 84.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Note',\n", " 'md': '### Note',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text contains a section that is cut off: \"Manipulating a distended...\" which may indicate further discussion on tissue handling techniques.',\n", " 'md': '- The text contains a section that is cut off: \"Manipulating a distended...\" which may indicate further discussion on tissue handling techniques.',\n", " 'bBox': {'x': 86, 'y': 102, 'w': 125.67, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'help you to plan the trocars’ location in the most effective way ( Figure 12.1).'}]},\n", " {'page': 158,\n", " 'text': 'bowel — you can perforate it. Dissecting an inflamed tissue too much —\\nyou can produce excessive bleeding. Much experience is needed, but a\\nfew rules and tips can help you sail more safely through stormy\\nemergency waters until you gain that experience:\\n\\n • ‘Big bites’ are less likely to tear delicate tissues you need to hold.\\n • Suction tip is a wonderful tool for dissecting inflamed tissues.\\n • Blunt dissection will help you to follow the anatomical planes,\\n especially when separating relatively fresh adhesions.\\n • Collapsed, post-obstruction bowel loops are the best place to start\\n when you look for the obstruction point.\\n • When ‘running’ the bowel, holding the mesentery just below the\\n bowel and not the bowel itself may reduce the risk of inadvertent\\n bowel injury.\\n\\n Procedures\\n\\n Choosing which emergency procedure to attempt laparoscopically is\\nnot always simple. Some procedures are within the consensus — a ‘hot’\\ngallbladder will rarely be approached initially by open surgery. In other\\nconditions — like in abdominal trauma — some will rarely attempt\\nlaparoscopy. In most cases the final decision will be a complex\\nconsideration of multiple factors, but if the necessary conditions\\n(equipment, experience) are met, we still have to ask ourselves: is it\\nworthwhile? What do we gain from laparoscopy and what do we risk?\\nThe best emergency procedures, listed below, to accomplish\\nlaparoscopically, are those with a large ‘delta’ — denoting a\\nsignificant difference and thus a large advantage/disadvantage ratio\\ncompared to open surgery.\\n\\n Here are only a few ‘laparoscopic’ comments for each of these\\nprocedures, as a comprehensive discussion of them is given in the\\nrelevant chapters.\\n\\n Laparoscopic cholecystectomy',\n", " 'md': '```markdown\\n## Surgical Tips for Emergency Procedures\\n\\nBowel surgery requires careful handling to avoid complications. Here are some essential tips:\\n\\n- **Big bites** are less likely to tear delicate tissues you need to hold.\\n- A **suction tip** is a wonderful tool for dissecting inflamed tissues.\\n- **Blunt dissection** will help you to follow the anatomical planes, especially when separating relatively fresh adhesions.\\n- **Collapsed, post-obstruction bowel loops** are the best place to start when you look for the obstruction point.\\n- When **running the bowel**, holding the mesentery just below the bowel and not the bowel itself may reduce the risk of inadvertent bowel injury.\\n\\n### Procedures\\n\\nChoosing which emergency procedure to attempt laparoscopically is not always simple. Some procedures are within the consensus — a ‘hot’ gallbladder will rarely be approached initially by open surgery. In other conditions — like in abdominal trauma — some will rarely attempt laparoscopy.\\n\\nIn most cases, the final decision will be a complex consideration of multiple factors, but if the necessary conditions (equipment, experience) are met, we still have to ask ourselves: is it worthwhile? What do we gain from laparoscopy and what do we risk?\\n\\nThe best emergency procedures to accomplish laparoscopically are those with a large ‘delta’ — denoting a significant difference and thus a large advantage/disadvantage ratio compared to open surgery.\\n\\nHere are only a few ‘laparoscopic’ comments for each of these procedures, as a comprehensive discussion of them is given in the relevant chapters.\\n\\n### Laparoscopic Cholecystectomy\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Tips for Emergency Procedures',\n", " 'md': '## Surgical Tips for Emergency Procedures',\n", " 'bBox': {'x': 86, 'y': 378, 'w': 91.06, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Bowel surgery requires careful handling to avoid complications. Here are some essential tips:\\n\\n- **Big bites** are less likely to tear delicate tissues you need to hold.\\n- A **suction tip** is a wonderful tool for dissecting inflamed tissues.\\n- **Blunt dissection** will help you to follow the anatomical planes, especially when separating relatively fresh adhesions.\\n- **Collapsed, post-obstruction bowel loops** are the best place to start when you look for the obstruction point.\\n- When **running the bowel**, holding the mesentery just below the bowel and not the bowel itself may reduce the risk of inadvertent bowel injury.',\n", " 'md': 'Bowel surgery requires careful handling to avoid complications. Here are some essential tips:\\n\\n- **Big bites** are less likely to tear delicate tissues you need to hold.\\n- A **suction tip** is a wonderful tool for dissecting inflamed tissues.\\n- **Blunt dissection** will help you to follow the anatomical planes, especially when separating relatively fresh adhesions.\\n- **Collapsed, post-obstruction bowel loops** are the best place to start when you look for the obstruction point.\\n- When **running the bowel**, holding the mesentery just below the bowel and not the bowel itself may reduce the risk of inadvertent bowel injury.',\n", " 'bBox': {'x': 100, 'y': 244, 'w': 343.06, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Procedures',\n", " 'md': '### Procedures',\n", " 'bBox': {'x': 86, 'y': 378, 'w': 91.06, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Choosing which emergency procedure to attempt laparoscopically is not always simple. Some procedures are within the consensus — a ‘hot’ gallbladder will rarely be approached initially by open surgery. In other conditions — like in abdominal trauma — some will rarely attempt laparoscopy.\\n\\nIn most cases, the final decision will be a complex consideration of multiple factors, but if the necessary conditions (equipment, experience) are met, we still have to ask ourselves: is it worthwhile? What do we gain from laparoscopy and what do we risk?\\n\\nThe best emergency procedures to accomplish laparoscopically are those with a large ‘delta’ — denoting a significant difference and thus a large advantage/disadvantage ratio compared to open surgery.\\n\\nHere are only a few ‘laparoscopic’ comments for each of these procedures, as a comprehensive discussion of them is given in the relevant chapters.',\n", " 'md': 'Choosing which emergency procedure to attempt laparoscopically is not always simple. Some procedures are within the consensus — a ‘hot’ gallbladder will rarely be approached initially by open surgery. In other conditions — like in abdominal trauma — some will rarely attempt laparoscopy.\\n\\nIn most cases, the final decision will be a complex consideration of multiple factors, but if the necessary conditions (equipment, experience) are met, we still have to ask ourselves: is it worthwhile? What do we gain from laparoscopy and what do we risk?\\n\\nThe best emergency procedures to accomplish laparoscopically are those with a large ‘delta’ — denoting a significant difference and thus a large advantage/disadvantage ratio compared to open surgery.\\n\\nHere are only a few ‘laparoscopic’ comments for each of these procedures, as a comprehensive discussion of them is given in the relevant chapters.',\n", " 'bBox': {'x': 72, 'y': 378, 'w': 467.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Laparoscopic Cholecystectomy',\n", " 'md': '### Laparoscopic Cholecystectomy',\n", " 'bBox': {'x': 86, 'y': 708, 'w': 246.49, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 159,\n", " 'text': ' Depending on your local practice, acutely inflamed gallbladders may\\nbe either operated upon or treated conservatively. But while open\\nsurgery for acute cholecystitis was once the bread and butter of\\nsurgical residents, laparoscopic surgery for this condition is quite\\ndemanding, requiring the presence of an experienced laparoscopist,\\nand familiarity with several maneuvers that will make safe removal\\nof the gallbladder possible:\\n\\n • Grasping a distended gallbladder is difficult. Aspirating the bile (you\\n can use the Veress needle for this) will make grasping possible.\\n • Blunt dissection, using the suction tip, is especially rewarding in\\n edematous, inflamed tissues.\\n • Anatomy may be obscure in inflamed conditions — don’t take\\n shortcuts; insist on obtaining the ‘critical view of safety’.\\n • If you can’t delineate the anatomy — consider alternative\\n approaches, like retrograde cholecystectomy or subtotal\\n cholecystectomy. Opening the gallbladder just above ħartmann’s\\n pouch, carefully evacuating the stones into a pre-placed collection\\n bag, and looking down into the gallbladder outlet may assist you in\\n delineation of the anatomy, and understanding where the cystic duct\\n hides. If still unclear — make sure you have cleared the stones and\\n then suture the cystic duct from within, or close ħartmann’s pouch\\n with sutures or an Endoloop®. If these maneuvers seem\\n ‘impossible’, you can simply leave a drain and bail out!\\n • Don’t forget the option of conversion! ‘Remembering’ that option\\n in hindsight after the patient has suffered a CBD injury or after you\\n have been sued, is not too helpful.\\n • Read much more about it in Chapter 20.\\n\\n Laparoscopic appendectomy\\n\\n The ‘delta’ mentioned above, compared to open appendectomy, is not\\ntoo big, and therefore the debate regarding which approach is preferable\\nis not over. Be that as it may, in practice we have seen a major increase\\nin the rate of laparoscopic appendectomy, so it’s here to stay. Its\\nadvantages are more pronounced in obese patients, in females, and',\n", " 'md': '```markdown\\n## Surgical Approaches to Acute Cholecystitis\\n\\nDepending on your local practice, acutely inflamed gallbladders may be either operated upon or treated conservatively. But while open surgery for acute cholecystitis was once the bread and butter of surgical residents, laparoscopic surgery for this condition is quite demanding, requiring the presence of an experienced laparoscopist and familiarity with several maneuvers that will make safe removal of the gallbladder possible:\\n\\n- Grasping a distended gallbladder is difficult. Aspirating the bile (you can use the Veress needle for this) will make grasping possible.\\n- Blunt dissection, using the suction tip, is especially rewarding in edematous, inflamed tissues.\\n- Anatomy may be obscure in inflamed conditions — don’t take shortcuts; insist on obtaining the ‘critical view of safety’.\\n- If you can’t delineate the anatomy — consider alternative approaches, like retrograde cholecystectomy or subtotal cholecystectomy. Opening the gallbladder just above Hartmann’s pouch, carefully evacuating the stones into a pre-placed collection bag, and looking down into the gallbladder outlet may assist you in delineation of the anatomy, and understanding where the cystic duct hides. If still unclear — make sure you have cleared the stones and then suture the cystic duct from within, or close Hartmann’s pouch with sutures or an Endoloop®. If these maneuvers seem ‘impossible’, you can simply leave a drain and bail out!\\n- Don’t forget the option of conversion! ‘Remembering’ that option in hindsight after the patient has suffered a CBD injury or after you have been sued, is not too helpful.\\n- Read much more about it in [Chapter 20](#).\\n\\n## Laparoscopic Appendectomy\\n\\nThe ‘delta’ mentioned above, compared to open appendectomy, is not too big, and therefore the debate regarding which approach is preferable is not over. Be that as it may, in practice we have seen a major increase in the rate of laparoscopic appendectomy, so it’s here to stay. Its advantages are more pronounced in obese patients, in females, and...\\n```\\n\\n### Notes:\\n- The text has been extracted and formatted into markdown.\\n- Hyperlink to Chapter 20 has been included.\\n- No images or formulas were identified in the provided text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Approaches to Acute Cholecystitis',\n", " 'md': '## Surgical Approaches to Acute Cholecystitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Depending on your local practice, acutely inflamed gallbladders may be either operated upon or treated conservatively. But while open surgery for acute cholecystitis was once the bread and butter of surgical residents, laparoscopic surgery for this condition is quite demanding, requiring the presence of an experienced laparoscopist and familiarity with several maneuvers that will make safe removal of the gallbladder possible:\\n\\n- Grasping a distended gallbladder is difficult. Aspirating the bile (you can use the Veress needle for this) will make grasping possible.\\n- Blunt dissection, using the suction tip, is especially rewarding in edematous, inflamed tissues.\\n- Anatomy may be obscure in inflamed conditions — don’t take shortcuts; insist on obtaining the ‘critical view of safety’.\\n- If you can’t delineate the anatomy — consider alternative approaches, like retrograde cholecystectomy or subtotal cholecystectomy. Opening the gallbladder just above Hartmann’s pouch, carefully evacuating the stones into a pre-placed collection bag, and looking down into the gallbladder outlet may assist you in delineation of the anatomy, and understanding where the cystic duct hides. If still unclear — make sure you have cleared the stones and then suture the cystic duct from within, or close Hartmann’s pouch with sutures or an Endoloop®. If these maneuvers seem ‘impossible’, you can simply leave a drain and bail out!\\n- Don’t forget the option of conversion! ‘Remembering’ that option in hindsight after the patient has suffered a CBD injury or after you have been sued, is not too helpful.\\n- Read much more about it in [Chapter 20](#).',\n", " 'md': 'Depending on your local practice, acutely inflamed gallbladders may be either operated upon or treated conservatively. But while open surgery for acute cholecystitis was once the bread and butter of surgical residents, laparoscopic surgery for this condition is quite demanding, requiring the presence of an experienced laparoscopist and familiarity with several maneuvers that will make safe removal of the gallbladder possible:\\n\\n- Grasping a distended gallbladder is difficult. Aspirating the bile (you can use the Veress needle for this) will make grasping possible.\\n- Blunt dissection, using the suction tip, is especially rewarding in edematous, inflamed tissues.\\n- Anatomy may be obscure in inflamed conditions — don’t take shortcuts; insist on obtaining the ‘critical view of safety’.\\n- If you can’t delineate the anatomy — consider alternative approaches, like retrograde cholecystectomy or subtotal cholecystectomy. Opening the gallbladder just above Hartmann’s pouch, carefully evacuating the stones into a pre-placed collection bag, and looking down into the gallbladder outlet may assist you in delineation of the anatomy, and understanding where the cystic duct hides. If still unclear — make sure you have cleared the stones and then suture the cystic duct from within, or close Hartmann’s pouch with sutures or an Endoloop®. If these maneuvers seem ‘impossible’, you can simply leave a drain and bail out!\\n- Don’t forget the option of conversion! ‘Remembering’ that option in hindsight after the patient has suffered a CBD injury or after you have been sued, is not too helpful.\\n- Read much more about it in [Chapter 20](#).',\n", " 'bBox': {'x': 72, 'y': 185, 'w': 437.64, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Laparoscopic Appendectomy',\n", " 'md': '## Laparoscopic Appendectomy',\n", " 'bBox': {'x': 86, 'y': 606, 'w': 229.01, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The ‘delta’ mentioned above, compared to open appendectomy, is not too big, and therefore the debate regarding which approach is preferable is not over. Be that as it may, in practice we have seen a major increase in the rate of laparoscopic appendectomy, so it’s here to stay. Its advantages are more pronounced in obese patients, in females, and...\\n```',\n", " 'md': 'The ‘delta’ mentioned above, compared to open appendectomy, is not too big, and therefore the debate regarding which approach is preferable is not over. Be that as it may, in practice we have seen a major increase in the rate of laparoscopic appendectomy, so it’s here to stay. Its advantages are more pronounced in obese patients, in females, and...\\n```',\n", " 'bBox': {'x': 72, 'y': 606, 'w': 468, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text has been extracted and formatted into markdown.\\n- Hyperlink to Chapter 20 has been included.\\n- No images or formulas were identified in the provided text.',\n", " 'md': '- The text has been extracted and formatted into markdown.\\n- Hyperlink to Chapter 20 has been included.\\n- No images or formulas were identified in the provided text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 160,\n", " 'text': 'where imaging modalities are less available.\\n\\n We will not dwell here too much on the technique (see Chapter 23),\\nand the trocar arrangement is really not that important — use what you\\nwere taught to do and what you feel comfortable with. But if you want to\\ndecrease the most quoted disadvantage — postoperative pelvic\\ncollection — you probably have to be careful while handling the\\ninflamed appendix, and avoid overzealous irrigation.\\n\\n Perforations and peritonitis\\n\\n You may not want to take an elderly, unstable, septic patient and pump\\nhis abdomen with CO2 (anyway you better resuscitate and stabilize him\\nbefore he crashes under anesthesia), but in many cases laparoscopy is\\nuseful in dealing with peritonitis. If you already have a diagnosis, like a\\nperforated peptic ulcer, all you need is peritoneal toilet and a few sutures\\nto complete the Graham patch, and laparoscopy is ideal: it will certainly\\nreduce the wound infection risk and other incision-related problems. Just\\nmake sure your laparoscopic suturing skills are well practiced.\\n\\n If the diagnosis is not known — laparoscopy may be a perfect\\ndiagnostic tool, once you decide that the patient needs surgery. Even if\\nconversion is needed — it may be done through a directed, limited\\nincision. The small bowel perforation, due to a fish-bone, may be\\nexteriorized and repaired (or resected), without a major midline\\nlaparotomy. Perforated diverticulitis can also be handled laparoscopically,\\nespecially if you like (and trust) the modern ‘lavage and drainage’\\napproach for ħinchey 3 cases (non-fecal peritonitis). If resection is\\nneeded, probably with a ħartmann’s procedure, and you have\\nlaparoscopic colectomy skills, they can be of use now. Otherwise, a\\nconversion through a lower midline laparotomy will usually suffice. But\\nagain — these procedures are for the experts — you need to polish\\nyour elective advanced laparoscopic skills before venturing into\\nsuch potential minefields.\\n\\n Small bowel obstruction',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nwhere imaging modalities are less available.\\n\\nWe will not dwell here too much on the technique (see Chapter 23), and the trocar arrangement is really not that important — use what you were taught to do and what you feel comfortable with. But if you want to decrease the most quoted disadvantage — postoperative pelvic collection — you probably have to be careful while handling the inflamed appendix, and avoid overzealous irrigation.\\n\\n### Perforations and Peritonitis\\n\\nYou may not want to take an elderly, unstable, septic patient and pump his abdomen with CO2 (anyway you better resuscitate and stabilize him before he crashes under anesthesia), but in many cases laparoscopy is useful in dealing with peritonitis. If you already have a diagnosis, like a perforated peptic ulcer, all you need is peritoneal toilet and a few sutures to complete the Graham patch, and laparoscopy is ideal: it will certainly reduce the wound infection risk and other incision-related problems. Just make sure your laparoscopic suturing skills are well practiced.\\n\\nIf the diagnosis is not known — laparoscopy may be a perfect diagnostic tool, once you decide that the patient needs surgery. Even if conversion is needed — it may be done through a directed, limited incision. The small bowel perforation, due to a fish-bone, may be exteriorized and repaired (or resected), without a major midline laparotomy. Perforated diverticulitis can also be handled laparoscopically, especially if you like (and trust) the modern ‘lavage and drainage’ approach for Hinchey 3 cases (non-fecal peritonitis). If resection is needed, probably with a Hartmann’s procedure, and you have laparoscopic colectomy skills, they can be of use now. Otherwise, a conversion through a lower midline laparotomy will usually suffice. But again — these procedures are for the experts — you need to polish your elective advanced laparoscopic skills before venturing into such potential minefields.\\n\\n### Small Bowel Obstruction\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured without any headers or footers.\\n- There are no formulas present in the text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'where imaging modalities are less available.\\n\\nWe will not dwell here too much on the technique (see Chapter 23), and the trocar arrangement is really not that important — use what you were taught to do and what you feel comfortable with. But if you want to decrease the most quoted disadvantage — postoperative pelvic collection — you probably have to be careful while handling the inflamed appendix, and avoid overzealous irrigation.',\n", " 'md': 'where imaging modalities are less available.\\n\\nWe will not dwell here too much on the technique (see Chapter 23), and the trocar arrangement is really not that important — use what you were taught to do and what you feel comfortable with. But if you want to decrease the most quoted disadvantage — postoperative pelvic collection — you probably have to be careful while handling the inflamed appendix, and avoid overzealous irrigation.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.43, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Perforations and Peritonitis',\n", " 'md': '### Perforations and Peritonitis',\n", " 'bBox': {'x': 86, 'y': 247, 'w': 216.06, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'You may not want to take an elderly, unstable, septic patient and pump his abdomen with CO2 (anyway you better resuscitate and stabilize him before he crashes under anesthesia), but in many cases laparoscopy is useful in dealing with peritonitis. If you already have a diagnosis, like a perforated peptic ulcer, all you need is peritoneal toilet and a few sutures to complete the Graham patch, and laparoscopy is ideal: it will certainly reduce the wound infection risk and other incision-related problems. Just make sure your laparoscopic suturing skills are well practiced.\\n\\nIf the diagnosis is not known — laparoscopy may be a perfect diagnostic tool, once you decide that the patient needs surgery. Even if conversion is needed — it may be done through a directed, limited incision. The small bowel perforation, due to a fish-bone, may be exteriorized and repaired (or resected), without a major midline laparotomy. Perforated diverticulitis can also be handled laparoscopically, especially if you like (and trust) the modern ‘lavage and drainage’ approach for Hinchey 3 cases (non-fecal peritonitis). If resection is needed, probably with a Hartmann’s procedure, and you have laparoscopic colectomy skills, they can be of use now. Otherwise, a conversion through a lower midline laparotomy will usually suffice. But again — these procedures are for the experts — you need to polish your elective advanced laparoscopic skills before venturing into such potential minefields.',\n", " 'md': 'You may not want to take an elderly, unstable, septic patient and pump his abdomen with CO2 (anyway you better resuscitate and stabilize him before he crashes under anesthesia), but in many cases laparoscopy is useful in dealing with peritonitis. If you already have a diagnosis, like a perforated peptic ulcer, all you need is peritoneal toilet and a few sutures to complete the Graham patch, and laparoscopy is ideal: it will certainly reduce the wound infection risk and other incision-related problems. Just make sure your laparoscopic suturing skills are well practiced.\\n\\nIf the diagnosis is not known — laparoscopy may be a perfect diagnostic tool, once you decide that the patient needs surgery. Even if conversion is needed — it may be done through a directed, limited incision. The small bowel perforation, due to a fish-bone, may be exteriorized and repaired (or resected), without a major midline laparotomy. Perforated diverticulitis can also be handled laparoscopically, especially if you like (and trust) the modern ‘lavage and drainage’ approach for Hinchey 3 cases (non-fecal peritonitis). If resection is needed, probably with a Hartmann’s procedure, and you have laparoscopic colectomy skills, they can be of use now. Otherwise, a conversion through a lower midline laparotomy will usually suffice. But again — these procedures are for the experts — you need to polish your elective advanced laparoscopic skills before venturing into such potential minefields.',\n", " 'bBox': {'x': 72, 'y': 283, 'w': 467.89, 'h': 14.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Small Bowel Obstruction',\n", " 'md': '### Small Bowel Obstruction',\n", " 'bBox': {'x': 86, 'y': 695, 'w': 191.23, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured without any headers or footers.\\n- There are no formulas present in the text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured without any headers or footers.\\n- There are no formulas present in the text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'and the trocar arrangement is really not that important — use what you'}]},\n", " {'page': 161,\n", " 'text': ' Though probably one of the more challenging emergency\\nprocedures by laparoscopy, this may also be one of the most\\nrewarding: cutting a single adhesive band can be a quick procedure that\\nprevents a closed loop obstruction from quickly progressing to bowel\\nnecrosis. Indeed, some obstruction cases are the result of multiple\\nadhesions, and extensive adhesiolysis is needed — not a task for a\\nlaparoscopic spring-chicken. But, when laparoscopic adhesiolysis is\\nsuccessful, the advantages to the patient are significant: the quick return\\nof bowel function, the reduced risk for new adhesions, and of course the\\nwound-associated complications (dehiscence is a real risk after\\nlaparotomy for obstruction, due to the distended bowel and increased\\nabdominal pressure).\\n\\n In order to achieve these advantages, your technique must be flawless.\\nThe risk of perforating an obstructed bowel is real, and spillage of the\\nhigh-pressure, static contents may lead to an uncontrollable and\\nirreversible sepsis. Going ‘in reverse’ from the collapsed, distal\\nbowel, avoiding bowel handling as much as possible, and avoiding\\nthe use of energy sources will help you avoid disaster.\\n\\n Incarcerated hernia\\n\\n Commonly an indication for an open procedure, incarcerated hernias,\\nwhether incisional or inguinal, can be approached laparoscopically.\\nIndeed, reducing the incarcerated contents by pulling (gently!) is usually\\neasier than by pushing, assisted of course by the muscle relaxation of the\\nabdominal wall. The hernia defect can also be repaired laparoscopically,\\nbut if you find necrotic bowel then conversion, resection and primary\\nhernia repair is your best bet. Of course, if your open hernia skills are\\nbetter than the lap ones in the elective situation this is what you\\nshould use in the emergency.\\n\\n Trauma\\n\\n As repeatedly mentioned above, abdominal trauma is not an\\nindication for laparoscopic surgery, but a few specific conditions\\nmake laparoscopy more appealing. Diaphragmatic laceration is',\n", " 'md': '```markdown\\n# Laparoscopic Emergency Procedures\\n\\nThough probably one of the more challenging emergency procedures by laparoscopy, this may also be one of the most rewarding: cutting a single adhesive band can be a quick procedure that prevents a closed loop obstruction from quickly progressing to bowel necrosis. Indeed, some obstruction cases are the result of multiple adhesions, and extensive adhesiolysis is needed — not a task for a laparoscopic spring-chicken. But, when laparoscopic adhesiolysis is successful, the advantages to the patient are significant: the quick return of bowel function, the reduced risk for new adhesions, and of course the wound-associated complications (dehiscence is a real risk after laparotomy for obstruction, due to the distended bowel and increased abdominal pressure).\\n\\nIn order to achieve these advantages, your technique must be flawless. The risk of perforating an obstructed bowel is real, and spillage of the high-pressure, static contents may lead to an uncontrollable and irreversible sepsis. Going ‘in reverse’ from the collapsed, distal bowel, avoiding bowel handling as much as possible, and avoiding the use of energy sources will help you avoid disaster.\\n\\n## Incarcerated Hernia\\n\\nCommonly an indication for an open procedure, incarcerated hernias, whether incisional or inguinal, can be approached laparoscopically. Indeed, reducing the incarcerated contents by pulling (gently!) is usually easier than by pushing, assisted of course by the muscle relaxation of the abdominal wall. The hernia defect can also be repaired laparoscopically, but if you find necrotic bowel then conversion, resection and primary hernia repair is your best bet. Of course, if your open hernia skills are better than the lap ones in the elective situation this is what you should use in the emergency.\\n\\n## Trauma\\n\\nAs repeatedly mentioned above, abdominal trauma is not an indication for laparoscopic surgery, but a few specific conditions make laparoscopy more appealing. Diaphragmatic laceration is .\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Laparoscopic Emergency Procedures',\n", " 'md': '# Laparoscopic Emergency Procedures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Though probably one of the more challenging emergency procedures by laparoscopy, this may also be one of the most rewarding: cutting a single adhesive band can be a quick procedure that prevents a closed loop obstruction from quickly progressing to bowel necrosis. Indeed, some obstruction cases are the result of multiple adhesions, and extensive adhesiolysis is needed — not a task for a laparoscopic spring-chicken. But, when laparoscopic adhesiolysis is successful, the advantages to the patient are significant: the quick return of bowel function, the reduced risk for new adhesions, and of course the wound-associated complications (dehiscence is a real risk after laparotomy for obstruction, due to the distended bowel and increased abdominal pressure).\\n\\nIn order to achieve these advantages, your technique must be flawless. The risk of perforating an obstructed bowel is real, and spillage of the high-pressure, static contents may lead to an uncontrollable and irreversible sepsis. Going ‘in reverse’ from the collapsed, distal bowel, avoiding bowel handling as much as possible, and avoiding the use of energy sources will help you avoid disaster.',\n", " 'md': 'Though probably one of the more challenging emergency procedures by laparoscopy, this may also be one of the most rewarding: cutting a single adhesive band can be a quick procedure that prevents a closed loop obstruction from quickly progressing to bowel necrosis. Indeed, some obstruction cases are the result of multiple adhesions, and extensive adhesiolysis is needed — not a task for a laparoscopic spring-chicken. But, when laparoscopic adhesiolysis is successful, the advantages to the patient are significant: the quick return of bowel function, the reduced risk for new adhesions, and of course the wound-associated complications (dehiscence is a real risk after laparotomy for obstruction, due to the distended bowel and increased abdominal pressure).\\n\\nIn order to achieve these advantages, your technique must be flawless. The risk of perforating an obstructed bowel is real, and spillage of the high-pressure, static contents may lead to an uncontrollable and irreversible sepsis. Going ‘in reverse’ from the collapsed, distal bowel, avoiding bowel handling as much as possible, and avoiding the use of energy sources will help you avoid disaster.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Incarcerated Hernia',\n", " 'md': '## Incarcerated Hernia',\n", " 'bBox': {'x': 86, 'y': 429, 'w': 152.67, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Commonly an indication for an open procedure, incarcerated hernias, whether incisional or inguinal, can be approached laparoscopically. Indeed, reducing the incarcerated contents by pulling (gently!) is usually easier than by pushing, assisted of course by the muscle relaxation of the abdominal wall. The hernia defect can also be repaired laparoscopically, but if you find necrotic bowel then conversion, resection and primary hernia repair is your best bet. Of course, if your open hernia skills are better than the lap ones in the elective situation this is what you should use in the emergency.',\n", " 'md': 'Commonly an indication for an open procedure, incarcerated hernias, whether incisional or inguinal, can be approached laparoscopically. Indeed, reducing the incarcerated contents by pulling (gently!) is usually easier than by pushing, assisted of course by the muscle relaxation of the abdominal wall. The hernia defect can also be repaired laparoscopically, but if you find necrotic bowel then conversion, resection and primary hernia repair is your best bet. Of course, if your open hernia skills are better than the lap ones in the elective situation this is what you should use in the emergency.',\n", " 'bBox': {'x': 72, 'y': 429, 'w': 467.78, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Trauma',\n", " 'md': '## Trauma',\n", " 'bBox': {'x': 86, 'y': 641, 'w': 58.88, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As repeatedly mentioned above, abdominal trauma is not an indication for laparoscopic surgery, but a few specific conditions make laparoscopy more appealing. Diaphragmatic laceration is .\\n```',\n", " 'md': 'As repeatedly mentioned above, abdominal trauma is not an indication for laparoscopic surgery, but a few specific conditions make laparoscopy more appealing. Diaphragmatic laceration is .\\n```',\n", " 'bBox': {'x': 86, 'y': 641, 'w': 58.88, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 162,\n", " 'text': 'sometimes difficult to diagnose, and if highly suspected, and no other\\nindications for abdominal exploration currently exist, laparoscopy, in a\\nstable patient, is a good alternative (especially on the left side).\\nDiagnosis, and non-absorbable suture repair are relatively easy. In a\\nhemodynamically-normal patient it may even be worthwhile to delay\\nsurgery until the next morning — make sure the patient really has no\\nother injuries, and have the procedure done by your expert laparoscopist,\\nwho doesn’t like to be moved out of his bed at night.\\n\\n Did I forget to mention anything important? What about SILS and\\nNOTES some crazy cowboy surgeon could ask. The answer has been\\nprovided by others.\\n\\n “NOTES (natural orifice transluminal endoscopic\\n surgery) is NUTS; SILS (single-incision laparoscopic\\n surgery) is SILLY.”\\n Mark Cheetham\\n “Stupid Innovation by Laparoscopic Surgeons.”\\n Mark Pleatman',\n", " 'md': '```markdown\\nSometimes difficult to diagnose, and if highly suspected, and no other indications for abdominal exploration currently exist, laparoscopy, in a stable patient, is a good alternative (especially on the left side). Diagnosis, and non-absorbable suture repair are relatively easy. In a hemodynamically-normal patient it may even be worthwhile to delay surgery until the next morning — make sure the patient really has no other injuries, and have the procedure done by your expert laparoscopist, who doesn’t like to be moved out of his bed at night.\\n\\nDid I forget to mention anything important? What about SILS and NOTES some crazy cowboy surgeon could ask. The answer has been provided by others.\\n\\n> “NOTES (natural orifice transluminal endoscopic surgery) is NUTS; SILS (single-incision laparoscopic surgery) is SILLY.”\\n> — Mark Cheetham\\n> “Stupid Innovation by Laparoscopic Surgeons.”\\n> — Mark Pleatman\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nSometimes difficult to diagnose, and if highly suspected, and no other indications for abdominal exploration currently exist, laparoscopy, in a stable patient, is a good alternative (especially on the left side). Diagnosis, and non-absorbable suture repair are relatively easy. In a hemodynamically-normal patient it may even be worthwhile to delay surgery until the next morning — make sure the patient really has no other injuries, and have the procedure done by your expert laparoscopist, who doesn’t like to be moved out of his bed at night.\\n\\nDid I forget to mention anything important? What about SILS and NOTES some crazy cowboy surgeon could ask. The answer has been provided by others.\\n\\n> “NOTES (natural orifice transluminal endoscopic surgery) is NUTS; SILS (single-incision laparoscopic surgery) is SILLY.”\\n> — Mark Cheetham\\n> “Stupid Innovation by Laparoscopic Surgeons.”\\n> — Mark Pleatman\\n```',\n", " 'md': '```markdown\\nSometimes difficult to diagnose, and if highly suspected, and no other indications for abdominal exploration currently exist, laparoscopy, in a stable patient, is a good alternative (especially on the left side). Diagnosis, and non-absorbable suture repair are relatively easy. In a hemodynamically-normal patient it may even be worthwhile to delay surgery until the next morning — make sure the patient really has no other injuries, and have the procedure done by your expert laparoscopist, who doesn’t like to be moved out of his bed at night.\\n\\nDid I forget to mention anything important? What about SILS and NOTES some crazy cowboy surgeon could ask. The answer has been provided by others.\\n\\n> “NOTES (natural orifice transluminal endoscopic surgery) is NUTS; SILS (single-incision laparoscopic surgery) is SILLY.”\\n> — Mark Cheetham\\n> “Stupid Innovation by Laparoscopic Surgeons.”\\n> — Mark Pleatman\\n```',\n", " 'bBox': {'x': 72, 'y': 186, 'w': 467.63, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 163,\n", " 'text': 'Chapter 13\\nPeritonitis: classification and principles of treatment\\nMoshe Schein and Roger Saadia\\n\\n The mechanical control of the source of infection, while\\n itself nonbiologic, determines the extent of the host biologic\\n response to the disease.\\n Ronald V. Maier\\n\\n In peritonitis — source control is above all.\\n\\n The finding of inflammation, bowel contents or pus, localized or\\ndispersed throughout the peritoneal cavity is common at emergency\\nlaparotomy. ħow is this scenario best handled? This chapter will discuss\\nsemantic distinctions and general aspects of the surgical treatment. For\\nthe management of individual causes of peritonitis you are referred to the\\nspecific chapters.\\n\\n Nomenclature\\n\\n Inflammation of the peritoneum is termed peritonitis. It is generally\\ncaused by a bacterial inoculum. This explains why peritonitis and intra-\\nabdominal infection (IAI) are used interchangeably. It is important to\\nnote though that these two terms are not synonymous, because\\nperitonitis may also be sterile as with the chemical peritonitis of early\\nperforation of a peptic ulcer or inadvertent infusion of enteral feeding\\nthrough a misplaced jejunostomy tube.',\n", " 'md': '```markdown\\n# Chapter 13\\n## Peritonitis: Classification and Principles of Treatment\\n**Authors:** Moshe Schein and Roger Saadia\\n\\n> \"The mechanical control of the source of infection, while itself nonbiologic, determines the extent of the host biologic response to the disease.\"\\n> — Ronald V. Maier\\n\\nIn peritonitis, source control is above all.\\n\\nThe finding of inflammation, bowel contents, or pus, localized or dispersed throughout the peritoneal cavity is common at emergency laparotomy. How is this scenario best handled? This chapter will discuss semantic distinctions and general aspects of the surgical treatment. For the management of individual causes of peritonitis, you are referred to the specific chapters.\\n\\n## Nomenclature\\n\\nInflammation of the peritoneum is termed peritonitis. It is generally caused by a bacterial inoculum. This explains why peritonitis and intra-abdominal infection (IAI) are used interchangeably. It is important to note though that these two terms are not synonymous, because peritonitis may also be sterile, as with the chemical peritonitis of early perforation of a peptic ulcer or inadvertent infusion of enteral feeding through a misplaced jejunostomy tube.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 13',\n", " 'md': '# Chapter 13',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 148.79, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Peritonitis: Classification and Principles of Treatment',\n", " 'md': '## Peritonitis: Classification and Principles of Treatment',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 456.86, 'h': 20.16}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Moshe Schein and Roger Saadia\\n\\n> \"The mechanical control of the source of infection, while itself nonbiologic, determines the extent of the host biologic response to the disease.\"\\n> — Ronald V. Maier\\n\\nIn peritonitis, source control is above all.\\n\\nThe finding of inflammation, bowel contents, or pus, localized or dispersed throughout the peritoneal cavity is common at emergency laparotomy. How is this scenario best handled? This chapter will discuss semantic distinctions and general aspects of the surgical treatment. For the management of individual causes of peritonitis, you are referred to the specific chapters.',\n", " 'md': '**Authors:** Moshe Schein and Roger Saadia\\n\\n> \"The mechanical control of the source of infection, while itself nonbiologic, determines the extent of the host biologic response to the disease.\"\\n> — Ronald V. Maier\\n\\nIn peritonitis, source control is above all.\\n\\nThe finding of inflammation, bowel contents, or pus, localized or dispersed throughout the peritoneal cavity is common at emergency laparotomy. How is this scenario best handled? This chapter will discuss semantic distinctions and general aspects of the surgical treatment. For the management of individual causes of peritonitis, you are referred to the specific chapters.',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 380.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Nomenclature',\n", " 'md': '## Nomenclature',\n", " 'bBox': {'x': 86, 'y': 558, 'w': 110.37, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Inflammation of the peritoneum is termed peritonitis. It is generally caused by a bacterial inoculum. This explains why peritonitis and intra-abdominal infection (IAI) are used interchangeably. It is important to note though that these two terms are not synonymous, because peritonitis may also be sterile, as with the chemical peritonitis of early perforation of a peptic ulcer or inadvertent infusion of enteral feeding through a misplaced jejunostomy tube.\\n```',\n", " 'md': 'Inflammation of the peritoneum is termed peritonitis. It is generally caused by a bacterial inoculum. This explains why peritonitis and intra-abdominal infection (IAI) are used interchangeably. It is important to note though that these two terms are not synonymous, because peritonitis may also be sterile, as with the chemical peritonitis of early perforation of a peptic ulcer or inadvertent infusion of enteral feeding through a misplaced jejunostomy tube.\\n```',\n", " 'bBox': {'x': 72, 'y': 694, 'w': 246.29, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 164,\n", " 'text': ' ħere are some definitions to confuse you more:\\n\\n• Intra-abdominal infection. For a condition to be labelled IAI, both\\n the intraperitoneal presence of micro-organisms (or their toxins) and\\n the inflammatory response of the peritoneum are required. A\\n purulent exudate is often found at laparotomy.\\n• Peritoneal contamination is different. It consists merely of the\\n soiling of the peritoneal cavity by a fluid rich in micro-organisms, as\\n in the immediate aftermath of a penetrating intestinal injury, before\\n an inflammatory response has taken place. Peritoneal\\n contamination occurs commonly, to varying degrees, in the\\n course of routine elective surgery when the lumen of the\\n gastrointestinal tract is breached.\\n• IAI can be diffuse as in generalized peritonitis or localized as in\\n intra-abdominal abscesses. The latter develop as a result of\\n effective host defences and represent a relatively successful\\n outcome of peritonitis. The mainstay of treatment is drainage. For\\n how, and by which route, find out in the dedicated chapter (\\n Chapter 46). Note that the severity spectrum, the location of IAI and\\n the ease of its ‘source control’ greatly impact the management and\\n outcome; so for example, locally perforated appendicitis does not\\n mandate the same duration of antibiotic administration as infected\\n pancreatic necrosis.\\n• Abdominal sepsis is still a term used very commonly but we,\\n semantic nudniks, do not like it. According to modern consensus\\n ‘sepsis’ means the conjunction of both the host’s response to\\n infection (SIRS) and a source of infection. Thus, the use of\\n ‘sepsis’, in the abdominal context, would not take into account the\\n important initial local inflammation within the peritoneal cavity. This\\n peritoneal response is analogous, at a local level, with SIRS at the\\n systemic level, because it represents, likewise, a non-specific\\n inflammatory response of the host to a variety of noxious stimuli, not\\n necessarily infectious. Strictly speaking, therefore, local\\n contamination, infection and sepsis refer to different processes. Yet,\\n they may coexist in the same patient, developing simultaneously or\\n consecutively — a continuum. Abdominal contamination may lead to\\n infection, which is invariably associated with a systemic\\n inflammatory response. Significantly, residual abdominal',\n", " 'md': '```markdown\\n# Definitions Related to Intra-abdominal Infection\\n\\n- **Intra-abdominal infection (IAI)**: For a condition to be labeled IAI, both the intraperitoneal presence of micro-organisms (or their toxins) and the inflammatory response of the peritoneum are required. A purulent exudate is often found at laparotomy.\\n\\n- **Peritoneal contamination**: This is different from IAI. It consists merely of the soiling of the peritoneal cavity by a fluid rich in micro-organisms, as seen in the immediate aftermath of a penetrating intestinal injury, before an inflammatory response has taken place. Peritoneal contamination occurs commonly, to varying degrees, during routine elective surgery when the lumen of the gastrointestinal tract is breached.\\n\\n- **Types of IAI**: IAI can be diffuse, as in generalized peritonitis, or localized, as in intra-abdominal abscesses. The latter develop as a result of effective host defenses and represent a relatively successful outcome of peritonitis. The mainstay of treatment is drainage. The severity spectrum, the location of IAI, and the ease of its ‘source control’ greatly impact management and outcome; for example, locally perforated appendicitis does not mandate the same duration of antibiotic administration as infected pancreatic necrosis.\\n\\n- **Abdominal sepsis**: This term is still used very commonly, but it is not favored by some. According to modern consensus, ‘sepsis’ means the conjunction of both the host’s response to infection (SIRS) and a source of infection. Thus, the use of ‘sepsis’ in the abdominal context does not take into account the important initial local inflammation within the peritoneal cavity. This peritoneal response is analogous, at a local level, to SIRS at the systemic level, as it represents a non-specific inflammatory response of the host to various noxious stimuli, not necessarily infectious. Strictly speaking, local contamination, infection, and sepsis refer to different processes. However, they may coexist in the same patient, developing simultaneously or consecutively—a continuum. Abdominal contamination may lead to infection, which is invariably associated with a systemic inflammatory response.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Definitions Related to Intra-abdominal Infection',\n", " 'md': '# Definitions Related to Intra-abdominal Infection',\n", " 'bBox': {'x': 465, 'y': 710, 'w': 71.94, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Intra-abdominal infection (IAI)**: For a condition to be labeled IAI, both the intraperitoneal presence of micro-organisms (or their toxins) and the inflammatory response of the peritoneum are required. A purulent exudate is often found at laparotomy.\\n\\n- **Peritoneal contamination**: This is different from IAI. It consists merely of the soiling of the peritoneal cavity by a fluid rich in micro-organisms, as seen in the immediate aftermath of a penetrating intestinal injury, before an inflammatory response has taken place. Peritoneal contamination occurs commonly, to varying degrees, during routine elective surgery when the lumen of the gastrointestinal tract is breached.\\n\\n- **Types of IAI**: IAI can be diffuse, as in generalized peritonitis, or localized, as in intra-abdominal abscesses. The latter develop as a result of effective host defenses and represent a relatively successful outcome of peritonitis. The mainstay of treatment is drainage. The severity spectrum, the location of IAI, and the ease of its ‘source control’ greatly impact management and outcome; for example, locally perforated appendicitis does not mandate the same duration of antibiotic administration as infected pancreatic necrosis.\\n\\n- **Abdominal sepsis**: This term is still used very commonly, but it is not favored by some. According to modern consensus, ‘sepsis’ means the conjunction of both the host’s response to infection (SIRS) and a source of infection. Thus, the use of ‘sepsis’ in the abdominal context does not take into account the important initial local inflammation within the peritoneal cavity. This peritoneal response is analogous, at a local level, to SIRS at the systemic level, as it represents a non-specific inflammatory response of the host to various noxious stimuli, not necessarily infectious. Strictly speaking, local contamination, infection, and sepsis refer to different processes. However, they may coexist in the same patient, developing simultaneously or consecutively—a continuum. Abdominal contamination may lead to infection, which is invariably associated with a systemic inflammatory response.\\n```',\n", " 'md': '- **Intra-abdominal infection (IAI)**: For a condition to be labeled IAI, both the intraperitoneal presence of micro-organisms (or their toxins) and the inflammatory response of the peritoneum are required. A purulent exudate is often found at laparotomy.\\n\\n- **Peritoneal contamination**: This is different from IAI. It consists merely of the soiling of the peritoneal cavity by a fluid rich in micro-organisms, as seen in the immediate aftermath of a penetrating intestinal injury, before an inflammatory response has taken place. Peritoneal contamination occurs commonly, to varying degrees, during routine elective surgery when the lumen of the gastrointestinal tract is breached.\\n\\n- **Types of IAI**: IAI can be diffuse, as in generalized peritonitis, or localized, as in intra-abdominal abscesses. The latter develop as a result of effective host defenses and represent a relatively successful outcome of peritonitis. The mainstay of treatment is drainage. The severity spectrum, the location of IAI, and the ease of its ‘source control’ greatly impact management and outcome; for example, locally perforated appendicitis does not mandate the same duration of antibiotic administration as infected pancreatic necrosis.\\n\\n- **Abdominal sepsis**: This term is still used very commonly, but it is not favored by some. According to modern consensus, ‘sepsis’ means the conjunction of both the host’s response to infection (SIRS) and a source of infection. Thus, the use of ‘sepsis’ in the abdominal context does not take into account the important initial local inflammation within the peritoneal cavity. This peritoneal response is analogous, at a local level, to SIRS at the systemic level, as it represents a non-specific inflammatory response of the host to various noxious stimuli, not necessarily infectious. Strictly speaking, local contamination, infection, and sepsis refer to different processes. However, they may coexist in the same patient, developing simultaneously or consecutively—a continuum. Abdominal contamination may lead to infection, which is invariably associated with a systemic inflammatory response.\\n```',\n", " 'bBox': {'x': 100, 'y': 138, 'w': 437, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'the ease of its ‘source control’ greatly impact the management and'}]},\n", " {'page': 165,\n", " 'text': 'inflammation or indeed the systemic\\nleukocytosis) may even persist after\\ninfection has been eradicated. Once set in motion, the\\ninflammatory cascade cannot be stopped simply by turning off\\nthe trigger.\\n response (fever,\\nthe intraperitoneal\\n\\n\\n\\n\\n Classification of peritonitis\\n\\n Secondary peritonitis\\n\\n This is caused by a breach in the anatomical integrity of a hollow viscus (e.g.\\n perforation or transmural necrosis). It is usually characterized by an aerobic and anaerobic\\n polymicrobial inoculum, reflecting the flora of the gastrointestinal tract. Management of this\\n condition is the ‘bread and butter’ of the general surgeon. Examples include perforated\\n appendicitis, perforated diverticular disease of the colon, strangulated obstruction of the small\\n bowel and ruptured tubo-ovarian abscess. It is largely because of secondary peritonitis\\n that you should train yourself to become an expert in the judicious use of antibiotics!\\n (Try at least to be as knowledgeable as your local infectious disease guru…).\\n\\n We draw your attention to a particularly important distinction.\\n Secondary peritonitis is said to be ‘community-acquired’ when it is the\\n reason for the hospital admission (e.g. the patient walks through the ER\\n doors with abdominal pain due to a perforated appendicitis). On the other\\n hand, ‘nosocomial’ secondary peritonitis is a morbid event occurring in\\n an already hospitalized patient (e.g. ischemic perforation of the colon in a\\n ventilated patient treated for severe pneumonia or the patient with\\n ‘postoperative peritonitis’ due to a leaking anastomosis). These two\\n entities differ significantly — the diagnosis of peritonitis is much easier\\n to make in the ER than in an ICU patient with multiple comorbidities; the\\n antibiotic treatment is standard broad-spectrum in community-acquired\\n peritonitis, whereas it needs to be tailored to a hospital-acquired, more\\n pathogenic and often unexpected flora in the patient with nosocomial\\n peritonitis. Finally, the prognosis is much less favourable in the\\n nosocomial variety.',\n", " 'md': '```markdown\\n## Classification of Peritonitis\\n\\n### Secondary Peritonitis\\n\\nThis is caused by a breach in the anatomical integrity of a hollow viscus (e.g. perforation or transmural necrosis). It is usually characterized by an aerobic and anaerobic polymicrobial inoculum, reflecting the flora of the gastrointestinal tract. Management of this condition is the ‘bread and butter’ of the general surgeon. Examples include perforated appendicitis, perforated diverticular disease of the colon, strangulated obstruction of the small bowel, and ruptured tubo-ovarian abscess. It is largely because of secondary peritonitis that you should train yourself to become an expert in the judicious use of antibiotics! (Try at least to be as knowledgeable as your local infectious disease guru…).\\n\\nWe draw your attention to a particularly important distinction. Secondary peritonitis is said to be ‘community-acquired’ when it is the reason for the hospital admission (e.g. the patient walks through the ER doors with abdominal pain due to a perforated appendicitis). On the other hand, ‘nosocomial’ secondary peritonitis is a morbid event occurring in an already hospitalized patient (e.g. ischemic perforation of the colon in a ventilated patient treated for severe pneumonia or the patient with ‘postoperative peritonitis’ due to a leaking anastomosis). These two entities differ significantly — the diagnosis of peritonitis is much easier to make in the ER than in an ICU patient with multiple comorbidities; the antibiotic treatment is standard broad-spectrum in community-acquired peritonitis, whereas it needs to be tailored to a hospital-acquired, more pathogenic and often unexpected flora in the patient with nosocomial peritonitis. Finally, the prognosis is much less favourable in the nosocomial variety.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Classification of Peritonitis',\n", " 'md': '## Classification of Peritonitis',\n", " 'bBox': {'x': 86, 'y': 197, 'w': 212.37, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Secondary Peritonitis',\n", " 'md': '### Secondary Peritonitis',\n", " 'bBox': {'x': 86, 'y': 241, 'w': 169.19, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is caused by a breach in the anatomical integrity of a hollow viscus (e.g. perforation or transmural necrosis). It is usually characterized by an aerobic and anaerobic polymicrobial inoculum, reflecting the flora of the gastrointestinal tract. Management of this condition is the ‘bread and butter’ of the general surgeon. Examples include perforated appendicitis, perforated diverticular disease of the colon, strangulated obstruction of the small bowel, and ruptured tubo-ovarian abscess. It is largely because of secondary peritonitis that you should train yourself to become an expert in the judicious use of antibiotics! (Try at least to be as knowledgeable as your local infectious disease guru…).\\n\\nWe draw your attention to a particularly important distinction. Secondary peritonitis is said to be ‘community-acquired’ when it is the reason for the hospital admission (e.g. the patient walks through the ER doors with abdominal pain due to a perforated appendicitis). On the other hand, ‘nosocomial’ secondary peritonitis is a morbid event occurring in an already hospitalized patient (e.g. ischemic perforation of the colon in a ventilated patient treated for severe pneumonia or the patient with ‘postoperative peritonitis’ due to a leaking anastomosis). These two entities differ significantly — the diagnosis of peritonitis is much easier to make in the ER than in an ICU patient with multiple comorbidities; the antibiotic treatment is standard broad-spectrum in community-acquired peritonitis, whereas it needs to be tailored to a hospital-acquired, more pathogenic and often unexpected flora in the patient with nosocomial peritonitis. Finally, the prognosis is much less favourable in the nosocomial variety.\\n```',\n", " 'md': 'This is caused by a breach in the anatomical integrity of a hollow viscus (e.g. perforation or transmural necrosis). It is usually characterized by an aerobic and anaerobic polymicrobial inoculum, reflecting the flora of the gastrointestinal tract. Management of this condition is the ‘bread and butter’ of the general surgeon. Examples include perforated appendicitis, perforated diverticular disease of the colon, strangulated obstruction of the small bowel, and ruptured tubo-ovarian abscess. It is largely because of secondary peritonitis that you should train yourself to become an expert in the judicious use of antibiotics! (Try at least to be as knowledgeable as your local infectious disease guru…).\\n\\nWe draw your attention to a particularly important distinction. Secondary peritonitis is said to be ‘community-acquired’ when it is the reason for the hospital admission (e.g. the patient walks through the ER doors with abdominal pain due to a perforated appendicitis). On the other hand, ‘nosocomial’ secondary peritonitis is a morbid event occurring in an already hospitalized patient (e.g. ischemic perforation of the colon in a ventilated patient treated for severe pneumonia or the patient with ‘postoperative peritonitis’ due to a leaking anastomosis). These two entities differ significantly — the diagnosis of peritonitis is much easier to make in the ER than in an ICU patient with multiple comorbidities; the antibiotic treatment is standard broad-spectrum in community-acquired peritonitis, whereas it needs to be tailored to a hospital-acquired, more pathogenic and often unexpected flora in the patient with nosocomial peritonitis. Finally, the prognosis is much less favourable in the nosocomial variety.\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.99, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 166,\n", " 'text': ' Primary peritonitis\\n\\n In contrast to secondary peritonitis, this is not caused by a loss of\\ngastrointestinal wall integrity and is not associated with leakage of\\nintestinal contents into the peritoneal cavity. The responsible micro-\\norganism, typically single (as opposed to the complex flora of\\nsecondary peritonitis), originates from a source outside of the\\nabdomen. In young girls, it is usually a Streptococcus gaining access\\nvia the genital tract. In patients with cirrhosis, Escherichia coli is thought\\nto be a blood-borne agent infecting the pre-existing ascites — a condition\\nreferred to as spontaneous bacterial peritonitis. In patients receiving\\nperitoneal dialysis, Staphylococcus migrates from the skin along the\\ndialysis catheter.\\n\\n In patients with a known predisposing factor (e.g. ascites\\nassociated with chronic liver disease), suspected primary peritonitis\\ncan be diagnosed by paracentesis (polymorphonuclear count in the\\nascitic fluid greater than 250 cells/mm3); a positive culture confirms the\\ndiagnosis but, even with a negative culture, antibiotic treatment should be\\ninstituted. Whenever possible, a diagnostic exploratory laparotomy\\nshould be avoided because of its prohibitive mortality; in an\\nadvanced cirrhotic patient, it often amounts to an autopsy in vivo.\\nInitial antibiotic treatment is empiric, until results of bacteriological\\nsensitivities become available.\\n\\n Primary peritonitis in patients without a known predisposing factor is\\nextremely rare. It is usually diagnosed at laparotomy for an ‘acute\\nabdomen’ revealing an odorless exudate without an apparent source.\\nThe diagnosis is reached by exclusion after a thorough abdominal\\nexploration and is confirmed by a Gram stain and culture which usually\\nisolates a solitary, aerobic organism — it is a ‘single-bug disease’. TB\\nperitonitis will be discussed elsewhere ( Chapter 38)\\n\\n Tertiary peritonitis\\n\\n This entity does exist, yet it is impossible to define it in a couple of\\nsentences. No wonder your mind (and sometimes ours) is clouded by',\n", " 'md': '# Primary and Tertiary Peritonitis\\n\\n## Primary Peritonitis\\n\\nIn contrast to secondary peritonitis, this is not caused by a loss of gastrointestinal wall integrity and is not associated with leakage of intestinal contents into the peritoneal cavity. The responsible microorganism, typically single (as opposed to the complex flora of secondary peritonitis), originates from a source outside of the abdomen. In young girls, it is usually a *Streptococcus* gaining access via the genital tract. In patients with cirrhosis, *Escherichia coli* is thought to be a blood-borne agent infecting the pre-existing ascites — a condition referred to as spontaneous bacterial peritonitis. In patients receiving peritoneal dialysis, *Staphylococcus* migrates from the skin along the dialysis catheter.\\n\\nIn patients with a known predisposing factor (e.g., ascites associated with chronic liver disease), suspected primary peritonitis can be diagnosed by paracentesis (polymorphonuclear count in the ascitic fluid greater than 250 cells/mm³); a positive culture confirms the diagnosis but, even with a negative culture, antibiotic treatment should be instituted. Whenever possible, a diagnostic exploratory laparotomy should be avoided because of its prohibitive mortality; in an advanced cirrhotic patient, it often amounts to an autopsy in vivo. Initial antibiotic treatment is empiric until results of bacteriological sensitivities become available.\\n\\nPrimary peritonitis in patients without a known predisposing factor is extremely rare. It is usually diagnosed at laparotomy for an ‘acute abdomen’ revealing an odorless exudate without an apparent source. The diagnosis is reached by exclusion after a thorough abdominal exploration and is confirmed by a Gram stain and culture which usually isolates a solitary, aerobic organism — it is a ‘single-bug disease’. TB peritonitis will be discussed elsewhere (Chapter 38).\\n\\n## Tertiary Peritonitis\\n\\nThis entity does exist, yet it is impossible to define it in a couple of sentences. No wonder your mind (and sometimes ours) is clouded by .',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Primary and Tertiary Peritonitis',\n", " 'md': '# Primary and Tertiary Peritonitis',\n", " 'bBox': {'x': 86, 'y': 654, 'w': 144.04, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Primary Peritonitis',\n", " 'md': '## Primary Peritonitis',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 146.19, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In contrast to secondary peritonitis, this is not caused by a loss of gastrointestinal wall integrity and is not associated with leakage of intestinal contents into the peritoneal cavity. The responsible microorganism, typically single (as opposed to the complex flora of secondary peritonitis), originates from a source outside of the abdomen. In young girls, it is usually a *Streptococcus* gaining access via the genital tract. In patients with cirrhosis, *Escherichia coli* is thought to be a blood-borne agent infecting the pre-existing ascites — a condition referred to as spontaneous bacterial peritonitis. In patients receiving peritoneal dialysis, *Staphylococcus* migrates from the skin along the dialysis catheter.\\n\\nIn patients with a known predisposing factor (e.g., ascites associated with chronic liver disease), suspected primary peritonitis can be diagnosed by paracentesis (polymorphonuclear count in the ascitic fluid greater than 250 cells/mm³); a positive culture confirms the diagnosis but, even with a negative culture, antibiotic treatment should be instituted. Whenever possible, a diagnostic exploratory laparotomy should be avoided because of its prohibitive mortality; in an advanced cirrhotic patient, it often amounts to an autopsy in vivo. Initial antibiotic treatment is empiric until results of bacteriological sensitivities become available.\\n\\nPrimary peritonitis in patients without a known predisposing factor is extremely rare. It is usually diagnosed at laparotomy for an ‘acute abdomen’ revealing an odorless exudate without an apparent source. The diagnosis is reached by exclusion after a thorough abdominal exploration and is confirmed by a Gram stain and culture which usually isolates a solitary, aerobic organism — it is a ‘single-bug disease’. TB peritonitis will be discussed elsewhere (Chapter 38).',\n", " 'md': 'In contrast to secondary peritonitis, this is not caused by a loss of gastrointestinal wall integrity and is not associated with leakage of intestinal contents into the peritoneal cavity. The responsible microorganism, typically single (as opposed to the complex flora of secondary peritonitis), originates from a source outside of the abdomen. In young girls, it is usually a *Streptococcus* gaining access via the genital tract. In patients with cirrhosis, *Escherichia coli* is thought to be a blood-borne agent infecting the pre-existing ascites — a condition referred to as spontaneous bacterial peritonitis. In patients receiving peritoneal dialysis, *Staphylococcus* migrates from the skin along the dialysis catheter.\\n\\nIn patients with a known predisposing factor (e.g., ascites associated with chronic liver disease), suspected primary peritonitis can be diagnosed by paracentesis (polymorphonuclear count in the ascitic fluid greater than 250 cells/mm³); a positive culture confirms the diagnosis but, even with a negative culture, antibiotic treatment should be instituted. Whenever possible, a diagnostic exploratory laparotomy should be avoided because of its prohibitive mortality; in an advanced cirrhotic patient, it often amounts to an autopsy in vivo. Initial antibiotic treatment is empiric until results of bacteriological sensitivities become available.\\n\\nPrimary peritonitis in patients without a known predisposing factor is extremely rare. It is usually diagnosed at laparotomy for an ‘acute abdomen’ revealing an odorless exudate without an apparent source. The diagnosis is reached by exclusion after a thorough abdominal exploration and is confirmed by a Gram stain and culture which usually isolates a solitary, aerobic organism — it is a ‘single-bug disease’. TB peritonitis will be discussed elsewhere (Chapter 38).',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.68, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tertiary Peritonitis',\n", " 'md': '## Tertiary Peritonitis',\n", " 'bBox': {'x': 86, 'y': 654, 'w': 144.04, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This entity does exist, yet it is impossible to define it in a couple of sentences. No wonder your mind (and sometimes ours) is clouded by .',\n", " 'md': 'This entity does exist, yet it is impossible to define it in a couple of sentences. No wonder your mind (and sometimes ours) is clouded by .',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 167,\n", " 'text': 'confusion. One way to understand this syndrome is to list its most\\ncommon characteristics:\\n\\n • It occurs in ICU patients with multi-organ dysfunction.\\n • It is the sequel of severe secondary peritonitis, typically treated with\\n multiple antibiotics and repeated abdominal explorations.\\n • At surgery, a thin, cloudy, poorly walled-off exudate is found in the\\n absence of a definite source of intra-abdominal infection.\\n • The microbial inoculum typical of tertiary peritonitis is unusual. In\\n some cases, highly pathogenic, antibiotic-resistant species (e.g.\\n Pseudomonas or Enterobacter) are encountered. In others, the flora\\n is really weird, consisting mainly of organisms of normally low\\n pathogenicity such as Staphylococcus epidermidis, Enterococcus\\n and Candida albicans. This is why these patients are thought to be\\n immunocompromised. Are these organisms the cause of the\\n syndrome in a host too weak to fight back or mere markers of a\\n deeper malaise?\\n\\n This syndrome illustrates the paradox of modern medicine. On the one\\nhand, it is an outcome of unsuccessful treatment of a severe secondary\\nperitonitis. On the other hand, high-tech interventions have permitted the\\nemergence of this category of patients who would have succumbed much\\nearlier to their disease only two or three decades ago (so, yes, a\\nmeasure of success). When peritonitis persists, despite adequate\\nsource control and repeated reoperations, think about tertiary\\nperitonitis!\\n\\n If a patient operated upon for secondary peritonitis has no evidence of anastomotic leak or\\n residual abscess, i.e. ‘normal’ CT, and is not smiling on day 7 — think about tertiary peritonitis!\\n Ari\\n\\n Let us look at a real-life example:\\n\\n A 75-year-old male undergoes an emergency subtotal colectomy with an ileorectal\\n anastomosis for an obstructing carcinoma of the sigmoid colon. He is rushed, 6 days later, for',\n", " 'md': '```markdown\\n## Characteristics of Tertiary Peritonitis\\n\\nOne way to understand this syndrome is to list its most common characteristics:\\n\\n- It occurs in ICU patients with multi-organ dysfunction.\\n- It is the sequel of severe secondary peritonitis, typically treated with multiple antibiotics and repeated abdominal explorations.\\n- At surgery, a thin, cloudy, poorly walled-off exudate is found in the absence of a definite source of intra-abdominal infection.\\n- The microbial inoculum typical of tertiary peritonitis is unusual. In some cases, highly pathogenic, antibiotic-resistant species (e.g. Pseudomonas or Enterobacter) are encountered. In others, the flora is really weird, consisting mainly of organisms of normally low pathogenicity such as Staphylococcus epidermidis, Enterococcus, and Candida albicans. This is why these patients are thought to be immunocompromised. Are these organisms the cause of the syndrome in a host too weak to fight back or mere markers of a deeper malaise?\\n\\nThis syndrome illustrates the paradox of modern medicine. On the one hand, it is an outcome of unsuccessful treatment of a severe secondary peritonitis. On the other hand, high-tech interventions have permitted the emergence of this category of patients who would have succumbed much earlier to their disease only two or three decades ago (so, yes, a measure of success). When peritonitis persists, despite adequate source control and repeated reoperations, think about tertiary peritonitis!\\n\\nIf a patient operated upon for secondary peritonitis has no evidence of anastomotic leak or residual abscess, i.e. ‘normal’ CT, and is not smiling on day 7 — think about tertiary peritonitis!\\n\\n### Real-Life Example\\n\\nA 75-year-old male undergoes an emergency subtotal colectomy with an ileorectal anastomosis for an obstructing carcinoma of the sigmoid colon. He is rushed, 6 days later, for .\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Characteristics of Tertiary Peritonitis',\n", " 'md': '## Characteristics of Tertiary Peritonitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'One way to understand this syndrome is to list its most common characteristics:\\n\\n- It occurs in ICU patients with multi-organ dysfunction.\\n- It is the sequel of severe secondary peritonitis, typically treated with multiple antibiotics and repeated abdominal explorations.\\n- At surgery, a thin, cloudy, poorly walled-off exudate is found in the absence of a definite source of intra-abdominal infection.\\n- The microbial inoculum typical of tertiary peritonitis is unusual. In some cases, highly pathogenic, antibiotic-resistant species (e.g. Pseudomonas or Enterobacter) are encountered. In others, the flora is really weird, consisting mainly of organisms of normally low pathogenicity such as Staphylococcus epidermidis, Enterococcus, and Candida albicans. This is why these patients are thought to be immunocompromised. Are these organisms the cause of the syndrome in a host too weak to fight back or mere markers of a deeper malaise?\\n\\nThis syndrome illustrates the paradox of modern medicine. On the one hand, it is an outcome of unsuccessful treatment of a severe secondary peritonitis. On the other hand, high-tech interventions have permitted the emergence of this category of patients who would have succumbed much earlier to their disease only two or three decades ago (so, yes, a measure of success). When peritonitis persists, despite adequate source control and repeated reoperations, think about tertiary peritonitis!\\n\\nIf a patient operated upon for secondary peritonitis has no evidence of anastomotic leak or residual abscess, i.e. ‘normal’ CT, and is not smiling on day 7 — think about tertiary peritonitis!',\n", " 'md': 'One way to understand this syndrome is to list its most common characteristics:\\n\\n- It occurs in ICU patients with multi-organ dysfunction.\\n- It is the sequel of severe secondary peritonitis, typically treated with multiple antibiotics and repeated abdominal explorations.\\n- At surgery, a thin, cloudy, poorly walled-off exudate is found in the absence of a definite source of intra-abdominal infection.\\n- The microbial inoculum typical of tertiary peritonitis is unusual. In some cases, highly pathogenic, antibiotic-resistant species (e.g. Pseudomonas or Enterobacter) are encountered. In others, the flora is really weird, consisting mainly of organisms of normally low pathogenicity such as Staphylococcus epidermidis, Enterococcus, and Candida albicans. This is why these patients are thought to be immunocompromised. Are these organisms the cause of the syndrome in a host too weak to fight back or mere markers of a deeper malaise?\\n\\nThis syndrome illustrates the paradox of modern medicine. On the one hand, it is an outcome of unsuccessful treatment of a severe secondary peritonitis. On the other hand, high-tech interventions have permitted the emergence of this category of patients who would have succumbed much earlier to their disease only two or three decades ago (so, yes, a measure of success). When peritonitis persists, despite adequate source control and repeated reoperations, think about tertiary peritonitis!\\n\\nIf a patient operated upon for secondary peritonitis has no evidence of anastomotic leak or residual abscess, i.e. ‘normal’ CT, and is not smiling on day 7 — think about tertiary peritonitis!',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Real-Life Example',\n", " 'md': '### Real-Life Example',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A 75-year-old male undergoes an emergency subtotal colectomy with an ileorectal anastomosis for an obstructing carcinoma of the sigmoid colon. He is rushed, 6 days later, for .\\n```',\n", " 'md': 'A 75-year-old male undergoes an emergency subtotal colectomy with an ileorectal anastomosis for an obstructing carcinoma of the sigmoid colon. He is rushed, 6 days later, for .\\n```',\n", " 'bBox': {'x': 79, 'y': 712, 'w': 453.37, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 168,\n", " 'text': ' a relaparotomy because of diffuse peritonitis and a documented free anastomotic leak. At\\n operation, his abdomen is found to be full of fecal material. It is cleansed and the anastomosis\\n is dismantled; the rectum is closed as in a Hartmann’s procedure and the ileum exteriorized as\\n an end-ileostomy. The abdomen is left open as a ‘laparostomy’. At a planned relaparotomy 48\\n hours later, residual collections of ‘thin’ pus are evacuated. The patient continues to be ‘septic’\\n and develops a multi-organ dysfunction syndrome (MODS). A CT scan of the abdomen shows\\n fluid in the pelvis and gutters; diagnostic aspiration reveals the presence of fungi. An antifungal\\n agent is added to the broad-spectrum antibiotics the patient is already receiving. He continues\\n to deteriorate; at relaparotomy, murky peritoneal fluid is found and cultured. It grows Candida\\n and Staph. epidermidis, triggering yet again an antibiotic readjustment. The MODS worsens,\\n leading to the patient’s demise 5 weeks after the first operation. The hospital bill amounts to a\\n staggering $250,000 (it could be a million in another ivory tower — as you know hospital billing\\n is random and doesn’t make any sense…).\\n\\n In tertiary peritonitis, further antimicrobial administration and operative\\ninterventions seem futile and may contribute to the peritoneal\\nsuperinfection and possibly to the aggravation of the SIRS-MODS\\ncomplex. The frequently fatal outcome of tertiary peritonitis indicates that\\ncurrent antibiotic-assisted, mechanical answers to severe peritonitis have\\nabout reached their limits, in an (at least for now) unsalvageable patient.\\nSome surgeons find it difficult to accept futility and avoid surgery when\\nfaced with peritonitis, especially since supportive care, even if successful,\\nis long and frustrating, and the pressure “to do something” is strong. Of\\ncourse, many general surgeons never come across this entity: their\\npatient either dies before reaching this phase or is transferred to an\\nivory tower…\\n\\n Management (secondary peritonitis)\\n\\n The outcome of IAI depends on the patient’s pre-morbid reserves, his current\\n physiological compromise and the virulence of the infection. Your goal is to assist the\\n patient’s own local and systemic defenses.',\n", " 'md': '```markdown\\n## Current Page Content\\n\\nA relaparotomy because of diffuse peritonitis and a documented free anastomotic leak. At operation, his abdomen is found to be full of fecal material. It is cleansed and the anastomosis is dismantled; the rectum is closed as in a Hartmann’s procedure and the ileum exteriorized as an end-ileostomy. The abdomen is left open as a ‘laparostomy’. At a planned relaparotomy 48 hours later, residual collections of ‘thin’ pus are evacuated. The patient continues to be ‘septic’ and develops a multi-organ dysfunction syndrome (MODS). A CT scan of the abdomen shows fluid in the pelvis and gutters; diagnostic aspiration reveals the presence of fungi. An antifungal agent is added to the broad-spectrum antibiotics the patient is already receiving. He continues to deteriorate; at relaparotomy, murky peritoneal fluid is found and cultured. It grows Candida and Staph. epidermidis, triggering yet again an antibiotic readjustment. The MODS worsens, leading to the patient’s demise 5 weeks after the first operation. The hospital bill amounts to a staggering $250,000 (it could be a million in another ivory tower — as you know hospital billing is random and doesn’t make any sense…).\\n\\nIn tertiary peritonitis, further antimicrobial administration and operative interventions seem futile and may contribute to the peritoneal superinfection and possibly to the aggravation of the SIRS-MODS complex. The frequently fatal outcome of tertiary peritonitis indicates that current antibiotic-assisted, mechanical answers to severe peritonitis have about reached their limits, in an (at least for now) unsalvageable patient. Some surgeons find it difficult to accept futility and avoid surgery when faced with peritonitis, especially since supportive care, even if successful, is long and frustrating, and the pressure “to do something” is strong. Of course, many general surgeons never come across this entity: their patient either dies before reaching this phase or is transferred to an ivory tower…\\n\\n### Management (secondary peritonitis)\\n\\nThe outcome of IAI depends on the patient’s pre-morbid reserves, his current physiological compromise and the virulence of the infection. Your goal is to assist the patient’s own local and systemic defenses.\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A relaparotomy because of diffuse peritonitis and a documented free anastomotic leak. At operation, his abdomen is found to be full of fecal material. It is cleansed and the anastomosis is dismantled; the rectum is closed as in a Hartmann’s procedure and the ileum exteriorized as an end-ileostomy. The abdomen is left open as a ‘laparostomy’. At a planned relaparotomy 48 hours later, residual collections of ‘thin’ pus are evacuated. The patient continues to be ‘septic’ and develops a multi-organ dysfunction syndrome (MODS). A CT scan of the abdomen shows fluid in the pelvis and gutters; diagnostic aspiration reveals the presence of fungi. An antifungal agent is added to the broad-spectrum antibiotics the patient is already receiving. He continues to deteriorate; at relaparotomy, murky peritoneal fluid is found and cultured. It grows Candida and Staph. epidermidis, triggering yet again an antibiotic readjustment. The MODS worsens, leading to the patient’s demise 5 weeks after the first operation. The hospital bill amounts to a staggering $250,000 (it could be a million in another ivory tower — as you know hospital billing is random and doesn’t make any sense…).\\n\\nIn tertiary peritonitis, further antimicrobial administration and operative interventions seem futile and may contribute to the peritoneal superinfection and possibly to the aggravation of the SIRS-MODS complex. The frequently fatal outcome of tertiary peritonitis indicates that current antibiotic-assisted, mechanical answers to severe peritonitis have about reached their limits, in an (at least for now) unsalvageable patient. Some surgeons find it difficult to accept futility and avoid surgery when faced with peritonitis, especially since supportive care, even if successful, is long and frustrating, and the pressure “to do something” is strong. Of course, many general surgeons never come across this entity: their patient either dies before reaching this phase or is transferred to an ivory tower…',\n", " 'md': 'A relaparotomy because of diffuse peritonitis and a documented free anastomotic leak. At operation, his abdomen is found to be full of fecal material. It is cleansed and the anastomosis is dismantled; the rectum is closed as in a Hartmann’s procedure and the ileum exteriorized as an end-ileostomy. The abdomen is left open as a ‘laparostomy’. At a planned relaparotomy 48 hours later, residual collections of ‘thin’ pus are evacuated. The patient continues to be ‘septic’ and develops a multi-organ dysfunction syndrome (MODS). A CT scan of the abdomen shows fluid in the pelvis and gutters; diagnostic aspiration reveals the presence of fungi. An antifungal agent is added to the broad-spectrum antibiotics the patient is already receiving. He continues to deteriorate; at relaparotomy, murky peritoneal fluid is found and cultured. It grows Candida and Staph. epidermidis, triggering yet again an antibiotic readjustment. The MODS worsens, leading to the patient’s demise 5 weeks after the first operation. The hospital bill amounts to a staggering $250,000 (it could be a million in another ivory tower — as you know hospital billing is random and doesn’t make any sense…).\\n\\nIn tertiary peritonitis, further antimicrobial administration and operative interventions seem futile and may contribute to the peritoneal superinfection and possibly to the aggravation of the SIRS-MODS complex. The frequently fatal outcome of tertiary peritonitis indicates that current antibiotic-assisted, mechanical answers to severe peritonitis have about reached their limits, in an (at least for now) unsalvageable patient. Some surgeons find it difficult to accept futility and avoid surgery when faced with peritonitis, especially since supportive care, even if successful, is long and frustrating, and the pressure “to do something” is strong. Of course, many general surgeons never come across this entity: their patient either dies before reaching this phase or is transferred to an ivory tower…',\n", " 'bBox': {'x': 72, 'y': 106, 'w': 467.89, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management (secondary peritonitis)',\n", " 'md': '### Management (secondary peritonitis)',\n", " 'bBox': {'x': 86, 'y': 597, 'w': 284.14, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The outcome of IAI depends on the patient’s pre-morbid reserves, his current physiological compromise and the virulence of the infection. Your goal is to assist the patient’s own local and systemic defenses.\\n```',\n", " 'md': 'The outcome of IAI depends on the patient’s pre-morbid reserves, his current physiological compromise and the virulence of the infection. Your goal is to assist the patient’s own local and systemic defenses.\\n```',\n", " 'bBox': {'x': 79, 'y': 388, 'w': 453.17, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 416, 'y': 388, 'w': 23.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 169,\n", " 'text': ' The philosophy of management in a typical case of secondary\\nperitonitis consists of initial adjunctive measures, source control,\\nfollowed by peritoneal toilet. More aggressive methods will also be\\ndiscussed.\\n\\n Adjunctive measures\\n\\n These refer to the stabilization of a sick patient by means of\\nappropriate fluid and electrolyte replenishment. The invasiveness of the\\nmonitoring should be tailored to the physiologic status of the patient.\\nBroad antibiotic coverage for aerobic and anaerobic gut flora should be\\nstarted early. In peritonitis, operating on a poorly resuscitated patient\\nis like throwing both ends of the rope at a drowning man.\\n\\n Source control 1\\n In some cases (e.g. acute uncomplicated diverticulitis or acute\\ncholecystitis), i.v. antibiotics suffice to effect source control, at least\\ninitially. In most etiologies of secondary peritonitis, the key to success is\\ntimely surgical intervention to interrupt the delivery of bacteria and\\nadjuvants of inflammation (bile, blood, fecal matter, barium) into the\\nperitoneal cavity. All other measures are futile if the operation does not\\nsuccessfully eradicate the infective source and reduce the inoculum to an\\namount that can be handled effectively by the patient’s defenses,\\nsupported by antibiotic therapy. This component of treatment is\\nuncontroversial. Source control frequently involves a simple procedure\\nsuch as an appendectomy or a patch-closure of a perforated ulcer.\\nOccasionally, a major resection to remove the infective focus is indicated,\\nsuch as gastrectomy for perforated gastric carcinoma or a colectomy for\\nperforated diverticulitis. Generally, the choice of the procedure (e.g.\\nstoma versus primary anastomosis), depends on the anatomical\\nsource of infection, the degree of peritoneal inflammation, the\\npatient’s premorbid reserves and the degree of SIRS, as will be\\ndiscussed in the individual chapters.\\n\\n Note that situations exist when the source cannot be eradicated\\nor the expected price to pay for its removal is deemed too high. Less',\n", " 'md': '```markdown\\n# Management of Secondary Peritonitis\\n\\nThe philosophy of management in a typical case of secondary peritonitis consists of initial adjunctive measures, source control, followed by peritoneal toilet. More aggressive methods will also be discussed.\\n\\n## Adjunctive Measures\\n\\nThese refer to the stabilization of a sick patient by means of appropriate fluid and electrolyte replenishment. The invasiveness of the monitoring should be tailored to the physiologic status of the patient. Broad antibiotic coverage for aerobic and anaerobic gut flora should be started early. In peritonitis, operating on a poorly resuscitated patient is like throwing both ends of the rope at a drowning man.\\n\\n## Source Control\\n\\nIn some cases (e.g., acute uncomplicated diverticulitis or acute cholecystitis), i.v. antibiotics suffice to effect source control, at least initially. In most etiologies of secondary peritonitis, the key to success is timely surgical intervention to interrupt the delivery of bacteria and adjuvants of inflammation (bile, blood, fecal matter, barium) into the peritoneal cavity. All other measures are futile if the operation does not successfully eradicate the infective source and reduce the inoculum to an amount that can be handled effectively by the patient’s defenses, supported by antibiotic therapy. This component of treatment is uncontroversial.\\n\\nSource control frequently involves a simple procedure such as an appendectomy or a patch-closure of a perforated ulcer. Occasionally, a major resection to remove the infective focus is indicated, such as gastrectomy for perforated gastric carcinoma or a colectomy for perforated diverticulitis. Generally, the choice of the procedure (e.g., stoma versus primary anastomosis) depends on the anatomical source of infection, the degree of peritoneal inflammation, the patient’s premorbid reserves, and the degree of SIRS, as will be discussed in the individual chapters.\\n\\nNote that situations exist when the source cannot be eradicated or the expected price to pay for its removal is deemed too high. Less\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management of Secondary Peritonitis',\n", " 'md': '# Management of Secondary Peritonitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The philosophy of management in a typical case of secondary peritonitis consists of initial adjunctive measures, source control, followed by peritoneal toilet. More aggressive methods will also be discussed.',\n", " 'md': 'The philosophy of management in a typical case of secondary peritonitis consists of initial adjunctive measures, source control, followed by peritoneal toilet. More aggressive methods will also be discussed.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 166.47, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Adjunctive Measures',\n", " 'md': '## Adjunctive Measures',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 166.47, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'These refer to the stabilization of a sick patient by means of appropriate fluid and electrolyte replenishment. The invasiveness of the monitoring should be tailored to the physiologic status of the patient. Broad antibiotic coverage for aerobic and anaerobic gut flora should be started early. In peritonitis, operating on a poorly resuscitated patient is like throwing both ends of the rope at a drowning man.',\n", " 'md': 'These refer to the stabilization of a sick patient by means of appropriate fluid and electrolyte replenishment. The invasiveness of the monitoring should be tailored to the physiologic status of the patient. Broad antibiotic coverage for aerobic and anaerobic gut flora should be started early. In peritonitis, operating on a poorly resuscitated patient is like throwing both ends of the rope at a drowning man.',\n", " 'bBox': {'x': 72, 'y': 281, 'w': 467.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Source Control',\n", " 'md': '## Source Control',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In some cases (e.g., acute uncomplicated diverticulitis or acute cholecystitis), i.v. antibiotics suffice to effect source control, at least initially. In most etiologies of secondary peritonitis, the key to success is timely surgical intervention to interrupt the delivery of bacteria and adjuvants of inflammation (bile, blood, fecal matter, barium) into the peritoneal cavity. All other measures are futile if the operation does not successfully eradicate the infective source and reduce the inoculum to an amount that can be handled effectively by the patient’s defenses, supported by antibiotic therapy. This component of treatment is uncontroversial.\\n\\nSource control frequently involves a simple procedure such as an appendectomy or a patch-closure of a perforated ulcer. Occasionally, a major resection to remove the infective focus is indicated, such as gastrectomy for perforated gastric carcinoma or a colectomy for perforated diverticulitis. Generally, the choice of the procedure (e.g., stoma versus primary anastomosis) depends on the anatomical source of infection, the degree of peritoneal inflammation, the patient’s premorbid reserves, and the degree of SIRS, as will be discussed in the individual chapters.\\n\\nNote that situations exist when the source cannot be eradicated or the expected price to pay for its removal is deemed too high. Less\\n```',\n", " 'md': 'In some cases (e.g., acute uncomplicated diverticulitis or acute cholecystitis), i.v. antibiotics suffice to effect source control, at least initially. In most etiologies of secondary peritonitis, the key to success is timely surgical intervention to interrupt the delivery of bacteria and adjuvants of inflammation (bile, blood, fecal matter, barium) into the peritoneal cavity. All other measures are futile if the operation does not successfully eradicate the infective source and reduce the inoculum to an amount that can be handled effectively by the patient’s defenses, supported by antibiotic therapy. This component of treatment is uncontroversial.\\n\\nSource control frequently involves a simple procedure such as an appendectomy or a patch-closure of a perforated ulcer. Occasionally, a major resection to remove the infective focus is indicated, such as gastrectomy for perforated gastric carcinoma or a colectomy for perforated diverticulitis. Generally, the choice of the procedure (e.g., stoma versus primary anastomosis) depends on the anatomical source of infection, the degree of peritoneal inflammation, the patient’s premorbid reserves, and the degree of SIRS, as will be discussed in the individual chapters.\\n\\nNote that situations exist when the source cannot be eradicated or the expected price to pay for its removal is deemed too high. Less\\n```',\n", " 'bBox': {'x': 72, 'y': 410, 'w': 467.87, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 170,\n", " 'text': 'radical options may then be used, such as diversion (e.g. proximal stoma\\nin a patient too unstable to tolerate a resection) or drainage (e.g. leaking\\nduodenum).\\n\\n Peritoneal toilet\\n\\n Once the source of infection is eradicated, cleaning the peritoneal\\ncavity is aimed at minimizing the intraperitoneal bacterial load.\\nSeveral maneuvers deserve discussion:\\n\\n • Liquid contaminants and infected exudates should be aspirated and\\n particulate matter removed by swabbing or mopping the peritoneal\\n surfaces with moist laparotomy pads. Do it gently for the\\n peritoneal surface is your friend!\\n • There is no scientific evidence that intra-operative peritoneal\\n lavage, cosmetically appealing and popular with surgeons as it\\n is, reduces mortality or infectious complications in patients\\n receiving adequate systemic antibiotics. Similarly, peritoneal\\n irrigation with antibiotics is not advantageous, and the addition of\\n antiseptics may produce local toxic effects. Irrigate copiously (to use\\n a term popular among American surgeons) if you wish but know\\n that, beyond wetting your own underwear and shoes, you will\\n probably not accomplish much ( Figure 13.1). Should you choose\\n to remain a dedicated irrigator, try to confine the irrigation to the\\n contaminated area — to avoid spreading s**t all around — and do\\n remember to suck out all the lavage fluid before you close; there is\\n evidence that leaving irrigation fluids behind interferes with\\n peritoneal defenses by ‘diluting the macrophages’. Perhaps\\n bacteria swim better than macrophages!',\n", " 'md': '```markdown\\n## Peritoneal Toilet\\n\\nOnce the source of infection is eradicated, cleaning the peritoneal cavity is aimed at minimizing the intraperitoneal bacterial load. Several maneuvers deserve discussion:\\n\\n- Liquid contaminants and infected exudates should be aspirated and particulate matter removed by swabbing or mopping the peritoneal surfaces with moist laparotomy pads. Do it gently for the peritoneal surface is your friend!\\n- There is no scientific evidence that intra-operative peritoneal lavage, cosmetically appealing and popular with surgeons as it is, reduces mortality or infectious complications in patients receiving adequate systemic antibiotics. Similarly, peritoneal irrigation with antibiotics is not advantageous, and the addition of antiseptics may produce local toxic effects. Irrigate copiously (to use a term popular among American surgeons) if you wish but know that, beyond wetting your own underwear and shoes, you will probably not accomplish much (Figure 13.1). Should you choose to remain a dedicated irrigator, try to confine the irrigation to the contaminated area — to avoid spreading s**t all around — and do remember to suck out all the lavage fluid before you close; there is evidence that leaving irrigation fluids behind interferes with peritoneal defenses by ‘diluting the macrophages’. Perhaps bacteria swim better than macrophages!\\n```\\n\\n### Figure 13.1\\n- **Description**: The figure likely illustrates a surgical procedure or technique related to peritoneal irrigation or cleaning. The specific content of the figure is not provided in the text, but it is referenced in the context of discussing the effectiveness of irrigation during surgery.\\n- **Summary**: This figure is referenced in the context of discussing the practice of peritoneal irrigation and its implications during surgical procedures.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Peritoneal Toilet',\n", " 'md': '## Peritoneal Toilet',\n", " 'bBox': {'x': 86, 'y': 162, 'w': 124.11, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Once the source of infection is eradicated, cleaning the peritoneal cavity is aimed at minimizing the intraperitoneal bacterial load. Several maneuvers deserve discussion:\\n\\n- Liquid contaminants and infected exudates should be aspirated and particulate matter removed by swabbing or mopping the peritoneal surfaces with moist laparotomy pads. Do it gently for the peritoneal surface is your friend!\\n- There is no scientific evidence that intra-operative peritoneal lavage, cosmetically appealing and popular with surgeons as it is, reduces mortality or infectious complications in patients receiving adequate systemic antibiotics. Similarly, peritoneal irrigation with antibiotics is not advantageous, and the addition of antiseptics may produce local toxic effects. Irrigate copiously (to use a term popular among American surgeons) if you wish but know that, beyond wetting your own underwear and shoes, you will probably not accomplish much (Figure 13.1). Should you choose to remain a dedicated irrigator, try to confine the irrigation to the contaminated area — to avoid spreading s**t all around — and do remember to suck out all the lavage fluid before you close; there is evidence that leaving irrigation fluids behind interferes with peritoneal defenses by ‘diluting the macrophages’. Perhaps bacteria swim better than macrophages!\\n```',\n", " 'md': 'Once the source of infection is eradicated, cleaning the peritoneal cavity is aimed at minimizing the intraperitoneal bacterial load. Several maneuvers deserve discussion:\\n\\n- Liquid contaminants and infected exudates should be aspirated and particulate matter removed by swabbing or mopping the peritoneal surfaces with moist laparotomy pads. Do it gently for the peritoneal surface is your friend!\\n- There is no scientific evidence that intra-operative peritoneal lavage, cosmetically appealing and popular with surgeons as it is, reduces mortality or infectious complications in patients receiving adequate systemic antibiotics. Similarly, peritoneal irrigation with antibiotics is not advantageous, and the addition of antiseptics may produce local toxic effects. Irrigate copiously (to use a term popular among American surgeons) if you wish but know that, beyond wetting your own underwear and shoes, you will probably not accomplish much (Figure 13.1). Should you choose to remain a dedicated irrigator, try to confine the irrigation to the contaminated area — to avoid spreading s**t all around — and do remember to suck out all the lavage fluid before you close; there is evidence that leaving irrigation fluids behind interferes with peritoneal defenses by ‘diluting the macrophages’. Perhaps bacteria swim better than macrophages!\\n```',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 466.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 13.1',\n", " 'md': '### Figure 13.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: The figure likely illustrates a surgical procedure or technique related to peritoneal irrigation or cleaning. The specific content of the figure is not provided in the text, but it is referenced in the context of discussing the effectiveness of irrigation during surgery.\\n- **Summary**: This figure is referenced in the context of discussing the practice of peritoneal irrigation and its implications during surgical procedures.',\n", " 'md': '- **Description**: The figure likely illustrates a surgical procedure or technique related to peritoneal irrigation or cleaning. The specific content of the figure is not provided in the text, but it is referenced in the context of discussing the effectiveness of irrigation during surgery.\\n- **Summary**: This figure is referenced in the context of discussing the practice of peritoneal irrigation and its implications during surgical procedures.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'to remain a dedicated irrigator, try to confine the irrigation to the'}]},\n", " {'page': 171,\n", " 'text': ' FeryA Jo4t\\nFigure 13.1. “OK guys, now it’s enough. I think the abdomen is clean…”\\n\\n • The concept of radical debridement of the peritoneal cavity is based\\n on the premise that fibrin is a nidus for microbial implantation, hence\\n the recommendation to peel off every bit of fibrin coating peritoneal\\n surfaces and viscera. The procedure is tedious, results in excessive\\n bleeding from the denuded peritoneal surfaces and endangers the\\n integrity of an already friable intestine. It did not withstand the test of\\n a prospective randomized study comparing it to a more conservative\\n approach. It is obsolete and harmful — just forget it!\\n • Despite the dictum that it is impossible effectively to drain the\\n free peritoneal cavity, drains are still used and often misused.\\n Their aim must be restricted to the evacuation of an ‘established’\\n abscess (when the residual cavity would not collapse or cannot be\\n filled with omentum or adjacent structures), to allow the escape of\\n potential secretions (e.g. bile, pancreatic juice) or, rarely, to establish\\n a controlled intestinal fistula when exteriorization is not possible. To\\n prevent intestinal erosion, soft drains should be left in place for the\\n shortest duration possible and well away from bowel wall. In\\n general, active-suction drainage may be more effective than the',\n", " 'md': '```markdown\\n# Page Content\\n\\n**Figure 13.1**: “OK guys, now it’s enough. I think the abdomen is clean…”\\n\\n- The concept of radical debridement of the peritoneal cavity is based on the premise that fibrin is a nidus for microbial implantation, hence the recommendation to peel off every bit of fibrin coating peritoneal surfaces and viscera. The procedure is tedious, results in excessive bleeding from the denuded peritoneal surfaces and endangers the integrity of an already friable intestine. It did not withstand the test of a prospective randomized study comparing it to a more conservative approach. It is obsolete and harmful — just forget it!\\n\\n- Despite the dictum that it is impossible effectively to drain the free peritoneal cavity, drains are still used and often misused. Their aim must be restricted to the evacuation of an ‘established’ abscess (when the residual cavity would not collapse or cannot be filled with omentum or adjacent structures), to allow the escape of potential secretions (e.g. bile, pancreatic juice) or, rarely, to establish a controlled intestinal fistula when exteriorization is not possible. To prevent intestinal erosion, soft drains should be left in place for the shortest duration possible and well away from bowel wall. In general, active-suction drainage may be more effective than the .\\n```',\n", " 'images': [{'name': 'img_p170_1.png',\n", " 'height': 566,\n", " 'width': 803,\n", " 'x': 107.27999999999975,\n", " 'y': 72,\n", " 'original_width': 1380,\n", " 'original_height': 973}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 13.1**: “OK guys, now it’s enough. I think the abdomen is clean…”\\n\\n- The concept of radical debridement of the peritoneal cavity is based on the premise that fibrin is a nidus for microbial implantation, hence the recommendation to peel off every bit of fibrin coating peritoneal surfaces and viscera. The procedure is tedious, results in excessive bleeding from the denuded peritoneal surfaces and endangers the integrity of an already friable intestine. It did not withstand the test of a prospective randomized study comparing it to a more conservative approach. It is obsolete and harmful — just forget it!\\n\\n- Despite the dictum that it is impossible effectively to drain the free peritoneal cavity, drains are still used and often misused. Their aim must be restricted to the evacuation of an ‘established’ abscess (when the residual cavity would not collapse or cannot be filled with omentum or adjacent structures), to allow the escape of potential secretions (e.g. bile, pancreatic juice) or, rarely, to establish a controlled intestinal fistula when exteriorization is not possible. To prevent intestinal erosion, soft drains should be left in place for the shortest duration possible and well away from bowel wall. In general, active-suction drainage may be more effective than the .\\n```',\n", " 'md': '**Figure 13.1**: “OK guys, now it’s enough. I think the abdomen is clean…”\\n\\n- The concept of radical debridement of the peritoneal cavity is based on the premise that fibrin is a nidus for microbial implantation, hence the recommendation to peel off every bit of fibrin coating peritoneal surfaces and viscera. The procedure is tedious, results in excessive bleeding from the denuded peritoneal surfaces and endangers the integrity of an already friable intestine. It did not withstand the test of a prospective randomized study comparing it to a more conservative approach. It is obsolete and harmful — just forget it!\\n\\n- Despite the dictum that it is impossible effectively to drain the free peritoneal cavity, drains are still used and often misused. Their aim must be restricted to the evacuation of an ‘established’ abscess (when the residual cavity would not collapse or cannot be filled with omentum or adjacent structures), to allow the escape of potential secretions (e.g. bile, pancreatic juice) or, rarely, to establish a controlled intestinal fistula when exteriorization is not possible. To prevent intestinal erosion, soft drains should be left in place for the shortest duration possible and well away from bowel wall. In general, active-suction drainage may be more effective than the .\\n```',\n", " 'bBox': {'x': 100, 'y': 420, 'w': 437.03, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 172,\n", " 'text': ' passive kind, and infectious complications can be reduced by\\n choosing ‘closed’ systems. Drains often provide a false sense of\\n security and reassurance ( Figure 13.2). We have all seen a\\n moribund postoperative patient with an abdomen ‘crying’ to be re-\\n explored with a surgeon in denial because his tiny four-quadrant\\n drains are dry and non-productive. (By the way, this is particularly\\n true of drains inserted to deal with postoperative hemorrhage; a tiny\\n trickle of blood from a drain may hide a huge intra-abdominal clot.)\\n Drains inserted close to an anastomosis “just in case it leaks”\\n are more likely to cause an anastomotic dehiscence than to\\n establish a controlled fistula. Read more about drains in the\\n dedicated chapter ( Chapter 39).\\n • The role of postoperative peritoneal lavage, through tube drains\\n left in place for this purpose, is at best questionable. Is it really\\n possible to irrigate the whole abdominal cavity? In our experience,\\n such tubes are rapidly walled-off by adhesions and adjacent tissues.\\n At the end of the day, you will be irrigating nothing more than the\\n drains’ tracks.\\n\\nFigure 13.2. “Which of the drains is draining?”',\n", " 'md': '```markdown\\n## Page Content\\n\\nPassive kind, and infectious complications can be reduced by choosing ‘closed’ systems. Drains often provide a false sense of security and reassurance (Figure 13.2). We have all seen a moribund postoperative patient with an abdomen ‘crying’ to be re-explored with a surgeon in denial because his tiny four-quadrant drains are dry and non-productive. (By the way, this is particularly true of drains inserted to deal with postoperative hemorrhage; a tiny trickle of blood from a drain may hide a huge intra-abdominal clot.) Drains inserted close to an anastomosis “just in case it leaks” are more likely to cause an anastomotic dehiscence than to establish a controlled fistula. Read more about drains in the dedicated chapter (Chapter 39).\\n\\n- The role of postoperative peritoneal lavage, through tube drains left in place for this purpose, is at best questionable. Is it really possible to irrigate the whole abdominal cavity? In our experience, such tubes are rapidly walled-off by adhesions and adjacent tissues. At the end of the day, you will be irrigating nothing more than the drains’ tracks.\\n\\n### Figure Descriptions\\n\\n**Figure 13.2**: “Which of the drains is draining?”\\nThis figure likely illustrates various types of drains used in postoperative care, highlighting their effectiveness and potential issues. The caption suggests a focus on the functionality of different drains in a clinical setting.\\n\\n```',\n", " 'images': [{'name': 'img_p171_1.png',\n", " 'height': 521,\n", " 'width': 792,\n", " 'x': 110.15999999999985,\n", " 'y': 403.19999999999993,\n", " 'original_width': 1359,\n", " 'original_height': 895}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Passive kind, and infectious complications can be reduced by choosing ‘closed’ systems. Drains often provide a false sense of security and reassurance (Figure 13.2). We have all seen a moribund postoperative patient with an abdomen ‘crying’ to be re-explored with a surgeon in denial because his tiny four-quadrant drains are dry and non-productive. (By the way, this is particularly true of drains inserted to deal with postoperative hemorrhage; a tiny trickle of blood from a drain may hide a huge intra-abdominal clot.) Drains inserted close to an anastomosis “just in case it leaks” are more likely to cause an anastomotic dehiscence than to establish a controlled fistula. Read more about drains in the dedicated chapter (Chapter 39).\\n\\n- The role of postoperative peritoneal lavage, through tube drains left in place for this purpose, is at best questionable. Is it really possible to irrigate the whole abdominal cavity? In our experience, such tubes are rapidly walled-off by adhesions and adjacent tissues. At the end of the day, you will be irrigating nothing more than the drains’ tracks.',\n", " 'md': 'Passive kind, and infectious complications can be reduced by choosing ‘closed’ systems. Drains often provide a false sense of security and reassurance (Figure 13.2). We have all seen a moribund postoperative patient with an abdomen ‘crying’ to be re-explored with a surgeon in denial because his tiny four-quadrant drains are dry and non-productive. (By the way, this is particularly true of drains inserted to deal with postoperative hemorrhage; a tiny trickle of blood from a drain may hide a huge intra-abdominal clot.) Drains inserted close to an anastomosis “just in case it leaks” are more likely to cause an anastomotic dehiscence than to establish a controlled fistula. Read more about drains in the dedicated chapter (Chapter 39).\\n\\n- The role of postoperative peritoneal lavage, through tube drains left in place for this purpose, is at best questionable. Is it really possible to irrigate the whole abdominal cavity? In our experience, such tubes are rapidly walled-off by adhesions and adjacent tissues. At the end of the day, you will be irrigating nothing more than the drains’ tracks.',\n", " 'bBox': {'x': 100, 'y': 102, 'w': 437.63, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Descriptions',\n", " 'md': '### Figure Descriptions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 13.2**: “Which of the drains is draining?”\\nThis figure likely illustrates various types of drains used in postoperative care, highlighting their effectiveness and potential issues. The caption suggests a focus on the functionality of different drains in a clinical setting.\\n\\n```',\n", " 'md': '**Figure 13.2**: “Which of the drains is draining?”\\nThis figure likely illustrates various types of drains used in postoperative care, highlighting their effectiveness and potential issues. The caption suggests a focus on the functionality of different drains in a clinical setting.\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'moribund postoperative patient with an abdomen ‘crying’ to be re-'},\n", " {'text': ''}]},\n", " {'page': 173,\n", " 'text': ' Aggressive modalities of management\\n In doubtful cases do not wait too long\\n Before exploring, for it is quite wrong\\n To act upon the slogan Wait and See,\\n When looking may provide the remedy.\\n Zachary Cope\\n\\n Most IAI patients respond to the combination of adequate source\\ncontrol, appropriate antibiotics and competent supportive management.\\nMight a few others need more? In the 1980s, it was believed that failure\\nof the initial standard operation could be accounted for by either\\npersisting or recurring infection diagnosed too late. Waiting for overt signs\\nof infection or organ failure as the indication for ‘on demand’ abdominal\\nre-exploration was thought to be at best questionable. ħence the\\nemergence of an aggressive management approach in the form of\\nplanned relaparotomy and open management of the abdomen\\n(laparostomy). These two modalities were often combined (they are\\ndiscussed more extensively in Part IV — “After the Operation”):\\n\\n • Planned relaparotomy pushes the process of source control to its\\n limit. By staging repeated operative interventions to follow the first\\n ‘index’ procedure for peritonitis, the surgeon makes a commitment to\\n return to the abdominal cavity again and again to re-explore,\\n evacuate, wash-out, debride or resect as needed, until the disease\\n process is definitively controlled. This dogged pursuit is justified by\\n local intra-abdominal conditions rather than the patient’s overall\\n status.\\n • Open management (laparostomy) is, in concept, an extension to\\n peritoneal toilet by providing maximal drainage for the purulent\\n abdomen. It facilitates frequent re-explorations. In addition, it serves\\n as prophylaxis to the abdominal compartment syndrome — in the\\n early days though, this advantage was not fully appreciated.\\n\\n Early results of these methods seemed promising, particularly in the\\nmanagement of infected pancreatic necrosis but were less favorable in\\ncases of postoperative peritonitis, perhaps because the sickest patients\\nwere included. Intestinal fistulas plagued simple open management, but',\n", " 'md': '```markdown\\n# Aggressive Modalities of Management\\n\\n> \"In doubtful cases do not wait too long\\n> Before exploring, for it is quite wrong\\n> To act upon the slogan Wait and See,\\n> When looking may provide the remedy.\"\\n> — Zachary Cope\\n\\nMost IAI patients respond to the combination of adequate source control, appropriate antibiotics, and competent supportive management. Might a few others need more? In the 1980s, it was believed that failure of the initial standard operation could be accounted for by either persisting or recurring infection diagnosed too late. Waiting for overt signs of infection or organ failure as the indication for ‘on demand’ abdominal re-exploration was thought to be at best questionable. Hence the emergence of an aggressive management approach in the form of planned relaparotomy and open management of the abdomen (laparostomy). These two modalities were often combined (they are discussed more extensively in Part IV — “After the Operation”):\\n\\n- **Planned relaparotomy** pushes the process of source control to its limit. By staging repeated operative interventions to follow the first ‘index’ procedure for peritonitis, the surgeon makes a commitment to return to the abdominal cavity again and again to re-explore, evacuate, wash-out, debride or resect as needed, until the disease process is definitively controlled. This dogged pursuit is justified by local intra-abdominal conditions rather than the patient’s overall status.\\n\\n- **Open management (laparostomy)** is, in concept, an extension to peritoneal toilet by providing maximal drainage for the purulent abdomen. It facilitates frequent re-explorations. In addition, it serves as prophylaxis to the abdominal compartment syndrome — in the early days though, this advantage was not fully appreciated.\\n\\nEarly results of these methods seemed promising, particularly in the management of infected pancreatic necrosis but were less favorable in cases of postoperative peritonitis, perhaps because the sickest patients were included. Intestinal fistulas plagued simple open management, but\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Aggressive Modalities of Management',\n", " 'md': '# Aggressive Modalities of Management',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 302.55, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '> \"In doubtful cases do not wait too long\\n> Before exploring, for it is quite wrong\\n> To act upon the slogan Wait and See,\\n> When looking may provide the remedy.\"\\n> — Zachary Cope\\n\\nMost IAI patients respond to the combination of adequate source control, appropriate antibiotics, and competent supportive management. Might a few others need more? In the 1980s, it was believed that failure of the initial standard operation could be accounted for by either persisting or recurring infection diagnosed too late. Waiting for overt signs of infection or organ failure as the indication for ‘on demand’ abdominal re-exploration was thought to be at best questionable. Hence the emergence of an aggressive management approach in the form of planned relaparotomy and open management of the abdomen (laparostomy). These two modalities were often combined (they are discussed more extensively in Part IV — “After the Operation”):\\n\\n- **Planned relaparotomy** pushes the process of source control to its limit. By staging repeated operative interventions to follow the first ‘index’ procedure for peritonitis, the surgeon makes a commitment to return to the abdominal cavity again and again to re-explore, evacuate, wash-out, debride or resect as needed, until the disease process is definitively controlled. This dogged pursuit is justified by local intra-abdominal conditions rather than the patient’s overall status.\\n\\n- **Open management (laparostomy)** is, in concept, an extension to peritoneal toilet by providing maximal drainage for the purulent abdomen. It facilitates frequent re-explorations. In addition, it serves as prophylaxis to the abdominal compartment syndrome — in the early days though, this advantage was not fully appreciated.\\n\\nEarly results of these methods seemed promising, particularly in the management of infected pancreatic necrosis but were less favorable in cases of postoperative peritonitis, perhaps because the sickest patients were included. Intestinal fistulas plagued simple open management, but\\n```',\n", " 'md': '> \"In doubtful cases do not wait too long\\n> Before exploring, for it is quite wrong\\n> To act upon the slogan Wait and See,\\n> When looking may provide the remedy.\"\\n> — Zachary Cope\\n\\nMost IAI patients respond to the combination of adequate source control, appropriate antibiotics, and competent supportive management. Might a few others need more? In the 1980s, it was believed that failure of the initial standard operation could be accounted for by either persisting or recurring infection diagnosed too late. Waiting for overt signs of infection or organ failure as the indication for ‘on demand’ abdominal re-exploration was thought to be at best questionable. Hence the emergence of an aggressive management approach in the form of planned relaparotomy and open management of the abdomen (laparostomy). These two modalities were often combined (they are discussed more extensively in Part IV — “After the Operation”):\\n\\n- **Planned relaparotomy** pushes the process of source control to its limit. By staging repeated operative interventions to follow the first ‘index’ procedure for peritonitis, the surgeon makes a commitment to return to the abdominal cavity again and again to re-explore, evacuate, wash-out, debride or resect as needed, until the disease process is definitively controlled. This dogged pursuit is justified by local intra-abdominal conditions rather than the patient’s overall status.\\n\\n- **Open management (laparostomy)** is, in concept, an extension to peritoneal toilet by providing maximal drainage for the purulent abdomen. It facilitates frequent re-explorations. In addition, it serves as prophylaxis to the abdominal compartment syndrome — in the early days though, this advantage was not fully appreciated.\\n\\nEarly results of these methods seemed promising, particularly in the management of infected pancreatic necrosis but were less favorable in cases of postoperative peritonitis, perhaps because the sickest patients were included. Intestinal fistulas plagued simple open management, but\\n```',\n", " 'bBox': {'x': 72, 'y': 121, 'w': 468, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 174,\n", " 'text': \"this problem was somewhat minimized by the introduction of modern\\ntemporary abdominal closure (TAC) techniques.\\n\\n ħowever, prospective randomized studies, imperfect as they were,\\ngiven the difficulties in patient enrolment and stratification, failed to show\\nan advantage for the planned relaparotomy policy and pointed to a higher\\ncomplication rate — in surgery, there is no free lunch! The possibility was\\nraised that relaparotomy constitutes a ‘second hit’ in patients in whom the\\ninflammatory response was already ‘switched-on’, escalating the SIRS. It\\nis more likely though that sick patients were subjected to a double\\niatrogenic insult: frequent trips out of the ICU and overly traumatic,\\nintempestive surgical manipulations. Is there still a place for this\\naggressive management? We believe there is one, in a very small\\nminority of carefully selected patients at the hands of expert teams.\\nWholesale application and relegating the relaparotomy performance\\nto junior staff at the end of the OR slate are recipes for disaster. Our\\nindications for these modalities are summarized in Table 13.1. Please\\ncontinue reading about this topic in Chapter 48.\\n Table 13.1. Indications for laparostomy/planned relaparotomy:\\n Critical patient condition (hemodynamic instability) precluding appropriate\\n source control at the first operation, thus calling for an 'abbreviated\\n laparotomy' or 'damage control' strategy:\\n Abdominal compartment syndrome due to excessive peritoneal (visceral)\\n swelling preventing tension-free abdominal closure_\\n Massive abdominal wall loss (e.g: post-traumatic, necrotizing fasciitis):\\n Inability to eliminate or to control the source of infection\\n Incomplete debridement of necrotic tissue (eg. infected pancreatic necrosis):\\n Uncertain viability of remaining bowel:\\n Uncontrolled bleeding (the need for 'packing' .\\n Need for peritoneal cultures?\\n\\n A 70-year-old male patient undergoes a laparotomy for perforated sigmoid diverticular disease\",\n", " 'md': \"```markdown\\n## Text Extraction\\n\\nThis problem was somewhat minimized by the introduction of modern temporary abdominal closure (TAC) techniques.\\n\\nHowever, prospective randomized studies, imperfect as they were, given the difficulties in patient enrolment and stratification, failed to show an advantage for the planned relaparotomy policy and pointed to a higher complication rate — in surgery, there is no free lunch! The possibility was raised that relaparotomy constitutes a ‘second hit’ in patients in whom the inflammatory response was already ‘switched-on’, escalating the SIRS. It is more likely though that sick patients were subjected to a double iatrogenic insult: frequent trips out of the ICU and overly traumatic, intempestive surgical manipulations. Is there still a place for this aggressive management? We believe there is one, in a very small minority of carefully selected patients at the hands of expert teams. Wholesale application and relegating the relaparotomy performance to junior staff at the end of the OR slate are recipes for disaster. Our indications for these modalities are summarized in Table 13.1. Please continue reading about this topic in Chapter 48.\\n\\n## Table 13.1: Indications for Laparostomy/Planned Relaparotomy\\n\\n| Indication |\\n|-----------------------------------------------------------------------------------------------------|\\n| Critical patient condition (hemodynamic instability) precluding appropriate source control at the first operation, thus calling for an 'abbreviated laparotomy' or 'damage control' strategy: |\\n| Abdominal compartment syndrome due to excessive peritoneal (visceral) swelling preventing tension-free abdominal closure. |\\n| Massive abdominal wall loss (e.g: post-traumatic, necrotizing fasciitis). |\\n| Inability to eliminate or to control the source of infection. |\\n| Incomplete debridement of necrotic tissue (e.g. infected pancreatic necrosis). |\\n| Uncertain viability of remaining bowel. |\\n| Uncontrolled bleeding (the need for 'packing'). |\\n| Need for peritoneal cultures? |\\n\\nA 70-year-old male patient undergoes a laparotomy for perforated sigmoid diverticular disease.\\n```\",\n", " 'images': [{'name': 'img_p173_1.png',\n", " 'height': 460,\n", " 'width': 819,\n", " 'x': 103.67999999999938,\n", " 'y': 383.03999999999996,\n", " 'original_width': 1407,\n", " 'original_height': 790}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This problem was somewhat minimized by the introduction of modern temporary abdominal closure (TAC) techniques.\\n\\nHowever, prospective randomized studies, imperfect as they were, given the difficulties in patient enrolment and stratification, failed to show an advantage for the planned relaparotomy policy and pointed to a higher complication rate — in surgery, there is no free lunch! The possibility was raised that relaparotomy constitutes a ‘second hit’ in patients in whom the inflammatory response was already ‘switched-on’, escalating the SIRS. It is more likely though that sick patients were subjected to a double iatrogenic insult: frequent trips out of the ICU and overly traumatic, intempestive surgical manipulations. Is there still a place for this aggressive management? We believe there is one, in a very small minority of carefully selected patients at the hands of expert teams. Wholesale application and relegating the relaparotomy performance to junior staff at the end of the OR slate are recipes for disaster. Our indications for these modalities are summarized in Table 13.1. Please continue reading about this topic in Chapter 48.',\n", " 'md': 'This problem was somewhat minimized by the introduction of modern temporary abdominal closure (TAC) techniques.\\n\\nHowever, prospective randomized studies, imperfect as they were, given the difficulties in patient enrolment and stratification, failed to show an advantage for the planned relaparotomy policy and pointed to a higher complication rate — in surgery, there is no free lunch! The possibility was raised that relaparotomy constitutes a ‘second hit’ in patients in whom the inflammatory response was already ‘switched-on’, escalating the SIRS. It is more likely though that sick patients were subjected to a double iatrogenic insult: frequent trips out of the ICU and overly traumatic, intempestive surgical manipulations. Is there still a place for this aggressive management? We believe there is one, in a very small minority of carefully selected patients at the hands of expert teams. Wholesale application and relegating the relaparotomy performance to junior staff at the end of the OR slate are recipes for disaster. Our indications for these modalities are summarized in Table 13.1. Please continue reading about this topic in Chapter 48.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 13.1: Indications for Laparostomy/Planned Relaparotomy',\n", " 'md': '## Table 13.1: Indications for Laparostomy/Planned Relaparotomy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Indication'],\n", " [\"Critical patient condition (hemodynamic instability) precluding appropriate source control at the first operation, thus calling for an 'abbreviated laparotomy' or 'damage control' strategy:\"],\n", " ['Abdominal compartment syndrome due to excessive peritoneal (visceral) swelling preventing tension-free abdominal closure.'],\n", " ['Massive abdominal wall loss (e.g: post-traumatic, necrotizing fasciitis).'],\n", " ['Inability to eliminate or to control the source of infection.'],\n", " ['Incomplete debridement of necrotic tissue (e.g. infected pancreatic necrosis).'],\n", " ['Uncertain viability of remaining bowel.'],\n", " [\"Uncontrolled bleeding (the need for 'packing').\"],\n", " ['Need for peritoneal cultures?']],\n", " 'md': \"| Indication |\\n|-----------------------------------------------------------------------------------------------------|\\n| Critical patient condition (hemodynamic instability) precluding appropriate source control at the first operation, thus calling for an 'abbreviated laparotomy' or 'damage control' strategy: |\\n| Abdominal compartment syndrome due to excessive peritoneal (visceral) swelling preventing tension-free abdominal closure. |\\n| Massive abdominal wall loss (e.g: post-traumatic, necrotizing fasciitis). |\\n| Inability to eliminate or to control the source of infection. |\\n| Incomplete debridement of necrotic tissue (e.g. infected pancreatic necrosis). |\\n| Uncertain viability of remaining bowel. |\\n| Uncontrolled bleeding (the need for 'packing'). |\\n| Need for peritoneal cultures? |\",\n", " 'isPerfectTable': True,\n", " 'csv': '\"Indication\"\\n\"Critical patient condition (hemodynamic instability) precluding appropriate source control at the first operation, thus calling for an \\'abbreviated laparotomy\\' or \\'damage control\\' strategy:\"\\n\"Abdominal compartment syndrome due to excessive peritoneal (visceral) swelling preventing tension-free abdominal closure.\"\\n\"Massive abdominal wall loss (e.g: post-traumatic, necrotizing fasciitis).\"\\n\"Inability to eliminate or to control the source of infection.\"\\n\"Incomplete debridement of necrotic tissue (e.g. infected pancreatic necrosis).\"\\n\"Uncertain viability of remaining bowel.\"\\n\"Uncontrolled bleeding (the need for \\'packing\\').\"\\n\"Need for peritoneal cultures?\"',\n", " 'bBox': {'x': 86, 'y': 429.04, 'w': 418.59, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A 70-year-old male patient undergoes a laparotomy for perforated sigmoid diverticular disease.\\n```',\n", " 'md': 'A 70-year-old male patient undergoes a laparotomy for perforated sigmoid diverticular disease.\\n```',\n", " 'bBox': {'x': 79, 'y': 697, 'w': 453.36, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 175,\n", " 'text': ' with generalized fecal peritonitis. Are you one of those surgeons who would send a specimen\\n of peritoneal fluid for culture? If so, how often do you follow-up the results and modify\\n accordingly your antibiotic regimen? What indeed can be gained by culturing Mr. Average\\n Citizen’s feces?\\n\\n This is a typical example of community-acquired secondary\\nperitonitis. The microbiology of this type of IAI is predictable and\\nresponds readily to an empiric broad-spectrum antibiotic regimen,\\ninitiated pre-operatively, that includes anti-anaerobic cover. In most\\ncases, culture results would become available only well after completion\\nof the antibiotic course.\\n\\n However, peritoneal cultures are useful in the following scenarios:\\n\\n • Primary peritonitis where there is no intra-abdominal source of\\n infection; the fluid contains an organism that has migrated from\\n somewhere else.\\n • Nosocomial secondary peritonitis (acquired in an already\\n hospitalized patient); the best example being postoperative\\n peritonitis.\\n • Tertiary peritonitis which is commonly associated with a peculiar\\n microbiology (see above).\\n • Peritonitis in the immunocompromised patient (AIDS, on\\n chemotherapy).\\n • Patients who are already on antibiotics, for whatever reason.\\n • Patients with a history of methicillin-resistant Staphylococcus aureus\\n (MRSA).\\n\\n “Shakiness of the hand may be some bar to the\\n successful performance of an operation, but he of a\\n shaky mind is hopeless.”\\n Sir William MacEwen',\n", " 'md': '```markdown\\n## Page Content\\n\\nThis is a typical example of community-acquired secondary peritonitis. The microbiology of this type of intra-abdominal infection (IAI) is predictable and responds readily to an empiric broad-spectrum antibiotic regimen, initiated pre-operatively, that includes anti-anaerobic cover. In most cases, culture results would become available only well after completion of the antibiotic course.\\n\\nHowever, peritoneal cultures are useful in the following scenarios:\\n\\n- Primary peritonitis where there is no intra-abdominal source of infection; the fluid contains an organism that has migrated from somewhere else.\\n- Nosocomial secondary peritonitis (acquired in an already hospitalized patient); the best example being postoperative peritonitis.\\n- Tertiary peritonitis which is commonly associated with a peculiar microbiology.\\n- Peritonitis in the immunocompromised patient (AIDS, on chemotherapy).\\n- Patients who are already on antibiotics, for whatever reason.\\n- Patients with a history of methicillin-resistant Staphylococcus aureus (MRSA).\\n\\n> “Shakiness of the hand may be some bar to the successful performance of an operation, but he of a shaky mind is hopeless.”\\n> — Sir William MacEwen\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted while excluding any diagonal text, headers, and footers.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 523, 'y': 641, 'w': 9.21, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 521, 'y': 492, 'w': 16.01, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is a typical example of community-acquired secondary peritonitis. The microbiology of this type of intra-abdominal infection (IAI) is predictable and responds readily to an empiric broad-spectrum antibiotic regimen, initiated pre-operatively, that includes anti-anaerobic cover. In most cases, culture results would become available only well after completion of the antibiotic course.\\n\\nHowever, peritoneal cultures are useful in the following scenarios:\\n\\n- Primary peritonitis where there is no intra-abdominal source of infection; the fluid contains an organism that has migrated from somewhere else.\\n- Nosocomial secondary peritonitis (acquired in an already hospitalized patient); the best example being postoperative peritonitis.\\n- Tertiary peritonitis which is commonly associated with a peculiar microbiology.\\n- Peritonitis in the immunocompromised patient (AIDS, on chemotherapy).\\n- Patients who are already on antibiotics, for whatever reason.\\n- Patients with a history of methicillin-resistant Staphylococcus aureus (MRSA).\\n\\n> “Shakiness of the hand may be some bar to the successful performance of an operation, but he of a shaky mind is hopeless.”\\n> — Sir William MacEwen\\n```',\n", " 'md': 'This is a typical example of community-acquired secondary peritonitis. The microbiology of this type of intra-abdominal infection (IAI) is predictable and responds readily to an empiric broad-spectrum antibiotic regimen, initiated pre-operatively, that includes anti-anaerobic cover. In most cases, culture results would become available only well after completion of the antibiotic course.\\n\\nHowever, peritoneal cultures are useful in the following scenarios:\\n\\n- Primary peritonitis where there is no intra-abdominal source of infection; the fluid contains an organism that has migrated from somewhere else.\\n- Nosocomial secondary peritonitis (acquired in an already hospitalized patient); the best example being postoperative peritonitis.\\n- Tertiary peritonitis which is commonly associated with a peculiar microbiology.\\n- Peritonitis in the immunocompromised patient (AIDS, on chemotherapy).\\n- Patients who are already on antibiotics, for whatever reason.\\n- Patients with a history of methicillin-resistant Staphylococcus aureus (MRSA).\\n\\n> “Shakiness of the hand may be some bar to the successful performance of an operation, but he of a shaky mind is hopeless.”\\n> — Sir William MacEwen\\n```',\n", " 'bBox': {'x': 72, 'y': 246, 'w': 467.54, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted while excluding any diagonal text, headers, and footers.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted while excluding any diagonal text, headers, and footers.',\n", " 'bBox': {'x': 311, 'y': 492, 'w': 226.01, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 176,\n", " 'text': '1 If you want to read much more about this topic, then find a copy of Source Control. Schein\\n M, Marshall J, Eds. Berlin, Heidelberg, New York: Springer, 2002.',\n", " 'md': '```markdown\\nIf you want to read much more about this topic, then find a copy of [Source Control](https://link.springer.com/book/10.1007/978-3-540-45529-0). Schein M, Marshall J, Eds. Berlin, Heidelberg, New York: Springer, 2002.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nIf you want to read much more about this topic, then find a copy of [Source Control](https://link.springer.com/book/10.1007/978-3-540-45529-0). Schein M, Marshall J, Eds. Berlin, Heidelberg, New York: Springer, 2002.\\n```',\n", " 'md': '```markdown\\nIf you want to read much more about this topic, then find a copy of [Source Control](https://link.springer.com/book/10.1007/978-3-540-45529-0). Schein M, Marshall J, Eds. Berlin, Heidelberg, New York: Springer, 2002.\\n```',\n", " 'bBox': {'x': 73, 'y': 97, 'w': 311.29, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 177,\n", " 'text': 'Chapter 14\\nThe intestinal anastomosis 1 (and stomata)\\nMark Cheetham, Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny\\nRosin and Jonathan E. Efron\\n\\n This chapter has been subdivided into the following two\\n sections:\\n\\n 1. Intestinal anastomosis.\\n 2. Intestinal stomata.\\n\\n The intestinal anastomosis 1\\n1 Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny\\n Rosin, Jonathan E. Efron\\n\\n Best is the enemy of good: the first layer is the best — why\\n spoil it?\\n\\n The ideal anastomosis\\n\\n The ideal intestinal anastomosis is the one which does not leak.\\nLeaks, although relatively rare, are a dreaded and potentially deadly\\ndisaster ( Chapter 47). In addition, the anastomosis should not\\nobstruct but allow normal function of the gastrointestinal tract within a few',\n", " 'md': '```markdown\\n# Chapter 14: The Intestinal Anastomosis and Stomata\\n\\n## Authors\\nMark Cheetham, Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\nThis chapter has been subdivided into the following two sections:\\n\\n1. Intestinal anastomosis.\\n2. Intestinal stomata.\\n\\n### The Intestinal Anastomosis\\n1. Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, Jonathan E. Efron\\n\\n> \"Best is the enemy of good: the first layer is the best — why spoil it?\"\\n\\n#### The Ideal Anastomosis\\nThe ideal intestinal anastomosis is the one which does not leak. Leaks, although relatively rare, are a dreaded and potentially deadly disaster (see Chapter 47). In addition, the anastomosis should not obstruct but allow normal function of the gastrointestinal tract within a few days post-operation.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 14: The Intestinal Anastomosis and Stomata',\n", " 'md': '# Chapter 14: The Intestinal Anastomosis and Stomata',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 148.79, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Authors',\n", " 'md': '## Authors',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Mark Cheetham, Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\nThis chapter has been subdivided into the following two sections:\\n\\n1. Intestinal anastomosis.\\n2. Intestinal stomata.',\n", " 'md': 'Mark Cheetham, Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, and Jonathan E. Efron\\n\\nThis chapter has been subdivided into the following two sections:\\n\\n1. Intestinal anastomosis.\\n2. Intestinal stomata.',\n", " 'bBox': {'x': 72, 'y': 241, 'w': 460.56, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Intestinal Anastomosis',\n", " 'md': '### The Intestinal Anastomosis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, Jonathan E. Efron\\n\\n> \"Best is the enemy of good: the first layer is the best — why spoil it?\"',\n", " 'md': '1. Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, Jonathan E. Efron\\n\\n> \"Best is the enemy of good: the first layer is the best — why spoil it?\"',\n", " 'bBox': {'x': 73, 'y': 517, 'w': 381.38, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'The Ideal Anastomosis',\n", " 'md': '#### The Ideal Anastomosis',\n", " 'bBox': {'x': 86, 'y': 629, 'w': 177.48, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The ideal intestinal anastomosis is the one which does not leak. Leaks, although relatively rare, are a dreaded and potentially deadly disaster (see Chapter 47). In addition, the anastomosis should not obstruct but allow normal function of the gastrointestinal tract within a few days post-operation.\\n```',\n", " 'md': 'The ideal intestinal anastomosis is the one which does not leak. Leaks, although relatively rare, are a dreaded and potentially deadly disaster (see Chapter 47). In addition, the anastomosis should not obstruct but allow normal function of the gastrointestinal tract within a few days post-operation.\\n```',\n", " 'bBox': {'x': 72, 'y': 682, 'w': 467.93, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'The intestinal anastomosis 1'},\n", " {'text': 'The intestinal anastomosis '},\n", " {'text': 'obstruct but allow normal function of the gastrointestinal tract within a few'}]},\n", " {'page': 178,\n", " 'text': 'days of construction.\\n PeRxa4\\nFigure 14.1. “Give it to me, nurse… This will be a perfect anastomosis!”\\n\\n Any experienced surgeon thinks that his own anastomotic technique,\\nadopted from his mentors and with a touch of personal virtuosity, is the\\n‘best’. Many methods are practiced: end-to-end, end-to-side or side-to-\\nside; single- versus double-layered, interrupted versus continuous, using\\nabsorbable versus non-absorbable and braided versus monofilament\\nsuture materials. We even know some obsessive-compulsive surgeons\\n(do you know any?) who carefully construct a three-layered anastomosis\\nin an interrupted fashion. Now add staplers to the mix. So where do we\\nstand? What is preferable? ( Figure 14.1).\\n\\n Pros and cons\\n\\n Numerous experimental and clinical studies support the following:\\n\\n • Leakage: the incidence of anastomotic dehiscence is not influenced\\n by the method used, provided the anastomosis is technically\\n sound; constructed with well-perfused bowel without tension,\\n and rendered water and airtight.\\n Stricture: the single-layer anastomosis is associated with a lower',\n", " 'md': '```markdown\\n## Page Content\\n\\nFigure 14.1. “Give it to me, nurse… This will be a perfect anastomosis!”\\n\\nAny experienced surgeon thinks that his own anastomotic technique, adopted from his mentors and with a touch of personal virtuosity, is the ‘best’. Many methods are practiced: end-to-end, end-to-side or side-to-side; single- versus double-layered, interrupted versus continuous, using absorbable versus non-absorbable and braided versus monofilament suture materials. We even know some obsessive-compulsive surgeons (do you know any?) who carefully construct a three-layered anastomosis in an interrupted fashion. Now add staplers to the mix. So where do we stand? What is preferable? (Figure 14.1).\\n\\n### Pros and cons\\n\\nNumerous experimental and clinical studies support the following:\\n\\n- **Leakage**: The incidence of anastomotic dehiscence is not influenced by the method used, provided the anastomosis is technically sound; constructed with well-perfused bowel without tension, and rendered water and airtight.\\n- **Stricture**: The single-layer anastomosis is associated with a lower...\\n\\n### Image Description\\n\\n**Figure 14.1**: This image likely depicts a surgical scenario involving an anastomosis, possibly illustrating the technique or tools used. The caption suggests a humorous or light-hearted interaction in a surgical context. The image may include surgical instruments or a representation of the anastomosis process.\\n\\n**Summary**: The figure emphasizes the subjective nature of surgical techniques and the various methods employed in anastomosis, highlighting the ongoing debate among surgeons regarding the best practices.\\n\\n```',\n", " 'images': [{'name': 'img_p177_1.png',\n", " 'height': 463,\n", " 'width': 482,\n", " 'x': 187.19999999999993,\n", " 'y': 99.36000000000001,\n", " 'original_width': 1324,\n", " 'original_height': 1272}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 14.1. “Give it to me, nurse… This will be a perfect anastomosis!”\\n\\nAny experienced surgeon thinks that his own anastomotic technique, adopted from his mentors and with a touch of personal virtuosity, is the ‘best’. Many methods are practiced: end-to-end, end-to-side or side-to-side; single- versus double-layered, interrupted versus continuous, using absorbable versus non-absorbable and braided versus monofilament suture materials. We even know some obsessive-compulsive surgeons (do you know any?) who carefully construct a three-layered anastomosis in an interrupted fashion. Now add staplers to the mix. So where do we stand? What is preferable? (Figure 14.1).',\n", " 'md': 'Figure 14.1. “Give it to me, nurse… This will be a perfect anastomosis!”\\n\\nAny experienced surgeon thinks that his own anastomotic technique, adopted from his mentors and with a touch of personal virtuosity, is the ‘best’. Many methods are practiced: end-to-end, end-to-side or side-to-side; single- versus double-layered, interrupted versus continuous, using absorbable versus non-absorbable and braided versus monofilament suture materials. We even know some obsessive-compulsive surgeons (do you know any?) who carefully construct a three-layered anastomosis in an interrupted fashion. Now add staplers to the mix. So where do we stand? What is preferable? (Figure 14.1).',\n", " 'bBox': {'x': 72, 'y': 348, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Pros and cons',\n", " 'md': '### Pros and cons',\n", " 'bBox': {'x': 86, 'y': 571, 'w': 114.03, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Numerous experimental and clinical studies support the following:\\n\\n- **Leakage**: The incidence of anastomotic dehiscence is not influenced by the method used, provided the anastomosis is technically sound; constructed with well-perfused bowel without tension, and rendered water and airtight.\\n- **Stricture**: The single-layer anastomosis is associated with a lower...',\n", " 'md': 'Numerous experimental and clinical studies support the following:\\n\\n- **Leakage**: The incidence of anastomotic dehiscence is not influenced by the method used, provided the anastomosis is technically sound; constructed with well-perfused bowel without tension, and rendered water and airtight.\\n- **Stricture**: The single-layer anastomosis is associated with a lower...',\n", " 'bBox': {'x': 86, 'y': 607, 'w': 417.4, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 14.1**: This image likely depicts a surgical scenario involving an anastomosis, possibly illustrating the technique or tools used. The caption suggests a humorous or light-hearted interaction in a surgical context. The image may include surgical instruments or a representation of the anastomosis process.\\n\\n**Summary**: The figure emphasizes the subjective nature of surgical techniques and the various methods employed in anastomosis, highlighting the ongoing debate among surgeons regarding the best practices.\\n\\n```',\n", " 'md': '**Figure 14.1**: This image likely depicts a surgical scenario involving an anastomosis, possibly illustrating the technique or tools used. The caption suggests a humorous or light-hearted interaction in a surgical context. The image may include surgical instruments or a representation of the anastomosis process.\\n\\n**Summary**: The figure emphasizes the subjective nature of surgical techniques and the various methods employed in anastomosis, highlighting the ongoing debate among surgeons regarding the best practices.\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 179,\n", " 'text': ' • risk of stricture formation than the multi-layered one. Strictures are\\n also commoner following the end-to-end anastomosis performed\\n with the circular stapler (especially when the smaller sizes are\\n used).\\n • Misadventure: intra-operative technical failures with staplers are\\n more frequent due to ‘misfires’. And you know the rule: “tools in the\\n hands of fools are prone to disasters.”\\n • Speed: stapled anastomoses, on average, are slightly faster than\\n those sutured by hand. The fewer the layers, the faster the\\n anastomosis and the continuous method is swifter than the\\n interrupted one. In practice, the time consumed in placing two hand-\\n fashioned purse-string sutures for a stapled circular anastomosis is\\n identical to that required to complete a hand-sutured, single-layered,\\n continuous anastomosis.\\n • Suture material: braided sutures (e.g. silk or Vicryl®) ‘saw’ through\\n tissues and, experimentally at least, are associated with greater\\n inflammation and activation of collagenases than monofilament\\n material (e.g. PDS®, Monocryl®, Maxon™ or even Prolene®).\\n Chromic catgut is too rapidly absorbed to support (alone) an\\n anastomosis. Monofilament slides better through the tissues and,\\n when used in a continuous fashion, is self-adjustable allowing equal\\n distribution of the tension around the entire circumference of the\\n anastomosis.\\n • Cost: staplers are much more expensive than sutures and, thus,\\n generally not cost-effective. The single-layer continuous technique\\n requires less suture material, and is therefore more economical than\\n the interrupted method.\\n\\n The choice of anastomotic technique: international\\n perspective\\n\\n To gauge the current ‘anastomotic philosophy’ around the world we\\nconducted an informal poll among members of the international online\\nsurgical forum — SURGINET. And here is a summary of the prevailing\\ntrends:',\n", " 'md': \"```markdown\\n## Current Page Content\\n\\n- **Risk of Stricture Formation**: There is a higher risk of stricture formation with the single-layered anastomosis compared to the multi-layered one. Strictures are also more common following end-to-end anastomosis performed with a circular stapler, especially when smaller sizes are used.\\n\\n- **Misadventure**: Intra-operative technical failures with staplers are more frequent due to 'misfires'. The saying goes: “tools in the hands of fools are prone to disasters.”\\n\\n- **Speed**: Stapled anastomoses are, on average, slightly faster than those sutured by hand. The fewer the layers, the faster the anastomosis; the continuous method is swifter than the interrupted one. In practice, the time consumed in placing two hand-fashioned purse-string sutures for a stapled circular anastomosis is identical to that required to complete a hand-sutured, single-layered, continuous anastomosis.\\n\\n- **Suture Material**: Braided sutures (e.g., silk or Vicryl®) can 'saw' through tissues and are associated with greater inflammation and activation of collagenases than monofilament materials (e.g., PDS®, Monocryl®, Maxon™, or even Prolene®). Chromic catgut is absorbed too rapidly to support an anastomosis alone. Monofilament sutures slide better through tissues and, when used continuously, are self-adjustable, allowing equal distribution of tension around the entire circumference of the anastomosis.\\n\\n- **Cost**: Staplers are significantly more expensive than sutures and are generally not cost-effective. The single-layer continuous technique requires less suture material, making it more economical than the interrupted method.\\n\\n### The Choice of Anastomotic Technique: International Perspective\\n\\nTo gauge the current 'anastomotic philosophy' around the world, we conducted an informal poll among members of the international online surgical forum — SURGINET. Here is a summary of the prevailing trends:\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- **Risk of Stricture Formation**: There is a higher risk of stricture formation with the single-layered anastomosis compared to the multi-layered one. Strictures are also more common following end-to-end anastomosis performed with a circular stapler, especially when smaller sizes are used.\\n\\n- **Misadventure**: Intra-operative technical failures with staplers are more frequent due to 'misfires'. The saying goes: “tools in the hands of fools are prone to disasters.”\\n\\n- **Speed**: Stapled anastomoses are, on average, slightly faster than those sutured by hand. The fewer the layers, the faster the anastomosis; the continuous method is swifter than the interrupted one. In practice, the time consumed in placing two hand-fashioned purse-string sutures for a stapled circular anastomosis is identical to that required to complete a hand-sutured, single-layered, continuous anastomosis.\\n\\n- **Suture Material**: Braided sutures (e.g., silk or Vicryl®) can 'saw' through tissues and are associated with greater inflammation and activation of collagenases than monofilament materials (e.g., PDS®, Monocryl®, Maxon™, or even Prolene®). Chromic catgut is absorbed too rapidly to support an anastomosis alone. Monofilament sutures slide better through tissues and, when used continuously, are self-adjustable, allowing equal distribution of tension around the entire circumference of the anastomosis.\\n\\n- **Cost**: Staplers are significantly more expensive than sutures and are generally not cost-effective. The single-layer continuous technique requires less suture material, making it more economical than the interrupted method.\",\n", " 'md': \"- **Risk of Stricture Formation**: There is a higher risk of stricture formation with the single-layered anastomosis compared to the multi-layered one. Strictures are also more common following end-to-end anastomosis performed with a circular stapler, especially when smaller sizes are used.\\n\\n- **Misadventure**: Intra-operative technical failures with staplers are more frequent due to 'misfires'. The saying goes: “tools in the hands of fools are prone to disasters.”\\n\\n- **Speed**: Stapled anastomoses are, on average, slightly faster than those sutured by hand. The fewer the layers, the faster the anastomosis; the continuous method is swifter than the interrupted one. In practice, the time consumed in placing two hand-fashioned purse-string sutures for a stapled circular anastomosis is identical to that required to complete a hand-sutured, single-layered, continuous anastomosis.\\n\\n- **Suture Material**: Braided sutures (e.g., silk or Vicryl®) can 'saw' through tissues and are associated with greater inflammation and activation of collagenases than monofilament materials (e.g., PDS®, Monocryl®, Maxon™, or even Prolene®). Chromic catgut is absorbed too rapidly to support an anastomosis alone. Monofilament sutures slide better through tissues and, when used continuously, are self-adjustable, allowing equal distribution of tension around the entire circumference of the anastomosis.\\n\\n- **Cost**: Staplers are significantly more expensive than sutures and are generally not cost-effective. The single-layer continuous technique requires less suture material, making it more economical than the interrupted method.\",\n", " 'bBox': {'x': 86, 'y': 188, 'w': 451.05, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Choice of Anastomotic Technique: International Perspective',\n", " 'md': '### The Choice of Anastomotic Technique: International Perspective',\n", " 'bBox': {'x': 86, 'y': 577, 'w': 99.32, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': \"To gauge the current 'anastomotic philosophy' around the world, we conducted an informal poll among members of the international online surgical forum — SURGINET. Here is a summary of the prevailing trends:\\n```\",\n", " 'md': \"To gauge the current 'anastomotic philosophy' around the world, we conducted an informal poll among members of the international online surgical forum — SURGINET. Here is a summary of the prevailing trends:\\n```\",\n", " 'bBox': {'x': 72, 'y': 577, 'w': 113.32, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 180,\n", " 'text': ' • Staplers vs. hands. A minority of surgeons are addicted to ‘stapler-\\n only’ or ‘hand-only’ technique. Most use both techniques on a\\n selective basis. The emphasis is to avoid staplers on ‘non-\\n healthy bowel’ — e.g. edematous, irradiated — or in what they\\n would consider ‘difficult circumstances’.\\n • Location. Most would use staplers for esophageal anastomoses\\n and for anastomosis of the rectum. Fashioning a new gastric lesser\\n curvature and closure of the duodenal stump during gastrectomy\\n are other popular indications for staplers. In all other sites, hand-\\n suturing is more popular.\\n • Suture material. Absorbable material is used by the vast majority.\\n The braided Vicryl® is popular but those who prefer the continuous-\\n running technique (see below) opt for monofilaments such as PDS®,\\n Maxon™ or Monocryl®.\\n • Single vs. two-layered anastomosis/interrupted vs. continuous.\\n Interestingly, European surgeons tend to practice a continuous\\n single-layer anastomosis using a monofilament. Single-layer\\n interrupted is practiced by many, especially in ‘difficult\\n circumstances’ or for the sigmoid and rectum. Old school teaching\\n prevails still in some places where two-layered anastomoses are\\n preferred — both continuous, but more commonly the inner layer\\n continuous (absorbable) and the outer interrupted (absorbable or\\n not).\\n\\n Our recommendations\\n\\n ‘Our’ in this case means (with the permission of the other Editors) what\\nMoshe thinks — we cannot write four different chapters based on each of\\nour dogmas, can we? (Danny, for example, prefers staplers from the\\nmouth to the anus, while Ari always uses continuous absorbable in two\\nlayers…).\\n\\n Well, using the WTLS (what the literature says) test, since all\\nmethods, if correctly performed, are safe, nobody can fault you for using\\nthe anastomotic method with which you are most familiar and\\ncomfortable. ħowever, applying the IIWM (if it were me) concept this is\\nour (MS) bias:',\n", " 'md': '```markdown\\n## Current Page Content\\n\\n- **Staplers vs. hands**: A minority of surgeons are addicted to ‘stapler-only’ or ‘hand-only’ technique. Most use both techniques on a selective basis. The emphasis is to avoid staplers on ‘non-healthy bowel’ — e.g. edematous, irradiated — or in what they would consider ‘difficult circumstances’.\\n\\n- **Location**: Most would use staplers for esophageal anastomoses and for anastomosis of the rectum. Fashioning a new gastric lesser curvature and closure of the duodenal stump during gastrectomy are other popular indications for staplers. In all other sites, hand-suturing is more popular.\\n\\n- **Suture material**: Absorbable material is used by the vast majority. The braided Vicryl® is popular but those who prefer the continuous-running technique (see below) opt for monofilaments such as PDS®, Maxon™ or Monocryl®.\\n\\n- **Single vs. two-layered anastomosis/interrupted vs. continuous**: Interestingly, European surgeons tend to practice a continuous single-layer anastomosis using a monofilament. Single-layer interrupted is practiced by many, especially in ‘difficult circumstances’ or for the sigmoid and rectum. Old school teaching prevails still in some places where two-layered anastomoses are preferred — both continuous, but more commonly the inner layer continuous (absorbable) and the outer interrupted (absorbable or not).\\n\\n### Our Recommendations\\n\\n‘Our’ in this case means (with the permission of the other Editors) what Moshe thinks — we cannot write four different chapters based on each of our dogmas, can we? (Danny, for example, prefers staplers from the mouth to the anus, while Ari always uses continuous absorbable in two layers…).\\n\\nWell, using the WTLS (what the literature says) test, since all methods, if correctly performed, are safe, nobody can fault you for using the anastomotic method with which you are most familiar and comfortable. However, applying the IIWM (if it were me) concept this is our (MS) bias:\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- All text has been extracted as per the guidelines.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Staplers vs. hands**: A minority of surgeons are addicted to ‘stapler-only’ or ‘hand-only’ technique. Most use both techniques on a selective basis. The emphasis is to avoid staplers on ‘non-healthy bowel’ — e.g. edematous, irradiated — or in what they would consider ‘difficult circumstances’.\\n\\n- **Location**: Most would use staplers for esophageal anastomoses and for anastomosis of the rectum. Fashioning a new gastric lesser curvature and closure of the duodenal stump during gastrectomy are other popular indications for staplers. In all other sites, hand-suturing is more popular.\\n\\n- **Suture material**: Absorbable material is used by the vast majority. The braided Vicryl® is popular but those who prefer the continuous-running technique (see below) opt for monofilaments such as PDS®, Maxon™ or Monocryl®.\\n\\n- **Single vs. two-layered anastomosis/interrupted vs. continuous**: Interestingly, European surgeons tend to practice a continuous single-layer anastomosis using a monofilament. Single-layer interrupted is practiced by many, especially in ‘difficult circumstances’ or for the sigmoid and rectum. Old school teaching prevails still in some places where two-layered anastomoses are preferred — both continuous, but more commonly the inner layer continuous (absorbable) and the outer interrupted (absorbable or not).',\n", " 'md': '- **Staplers vs. hands**: A minority of surgeons are addicted to ‘stapler-only’ or ‘hand-only’ technique. Most use both techniques on a selective basis. The emphasis is to avoid staplers on ‘non-healthy bowel’ — e.g. edematous, irradiated — or in what they would consider ‘difficult circumstances’.\\n\\n- **Location**: Most would use staplers for esophageal anastomoses and for anastomosis of the rectum. Fashioning a new gastric lesser curvature and closure of the duodenal stump during gastrectomy are other popular indications for staplers. In all other sites, hand-suturing is more popular.\\n\\n- **Suture material**: Absorbable material is used by the vast majority. The braided Vicryl® is popular but those who prefer the continuous-running technique (see below) opt for monofilaments such as PDS®, Maxon™ or Monocryl®.\\n\\n- **Single vs. two-layered anastomosis/interrupted vs. continuous**: Interestingly, European surgeons tend to practice a continuous single-layer anastomosis using a monofilament. Single-layer interrupted is practiced by many, especially in ‘difficult circumstances’ or for the sigmoid and rectum. Old school teaching prevails still in some places where two-layered anastomoses are preferred — both continuous, but more commonly the inner layer continuous (absorbable) and the outer interrupted (absorbable or not).',\n", " 'bBox': {'x': 100, 'y': 136, 'w': 437.37, 'h': 17.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Our Recommendations',\n", " 'md': '### Our Recommendations',\n", " 'bBox': {'x': 86, 'y': 510, 'w': 176.56, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '‘Our’ in this case means (with the permission of the other Editors) what Moshe thinks — we cannot write four different chapters based on each of our dogmas, can we? (Danny, for example, prefers staplers from the mouth to the anus, while Ari always uses continuous absorbable in two layers…).\\n\\nWell, using the WTLS (what the literature says) test, since all methods, if correctly performed, are safe, nobody can fault you for using the anastomotic method with which you are most familiar and comfortable. However, applying the IIWM (if it were me) concept this is our (MS) bias:\\n```',\n", " 'md': '‘Our’ in this case means (with the permission of the other Editors) what Moshe thinks — we cannot write four different chapters based on each of our dogmas, can we? (Danny, for example, prefers staplers from the mouth to the anus, while Ari always uses continuous absorbable in two layers…).\\n\\nWell, using the WTLS (what the literature says) test, since all methods, if correctly performed, are safe, nobody can fault you for using the anastomotic method with which you are most familiar and comfortable. However, applying the IIWM (if it were me) concept this is our (MS) bias:\\n```',\n", " 'bBox': {'x': 72, 'y': 366, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- All text has been extracted as per the guidelines.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- All text has been extracted as per the guidelines.',\n", " 'bBox': {'x': 187, 'y': 383, 'w': 14.4, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 181,\n", " 'text': ' We maintain that the one-layer, continuous method, using a\\nmonofilament suture material, is the one that a ‘modern surgeon’ should\\nadopt, because it is fast, cheap and safe. What is good for the high-\\npressure vascular anastomosis should be just as good for the low-\\npressure intestinal one. If the first layer suffices why narrow and injure it\\nwith inverted and strangulated tissue? Would you put a well-done\\nhamburger back on the grill? As with any beautiful piece of art, less is\\nmore.\\n\\n We acknowledge that staplers are elegant, admired by the operating\\nroom staff, ‘fun’ to use and of great financial benefit to the manufacturers.\\nCertainly, staples may be advantageous in selected areas, deep in the\\npelvis or high under the diaphragm, for rectal or esophageal\\nanastomoses, respectively. But those types of anastomoses are\\nseldom performed in emergency situations. Furthermore, as a\\nsurgical trainee you should start using staplers only after achieving\\nmaximal proficiency in manual techniques, and in difficult\\ncircumstances. Even the stapler aficionado has to use his hands when\\nthe instrument misfires, or cannot be used because of specific anatomic\\nconstraints such as the retroperitoneal duodenum.\\n\\n There are stapler tricks even for that… just use the EEA™ stapler, place the anvil in the\\n duodenum using a purse-string, and construct an end-to-side anastomosis to the small bowel.\\n Not that different from an esophagojejunostomy. Danny\\n\\n The modern surgeon, and the trainee too, need to be equally proficient\\nin both hand-sewn and stapled anastomotic techniques; we suggest,\\nhowever, that before driving a truck you should be able to manage a car.\\n\\n The edematous bowel\\n\\n There is some evidence (not level I) that, in trauma patients, stapled\\nintestinal anastomoses are more prone to leak than hand-sewn\\nones. This has been attributed to the post-resuscitation bowel edema\\nwhich develops after severe injury (the staplers cannot ‘adjust’ to the\\nswelling of the bowel — the surgeon’s hands can). It is also our',\n", " 'md': '```markdown\\nWe maintain that the one-layer, continuous method, using a monofilament suture material, is the one that a ‘modern surgeon’ should adopt, because it is fast, cheap and safe. What is good for the high-pressure vascular anastomosis should be just as good for the low-pressure intestinal one. If the first layer suffices why narrow and injure it with inverted and strangulated tissue? Would you put a well-done hamburger back on the grill? As with any beautiful piece of art, less is more.\\n\\nWe acknowledge that staplers are elegant, admired by the operating room staff, ‘fun’ to use and of great financial benefit to the manufacturers. Certainly, staples may be advantageous in selected areas, deep in the pelvis or high under the diaphragm, for rectal or esophageal anastomoses, respectively. But those types of anastomoses are seldom performed in emergency situations. Furthermore, as a surgical trainee you should start using staplers only after achieving maximal proficiency in manual techniques, and in difficult circumstances. Even the stapler aficionado has to use his hands when the instrument misfires, or cannot be used because of specific anatomic constraints such as the retroperitoneal duodenum.\\n\\nThere are stapler tricks even for that… just use the EEA™ stapler, place the anvil in the duodenum using a purse-string, and construct an end-to-side anastomosis to the small bowel. Not that different from an esophagojejunostomy. Danny\\n\\nThe modern surgeon, and the trainee too, need to be equally proficient in both hand-sewn and stapled anastomotic techniques; we suggest, however, that before driving a truck you should be able to manage a car.\\n\\n### The edematous bowel\\n\\nThere is some evidence (not level I) that, in trauma patients, stapled intestinal anastomoses are more prone to leak than hand-sewn ones. This has been attributed to the post-resuscitation bowel edema which develops after severe injury (the staplers cannot ‘adjust’ to the swelling of the bowel — the surgeon’s hands can). It is also our\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nWe maintain that the one-layer, continuous method, using a monofilament suture material, is the one that a ‘modern surgeon’ should adopt, because it is fast, cheap and safe. What is good for the high-pressure vascular anastomosis should be just as good for the low-pressure intestinal one. If the first layer suffices why narrow and injure it with inverted and strangulated tissue? Would you put a well-done hamburger back on the grill? As with any beautiful piece of art, less is more.\\n\\nWe acknowledge that staplers are elegant, admired by the operating room staff, ‘fun’ to use and of great financial benefit to the manufacturers. Certainly, staples may be advantageous in selected areas, deep in the pelvis or high under the diaphragm, for rectal or esophageal anastomoses, respectively. But those types of anastomoses are seldom performed in emergency situations. Furthermore, as a surgical trainee you should start using staplers only after achieving maximal proficiency in manual techniques, and in difficult circumstances. Even the stapler aficionado has to use his hands when the instrument misfires, or cannot be used because of specific anatomic constraints such as the retroperitoneal duodenum.\\n\\nThere are stapler tricks even for that… just use the EEA™ stapler, place the anvil in the duodenum using a purse-string, and construct an end-to-side anastomosis to the small bowel. Not that different from an esophagojejunostomy. Danny\\n\\nThe modern surgeon, and the trainee too, need to be equally proficient in both hand-sewn and stapled anastomotic techniques; we suggest, however, that before driving a truck you should be able to manage a car.',\n", " 'md': '```markdown\\nWe maintain that the one-layer, continuous method, using a monofilament suture material, is the one that a ‘modern surgeon’ should adopt, because it is fast, cheap and safe. What is good for the high-pressure vascular anastomosis should be just as good for the low-pressure intestinal one. If the first layer suffices why narrow and injure it with inverted and strangulated tissue? Would you put a well-done hamburger back on the grill? As with any beautiful piece of art, less is more.\\n\\nWe acknowledge that staplers are elegant, admired by the operating room staff, ‘fun’ to use and of great financial benefit to the manufacturers. Certainly, staples may be advantageous in selected areas, deep in the pelvis or high under the diaphragm, for rectal or esophageal anastomoses, respectively. But those types of anastomoses are seldom performed in emergency situations. Furthermore, as a surgical trainee you should start using staplers only after achieving maximal proficiency in manual techniques, and in difficult circumstances. Even the stapler aficionado has to use his hands when the instrument misfires, or cannot be used because of specific anatomic constraints such as the retroperitoneal duodenum.\\n\\nThere are stapler tricks even for that… just use the EEA™ stapler, place the anvil in the duodenum using a purse-string, and construct an end-to-side anastomosis to the small bowel. Not that different from an esophagojejunostomy. Danny\\n\\nThe modern surgeon, and the trainee too, need to be equally proficient in both hand-sewn and stapled anastomotic techniques; we suggest, however, that before driving a truck you should be able to manage a car.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.82, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The edematous bowel',\n", " 'md': '### The edematous bowel',\n", " 'bBox': {'x': 86, 'y': 601, 'w': 172.89, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'There is some evidence (not level I) that, in trauma patients, stapled intestinal anastomoses are more prone to leak than hand-sewn ones. This has been attributed to the post-resuscitation bowel edema which develops after severe injury (the staplers cannot ‘adjust’ to the swelling of the bowel — the surgeon’s hands can). It is also our\\n```',\n", " 'md': 'There is some evidence (not level I) that, in trauma patients, stapled intestinal anastomoses are more prone to leak than hand-sewn ones. This has been attributed to the post-resuscitation bowel edema which develops after severe injury (the staplers cannot ‘adjust’ to the swelling of the bowel — the surgeon’s hands can). It is also our\\n```',\n", " 'bBox': {'x': 86, 'y': 353, 'w': 452.92, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 182,\n", " 'text': 'impression that a continuous, monolayer anastomosis occasionally fails\\nwhen performed in edematous bowel (e.g. after massive fluid\\nresuscitation or severe peritonitis). From findings at reoperation we have\\nlearned that subsequently, as the bowel edema subsides, the suture\\nbecomes loose, leading to anastomotic dehiscence. The same\\narguments may apply when resection for obstruction has been\\nperformed; the proximal dilated, thickened bowel does not conform to the\\nstaples in the same way that the distal gut does.\\n\\n Therefore, when anastomosing swollen, edematous bowel we\\n prefer not to use staplers or the continuous hand-sutured\\n method. Instead, we use a closely placed single layer of\\n interrupted sutures — individually tied “not too tight, not too\\n loose” — in order to avoid cutting through the bowel edges, but\\n also to obviate the risk of loosening after the edema subsides.\\n\\n A similar interrupted technique may be preferred in colo-colo\\nanastomoses where the avoidance of the hemostatic effects of\\ncontinuous sutures may have theoretical advantages. Furthermore, in\\nthis situation, the ability of the colon to change dramatically in diameter\\nunder normal physiological conditions may be impaired if a continuous\\nsuture with its fixed length is utilized. We admit, however, that scientific\\ndata to back these hypotheses are lacking.\\n\\n And remember: when the bowel edges are not ‘perfect’ take deeper bites!\\n Incorporate more tissue into the anastomosis! Yes — up to a cm! When assisting\\n a younger surgeon we constantly hear ourselves pleading: take a\\n larger bite!\\n\\n How we do it\\n\\n Our preferred continuous, monolayered anastomosis uses one\\ndouble-armed, or two regular, 3-0 or 4-0 monofilament sutures (PDS® or',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nThe impression that a continuous, monolayer anastomosis occasionally fails when performed in edematous bowel (e.g. after massive fluid resuscitation or severe peritonitis). From findings at reoperation we have learned that subsequently, as the bowel edema subsides, the suture becomes loose, leading to anastomotic dehiscence. The same arguments may apply when resection for obstruction has been performed; the proximal dilated, thickened bowel does not conform to the staples in the same way that the distal gut does.\\n\\nTherefore, when anastomosing swollen, edematous bowel we prefer not to use staplers or the continuous hand-sutured method. Instead, we use a closely placed single layer of interrupted sutures — individually tied “not too tight, not too loose” — in order to avoid cutting through the bowel edges, but also to obviate the risk of loosening after the edema subsides.\\n\\nA similar interrupted technique may be preferred in colo-colo anastomoses where the avoidance of the hemostatic effects of continuous sutures may have theoretical advantages. Furthermore, in this situation, the ability of the colon to change dramatically in diameter under normal physiological conditions may be impaired if a continuous suture with its fixed length is utilized. We admit, however, that scientific data to back these hypotheses are lacking.\\n\\nAnd remember: when the bowel edges are not ‘perfect’ take deeper bites! Incorporate more tissue into the anastomosis! Yes — up to a cm! When assisting a younger surgeon we constantly hear ourselves pleading: take a larger bite!\\n\\nHow we do it\\n\\nOur preferred continuous, monolayered anastomosis uses one double-armed, or two regular, 3-0 or 4-0 monofilament sutures (PDS® or ...\\n\\n## Image Identification and Description\\n\\n*No images or figures were identified on this page.*\\n\\n## Formulas\\n\\n*No formulas were identified on this page.*\\n\\n## Tables\\n\\n*No tables were identified on this page.*\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 281, 'y': 287, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 281, 'y': 287, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The impression that a continuous, monolayer anastomosis occasionally fails when performed in edematous bowel (e.g. after massive fluid resuscitation or severe peritonitis). From findings at reoperation we have learned that subsequently, as the bowel edema subsides, the suture becomes loose, leading to anastomotic dehiscence. The same arguments may apply when resection for obstruction has been performed; the proximal dilated, thickened bowel does not conform to the staples in the same way that the distal gut does.\\n\\nTherefore, when anastomosing swollen, edematous bowel we prefer not to use staplers or the continuous hand-sutured method. Instead, we use a closely placed single layer of interrupted sutures — individually tied “not too tight, not too loose” — in order to avoid cutting through the bowel edges, but also to obviate the risk of loosening after the edema subsides.\\n\\nA similar interrupted technique may be preferred in colo-colo anastomoses where the avoidance of the hemostatic effects of continuous sutures may have theoretical advantages. Furthermore, in this situation, the ability of the colon to change dramatically in diameter under normal physiological conditions may be impaired if a continuous suture with its fixed length is utilized. We admit, however, that scientific data to back these hypotheses are lacking.\\n\\nAnd remember: when the bowel edges are not ‘perfect’ take deeper bites! Incorporate more tissue into the anastomosis! Yes — up to a cm! When assisting a younger surgeon we constantly hear ourselves pleading: take a larger bite!\\n\\nHow we do it\\n\\nOur preferred continuous, monolayered anastomosis uses one double-armed, or two regular, 3-0 or 4-0 monofilament sutures (PDS® or ...',\n", " 'md': 'The impression that a continuous, monolayer anastomosis occasionally fails when performed in edematous bowel (e.g. after massive fluid resuscitation or severe peritonitis). From findings at reoperation we have learned that subsequently, as the bowel edema subsides, the suture becomes loose, leading to anastomotic dehiscence. The same arguments may apply when resection for obstruction has been performed; the proximal dilated, thickened bowel does not conform to the staples in the same way that the distal gut does.\\n\\nTherefore, when anastomosing swollen, edematous bowel we prefer not to use staplers or the continuous hand-sutured method. Instead, we use a closely placed single layer of interrupted sutures — individually tied “not too tight, not too loose” — in order to avoid cutting through the bowel edges, but also to obviate the risk of loosening after the edema subsides.\\n\\nA similar interrupted technique may be preferred in colo-colo anastomoses where the avoidance of the hemostatic effects of continuous sutures may have theoretical advantages. Furthermore, in this situation, the ability of the colon to change dramatically in diameter under normal physiological conditions may be impaired if a continuous suture with its fixed length is utilized. We admit, however, that scientific data to back these hypotheses are lacking.\\n\\nAnd remember: when the bowel edges are not ‘perfect’ take deeper bites! Incorporate more tissue into the anastomosis! Yes — up to a cm! When assisting a younger surgeon we constantly hear ourselves pleading: take a larger bite!\\n\\nHow we do it\\n\\nOur preferred continuous, monolayered anastomosis uses one double-armed, or two regular, 3-0 or 4-0 monofilament sutures (PDS® or ...',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.74, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 281, 'y': 287, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*',\n", " 'md': '*No images or figures were identified on this page.*',\n", " 'bBox': {'x': 213, 'y': 268, 'w': 93.39, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formulas',\n", " 'md': '## Formulas',\n", " 'bBox': {'x': 281, 'y': 268, 'w': 25.39, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '*No formulas were identified on this page.*',\n", " 'md': '*No formulas were identified on this page.*',\n", " 'bBox': {'x': 213, 'y': 268, 'w': 93.39, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 281, 'y': 287, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '*No tables were identified on this page.*\\n```',\n", " 'md': '*No tables were identified on this page.*\\n```',\n", " 'bBox': {'x': 213, 'y': 287, 'w': 19.2, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 183,\n", " 'text': 'Maxon™). No bowel clamps are used, as we like to assess the adequacy\\nof blood supply to the bowel edges. It is not necessary to devascularize\\nthe bowel edges by ‘cleaning off’ the fat at the mesenteric side or\\nremoving appendices epiploicae. The suture line begins at the\\nposterior/mesenteric wall, running ‘over and over’ towards both sides to\\nmeet, and be tied, anteriorly (at the anti-mesenteric border). The secret is\\nto take generous bites through the submucosa, muscularis and serosa\\nand avoid the mucosa (“big bites outside, small bites inside”), thus\\ninverting it. This suturing technique is known variously as extra-mucosal\\nor sero-submucosal. The needle exit or entry site on the serosal side is 5-\\n7mm from the bowel edge (we repeat: even 1cm or more when the\\nbowel is thin or edematous — too big bites can’t harm but too small\\ncan leak), while the distance between the bites should be such as not to\\nallow access to the tips of a Debakey forceps (3-4mm). The assistant\\nwho ‘follows’ the suture should use just enough tension to maintain\\napproximation and avoid strangulation of the tissue (a reliable assistant\\nis crucial!) In addition to the end-to-end situation, this technique suits\\nalso both the end-to-side and side-to-side versions and in essence it is\\nthe intestinal version of a routine vascular anastomosis, except that the\\nvascular one is everted. Essentially, you create an inverted and safe\\nanastomosis, with a wide lumen, using only a suture or two, in less than\\n15 minutes.\\n\\n In ‘difficult’ situations, when the anastomotic site is relatively\\ninaccessible, or the bowel edematous, we prefer a one-layer\\ninterrupted technique, which allows more accurate placement of\\nsutures and the theoretical advantages mentioned above. For this\\npurpose we use Vicryl® sutures, 3-0 or 4-0, which are easier to tie than\\nmonofilament. Again, we start with the posterior wall and progress,\\nalternately, on each side to meet at the front. As with the continuous\\nmethod, we take big bites on the outside and tiny on the inside, inverting\\nthe mucosa. All sutures, except the last few at the front, are tied inside\\nthe lumen.\\n\\n Now raise your right hand and repeat: BIG BITES, BIG BITES, BIG BITES, BIG B…',\n", " 'md': '```markdown\\n## Surgical Technique for Bowel Anastomosis\\n\\nNo bowel clamps are used, as we like to assess the adequacy of blood supply to the bowel edges. It is not necessary to devascularize the bowel edges by ‘cleaning off’ the fat at the mesenteric side or removing appendices epiploicae. The suture line begins at the posterior/mesenteric wall, running ‘over and over’ towards both sides to meet, and be tied, anteriorly (at the anti-mesenteric border). The secret is to take generous bites through the submucosa, muscularis, and serosa and avoid the mucosa (“big bites outside, small bites inside”), thus inverting it. This suturing technique is known variously as extra-mucosal or sero-submucosal.\\n\\nThe needle exit or entry site on the serosal side is 5-7mm from the bowel edge (we repeat: even 1cm or more when the bowel is thin or edematous — too big bites can’t harm but too small can leak), while the distance between the bites should be such as not to allow access to the tips of a Debakey forceps (3-4mm). The assistant who ‘follows’ the suture should use just enough tension to maintain approximation and avoid strangulation of the tissue (a reliable assistant is crucial!).\\n\\nIn addition to the end-to-end situation, this technique suits also both the end-to-side and side-to-side versions and in essence, it is the intestinal version of a routine vascular anastomosis, except that the vascular one is everted. Essentially, you create an inverted and safe anastomosis, with a wide lumen, using only a suture or two, in less than 15 minutes.\\n\\nIn ‘difficult’ situations, when the anastomotic site is relatively inaccessible, or the bowel edematous, we prefer a one-layer interrupted technique, which allows more accurate placement of sutures and the theoretical advantages mentioned above. For this purpose, we use Vicryl® sutures, 3-0 or 4-0, which are easier to tie than monofilament. Again, we start with the posterior wall and progress, alternately, on each side to meet at the front. As with the continuous method, we take big bites on the outside and tiny on the inside, inverting the mucosa. All sutures, except the last few at the front, are tied inside the lumen.\\n\\nNow raise your right hand and repeat: BIG BITES, BIG BITES, BIG BITES, BIG B…\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Technique for Bowel Anastomosis',\n", " 'md': '## Surgical Technique for Bowel Anastomosis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'No bowel clamps are used, as we like to assess the adequacy of blood supply to the bowel edges. It is not necessary to devascularize the bowel edges by ‘cleaning off’ the fat at the mesenteric side or removing appendices epiploicae. The suture line begins at the posterior/mesenteric wall, running ‘over and over’ towards both sides to meet, and be tied, anteriorly (at the anti-mesenteric border). The secret is to take generous bites through the submucosa, muscularis, and serosa and avoid the mucosa (“big bites outside, small bites inside”), thus inverting it. This suturing technique is known variously as extra-mucosal or sero-submucosal.\\n\\nThe needle exit or entry site on the serosal side is 5-7mm from the bowel edge (we repeat: even 1cm or more when the bowel is thin or edematous — too big bites can’t harm but too small can leak), while the distance between the bites should be such as not to allow access to the tips of a Debakey forceps (3-4mm). The assistant who ‘follows’ the suture should use just enough tension to maintain approximation and avoid strangulation of the tissue (a reliable assistant is crucial!).\\n\\nIn addition to the end-to-end situation, this technique suits also both the end-to-side and side-to-side versions and in essence, it is the intestinal version of a routine vascular anastomosis, except that the vascular one is everted. Essentially, you create an inverted and safe anastomosis, with a wide lumen, using only a suture or two, in less than 15 minutes.\\n\\nIn ‘difficult’ situations, when the anastomotic site is relatively inaccessible, or the bowel edematous, we prefer a one-layer interrupted technique, which allows more accurate placement of sutures and the theoretical advantages mentioned above. For this purpose, we use Vicryl® sutures, 3-0 or 4-0, which are easier to tie than monofilament. Again, we start with the posterior wall and progress, alternately, on each side to meet at the front. As with the continuous method, we take big bites on the outside and tiny on the inside, inverting the mucosa. All sutures, except the last few at the front, are tied inside the lumen.\\n\\nNow raise your right hand and repeat: BIG BITES, BIG BITES, BIG BITES, BIG B…\\n```',\n", " 'md': 'No bowel clamps are used, as we like to assess the adequacy of blood supply to the bowel edges. It is not necessary to devascularize the bowel edges by ‘cleaning off’ the fat at the mesenteric side or removing appendices epiploicae. The suture line begins at the posterior/mesenteric wall, running ‘over and over’ towards both sides to meet, and be tied, anteriorly (at the anti-mesenteric border). The secret is to take generous bites through the submucosa, muscularis, and serosa and avoid the mucosa (“big bites outside, small bites inside”), thus inverting it. This suturing technique is known variously as extra-mucosal or sero-submucosal.\\n\\nThe needle exit or entry site on the serosal side is 5-7mm from the bowel edge (we repeat: even 1cm or more when the bowel is thin or edematous — too big bites can’t harm but too small can leak), while the distance between the bites should be such as not to allow access to the tips of a Debakey forceps (3-4mm). The assistant who ‘follows’ the suture should use just enough tension to maintain approximation and avoid strangulation of the tissue (a reliable assistant is crucial!).\\n\\nIn addition to the end-to-end situation, this technique suits also both the end-to-side and side-to-side versions and in essence, it is the intestinal version of a routine vascular anastomosis, except that the vascular one is everted. Essentially, you create an inverted and safe anastomosis, with a wide lumen, using only a suture or two, in less than 15 minutes.\\n\\nIn ‘difficult’ situations, when the anastomotic site is relatively inaccessible, or the bowel edematous, we prefer a one-layer interrupted technique, which allows more accurate placement of sutures and the theoretical advantages mentioned above. For this purpose, we use Vicryl® sutures, 3-0 or 4-0, which are easier to tie than monofilament. Again, we start with the posterior wall and progress, alternately, on each side to meet at the front. As with the continuous method, we take big bites on the outside and tiny on the inside, inverting the mucosa. All sutures, except the last few at the front, are tied inside the lumen.\\n\\nNow raise your right hand and repeat: BIG BITES, BIG BITES, BIG BITES, BIG B…\\n```',\n", " 'bBox': {'x': 72, 'y': 104, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 184,\n", " 'text': ' A few more words on staplers\\n\\n You will learn the correct use of staplers from your mentors. Despite\\nappearances, we are not rigidly ‘staplerophobic’. We use staplers\\ngenerously in emergency situations to occlude, rather than anastomose;\\na classic example would be closure of the rectum after a ħartmann’s\\nprocedure or small bowel transection in an abbreviated laparotomy for\\ntrauma or ischemia. Doing a functional end-to-end small bowel or\\nileocolic anastomosis after small bowel resection or right hemicolectomy,\\nrespectively — using a linear cutting (GIA™) and linear occluding (TA)\\nstaplers makes sense to us. But a side-to-side gastrojejunostomy, when\\nyou insert the GIA™ into the stomach and small bowel through two holes,\\nwhich you then have to close with sutures, makes no sense, as the\\ncombined size of the gastric and jejunal enterotomies is almost that of the\\ngastrojejunostomy which you could have created and sutured by hand.\\nMoreover, these enterotomies which are used to insert the jaws of the\\nlinear cutting staplers, and are then closed by hand, seem to be the\\nAchilles’ heel of the anastomosis — they, rather than the staple line, are\\noften the site of a leak.\\n\\n As is true for anything in surgery — it’s the final outcome that matters. And what determines the\\n outcome of an anastomosis are mainly the conditions of the bowel, the surroundings and the\\n patient. The technical variant has little effect as long as it is done in an accurate and meticulous\\n way. So for me, all these calculations about size of enterotomies or overall time from start to\\n finish of an anastomosis are meaningless. I have seen laparoscopic hand-sewn anastomoses\\n done quicker than open stapled ones… And I have seen places where the cost of 15 minutes of\\n OR time is greater than the cost of the staplers… So the choice is multifactorial, based on cost,\\n speed, and mainly personal preferences. As long as your leak rate is not\\n exceptional, and you are proficient in all the variations — you are\\n free to choose. Danny\\n\\n Testing the anastomosis\\n\\n A correctly performed anastomosis — that is, if it is indicated —\\nshould not leak. There is little point in routinely testing your simple intra-',\n", " 'md': '```markdown\\n# A few more words on staplers\\n\\nYou will learn the correct use of staplers from your mentors. Despite appearances, we are not rigidly ‘staplerophobic’. We use staplers generously in emergency situations to occlude, rather than anastomose; a classic example would be closure of the rectum after a Hartmann’s procedure or small bowel transection in an abbreviated laparotomy for trauma or ischemia. Doing a functional end-to-end small bowel or ileocolic anastomosis after small bowel resection or right hemicolectomy, respectively — using a linear cutting (GIA™) and linear occluding (TA) staplers makes sense to us. But a side-to-side gastrojejunostomy, when you insert the GIA™ into the stomach and small bowel through two holes, which you then have to close with sutures, makes no sense, as the combined size of the gastric and jejunal enterotomies is almost that of the gastrojejunostomy which you could have created and sutured by hand. Moreover, these enterotomies which are used to insert the jaws of the linear cutting staplers, and are then closed by hand, seem to be the Achilles’ heel of the anastomosis — they, rather than the staple line, are often the site of a leak.\\n\\nAs is true for anything in surgery — it’s the final outcome that matters. And what determines the outcome of an anastomosis are mainly the conditions of the bowel, the surroundings and the patient. The technical variant has little effect as long as it is done in an accurate and meticulous way. So for me, all these calculations about size of enterotomies or overall time from start to finish of an anastomosis are meaningless. I have seen laparoscopic hand-sewn anastomoses done quicker than open stapled ones… And I have seen places where the cost of 15 minutes of OR time is greater than the cost of the staplers… So the choice is multifactorial, based on cost, speed, and mainly personal preferences. As long as your leak rate is not exceptional, and you are proficient in all the variations — you are free to choose. Danny\\n\\n## Testing the anastomosis\\n\\nA correctly performed anastomosis — that is, if it is indicated — should not leak. There is little point in routinely testing your simple intra-\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted into markdown.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'A few more words on staplers',\n", " 'md': '# A few more words on staplers',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 234.77, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'You will learn the correct use of staplers from your mentors. Despite appearances, we are not rigidly ‘staplerophobic’. We use staplers generously in emergency situations to occlude, rather than anastomose; a classic example would be closure of the rectum after a Hartmann’s procedure or small bowel transection in an abbreviated laparotomy for trauma or ischemia. Doing a functional end-to-end small bowel or ileocolic anastomosis after small bowel resection or right hemicolectomy, respectively — using a linear cutting (GIA™) and linear occluding (TA) staplers makes sense to us. But a side-to-side gastrojejunostomy, when you insert the GIA™ into the stomach and small bowel through two holes, which you then have to close with sutures, makes no sense, as the combined size of the gastric and jejunal enterotomies is almost that of the gastrojejunostomy which you could have created and sutured by hand. Moreover, these enterotomies which are used to insert the jaws of the linear cutting staplers, and are then closed by hand, seem to be the Achilles’ heel of the anastomosis — they, rather than the staple line, are often the site of a leak.\\n\\nAs is true for anything in surgery — it’s the final outcome that matters. And what determines the outcome of an anastomosis are mainly the conditions of the bowel, the surroundings and the patient. The technical variant has little effect as long as it is done in an accurate and meticulous way. So for me, all these calculations about size of enterotomies or overall time from start to finish of an anastomosis are meaningless. I have seen laparoscopic hand-sewn anastomoses done quicker than open stapled ones… And I have seen places where the cost of 15 minutes of OR time is greater than the cost of the staplers… So the choice is multifactorial, based on cost, speed, and mainly personal preferences. As long as your leak rate is not exceptional, and you are proficient in all the variations — you are free to choose. Danny',\n", " 'md': 'You will learn the correct use of staplers from your mentors. Despite appearances, we are not rigidly ‘staplerophobic’. We use staplers generously in emergency situations to occlude, rather than anastomose; a classic example would be closure of the rectum after a Hartmann’s procedure or small bowel transection in an abbreviated laparotomy for trauma or ischemia. Doing a functional end-to-end small bowel or ileocolic anastomosis after small bowel resection or right hemicolectomy, respectively — using a linear cutting (GIA™) and linear occluding (TA) staplers makes sense to us. But a side-to-side gastrojejunostomy, when you insert the GIA™ into the stomach and small bowel through two holes, which you then have to close with sutures, makes no sense, as the combined size of the gastric and jejunal enterotomies is almost that of the gastrojejunostomy which you could have created and sutured by hand. Moreover, these enterotomies which are used to insert the jaws of the linear cutting staplers, and are then closed by hand, seem to be the Achilles’ heel of the anastomosis — they, rather than the staple line, are often the site of a leak.\\n\\nAs is true for anything in surgery — it’s the final outcome that matters. And what determines the outcome of an anastomosis are mainly the conditions of the bowel, the surroundings and the patient. The technical variant has little effect as long as it is done in an accurate and meticulous way. So for me, all these calculations about size of enterotomies or overall time from start to finish of an anastomosis are meaningless. I have seen laparoscopic hand-sewn anastomoses done quicker than open stapled ones… And I have seen places where the cost of 15 minutes of OR time is greater than the cost of the staplers… So the choice is multifactorial, based on cost, speed, and mainly personal preferences. As long as your leak rate is not exceptional, and you are proficient in all the variations — you are free to choose. Danny',\n", " 'bBox': {'x': 72, 'y': 157, 'w': 467.83, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Testing the anastomosis',\n", " 'md': '## Testing the anastomosis',\n", " 'bBox': {'x': 86, 'y': 660, 'w': 192.81, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A correctly performed anastomosis — that is, if it is indicated — should not leak. There is little point in routinely testing your simple intra-\\n```',\n", " 'md': 'A correctly performed anastomosis — that is, if it is indicated — should not leak. There is little point in routinely testing your simple intra-\\n```',\n", " 'bBox': {'x': 72, 'y': 696, 'w': 467.36, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted into markdown.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted into markdown.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 185,\n", " 'text': 'abdominal intestinal anastomosis; the common practice of pinching-\\nmasturbating the anastomosis to confirm an adequate lumen is laughable\\nif you used a one-layer technique as described above. ‘Problematic’\\nanastomoses, such as those performed in the lower rectum, should be\\ntested: simply clamp the bowel above the anastomosis, fill the pelvis with\\nsaline and inject air into the rectum. Instead of air you may wish to use\\ndye. If air bubbles (or dye) are observed leaking, an attempt to identify\\nand correct the defect is indicated; if unsuccessful or doubtful, a proximal\\ndiverting stoma is necessary. We (some of us anyway) also test the\\nclosure of a perforated duodenal ulcer by injecting dye into the stomach.\\n\\n When not to perform an anastomosis?\\n\\n We wish we had an exact answer! In broad terms, whenever the\\nprobability of a leak is high, avoid an anastomosis since any anastomotic\\nleak portends disastrous consequences ( Chapter 47). So how do you\\naccurately predict anastomotic failure?\\n\\n Traditionally, the avoidance of colonic suture lines during emergency\\noperations for trauma, obstruction, or perforation was the standard\\npractice. But times have changed; during World War II a colostomy was\\nmandatory for any colonic injury, but nowadays we successfully repair\\nmost of these wounds ( Chapter 32). Furthermore, three- or two-stage\\nprocedures for colonic obstruction have been replaced in selected cases\\nby the one-stage resection with anastomosis ( Chapter 27). And, as\\nyou will read in Chapters 27 and 28, the issue of whether the large\\nbowel is ‘prepared’ or not has become a non-issue (at least to most of\\nus). Multiple prospective randomized trials show that safe colorectal\\nsuture lines can be effected in unprepared bowel.',\n", " 'md': '```markdown\\n## Abdominal Intestinal Anastomosis\\n\\nThe common practice of pinching the anastomosis to confirm an adequate lumen is laughable if you used a one-layer technique as described above. ‘Problematic’ anastomoses, such as those performed in the lower rectum, should be tested: simply clamp the bowel above the anastomosis, fill the pelvis with saline, and inject air into the rectum. Instead of air, you may wish to use dye. If air bubbles (or dye) are observed leaking, an attempt to identify and correct the defect is indicated; if unsuccessful or doubtful, a proximal diverting stoma is necessary. We (some of us anyway) also test the closure of a perforated duodenal ulcer by injecting dye into the stomach.\\n\\n### When Not to Perform an Anastomosis?\\n\\nWe wish we had an exact answer! In broad terms, whenever the probability of a leak is high, avoid an anastomosis since any anastomotic leak portends disastrous consequences (Chapter 47). So how do you accurately predict anastomotic failure?\\n\\nTraditionally, the avoidance of colonic suture lines during emergency operations for trauma, obstruction, or perforation was the standard practice. But times have changed; during World War II, a colostomy was mandatory for any colonic injury, but nowadays we successfully repair most of these wounds (Chapter 32). Furthermore, three- or two-stage procedures for colonic obstruction have been replaced in selected cases by the one-stage resection with anastomosis (Chapter 27). And, as you will read in Chapters 27 and 28, the issue of whether the large bowel is ‘prepared’ or not has become a non-issue (at least to most of us). Multiple prospective randomized trials show that safe colorectal suture lines can be effected in unprepared bowel.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Intestinal Anastomosis',\n", " 'md': '## Abdominal Intestinal Anastomosis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The common practice of pinching the anastomosis to confirm an adequate lumen is laughable if you used a one-layer technique as described above. ‘Problematic’ anastomoses, such as those performed in the lower rectum, should be tested: simply clamp the bowel above the anastomosis, fill the pelvis with saline, and inject air into the rectum. Instead of air, you may wish to use dye. If air bubbles (or dye) are observed leaking, an attempt to identify and correct the defect is indicated; if unsuccessful or doubtful, a proximal diverting stoma is necessary. We (some of us anyway) also test the closure of a perforated duodenal ulcer by injecting dye into the stomach.',\n", " 'md': 'The common practice of pinching the anastomosis to confirm an adequate lumen is laughable if you used a one-layer technique as described above. ‘Problematic’ anastomoses, such as those performed in the lower rectum, should be tested: simply clamp the bowel above the anastomosis, fill the pelvis with saline, and inject air into the rectum. Instead of air, you may wish to use dye. If air bubbles (or dye) are observed leaking, an attempt to identify and correct the defect is indicated; if unsuccessful or doubtful, a proximal diverting stoma is necessary. We (some of us anyway) also test the closure of a perforated duodenal ulcer by injecting dye into the stomach.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.36, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'When Not to Perform an Anastomosis?',\n", " 'md': '### When Not to Perform an Anastomosis?',\n", " 'bBox': {'x': 86, 'y': 278, 'w': 302.51, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'We wish we had an exact answer! In broad terms, whenever the probability of a leak is high, avoid an anastomosis since any anastomotic leak portends disastrous consequences (Chapter 47). So how do you accurately predict anastomotic failure?\\n\\nTraditionally, the avoidance of colonic suture lines during emergency operations for trauma, obstruction, or perforation was the standard practice. But times have changed; during World War II, a colostomy was mandatory for any colonic injury, but nowadays we successfully repair most of these wounds (Chapter 32). Furthermore, three- or two-stage procedures for colonic obstruction have been replaced in selected cases by the one-stage resection with anastomosis (Chapter 27). And, as you will read in Chapters 27 and 28, the issue of whether the large bowel is ‘prepared’ or not has become a non-issue (at least to most of us). Multiple prospective randomized trials show that safe colorectal suture lines can be effected in unprepared bowel.\\n```',\n", " 'md': 'We wish we had an exact answer! In broad terms, whenever the probability of a leak is high, avoid an anastomosis since any anastomotic leak portends disastrous consequences (Chapter 47). So how do you accurately predict anastomotic failure?\\n\\nTraditionally, the avoidance of colonic suture lines during emergency operations for trauma, obstruction, or perforation was the standard practice. But times have changed; during World War II, a colostomy was mandatory for any colonic injury, but nowadays we successfully repair most of these wounds (Chapter 32). Furthermore, three- or two-stage procedures for colonic obstruction have been replaced in selected cases by the one-stage resection with anastomosis (Chapter 27). And, as you will read in Chapters 27 and 28, the issue of whether the large bowel is ‘prepared’ or not has become a non-issue (at least to most of us). Multiple prospective randomized trials show that safe colorectal suture lines can be effected in unprepared bowel.\\n```',\n", " 'bBox': {'x': 72, 'y': 330, 'w': 467.81, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'procedures for colonic obstruction have been replaced in selected cases'},\n", " {'text': ' Chapters 27 and 28, the issue of whether the large'},\n", " {'text': 'bowel is ‘prepared’ or not has become a non-issue (at least to most of'},\n", " {'text': 'bowel is ‘prepared’ or not has become a non-issue (at least to most of'}]},\n", " {'page': 186,\n", " 'text': ' Table 14.1. Factors that may influence uS not to anastomose:\\n Diffuse established peritonitis_\\n Postoperative peritonitis.\\n Leaking anastomosis\\n Mesenteric ischemia.\\n Extreme bowel edema/distension:\\n Extreme malnutrition with low serum albumin.\\n Chronic steroid intake.\\n Unstable patient (damage control situation):\\n It is difficult to lay down precise guidelines as to when an\\nintestinal anastomosis is not to be made. You should make a careful\\ndecision after considering the condition of the patient, the intestine,\\nand the peritoneal cavity. Generally, we would avoid a colonic\\nanastomosis in the presence of established and diffuse intra-abdominal\\ninfection (as opposed to contamination) and under the conditions listed in\\n Table 14.1. Regarding the small bowel, anastomosis is indicated in\\nmost instances; however, when more than one of the factors listed in the\\ntable are present we tend to err on the conservative side and exteriorize\\nor divert, depending on technical circumstances.\\n\\n No formula or algorithm is available, so use your judgment and try not\\nto be too obsessive in always attempting an anastomosis — look at\\nFigure 14.2 — is this your boss? Yes, we know that you wish the patient\\nwell by wanting to spare him a stoma, but he will not be impressed if he is\\ndead! You should not be fearful of creating a high small bowel stoma.\\nPreviously these were considered to be unmanageable, but with total\\nparenteral nutrition, techniques of distal enteric feeding and re-infusion,\\nsomatostatin, and stoma care, these temporary proximal intestinal ‘vents’\\ncan be life-saving (see also Chapters 47 and 48). On the other hand,\\ndo not be a wussy (look at the Urban Dictionary) by avoiding an\\nanastomosis when it is indicated and possible.',\n", " 'md': '```markdown\\n## Table 14.1. Factors that may influence uS not to anastomose:\\n\\n| Factors Influencing Non-Anastomosis |\\n|------------------------------------------------------|\\n| Diffuse established peritonitis |\\n| Postoperative peritonitis |\\n| Leaking anastomosis |\\n| Mesenteric ischemia |\\n| Extreme bowel edema/distension |\\n| Extreme malnutrition with low serum albumin |\\n| Chronic steroid intake |\\n| Unstable patient (damage control situation) |\\n\\nIt is difficult to lay down precise guidelines as to when an intestinal anastomosis is not to be made. You should make a careful decision after considering the condition of the patient, the intestine, and the peritoneal cavity. Generally, we would avoid a colonic anastomosis in the presence of established and diffuse intra-abdominal infection (as opposed to contamination) and under the conditions listed in Table 14.1. Regarding the small bowel, anastomosis is indicated in most instances; however, when more than one of the factors listed in the table are present we tend to err on the conservative side and exteriorize or divert, depending on technical circumstances.\\n\\nNo formula or algorithm is available, so use your judgment and try not to be too obsessive in always attempting an anastomosis — look at Figure 14.2 — is this your boss? Yes, we know that you wish the patient well by wanting to spare him a stoma, but he will not be impressed if he is dead! You should not be fearful of creating a high small bowel stoma. Previously these were considered to be unmanageable, but with total parenteral nutrition, techniques of distal enteric feeding and re-infusion, somatostatin, and stoma care, these temporary proximal intestinal ‘vents’ can be life-saving (see also Chapters 47 and 48). On the other hand, do not be a wussy (look at the Urban Dictionary) by avoiding an anastomosis when it is indicated and possible.\\n\\n### Figure 14.2\\n\\n```',\n", " 'images': [{'name': 'img_p185_1.png',\n", " 'height': 382,\n", " 'width': 812,\n", " 'x': 105.11999999999989,\n", " 'y': 72,\n", " 'original_width': 1396,\n", " 'original_height': 656}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 14.1. Factors that may influence uS not to anastomose:',\n", " 'md': '## Table 14.1. Factors that may influence uS not to anastomose:',\n", " 'bBox': {'x': 110.56, 'y': 75.46, 'w': 369.6, 'h': 17.78}},\n", " {'type': 'table',\n", " 'rows': [['Factors Influencing Non-Anastomosis'],\n", " ['Diffuse established peritonitis'],\n", " ['Postoperative peritonitis'],\n", " ['Leaking anastomosis'],\n", " ['Mesenteric ischemia'],\n", " ['Extreme bowel edema/distension'],\n", " ['Extreme malnutrition with low serum albumin'],\n", " ['Chronic steroid intake'],\n", " ['Unstable patient (damage control situation)']],\n", " 'md': '| Factors Influencing Non-Anastomosis |\\n|------------------------------------------------------|\\n| Diffuse established peritonitis |\\n| Postoperative peritonitis |\\n| Leaking anastomosis |\\n| Mesenteric ischemia |\\n| Extreme bowel edema/distension |\\n| Extreme malnutrition with low serum albumin |\\n| Chronic steroid intake |\\n| Unstable patient (damage control situation) |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Factors Influencing Non-Anastomosis\"\\n\"Diffuse established peritonitis\"\\n\"Postoperative peritonitis\"\\n\"Leaking anastomosis\"\\n\"Mesenteric ischemia\"\\n\"Extreme bowel edema/distension\"\\n\"Extreme malnutrition with low serum albumin\"\\n\"Chronic steroid intake\"\\n\"Unstable patient (damage control situation)\"',\n", " 'bBox': {'x': 150.64, 'y': 151.01, 'w': 95, 'h': 12.84}},\n", " {'type': 'text',\n", " 'value': 'It is difficult to lay down precise guidelines as to when an intestinal anastomosis is not to be made. You should make a careful decision after considering the condition of the patient, the intestine, and the peritoneal cavity. Generally, we would avoid a colonic anastomosis in the presence of established and diffuse intra-abdominal infection (as opposed to contamination) and under the conditions listed in Table 14.1. Regarding the small bowel, anastomosis is indicated in most instances; however, when more than one of the factors listed in the table are present we tend to err on the conservative side and exteriorize or divert, depending on technical circumstances.\\n\\nNo formula or algorithm is available, so use your judgment and try not to be too obsessive in always attempting an anastomosis — look at Figure 14.2 — is this your boss? Yes, we know that you wish the patient well by wanting to spare him a stoma, but he will not be impressed if he is dead! You should not be fearful of creating a high small bowel stoma. Previously these were considered to be unmanageable, but with total parenteral nutrition, techniques of distal enteric feeding and re-infusion, somatostatin, and stoma care, these temporary proximal intestinal ‘vents’ can be life-saving (see also Chapters 47 and 48). On the other hand, do not be a wussy (look at the Urban Dictionary) by avoiding an anastomosis when it is indicated and possible.',\n", " 'md': 'It is difficult to lay down precise guidelines as to when an intestinal anastomosis is not to be made. You should make a careful decision after considering the condition of the patient, the intestine, and the peritoneal cavity. Generally, we would avoid a colonic anastomosis in the presence of established and diffuse intra-abdominal infection (as opposed to contamination) and under the conditions listed in Table 14.1. Regarding the small bowel, anastomosis is indicated in most instances; however, when more than one of the factors listed in the table are present we tend to err on the conservative side and exteriorize or divert, depending on technical circumstances.\\n\\nNo formula or algorithm is available, so use your judgment and try not to be too obsessive in always attempting an anastomosis — look at Figure 14.2 — is this your boss? Yes, we know that you wish the patient well by wanting to spare him a stoma, but he will not be impressed if he is dead! You should not be fearful of creating a high small bowel stoma. Previously these were considered to be unmanageable, but with total parenteral nutrition, techniques of distal enteric feeding and re-infusion, somatostatin, and stoma care, these temporary proximal intestinal ‘vents’ can be life-saving (see also Chapters 47 and 48). On the other hand, do not be a wussy (look at the Urban Dictionary) by avoiding an anastomosis when it is indicated and possible.',\n", " 'bBox': {'x': 72, 'y': 309, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 14.2',\n", " 'md': '### Figure 14.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '\\n```',\n", " 'md': '\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'most instances; however, when more than one of the factors listed in the'},\n", " {'text': 'Figure 14.2 — is this your boss? Yes, we know that you wish the patient well by wanting to spare him a stoma, but he will not be impressed if he is'},\n", " {'text': ' (look at the Urban Dictionary) by avoiding an'},\n", " {'text': ' (look at the Urban Dictionary) by avoiding an'}]},\n", " {'page': 187,\n", " 'text': ' Tecy- 2e44\\n Figure 14.2. Anesthetist: “Systolic blood pressure 60… hemoglobin 5…” Assistant to\\n surgeon: “Boss, pre-op albumin was 1.5…” Surgeon to nurse: “Get me the TA and GIA™.\\n Let me join the ileum with the colon. Will take me 3 minutes…”\\n\\n Whatever you do, some people will be unhappy. You can’t please\\n everybody, can you? If you do a colostomy there will be always someone to ask you why\\n not primary anastomosis? If you do a primary anastomosis there will be always\\n someone to say why not colostomy? Only being a football coach is worse in this regard.\\n\\n So let us leave you with this...\\n\\n The intestinal anastomosis is the ‘elective’ part of the emergency\\noperation you are going to perform. Remember — your aim is to save life\\nand minimize morbidity; create an anastomosis when its chances of\\nsuccess are at least reasonable. There are many ways to skin a cat\\nand to fashion an anastomosis. Master a few methods and use them\\nselectively.\\n\\n Intestinal stomata 2\\n 2 Mark Cheetham',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Text\\nFigure 14.2. Anesthetist: “Systolic blood pressure 60… hemoglobin 5…” Assistant to surgeon: “Boss, pre-op albumin was 1.5…” Surgeon to nurse: “Get me the TA and GIA™. Let me join the ileum with the colon. Will take me 3 minutes…”\\n\\nWhatever you do, some people will be unhappy. You can’t please everybody, can you? If you do a colostomy there will be always someone to ask you why not primary anastomosis? If you do a primary anastomosis there will be always someone to say why not colostomy? Only being a football coach is worse in this regard.\\n\\nSo let us leave you with this...\\n\\nThe intestinal anastomosis is the ‘elective’ part of the emergency operation you are going to perform. Remember — your aim is to save life and minimize morbidity; create an anastomosis when its chances of success are at least reasonable. There are many ways to skin a cat and to fashion an anastomosis. Master a few methods and use them selectively.\\n\\n### Image Identification and Description\\n**Figure 14.2**: The image depicts a surgical scene with dialogue among the anesthetist, assistant surgeon, and surgeon. The anesthetist is monitoring vital signs, while the assistant provides pre-operative information. The surgeon is instructing the nurse to prepare specific surgical tools and is discussing the procedure to join the ileum with the colon.\\n\\n**Summary**: This figure illustrates the communication and decision-making process in a surgical setting, highlighting the urgency and complexity of emergency operations.\\n\\n### Author\\nMark Cheetham\\n```',\n", " 'images': [{'name': 'img_p186_1.png',\n", " 'height': 469,\n", " 'width': 603,\n", " 'x': 156.96000000000004,\n", " 'y': 82.79999999999998,\n", " 'original_width': 1380,\n", " 'original_height': 1075}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 14.2. Anesthetist: “Systolic blood pressure 60… hemoglobin 5…” Assistant to surgeon: “Boss, pre-op albumin was 1.5…” Surgeon to nurse: “Get me the TA and GIA™. Let me join the ileum with the colon. Will take me 3 minutes…”\\n\\nWhatever you do, some people will be unhappy. You can’t please everybody, can you? If you do a colostomy there will be always someone to ask you why not primary anastomosis? If you do a primary anastomosis there will be always someone to say why not colostomy? Only being a football coach is worse in this regard.\\n\\nSo let us leave you with this...\\n\\nThe intestinal anastomosis is the ‘elective’ part of the emergency operation you are going to perform. Remember — your aim is to save life and minimize morbidity; create an anastomosis when its chances of success are at least reasonable. There are many ways to skin a cat and to fashion an anastomosis. Master a few methods and use them selectively.',\n", " 'md': 'Figure 14.2. Anesthetist: “Systolic blood pressure 60… hemoglobin 5…” Assistant to surgeon: “Boss, pre-op albumin was 1.5…” Surgeon to nurse: “Get me the TA and GIA™. Let me join the ileum with the colon. Will take me 3 minutes…”\\n\\nWhatever you do, some people will be unhappy. You can’t please everybody, can you? If you do a colostomy there will be always someone to ask you why not primary anastomosis? If you do a primary anastomosis there will be always someone to say why not colostomy? Only being a football coach is worse in this regard.\\n\\nSo let us leave you with this...\\n\\nThe intestinal anastomosis is the ‘elective’ part of the emergency operation you are going to perform. Remember — your aim is to save life and minimize morbidity; create an anastomosis when its chances of success are at least reasonable. There are many ways to skin a cat and to fashion an anastomosis. Master a few methods and use them selectively.',\n", " 'bBox': {'x': 72, 'y': 335, 'w': 467.44, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 14.2**: The image depicts a surgical scene with dialogue among the anesthetist, assistant surgeon, and surgeon. The anesthetist is monitoring vital signs, while the assistant provides pre-operative information. The surgeon is instructing the nurse to prepare specific surgical tools and is discussing the procedure to join the ileum with the colon.\\n\\n**Summary**: This figure illustrates the communication and decision-making process in a surgical setting, highlighting the urgency and complexity of emergency operations.',\n", " 'md': '**Figure 14.2**: The image depicts a surgical scene with dialogue among the anesthetist, assistant surgeon, and surgeon. The anesthetist is monitoring vital signs, while the assistant provides pre-operative information. The surgeon is instructing the nurse to prepare specific surgical tools and is discussing the procedure to join the ileum with the colon.\\n\\n**Summary**: This figure illustrates the communication and decision-making process in a surgical setting, highlighting the urgency and complexity of emergency operations.',\n", " 'bBox': {'x': 73, 'y': 700, 'w': 16.01, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Author',\n", " 'md': '### Author',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Mark Cheetham\\n```',\n", " 'md': 'Mark Cheetham\\n```',\n", " 'bBox': {'x': 100, 'y': 705, 'w': 117.73, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Intestinal stomata 2'}]},\n", " {'page': 188,\n", " 'text': ' Throughout surgical history surgeons have viewed the creation of an\\nintestinal stoma with distaste but, at the same time understood its\\npotential life-saving value — as reflected by these two quotes from\\nmaster surgeons:\\n\\n Of all the diseases to which man is liable, there is no one so\\n inconvenient and disgusting as the artificial anus. How\\n wretched is the patient from whom, despite his will, the\\n alimentary, bilious and fecal matter contained in his\\n intestines are constantly escaping.\\n Guillaume Dupuytren\\n\\n About colostomy: But it is surely far better to part with one\\n of the conveniences of Life, than to part with Life itself.\\n Besides, the excrements that are voided by this passage,\\n are not altogether so offensive, as those that are voided per\\n anum.\\n Lorenz Heister\\n\\n This is perhaps the right time and place to discuss general concepts concerning the\\n construction of intestinal stomata. Mr. Cheetham kindly agreed to share lessons from his vast\\n experience. You will read more about specific indications for small or large bowel stomata in the\\n relevant individual chapters. The Editors\\n\\n There are only two indications to create a stoma; when you\\n want to and when you need to.\\n R. John Nicholls\\n\\n Patients and surgeons have differing views of stomata. For a\\npsychologically unprepared patient who recovers from emergency\\nsurgery, a stoma is a devastating insult to their body image and sexuality.\\nTo the surgeon, a stoma may be seen as an insult to professional pride;\\nits mere presence implies that he cannot even join a piece of bowel\\ntogether properly. Go to any surgical conference and you will see papers\\non how clever surgeons completely avoid stomata with their\\nrobotic/SILS/blah, blah blah…',\n", " 'md': '```markdown\\nThroughout surgical history, surgeons have viewed the creation of an intestinal stoma with distaste but, at the same time, understood its potential life-saving value — as reflected by these two quotes from master surgeons:\\n\\n> Of all the diseases to which man is liable, there is no one so inconvenient and disgusting as the artificial anus. How wretched is the patient from whom, despite his will, the alimentary, bilious and fecal matter contained in his intestines are constantly escaping.\\n> — Guillaume Dupuytren\\n\\n> About colostomy: But it is surely far better to part with one of the conveniences of Life, than to part with Life itself. Besides, the excrements that are voided by this passage, are not altogether so offensive, as those that are voided per anum.\\n> — Lorenz Heister\\n\\nThis is perhaps the right time and place to discuss general concepts concerning the construction of intestinal stomata. Mr. Cheetham kindly agreed to share lessons from his vast experience. You will read more about specific indications for small or large bowel stomata in the relevant individual chapters. The Editors\\n\\n> There are only two indications to create a stoma; when you want to and when you need to.\\n> — R. John Nicholls\\n\\nPatients and surgeons have differing views of stomata. For a psychologically unprepared patient who recovers from emergency surgery, a stoma is a devastating insult to their body image and sexuality. To the surgeon, a stoma may be seen as an insult to professional pride; its mere presence implies that he cannot even join a piece of bowel together properly. Go to any surgical conference and you will see papers on how clever surgeons completely avoid stomata with their robotic/SILS/blah, blah blah…\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nThroughout surgical history, surgeons have viewed the creation of an intestinal stoma with distaste but, at the same time, understood its potential life-saving value — as reflected by these two quotes from master surgeons:\\n\\n> Of all the diseases to which man is liable, there is no one so inconvenient and disgusting as the artificial anus. How wretched is the patient from whom, despite his will, the alimentary, bilious and fecal matter contained in his intestines are constantly escaping.\\n> — Guillaume Dupuytren\\n\\n> About colostomy: But it is surely far better to part with one of the conveniences of Life, than to part with Life itself. Besides, the excrements that are voided by this passage, are not altogether so offensive, as those that are voided per anum.\\n> — Lorenz Heister\\n\\nThis is perhaps the right time and place to discuss general concepts concerning the construction of intestinal stomata. Mr. Cheetham kindly agreed to share lessons from his vast experience. You will read more about specific indications for small or large bowel stomata in the relevant individual chapters. The Editors\\n\\n> There are only two indications to create a stoma; when you want to and when you need to.\\n> — R. John Nicholls\\n\\nPatients and surgeons have differing views of stomata. For a psychologically unprepared patient who recovers from emergency surgery, a stoma is a devastating insult to their body image and sexuality. To the surgeon, a stoma may be seen as an insult to professional pride; its mere presence implies that he cannot even join a piece of bowel together properly. Go to any surgical conference and you will see papers on how clever surgeons completely avoid stomata with their robotic/SILS/blah, blah blah…\\n```',\n", " 'md': '```markdown\\nThroughout surgical history, surgeons have viewed the creation of an intestinal stoma with distaste but, at the same time, understood its potential life-saving value — as reflected by these two quotes from master surgeons:\\n\\n> Of all the diseases to which man is liable, there is no one so inconvenient and disgusting as the artificial anus. How wretched is the patient from whom, despite his will, the alimentary, bilious and fecal matter contained in his intestines are constantly escaping.\\n> — Guillaume Dupuytren\\n\\n> About colostomy: But it is surely far better to part with one of the conveniences of Life, than to part with Life itself. Besides, the excrements that are voided by this passage, are not altogether so offensive, as those that are voided per anum.\\n> — Lorenz Heister\\n\\nThis is perhaps the right time and place to discuss general concepts concerning the construction of intestinal stomata. Mr. Cheetham kindly agreed to share lessons from his vast experience. You will read more about specific indications for small or large bowel stomata in the relevant individual chapters. The Editors\\n\\n> There are only two indications to create a stoma; when you want to and when you need to.\\n> — R. John Nicholls\\n\\nPatients and surgeons have differing views of stomata. For a psychologically unprepared patient who recovers from emergency surgery, a stoma is a devastating insult to their body image and sexuality. To the surgeon, a stoma may be seen as an insult to professional pride; its mere presence implies that he cannot even join a piece of bowel together properly. Go to any surgical conference and you will see papers on how clever surgeons completely avoid stomata with their robotic/SILS/blah, blah blah…\\n```',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.92, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 189,\n", " 'text': ' But common-sense surgeons know that a well-made stoma in the right setting can be\\n life-saving (and also improve the quality of life for some patients — but that’s another\\n story). In this chapter I will discuss the whys and wherefores of common stomata and\\n also some tips for more unusual situations.\\n\\n The emergency stoma: why and when\\n\\n The most common reason to create a stoma as part of an\\nemergency abdominal operation is that the risk of anastomotic\\nleakage is considered too high. For example, during an operation to\\ncorrect a left colon anastomotic leak it is usually wise to either exteriorize\\nthe leak or if this is not possible, then completely take down the\\nanastomosis by stapling off the distal limb and creating a proximal end\\nstoma (à la ħartmann).\\n\\n One could summarize the most common indications for a stoma\\nin emergency surgery as follows:\\n\\n • Surgery for anastomotic leak.\\n • Surgery for fecal peritonitis.\\n • Bowel resection in a patient with major risks for leakage.\\n • Surgery for fulminant colitis.\\n • To allow healing of a perineal wound or sepsis.\\n • To divert above an entercutanous fistula.\\n There are a few types of stomata from which to choose for the\\nabove indications:\\n\\n • End colostomy.\\n • Loop colostomy (sigmoid or transverse).',\n", " 'md': '```markdown\\n# Common Stomata in Emergency Surgery\\n\\nBut common-sense surgeons know that a well-made stoma in the right setting can be life-saving (and also improve the quality of life for some patients — but that’s another story). In this chapter, I will discuss the whys and wherefores of common stomata and also some tips for more unusual situations.\\n\\n## The Emergency Stoma: Why and When\\n\\nThe most common reason to create a stoma as part of an emergency abdominal operation is that the risk of anastomotic leakage is considered too high. For example, during an operation to correct a left colon anastomotic leak, it is usually wise to either exteriorize the leak or, if this is not possible, then completely take down the anastomosis by stapling off the distal limb and creating a proximal end stoma (à la Hartmann).\\n\\nOne could summarize the most common indications for a stoma in emergency surgery as follows:\\n\\n- Surgery for anastomotic leak.\\n- Surgery for fecal peritonitis.\\n- Bowel resection in a patient with major risks for leakage.\\n- Surgery for fulminant colitis.\\n- To allow healing of a perineal wound or sepsis.\\n- To divert above an enterocutaneous fistula.\\n\\nThere are a few types of stomata from which to choose for the above indications:\\n\\n- End colostomy.\\n- Loop colostomy (sigmoid or transverse).\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Common Stomata in Emergency Surgery',\n", " 'md': '# Common Stomata in Emergency Surgery',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'But common-sense surgeons know that a well-made stoma in the right setting can be life-saving (and also improve the quality of life for some patients — but that’s another story). In this chapter, I will discuss the whys and wherefores of common stomata and also some tips for more unusual situations.',\n", " 'md': 'But common-sense surgeons know that a well-made stoma in the right setting can be life-saving (and also improve the quality of life for some patients — but that’s another story). In this chapter, I will discuss the whys and wherefores of common stomata and also some tips for more unusual situations.',\n", " 'bBox': {'x': 79, 'y': 93, 'w': 453.44, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Emergency Stoma: Why and When',\n", " 'md': '## The Emergency Stoma: Why and When',\n", " 'bBox': {'x': 86, 'y': 204, 'w': 297.95, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The most common reason to create a stoma as part of an emergency abdominal operation is that the risk of anastomotic leakage is considered too high. For example, during an operation to correct a left colon anastomotic leak, it is usually wise to either exteriorize the leak or, if this is not possible, then completely take down the anastomosis by stapling off the distal limb and creating a proximal end stoma (à la Hartmann).\\n\\nOne could summarize the most common indications for a stoma in emergency surgery as follows:\\n\\n- Surgery for anastomotic leak.\\n- Surgery for fecal peritonitis.\\n- Bowel resection in a patient with major risks for leakage.\\n- Surgery for fulminant colitis.\\n- To allow healing of a perineal wound or sepsis.\\n- To divert above an enterocutaneous fistula.\\n\\nThere are a few types of stomata from which to choose for the above indications:\\n\\n- End colostomy.\\n- Loop colostomy (sigmoid or transverse).\\n```',\n", " 'md': 'The most common reason to create a stoma as part of an emergency abdominal operation is that the risk of anastomotic leakage is considered too high. For example, during an operation to correct a left colon anastomotic leak, it is usually wise to either exteriorize the leak or, if this is not possible, then completely take down the anastomosis by stapling off the distal limb and creating a proximal end stoma (à la Hartmann).\\n\\nOne could summarize the most common indications for a stoma in emergency surgery as follows:\\n\\n- Surgery for anastomotic leak.\\n- Surgery for fecal peritonitis.\\n- Bowel resection in a patient with major risks for leakage.\\n- Surgery for fulminant colitis.\\n- To allow healing of a perineal wound or sepsis.\\n- To divert above an enterocutaneous fistula.\\n\\nThere are a few types of stomata from which to choose for the above indications:\\n\\n- End colostomy.\\n- Loop colostomy (sigmoid or transverse).\\n```',\n", " 'bBox': {'x': 72, 'y': 391, 'w': 358.2, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 190,\n", " 'text': ' • Double-barrel colostomy.\\n • Blow holes.\\n • Cecostomy.\\n • End ileostomy.\\n • Loop ileostomy.\\n • Jejunostomy.\\n • Ileocolostomy (double-barrel).\\n\\n How to make an emergency stoma\\n\\n Siting a stoma\\n\\nFigure 14.3. The ‘triangle of stomata’.',\n", " 'md': \"```markdown\\n## Stoma Types\\n\\n- Double-barrel colostomy.\\n- Blow holes.\\n- Cecostomy.\\n- End ileostomy.\\n- Loop ileostomy.\\n- Jejunostomy.\\n- Ileocolostomy (double-barrel).\\n\\n### How to make an emergency stoma\\n\\n### Siting a stoma\\n\\n![Figure 14.3: The ‘triangle of stomata’.]()\\n**Description:** This figure illustrates the 'triangle of stomata', which likely represents the anatomical positioning or relationship of various types of stomas. The details of the image are not extractable, but it serves as a visual guide for understanding stoma placement.\\n```\",\n", " 'images': [{'name': 'img_p189_1.png',\n", " 'height': 626,\n", " 'width': 447,\n", " 'x': 195.84000000000015,\n", " 'y': 364.32,\n", " 'original_width': 768,\n", " 'original_height': 1076}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Stoma Types',\n", " 'md': '## Stoma Types',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Double-barrel colostomy.\\n- Blow holes.\\n- Cecostomy.\\n- End ileostomy.\\n- Loop ileostomy.\\n- Jejunostomy.\\n- Ileocolostomy (double-barrel).',\n", " 'md': '- Double-barrel colostomy.\\n- Blow holes.\\n- Cecostomy.\\n- End ileostomy.\\n- Loop ileostomy.\\n- Jejunostomy.\\n- Ileocolostomy (double-barrel).',\n", " 'bBox': {'x': 100, 'y': 86, 'w': 190.3, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'How to make an emergency stoma',\n", " 'md': '### How to make an emergency stoma',\n", " 'bBox': {'x': 86, 'y': 306, 'w': 271.3, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Siting a stoma',\n", " 'md': '### Siting a stoma',\n", " 'bBox': {'x': 86, 'y': 350, 'w': 113.09, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': \"![Figure 14.3: The ‘triangle of stomata’.]()\\n**Description:** This figure illustrates the 'triangle of stomata', which likely represents the anatomical positioning or relationship of various types of stomas. The details of the image are not extractable, but it serves as a visual guide for understanding stoma placement.\\n```\",\n", " 'md': \"![Figure 14.3: The ‘triangle of stomata’.]()\\n**Description:** This figure illustrates the 'triangle of stomata', which likely represents the anatomical positioning or relationship of various types of stomas. The details of the image are not extractable, but it serves as a visual guide for understanding stoma placement.\\n```\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 191,\n", " 'text': ' Patients who have planned surgery involving a stoma typically see a\\n‘bag lady’ (a stoma nurse or enterostomal therapist) prior to operation.\\nThis consultation helps to prepare the patient psychologically and\\npractically for their surgery. A key part of this process is marking the site\\nfor the planned stoma. The patient is usually examined lying and\\nstanding, and their clothing preferences are taken into account. An\\nemergency abdominal surgeon does not have the luxury of access\\nto a stoma nurse at 2 in the morning when confronted with a sick\\npatient with a perforated colon (actually, even if you can find one, a\\nstoma nurse will often tell you that they cannot site a stoma in a patient\\nwith a tender distended abdomen). So you need to have a reasonable\\nunderstanding of where to place your stoma.\\n\\n You should aim to place your stoma through a flat part of the skin\\naway from scars, bony prominences and skin creases. In practice,\\nthink of an imaginary triangle with points at the umbilicus, anterior\\nsuperior iliac skin and the mid-point of the costal margin and then site\\nyour stoma through this triangle (on either side) — the triangle of stomata\\n( Figure 14.3).\\n\\n For a more nuanced version of this, you should vary how high or low in\\nthe triangle you cut according to the clinical situation. Skinny young girls\\nwith Crohn’s disease tend to prefer a stoma low down in the abdomen to\\nfit with their wardrobe. This site would, of course, be a disaster in a 250lb\\nbeer-swilling man needing a ħartmann’s procedure; for him place the\\nstoma higher above the beer belly, so he can see to change his stoma\\npouch. In practice with visceral oedema and distended bowel loops\\nyou may need to place your stoma where it can reach the skin\\nwithout tension, rather than the optimal site. Whatever you do,\\nbringing the stoma, or even a mucous fistula out through the surgical\\nwound, is not something that I would advise (see Figure 14.4).',\n", " 'md': '```markdown\\n## Stoma Placement Considerations\\n\\nPatients who have planned surgery involving a stoma typically see a ‘bag lady’ (a stoma nurse or enterostomal therapist) prior to operation. This consultation helps to prepare the patient psychologically and practically for their surgery. A key part of this process is marking the site for the planned stoma. The patient is usually examined lying and standing, and their clothing preferences are taken into account. An emergency abdominal surgeon does not have the luxury of access to a stoma nurse at 2 in the morning when confronted with a sick patient with a perforated colon (actually, even if you can find one, a stoma nurse will often tell you that they cannot site a stoma in a patient with a tender distended abdomen). So you need to have a reasonable understanding of where to place your stoma.\\n\\nYou should aim to place your stoma through a flat part of the skin away from scars, bony prominences, and skin creases. In practice, think of an imaginary triangle with points at the umbilicus, anterior superior iliac skin, and the mid-point of the costal margin and then site your stoma through this triangle (on either side) — the triangle of stomata (Figure 14.3).\\n\\nFor a more nuanced version of this, you should vary how high or low in the triangle you cut according to the clinical situation. Skinny young girls with Crohn’s disease tend to prefer a stoma low down in the abdomen to fit with their wardrobe. This site would, of course, be a disaster in a 250lb beer-swilling man needing a Hartmann’s procedure; for him, place the stoma higher above the beer belly, so he can see to change his stoma pouch. In practice, with visceral oedema and distended bowel loops, you may need to place your stoma where it can reach the skin without tension, rather than the optimal site. Whatever you do, bringing the stoma, or even a mucous fistula out through the surgical wound, is not something that I would advise (see Figure 14.4).\\n\\n### Figures\\n\\n- **Figure 14.3**: The triangle of stomata, illustrating the ideal placement area for a stoma based on anatomical landmarks.\\n- **Figure 14.4**: \\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Stoma Placement Considerations',\n", " 'md': '## Stoma Placement Considerations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Patients who have planned surgery involving a stoma typically see a ‘bag lady’ (a stoma nurse or enterostomal therapist) prior to operation. This consultation helps to prepare the patient psychologically and practically for their surgery. A key part of this process is marking the site for the planned stoma. The patient is usually examined lying and standing, and their clothing preferences are taken into account. An emergency abdominal surgeon does not have the luxury of access to a stoma nurse at 2 in the morning when confronted with a sick patient with a perforated colon (actually, even if you can find one, a stoma nurse will often tell you that they cannot site a stoma in a patient with a tender distended abdomen). So you need to have a reasonable understanding of where to place your stoma.\\n\\nYou should aim to place your stoma through a flat part of the skin away from scars, bony prominences, and skin creases. In practice, think of an imaginary triangle with points at the umbilicus, anterior superior iliac skin, and the mid-point of the costal margin and then site your stoma through this triangle (on either side) — the triangle of stomata (Figure 14.3).\\n\\nFor a more nuanced version of this, you should vary how high or low in the triangle you cut according to the clinical situation. Skinny young girls with Crohn’s disease tend to prefer a stoma low down in the abdomen to fit with their wardrobe. This site would, of course, be a disaster in a 250lb beer-swilling man needing a Hartmann’s procedure; for him, place the stoma higher above the beer belly, so he can see to change his stoma pouch. In practice, with visceral oedema and distended bowel loops, you may need to place your stoma where it can reach the skin without tension, rather than the optimal site. Whatever you do, bringing the stoma, or even a mucous fistula out through the surgical wound, is not something that I would advise (see Figure 14.4).',\n", " 'md': 'Patients who have planned surgery involving a stoma typically see a ‘bag lady’ (a stoma nurse or enterostomal therapist) prior to operation. This consultation helps to prepare the patient psychologically and practically for their surgery. A key part of this process is marking the site for the planned stoma. The patient is usually examined lying and standing, and their clothing preferences are taken into account. An emergency abdominal surgeon does not have the luxury of access to a stoma nurse at 2 in the morning when confronted with a sick patient with a perforated colon (actually, even if you can find one, a stoma nurse will often tell you that they cannot site a stoma in a patient with a tender distended abdomen). So you need to have a reasonable understanding of where to place your stoma.\\n\\nYou should aim to place your stoma through a flat part of the skin away from scars, bony prominences, and skin creases. In practice, think of an imaginary triangle with points at the umbilicus, anterior superior iliac skin, and the mid-point of the costal margin and then site your stoma through this triangle (on either side) — the triangle of stomata (Figure 14.3).\\n\\nFor a more nuanced version of this, you should vary how high or low in the triangle you cut according to the clinical situation. Skinny young girls with Crohn’s disease tend to prefer a stoma low down in the abdomen to fit with their wardrobe. This site would, of course, be a disaster in a 250lb beer-swilling man needing a Hartmann’s procedure; for him, place the stoma higher above the beer belly, so he can see to change his stoma pouch. In practice, with visceral oedema and distended bowel loops, you may need to place your stoma where it can reach the skin without tension, rather than the optimal site. Whatever you do, bringing the stoma, or even a mucous fistula out through the surgical wound, is not something that I would advise (see Figure 14.4).',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 14.3**: The triangle of stomata, illustrating the ideal placement area for a stoma based on anatomical landmarks.\\n- **Figure 14.4**: \\n```',\n", " 'md': '- **Figure 14.3**: The triangle of stomata, illustrating the ideal placement area for a stoma based on anatomical landmarks.\\n- **Figure 14.4**: \\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 192,\n", " 'text': ' 73\\nFigure 14.4. Bringing a colostomy out through a laparotomy incision is like putting a toilet\\nin the kitchen.\\n\\n Making a stoma — general principles\\n\\n Consider a stoma as an anastomosis between bowel and skin;\\nyou should aim to bring together well-vascularized tissues with\\nminimal tension and pay attention to surgical technique (although to\\nbe fair the consequences of a ‘leak’ from a stoma are less serious than\\nthose from an anastomotic leak — that’s why you made a stoma in the\\nfirst place, wasn’t it?).\\n\\n You should make the stoma trephine as small (or large) as possible to\\nallow delivery of the bowel without any vascular compromise. The\\ntrephine may be made by elevating the skin with a tissue forceps and\\nusing a scalpel to excise a disk of skin. In my hands, this invariably\\nresults in a much too large, ragged skin defect. So as an alternative, a\\ncruciate incision can be made at the site of the stoma, excising the\\ncorners to make a circular trephine. Conventionally, the external',\n", " 'md': '```markdown\\n# Page 73\\n\\n## Figure 14.4\\n**Description:** Bringing a colostomy out through a laparotomy incision is likened to putting a toilet in the kitchen. This figure illustrates the concept of creating a stoma in a surgical context.\\n\\n## Making a stoma — general principles\\n- Consider a stoma as an anastomosis between bowel and skin; you should aim to bring together well-vascularized tissues with minimal tension and pay attention to surgical technique (although to be fair, the consequences of a ‘leak’ from a stoma are less serious than those from an anastomotic leak — that’s why you made a stoma in the first place, wasn’t it?).\\n\\n- You should make the stoma trephine as small (or large) as possible to allow delivery of the bowel without any vascular compromise. The trephine may be made by elevating the skin with a tissue forceps and using a scalpel to excise a disk of skin. In my hands, this invariably results in a much too large, ragged skin defect. So as an alternative, a cruciate incision can be made at the site of the stoma, excising the corners to make a circular trephine. Conventionally, the external...\\n```',\n", " 'images': [{'name': 'img_p191_1.png',\n", " 'height': 563,\n", " 'width': 803,\n", " 'x': 107.27999999999975,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1380,\n", " 'original_height': 967}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page 73',\n", " 'md': '# Page 73',\n", " 'bBox': {'x': 328.52, 'y': 247.61, 'w': 33.66, 'h': 46.52}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 14.4',\n", " 'md': '## Figure 14.4',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** Bringing a colostomy out through a laparotomy incision is likened to putting a toilet in the kitchen. This figure illustrates the concept of creating a stoma in a surgical context.',\n", " 'md': '**Description:** Bringing a colostomy out through a laparotomy incision is likened to putting a toilet in the kitchen. This figure illustrates the concept of creating a stoma in a surgical context.',\n", " 'bBox': {'x': 75, 'y': 394, 'w': 72.5, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Making a stoma — general principles',\n", " 'md': '## Making a stoma — general principles',\n", " 'bBox': {'x': 86, 'y': 448, 'w': 291.49, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Consider a stoma as an anastomosis between bowel and skin; you should aim to bring together well-vascularized tissues with minimal tension and pay attention to surgical technique (although to be fair, the consequences of a ‘leak’ from a stoma are less serious than those from an anastomotic leak — that’s why you made a stoma in the first place, wasn’t it?).\\n\\n- You should make the stoma trephine as small (or large) as possible to allow delivery of the bowel without any vascular compromise. The trephine may be made by elevating the skin with a tissue forceps and using a scalpel to excise a disk of skin. In my hands, this invariably results in a much too large, ragged skin defect. So as an alternative, a cruciate incision can be made at the site of the stoma, excising the corners to make a circular trephine. Conventionally, the external...\\n```',\n", " 'md': '- Consider a stoma as an anastomosis between bowel and skin; you should aim to bring together well-vascularized tissues with minimal tension and pay attention to surgical technique (although to be fair, the consequences of a ‘leak’ from a stoma are less serious than those from an anastomotic leak — that’s why you made a stoma in the first place, wasn’t it?).\\n\\n- You should make the stoma trephine as small (or large) as possible to allow delivery of the bowel without any vascular compromise. The trephine may be made by elevating the skin with a tissue forceps and using a scalpel to excise a disk of skin. In my hands, this invariably results in a much too large, ragged skin defect. So as an alternative, a cruciate incision can be made at the site of the stoma, excising the corners to make a circular trephine. Conventionally, the external...\\n```',\n", " 'bBox': {'x': 72, 'y': 517, 'w': 467.93, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 193,\n", " 'text': 'oblique aponeurosis is incised in a cruciform manner, and the underlying\\nrectus abdominis is split in the line of its fibers. The posterior rectus\\nsheath and peritoneum are elevated between two clips and incised to\\nenter the abdominal cavity. Be careful not to injure the inferior\\nepigastric artery at this point — it’s a real pain in the arse to have to\\nfuddle in the depths of a small stoma incision to stop bleeding at the end\\nof a long laparotomy.\\n\\n The bowel to be used for the stoma is grasped with an atraumatic\\nclamp inserted through the stoma trephine and delivered outside. If you\\nare making a loop stoma, a nylon tape can be looped through a hole in\\nthe mesentery and used to guide out the bowel.\\n\\n Maturation of the stoma is performed (after any other wounds\\nhave been closed and dressed) as follows:\\n\\n • An ileostomy should be spouted (known as the ‘Brooke’s\\n ileostomy’) to facilitate collection of liquid effluent. The spout can be\\n created by inserting a Babcock clamp into the lumen, grasping the\\n mucosa, and pulling to create the spout. Alternatively, three everting\\n sutures are placed though the serosa about 4-5cm from the opened\\n bowel. These sutures are held in clamps until all are placed and\\n then tightened to spout the ileostomy. Be careful with these everting\\n sutures; if placed too deeply they can cause a difficult fistula at the\\n mucocutaneous junction. By varying the height of these everting\\n sutures, it is possible to create a slight downward tilt to the ileostomy\\n spout which will make stoma management easier. If the patient is\\n obese or the small bowel mesentery is short, it may be\\n extremely difficult to form a spouted ileostomy without any\\n tension. In these circumstances, it may be useful to close the\\n end of the ileum with a linear cutting staple and form a loop\\n ileostomy just proximal to this (an end-loop ileostomy). A loop\\n ileostomy is formed in a similar manner with the proximal end\\n everted to form a spout. It is crucial that the correct (i.e. proximal)\\n limb of the ileostomy is everted; as an alternative both proximal and\\n distal limbs can be spouted. A rod is almost always unnecessary\\n when creating a loop ileostomy.\\n • A colostomy, in contrast, does not need a spout. Although',\n", " 'md': '```markdown\\n## Surgical Procedure for Stoma Creation\\n\\nThe oblique aponeurosis is incised in a cruciform manner, and the underlying rectus abdominis is split in the line of its fibers. The posterior rectus sheath and peritoneum are elevated between two clips and incised to enter the abdominal cavity. Be careful not to injure the inferior epigastric artery at this point — it’s a real pain in the arse to have to fuddle in the depths of a small stoma incision to stop bleeding at the end of a long laparotomy.\\n\\nThe bowel to be used for the stoma is grasped with an atraumatic clamp inserted through the stoma trephine and delivered outside. If you are making a loop stoma, a nylon tape can be looped through a hole in the mesentery and used to guide out the bowel.\\n\\n### Maturation of the Stoma\\n\\nMaturation of the stoma is performed (after any other wounds have been closed and dressed) as follows:\\n\\n- An ileostomy should be spouted (known as the ‘Brooke’s ileostomy’) to facilitate collection of liquid effluent. The spout can be created by inserting a Babcock clamp into the lumen, grasping the mucosa, and pulling to create the spout. Alternatively, three everting sutures are placed through the serosa about 4-5 cm from the opened bowel. These sutures are held in clamps until all are placed and then tightened to spout the ileostomy. Be careful with these everting sutures; if placed too deeply they can cause a difficult fistula at the mucocutaneous junction. By varying the height of these everting sutures, it is possible to create a slight downward tilt to the ileostomy spout which will make stoma management easier. If the patient is obese or the small bowel mesentery is short, it may be extremely difficult to form a spouted ileostomy without any tension. In these circumstances, it may be useful to close the end of the ileum with a linear cutting staple and form a loop ileostomy just proximal to this (an end-loop ileostomy). A loop ileostomy is formed in a similar manner with the proximal end everted to form a spout. It is crucial that the correct (i.e. proximal) limb of the ileostomy is everted; as an alternative both proximal and distal limbs can be spouted. A rod is almost always unnecessary when creating a loop ileostomy.\\n\\n- A colostomy, in contrast, does not need a spout.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Procedure for Stoma Creation',\n", " 'md': '## Surgical Procedure for Stoma Creation',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The oblique aponeurosis is incised in a cruciform manner, and the underlying rectus abdominis is split in the line of its fibers. The posterior rectus sheath and peritoneum are elevated between two clips and incised to enter the abdominal cavity. Be careful not to injure the inferior epigastric artery at this point — it’s a real pain in the arse to have to fuddle in the depths of a small stoma incision to stop bleeding at the end of a long laparotomy.\\n\\nThe bowel to be used for the stoma is grasped with an atraumatic clamp inserted through the stoma trephine and delivered outside. If you are making a loop stoma, a nylon tape can be looped through a hole in the mesentery and used to guide out the bowel.',\n", " 'md': 'The oblique aponeurosis is incised in a cruciform manner, and the underlying rectus abdominis is split in the line of its fibers. The posterior rectus sheath and peritoneum are elevated between two clips and incised to enter the abdominal cavity. Be careful not to injure the inferior epigastric artery at this point — it’s a real pain in the arse to have to fuddle in the depths of a small stoma incision to stop bleeding at the end of a long laparotomy.\\n\\nThe bowel to be used for the stoma is grasped with an atraumatic clamp inserted through the stoma trephine and delivered outside. If you are making a loop stoma, a nylon tape can be looped through a hole in the mesentery and used to guide out the bowel.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Maturation of the Stoma',\n", " 'md': '### Maturation of the Stoma',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Maturation of the stoma is performed (after any other wounds have been closed and dressed) as follows:\\n\\n- An ileostomy should be spouted (known as the ‘Brooke’s ileostomy’) to facilitate collection of liquid effluent. The spout can be created by inserting a Babcock clamp into the lumen, grasping the mucosa, and pulling to create the spout. Alternatively, three everting sutures are placed through the serosa about 4-5 cm from the opened bowel. These sutures are held in clamps until all are placed and then tightened to spout the ileostomy. Be careful with these everting sutures; if placed too deeply they can cause a difficult fistula at the mucocutaneous junction. By varying the height of these everting sutures, it is possible to create a slight downward tilt to the ileostomy spout which will make stoma management easier. If the patient is obese or the small bowel mesentery is short, it may be extremely difficult to form a spouted ileostomy without any tension. In these circumstances, it may be useful to close the end of the ileum with a linear cutting staple and form a loop ileostomy just proximal to this (an end-loop ileostomy). A loop ileostomy is formed in a similar manner with the proximal end everted to form a spout. It is crucial that the correct (i.e. proximal) limb of the ileostomy is everted; as an alternative both proximal and distal limbs can be spouted. A rod is almost always unnecessary when creating a loop ileostomy.\\n\\n- A colostomy, in contrast, does not need a spout.\\n```',\n", " 'md': 'Maturation of the stoma is performed (after any other wounds have been closed and dressed) as follows:\\n\\n- An ileostomy should be spouted (known as the ‘Brooke’s ileostomy’) to facilitate collection of liquid effluent. The spout can be created by inserting a Babcock clamp into the lumen, grasping the mucosa, and pulling to create the spout. Alternatively, three everting sutures are placed through the serosa about 4-5 cm from the opened bowel. These sutures are held in clamps until all are placed and then tightened to spout the ileostomy. Be careful with these everting sutures; if placed too deeply they can cause a difficult fistula at the mucocutaneous junction. By varying the height of these everting sutures, it is possible to create a slight downward tilt to the ileostomy spout which will make stoma management easier. If the patient is obese or the small bowel mesentery is short, it may be extremely difficult to form a spouted ileostomy without any tension. In these circumstances, it may be useful to close the end of the ileum with a linear cutting staple and form a loop ileostomy just proximal to this (an end-loop ileostomy). A loop ileostomy is formed in a similar manner with the proximal end everted to form a spout. It is crucial that the correct (i.e. proximal) limb of the ileostomy is everted; as an alternative both proximal and distal limbs can be spouted. A rod is almost always unnecessary when creating a loop ileostomy.\\n\\n- A colostomy, in contrast, does not need a spout.\\n```',\n", " 'bBox': {'x': 72, 'y': 322, 'w': 437.04, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 194,\n", " 'text': ' traditionally a colostomy was formed flush with the skin, there are\\n some advantages to creating a ‘minimally-raised’ colostomy which\\n reduces leaking and pancaking (pooling of semi-solid stool under\\n the stoma appliance). Again, fine absorbable sutures should be\\n used to stitch the full thickness of the bowel, including the mucosa,\\n to skin following wound closure.\\n\\n After an operation to create a stoma, I usually seal the laparotomy\\nwound with a liberal application of skin glue, the theory being that if there\\nis an early leak from the stoma appliance it will not contaminate and\\ninfect the wound. Anecdotally this does seem to work, although if the\\nwound is grossly contaminated at the time of an emergency operation\\n(e.g. fecal peritonitis) this is probably pointless (under these\\ncircumstances, I either leave the skin open or gently approximate it with a\\nfew interrupted nylon sutures).\\n\\n End colostomy\\n\\n In the setting of emergency surgery, an end colostomy is usually\\nperformed during a ħartmann’s procedure to resect the sigmoid colon for\\nperforation or (perhaps less commonly nowadays) for large bowel\\nobstruction. The stoma is usually sited in the left iliac fossa. The\\nchallenge here is to deliver a sufficient length of healthy colon to create a\\ntension-free colostomy. It may be necessary to formally mobilize the\\nsplenic flexure and pedicle the colon based on the middle colic\\nvessels to achieve this. Ensure that the end of the bowel to be matured\\nas the colostomy sits ‘comfortably’ on the surface of the skin before\\nclosing the abdomen. If you are worried that it is too tight, then it\\nprobably is; under these circumstances mobilize the colon now\\nbefore closing.\\n\\n In addition to mobilizing the splenic flexure, high ligation of the inferior mesenteric artery and\\n vein would provide additional length and a ‘thinner’ mesenteric pedicle, thus facilitating a left-\\n sided colostomy in the morbidly obese patient. I find it necessary at times. Jon\\n\\n Loop colostomy',\n", " 'md': '```markdown\\n## Colostomy Techniques\\n\\nTraditionally, a colostomy was formed flush with the skin; however, there are some advantages to creating a ‘minimally-raised’ colostomy, which reduces leaking and pancaking (pooling of semi-solid stool under the stoma appliance). Fine absorbable sutures should be used to stitch the full thickness of the bowel, including the mucosa, to the skin following wound closure.\\n\\nAfter an operation to create a stoma, I usually seal the laparotomy wound with a liberal application of skin glue. The theory is that if there is an early leak from the stoma appliance, it will not contaminate and infect the wound. Anecdotally, this does seem to work, although if the wound is grossly contaminated at the time of an emergency operation (e.g., fecal peritonitis), this is probably pointless. Under these circumstances, I either leave the skin open or gently approximate it with a few interrupted nylon sutures.\\n\\n### End Colostomy\\n\\nIn the setting of emergency surgery, an end colostomy is usually performed during a Hartmann’s procedure to resect the sigmoid colon for perforation or (perhaps less commonly nowadays) for large bowel obstruction. The stoma is usually sited in the left iliac fossa. The challenge here is to deliver a sufficient length of healthy colon to create a tension-free colostomy. It may be necessary to formally mobilize the splenic flexure and pedicle the colon based on the middle colic vessels to achieve this. Ensure that the end of the bowel to be matured as the colostomy sits ‘comfortably’ on the surface of the skin before closing the abdomen. If you are worried that it is too tight, then it probably is; under these circumstances, mobilize the colon now before closing.\\n\\nIn addition to mobilizing the splenic flexure, high ligation of the inferior mesenteric artery and vein would provide additional length and a ‘thinner’ mesenteric pedicle, thus facilitating a left-sided colostomy in the morbidly obese patient. I find it necessary at times.\\n\\n### Loop Colostomy\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Colostomy Techniques',\n", " 'md': '## Colostomy Techniques',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Traditionally, a colostomy was formed flush with the skin; however, there are some advantages to creating a ‘minimally-raised’ colostomy, which reduces leaking and pancaking (pooling of semi-solid stool under the stoma appliance). Fine absorbable sutures should be used to stitch the full thickness of the bowel, including the mucosa, to the skin following wound closure.\\n\\nAfter an operation to create a stoma, I usually seal the laparotomy wound with a liberal application of skin glue. The theory is that if there is an early leak from the stoma appliance, it will not contaminate and infect the wound. Anecdotally, this does seem to work, although if the wound is grossly contaminated at the time of an emergency operation (e.g., fecal peritonitis), this is probably pointless. Under these circumstances, I either leave the skin open or gently approximate it with a few interrupted nylon sutures.',\n", " 'md': 'Traditionally, a colostomy was formed flush with the skin; however, there are some advantages to creating a ‘minimally-raised’ colostomy, which reduces leaking and pancaking (pooling of semi-solid stool under the stoma appliance). Fine absorbable sutures should be used to stitch the full thickness of the bowel, including the mucosa, to the skin following wound closure.\\n\\nAfter an operation to create a stoma, I usually seal the laparotomy wound with a liberal application of skin glue. The theory is that if there is an early leak from the stoma appliance, it will not contaminate and infect the wound. Anecdotally, this does seem to work, although if the wound is grossly contaminated at the time of an emergency operation (e.g., fecal peritonitis), this is probably pointless. Under these circumstances, I either leave the skin open or gently approximate it with a few interrupted nylon sutures.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.66, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'End Colostomy',\n", " 'md': '### End Colostomy',\n", " 'bBox': {'x': 86, 'y': 365, 'w': 118.62, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In the setting of emergency surgery, an end colostomy is usually performed during a Hartmann’s procedure to resect the sigmoid colon for perforation or (perhaps less commonly nowadays) for large bowel obstruction. The stoma is usually sited in the left iliac fossa. The challenge here is to deliver a sufficient length of healthy colon to create a tension-free colostomy. It may be necessary to formally mobilize the splenic flexure and pedicle the colon based on the middle colic vessels to achieve this. Ensure that the end of the bowel to be matured as the colostomy sits ‘comfortably’ on the surface of the skin before closing the abdomen. If you are worried that it is too tight, then it probably is; under these circumstances, mobilize the colon now before closing.\\n\\nIn addition to mobilizing the splenic flexure, high ligation of the inferior mesenteric artery and vein would provide additional length and a ‘thinner’ mesenteric pedicle, thus facilitating a left-sided colostomy in the morbidly obese patient. I find it necessary at times.',\n", " 'md': 'In the setting of emergency surgery, an end colostomy is usually performed during a Hartmann’s procedure to resect the sigmoid colon for perforation or (perhaps less commonly nowadays) for large bowel obstruction. The stoma is usually sited in the left iliac fossa. The challenge here is to deliver a sufficient length of healthy colon to create a tension-free colostomy. It may be necessary to formally mobilize the splenic flexure and pedicle the colon based on the middle colic vessels to achieve this. Ensure that the end of the bowel to be matured as the colostomy sits ‘comfortably’ on the surface of the skin before closing the abdomen. If you are worried that it is too tight, then it probably is; under these circumstances, mobilize the colon now before closing.\\n\\nIn addition to mobilizing the splenic flexure, high ligation of the inferior mesenteric artery and vein would provide additional length and a ‘thinner’ mesenteric pedicle, thus facilitating a left-sided colostomy in the morbidly obese patient. I find it necessary at times.',\n", " 'bBox': {'x': 72, 'y': 288, 'w': 467.82, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Loop Colostomy',\n", " 'md': '### Loop Colostomy',\n", " 'bBox': {'x': 86, 'y': 714, 'w': 127.82, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 195,\n", " 'text': ' Two types of loop colostomy are useful in the emergency setting — a\\ntransverse loop colostomy or a sigmoid loop colostomy:\\n\\n • A transverse loop colostomy is useful to relieve obstruction in a\\n patient who is unfit for a major resection or more rarely as part of a\\n staged procedure (you will then later proceed with a planned\\n resection). It is possible to perform a loop transverse colostomy\\n without a laparotomy by making a trephine incision in the right upper\\n quadrant; indeed on rare occasions, I have even performed this\\n under ketamine and local anaesthetic (although this wasn’t much fun\\n for surgeon or patient!). Distal limb prolapse is a fairly frequent\\n problem with a transverse loop colostomy, but this can be dealt with\\n later.\\n • A sigmoid loop colostomy is easier for a patient to care for;\\n certainly there are fewer problems with colostomy prolapse with this\\n stoma. It is useful for ‘defunctioning’ in a patient with a major\\n perineal wound (an emergency setting of Fournier’s gangrene or an\\n open fractured pelvis would be typical examples of this). It is rarely\\n possible to create a sigmoid loop colostomy to relieve large\\n bowel obstruction due to problems with length and a grossly\\n distended colon.\\n\\n End ileostomy\\n\\n In the setting of emergency surgery, an end ileostomy is usually\\nperformed as part of a subtotal colectomy for colitis. Typically it is\\nsited in the right iliac fossa, although the mobility of the small bowel\\nmesentery means that it can be sited almost anywhere if necessary. The\\nsmall bowel mesentery should be trimmed back carefully to pedicle the\\nbowel leading up to the stoma. Do this carefully or you risk completely\\ndevitalizing the stoma. Also be careful when delivering the stoma through\\nyour trephine incision; if the incision is too small or you are rough with the\\ntissues, you may strip back the mesentery during delivery (another way\\nof devitalizing the stoma). One more important issue is to preserve the\\nvasculature for a future ileal pouch — that will be viable and also reach\\nthe pelvic floor.',\n", " 'md': '```markdown\\n## Loop Colostomy Types\\n\\nTwo types of loop colostomy are useful in the emergency setting — a transverse loop colostomy or a sigmoid loop colostomy:\\n\\n- **Transverse Loop Colostomy**:\\n- Useful to relieve obstruction in a patient who is unfit for a major resection or more rarely as part of a staged procedure (you will then later proceed with a planned resection).\\n- It is possible to perform a loop transverse colostomy without a laparotomy by making a trephine incision in the right upper quadrant; indeed on rare occasions, I have even performed this under ketamine and local anaesthetic (although this wasn’t much fun for surgeon or patient!).\\n- Distal limb prolapse is a fairly frequent problem with a transverse loop colostomy, but this can be dealt with later.\\n\\n- **Sigmoid Loop Colostomy**:\\n- Easier for a patient to care for; certainly there are fewer problems with colostomy prolapse with this stoma.\\n- Useful for ‘defunctioning’ in a patient with a major perineal wound (an emergency setting of Fournier’s gangrene or an open fractured pelvis would be typical examples of this).\\n- It is rarely possible to create a sigmoid loop colostomy to relieve large bowel obstruction due to problems with length and a grossly distended colon.\\n\\n## End Ileostomy\\n\\nIn the setting of emergency surgery, an end ileostomy is usually performed as part of a subtotal colectomy for colitis. Typically it is sited in the right iliac fossa, although the mobility of the small bowel mesentery means that it can be sited almost anywhere if necessary.\\n\\n- The small bowel mesentery should be trimmed back carefully to pedicle the bowel leading up to the stoma.\\n- Do this carefully or you risk completely devitalizing the stoma.\\n- Also be careful when delivering the stoma through your trephine incision; if the incision is too small or you are rough with the tissues, you may strip back the mesentery during delivery (another way of devitalizing the stoma).\\n- One more important issue is to preserve the vasculature for a future ileal pouch — that will be viable and also reach the pelvic floor.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Loop Colostomy Types',\n", " 'md': '## Loop Colostomy Types',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Two types of loop colostomy are useful in the emergency setting — a transverse loop colostomy or a sigmoid loop colostomy:\\n\\n- **Transverse Loop Colostomy**:\\n- Useful to relieve obstruction in a patient who is unfit for a major resection or more rarely as part of a staged procedure (you will then later proceed with a planned resection).\\n- It is possible to perform a loop transverse colostomy without a laparotomy by making a trephine incision in the right upper quadrant; indeed on rare occasions, I have even performed this under ketamine and local anaesthetic (although this wasn’t much fun for surgeon or patient!).\\n- Distal limb prolapse is a fairly frequent problem with a transverse loop colostomy, but this can be dealt with later.\\n\\n- **Sigmoid Loop Colostomy**:\\n- Easier for a patient to care for; certainly there are fewer problems with colostomy prolapse with this stoma.\\n- Useful for ‘defunctioning’ in a patient with a major perineal wound (an emergency setting of Fournier’s gangrene or an open fractured pelvis would be typical examples of this).\\n- It is rarely possible to create a sigmoid loop colostomy to relieve large bowel obstruction due to problems with length and a grossly distended colon.',\n", " 'md': 'Two types of loop colostomy are useful in the emergency setting — a transverse loop colostomy or a sigmoid loop colostomy:\\n\\n- **Transverse Loop Colostomy**:\\n- Useful to relieve obstruction in a patient who is unfit for a major resection or more rarely as part of a staged procedure (you will then later proceed with a planned resection).\\n- It is possible to perform a loop transverse colostomy without a laparotomy by making a trephine incision in the right upper quadrant; indeed on rare occasions, I have even performed this under ketamine and local anaesthetic (although this wasn’t much fun for surgeon or patient!).\\n- Distal limb prolapse is a fairly frequent problem with a transverse loop colostomy, but this can be dealt with later.\\n\\n- **Sigmoid Loop Colostomy**:\\n- Easier for a patient to care for; certainly there are fewer problems with colostomy prolapse with this stoma.\\n- Useful for ‘defunctioning’ in a patient with a major perineal wound (an emergency setting of Fournier’s gangrene or an open fractured pelvis would be typical examples of this).\\n- It is rarely possible to create a sigmoid loop colostomy to relieve large bowel obstruction due to problems with length and a grossly distended colon.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.38, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'End Ileostomy',\n", " 'md': '## End Ileostomy',\n", " 'bBox': {'x': 86, 'y': 468, 'w': 113.1, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In the setting of emergency surgery, an end ileostomy is usually performed as part of a subtotal colectomy for colitis. Typically it is sited in the right iliac fossa, although the mobility of the small bowel mesentery means that it can be sited almost anywhere if necessary.\\n\\n- The small bowel mesentery should be trimmed back carefully to pedicle the bowel leading up to the stoma.\\n- Do this carefully or you risk completely devitalizing the stoma.\\n- Also be careful when delivering the stoma through your trephine incision; if the incision is too small or you are rough with the tissues, you may strip back the mesentery during delivery (another way of devitalizing the stoma).\\n- One more important issue is to preserve the vasculature for a future ileal pouch — that will be viable and also reach the pelvic floor.\\n```',\n", " 'md': 'In the setting of emergency surgery, an end ileostomy is usually performed as part of a subtotal colectomy for colitis. Typically it is sited in the right iliac fossa, although the mobility of the small bowel mesentery means that it can be sited almost anywhere if necessary.\\n\\n- The small bowel mesentery should be trimmed back carefully to pedicle the bowel leading up to the stoma.\\n- Do this carefully or you risk completely devitalizing the stoma.\\n- Also be careful when delivering the stoma through your trephine incision; if the incision is too small or you are rough with the tissues, you may strip back the mesentery during delivery (another way of devitalizing the stoma).\\n- One more important issue is to preserve the vasculature for a future ileal pouch — that will be viable and also reach the pelvic floor.\\n```',\n", " 'bBox': {'x': 72, 'y': 468, 'w': 467.57, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 196,\n", " 'text': ' Loop ileostomy\\n\\n A loop ileostomy has only limited use in emergency surgery.\\nPerhaps one example where it may be used is in a morbidly obese\\npatient with acute perforated diverticulitis. An emergency sigmoid\\nresection in this setting is a formidable challenge; occasionally it may be\\nbetter to make a proximal stoma and then later perform an elective\\nresection. When operating on a morbidly obese patient with a thick\\nabdominal wall and a short mesocolon, a loop ileostomy may be the only\\nfeasible stoma. Unfortunately such problems have already spilled from\\nthe mother of the fatties (USA) to us…\\n\\n Mucous fistula\\n\\n A mucous fistula is a stoma created from the proximal end of a\\ndiverted part of bowel. The classic example would be following an\\nemergency colectomy for colitis, when the end of the rectal stump would\\nbe brought to the surface and matured as a second stoma. Patients and\\ntheir stoma nurses on the whole hate mucous fistulae; they smell and\\nresult in a second stoma appliance. There is good evidence that in most\\ncases of ulcerative colitis, it is safe to close the rectal stump and leave it\\nintraperitoneally. Very rarely the colon is so friable that it is not possible to\\nclose the stump safely either with sutures or staples. In these\\ncircumstances, I have left a long stump and exteriorized it through the left\\niliac fossa. As the colon is friable it will not hold sutures well and I have\\nused a neonatal umbilical clamp to hold the colon above the skin level\\n(this sloughs off in a few weeks, leaving a neat and secure mucous\\nfistula).\\n\\n Ileocolostomy (double-barrel)\\n\\n If you have resected the right colon, but maintain that it is unsafe\\nto perform an ileocolic anastomosis, it is worth considering creating\\na double-barrel ileocolostomy. ħere, both ends of the bowel (terminal\\nileum and colon) are brought out through the same trephine — you can\\nsuture the back walls of the two segments together if you wish. The\\nadvantages of this approach are that for the patient there is only one',\n", " 'md': '```markdown\\n# Loop Ileostomy\\n\\nA loop ileostomy has only limited use in emergency surgery. Perhaps one example where it may be used is in a morbidly obese patient with acute perforated diverticulitis. An emergency sigmoid resection in this setting is a formidable challenge; occasionally it may be better to make a proximal stoma and then later perform an elective resection. When operating on a morbidly obese patient with a thick abdominal wall and a short mesocolon, a loop ileostomy may be the only feasible stoma. Unfortunately, such problems have already spilled from the mother of the fatties (USA) to us…\\n\\n# Mucous Fistula\\n\\nA mucous fistula is a stoma created from the proximal end of a diverted part of bowel. The classic example would be following an emergency colectomy for colitis, when the end of the rectal stump would be brought to the surface and matured as a second stoma. Patients and their stoma nurses on the whole hate mucous fistulae; they smell and result in a second stoma appliance. There is good evidence that in most cases of ulcerative colitis, it is safe to close the rectal stump and leave it intraperitoneally. Very rarely the colon is so friable that it is not possible to close the stump safely either with sutures or staples. In these circumstances, I have left a long stump and exteriorized it through the left iliac fossa. As the colon is friable it will not hold sutures well and I have used a neonatal umbilical clamp to hold the colon above the skin level (this sloughs off in a few weeks, leaving a neat and secure mucous fistula).\\n\\n# Ileocolostomy (Double-Barrel)\\n\\nIf you have resected the right colon, but maintain that it is unsafe to perform an ileocolic anastomosis, it is worth considering creating a double-barrel ileocolostomy. Here, both ends of the bowel (terminal ileum and colon) are brought out through the same trephine — you can suture the back walls of the two segments together if you wish. The advantages of this approach are that for the patient there is only one...\\n```\\n\\n### Notes:\\n- The text has been extracted and structured into markdown format.\\n- No images, graphs, or tables were identified in the provided text. If there are any images or figures on the page, please provide their descriptions or context for further extraction.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Loop Ileostomy',\n", " 'md': '# Loop Ileostomy',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 122.29, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A loop ileostomy has only limited use in emergency surgery. Perhaps one example where it may be used is in a morbidly obese patient with acute perforated diverticulitis. An emergency sigmoid resection in this setting is a formidable challenge; occasionally it may be better to make a proximal stoma and then later perform an elective resection. When operating on a morbidly obese patient with a thick abdominal wall and a short mesocolon, a loop ileostomy may be the only feasible stoma. Unfortunately, such problems have already spilled from the mother of the fatties (USA) to us…',\n", " 'md': 'A loop ileostomy has only limited use in emergency surgery. Perhaps one example where it may be used is in a morbidly obese patient with acute perforated diverticulitis. An emergency sigmoid resection in this setting is a formidable challenge; occasionally it may be better to make a proximal stoma and then later perform an elective resection. When operating on a morbidly obese patient with a thick abdominal wall and a short mesocolon, a loop ileostomy may be the only feasible stoma. Unfortunately, such problems have already spilled from the mother of the fatties (USA) to us…',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.93, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Mucous Fistula',\n", " 'md': '# Mucous Fistula',\n", " 'bBox': {'x': 86, 'y': 299, 'w': 115.86, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A mucous fistula is a stoma created from the proximal end of a diverted part of bowel. The classic example would be following an emergency colectomy for colitis, when the end of the rectal stump would be brought to the surface and matured as a second stoma. Patients and their stoma nurses on the whole hate mucous fistulae; they smell and result in a second stoma appliance. There is good evidence that in most cases of ulcerative colitis, it is safe to close the rectal stump and leave it intraperitoneally. Very rarely the colon is so friable that it is not possible to close the stump safely either with sutures or staples. In these circumstances, I have left a long stump and exteriorized it through the left iliac fossa. As the colon is friable it will not hold sutures well and I have used a neonatal umbilical clamp to hold the colon above the skin level (this sloughs off in a few weeks, leaving a neat and secure mucous fistula).',\n", " 'md': 'A mucous fistula is a stoma created from the proximal end of a diverted part of bowel. The classic example would be following an emergency colectomy for colitis, when the end of the rectal stump would be brought to the surface and matured as a second stoma. Patients and their stoma nurses on the whole hate mucous fistulae; they smell and result in a second stoma appliance. There is good evidence that in most cases of ulcerative colitis, it is safe to close the rectal stump and leave it intraperitoneally. Very rarely the colon is so friable that it is not possible to close the stump safely either with sutures or staples. In these circumstances, I have left a long stump and exteriorized it through the left iliac fossa. As the colon is friable it will not hold sutures well and I have used a neonatal umbilical clamp to hold the colon above the skin level (this sloughs off in a few weeks, leaving a neat and secure mucous fistula).',\n", " 'bBox': {'x': 72, 'y': 299, 'w': 467.61, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Ileocolostomy (Double-Barrel)',\n", " 'md': '# Ileocolostomy (Double-Barrel)',\n", " 'bBox': {'x': 86, 'y': 594, 'w': 232.62, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'If you have resected the right colon, but maintain that it is unsafe to perform an ileocolic anastomosis, it is worth considering creating a double-barrel ileocolostomy. Here, both ends of the bowel (terminal ileum and colon) are brought out through the same trephine — you can suture the back walls of the two segments together if you wish. The advantages of this approach are that for the patient there is only one...\\n```',\n", " 'md': 'If you have resected the right colon, but maintain that it is unsafe to perform an ileocolic anastomosis, it is worth considering creating a double-barrel ileocolostomy. Here, both ends of the bowel (terminal ileum and colon) are brought out through the same trephine — you can suture the back walls of the two segments together if you wish. The advantages of this approach are that for the patient there is only one...\\n```',\n", " 'bBox': {'x': 72, 'y': 630, 'w': 467.61, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text has been extracted and structured into markdown format.\\n- No images, graphs, or tables were identified in the provided text. If there are any images or figures on the page, please provide their descriptions or context for further extraction.',\n", " 'md': '- The text has been extracted and structured into markdown format.\\n- No images, graphs, or tables were identified in the provided text. If there are any images or figures on the page, please provide their descriptions or context for further extraction.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 197,\n", " 'text': 'stoma appliance needed and for the surgeon it is then possible to close\\nthis later without a formal laparotomy. An ileocolostomy is useful in two\\nsituations: following a reoperation for a leaking ileocolic anastomosis or\\nat the primary procedure when the risk of a leak is high (classic examples\\nof this are an emaciated, steroid-dependent patient with Crohn’s disease\\nor a patient with fecal peritonitis from a perforated caecum).\\n\\n Jejunostomy\\n\\n Rarely will you need to create a jejunostomy. There is often a\\nreluctance to create a proximal stoma due to the perceived risks of a\\nhigh-output stoma; however, in some situations you will need to balance\\nthis risk against that of an anastomotic leak or uncontrolled abdominal\\nsepsis. You may need to make a jejunostomy when there is an\\nunrecognized enterotomy in the proximal bowel or to divert the intestinal\\ncontents from a complex enterocutaneous fistula. This is the ultimate\\nbailout stoma and usually indicates that the patient has had an\\nabdominal catastrophe or that the surgeon has cocked up. Because\\nyou will rarely need to do this it will be an unfamiliar procedure to you.\\nħere are some tips:\\n\\n • Make your stoma trephine where the relevant piece of jejunum will\\n reach (this is usually in the left upper quadrant).\\n • Pull the end or loop of jejunum through the trephine as normal.\\n • You will find that it’s much harder to spout a jejunostomy than an\\n ileostomy due to the thickness of the bowel wall and the short\\n mesentery; don’t worry too much about that, remember this is a\\n bailout stoma!\\n • The vascular pattern of the jejunum does not allow you to pedicle\\n the bowel as you would do for an end ileostomy, so don’t bother\\n trying; you are likely to devascularize a section of jejunum if you do.\\n • Open and mature the stoma as usual with interrupted fine\\n absorbable sutures.\\n • It is likely to look awful compared to your usual stomata, c’est la vie!',\n", " 'md': '```markdown\\n## Jejunostomy\\n\\nRarely will you need to create a jejunostomy. There is often a reluctance to create a proximal stoma due to the perceived risks of a high-output stoma; however, in some situations, you will need to balance this risk against that of an anastomotic leak or uncontrolled abdominal sepsis. You may need to make a jejunostomy when there is an unrecognized enterotomy in the proximal bowel or to divert the intestinal contents from a complex enterocutaneous fistula. This is the ultimate bailout stoma and usually indicates that the patient has had an abdominal catastrophe or that the surgeon has made a mistake. Because you will rarely need to do this, it will be an unfamiliar procedure to you. Here are some tips:\\n\\n- Make your stoma trephine where the relevant piece of jejunum will reach (this is usually in the left upper quadrant).\\n- Pull the end or loop of jejunum through the trephine as normal.\\n- You will find that it’s much harder to spout a jejunostomy than an ileostomy due to the thickness of the bowel wall and the short mesentery; don’t worry too much about that, remember this is a bailout stoma!\\n- The vascular pattern of the jejunum does not allow you to pedicle the bowel as you would do for an end ileostomy, so don’t bother trying; you are likely to devascularize a section of jejunum if you do.\\n- Open and mature the stoma as usual with interrupted fine absorbable sutures.\\n- It is likely to look awful compared to your usual stomata, c’est la vie!\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Jejunostomy',\n", " 'md': '## Jejunostomy',\n", " 'bBox': {'x': 86, 'y': 211, 'w': 102.09, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Rarely will you need to create a jejunostomy. There is often a reluctance to create a proximal stoma due to the perceived risks of a high-output stoma; however, in some situations, you will need to balance this risk against that of an anastomotic leak or uncontrolled abdominal sepsis. You may need to make a jejunostomy when there is an unrecognized enterotomy in the proximal bowel or to divert the intestinal contents from a complex enterocutaneous fistula. This is the ultimate bailout stoma and usually indicates that the patient has had an abdominal catastrophe or that the surgeon has made a mistake. Because you will rarely need to do this, it will be an unfamiliar procedure to you. Here are some tips:\\n\\n- Make your stoma trephine where the relevant piece of jejunum will reach (this is usually in the left upper quadrant).\\n- Pull the end or loop of jejunum through the trephine as normal.\\n- You will find that it’s much harder to spout a jejunostomy than an ileostomy due to the thickness of the bowel wall and the short mesentery; don’t worry too much about that, remember this is a bailout stoma!\\n- The vascular pattern of the jejunum does not allow you to pedicle the bowel as you would do for an end ileostomy, so don’t bother trying; you are likely to devascularize a section of jejunum if you do.\\n- Open and mature the stoma as usual with interrupted fine absorbable sutures.\\n- It is likely to look awful compared to your usual stomata, c’est la vie!\\n```',\n", " 'md': 'Rarely will you need to create a jejunostomy. There is often a reluctance to create a proximal stoma due to the perceived risks of a high-output stoma; however, in some situations, you will need to balance this risk against that of an anastomotic leak or uncontrolled abdominal sepsis. You may need to make a jejunostomy when there is an unrecognized enterotomy in the proximal bowel or to divert the intestinal contents from a complex enterocutaneous fistula. This is the ultimate bailout stoma and usually indicates that the patient has had an abdominal catastrophe or that the surgeon has made a mistake. Because you will rarely need to do this, it will be an unfamiliar procedure to you. Here are some tips:\\n\\n- Make your stoma trephine where the relevant piece of jejunum will reach (this is usually in the left upper quadrant).\\n- Pull the end or loop of jejunum through the trephine as normal.\\n- You will find that it’s much harder to spout a jejunostomy than an ileostomy due to the thickness of the bowel wall and the short mesentery; don’t worry too much about that, remember this is a bailout stoma!\\n- The vascular pattern of the jejunum does not allow you to pedicle the bowel as you would do for an end ileostomy, so don’t bother trying; you are likely to devascularize a section of jejunum if you do.\\n- Open and mature the stoma as usual with interrupted fine absorbable sutures.\\n- It is likely to look awful compared to your usual stomata, c’est la vie!\\n```',\n", " 'bBox': {'x': 72, 'y': 211, 'w': 467.5, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 198,\n", " 'text': ' ‘Blow-hole’ colostomy and cecostomy\\n\\n Some surgeons think of blow-hole stomata as obsolete, and others\\ndon’t even know what they are. But we think this deserves a brief\\nmention, for the rare case when it may be the best solution\\navailable.\\n\\n A blow-hole stoma is constructed using only the anterior bowel wall,\\nwhich is opened and sutured to the skin, without mobilizing or\\nexteriorizing the bowel above the skin level. The sole purpose of this\\nstoma is decompression, as it does not completely divert the fecal\\nstream, so it may be useful to alleviate colonic obstruction when more\\ncomplicated solutions are not appropriate due to the patient’s general\\ncondition. Naturally, it is reserved for old, debilitated, high-risk\\npatients, and its main advantage is the simplicity that makes it\\npossible to construct under local anesthesia.\\n\\n The classic blow-hole stoma is a surgical cecostomy (as opposed\\nto tube-cecostomy, that rarely functions as expected due to blockage of\\nthe tube and leakage around it). Take, for example, a 90-year-old patient\\nwith severe heart failure and an obstructing tumor at the splenic flexure:\\nhis best chance to leave the hospital would be by performing the minimal\\nprocedure to decompress the bowel before it perforates, without trying to\\n‘cure’ him by heroic colectomy. Even a transverse loop colostomy, which\\nmandates general anesthesia, may be too much for him. So through a\\nMcBurney incision (as for appendectomy) you eviscerate the cecum\\nand fix the eviscerated segment to the abdominal wall defect all\\naround. Then you open the cecum, suck the crap out, and you mature\\nthe opening to the skin. The skin level stoma is not bulky, and usually\\neasy to manage. Its main complications are retraction and stenosis, but\\nthese can be prevented by the steps I have mentioned above ( Figure\\n14.5).',\n", " 'md': '# Blow-hole Colostomy and Cecostomy\\n\\nSome surgeons think of blow-hole stomata as obsolete, and others don’t even know what they are. But we think this deserves a brief mention, for the rare case when it may be the best solution available.\\n\\nA blow-hole stoma is constructed using only the anterior bowel wall, which is opened and sutured to the skin, without mobilizing or exteriorizing the bowel above the skin level. The sole purpose of this stoma is decompression, as it does not completely divert the fecal stream, so it may be useful to alleviate colonic obstruction when more complicated solutions are not appropriate due to the patient’s general condition. Naturally, it is reserved for old, debilitated, high-risk patients, and its main advantage is the simplicity that makes it possible to construct under local anesthesia.\\n\\nThe classic blow-hole stoma is a surgical cecostomy (as opposed to tube-cecostomy, that rarely functions as expected due to blockage of the tube and leakage around it). Take, for example, a 90-year-old patient with severe heart failure and an obstructing tumor at the splenic flexure: his best chance to leave the hospital would be by performing the minimal procedure to decompress the bowel before it perforates, without trying to ‘cure’ him by heroic colectomy. Even a transverse loop colostomy, which mandates general anesthesia, may be too much for him. So through a McBurney incision (as for appendectomy) you eviscerate the cecum and fix the eviscerated segment to the abdominal wall defect all around. Then you open the cecum, suck the crap out, and you mature the opening to the skin. The skin level stoma is not bulky, and usually easy to manage. Its main complications are retraction and stenosis, but these can be prevented by the steps I have mentioned above (Figure 14.5).\\n\\n## Figure 14.5\\n*Description*: This figure likely illustrates the surgical procedure for creating a blow-hole stoma or cecostomy, showing the steps involved in eviscerating the cecum and suturing it to the abdominal wall. The image may include anatomical references and possibly highlight the incision site.\\n\\n*Summary*: The figure provides a visual representation of the blow-hole stoma procedure, emphasizing its simplicity and suitability for high-risk patients.',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Blow-hole Colostomy and Cecostomy',\n", " 'md': '# Blow-hole Colostomy and Cecostomy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Some surgeons think of blow-hole stomata as obsolete, and others don’t even know what they are. But we think this deserves a brief mention, for the rare case when it may be the best solution available.\\n\\nA blow-hole stoma is constructed using only the anterior bowel wall, which is opened and sutured to the skin, without mobilizing or exteriorizing the bowel above the skin level. The sole purpose of this stoma is decompression, as it does not completely divert the fecal stream, so it may be useful to alleviate colonic obstruction when more complicated solutions are not appropriate due to the patient’s general condition. Naturally, it is reserved for old, debilitated, high-risk patients, and its main advantage is the simplicity that makes it possible to construct under local anesthesia.\\n\\nThe classic blow-hole stoma is a surgical cecostomy (as opposed to tube-cecostomy, that rarely functions as expected due to blockage of the tube and leakage around it). Take, for example, a 90-year-old patient with severe heart failure and an obstructing tumor at the splenic flexure: his best chance to leave the hospital would be by performing the minimal procedure to decompress the bowel before it perforates, without trying to ‘cure’ him by heroic colectomy. Even a transverse loop colostomy, which mandates general anesthesia, may be too much for him. So through a McBurney incision (as for appendectomy) you eviscerate the cecum and fix the eviscerated segment to the abdominal wall defect all around. Then you open the cecum, suck the crap out, and you mature the opening to the skin. The skin level stoma is not bulky, and usually easy to manage. Its main complications are retraction and stenosis, but these can be prevented by the steps I have mentioned above (Figure 14.5).',\n", " 'md': 'Some surgeons think of blow-hole stomata as obsolete, and others don’t even know what they are. But we think this deserves a brief mention, for the rare case when it may be the best solution available.\\n\\nA blow-hole stoma is constructed using only the anterior bowel wall, which is opened and sutured to the skin, without mobilizing or exteriorizing the bowel above the skin level. The sole purpose of this stoma is decompression, as it does not completely divert the fecal stream, so it may be useful to alleviate colonic obstruction when more complicated solutions are not appropriate due to the patient’s general condition. Naturally, it is reserved for old, debilitated, high-risk patients, and its main advantage is the simplicity that makes it possible to construct under local anesthesia.\\n\\nThe classic blow-hole stoma is a surgical cecostomy (as opposed to tube-cecostomy, that rarely functions as expected due to blockage of the tube and leakage around it). Take, for example, a 90-year-old patient with severe heart failure and an obstructing tumor at the splenic flexure: his best chance to leave the hospital would be by performing the minimal procedure to decompress the bowel before it perforates, without trying to ‘cure’ him by heroic colectomy. Even a transverse loop colostomy, which mandates general anesthesia, may be too much for him. So through a McBurney incision (as for appendectomy) you eviscerate the cecum and fix the eviscerated segment to the abdominal wall defect all around. Then you open the cecum, suck the crap out, and you mature the opening to the skin. The skin level stoma is not bulky, and usually easy to manage. Its main complications are retraction and stenosis, but these can be prevented by the steps I have mentioned above (Figure 14.5).',\n", " 'bBox': {'x': 72, 'y': 173, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 14.5',\n", " 'md': '## Figure 14.5',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*Description*: This figure likely illustrates the surgical procedure for creating a blow-hole stoma or cecostomy, showing the steps involved in eviscerating the cecum and suturing it to the abdominal wall. The image may include anatomical references and possibly highlight the incision site.\\n\\n*Summary*: The figure provides a visual representation of the blow-hole stoma procedure, emphasizing its simplicity and suitability for high-risk patients.',\n", " 'md': '*Description*: This figure likely illustrates the surgical procedure for creating a blow-hole stoma or cecostomy, showing the steps involved in eviscerating the cecum and suturing it to the abdominal wall. The image may include anatomical references and possibly highlight the incision site.\\n\\n*Summary*: The figure provides a visual representation of the blow-hole stoma procedure, emphasizing its simplicity and suitability for high-risk patients.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'these can be prevented by the steps I have mentioned above ( Figure 14.5).'}]},\n", " {'page': 199,\n", " 'text': ' Sutures to skin\\n Skin Mucosa Skin\\n Fat Fat\\n Muscle Muscle\\n Lumen\\n PeRYA 2014\\n Figure 14.5. Blow-hole stoma.\\n\\n Making a stoma in a fat person\\n\\n The challenge of making a stoma in the ever too frequent\\nmorbidly obese patient cannot be underestimated. ħere are some\\ntips for when you find yourself in this sorry (reflected by the number of\\ntimes the F word is uttered during the operation) situation:\\n\\n • Site the stoma higher than you would normally (it will not be visible\\n to the patient if it’s under the fat apron).\\n • Make the stoma trephine larger (the mesocolon will be thick and\\n friable and will not come through a conventional-sized hole).\\n • Make sure that you fully mobilize the colon before making a\\n colostomy (the panniculus and its attached colostomy moves\\n vertically several inches on standing).\\n • Consider an end-loop stoma if you are still struggling for length\\n (to do this staple off the end of the bowel and then make a loop\\n stoma just proximal to this).',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\nSutures to skin\\nSkin Mucosa Skin\\nFat Fat\\nMuscle Muscle\\nLumen\\nPeRYA 2014\\n\\nFigure 14.5. Blow-hole stoma.\\n\\nMaking a stoma in a fat person\\n\\nThe challenge of making a stoma in the ever too frequent morbidly obese patient cannot be underestimated. Here are some tips for when you find yourself in this sorry (reflected by the number of times the F word is uttered during the operation) situation:\\n\\n- Site the stoma higher than you would normally (it will not be visible to the patient if it’s under the fat apron).\\n- Make the stoma trephine larger (the mesocolon will be thick and friable and will not come through a conventional-sized hole).\\n- Make sure that you fully mobilize the colon before making a colostomy (the panniculus and its attached colostomy moves vertically several inches on standing).\\n- Consider an end-loop stoma if you are still struggling for length (to do this staple off the end of the bowel and then make a loop stoma just proximal to this).\\n\\n## Image Identification and Description\\n**Figure 14.5**: This figure illustrates a blow-hole stoma, depicting the anatomical layers involved in the procedure. The diagram shows the relationship between skin, fat, muscle, and the lumen, providing a visual representation of the surgical site. The image is crucial for understanding the challenges faced when creating a stoma in a morbidly obese patient.\\n\\n### Summary\\nThe page discusses the complexities of creating a stoma in morbidly obese patients, providing practical tips for surgeons. The accompanying figure (Figure 14.5) visually represents the anatomical considerations necessary for this procedure.\\n```',\n", " 'images': [{'name': 'img_p198_1.png',\n", " 'height': 549,\n", " 'width': 688,\n", " 'x': 136.07999999999993,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1182,\n", " 'original_height': 943}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Sutures to skin\\nSkin Mucosa Skin\\nFat Fat\\nMuscle Muscle\\nLumen\\nPeRYA 2014\\n\\nFigure 14.5. Blow-hole stoma.\\n\\nMaking a stoma in a fat person\\n\\nThe challenge of making a stoma in the ever too frequent morbidly obese patient cannot be underestimated. Here are some tips for when you find yourself in this sorry (reflected by the number of times the F word is uttered during the operation) situation:\\n\\n- Site the stoma higher than you would normally (it will not be visible to the patient if it’s under the fat apron).\\n- Make the stoma trephine larger (the mesocolon will be thick and friable and will not come through a conventional-sized hole).\\n- Make sure that you fully mobilize the colon before making a colostomy (the panniculus and its attached colostomy moves vertically several inches on standing).\\n- Consider an end-loop stoma if you are still struggling for length (to do this staple off the end of the bowel and then make a loop stoma just proximal to this).',\n", " 'md': 'Sutures to skin\\nSkin Mucosa Skin\\nFat Fat\\nMuscle Muscle\\nLumen\\nPeRYA 2014\\n\\nFigure 14.5. Blow-hole stoma.\\n\\nMaking a stoma in a fat person\\n\\nThe challenge of making a stoma in the ever too frequent morbidly obese patient cannot be underestimated. Here are some tips for when you find yourself in this sorry (reflected by the number of times the F word is uttered during the operation) situation:\\n\\n- Site the stoma higher than you would normally (it will not be visible to the patient if it’s under the fat apron).\\n- Make the stoma trephine larger (the mesocolon will be thick and friable and will not come through a conventional-sized hole).\\n- Make sure that you fully mobilize the colon before making a colostomy (the panniculus and its attached colostomy moves vertically several inches on standing).\\n- Consider an end-loop stoma if you are still struggling for length (to do this staple off the end of the bowel and then make a loop stoma just proximal to this).',\n", " 'bBox': {'x': 72, 'y': 147.08, 'w': 436.98, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 14.5**: This figure illustrates a blow-hole stoma, depicting the anatomical layers involved in the procedure. The diagram shows the relationship between skin, fat, muscle, and the lumen, providing a visual representation of the surgical site. The image is crucial for understanding the challenges faced when creating a stoma in a morbidly obese patient.',\n", " 'md': '**Figure 14.5**: This figure illustrates a blow-hole stoma, depicting the anatomical layers involved in the procedure. The diagram shows the relationship between skin, fat, muscle, and the lumen, providing a visual representation of the surgical site. The image is crucial for understanding the challenges faced when creating a stoma in a morbidly obese patient.',\n", " 'bBox': {'x': 136.08, 'y': 186.14, 'w': 82.67, 'h': 12.86}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The page discusses the complexities of creating a stoma in morbidly obese patients, providing practical tips for surgeons. The accompanying figure (Figure 14.5) visually represents the anatomical considerations necessary for this procedure.\\n```',\n", " 'md': 'The page discusses the complexities of creating a stoma in morbidly obese patients, providing practical tips for surgeons. The accompanying figure (Figure 14.5) visually represents the anatomical considerations necessary for this procedure.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 200,\n", " 'text': ' • Go back to your room and open the well-earned bottle of\\n Glensomething.\\n\\n Postoperative care of a stoma\\n\\n Although not quite a window into the soul, a stoma does allow you\\ndirect access to visualize the visceral circulation. You should therefore\\nlook at the stoma directly on the first postoperative day. A transparent\\nstoma pouch usually allows a good view of a stoma, but if you can’t see it\\nproperly don’t be lazy; remove the stoma pouch and make sure that you\\nhave a good view; if the light on the ward is poor then use a torch\\n(Americanos would call it a flashlight).\\n\\n Stoma ischemia\\n\\n Stoma ischemia is usually evident early in the postoperative\\nperiod. This may be caused by either a generalized state of hypotension\\nor, more commonly, a technical problem during the construction of the\\nstoma. The severity of ischemia may vary from minor mucosal\\nhypoperfusion to a black, completely necrotic stoma. Again, all newly\\nformed stomata should be inspected the day following surgery to\\nassess their viability. If a colostomy looks ischemic, it can be useful to\\nuse either a proctoscope or a test tube inserted into the stoma to assess\\nthe viability of the bowel under the fascia. Use a pen torch to assess the\\nviability of the mucosa.\\n\\n Urgent surgery to resect and refashion the stoma will be needed if\\nthe bowel leading up to the colostomy is necrotic. Conversely, if the\\nbowel immediately under the stoma is pink, then you can afford to wait. It\\nis likely that the mucosa will slough off the stoma and that the late result\\nwill be a stenosed stoma. This can be dealt with on its own merits later,\\nbut this is preferable to a difficult relaparotomy in the early postoperative\\nperiod. A black ileostomy in contrast should usually be revised\\nurgently (here length is usually less of an issue, and it is often possible\\nto revise an end ileostomy locally without a laparotomy).\\n\\n If the colostomy appears black then it is black — do not succumb',\n", " 'md': '```markdown\\n# Postoperative Care of a Stoma\\n\\nAlthough not quite a window into the soul, a stoma does allow you direct access to visualize the visceral circulation. You should therefore look at the stoma directly on the first postoperative day. A transparent stoma pouch usually allows a good view of a stoma, but if you can’t see it properly don’t be lazy; remove the stoma pouch and make sure that you have a good view; if the light on the ward is poor then use a torch (Americans would call it a flashlight).\\n\\n## Stoma Ischemia\\n\\nStoma ischemia is usually evident early in the postoperative period. This may be caused by either a generalized state of hypotension or, more commonly, a technical problem during the construction of the stoma. The severity of ischemia may vary from minor mucosal hypoperfusion to a black, completely necrotic stoma. Again, all newly formed stomata should be inspected the day following surgery to assess their viability. If a colostomy looks ischemic, it can be useful to use either a proctoscope or a test tube inserted into the stoma to assess the viability of the bowel under the fascia. Use a pen torch to assess the viability of the mucosa.\\n\\nUrgent surgery to resect and refashion the stoma will be needed if the bowel leading up to the colostomy is necrotic. Conversely, if the bowel immediately under the stoma is pink, then you can afford to wait. It is likely that the mucosa will slough off the stoma and that the late result will be a stenosed stoma. This can be dealt with on its own merits later, but this is preferable to a difficult relaparotomy in the early postoperative period. A black ileostomy in contrast should usually be revised urgently (here length is usually less of an issue, and it is often possible to revise an end ileostomy locally without a laparotomy).\\n\\nIf the colostomy appears black then it is black — do not succumb.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Postoperative Care of a Stoma',\n", " 'md': '# Postoperative Care of a Stoma',\n", " 'bBox': {'x': 86, 'y': 147, 'w': 235.42, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Although not quite a window into the soul, a stoma does allow you direct access to visualize the visceral circulation. You should therefore look at the stoma directly on the first postoperative day. A transparent stoma pouch usually allows a good view of a stoma, but if you can’t see it properly don’t be lazy; remove the stoma pouch and make sure that you have a good view; if the light on the ward is poor then use a torch (Americans would call it a flashlight).',\n", " 'md': 'Although not quite a window into the soul, a stoma does allow you direct access to visualize the visceral circulation. You should therefore look at the stoma directly on the first postoperative day. A transparent stoma pouch usually allows a good view of a stoma, but if you can’t see it properly don’t be lazy; remove the stoma pouch and make sure that you have a good view; if the light on the ward is poor then use a torch (Americans would call it a flashlight).',\n", " 'bBox': {'x': 72, 'y': 233, 'w': 467.6, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Stoma Ischemia',\n", " 'md': '## Stoma Ischemia',\n", " 'bBox': {'x': 86, 'y': 325, 'w': 125.99, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Stoma ischemia is usually evident early in the postoperative period. This may be caused by either a generalized state of hypotension or, more commonly, a technical problem during the construction of the stoma. The severity of ischemia may vary from minor mucosal hypoperfusion to a black, completely necrotic stoma. Again, all newly formed stomata should be inspected the day following surgery to assess their viability. If a colostomy looks ischemic, it can be useful to use either a proctoscope or a test tube inserted into the stoma to assess the viability of the bowel under the fascia. Use a pen torch to assess the viability of the mucosa.\\n\\nUrgent surgery to resect and refashion the stoma will be needed if the bowel leading up to the colostomy is necrotic. Conversely, if the bowel immediately under the stoma is pink, then you can afford to wait. It is likely that the mucosa will slough off the stoma and that the late result will be a stenosed stoma. This can be dealt with on its own merits later, but this is preferable to a difficult relaparotomy in the early postoperative period. A black ileostomy in contrast should usually be revised urgently (here length is usually less of an issue, and it is often possible to revise an end ileostomy locally without a laparotomy).\\n\\nIf the colostomy appears black then it is black — do not succumb.\\n```',\n", " 'md': 'Stoma ischemia is usually evident early in the postoperative period. This may be caused by either a generalized state of hypotension or, more commonly, a technical problem during the construction of the stoma. The severity of ischemia may vary from minor mucosal hypoperfusion to a black, completely necrotic stoma. Again, all newly formed stomata should be inspected the day following surgery to assess their viability. If a colostomy looks ischemic, it can be useful to use either a proctoscope or a test tube inserted into the stoma to assess the viability of the bowel under the fascia. Use a pen torch to assess the viability of the mucosa.\\n\\nUrgent surgery to resect and refashion the stoma will be needed if the bowel leading up to the colostomy is necrotic. Conversely, if the bowel immediately under the stoma is pink, then you can afford to wait. It is likely that the mucosa will slough off the stoma and that the late result will be a stenosed stoma. This can be dealt with on its own merits later, but this is preferable to a difficult relaparotomy in the early postoperative period. A black ileostomy in contrast should usually be revised urgently (here length is usually less of an issue, and it is often possible to revise an end ileostomy locally without a laparotomy).\\n\\nIf the colostomy appears black then it is black — do not succumb.\\n```',\n", " 'bBox': {'x': 72, 'y': 325, 'w': 467.83, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 201,\n", " 'text': 'to that stupid little voice in your brain telling you that it isn’t black!\\n\\n High-output stoma\\n\\n A fully adapted end ileostomy has a daily output of approximately\\n500ml. In the initial postoperative period, ileostomy output is often much\\ngreater than this (1000-1800ml). A high-output state occurs in about 15%\\nof patients having an ileostomy. This high volume of stoma output usually\\nreduces in the first few postoperative days. The factors causing a high-\\noutput stoma (greater than 2L/day) are all more common in patients\\nhaving emergency surgery:\\n\\n • Proximal stomata (i.e. jejunostomy).\\n • Intra-abdominal sepsis.\\n • Following resolution of postoperative ileus or small bowel\\n obstruction.\\n\\n If a stoma is producing more than 1000ml/day, then intravenous fluid\\nreplacement with ħartmann’s solution (Ringer’s) or normal saline will be\\nneeded. Restriction of oral hypotonic fluids will help reduce stoma output.\\nClose monitoring of electrolytes is important; deficiencies of sodium,\\nmagnesium, and potassium are common in these patients.\\n\\n Other adjuncts to reduce a high-output stoma include:\\n\\n • Low-fiber diet.\\n • Proton pump inhibitors (such as omeprazole, 40mg daily).\\n • Antimotility agents such as loperamide (in this circumstance, a high\\n dose of up to 8mg four times a day may be needed) or codeine\\n phosphate (60mg four times a day).\\n\\n Mucocutaneous separation',\n", " 'md': '```markdown\\n## High-output stoma\\n\\nA fully adapted end ileostomy has a daily output of approximately 500ml. In the initial postoperative period, ileostomy output is often much greater than this (1000-1800ml). A high-output state occurs in about 15% of patients having an ileostomy. This high volume of stoma output usually reduces in the first few postoperative days. The factors causing a high-output stoma (greater than 2L/day) are all more common in patients having emergency surgery:\\n\\n- Proximal stomata (i.e. jejunostomy).\\n- Intra-abdominal sepsis.\\n- Following resolution of postoperative ileus or small bowel obstruction.\\n\\nIf a stoma is producing more than 1000ml/day, then intravenous fluid replacement with Hartmann’s solution (Ringer’s) or normal saline will be needed. Restriction of oral hypotonic fluids will help reduce stoma output. Close monitoring of electrolytes is important; deficiencies of sodium, magnesium, and potassium are common in these patients.\\n\\nOther adjuncts to reduce a high-output stoma include:\\n\\n- Low-fiber diet.\\n- Proton pump inhibitors (such as omeprazole, 40mg daily).\\n- Antimotility agents such as loperamide (in this circumstance, a high dose of up to 8mg four times a day may be needed) or codeine phosphate (60mg four times a day).\\n\\n### Mucocutaneous separation\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'High-output stoma',\n", " 'md': '## High-output stoma',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 147.11, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A fully adapted end ileostomy has a daily output of approximately 500ml. In the initial postoperative period, ileostomy output is often much greater than this (1000-1800ml). A high-output state occurs in about 15% of patients having an ileostomy. This high volume of stoma output usually reduces in the first few postoperative days. The factors causing a high-output stoma (greater than 2L/day) are all more common in patients having emergency surgery:\\n\\n- Proximal stomata (i.e. jejunostomy).\\n- Intra-abdominal sepsis.\\n- Following resolution of postoperative ileus or small bowel obstruction.\\n\\nIf a stoma is producing more than 1000ml/day, then intravenous fluid replacement with Hartmann’s solution (Ringer’s) or normal saline will be needed. Restriction of oral hypotonic fluids will help reduce stoma output. Close monitoring of electrolytes is important; deficiencies of sodium, magnesium, and potassium are common in these patients.\\n\\nOther adjuncts to reduce a high-output stoma include:\\n\\n- Low-fiber diet.\\n- Proton pump inhibitors (such as omeprazole, 40mg daily).\\n- Antimotility agents such as loperamide (in this circumstance, a high dose of up to 8mg four times a day may be needed) or codeine phosphate (60mg four times a day).',\n", " 'md': 'A fully adapted end ileostomy has a daily output of approximately 500ml. In the initial postoperative period, ileostomy output is often much greater than this (1000-1800ml). A high-output state occurs in about 15% of patients having an ileostomy. This high volume of stoma output usually reduces in the first few postoperative days. The factors causing a high-output stoma (greater than 2L/day) are all more common in patients having emergency surgery:\\n\\n- Proximal stomata (i.e. jejunostomy).\\n- Intra-abdominal sepsis.\\n- Following resolution of postoperative ileus or small bowel obstruction.\\n\\nIf a stoma is producing more than 1000ml/day, then intravenous fluid replacement with Hartmann’s solution (Ringer’s) or normal saline will be needed. Restriction of oral hypotonic fluids will help reduce stoma output. Close monitoring of electrolytes is important; deficiencies of sodium, magnesium, and potassium are common in these patients.\\n\\nOther adjuncts to reduce a high-output stoma include:\\n\\n- Low-fiber diet.\\n- Proton pump inhibitors (such as omeprazole, 40mg daily).\\n- Antimotility agents such as loperamide (in this circumstance, a high dose of up to 8mg four times a day may be needed) or codeine phosphate (60mg four times a day).',\n", " 'bBox': {'x': 72, 'y': 129, 'w': 467.96, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Mucocutaneous separation',\n", " 'md': '### Mucocutaneous separation',\n", " 'bBox': {'x': 86, 'y': 682, 'w': 214.28, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 202,\n", " 'text': ' Mucocutaneous separation is relatively common after an\\nemergency operation to form a stoma. The degree of separation is\\nusually fairly minor and with careful stoma management most will heal on\\ntheir own. Attempts at resuturing are usually not helpful; resist the urge to\\nrevise the stoma early on as this will be difficult and potentially\\nhazardous.\\n\\n Other stoma complications\\n\\n As a surgeon practicing emergency abdominal surgery, you will be well\\naware of the many other later complications which can occur after\\ncreating a stoma. Further discussion of the management of these\\ncomplications is beyond the scope of this book. The interested reader is\\nadvised to consult my chapter (#14) in Schein’s Common Sense\\nPrevention and Management of Surgical Complications for a more in-\\ndepth discussion.\\n\\n Final remarks\\n\\n A well-constructed stoma can make all the difference between success and failure of an\\n emergency abdominal operation. Consider the stoma to be an anastomosis between skin and\\n bowel and you won’t go far wrong. Don’t close the abdomen and go for a coffee, leaving the\\n resident to mature the stoma unsupervised; a tiny error here can make a huge difference.\\n\\n This book is about emergency treatment so we won’t bore you with late\\ncomplications or the ‘take down’ of the stoma. But we’ll end with a\\ncomment by a wise man.\\n\\n “There is no law that says that a colostomy must be\\n closed.”\\n Leo A. Gordon',\n", " 'md': '```markdown\\n## Mucocutaneous Separation\\n\\nMucocutaneous separation is relatively common after an emergency operation to form a stoma. The degree of separation is usually fairly minor and with careful stoma management, most will heal on their own. Attempts at resuturing are usually not helpful; resist the urge to revise the stoma early on as this will be difficult and potentially hazardous.\\n\\n### Other Stoma Complications\\n\\nAs a surgeon practicing emergency abdominal surgery, you will be well aware of the many other later complications which can occur after creating a stoma. Further discussion of the management of these complications is beyond the scope of this book. The interested reader is advised to consult my chapter (#14) in Schein’s Common Sense Prevention and Management of Surgical Complications for a more in-depth discussion.\\n\\n### Final Remarks\\n\\nA well-constructed stoma can make all the difference between success and failure of an emergency abdominal operation. Consider the stoma to be an anastomosis between skin and bowel and you won’t go far wrong. Don’t close the abdomen and go for a coffee, leaving the resident to mature the stoma unsupervised; a tiny error here can make a huge difference.\\n\\nThis book is about emergency treatment so we won’t bore you with late complications or the ‘take down’ of the stoma. But we’ll end with a comment by a wise man.\\n\\n> “There is no law that says that a colostomy must be closed.”\\n> — Leo A. Gordon\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Mucocutaneous Separation',\n", " 'md': '## Mucocutaneous Separation',\n", " 'bBox': {'x': 86, 'y': 85, 'w': 113.5, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Mucocutaneous separation is relatively common after an emergency operation to form a stoma. The degree of separation is usually fairly minor and with careful stoma management, most will heal on their own. Attempts at resuturing are usually not helpful; resist the urge to revise the stoma early on as this will be difficult and potentially hazardous.',\n", " 'md': 'Mucocutaneous separation is relatively common after an emergency operation to form a stoma. The degree of separation is usually fairly minor and with careful stoma management, most will heal on their own. Attempts at resuturing are usually not helpful; resist the urge to revise the stoma early on as this will be difficult and potentially hazardous.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.56, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Other Stoma Complications',\n", " 'md': '### Other Stoma Complications',\n", " 'bBox': {'x': 86, 'y': 211, 'w': 213.33, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As a surgeon practicing emergency abdominal surgery, you will be well aware of the many other later complications which can occur after creating a stoma. Further discussion of the management of these complications is beyond the scope of this book. The interested reader is advised to consult my chapter (#14) in Schein’s Common Sense Prevention and Management of Surgical Complications for a more in-depth discussion.',\n", " 'md': 'As a surgeon practicing emergency abdominal surgery, you will be well aware of the many other later complications which can occur after creating a stoma. Further discussion of the management of these complications is beyond the scope of this book. The interested reader is advised to consult my chapter (#14) in Schein’s Common Sense Prevention and Management of Surgical Complications for a more in-depth discussion.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.59, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Final Remarks',\n", " 'md': '### Final Remarks',\n", " 'bBox': {'x': 86, 'y': 390, 'w': 107.6, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A well-constructed stoma can make all the difference between success and failure of an emergency abdominal operation. Consider the stoma to be an anastomosis between skin and bowel and you won’t go far wrong. Don’t close the abdomen and go for a coffee, leaving the resident to mature the stoma unsupervised; a tiny error here can make a huge difference.\\n\\nThis book is about emergency treatment so we won’t bore you with late complications or the ‘take down’ of the stoma. But we’ll end with a comment by a wise man.\\n\\n> “There is no law that says that a colostomy must be closed.”\\n> — Leo A. Gordon\\n```',\n", " 'md': 'A well-constructed stoma can make all the difference between success and failure of an emergency abdominal operation. Consider the stoma to be an anastomosis between skin and bowel and you won’t go far wrong. Don’t close the abdomen and go for a coffee, leaving the resident to mature the stoma unsupervised; a tiny error here can make a huge difference.\\n\\nThis book is about emergency treatment so we won’t bore you with late complications or the ‘take down’ of the stoma. But we’ll end with a comment by a wise man.\\n\\n> “There is no law that says that a colostomy must be closed.”\\n> — Leo A. Gordon\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 460.33, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 203,\n", " 'text': '1 For a comprehensive treatise on anastomotic leak, look at Chapter 6, Schein’s Common\\n Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm\\n publishing, 2013.\\n2 Professor Luis Carriquiry contributed to this section in the previous edition.',\n", " 'md': '```markdown\\n# Page Content\\n\\nFor a comprehensive treatise on anastomotic leak, look at Chapter 6, Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013.\\n\\nProfessor Luis Carriquiry contributed to this section in the previous edition.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'For a comprehensive treatise on anastomotic leak, look at Chapter 6, Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013.\\n\\nProfessor Luis Carriquiry contributed to this section in the previous edition.\\n```',\n", " 'md': 'For a comprehensive treatise on anastomotic leak, look at Chapter 6, Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013.\\n\\nProfessor Luis Carriquiry contributed to this section in the previous edition.\\n```',\n", " 'bBox': {'x': 73, 'y': 84, 'w': 354.83, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'},\n", " {'text': 'Sense Prevention and Management of Surgical Complications'},\n", " {'text': '2'}]},\n", " {'page': 204,\n", " 'text': 'Chapter 15\\nEsophageal emergencies\\nBrandon H. Tieu and John G. Hunter 1\\n\\n On esophageal perforations: When it [occurs] it can be\\n recognized but it cannot be remedied by the medical\\n profession.\\n Herman Boerhaave\\n\\n The evaluation and management of esophageal emergencies is a\\ndaunting task that may result in restless nights if done incorrectly. The\\nesophagus is a musculomembranous tube without a serosal membrane\\nthat is responsible for transmitting oral intake from the mouth to the\\nstomach. When this fails to happen in a coordinated and organized\\nfashion, adverse events can occur resulting in obstruction, retching and\\nperforation. Mediastinitis can rapidly develop from the spillage of\\noral and enteral bacteria into the loose, areolar, and poorly\\nvascularized planes of the mediastinum.\\n\\n This chapter will cover the presentation, evaluation, and management\\nof esophageal perforations as well as foreign body ingestion and\\nobstruction.\\n\\n Esophageal perforation\\n\\n The admiral had eaten a heavy meal. During the next few hours he had taken small cups of a\\n mild emetic, as was usual when he was feeling heavy. Four times he had about 28g of olive oil',\n", " 'md': '```markdown\\n# Chapter 15: Esophageal Emergencies\\n**Authors:** Brandon H. Tieu and John G. Hunter\\n\\n> \"On esophageal perforations: When it [occurs] it can be recognized but it cannot be remedied by the medical profession.\"\\n> — Herman Boerhaave\\n\\nThe evaluation and management of esophageal emergencies is a daunting task that may result in restless nights if done incorrectly. The esophagus is a musculomembranous tube without a serosal membrane that is responsible for transmitting oral intake from the mouth to the stomach. When this fails to happen in a coordinated and organized fashion, adverse events can occur resulting in obstruction, retching, and perforation. Mediastinitis can rapidly develop from the spillage of oral and enteral bacteria into the loose, areolar, and poorly vascularized planes of the mediastinum.\\n\\nThis chapter will cover the presentation, evaluation, and management of esophageal perforations as well as foreign body ingestion and obstruction.\\n\\n## Esophageal Perforation\\n\\nThe admiral had eaten a heavy meal. During the next few hours he had taken small cups of a mild emetic, as was usual when he was feeling heavy. Four times he had about 28g of olive oil.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 15: Esophageal Emergencies',\n", " 'md': '# Chapter 15: Esophageal Emergencies',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 227.39, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Brandon H. Tieu and John G. Hunter\\n\\n> \"On esophageal perforations: When it [occurs] it can be recognized but it cannot be remedied by the medical profession.\"\\n> — Herman Boerhaave\\n\\nThe evaluation and management of esophageal emergencies is a daunting task that may result in restless nights if done incorrectly. The esophagus is a musculomembranous tube without a serosal membrane that is responsible for transmitting oral intake from the mouth to the stomach. When this fails to happen in a coordinated and organized fashion, adverse events can occur resulting in obstruction, retching, and perforation. Mediastinitis can rapidly develop from the spillage of oral and enteral bacteria into the loose, areolar, and poorly vascularized planes of the mediastinum.\\n\\nThis chapter will cover the presentation, evaluation, and management of esophageal perforations as well as foreign body ingestion and obstruction.',\n", " 'md': '**Authors:** Brandon H. Tieu and John G. Hunter\\n\\n> \"On esophageal perforations: When it [occurs] it can be recognized but it cannot be remedied by the medical profession.\"\\n> — Herman Boerhaave\\n\\nThe evaluation and management of esophageal emergencies is a daunting task that may result in restless nights if done incorrectly. The esophagus is a musculomembranous tube without a serosal membrane that is responsible for transmitting oral intake from the mouth to the stomach. When this fails to happen in a coordinated and organized fashion, adverse events can occur resulting in obstruction, retching, and perforation. Mediastinitis can rapidly develop from the spillage of oral and enteral bacteria into the loose, areolar, and poorly vascularized planes of the mediastinum.\\n\\nThis chapter will cover the presentation, evaluation, and management of esophageal perforations as well as foreign body ingestion and obstruction.',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 453.06, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Esophageal Perforation',\n", " 'md': '## Esophageal Perforation',\n", " 'bBox': {'x': 86, 'y': 646, 'w': 184.83, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The admiral had eaten a heavy meal. During the next few hours he had taken small cups of a mild emetic, as was usual when he was feeling heavy. Four times he had about 28g of olive oil.\\n```',\n", " 'md': 'The admiral had eaten a heavy meal. During the next few hours he had taken small cups of a mild emetic, as was usual when he was feeling heavy. Four times he had about 28g of olive oil.\\n```',\n", " 'bBox': {'x': 79, 'y': 692, 'w': 453.52, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Brandon H. Tieu and John G. Hunter 1'}]},\n", " {'page': 205,\n", " 'text': ' and later drank about 180g of beer. When this did not have the desired effect, he took another\\n four cups. He tried to throw up, but suddenly screamed because of an excruciating pain in the\\n chest. He immediately declared himself dying and started praying. It was a very sick patient,\\n though free of fever, who met Boerhaave. The house physician, Dr. de Bye, had tried\\n bleeding. There were no symptoms of any known disease or poisoning, and the two physicians\\n ordered another bleeding, something non-alcoholic to drink and warm compresses. But, in\\n vain, the baron succumbed the next day. Herman Boerhaave (1668-1738) conducted\\n an autopsy that revealed the rent in the oesophagus and the contents of a previous meal, gas,\\n and fluid in the chest.\\n\\n Esophageal perforations are uncommon but potentially lethal\\nconditions that require prompt diagnosis and treatment. ħistorically,\\nmortality rates have been as high as 80%. Due to its rarity, most\\nsurgeons have a limited experience in the management of this condition.\\nHowever, over the last two decades, with the advances in imaging\\ntechniques and critical care medicine, and the entrenchment of\\nuniform management modalities, mortality rates have significantly\\nimproved following esophageal perforation.\\n\\n Etiology\\n\\n Cervical esophageal perforations\\n\\n Iatrogenic injury (endoscopy, anterior spinal fusions, or endoscopic\\nrepair of Zenker’s diverticulum) causes the majority of cervical\\nesophageal perforations, followed by penetrating trauma, or foreign\\nbody ingestion. Sharp foreign bodies (needles, bones) can cause an\\nimmediate perforation, while a blunt foreign body can cause pressure\\nnecrosis and a delayed perforation. This most commonly occurs at the\\nlevel of cricopharyngeus, which is the narrowest portion of the\\nesophagus.\\n\\n Thoracic and abdominal perforations',\n", " 'md': '```markdown\\n## Esophageal Perforations\\n\\nand later drank about 180g of beer. When this did not have the desired effect, he took another four cups. He tried to throw up, but suddenly screamed because of an excruciating pain in the chest. He immediately declared himself dying and started praying. It was a very sick patient, though free of fever, who met Boerhaave. The house physician, Dr. de Bye, had tried bleeding. There were no symptoms of any known disease or poisoning, and the two physicians ordered another bleeding, something non-alcoholic to drink and warm compresses. But, in vain, the baron succumbed the next day. Herman Boerhaave (1668-1738) conducted an autopsy that revealed the rent in the oesophagus and the contents of a previous meal, gas, and fluid in the chest.\\n\\nEsophageal perforations are uncommon but potentially lethal conditions that require prompt diagnosis and treatment. Historically, mortality rates have been as high as 80%. Due to its rarity, most surgeons have a limited experience in the management of this condition. However, over the last two decades, with the advances in imaging techniques and critical care medicine, and the entrenchment of uniform management modalities, mortality rates have significantly improved following esophageal perforation.\\n\\n### Etiology\\n\\n#### Cervical Esophageal Perforations\\n\\nIatrogenic injury (endoscopy, anterior spinal fusions, or endoscopic repair of Zenker’s diverticulum) causes the majority of cervical esophageal perforations, followed by penetrating trauma, or foreign body ingestion. Sharp foreign bodies (needles, bones) can cause an immediate perforation, while a blunt foreign body can cause pressure necrosis and a delayed perforation. This most commonly occurs at the level of cricopharyngeus, which is the narrowest portion of the esophagus.\\n\\n#### Thoracic and Abdominal Perforations\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Esophageal Perforations',\n", " 'md': '## Esophageal Perforations',\n", " 'bBox': {'x': 86, 'y': 295, 'w': 79.99, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'and later drank about 180g of beer. When this did not have the desired effect, he took another four cups. He tried to throw up, but suddenly screamed because of an excruciating pain in the chest. He immediately declared himself dying and started praying. It was a very sick patient, though free of fever, who met Boerhaave. The house physician, Dr. de Bye, had tried bleeding. There were no symptoms of any known disease or poisoning, and the two physicians ordered another bleeding, something non-alcoholic to drink and warm compresses. But, in vain, the baron succumbed the next day. Herman Boerhaave (1668-1738) conducted an autopsy that revealed the rent in the oesophagus and the contents of a previous meal, gas, and fluid in the chest.\\n\\nEsophageal perforations are uncommon but potentially lethal conditions that require prompt diagnosis and treatment. Historically, mortality rates have been as high as 80%. Due to its rarity, most surgeons have a limited experience in the management of this condition. However, over the last two decades, with the advances in imaging techniques and critical care medicine, and the entrenchment of uniform management modalities, mortality rates have significantly improved following esophageal perforation.',\n", " 'md': 'and later drank about 180g of beer. When this did not have the desired effect, he took another four cups. He tried to throw up, but suddenly screamed because of an excruciating pain in the chest. He immediately declared himself dying and started praying. It was a very sick patient, though free of fever, who met Boerhaave. The house physician, Dr. de Bye, had tried bleeding. There were no symptoms of any known disease or poisoning, and the two physicians ordered another bleeding, something non-alcoholic to drink and warm compresses. But, in vain, the baron succumbed the next day. Herman Boerhaave (1668-1738) conducted an autopsy that revealed the rent in the oesophagus and the contents of a previous meal, gas, and fluid in the chest.\\n\\nEsophageal perforations are uncommon but potentially lethal conditions that require prompt diagnosis and treatment. Historically, mortality rates have been as high as 80%. Due to its rarity, most surgeons have a limited experience in the management of this condition. However, over the last two decades, with the advances in imaging techniques and critical care medicine, and the entrenchment of uniform management modalities, mortality rates have significantly improved following esophageal perforation.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.86, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Etiology',\n", " 'md': '### Etiology',\n", " 'bBox': {'x': 86, 'y': 454, 'w': 65.28, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Cervical Esophageal Perforations',\n", " 'md': '#### Cervical Esophageal Perforations',\n", " 'bBox': {'x': 86, 'y': 295, 'w': 261.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Iatrogenic injury (endoscopy, anterior spinal fusions, or endoscopic repair of Zenker’s diverticulum) causes the majority of cervical esophageal perforations, followed by penetrating trauma, or foreign body ingestion. Sharp foreign bodies (needles, bones) can cause an immediate perforation, while a blunt foreign body can cause pressure necrosis and a delayed perforation. This most commonly occurs at the level of cricopharyngeus, which is the narrowest portion of the esophagus.',\n", " 'md': 'Iatrogenic injury (endoscopy, anterior spinal fusions, or endoscopic repair of Zenker’s diverticulum) causes the majority of cervical esophageal perforations, followed by penetrating trauma, or foreign body ingestion. Sharp foreign bodies (needles, bones) can cause an immediate perforation, while a blunt foreign body can cause pressure necrosis and a delayed perforation. This most commonly occurs at the level of cricopharyngeus, which is the narrowest portion of the esophagus.',\n", " 'bBox': {'x': 72, 'y': 295, 'w': 467.14, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Thoracic and Abdominal Perforations',\n", " 'md': '#### Thoracic and Abdominal Perforations',\n", " 'bBox': {'x': 86, 'y': 692, 'w': 291.48, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 206,\n", " 'text': ' In these locations perforations occur from a variety of causes:\\niatrogenic injury, caustic ingestion (accidental or intentional — suicidal or\\nhomicidal…), foreign body ingestion, penetrating trauma, or barotrauma\\n(retching and vomiting — Boerhaave’s syndrome!). Iatrogenic injury can\\noccur during endoscopy with inappropriate sedation, during dilatation for\\nbenign strictures or achalasia, with sclerosing therapy for varices, after\\nesophageal biopsies, during removal of a foreign body, and with\\ntransesophageal echocardiography. Operative injuries resulting in\\nperforation can occur with antireflux procedures or after an unrecognized\\nmucosal injury during a myotomy for achalasia. Caustic ingestion can\\nresult in acute or delayed perforations depending on the severity of injury.\\nThe severity of injury is dependent on the pħ of the substance (alkali\\nworse than acid), volume ingested, and duration of exposure. With\\npenetrating injuries to the esophagus, especially from a gunshot wound,\\nthe patient often suffers associated cardiovascular or tracheobronchial\\ninjuries that require immediate attention and take precedence over the\\nesophageal injury.\\n\\n Barotrauma due to retching/vomiting resulting in spontaneous\\nperforation (Boerhaave’s syndrome) accounts for about 10-15% of\\nthoracic perforations. It is caused by a lack of coordinated relaxation of\\nthe esophageal sphincters when there is increased intra-abdominal\\npressure created by rapid descent of the diaphragm and contraction of\\nthe abdominal wall. This results in increased intraesophageal\\npressure that leads to rupture along the left posterolateral wall of\\nthe esophagus.\\n\\n Some basics…\\n\\n A thorough history and/or direct communication with the endoscopist\\nwill generally give the cause and location of the suspected perforation.\\nPatients most commonly present complaining of pain but can also\\ncomplain of dyspnea, nausea/vomiting, and dysphagia. Neck pain with a\\ncervical perforation is worsened with swallowing and neck flexion.\\n\\n Cervical perforations are better contained due to the limited space for\\nspread provided by the middle and deep cervical fascia. However, if an\\nuncontained cervical leak is left untreated the infection can spread',\n", " 'md': '```markdown\\n## Causes of Esophageal Perforations\\n\\nIn these locations, perforations occur from a variety of causes: iatrogenic injury, caustic ingestion (accidental or intentional — suicidal or homicidal…), foreign body ingestion, penetrating trauma, or barotrauma (retching and vomiting — Boerhaave’s syndrome!).\\n\\nIatrogenic injury can occur during endoscopy with inappropriate sedation, during dilatation for benign strictures or achalasia, with sclerosing therapy for varices, after esophageal biopsies, during removal of a foreign body, and with transesophageal echocardiography. Operative injuries resulting in perforation can occur with antireflux procedures or after an unrecognized mucosal injury during a myotomy for achalasia.\\n\\nCaustic ingestion can result in acute or delayed perforations depending on the severity of injury. The severity of injury is dependent on the pH of the substance (alkali worse than acid), volume ingested, and duration of exposure. With penetrating injuries to the esophagus, especially from a gunshot wound, the patient often suffers associated cardiovascular or tracheobronchial injuries that require immediate attention and take precedence over the esophageal injury.\\n\\nBarotrauma due to retching/vomiting resulting in spontaneous perforation (Boerhaave’s syndrome) accounts for about 10-15% of thoracic perforations. It is caused by a lack of coordinated relaxation of the esophageal sphincters when there is increased intra-abdominal pressure created by rapid descent of the diaphragm and contraction of the abdominal wall. This results in increased intraesophageal pressure that leads to rupture along the left posterolateral wall of the esophagus.\\n\\n### Clinical Presentation\\n\\nA thorough history and/or direct communication with the endoscopist will generally give the cause and location of the suspected perforation. Patients most commonly present complaining of pain but can also complain of dyspnea, nausea/vomiting, and dysphagia. Neck pain with a cervical perforation is worsened with swallowing and neck flexion.\\n\\nCervical perforations are better contained due to the limited space for spread provided by the middle and deep cervical fascia. However, if an uncontained cervical leak is left untreated, the infection can spread.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Causes of Esophageal Perforations',\n", " 'md': '## Causes of Esophageal Perforations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In these locations, perforations occur from a variety of causes: iatrogenic injury, caustic ingestion (accidental or intentional — suicidal or homicidal…), foreign body ingestion, penetrating trauma, or barotrauma (retching and vomiting — Boerhaave’s syndrome!).\\n\\nIatrogenic injury can occur during endoscopy with inappropriate sedation, during dilatation for benign strictures or achalasia, with sclerosing therapy for varices, after esophageal biopsies, during removal of a foreign body, and with transesophageal echocardiography. Operative injuries resulting in perforation can occur with antireflux procedures or after an unrecognized mucosal injury during a myotomy for achalasia.\\n\\nCaustic ingestion can result in acute or delayed perforations depending on the severity of injury. The severity of injury is dependent on the pH of the substance (alkali worse than acid), volume ingested, and duration of exposure. With penetrating injuries to the esophagus, especially from a gunshot wound, the patient often suffers associated cardiovascular or tracheobronchial injuries that require immediate attention and take precedence over the esophageal injury.\\n\\nBarotrauma due to retching/vomiting resulting in spontaneous perforation (Boerhaave’s syndrome) accounts for about 10-15% of thoracic perforations. It is caused by a lack of coordinated relaxation of the esophageal sphincters when there is increased intra-abdominal pressure created by rapid descent of the diaphragm and contraction of the abdominal wall. This results in increased intraesophageal pressure that leads to rupture along the left posterolateral wall of the esophagus.',\n", " 'md': 'In these locations, perforations occur from a variety of causes: iatrogenic injury, caustic ingestion (accidental or intentional — suicidal or homicidal…), foreign body ingestion, penetrating trauma, or barotrauma (retching and vomiting — Boerhaave’s syndrome!).\\n\\nIatrogenic injury can occur during endoscopy with inappropriate sedation, during dilatation for benign strictures or achalasia, with sclerosing therapy for varices, after esophageal biopsies, during removal of a foreign body, and with transesophageal echocardiography. Operative injuries resulting in perforation can occur with antireflux procedures or after an unrecognized mucosal injury during a myotomy for achalasia.\\n\\nCaustic ingestion can result in acute or delayed perforations depending on the severity of injury. The severity of injury is dependent on the pH of the substance (alkali worse than acid), volume ingested, and duration of exposure. With penetrating injuries to the esophagus, especially from a gunshot wound, the patient often suffers associated cardiovascular or tracheobronchial injuries that require immediate attention and take precedence over the esophageal injury.\\n\\nBarotrauma due to retching/vomiting resulting in spontaneous perforation (Boerhaave’s syndrome) accounts for about 10-15% of thoracic perforations. It is caused by a lack of coordinated relaxation of the esophageal sphincters when there is increased intra-abdominal pressure created by rapid descent of the diaphragm and contraction of the abdominal wall. This results in increased intraesophageal pressure that leads to rupture along the left posterolateral wall of the esophagus.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Clinical Presentation',\n", " 'md': '### Clinical Presentation',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A thorough history and/or direct communication with the endoscopist will generally give the cause and location of the suspected perforation. Patients most commonly present complaining of pain but can also complain of dyspnea, nausea/vomiting, and dysphagia. Neck pain with a cervical perforation is worsened with swallowing and neck flexion.\\n\\nCervical perforations are better contained due to the limited space for spread provided by the middle and deep cervical fascia. However, if an uncontained cervical leak is left untreated, the infection can spread.\\n```',\n", " 'md': 'A thorough history and/or direct communication with the endoscopist will generally give the cause and location of the suspected perforation. Patients most commonly present complaining of pain but can also complain of dyspnea, nausea/vomiting, and dysphagia. Neck pain with a cervical perforation is worsened with swallowing and neck flexion.\\n\\nCervical perforations are better contained due to the limited space for spread provided by the middle and deep cervical fascia. However, if an uncontained cervical leak is left untreated, the infection can spread.\\n```',\n", " 'bBox': {'x': 72, 'y': 630, 'w': 467.73, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 207,\n", " 'text': 'through the thoracic inlet along the prevertebral space or the\\nanterior pretracheal space — descending substernally and cause\\nmediastinitis.\\n\\n Pain from a thoracic perforation may cause precordial, back or\\nepigastric discomfort. Perforations into the abdomen will lead to\\nabdominal pain and peritonitis.\\n\\n On examination, there may be subcutaneous emphysema and\\ncrepitus in the neck or anterior chest wall. On auscultation, a Hamman\\nsign — a precordial crunching sound that is synchronous with the heart\\nbeating against the pneumomediastinum — can be appreciated. The\\ncombination of fever, tachycardia, leukocytosis, and hypotension\\nstrongly points to the presence of mediastinitis and systemic\\ninfection.\\n\\n Diagnostic work-up\\n\\n • On chest X-ray, findings include pneumomediastinum, a widened\\n mediastinum with a fluid collection, pneumothorax, subcutaneous\\n emphysema extending to the neck, and/or a pleural effusion. For\\n cervical perforations, a lateral neck film may show a widened\\n prevertebral space and anterior displacement of the esophagus and\\n trachea.\\n • Traditional esophagograms with water-soluble contrast, followed\\n by barium if the water-soluble tests are negative, are still valuable to\\n diagnose a leak. However, there is a 10% false-negative rate in\\n thoracic perforations and it can be higher for cervical\\n perforations.\\n • A CT esophagogram with contrast can provide additional detail\\n including the extent of the perforation, degree of contamination of\\n the mediastinum or pleural space, and associated esophageal\\n pathology (distal obstruction, mass, dilated esophagus\\n suggestive of achalasia) that will affect the management or\\n operative intervention. Other subtle signs to look for that\\n suggest esophageal injury on CT include: esophageal wall\\n thickening, a focal esophageal wall defect, and mediastinal',\n", " 'md': '```markdown\\n## Diagnostic Work-up\\n\\n- On chest X-ray, findings include pneumomediastinum, a widened mediastinum with a fluid collection, pneumothorax, subcutaneous emphysema extending to the neck, and/or a pleural effusion. For cervical perforations, a lateral neck film may show a widened prevertebral space and anterior displacement of the esophagus and trachea.\\n- Traditional esophagograms with water-soluble contrast, followed by barium if the water-soluble tests are negative, are still valuable to diagnose a leak. However, there is a 10% false-negative rate in thoracic perforations and it can be higher for cervical perforations.\\n- A CT esophagogram with contrast can provide additional detail including the extent of the perforation, degree of contamination of the mediastinum or pleural space, and associated esophageal pathology (distal obstruction, mass, dilated esophagus suggestive of achalasia) that will affect the management or operative intervention. Other subtle signs to look for that suggest esophageal injury on CT include: esophageal wall thickening, a focal esophageal wall defect, and mediastinal .\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnostic Work-up',\n", " 'md': '## Diagnostic Work-up',\n", " 'bBox': {'x': 86, 'y': 365, 'w': 153.56, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- On chest X-ray, findings include pneumomediastinum, a widened mediastinum with a fluid collection, pneumothorax, subcutaneous emphysema extending to the neck, and/or a pleural effusion. For cervical perforations, a lateral neck film may show a widened prevertebral space and anterior displacement of the esophagus and trachea.\\n- Traditional esophagograms with water-soluble contrast, followed by barium if the water-soluble tests are negative, are still valuable to diagnose a leak. However, there is a 10% false-negative rate in thoracic perforations and it can be higher for cervical perforations.\\n- A CT esophagogram with contrast can provide additional detail including the extent of the perforation, degree of contamination of the mediastinum or pleural space, and associated esophageal pathology (distal obstruction, mass, dilated esophagus suggestive of achalasia) that will affect the management or operative intervention. Other subtle signs to look for that suggest esophageal injury on CT include: esophageal wall thickening, a focal esophageal wall defect, and mediastinal .\\n```',\n", " 'md': '- On chest X-ray, findings include pneumomediastinum, a widened mediastinum with a fluid collection, pneumothorax, subcutaneous emphysema extending to the neck, and/or a pleural effusion. For cervical perforations, a lateral neck film may show a widened prevertebral space and anterior displacement of the esophagus and trachea.\\n- Traditional esophagograms with water-soluble contrast, followed by barium if the water-soluble tests are negative, are still valuable to diagnose a leak. However, there is a 10% false-negative rate in thoracic perforations and it can be higher for cervical perforations.\\n- A CT esophagogram with contrast can provide additional detail including the extent of the perforation, degree of contamination of the mediastinum or pleural space, and associated esophageal pathology (distal obstruction, mass, dilated esophagus suggestive of achalasia) that will affect the management or operative intervention. Other subtle signs to look for that suggest esophageal injury on CT include: esophageal wall thickening, a focal esophageal wall defect, and mediastinal .\\n```',\n", " 'bBox': {'x': 100, 'y': 468, 'w': 436.86, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 208,\n", " 'text': ' inflammation. We have found the additional information and detail\\n with CT to be worth the cost. Anyway, these days when we are\\n called to see these patients they have already had a CT from the\\n scalp to their toes…\\n • Flexible endoscopy remains an important component to evaluate\\n the esophagus in penetrating neck trauma, especially in the\\n intubated or unstable patient. When an esophageal injury is\\n suspected at the time of diagnostic endoscopy, a nagogastric\\n tube should be inserted under direct visualization. Traditionally,\\n flexible endoscopy is not recommended as a diagnostic tool in\\n suspected thoracic and abdominal perforations. This is due to\\n concerns that insufflation will worsen the contamination; however,\\n this phenomenon has not been clearly proven. If an injury is\\n identified by history (“I perforated the esophagus during\\n endoscopy”), esophagogram, or CT esophagogram, then a\\n diagnostic endoscopy is not needed. But diagnostic endoscopy is\\n useful to identify associated esophageal pathology — mass,\\n ring, web, or stricture — just prior to operative intervention as\\n this may change the surgical plan (e.g. from primary repair to\\n esophagectomy for localized cancer). As discussed below,\\n endoscopy is also useful for therapeutic interventions such as the\\n placement of a covered stent in stable patients with limited\\n mediastinal contamination or for removal of a foreign body. On the\\n role of endoscopy for caustic injury continue reading…\\n\\n Management\\n\\n Historically, the key word emphasized in the treatment of\\nesophageal perforation was EARLY. During the last century, the\\nstandard approach was operative intervention with outcomes linked to\\n‘early’ repair within the first 24 hours. Delayed or ‘late’ therapeutic\\nintervention resulted in a four-fold increase in the risk of mortality.\\n\\n Today, while the importance of early diagnosis and treatment is still\\nvalid — the emphasis is on tailoring the management to the site and\\nnature of the perforation in the individual patient. Some perforations can\\nbe successfully treated with non-operative management or',\n", " 'md': '```markdown\\n## Current Page Content\\n\\nInflammation. We have found the additional information and detail with CT to be worth the cost. Anyway, these days when we are called to see these patients they have already had a CT from the scalp to their toes…\\n\\n- Flexible endoscopy remains an important component to evaluate the esophagus in penetrating neck trauma, especially in the intubated or unstable patient. When an esophageal injury is suspected at the time of diagnostic endoscopy, a nasogastric tube should be inserted under direct visualization. Traditionally, flexible endoscopy is not recommended as a diagnostic tool in suspected thoracic and abdominal perforations. This is due to concerns that insufflation will worsen the contamination; however, this phenomenon has not been clearly proven. If an injury is identified by history (“I perforated the esophagus during endoscopy”), esophagogram, or CT esophagogram, then a diagnostic endoscopy is not needed. But diagnostic endoscopy is useful to identify associated esophageal pathology — mass, ring, web, or stricture — just prior to operative intervention as this may change the surgical plan (e.g. from primary repair to esophagectomy for localized cancer). As discussed below, endoscopy is also useful for therapeutic interventions such as the placement of a covered stent in stable patients with limited mediastinal contamination or for removal of a foreign body. On the role of endoscopy for caustic injury continue reading…\\n\\n### Management\\n\\nHistorically, the key word emphasized in the treatment of esophageal perforation was EARLY. During the last century, the standard approach was operative intervention with outcomes linked to ‘early’ repair within the first 24 hours. Delayed or ‘late’ therapeutic intervention resulted in a four-fold increase in the risk of mortality.\\n\\nToday, while the importance of early diagnosis and treatment is still valid — the emphasis is on tailoring the management to the site and nature of the perforation in the individual patient. Some perforations can be successfully treated with non-operative management or...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and structured according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 529, 'y': 320, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 529, 'y': 320, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Inflammation. We have found the additional information and detail with CT to be worth the cost. Anyway, these days when we are called to see these patients they have already had a CT from the scalp to their toes…\\n\\n- Flexible endoscopy remains an important component to evaluate the esophagus in penetrating neck trauma, especially in the intubated or unstable patient. When an esophageal injury is suspected at the time of diagnostic endoscopy, a nasogastric tube should be inserted under direct visualization. Traditionally, flexible endoscopy is not recommended as a diagnostic tool in suspected thoracic and abdominal perforations. This is due to concerns that insufflation will worsen the contamination; however, this phenomenon has not been clearly proven. If an injury is identified by history (“I perforated the esophagus during endoscopy”), esophagogram, or CT esophagogram, then a diagnostic endoscopy is not needed. But diagnostic endoscopy is useful to identify associated esophageal pathology — mass, ring, web, or stricture — just prior to operative intervention as this may change the surgical plan (e.g. from primary repair to esophagectomy for localized cancer). As discussed below, endoscopy is also useful for therapeutic interventions such as the placement of a covered stent in stable patients with limited mediastinal contamination or for removal of a foreign body. On the role of endoscopy for caustic injury continue reading…',\n", " 'md': 'Inflammation. We have found the additional information and detail with CT to be worth the cost. Anyway, these days when we are called to see these patients they have already had a CT from the scalp to their toes…\\n\\n- Flexible endoscopy remains an important component to evaluate the esophagus in penetrating neck trauma, especially in the intubated or unstable patient. When an esophageal injury is suspected at the time of diagnostic endoscopy, a nasogastric tube should be inserted under direct visualization. Traditionally, flexible endoscopy is not recommended as a diagnostic tool in suspected thoracic and abdominal perforations. This is due to concerns that insufflation will worsen the contamination; however, this phenomenon has not been clearly proven. If an injury is identified by history (“I perforated the esophagus during endoscopy”), esophagogram, or CT esophagogram, then a diagnostic endoscopy is not needed. But diagnostic endoscopy is useful to identify associated esophageal pathology — mass, ring, web, or stricture — just prior to operative intervention as this may change the surgical plan (e.g. from primary repair to esophagectomy for localized cancer). As discussed below, endoscopy is also useful for therapeutic interventions such as the placement of a covered stent in stable patients with limited mediastinal contamination or for removal of a foreign body. On the role of endoscopy for caustic injury continue reading…',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 464.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management',\n", " 'md': '### Management',\n", " 'bBox': {'x': 86, 'y': 320, 'w': 451.01, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Historically, the key word emphasized in the treatment of esophageal perforation was EARLY. During the last century, the standard approach was operative intervention with outcomes linked to ‘early’ repair within the first 24 hours. Delayed or ‘late’ therapeutic intervention resulted in a four-fold increase in the risk of mortality.\\n\\nToday, while the importance of early diagnosis and treatment is still valid — the emphasis is on tailoring the management to the site and nature of the perforation in the individual patient. Some perforations can be successfully treated with non-operative management or...\\n```',\n", " 'md': 'Historically, the key word emphasized in the treatment of esophageal perforation was EARLY. During the last century, the standard approach was operative intervention with outcomes linked to ‘early’ repair within the first 24 hours. Delayed or ‘late’ therapeutic intervention resulted in a four-fold increase in the risk of mortality.\\n\\nToday, while the importance of early diagnosis and treatment is still valid — the emphasis is on tailoring the management to the site and nature of the perforation in the individual patient. Some perforations can be successfully treated with non-operative management or...\\n```',\n", " 'bBox': {'x': 72, 'y': 304, 'w': 466.89, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and structured according to the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and structured according to the requirements.',\n", " 'bBox': {'x': 100, 'y': 304, 'w': 61.57, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 209,\n", " 'text': 'minimally invasive therapies when the principles listed below are\\nfollowed. Today, patients with delayed/neglected perforations can be\\nsalvaged — that is, if treated along the lines described below.\\n\\n So again: the management and outcomes are dependent on the\\npatient’s condition, any associated esophageal disorder, and (very\\nimportant!) early recognition and diagnosis of the perforation.\\n\\n The general tenets in the management of perforations include:\\n\\n Controlling the source of infection.\\n Early and adequate drainage.\\n Administration of antibiotics.\\n Providing adequate nutrition.\\n\\n A few more basics…\\n\\n Once the diagnosis is established the patient should be made nil\\nper mouth (NPO), started on broad-spectrum antibiotics, and\\nresuscitated as needed. Intravenous antibiotics should cover for\\naerobes and anaerobes; suitable examples are piperacillin/tazobactam,\\nampicillin/sulbactam, or carbapenem. Antifungal coverage is reserved\\nfor immunosuppressed patients, hospitalized patients already on\\nantibiotic therapy, and those who fail to improve on standard\\nantibiotic therapy.\\n\\n When surgical repair is indicated (see below) the following\\nprinciples should be followed: devitalized tissue should be debrided\\nfrom the site of perforation, the muscular layer should be incised so that\\nthe entire extent of the mucosal injury is exposed, and the mucosal and\\nmuscular layers must be approximated precisely to avoid narrowing of\\nthe lumen. An important aspect to remember is that not all perforations\\nare created equal. ħowever, if the general tenets of management listed\\nabove are followed, the patient will have the best chance of a favorable\\noutcome.',\n", " 'md': '```markdown\\n# Management of Perforations\\n\\nMinimally invasive therapies can be effective when the principles listed below are followed. Today, patients with delayed or neglected perforations can be salvaged if treated according to the guidelines described.\\n\\nThe management and outcomes depend on the patient’s condition, any associated esophageal disorder, and (very importantly!) early recognition and diagnosis of the perforation.\\n\\n## General Tenets in the Management of Perforations\\n\\n1. Controlling the source of infection.\\n2. Early and adequate drainage.\\n3. Administration of antibiotics.\\n4. Providing adequate nutrition.\\n\\n### Additional Basics\\n\\nOnce the diagnosis is established, the patient should be made nil per mouth (NPO), started on broad-spectrum antibiotics, and resuscitated as needed. Intravenous antibiotics should cover for aerobes and anaerobes; suitable examples include piperacillin/tazobactam, ampicillin/sulbactam, or carbapenem. Antifungal coverage is reserved for immunosuppressed patients, hospitalized patients already on antibiotic therapy, and those who fail to improve on standard antibiotic therapy.\\n\\nWhen surgical repair is indicated, the following principles should be followed:\\n- Devitalized tissue should be debrided from the site of perforation.\\n- The muscular layer should be incised to expose the entire extent of the mucosal injury.\\n- The mucosal and muscular layers must be approximated precisely to avoid narrowing of the lumen.\\n\\nAn important aspect to remember is that not all perforations are created equal. However, if the general tenets of management listed above are followed, the patient will have the best chance of a favorable outcome.\\n```',\n", " 'images': [{'name': 'img_p208_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 254.88},\n", " {'name': 'img_p208_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 276.47999999999996},\n", " {'name': 'img_p208_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 298.08},\n", " {'name': 'img_p208_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 319.68}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management of Perforations',\n", " 'md': '# Management of Perforations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Minimally invasive therapies can be effective when the principles listed below are followed. Today, patients with delayed or neglected perforations can be salvaged if treated according to the guidelines described.\\n\\nThe management and outcomes depend on the patient’s condition, any associated esophageal disorder, and (very importantly!) early recognition and diagnosis of the perforation.',\n", " 'md': 'Minimally invasive therapies can be effective when the principles listed below are followed. Today, patients with delayed or neglected perforations can be salvaged if treated according to the guidelines described.\\n\\nThe management and outcomes depend on the patient’s condition, any associated esophageal disorder, and (very importantly!) early recognition and diagnosis of the perforation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'General Tenets in the Management of Perforations',\n", " 'md': '## General Tenets in the Management of Perforations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. Controlling the source of infection.\\n2. Early and adequate drainage.\\n3. Administration of antibiotics.\\n4. Providing adequate nutrition.',\n", " 'md': '1. Controlling the source of infection.\\n2. Early and adequate drainage.\\n3. Administration of antibiotics.\\n4. Providing adequate nutrition.',\n", " 'bBox': {'x': 131, 'y': 267, 'w': 163.03, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Additional Basics',\n", " 'md': '### Additional Basics',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Once the diagnosis is established, the patient should be made nil per mouth (NPO), started on broad-spectrum antibiotics, and resuscitated as needed. Intravenous antibiotics should cover for aerobes and anaerobes; suitable examples include piperacillin/tazobactam, ampicillin/sulbactam, or carbapenem. Antifungal coverage is reserved for immunosuppressed patients, hospitalized patients already on antibiotic therapy, and those who fail to improve on standard antibiotic therapy.\\n\\nWhen surgical repair is indicated, the following principles should be followed:\\n- Devitalized tissue should be debrided from the site of perforation.\\n- The muscular layer should be incised to expose the entire extent of the mucosal injury.\\n- The mucosal and muscular layers must be approximated precisely to avoid narrowing of the lumen.\\n\\nAn important aspect to remember is that not all perforations are created equal. However, if the general tenets of management listed above are followed, the patient will have the best chance of a favorable outcome.\\n```',\n", " 'md': 'Once the diagnosis is established, the patient should be made nil per mouth (NPO), started on broad-spectrum antibiotics, and resuscitated as needed. Intravenous antibiotics should cover for aerobes and anaerobes; suitable examples include piperacillin/tazobactam, ampicillin/sulbactam, or carbapenem. Antifungal coverage is reserved for immunosuppressed patients, hospitalized patients already on antibiotic therapy, and those who fail to improve on standard antibiotic therapy.\\n\\nWhen surgical repair is indicated, the following principles should be followed:\\n- Devitalized tissue should be debrided from the site of perforation.\\n- The muscular layer should be incised to expose the entire extent of the mucosal injury.\\n- The mucosal and muscular layers must be approximated precisely to avoid narrowing of the lumen.\\n\\nAn important aspect to remember is that not all perforations are created equal. However, if the general tenets of management listed above are followed, the patient will have the best chance of a favorable outcome.\\n```',\n", " 'bBox': {'x': 72, 'y': 489, 'w': 467.6, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 210,\n", " 'text': ' Perforations that permit a trial of conservative therapy\\n\\n Non-operative management of intramural perforations or small,\\ncontained leaks in patients without obstructive esophageal disease\\nshould be considered. Most iatrogenic endoscopic injuries are localized\\nand contained, and if recognized quickly will have limited contamination\\nof the mediastinum.\\n 0\\n 0\\nFigure 15.1. Image from a CT esophagogram of a contained perforation following a night\\nof alcohol consumption and retching. The pneumomediastinum outlines the esophagus\\nand great vessels without a mediastinal fluid collection or pleural effusions. This patient\\nwas successfully managed non-operatively.\\n\\n Generally, the esophagogram and CT will show air in the neck or\\nmediastinum but without free extravasation of contrast, a fluid\\ncollection or pleural effusions ( Figure 15.1). These patients should\\nshow no signs of systemic infection or sepsis, have minimal\\nsymptoms (neck or chest pain) and not have a malignancy, distal\\nobstruction, or stricture.\\n\\n In the setting of a cervical or thoracic perforation, frequent\\nreassessment of the patient’s clinical status for signs and symptoms (e.g.\\nnew or increasing neck and chest pain, odynophagia, new or persistent',\n", " 'md': '```markdown\\n## Perforations that Permit a Trial of Conservative Therapy\\n\\nNon-operative management of intramural perforations or small, contained leaks in patients without obstructive esophageal disease should be considered. Most iatrogenic endoscopic injuries are localized and contained, and if recognized quickly will have limited contamination of the mediastinum.\\n\\n### Figure 15.1\\n![Figure 15.1]()\\n*Image from a CT esophagogram of a contained perforation following a night of alcohol consumption and retching. The pneumomediastinum outlines the esophagus and great vessels without a mediastinal fluid collection or pleural effusions. This patient was successfully managed non-operatively.*\\n\\nGenerally, the esophagogram and CT will show air in the neck or mediastinum but without free extravasation of contrast, a fluid collection, or pleural effusions (Figure 15.1). These patients should show no signs of systemic infection or sepsis, have minimal symptoms (neck or chest pain), and not have a malignancy, distal obstruction, or stricture.\\n\\nIn the setting of a cervical or thoracic perforation, frequent reassessment of the patient’s clinical status for signs and symptoms (e.g., new or increasing neck and chest pain, odynophagia, new or persistent) is essential.\\n```',\n", " 'images': [{'name': 'img_p209_1.png',\n", " 'height': 508,\n", " 'width': 795,\n", " 'x': 109.44000000000005,\n", " 'y': 203.75999999999996,\n", " 'original_width': 1364,\n", " 'original_height': 872}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Perforations that Permit a Trial of Conservative Therapy',\n", " 'md': '## Perforations that Permit a Trial of Conservative Therapy',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 426.64, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Non-operative management of intramural perforations or small, contained leaks in patients without obstructive esophageal disease should be considered. Most iatrogenic endoscopic injuries are localized and contained, and if recognized quickly will have limited contamination of the mediastinum.',\n", " 'md': 'Non-operative management of intramural perforations or small, contained leaks in patients without obstructive esophageal disease should be considered. Most iatrogenic endoscopic injuries are localized and contained, and if recognized quickly will have limited contamination of the mediastinum.',\n", " 'bBox': {'x': 72, 'y': 140, 'w': 467.58, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 15.1',\n", " 'md': '### Figure 15.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '![Figure 15.1]()\\n*Image from a CT esophagogram of a contained perforation following a night of alcohol consumption and retching. The pneumomediastinum outlines the esophagus and great vessels without a mediastinal fluid collection or pleural effusions. This patient was successfully managed non-operatively.*\\n\\nGenerally, the esophagogram and CT will show air in the neck or mediastinum but without free extravasation of contrast, a fluid collection, or pleural effusions (Figure 15.1). These patients should show no signs of systemic infection or sepsis, have minimal symptoms (neck or chest pain), and not have a malignancy, distal obstruction, or stricture.\\n\\nIn the setting of a cervical or thoracic perforation, frequent reassessment of the patient’s clinical status for signs and symptoms (e.g., new or increasing neck and chest pain, odynophagia, new or persistent) is essential.\\n```',\n", " 'md': '![Figure 15.1]()\\n*Image from a CT esophagogram of a contained perforation following a night of alcohol consumption and retching. The pneumomediastinum outlines the esophagus and great vessels without a mediastinal fluid collection or pleural effusions. This patient was successfully managed non-operatively.*\\n\\nGenerally, the esophagogram and CT will show air in the neck or mediastinum but without free extravasation of contrast, a fluid collection, or pleural effusions (Figure 15.1). These patients should show no signs of systemic infection or sepsis, have minimal symptoms (neck or chest pain), and not have a malignancy, distal obstruction, or stricture.\\n\\nIn the setting of a cervical or thoracic perforation, frequent reassessment of the patient’s clinical status for signs and symptoms (e.g., new or increasing neck and chest pain, odynophagia, new or persistent) is essential.\\n```',\n", " 'bBox': {'x': 72, 'y': 487, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'show no signs of systemic infection or sepsis, have minimal'}]},\n", " {'page': 211,\n", " 'text': 'fevers, tachycardia, and rising leukocytosis) of an uncontrolled\\nperforation, abscess, or mediastinitis are required while the patient is\\nNPO and on systemic antibiotics. One should have a low threshold for\\nearly intervention (see below) if the patient’s clinical status\\nchanges.\\n\\n A repeat esophagogram after 5 days of conservative therapy should be\\nperformed and a diet initiated if no leak is detected. Close monitoring for\\nanother day is necessary to account for the occasional false-negative\\nesophagogram once oral intake is started.\\n\\n Perforations that need operative intervention\\n\\n Patients that arrive with an esophageal perforation in need of early\\nintervention present with severe neck, chest or abdominal pain. Those\\nwith mediastinitis, peritonitis, or systemic infection typically will be febrile,\\ntachycardic, and hypotensive with a leukocytosis. Crepitus, a Hamman\\ncrunch, or peritonitis can be noted on exam and suggest the area or\\nextent of perforation. A chest X-ray, esophagogram, or CT\\nesophagogram will demonstrate uncontained extravasation of contrast\\nalong with subcutaneous emphysema in the neck, pneumomediastinum\\nor pneumoperitoneum, hydropneumothorax, and mediastinal or\\nperitoneal fluid collections based on the location of the perforation (\\nFigure 15.2).\\n\\n Traditionally, attempted primary repair of a perforation has been\\nlimited to presentations within 24 hours, but over the years that time\\nperiod has been liberalized as more experience has been gathered\\nabout successful repair of ‘older’ perforations.',\n", " 'md': '```markdown\\n## Clinical Management of Esophageal Perforations\\n\\nFevers, tachycardia, and rising leukocytosis of an uncontrolled perforation, abscess, or mediastinitis are required while the patient is NPO and on systemic antibiotics. One should have a low threshold for early intervention if the patient’s clinical status changes.\\n\\nA repeat esophagogram after 5 days of conservative therapy should be performed and a diet initiated if no leak is detected. Close monitoring for another day is necessary to account for the occasional false-negative esophagogram once oral intake is started.\\n\\n### Perforations that need operative intervention\\n\\nPatients that arrive with an esophageal perforation in need of early intervention present with severe neck, chest, or abdominal pain. Those with mediastinitis, peritonitis, or systemic infection typically will be febrile, tachycardic, and hypotensive with a leukocytosis. Crepitus, a Hamman crunch, or peritonitis can be noted on exam and suggest the area or extent of perforation. A chest X-ray, esophagogram, or CT esophagogram will demonstrate uncontained extravasation of contrast along with subcutaneous emphysema in the neck, pneumomediastinum or pneumoperitoneum, hydropneumothorax, and mediastinal or peritoneal fluid collections based on the location of the perforation (Figure 15.2).\\n\\nTraditionally, attempted primary repair of a perforation has been limited to presentations within 24 hours, but over the years that time period has been liberalized as more experience has been gathered about successful repair of ‘older’ perforations.\\n\\n### Figure 15.2 Description\\n- **Figure 15.2**: This figure likely illustrates the results of imaging studies (such as a chest X-ray or CT esophagogram) showing uncontained extravasation of contrast, subcutaneous emphysema, pneumomediastinum, or other complications associated with esophageal perforation. The specific details of the image are not provided in the text, but it is critical for understanding the extent of the perforation and guiding treatment decisions.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Management of Esophageal Perforations',\n", " 'md': '## Clinical Management of Esophageal Perforations',\n", " 'bBox': {'x': 127, 'y': 399, 'w': 16, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Fevers, tachycardia, and rising leukocytosis of an uncontrolled perforation, abscess, or mediastinitis are required while the patient is NPO and on systemic antibiotics. One should have a low threshold for early intervention if the patient’s clinical status changes.\\n\\nA repeat esophagogram after 5 days of conservative therapy should be performed and a diet initiated if no leak is detected. Close monitoring for another day is necessary to account for the occasional false-negative esophagogram once oral intake is started.',\n", " 'md': 'Fevers, tachycardia, and rising leukocytosis of an uncontrolled perforation, abscess, or mediastinitis are required while the patient is NPO and on systemic antibiotics. One should have a low threshold for early intervention if the patient’s clinical status changes.\\n\\nA repeat esophagogram after 5 days of conservative therapy should be performed and a diet initiated if no leak is detected. Close monitoring for another day is necessary to account for the occasional false-negative esophagogram once oral intake is started.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.49, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Perforations that need operative intervention',\n", " 'md': '### Perforations that need operative intervention',\n", " 'bBox': {'x': 86, 'y': 280, 'w': 353.09, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Patients that arrive with an esophageal perforation in need of early intervention present with severe neck, chest, or abdominal pain. Those with mediastinitis, peritonitis, or systemic infection typically will be febrile, tachycardic, and hypotensive with a leukocytosis. Crepitus, a Hamman crunch, or peritonitis can be noted on exam and suggest the area or extent of perforation. A chest X-ray, esophagogram, or CT esophagogram will demonstrate uncontained extravasation of contrast along with subcutaneous emphysema in the neck, pneumomediastinum or pneumoperitoneum, hydropneumothorax, and mediastinal or peritoneal fluid collections based on the location of the perforation (Figure 15.2).\\n\\nTraditionally, attempted primary repair of a perforation has been limited to presentations within 24 hours, but over the years that time period has been liberalized as more experience has been gathered about successful repair of ‘older’ perforations.',\n", " 'md': 'Patients that arrive with an esophageal perforation in need of early intervention present with severe neck, chest, or abdominal pain. Those with mediastinitis, peritonitis, or systemic infection typically will be febrile, tachycardic, and hypotensive with a leukocytosis. Crepitus, a Hamman crunch, or peritonitis can be noted on exam and suggest the area or extent of perforation. A chest X-ray, esophagogram, or CT esophagogram will demonstrate uncontained extravasation of contrast along with subcutaneous emphysema in the neck, pneumomediastinum or pneumoperitoneum, hydropneumothorax, and mediastinal or peritoneal fluid collections based on the location of the perforation (Figure 15.2).\\n\\nTraditionally, attempted primary repair of a perforation has been limited to presentations within 24 hours, but over the years that time period has been liberalized as more experience has been gathered about successful repair of ‘older’ perforations.',\n", " 'bBox': {'x': 72, 'y': 349, 'w': 467.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 15.2 Description',\n", " 'md': '### Figure 15.2 Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 15.2**: This figure likely illustrates the results of imaging studies (such as a chest X-ray or CT esophagogram) showing uncontained extravasation of contrast, subcutaneous emphysema, pneumomediastinum, or other complications associated with esophageal perforation. The specific details of the image are not provided in the text, but it is critical for understanding the extent of the perforation and guiding treatment decisions.\\n```',\n", " 'md': '- **Figure 15.2**: This figure likely illustrates the results of imaging studies (such as a chest X-ray or CT esophagogram) showing uncontained extravasation of contrast, subcutaneous emphysema, pneumomediastinum, or other complications associated with esophageal perforation. The specific details of the image are not provided in the text, but it is critical for understanding the extent of the perforation and guiding treatment decisions.\\n```',\n", " 'bBox': {'x': 72, 'y': 399, 'w': 76.76, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Figure 15.2).'}]},\n", " {'page': 212,\n", " 'text': ' Figure 15.2. Image of a CT esophagogram with a non-contained leak from spontaneous\\n perforation of the thoracic esophagus following retching. The CT esophagogram shows\\n contrast extravasation (on the right) with large bilateral pleural effusions.\\n\\n The operation: acute injuries and primary surgical repair\\n\\n Cervical perforations\\n\\n An incision is made along the lower third of the anterior border of\\nthe sternocleidomastoid (SCM). This can be done from either side of\\nthe neck based on the site of extravasation or abscess, but traditionally is\\napproached from the left neck. The SCM, internal jugular vein and carotid\\nsheath are retracted laterally. The middle thyroid vein is ligated to allow\\nfor better exposure of the trachea and esophagus.\\n\\n Bluntly dissect down to the prevertebral space and behind the\\nesophagus. Allis clamps on the thyroid can help rotate the\\nlaryngotracheal complex over for better exposure of the esophagus.\\nComplete the dissection of the esophagus away from the membranous\\ntrachea, avoiding injury to the recurrent laryngeal nerve, and identify the\\narea of perforation.\\n\\n All devitalized tissue should be resected and a two-layer primary repair\\nis then performed. The mucosal layer is repaired with an absorbable\\nsuture (4-0 polydioxanone or polyglactin) and the muscular layer\\napproximated with your suture of choice (we use 3-0 silk). For patients',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Figure 15.2\\n**Description:** Image of a CT esophagogram with a non-contained leak from spontaneous perforation of the thoracic esophagus following retching. The CT esophagogram shows contrast extravasation (on the right) with large bilateral pleural effusions.\\n\\n----\\n\\n### The operation: acute injuries and primary surgical repair\\n\\n#### Cervical perforations\\nAn incision is made along the lower third of the anterior border of the sternocleidomastoid (SCM). This can be done from either side of the neck based on the site of extravasation or abscess, but traditionally is approached from the left neck. The SCM, internal jugular vein, and carotid sheath are retracted laterally. The middle thyroid vein is ligated to allow for better exposure of the trachea and esophagus.\\n\\nBluntly dissect down to the prevertebral space and behind the esophagus. Allis clamps on the thyroid can help rotate the laryngotracheal complex over for better exposure of the esophagus. Complete the dissection of the esophagus away from the membranous trachea, avoiding injury to the recurrent laryngeal nerve, and identify the area of perforation.\\n\\nAll devitalized tissue should be resected and a two-layer primary repair is then performed. The mucosal layer is repaired with an absorbable suture (4-0 polydioxanone or polyglactin) and the muscular layer approximated with your suture of choice (we use 3-0 silk).\\n```',\n", " 'images': [{'name': 'img_p211_1.png',\n", " 'height': 319,\n", " 'width': 419,\n", " 'x': 202.3199999999997,\n", " 'y': 82.79999999999998,\n", " 'original_width': 1152,\n", " 'original_height': 877}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 15.2',\n", " 'md': '## Figure 15.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** Image of a CT esophagogram with a non-contained leak from spontaneous perforation of the thoracic esophagus following retching. The CT esophagogram shows contrast extravasation (on the right) with large bilateral pleural effusions.\\n\\n----',\n", " 'md': '**Description:** Image of a CT esophagogram with a non-contained leak from spontaneous perforation of the thoracic esophagus following retching. The CT esophagogram shows contrast extravasation (on the right) with large bilateral pleural effusions.\\n\\n----',\n", " 'bBox': {'x': 75, 'y': 273, 'w': 460.26, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The operation: acute injuries and primary surgical repair',\n", " 'md': '### The operation: acute injuries and primary surgical repair',\n", " 'bBox': {'x': 86, 'y': 340, 'w': 444.1, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Cervical perforations',\n", " 'md': '#### Cervical perforations',\n", " 'bBox': {'x': 86, 'y': 384, 'w': 165.53, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'An incision is made along the lower third of the anterior border of the sternocleidomastoid (SCM). This can be done from either side of the neck based on the site of extravasation or abscess, but traditionally is approached from the left neck. The SCM, internal jugular vein, and carotid sheath are retracted laterally. The middle thyroid vein is ligated to allow for better exposure of the trachea and esophagus.\\n\\nBluntly dissect down to the prevertebral space and behind the esophagus. Allis clamps on the thyroid can help rotate the laryngotracheal complex over for better exposure of the esophagus. Complete the dissection of the esophagus away from the membranous trachea, avoiding injury to the recurrent laryngeal nerve, and identify the area of perforation.\\n\\nAll devitalized tissue should be resected and a two-layer primary repair is then performed. The mucosal layer is repaired with an absorbable suture (4-0 polydioxanone or polyglactin) and the muscular layer approximated with your suture of choice (we use 3-0 silk).\\n```',\n", " 'md': 'An incision is made along the lower third of the anterior border of the sternocleidomastoid (SCM). This can be done from either side of the neck based on the site of extravasation or abscess, but traditionally is approached from the left neck. The SCM, internal jugular vein, and carotid sheath are retracted laterally. The middle thyroid vein is ligated to allow for better exposure of the trachea and esophagus.\\n\\nBluntly dissect down to the prevertebral space and behind the esophagus. Allis clamps on the thyroid can help rotate the laryngotracheal complex over for better exposure of the esophagus. Complete the dissection of the esophagus away from the membranous trachea, avoiding injury to the recurrent laryngeal nerve, and identify the area of perforation.\\n\\nAll devitalized tissue should be resected and a two-layer primary repair is then performed. The mucosal layer is repaired with an absorbable suture (4-0 polydioxanone or polyglactin) and the muscular layer approximated with your suture of choice (we use 3-0 silk).\\n```',\n", " 'bBox': {'x': 72, 'y': 420, 'w': 467.61, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 213,\n", " 'text': 'with advanced local/systemic sepsis we would buttress the repair with the\\nhelp of the SCM — this, we believe, can help prevent postoperative\\nleaks. The SCM flap should also be used as an ‘onlay’ patch when there\\nis a large defect (>1/3-1/2 of the circumference) in the esophagus to\\nprevent narrowing of the lumen with primary repair. The SCM is\\nmobilized off the clavicle, medially rotated and sewn to the edges of\\nthe defect after the devitalized tissue has been resected.\\n\\n In rare instances (e.g. a reoperative field with severe contamination\\nand obliteration of the tissue planes; a small defect), the perforation may\\nnot be clearly identified and thus the area should be widely drained with\\n19Fr Jackson-Pratt® (JP) drains. Fluid collections in the upper\\nmediastinum can also be drained through this approach with finger\\ndissection along the prevertebral space and anterior mediastinum. Once\\nagain, JP drains are used to drain the mediastinum.\\n\\n Thoracic perforations ( Figures 15.3 and 15.4)\\n\\n Perforations or trauma to the proximal two-thirds of the esophagus\\nshould be approached from a right thoracotomy through the 4th-6th\\nintercostal space. Repair of distal esophageal perforations should\\nbe through a left thoracotomy in the 7th or 8th intercostal space.\\n\\n We usually start with endoscopy in the operating room. This\\nallows us to visualize directly the location and size of the defect. If it is\\nlarge and/or long then we may choose to harvest an omental flap to\\nprovide an adequate amount of vascularized tissue for coverage.\\n\\n To avoid a ‘triple flip’ of the patient (lateral-decubitus-supine-\\nlateral-decubitus); the laparotomy for the J-tube (and harvesting of\\nthe omentum, if necessary) would be done first.\\n\\n With perforations that are identified early and have limited\\ncontamination of the mediastinum, the planes of dissection will be\\npreserved. On the other hand, older perforations with severe\\ncontamination of the mediastinum and pleural space will have\\nedematous, inflamed tissue that will obscure the natural operative planes.',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nWith advanced local/systemic sepsis, we would buttress the repair with the help of the SCM — this, we believe, can help prevent postoperative leaks. The SCM flap should also be used as an ‘onlay’ patch when there is a large defect (>1/3-1/2 of the circumference) in the esophagus to prevent narrowing of the lumen with primary repair. The SCM is mobilized off the clavicle, medially rotated, and sewn to the edges of the defect after the devitalized tissue has been resected.\\n\\nIn rare instances (e.g., a reoperative field with severe contamination and obliteration of the tissue planes; a small defect), the perforation may not be clearly identified and thus the area should be widely drained with 19Fr Jackson-Pratt® (JP) drains. Fluid collections in the upper mediastinum can also be drained through this approach with finger dissection along the prevertebral space and anterior mediastinum. Once again, JP drains are used to drain the mediastinum.\\n\\n### Thoracic Perforations (Figures 15.3 and 15.4)\\n\\nPerforations or trauma to the proximal two-thirds of the esophagus should be approached from a right thoracotomy through the 4th-6th intercostal space. Repair of distal esophageal perforations should be through a left thoracotomy in the 7th or 8th intercostal space.\\n\\nWe usually start with endoscopy in the operating room. This allows us to visualize directly the location and size of the defect. If it is large and/or long, then we may choose to harvest an omental flap to provide an adequate amount of vascularized tissue for coverage.\\n\\nTo avoid a ‘triple flip’ of the patient (lateral-decubitus-supine-lateral-decubitus); the laparotomy for the J-tube (and harvesting of the omentum, if necessary) would be done first.\\n\\nWith perforations that are identified early and have limited contamination of the mediastinum, the planes of dissection will be preserved. On the other hand, older perforations with severe contamination of the mediastinum and pleural space will have edematous, inflamed tissue that will obscure the natural operative planes.\\n\\n## Image Identification and Description\\n\\n### Figure 15.3\\n*Description:* This figure likely illustrates the approach for thoracic perforations, showing the right thoracotomy through the 4th-6th intercostal space. The image may include anatomical landmarks and surgical instruments used during the procedure.\\n\\n### Figure 15.4\\n*Description:* This figure likely depicts the repair of distal esophageal perforations through a left thoracotomy in the 7th or 8th intercostal space. Similar to Figure 15.3, it may include relevant anatomical details and surgical techniques.\\n\\n*Note:* The specific content of Figures 15.3 and 15.4 is not provided in the text, and thus, detailed descriptions of these figures cannot be extracted. They are referenced for context regarding thoracic perforations.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'With advanced local/systemic sepsis, we would buttress the repair with the help of the SCM — this, we believe, can help prevent postoperative leaks. The SCM flap should also be used as an ‘onlay’ patch when there is a large defect (>1/3-1/2 of the circumference) in the esophagus to prevent narrowing of the lumen with primary repair. The SCM is mobilized off the clavicle, medially rotated, and sewn to the edges of the defect after the devitalized tissue has been resected.\\n\\nIn rare instances (e.g., a reoperative field with severe contamination and obliteration of the tissue planes; a small defect), the perforation may not be clearly identified and thus the area should be widely drained with 19Fr Jackson-Pratt® (JP) drains. Fluid collections in the upper mediastinum can also be drained through this approach with finger dissection along the prevertebral space and anterior mediastinum. Once again, JP drains are used to drain the mediastinum.',\n", " 'md': 'With advanced local/systemic sepsis, we would buttress the repair with the help of the SCM — this, we believe, can help prevent postoperative leaks. The SCM flap should also be used as an ‘onlay’ patch when there is a large defect (>1/3-1/2 of the circumference) in the esophagus to prevent narrowing of the lumen with primary repair. The SCM is mobilized off the clavicle, medially rotated, and sewn to the edges of the defect after the devitalized tissue has been resected.\\n\\nIn rare instances (e.g., a reoperative field with severe contamination and obliteration of the tissue planes; a small defect), the perforation may not be clearly identified and thus the area should be widely drained with 19Fr Jackson-Pratt® (JP) drains. Fluid collections in the upper mediastinum can also be drained through this approach with finger dissection along the prevertebral space and anterior mediastinum. Once again, JP drains are used to drain the mediastinum.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Thoracic Perforations (Figures 15.3 and 15.4)',\n", " 'md': '### Thoracic Perforations (Figures 15.3 and 15.4)',\n", " 'bBox': {'x': 86, 'y': 365, 'w': 180.22, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Perforations or trauma to the proximal two-thirds of the esophagus should be approached from a right thoracotomy through the 4th-6th intercostal space. Repair of distal esophageal perforations should be through a left thoracotomy in the 7th or 8th intercostal space.\\n\\nWe usually start with endoscopy in the operating room. This allows us to visualize directly the location and size of the defect. If it is large and/or long, then we may choose to harvest an omental flap to provide an adequate amount of vascularized tissue for coverage.\\n\\nTo avoid a ‘triple flip’ of the patient (lateral-decubitus-supine-lateral-decubitus); the laparotomy for the J-tube (and harvesting of the omentum, if necessary) would be done first.\\n\\nWith perforations that are identified early and have limited contamination of the mediastinum, the planes of dissection will be preserved. On the other hand, older perforations with severe contamination of the mediastinum and pleural space will have edematous, inflamed tissue that will obscure the natural operative planes.',\n", " 'md': 'Perforations or trauma to the proximal two-thirds of the esophagus should be approached from a right thoracotomy through the 4th-6th intercostal space. Repair of distal esophageal perforations should be through a left thoracotomy in the 7th or 8th intercostal space.\\n\\nWe usually start with endoscopy in the operating room. This allows us to visualize directly the location and size of the defect. If it is large and/or long, then we may choose to harvest an omental flap to provide an adequate amount of vascularized tissue for coverage.\\n\\nTo avoid a ‘triple flip’ of the patient (lateral-decubitus-supine-lateral-decubitus); the laparotomy for the J-tube (and harvesting of the omentum, if necessary) would be done first.\\n\\nWith perforations that are identified early and have limited contamination of the mediastinum, the planes of dissection will be preserved. On the other hand, older perforations with severe contamination of the mediastinum and pleural space will have edematous, inflamed tissue that will obscure the natural operative planes.',\n", " 'bBox': {'x': 72, 'y': 401, 'w': 467.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 413, 'y': 639, 'w': 28, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 15.3',\n", " 'md': '### Figure 15.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*Description:* This figure likely illustrates the approach for thoracic perforations, showing the right thoracotomy through the 4th-6th intercostal space. The image may include anatomical landmarks and surgical instruments used during the procedure.',\n", " 'md': '*Description:* This figure likely illustrates the approach for thoracic perforations, showing the right thoracotomy through the 4th-6th intercostal space. The image may include anatomical landmarks and surgical instruments used during the procedure.',\n", " 'bBox': {'x': 413, 'y': 639, 'w': 28, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 15.4',\n", " 'md': '### Figure 15.4',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*Description:* This figure likely depicts the repair of distal esophageal perforations through a left thoracotomy in the 7th or 8th intercostal space. Similar to Figure 15.3, it may include relevant anatomical details and surgical techniques.\\n\\n*Note:* The specific content of Figures 15.3 and 15.4 is not provided in the text, and thus, detailed descriptions of these figures cannot be extracted. They are referenced for context regarding thoracic perforations.\\n```',\n", " 'md': '*Description:* This figure likely depicts the repair of distal esophageal perforations through a left thoracotomy in the 7th or 8th intercostal space. Similar to Figure 15.3, it may include relevant anatomical details and surgical techniques.\\n\\n*Note:* The specific content of Figures 15.3 and 15.4 is not provided in the text, and thus, detailed descriptions of these figures cannot be extracted. They are referenced for context regarding thoracic perforations.\\n```',\n", " 'bBox': {'x': 129, 'y': 639, 'w': 79.96, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 214,\n", " 'text': 'In this scenario, the area of perforation is usually located at the most\\ninflamed and edematous areas. Therefore, to get around the\\nesophagus, start your dissection away from this area. For example,\\nwith a distal perforation, dissect out the esophagus above the level of the\\ncarina. Special attention to dissection of the esophagus off the trachea\\nwill prevent an inadvertent injury to the membranous airway.\\n Diaphragm\\n Back\\n Figure 15.3. Primary repair of a distal esophageal perforation secondary to barotrauma\\n through a left thoracotomy. The atraumatic forceps identify the area of perforation.\\n\\n Once the esophagus has been mobilized, place a Penrose drain\\naround it, and then using this as a guide, dissect out its distal portion.\\nThe margins of the perforation should be identified and debrided back to\\nviable tissue. A nasogastric tube is now placed and guided into the\\nstomach.\\n\\n The defect is then closed in two layers — as mentioned above. It is\\nimperative to assure the entire length of the mucosal defect is\\nrepaired. An intercostal muscle flap (see below) is used as a\\nbuttress by suturing it over the repair (interrupted 4-0 polyglactin).\\nOther options for autologous flaps include pericardial fat, diaphragm or',\n", " 'md': '```markdown\\nIn this scenario, the area of perforation is usually located at the most inflamed and edematous areas. Therefore, to get around the esophagus, start your dissection away from this area. For example, with a distal perforation, dissect out the esophagus above the level of the carina. Special attention to dissection of the esophagus off the trachea will prevent an inadvertent injury to the membranous airway.\\n\\n### Figure 15.3\\n**Caption:** Primary repair of a distal esophageal perforation secondary to barotrauma through a left thoracotomy. The atraumatic forceps identify the area of perforation.\\n\\nOnce the esophagus has been mobilized, place a Penrose drain around it, and then using this as a guide, dissect out its distal portion. The margins of the perforation should be identified and debrided back to viable tissue. A nasogastric tube is now placed and guided into the stomach.\\n\\nThe defect is then closed in two layers — as mentioned above. It is imperative to assure the entire length of the mucosal defect is repaired. An intercostal muscle flap (see below) is used as a buttress by suturing it over the repair (interrupted 4-0 polyglactin). Other options for autologous flaps include pericardial fat, diaphragm or .\\n```',\n", " 'images': [{'name': 'img_p213_1.png',\n", " 'height': 575,\n", " 'width': 802,\n", " 'x': 108,\n", " 'y': 182.16000000000003,\n", " 'original_width': 1377,\n", " 'original_height': 988}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nIn this scenario, the area of perforation is usually located at the most inflamed and edematous areas. Therefore, to get around the esophagus, start your dissection away from this area. For example, with a distal perforation, dissect out the esophagus above the level of the carina. Special attention to dissection of the esophagus off the trachea will prevent an inadvertent injury to the membranous airway.',\n", " 'md': '```markdown\\nIn this scenario, the area of perforation is usually located at the most inflamed and edematous areas. Therefore, to get around the esophagus, start your dissection away from this area. For example, with a distal perforation, dissect out the esophagus above the level of the carina. Special attention to dissection of the esophagus off the trachea will prevent an inadvertent injury to the membranous airway.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.82, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 15.3',\n", " 'md': '### Figure 15.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** Primary repair of a distal esophageal perforation secondary to barotrauma through a left thoracotomy. The atraumatic forceps identify the area of perforation.\\n\\nOnce the esophagus has been mobilized, place a Penrose drain around it, and then using this as a guide, dissect out its distal portion. The margins of the perforation should be identified and debrided back to viable tissue. A nasogastric tube is now placed and guided into the stomach.\\n\\nThe defect is then closed in two layers — as mentioned above. It is imperative to assure the entire length of the mucosal defect is repaired. An intercostal muscle flap (see below) is used as a buttress by suturing it over the repair (interrupted 4-0 polyglactin). Other options for autologous flaps include pericardial fat, diaphragm or .\\n```',\n", " 'md': '**Caption:** Primary repair of a distal esophageal perforation secondary to barotrauma through a left thoracotomy. The atraumatic forceps identify the area of perforation.\\n\\nOnce the esophagus has been mobilized, place a Penrose drain around it, and then using this as a guide, dissect out its distal portion. The margins of the perforation should be identified and debrided back to viable tissue. A nasogastric tube is now placed and guided into the stomach.\\n\\nThe defect is then closed in two layers — as mentioned above. It is imperative to assure the entire length of the mucosal defect is repaired. An intercostal muscle flap (see below) is used as a buttress by suturing it over the repair (interrupted 4-0 polyglactin). Other options for autologous flaps include pericardial fat, diaphragm or .\\n```',\n", " 'bBox': {'x': 72, 'y': 273.17, 'w': 467.6, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 215,\n", " 'text': 'omentum (again, see below). Two chest tubes (at least 28F) are placed\\nwith one lying in the posterior mediastinum to drain any postoperative\\nleaks and the thoracotomy is closed.\\n Pericardial Fat\\n ICM\\n Diaphragm\\n Figure 15.4. The perforation has been repaired and buttressed with an intercostal muscle\\n flap. ICM = intercostal muscle.\\n\\n The omentum is brought through a separate incision in the\\ndiaphragm — preferably a circumferential incision along the\\nposterolateral diaphragm to avoid injury to the phrenic nerves or their\\nmajor branches. Once it is brought through this defect, it is secured over\\nthe esophageal repair and at the diaphragm to reduce tension. The\\ndiaphragmatic defect is reapproximated around the omentum to prevent\\nherniation, but should not strangulate the omental flap.\\n\\n Finally, a few words on how to mobilize an intercostal muscle\\n(ICM) flap. Start by mobilizing the ICM and pleura off the inferior rib by\\nincising the periosteum using electrocautery. The superior aspect of the\\nICM, pleura, and neurovascular bundle is mobilized off the upper rib\\ncarefully so as to not injure the neurovascular bundle. The ICM is\\nmobilized as far anteriorly as possible stopping usually 1-2cm from the',\n", " 'md': '```markdown\\n## Page Content\\n\\nThe omentum (again, see below). Two chest tubes (at least 28F) are placed with one lying in the posterior mediastinum to drain any postoperative leaks and the thoracotomy is closed.\\n\\n### Pericardial Fat\\n**ICM**\\n**Diaphragm**\\n\\n**Figure 15.4**. The perforation has been repaired and buttressed with an intercostal muscle flap. ICM = intercostal muscle.\\n\\nThe omentum is brought through a separate incision in the diaphragm — preferably a circumferential incision along the posterolateral diaphragm to avoid injury to the phrenic nerves or their major branches. Once it is brought through this defect, it is secured over the esophageal repair and at the diaphragm to reduce tension. The diaphragmatic defect is reapproximated around the omentum to prevent herniation, but should not strangulate the omental flap.\\n\\nFinally, a few words on how to mobilize an intercostal muscle (ICM) flap. Start by mobilizing the ICM and pleura off the inferior rib by incising the periosteum using electrocautery. The superior aspect of the ICM, pleura, and neurovascular bundle is mobilized off the upper rib carefully so as to not injure the neurovascular bundle. The ICM is mobilized as far anteriorly as possible stopping usually 1-2cm from the...\\n```\\n\\n### Image Description\\n- **Figure 15.4**: This figure illustrates the surgical procedure where a perforation has been repaired and buttressed with an intercostal muscle flap. The image likely shows the anatomical positioning of the intercostal muscle flap in relation to the diaphragm and other surrounding structures. The caption clarifies that ICM stands for intercostal muscle.',\n", " 'images': [{'name': 'img_p214_1.png',\n", " 'height': 578,\n", " 'width': 803,\n", " 'x': 107.27999999999975,\n", " 'y': 132.48000000000002,\n", " 'original_width': 1380,\n", " 'original_height': 992}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The omentum (again, see below). Two chest tubes (at least 28F) are placed with one lying in the posterior mediastinum to drain any postoperative leaks and the thoracotomy is closed.',\n", " 'md': 'The omentum (again, see below). Two chest tubes (at least 28F) are placed with one lying in the posterior mediastinum to drain any postoperative leaks and the thoracotomy is closed.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.74, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Pericardial Fat',\n", " 'md': '### Pericardial Fat',\n", " 'bBox': {'x': 117.18, 'y': 215.56, 'w': 64.34, 'h': 11.87}},\n", " {'type': 'text',\n", " 'value': '**ICM**\\n**Diaphragm**\\n\\n**Figure 15.4**. The perforation has been repaired and buttressed with an intercostal muscle flap. ICM = intercostal muscle.\\n\\nThe omentum is brought through a separate incision in the diaphragm — preferably a circumferential incision along the posterolateral diaphragm to avoid injury to the phrenic nerves or their major branches. Once it is brought through this defect, it is secured over the esophageal repair and at the diaphragm to reduce tension. The diaphragmatic defect is reapproximated around the omentum to prevent herniation, but should not strangulate the omental flap.\\n\\nFinally, a few words on how to mobilize an intercostal muscle (ICM) flap. Start by mobilizing the ICM and pleura off the inferior rib by incising the periosteum using electrocautery. The superior aspect of the ICM, pleura, and neurovascular bundle is mobilized off the upper rib carefully so as to not injure the neurovascular bundle. The ICM is mobilized as far anteriorly as possible stopping usually 1-2cm from the...\\n```',\n", " 'md': '**ICM**\\n**Diaphragm**\\n\\n**Figure 15.4**. The perforation has been repaired and buttressed with an intercostal muscle flap. ICM = intercostal muscle.\\n\\nThe omentum is brought through a separate incision in the diaphragm — preferably a circumferential incision along the posterolateral diaphragm to avoid injury to the phrenic nerves or their major branches. Once it is brought through this defect, it is secured over the esophageal repair and at the diaphragm to reduce tension. The diaphragmatic defect is reapproximated around the omentum to prevent herniation, but should not strangulate the omental flap.\\n\\nFinally, a few words on how to mobilize an intercostal muscle (ICM) flap. Start by mobilizing the ICM and pleura off the inferior rib by incising the periosteum using electrocautery. The superior aspect of the ICM, pleura, and neurovascular bundle is mobilized off the upper rib carefully so as to not injure the neurovascular bundle. The ICM is mobilized as far anteriorly as possible stopping usually 1-2cm from the...\\n```',\n", " 'bBox': {'x': 72, 'y': 312, 'w': 467.59, 'h': 14.84}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 15.4**: This figure illustrates the surgical procedure where a perforation has been repaired and buttressed with an intercostal muscle flap. The image likely shows the anatomical positioning of the intercostal muscle flap in relation to the diaphragm and other surrounding structures. The caption clarifies that ICM stands for intercostal muscle.',\n", " 'md': '- **Figure 15.4**: This figure illustrates the surgical procedure where a perforation has been repaired and buttressed with an intercostal muscle flap. The image likely shows the anatomical positioning of the intercostal muscle flap in relation to the diaphragm and other surrounding structures. The caption clarifies that ICM stands for intercostal muscle.',\n", " 'bBox': {'x': 72, 'y': 312, 'w': 325.81, 'h': 14.84}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 216,\n", " 'text': 'internal mammary artery and then as far as needed posteriorly based on\\nthe length of the defect. It is transected anteriorly and the IC artery and\\nvein are ligated.\\n\\n Abdominal perforations\\n\\n Uncontained perforations in the abdomen can quickly spread through\\nthe peritoneal cavity resulting in peritonitis and sepsis necessitating\\noperative repair. A midline laparotomy incision is generally used, but\\na laparoscopic approach can be used by the experienced\\nlaparoscopic surgeon. Open or laparoscopic, the perforation is\\nprimarily repaired and buttressed with a partial wrap of the gastric\\nfundus. Alternatively, the omentum can be used as a buttress. A\\nnasogastric tube is carefully guided into the stomach and a\\njejunostomy tube is placed for enteral nutrition. If the perforation\\nleads to contamination of the mediastinum, this can be adequately\\ndrained through the esophageal hiatus while pleural effusions can be\\ntreated with chest tubes.\\n\\n Transendoscopic therapy\\n\\n Originally, esophageal stents were used to treat malignant strictures.\\nMore recently, with the development of completely covered stents, they\\nhave been used to treat perforations, esophageal anastomotic leaks, and\\nfistulas.\\n\\n Indications for their use:\\n\\n • Immediately recognized injury or perforation during endoscopy or\\n dilation procedures.\\n • A contained perforation with only the presence of\\n pneumomediastinum or minimal contrast extravasation.\\n • Septic patients as a temporary measure of source control.\\n • Anastomotic leaks.\\n • Palliative therapy for malignant perforations or fistulas.',\n", " 'md': '```markdown\\n## Abdominal Perforations\\n\\nUncontained perforations in the abdomen can quickly spread through the peritoneal cavity resulting in peritonitis and sepsis necessitating operative repair. A midline laparotomy incision is generally used, but a laparoscopic approach can be used by the experienced laparoscopic surgeon. Open or laparoscopic, the perforation is primarily repaired and buttressed with a partial wrap of the gastric fundus. Alternatively, the omentum can be used as a buttress. A nasogastric tube is carefully guided into the stomach and a jejunostomy tube is placed for enteral nutrition. If the perforation leads to contamination of the mediastinum, this can be adequately drained through the esophageal hiatus while pleural effusions can be treated with chest tubes.\\n\\n## Transendoscopic Therapy\\n\\nOriginally, esophageal stents were used to treat malignant strictures. More recently, with the development of completely covered stents, they have been used to treat perforations, esophageal anastomotic leaks, and fistulas.\\n\\n### Indications for Their Use:\\n\\n- Immediately recognized injury or perforation during endoscopy or dilation procedures.\\n- A contained perforation with only the presence of pneumomediastinum or minimal contrast extravasation.\\n- Septic patients as a temporary measure of source control.\\n- Anastomotic leaks.\\n- Palliative therapy for malignant perforations or fistulas.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Perforations',\n", " 'md': '## Abdominal Perforations',\n", " 'bBox': {'x': 86, 'y': 162, 'w': 186.65, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Uncontained perforations in the abdomen can quickly spread through the peritoneal cavity resulting in peritonitis and sepsis necessitating operative repair. A midline laparotomy incision is generally used, but a laparoscopic approach can be used by the experienced laparoscopic surgeon. Open or laparoscopic, the perforation is primarily repaired and buttressed with a partial wrap of the gastric fundus. Alternatively, the omentum can be used as a buttress. A nasogastric tube is carefully guided into the stomach and a jejunostomy tube is placed for enteral nutrition. If the perforation leads to contamination of the mediastinum, this can be adequately drained through the esophageal hiatus while pleural effusions can be treated with chest tubes.',\n", " 'md': 'Uncontained perforations in the abdomen can quickly spread through the peritoneal cavity resulting in peritonitis and sepsis necessitating operative repair. A midline laparotomy incision is generally used, but a laparoscopic approach can be used by the experienced laparoscopic surgeon. Open or laparoscopic, the perforation is primarily repaired and buttressed with a partial wrap of the gastric fundus. Alternatively, the omentum can be used as a buttress. A nasogastric tube is carefully guided into the stomach and a jejunostomy tube is placed for enteral nutrition. If the perforation leads to contamination of the mediastinum, this can be adequately drained through the esophageal hiatus while pleural effusions can be treated with chest tubes.',\n", " 'bBox': {'x': 72, 'y': 231, 'w': 466.46, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Transendoscopic Therapy',\n", " 'md': '## Transendoscopic Therapy',\n", " 'bBox': {'x': 86, 'y': 423, 'w': 200.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Originally, esophageal stents were used to treat malignant strictures. More recently, with the development of completely covered stents, they have been used to treat perforations, esophageal anastomotic leaks, and fistulas.',\n", " 'md': 'Originally, esophageal stents were used to treat malignant strictures. More recently, with the development of completely covered stents, they have been used to treat perforations, esophageal anastomotic leaks, and fistulas.',\n", " 'bBox': {'x': 72, 'y': 492, 'w': 467.48, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Indications for Their Use:',\n", " 'md': '### Indications for Their Use:',\n", " 'bBox': {'x': 86, 'y': 544, 'w': 167, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- Immediately recognized injury or perforation during endoscopy or dilation procedures.\\n- A contained perforation with only the presence of pneumomediastinum or minimal contrast extravasation.\\n- Septic patients as a temporary measure of source control.\\n- Anastomotic leaks.\\n- Palliative therapy for malignant perforations or fistulas.\\n```',\n", " 'md': '- Immediately recognized injury or perforation during endoscopy or dilation procedures.\\n- A contained perforation with only the presence of pneumomediastinum or minimal contrast extravasation.\\n- Septic patients as a temporary measure of source control.\\n- Anastomotic leaks.\\n- Palliative therapy for malignant perforations or fistulas.\\n```',\n", " 'bBox': {'x': 72, 'y': 509, 'w': 368.62, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 217,\n", " 'text': ' Both plastic and metal covered stents have been used with good\\ntechnical and clinical success (i.e. healing the perforation). The stents are\\ntypically deployed under both endoscopic and fluoroscopic guidance.\\nSome of the drawbacks to this approach are the need for technical\\nexpertise, lack of clear guidelines of when to remove the stents and\\npotential costs. Complications include stent migration and the need for\\nreintervention and stent perforation. Migration is more common after\\nplacement in a ‘normal’ esophagus. Appropriate stent sizing and\\nplacement just proximal to the gastroesophageal junction can minimize\\nthe risk of migration.\\n\\n Endoscopic clips are now available (and FDA approved in the\\nUSA) to repair intestinal defects. They should be used for small (<2cm)\\nimmediately recognized iatrogenic injuries.\\n\\n If mediastinal or pleural fluid collections are noted, they need to be\\ndrained. Hybrid procedures are now commonly employed;\\nendoscopic treatment of perforations is used in conjunction with\\nimage-guided drains or minimally invasive surgery (thoracoscopy)\\nto treat these collections and other complicating processes such as\\nempyema or trapped lung.\\n\\n Remember: if you wish to experiment with such minimal access\\nmodalities — be ready to become aggressive, if needed, before it is\\ntoo late!\\n\\n Perforations: difficult clinical scenarios\\n\\n Delayed presentation or diagnosis of perforation\\n\\n Some patients will present or be diagnosed in a delayed fashion. They\\nwill often present with sepsis and require aggressive resuscitation and\\nhemodynamic support. In these instances, definitive repair may not\\nbe an option. The principles of treatment remain the same (control\\nsource of sepsis, drain infected fluid collections, administer antibiotics,\\nand provide nutritional support), but alternative strategies are used to',\n", " 'md': '```markdown\\n## Current Page Content\\n\\nBoth plastic and metal covered stents have been used with good technical and clinical success (i.e. healing the perforation). The stents are typically deployed under both endoscopic and fluoroscopic guidance. Some of the drawbacks to this approach are the need for technical expertise, lack of clear guidelines of when to remove the stents and potential costs. Complications include stent migration and the need for reintervention and stent perforation. Migration is more common after placement in a ‘normal’ esophagus. Appropriate stent sizing and placement just proximal to the gastroesophageal junction can minimize the risk of migration.\\n\\nEndoscopic clips are now available (and FDA approved in the USA) to repair intestinal defects. They should be used for small (<2cm) immediately recognized iatrogenic injuries.\\n\\nIf mediastinal or pleural fluid collections are noted, they need to be drained. Hybrid procedures are now commonly employed; endoscopic treatment of perforations is used in conjunction with image-guided drains or minimally invasive surgery (thoracoscopy) to treat these collections and other complicating processes such as empyema or trapped lung.\\n\\nRemember: if you wish to experiment with such minimal access modalities — be ready to become aggressive, if needed, before it is too late!\\n\\n### Perforations: Difficult Clinical Scenarios\\n\\n#### Delayed Presentation or Diagnosis of Perforation\\n\\nSome patients will present or be diagnosed in a delayed fashion. They will often present with sepsis and require aggressive resuscitation and hemodynamic support. In these instances, definitive repair may not be an option. The principles of treatment remain the same (control source of sepsis, drain infected fluid collections, administer antibiotics, and provide nutritional support), but alternative strategies are used to...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured appropriately.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Both plastic and metal covered stents have been used with good technical and clinical success (i.e. healing the perforation). The stents are typically deployed under both endoscopic and fluoroscopic guidance. Some of the drawbacks to this approach are the need for technical expertise, lack of clear guidelines of when to remove the stents and potential costs. Complications include stent migration and the need for reintervention and stent perforation. Migration is more common after placement in a ‘normal’ esophagus. Appropriate stent sizing and placement just proximal to the gastroesophageal junction can minimize the risk of migration.\\n\\nEndoscopic clips are now available (and FDA approved in the USA) to repair intestinal defects. They should be used for small (<2cm) immediately recognized iatrogenic injuries.\\n\\nIf mediastinal or pleural fluid collections are noted, they need to be drained. Hybrid procedures are now commonly employed; endoscopic treatment of perforations is used in conjunction with image-guided drains or minimally invasive surgery (thoracoscopy) to treat these collections and other complicating processes such as empyema or trapped lung.\\n\\nRemember: if you wish to experiment with such minimal access modalities — be ready to become aggressive, if needed, before it is too late!',\n", " 'md': 'Both plastic and metal covered stents have been used with good technical and clinical success (i.e. healing the perforation). The stents are typically deployed under both endoscopic and fluoroscopic guidance. Some of the drawbacks to this approach are the need for technical expertise, lack of clear guidelines of when to remove the stents and potential costs. Complications include stent migration and the need for reintervention and stent perforation. Migration is more common after placement in a ‘normal’ esophagus. Appropriate stent sizing and placement just proximal to the gastroesophageal junction can minimize the risk of migration.\\n\\nEndoscopic clips are now available (and FDA approved in the USA) to repair intestinal defects. They should be used for small (<2cm) immediately recognized iatrogenic injuries.\\n\\nIf mediastinal or pleural fluid collections are noted, they need to be drained. Hybrid procedures are now commonly employed; endoscopic treatment of perforations is used in conjunction with image-guided drains or minimally invasive surgery (thoracoscopy) to treat these collections and other complicating processes such as empyema or trapped lung.\\n\\nRemember: if you wish to experiment with such minimal access modalities — be ready to become aggressive, if needed, before it is too late!',\n", " 'bBox': {'x': 72, 'y': 123, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Perforations: Difficult Clinical Scenarios',\n", " 'md': '### Perforations: Difficult Clinical Scenarios',\n", " 'bBox': {'x': 86, 'y': 553, 'w': 309.84, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Delayed Presentation or Diagnosis of Perforation',\n", " 'md': '#### Delayed Presentation or Diagnosis of Perforation',\n", " 'bBox': {'x': 86, 'y': 597, 'w': 382.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Some patients will present or be diagnosed in a delayed fashion. They will often present with sepsis and require aggressive resuscitation and hemodynamic support. In these instances, definitive repair may not be an option. The principles of treatment remain the same (control source of sepsis, drain infected fluid collections, administer antibiotics, and provide nutritional support), but alternative strategies are used to...\\n```',\n", " 'md': 'Some patients will present or be diagnosed in a delayed fashion. They will often present with sepsis and require aggressive resuscitation and hemodynamic support. In these instances, definitive repair may not be an option. The principles of treatment remain the same (control source of sepsis, drain infected fluid collections, administer antibiotics, and provide nutritional support), but alternative strategies are used to...\\n```',\n", " 'bBox': {'x': 86, 'y': 376, 'w': 453.44, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured appropriately.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured appropriately.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 218,\n", " 'text': 'accomplish the required tasks. If available to the surgeon, esophageal\\nstenting and drain placement can provide immediate source control. At\\nsurgery, the esophagus will be edematous and extremely friable making\\nsuccessful primary repair unlikely.\\n\\n Options to consider are repair over a T-tube, creating a controlled\\nfistula, or esophageal exclusion. T-tube placement is considered\\nwhen there is a significant delay in diagnosis, in unstable patients, or\\nwhen successful primary repair is unlikely or will result in severe\\nnarrowing due to extensive mucosal or muscular damage 2. Esophageal\\ndiversion is considered if there is a non-viable, necrotic esophagus,\\nhemodynamic instability, and the underlying pathology precludes primary\\nrepair. This consists of a cervical esophagostomy (we perform an ‘end’-\\nesophagostomy because we completely divide the proximal esophagus.\\nħowever, some prefer to do a side-esophagostomy because they use an\\nabsorbable suture to tie off the proximal esophagus temporarily) and\\nstapling of the distal esophagus at the gastroesophageal junction; then\\nwe place a gastrostomy and a jejunostomy tube. The thoracic esophagus\\ndoes not need to be resected, provided the posterior mediastinum is well\\ndrained, and an end-cervical esophagostomy is created using the left\\nneck dissection described above. Every effort should be made to\\nmaximize the remaining length of proximal esophagus. If the proximal\\nesophagus is long enough, the esophagostomy can be created on the\\nanterior chest wall by tunneling it in the subcutaneous tissue over the\\nclavicle. The stoma appliance sits better on the chest and can be hidden\\nunder the patient’s clothes. This extended length allows for easier\\nreconstruction with either a gastric conduit or colon interposition at\\na later date. It is not uncommon for these delayed presentations to have\\nan associated empyema. If the lung is found to be trapped at surgery,\\nthen a decortication should be performed and all loculated fluid\\ncollections drained.\\n\\n Be that as it may, every attempt should be made to preserve the\\nesophagus and gastrointestinal continuity — it is becoming\\nexceedingly rare that esophageal exclusion is needed.\\n\\n Benign strictures',\n", " 'md': '```markdown\\n## Esophageal Surgery Considerations\\n\\nAccomplishing the required tasks is crucial. If available to the surgeon, esophageal stenting and drain placement can provide immediate source control. At surgery, the esophagus will be edematous and extremely friable, making successful primary repair unlikely.\\n\\nOptions to consider are:\\n- Repair over a T-tube\\n- Creating a controlled fistula\\n- Esophageal exclusion\\n\\nT-tube placement is considered when there is a significant delay in diagnosis, in unstable patients, or when successful primary repair is unlikely or will result in severe narrowing due to extensive mucosal or muscular damage. Esophageal diversion is considered if there is a non-viable, necrotic esophagus, hemodynamic instability, and the underlying pathology precludes primary repair. This consists of a cervical esophagostomy (we perform an ‘end’-esophagostomy because we completely divide the proximal esophagus. However, some prefer to do a side-esophagostomy because they use an absorbable suture to tie off the proximal esophagus temporarily) and stapling of the distal esophagus at the gastroesophageal junction; then we place a gastrostomy and a jejunostomy tube.\\n\\nThe thoracic esophagus does not need to be resected, provided the posterior mediastinum is well drained, and an end-cervical esophagostomy is created using the left neck dissection described above. Every effort should be made to maximize the remaining length of the proximal esophagus. If the proximal esophagus is long enough, the esophagostomy can be created on the anterior chest wall by tunneling it in the subcutaneous tissue over the clavicle. The stoma appliance sits better on the chest and can be hidden under the patient’s clothes. This extended length allows for easier reconstruction with either a gastric conduit or colon interposition at a later date.\\n\\nIt is not uncommon for these delayed presentations to have an associated empyema. If the lung is found to be trapped at surgery, then a decortication should be performed and all loculated fluid collections drained.\\n\\nBe that as it may, every attempt should be made to preserve the esophagus and gastrointestinal continuity — it is becoming exceedingly rare that esophageal exclusion is needed.\\n\\n### Benign Strictures\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Esophageal Surgery Considerations',\n", " 'md': '## Esophageal Surgery Considerations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Accomplishing the required tasks is crucial. If available to the surgeon, esophageal stenting and drain placement can provide immediate source control. At surgery, the esophagus will be edematous and extremely friable, making successful primary repair unlikely.\\n\\nOptions to consider are:\\n- Repair over a T-tube\\n- Creating a controlled fistula\\n- Esophageal exclusion\\n\\nT-tube placement is considered when there is a significant delay in diagnosis, in unstable patients, or when successful primary repair is unlikely or will result in severe narrowing due to extensive mucosal or muscular damage. Esophageal diversion is considered if there is a non-viable, necrotic esophagus, hemodynamic instability, and the underlying pathology precludes primary repair. This consists of a cervical esophagostomy (we perform an ‘end’-esophagostomy because we completely divide the proximal esophagus. However, some prefer to do a side-esophagostomy because they use an absorbable suture to tie off the proximal esophagus temporarily) and stapling of the distal esophagus at the gastroesophageal junction; then we place a gastrostomy and a jejunostomy tube.\\n\\nThe thoracic esophagus does not need to be resected, provided the posterior mediastinum is well drained, and an end-cervical esophagostomy is created using the left neck dissection described above. Every effort should be made to maximize the remaining length of the proximal esophagus. If the proximal esophagus is long enough, the esophagostomy can be created on the anterior chest wall by tunneling it in the subcutaneous tissue over the clavicle. The stoma appliance sits better on the chest and can be hidden under the patient’s clothes. This extended length allows for easier reconstruction with either a gastric conduit or colon interposition at a later date.\\n\\nIt is not uncommon for these delayed presentations to have an associated empyema. If the lung is found to be trapped at surgery, then a decortication should be performed and all loculated fluid collections drained.\\n\\nBe that as it may, every attempt should be made to preserve the esophagus and gastrointestinal continuity — it is becoming exceedingly rare that esophageal exclusion is needed.',\n", " 'md': 'Accomplishing the required tasks is crucial. If available to the surgeon, esophageal stenting and drain placement can provide immediate source control. At surgery, the esophagus will be edematous and extremely friable, making successful primary repair unlikely.\\n\\nOptions to consider are:\\n- Repair over a T-tube\\n- Creating a controlled fistula\\n- Esophageal exclusion\\n\\nT-tube placement is considered when there is a significant delay in diagnosis, in unstable patients, or when successful primary repair is unlikely or will result in severe narrowing due to extensive mucosal or muscular damage. Esophageal diversion is considered if there is a non-viable, necrotic esophagus, hemodynamic instability, and the underlying pathology precludes primary repair. This consists of a cervical esophagostomy (we perform an ‘end’-esophagostomy because we completely divide the proximal esophagus. However, some prefer to do a side-esophagostomy because they use an absorbable suture to tie off the proximal esophagus temporarily) and stapling of the distal esophagus at the gastroesophageal junction; then we place a gastrostomy and a jejunostomy tube.\\n\\nThe thoracic esophagus does not need to be resected, provided the posterior mediastinum is well drained, and an end-cervical esophagostomy is created using the left neck dissection described above. Every effort should be made to maximize the remaining length of the proximal esophagus. If the proximal esophagus is long enough, the esophagostomy can be created on the anterior chest wall by tunneling it in the subcutaneous tissue over the clavicle. The stoma appliance sits better on the chest and can be hidden under the patient’s clothes. This extended length allows for easier reconstruction with either a gastric conduit or colon interposition at a later date.\\n\\nIt is not uncommon for these delayed presentations to have an associated empyema. If the lung is found to be trapped at surgery, then a decortication should be performed and all loculated fluid collections drained.\\n\\nBe that as it may, every attempt should be made to preserve the esophagus and gastrointestinal continuity — it is becoming exceedingly rare that esophageal exclusion is needed.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.92, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Benign Strictures',\n", " 'md': '### Benign Strictures',\n", " 'bBox': {'x': 86, 'y': 698, 'w': 136.1, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 219,\n", " 'text': ' Primary repair of a perforation associated with a distal stricture is\\nunlikely to heal. Perforations do not develop spontaneously but arise\\nfrom attempted dilation of the stricture. If the perforation occurs at or near\\na distal benign stricture, then the stomach should be used as part of the\\nrepair or as a buttress by creating a partial fundoplication. The\\nesophagus is usually foreshortened in these instances and a Collis\\ngastroplasty is needed to lengthen the esophagus. If repair is not\\ntechnically feasible due to a long stricture then an esophagectomy should\\nbe performed. If the patient is deemed unfit for such a major procedure,\\nthen a T-tube is placed along with drains until the patient is able to have\\nan esophagectomy. Inflammation and fibrosis from the perforation and\\nstricture will make the mediastinal dissection challenging, so an Ivor-\\nLewis or McKeown (3-field) approach will help with the thoracic\\ndissection.\\n\\n Motility disorders\\n\\n When a perforation occurs after pneumatic dilatation for an underlying\\nmotility disorder such as achalasia or diffuse esophageal spasm, then the\\nprimary repair should be accompanied by a long myotomy, performed\\n180° opposite the repair, and partial gastric fundoplication. If the patient\\nwas predetermined to have a defunctionalized esophagus from the\\nmotility disorder (e.g. end-stage achalasia), then he should have an\\nesophagectomy.\\n\\n Malignancy\\n\\n Patients that present with a perforation in the setting of widely\\ndisseminated esophageal cancer or tracheoesophageal fistulas\\nshould be treated with stent placement. Esophagectomy should be\\nreserved for hemodynamically stable patients with non-disseminated\\ndisease. Reconstruction can be performed immediately if the patient\\nremains hemodynamically stable and there are no concerns about the\\ngastric conduit (no ischemia); otherwise a cervical esophagostomy is\\ncreated with placement of a gastrostomy and feeding jejunostomy tube.\\nWe do not find that placement of a gastrostomy tube limits our ability to\\nuse the stomach as a conduit during subsequent reconstruction.',\n", " 'md': '```markdown\\n# Primary Repair of Perforations Associated with Distal Strictures\\n\\nPrimary repair of a perforation associated with a distal stricture is unlikely to heal. Perforations do not develop spontaneously but arise from attempted dilation of the stricture. If the perforation occurs at or near a distal benign stricture, then the stomach should be used as part of the repair or as a buttress by creating a partial fundoplication. The esophagus is usually foreshortened in these instances and a Collis gastroplasty is needed to lengthen the esophagus. If repair is not technically feasible due to a long stricture then an esophagectomy should be performed. If the patient is deemed unfit for such a major procedure, then a T-tube is placed along with drains until the patient is able to have an esophagectomy. Inflammation and fibrosis from the perforation and stricture will make the mediastinal dissection challenging, so an Ivor-Lewis or McKeown (3-field) approach will help with the thoracic dissection.\\n\\n## Motility Disorders\\n\\nWhen a perforation occurs after pneumatic dilatation for an underlying motility disorder such as achalasia or diffuse esophageal spasm, then the primary repair should be accompanied by a long myotomy, performed 180° opposite the repair, and partial gastric fundoplication. If the patient was predetermined to have a defunctionalized esophagus from the motility disorder (e.g. end-stage achalasia), then he should have an esophagectomy.\\n\\n## Malignancy\\n\\nPatients that present with a perforation in the setting of widely disseminated esophageal cancer or tracheoesophageal fistulas should be treated with stent placement. Esophagectomy should be reserved for hemodynamically stable patients with non-disseminated disease. Reconstruction can be performed immediately if the patient remains hemodynamically stable and there are no concerns about the gastric conduit (no ischemia); otherwise, a cervical esophagostomy is created with placement of a gastrostomy and feeding jejunostomy tube. We do not find that placement of a gastrostomy tube limits our ability to use the stomach as a conduit during subsequent reconstruction.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Primary Repair of Perforations Associated with Distal Strictures',\n", " 'md': '# Primary Repair of Perforations Associated with Distal Strictures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Primary repair of a perforation associated with a distal stricture is unlikely to heal. Perforations do not develop spontaneously but arise from attempted dilation of the stricture. If the perforation occurs at or near a distal benign stricture, then the stomach should be used as part of the repair or as a buttress by creating a partial fundoplication. The esophagus is usually foreshortened in these instances and a Collis gastroplasty is needed to lengthen the esophagus. If repair is not technically feasible due to a long stricture then an esophagectomy should be performed. If the patient is deemed unfit for such a major procedure, then a T-tube is placed along with drains until the patient is able to have an esophagectomy. Inflammation and fibrosis from the perforation and stricture will make the mediastinal dissection challenging, so an Ivor-Lewis or McKeown (3-field) approach will help with the thoracic dissection.',\n", " 'md': 'Primary repair of a perforation associated with a distal stricture is unlikely to heal. Perforations do not develop spontaneously but arise from attempted dilation of the stricture. If the perforation occurs at or near a distal benign stricture, then the stomach should be used as part of the repair or as a buttress by creating a partial fundoplication. The esophagus is usually foreshortened in these instances and a Collis gastroplasty is needed to lengthen the esophagus. If repair is not technically feasible due to a long stricture then an esophagectomy should be performed. If the patient is deemed unfit for such a major procedure, then a T-tube is placed along with drains until the patient is able to have an esophagectomy. Inflammation and fibrosis from the perforation and stricture will make the mediastinal dissection challenging, so an Ivor-Lewis or McKeown (3-field) approach will help with the thoracic dissection.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Motility Disorders',\n", " 'md': '## Motility Disorders',\n", " 'bBox': {'x': 86, 'y': 344, 'w': 137.91, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'When a perforation occurs after pneumatic dilatation for an underlying motility disorder such as achalasia or diffuse esophageal spasm, then the primary repair should be accompanied by a long myotomy, performed 180° opposite the repair, and partial gastric fundoplication. If the patient was predetermined to have a defunctionalized esophagus from the motility disorder (e.g. end-stage achalasia), then he should have an esophagectomy.',\n", " 'md': 'When a perforation occurs after pneumatic dilatation for an underlying motility disorder such as achalasia or diffuse esophageal spasm, then the primary repair should be accompanied by a long myotomy, performed 180° opposite the repair, and partial gastric fundoplication. If the patient was predetermined to have a defunctionalized esophagus from the motility disorder (e.g. end-stage achalasia), then he should have an esophagectomy.',\n", " 'bBox': {'x': 72, 'y': 380, 'w': 467.9, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Malignancy',\n", " 'md': '## Malignancy',\n", " 'bBox': {'x': 86, 'y': 522, 'w': 90.13, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Patients that present with a perforation in the setting of widely disseminated esophageal cancer or tracheoesophageal fistulas should be treated with stent placement. Esophagectomy should be reserved for hemodynamically stable patients with non-disseminated disease. Reconstruction can be performed immediately if the patient remains hemodynamically stable and there are no concerns about the gastric conduit (no ischemia); otherwise, a cervical esophagostomy is created with placement of a gastrostomy and feeding jejunostomy tube. We do not find that placement of a gastrostomy tube limits our ability to use the stomach as a conduit during subsequent reconstruction.\\n```',\n", " 'md': 'Patients that present with a perforation in the setting of widely disseminated esophageal cancer or tracheoesophageal fistulas should be treated with stent placement. Esophagectomy should be reserved for hemodynamically stable patients with non-disseminated disease. Reconstruction can be performed immediately if the patient remains hemodynamically stable and there are no concerns about the gastric conduit (no ischemia); otherwise, a cervical esophagostomy is created with placement of a gastrostomy and feeding jejunostomy tube. We do not find that placement of a gastrostomy tube limits our ability to use the stomach as a conduit during subsequent reconstruction.\\n```',\n", " 'bBox': {'x': 72, 'y': 691, 'w': 467.31, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 220,\n", " 'text': ' Caustic injuries\\n\\n As mentioned above, the severity of caustic injury is dependent on the\\nsubstance ingested, volume, and duration of exposure. Alkali agents\\ntend to penetrate the oropharynx and esophagus more than acid, leading\\nto a ‘deeper’ injury and higher risk of immediate perforation. In addition,\\nalkali agents are usually odorless and tasteless so a greater volume is\\nconsumed. In contrast, acids tend to taste bitter and cause immediate\\ndiscomfort with ingestion, causing the patient to spit it out before there is\\nsignificant exposure to the esophagus.\\n\\n Patients with severe injuries will present with oral pain, an inability to\\ntolerate their saliva, and evidence of laryngeal edema with hoarseness,\\nstridor, or dyspnea. The surgeon needs to have the equipment ready\\nfor immediate intubation or an emergency surgical airway. Induced\\nvomiting is contraindicated as it will re-expose the esophagus to caustic\\ninjury.\\n\\n Diagnosis\\n A chest X-ray and CT scan are obtained to look for a perforation,\\nbut the definitive test to evaluate the severity of injury is early,\\nflexible endoscopy. Extreme caution should be used during endoscopy\\nwith the use of a pediatric scope and minimal insufflation to lessen the\\nrisk of an iatrogenic perforation. The scope should be passed only\\nuntil the initial area of injury is noted and severity of injury can be\\naccessed, as navigation beyond this area carries a high risk of iatrogenic\\nmucosal injury or full-thickness perforation. With first-degree injuries,\\nthere is mucosal hyperemia and edema signifying a mucosal injury.\\nSecond-degree injuries will have hemorrhagic, exudative, or ulcerative\\npseudomembranes. These injuries are through the mucosa but not the\\nmuscularis. Third-degree injuries are full-thickness injuries with eschar\\nand charring, or complete obliteration of the lumen by edema.\\n\\n Treatment\\n Patients are made NPO and started on broad-spectrum antibiotics.\\nThe majority of patients can be managed non-operatively but are at\\nhigh risk for late strictures — the management of which is beyond the',\n", " 'md': '```markdown\\n# Caustic Injuries\\n\\nAs mentioned above, the severity of caustic injury is dependent on the substance ingested, volume, and duration of exposure. Alkali agents tend to penetrate the oropharynx and esophagus more than acid, leading to a ‘deeper’ injury and higher risk of immediate perforation. In addition, alkali agents are usually odorless and tasteless so a greater volume is consumed. In contrast, acids tend to taste bitter and cause immediate discomfort with ingestion, causing the patient to spit it out before there is significant exposure to the esophagus.\\n\\nPatients with severe injuries will present with oral pain, an inability to tolerate their saliva, and evidence of laryngeal edema with hoarseness, stridor, or dyspnea. The surgeon needs to have the equipment ready for immediate intubation or an emergency surgical airway. Induced vomiting is contraindicated as it will re-expose the esophagus to caustic injury.\\n\\n## Diagnosis\\n\\nA chest X-ray and CT scan are obtained to look for a perforation, but the definitive test to evaluate the severity of injury is early, flexible endoscopy. Extreme caution should be used during endoscopy with the use of a pediatric scope and minimal insufflation to lessen the risk of an iatrogenic perforation. The scope should be passed only until the initial area of injury is noted and severity of injury can be accessed, as navigation beyond this area carries a high risk of iatrogenic mucosal injury or full-thickness perforation.\\n\\nWith first-degree injuries, there is mucosal hyperemia and edema signifying a mucosal injury. Second-degree injuries will have hemorrhagic, exudative, or ulcerative pseudomembranes. These injuries are through the mucosa but not the muscularis. Third-degree injuries are full-thickness injuries with eschar and charring, or complete obliteration of the lumen by edema.\\n\\n## Treatment\\n\\nPatients are made NPO and started on broad-spectrum antibiotics. The majority of patients can be managed non-operatively but are at high risk for late strictures — the management of which is beyond the scope of this document.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Caustic Injuries',\n", " 'md': '# Caustic Injuries',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 123.21, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As mentioned above, the severity of caustic injury is dependent on the substance ingested, volume, and duration of exposure. Alkali agents tend to penetrate the oropharynx and esophagus more than acid, leading to a ‘deeper’ injury and higher risk of immediate perforation. In addition, alkali agents are usually odorless and tasteless so a greater volume is consumed. In contrast, acids tend to taste bitter and cause immediate discomfort with ingestion, causing the patient to spit it out before there is significant exposure to the esophagus.\\n\\nPatients with severe injuries will present with oral pain, an inability to tolerate their saliva, and evidence of laryngeal edema with hoarseness, stridor, or dyspnea. The surgeon needs to have the equipment ready for immediate intubation or an emergency surgical airway. Induced vomiting is contraindicated as it will re-expose the esophagus to caustic injury.',\n", " 'md': 'As mentioned above, the severity of caustic injury is dependent on the substance ingested, volume, and duration of exposure. Alkali agents tend to penetrate the oropharynx and esophagus more than acid, leading to a ‘deeper’ injury and higher risk of immediate perforation. In addition, alkali agents are usually odorless and tasteless so a greater volume is consumed. In contrast, acids tend to taste bitter and cause immediate discomfort with ingestion, causing the patient to spit it out before there is significant exposure to the esophagus.\\n\\nPatients with severe injuries will present with oral pain, an inability to tolerate their saliva, and evidence of laryngeal edema with hoarseness, stridor, or dyspnea. The surgeon needs to have the equipment ready for immediate intubation or an emergency surgical airway. Induced vomiting is contraindicated as it will re-expose the esophagus to caustic injury.',\n", " 'bBox': {'x': 72, 'y': 124, 'w': 467.92, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnosis',\n", " 'md': '## Diagnosis',\n", " 'bBox': {'x': 86, 'y': 396, 'w': 68.75, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'A chest X-ray and CT scan are obtained to look for a perforation, but the definitive test to evaluate the severity of injury is early, flexible endoscopy. Extreme caution should be used during endoscopy with the use of a pediatric scope and minimal insufflation to lessen the risk of an iatrogenic perforation. The scope should be passed only until the initial area of injury is noted and severity of injury can be accessed, as navigation beyond this area carries a high risk of iatrogenic mucosal injury or full-thickness perforation.\\n\\nWith first-degree injuries, there is mucosal hyperemia and edema signifying a mucosal injury. Second-degree injuries will have hemorrhagic, exudative, or ulcerative pseudomembranes. These injuries are through the mucosa but not the muscularis. Third-degree injuries are full-thickness injuries with eschar and charring, or complete obliteration of the lumen by edema.',\n", " 'md': 'A chest X-ray and CT scan are obtained to look for a perforation, but the definitive test to evaluate the severity of injury is early, flexible endoscopy. Extreme caution should be used during endoscopy with the use of a pediatric scope and minimal insufflation to lessen the risk of an iatrogenic perforation. The scope should be passed only until the initial area of injury is noted and severity of injury can be accessed, as navigation beyond this area carries a high risk of iatrogenic mucosal injury or full-thickness perforation.\\n\\nWith first-degree injuries, there is mucosal hyperemia and edema signifying a mucosal injury. Second-degree injuries will have hemorrhagic, exudative, or ulcerative pseudomembranes. These injuries are through the mucosa but not the muscularis. Third-degree injuries are full-thickness injuries with eschar and charring, or complete obliteration of the lumen by edema.',\n", " 'bBox': {'x': 72, 'y': 358, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Treatment',\n", " 'md': '## Treatment',\n", " 'bBox': {'x': 86, 'y': 655, 'w': 69.3, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Patients are made NPO and started on broad-spectrum antibiotics. The majority of patients can be managed non-operatively but are at high risk for late strictures — the management of which is beyond the scope of this document.\\n```',\n", " 'md': 'Patients are made NPO and started on broad-spectrum antibiotics. The majority of patients can be managed non-operatively but are at high risk for late strictures — the management of which is beyond the scope of this document.\\n```',\n", " 'bBox': {'x': 72, 'y': 692, 'w': 467.43, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 221,\n", " 'text': 'scope of this chapter.\\n\\n Patients with perforations from caustic injuries should be taken to\\nsurgery. If there is an obviously necrotic esophagus then proceed with\\nresection. Attempt to preserve as much proximal esophagus as possible.\\nIf you are unsure about the viability of the esophagus or the extent of\\nresection then place drains and plan for a second-look operation in 12-24\\nhours. A laparotomy is performed for gastrostomy and feeding\\njejunostomy placement. Based on the viability of the stomach, a partial or\\ntotal gastrectomy may be required. Reconstruction is delayed for 3-6\\nmonths to allow the patient to recover.\\n\\n So the key points are…\\n\\n • Suspect a perforation.\\n • Early recognition and diagnosis should be a priority.\\n • Assess and identify any underlying esophageal pathology.\\n • Initiate broad-spectrum antibiotics, provide nutritional support,\\n control the source of infection, and achieve adequate drainage of all\\n fluid collections.\\n • Most esophageal perforations can be primarily repaired.\\n • Alternative treatment of esophageal perforations (i.e. non-operative\\n therapy, esophageal stents) can be considered in selected cases.\\n\\n Esophageal foreign body ingestion or obstruction\\n\\n The basics…\\n\\n Foreign body (FB) ingestion or obstruction is more commonly seen in\\nchildren, the elderly, prisoners, or adults with psychiatric disorders. It\\naccounts for approximately 1500 deaths annually in the United States.\\nObjects such as coins and small toys are the most commonly\\ningested FB in children, while food boluses account for the majority',\n", " 'md': '```markdown\\n## Scope of this Chapter\\n\\nPatients with perforations from caustic injuries should be taken to surgery. If there is an obviously necrotic esophagus then proceed with resection. Attempt to preserve as much proximal esophagus as possible. If you are unsure about the viability of the esophagus or the extent of resection then place drains and plan for a second-look operation in 12-24 hours. A laparotomy is performed for gastrostomy and feeding jejunostomy placement. Based on the viability of the stomach, a partial or total gastrectomy may be required. Reconstruction is delayed for 3-6 months to allow the patient to recover.\\n\\n### Key Points\\n- Suspect a perforation.\\n- Early recognition and diagnosis should be a priority.\\n- Assess and identify any underlying esophageal pathology.\\n- Initiate broad-spectrum antibiotics, provide nutritional support, control the source of infection, and achieve adequate drainage of all fluid collections.\\n- Most esophageal perforations can be primarily repaired.\\n- Alternative treatment of esophageal perforations (i.e. non-operative therapy, esophageal stents) can be considered in selected cases.\\n\\n## Esophageal Foreign Body Ingestion or Obstruction\\n\\n### The Basics\\nForeign body (FB) ingestion or obstruction is more commonly seen in children, the elderly, prisoners, or adults with psychiatric disorders. It accounts for approximately 1500 deaths annually in the United States. Objects such as coins and small toys are the most commonly ingested FB in children, while food boluses account for the majority.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Scope of this Chapter',\n", " 'md': '## Scope of this Chapter',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Patients with perforations from caustic injuries should be taken to surgery. If there is an obviously necrotic esophagus then proceed with resection. Attempt to preserve as much proximal esophagus as possible. If you are unsure about the viability of the esophagus or the extent of resection then place drains and plan for a second-look operation in 12-24 hours. A laparotomy is performed for gastrostomy and feeding jejunostomy placement. Based on the viability of the stomach, a partial or total gastrectomy may be required. Reconstruction is delayed for 3-6 months to allow the patient to recover.',\n", " 'md': 'Patients with perforations from caustic injuries should be taken to surgery. If there is an obviously necrotic esophagus then proceed with resection. Attempt to preserve as much proximal esophagus as possible. If you are unsure about the viability of the esophagus or the extent of resection then place drains and plan for a second-look operation in 12-24 hours. A laparotomy is performed for gastrostomy and feeding jejunostomy placement. Based on the viability of the stomach, a partial or total gastrectomy may be required. Reconstruction is delayed for 3-6 months to allow the patient to recover.',\n", " 'bBox': {'x': 72, 'y': 121, 'w': 467.55, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key Points',\n", " 'md': '### Key Points',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Suspect a perforation.\\n- Early recognition and diagnosis should be a priority.\\n- Assess and identify any underlying esophageal pathology.\\n- Initiate broad-spectrum antibiotics, provide nutritional support, control the source of infection, and achieve adequate drainage of all fluid collections.\\n- Most esophageal perforations can be primarily repaired.\\n- Alternative treatment of esophageal perforations (i.e. non-operative therapy, esophageal stents) can be considered in selected cases.',\n", " 'md': '- Suspect a perforation.\\n- Early recognition and diagnosis should be a priority.\\n- Assess and identify any underlying esophageal pathology.\\n- Initiate broad-spectrum antibiotics, provide nutritional support, control the source of infection, and achieve adequate drainage of all fluid collections.\\n- Most esophageal perforations can be primarily repaired.\\n- Alternative treatment of esophageal perforations (i.e. non-operative therapy, esophageal stents) can be considered in selected cases.',\n", " 'bBox': {'x': 100, 'y': 333, 'w': 436.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Esophageal Foreign Body Ingestion or Obstruction',\n", " 'md': '## Esophageal Foreign Body Ingestion or Obstruction',\n", " 'bBox': {'x': 86, 'y': 560, 'w': 392.6, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Basics',\n", " 'md': '### The Basics',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Foreign body (FB) ingestion or obstruction is more commonly seen in children, the elderly, prisoners, or adults with psychiatric disorders. It accounts for approximately 1500 deaths annually in the United States. Objects such as coins and small toys are the most commonly ingested FB in children, while food boluses account for the majority.\\n```',\n", " 'md': 'Foreign body (FB) ingestion or obstruction is more commonly seen in children, the elderly, prisoners, or adults with psychiatric disorders. It accounts for approximately 1500 deaths annually in the United States. Objects such as coins and small toys are the most commonly ingested FB in children, while food boluses account for the majority.\\n```',\n", " 'bBox': {'x': 72, 'y': 639, 'w': 467.93, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 222,\n", " 'text': 'of FB impactions in adults. Bone splinters and other sharp objects (like\\nchicken bones) usually get lodged in the hypopharynx or cervical\\nesophagus, and result in injuries to the esophageal wall. FB impactions\\ncan occur along the entire length of the esophagus but are more likely to\\nbe lodged in areas that are physiologically (upper esophageal sphincter,\\naortic arch, or lower esophageal sphincter) or pathologically (stricture or\\ntumor) narrowed.\\n\\n A history of, or witnessed, FB ingestion aids in the early diagnosis and\\npotential treatment. Symptoms suggestive of FB or food impaction are\\nodynophagia, dysphagia, regurgitation and an inability to swallow saliva.\\nAny history regarding previous episodes, swallowing difficulties, or\\nunderlying esophageal pathology is helpful. If there is a strong\\nsuggestion of FB ingestion, radiographic evaluation starts with a\\nconventional X-ray of the neck, chest and abdomen. Certain radiopaque\\nobjects (coins, batteries, nails) can be visualized and localized with this\\nmodality. If the history and diagnosis are less clear, then a CT should be\\nobtained to aid in the diagnosis, localize any FB, evaluate for perforation,\\nand to identify any distal mass or stricture.\\n\\n Note that not all cases presenting with acute esophageal obstruction are children or crazy\\n adults. Many such patients are relatively normal adults who experience a bolus of food\\n impacted in their gullet. For instance, last year, while relishing a grilled chicken, a chunk of its\\n breast, covered with oily skin jammed in my mid-esophagus — even a few mouthfuls of red\\n wine failed to flush it down. The odynophagia and retching which developed were cured only by\\n an endoscopy, pushing the chicken into the stomach. The distal esophagus was observed to be\\n a little inflamed due to reflux. Most food boluses will be relieved by gentle\\n pushing with a flexible scope. Any resistance means: stop and get\\n someone who knows how to use a rigid scope and can pick the\\n stuff out piecemeal. Then exclude distal esophageal pathology.\\n Moshe\\n (We are not absolutely sure that Moshe is a ‘non-crazy adult’! The Editors.)\\n\\n Management ( Figure 15.5)',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nFB impactions in adults. Bone splinters and other sharp objects (like chicken bones) usually get lodged in the hypopharynx or cervical esophagus, and result in injuries to the esophageal wall. FB impactions can occur along the entire length of the esophagus but are more likely to be lodged in areas that are physiologically (upper esophageal sphincter, aortic arch, or lower esophageal sphincter) or pathologically (stricture or tumor) narrowed.\\n\\nA history of, or witnessed, FB ingestion aids in the early diagnosis and potential treatment. Symptoms suggestive of FB or food impaction are odynophagia, dysphagia, regurgitation and an inability to swallow saliva. Any history regarding previous episodes, swallowing difficulties, or underlying esophageal pathology is helpful. If there is a strong suggestion of FB ingestion, radiographic evaluation starts with a conventional X-ray of the neck, chest and abdomen. Certain radiopaque objects (coins, batteries, nails) can be visualized and localized with this modality. If the history and diagnosis are less clear, then a CT should be obtained to aid in the diagnosis, localize any FB, evaluate for perforation, and to identify any distal mass or stricture.\\n\\nNote that not all cases presenting with acute esophageal obstruction are children or crazy adults. Many such patients are relatively normal adults who experience a bolus of food impacted in their gullet. For instance, last year, while relishing a grilled chicken, a chunk of its breast, covered with oily skin jammed in my mid-esophagus — even a few mouthfuls of red wine failed to flush it down. The odynophagia and retching which developed were cured only by an endoscopy, pushing the chicken into the stomach. The distal esophagus was observed to be a little inflamed due to reflux. Most food boluses will be relieved by gentle pushing with a flexible scope. Any resistance means: stop and get someone who knows how to use a rigid scope and can pick the stuff out piecemeal. Then exclude distal esophageal pathology. Moshe (We are not absolutely sure that Moshe is a ‘non-crazy adult’! The Editors.)\\n\\n## Figure Identification\\n\\n**Figure 15.5**: Management\\n\\n### Description\\nThe figure likely illustrates the management strategies for foreign body (FB) impactions in adults, although the specific content of the figure is not provided in the text. The context suggests it may include various methods of diagnosis and treatment, possibly including endoscopy and radiographic evaluations.\\n\\n### Summary\\nThis figure is essential for understanding the clinical approach to managing FB impactions, highlighting the importance of both history-taking and imaging in diagnosing the condition effectively.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'FB impactions in adults. Bone splinters and other sharp objects (like chicken bones) usually get lodged in the hypopharynx or cervical esophagus, and result in injuries to the esophageal wall. FB impactions can occur along the entire length of the esophagus but are more likely to be lodged in areas that are physiologically (upper esophageal sphincter, aortic arch, or lower esophageal sphincter) or pathologically (stricture or tumor) narrowed.\\n\\nA history of, or witnessed, FB ingestion aids in the early diagnosis and potential treatment. Symptoms suggestive of FB or food impaction are odynophagia, dysphagia, regurgitation and an inability to swallow saliva. Any history regarding previous episodes, swallowing difficulties, or underlying esophageal pathology is helpful. If there is a strong suggestion of FB ingestion, radiographic evaluation starts with a conventional X-ray of the neck, chest and abdomen. Certain radiopaque objects (coins, batteries, nails) can be visualized and localized with this modality. If the history and diagnosis are less clear, then a CT should be obtained to aid in the diagnosis, localize any FB, evaluate for perforation, and to identify any distal mass or stricture.\\n\\nNote that not all cases presenting with acute esophageal obstruction are children or crazy adults. Many such patients are relatively normal adults who experience a bolus of food impacted in their gullet. For instance, last year, while relishing a grilled chicken, a chunk of its breast, covered with oily skin jammed in my mid-esophagus — even a few mouthfuls of red wine failed to flush it down. The odynophagia and retching which developed were cured only by an endoscopy, pushing the chicken into the stomach. The distal esophagus was observed to be a little inflamed due to reflux. Most food boluses will be relieved by gentle pushing with a flexible scope. Any resistance means: stop and get someone who knows how to use a rigid scope and can pick the stuff out piecemeal. Then exclude distal esophageal pathology. Moshe (We are not absolutely sure that Moshe is a ‘non-crazy adult’! The Editors.)',\n", " 'md': 'FB impactions in adults. Bone splinters and other sharp objects (like chicken bones) usually get lodged in the hypopharynx or cervical esophagus, and result in injuries to the esophageal wall. FB impactions can occur along the entire length of the esophagus but are more likely to be lodged in areas that are physiologically (upper esophageal sphincter, aortic arch, or lower esophageal sphincter) or pathologically (stricture or tumor) narrowed.\\n\\nA history of, or witnessed, FB ingestion aids in the early diagnosis and potential treatment. Symptoms suggestive of FB or food impaction are odynophagia, dysphagia, regurgitation and an inability to swallow saliva. Any history regarding previous episodes, swallowing difficulties, or underlying esophageal pathology is helpful. If there is a strong suggestion of FB ingestion, radiographic evaluation starts with a conventional X-ray of the neck, chest and abdomen. Certain radiopaque objects (coins, batteries, nails) can be visualized and localized with this modality. If the history and diagnosis are less clear, then a CT should be obtained to aid in the diagnosis, localize any FB, evaluate for perforation, and to identify any distal mass or stricture.\\n\\nNote that not all cases presenting with acute esophageal obstruction are children or crazy adults. Many such patients are relatively normal adults who experience a bolus of food impacted in their gullet. For instance, last year, while relishing a grilled chicken, a chunk of its breast, covered with oily skin jammed in my mid-esophagus — even a few mouthfuls of red wine failed to flush it down. The odynophagia and retching which developed were cured only by an endoscopy, pushing the chicken into the stomach. The distal esophagus was observed to be a little inflamed due to reflux. Most food boluses will be relieved by gentle pushing with a flexible scope. Any resistance means: stop and get someone who knows how to use a rigid scope and can pick the stuff out piecemeal. Then exclude distal esophageal pathology. Moshe (We are not absolutely sure that Moshe is a ‘non-crazy adult’! The Editors.)',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.76, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure Identification',\n", " 'md': '## Figure Identification',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 15.5**: Management',\n", " 'md': '**Figure 15.5**: Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Description',\n", " 'md': '### Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The figure likely illustrates the management strategies for foreign body (FB) impactions in adults, although the specific content of the figure is not provided in the text. The context suggests it may include various methods of diagnosis and treatment, possibly including endoscopy and radiographic evaluations.',\n", " 'md': 'The figure likely illustrates the management strategies for foreign body (FB) impactions in adults, although the specific content of the figure is not provided in the text. The context suggests it may include various methods of diagnosis and treatment, possibly including endoscopy and radiographic evaluations.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This figure is essential for understanding the clinical approach to managing FB impactions, highlighting the importance of both history-taking and imaging in diagnosing the condition effectively.\\n```',\n", " 'md': 'This figure is essential for understanding the clinical approach to managing FB impactions, highlighting the importance of both history-taking and imaging in diagnosing the condition effectively.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 223,\n", " 'text': ' The majority of swallowed FB will pass into the stomach without\\ndifficulty; however, approximately 10-20% of them will need to be\\nremoved. Nearly all impacted FB can be removed with endoscopy\\nwith only 1-2% requiring surgery for extraction. Disc batteries contain\\na high concentration of alkali solution that is released and may cause\\nsevere caustic injury to the esophagus — thus they should be removed\\nurgently! Emergency removal of other impacted foreign bodies is less\\ncritical but earlier extraction decreases the risk of esophageal injury\\n(pressure necrosis and perforation). As mentioned above, the\\noverwhelming majority of ingested FB will pass into the stomach so some\\nsmall, round, non-corrosive objects can be initially observed.\\nUnfortunately, the amount of time one should wait for this to occur is not\\nwell defined. We would recommend that if a non-obstructive FB has\\nnot progressed distally or completely passed into the stomach\\nwithin 12 hours then endoscopy should be performed.\\n\\n The goals of endoscopy should be to evaluate the esophagus, extract\\nthe FB, and perform a post-extraction evaluation of the esophagus for\\ninjury. Objects located in the hypopharynx can be removed with direct\\nlaryngoscopy and McGill forceps. Otherwise, flexible endoscopy is\\nperformed and small particles or objects are removed with fenestrated\\nforceps, a wire basket, or polyp net. We recommend this be performed\\nwith general anesthesia because it provides the optimal conditions\\nfor the procedure: a still patient, all the time you need, and airway\\nprotection to reduce the risk of aspiration.\\n\\n Rigid esophagoscopy requires special expertise but the rigid scopes\\ncome in different diameters and lengths to allow the use of larger\\ngraspers for FB extraction. With sharp objects, they should be extracted\\nwith the sharp edge as the trailing point. If extraction is not possible,\\nsome impactions can be pushed into the stomach. This should be\\ndone with caution as underlying esophageal pathology, if not known pre-\\noperatively, can lead to complications with attempted advancement of the\\nimpaction. If any resistance is encountered then advancement should be\\naborted and surgical extraction performed. Once the impacted FB is\\nextracted, endoscopy should be repeated to assess the esophagus for\\nany injury or underlying cause such as a stricture or mass.',\n", " 'md': '```markdown\\n## Foreign Body (FB) Management in the Esophagus\\n\\nThe majority of swallowed foreign bodies (FB) will pass into the stomach without difficulty; however, approximately 10-20% of them will need to be removed. Nearly all impacted FB can be removed with endoscopy, with only 1-2% requiring surgery for extraction. Disc batteries contain a high concentration of alkali solution that is released and may cause severe caustic injury to the esophagus — thus they should be removed urgently! Emergency removal of other impacted foreign bodies is less critical, but earlier extraction decreases the risk of esophageal injury (pressure necrosis and perforation).\\n\\nAs mentioned above, the overwhelming majority of ingested FB will pass into the stomach, so some small, round, non-corrosive objects can be initially observed. Unfortunately, the amount of time one should wait for this to occur is not well defined. We would recommend that if a non-obstructive FB has not progressed distally or completely passed into the stomach within 12 hours, then endoscopy should be performed.\\n\\nThe goals of endoscopy should be to evaluate the esophagus, extract the FB, and perform a post-extraction evaluation of the esophagus for injury. Objects located in the hypopharynx can be removed with direct laryngoscopy and McGill forceps. Otherwise, flexible endoscopy is performed, and small particles or objects are removed with fenestrated forceps, a wire basket, or polyp net. We recommend this be performed with general anesthesia because it provides the optimal conditions for the procedure: a still patient, all the time you need, and airway protection to reduce the risk of aspiration.\\n\\nRigid esophagoscopy requires special expertise, but the rigid scopes come in different diameters and lengths to allow the use of larger graspers for FB extraction. With sharp objects, they should be extracted with the sharp edge as the trailing point. If extraction is not possible, some impactions can be pushed into the stomach. This should be done with caution as underlying esophageal pathology, if not known pre-operatively, can lead to complications with attempted advancement of the impaction. If any resistance is encountered, then advancement should be aborted and surgical extraction performed. Once the impacted FB is extracted, endoscopy should be repeated to assess the esophagus for any injury or underlying cause such as a stricture or mass.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Foreign Body (FB) Management in the Esophagus',\n", " 'md': '## Foreign Body (FB) Management in the Esophagus',\n", " 'bBox': {'x': 519, 'y': 218, 'w': 20, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The majority of swallowed foreign bodies (FB) will pass into the stomach without difficulty; however, approximately 10-20% of them will need to be removed. Nearly all impacted FB can be removed with endoscopy, with only 1-2% requiring surgery for extraction. Disc batteries contain a high concentration of alkali solution that is released and may cause severe caustic injury to the esophagus — thus they should be removed urgently! Emergency removal of other impacted foreign bodies is less critical, but earlier extraction decreases the risk of esophageal injury (pressure necrosis and perforation).\\n\\nAs mentioned above, the overwhelming majority of ingested FB will pass into the stomach, so some small, round, non-corrosive objects can be initially observed. Unfortunately, the amount of time one should wait for this to occur is not well defined. We would recommend that if a non-obstructive FB has not progressed distally or completely passed into the stomach within 12 hours, then endoscopy should be performed.\\n\\nThe goals of endoscopy should be to evaluate the esophagus, extract the FB, and perform a post-extraction evaluation of the esophagus for injury. Objects located in the hypopharynx can be removed with direct laryngoscopy and McGill forceps. Otherwise, flexible endoscopy is performed, and small particles or objects are removed with fenestrated forceps, a wire basket, or polyp net. We recommend this be performed with general anesthesia because it provides the optimal conditions for the procedure: a still patient, all the time you need, and airway protection to reduce the risk of aspiration.\\n\\nRigid esophagoscopy requires special expertise, but the rigid scopes come in different diameters and lengths to allow the use of larger graspers for FB extraction. With sharp objects, they should be extracted with the sharp edge as the trailing point. If extraction is not possible, some impactions can be pushed into the stomach. This should be done with caution as underlying esophageal pathology, if not known pre-operatively, can lead to complications with attempted advancement of the impaction. If any resistance is encountered, then advancement should be aborted and surgical extraction performed. Once the impacted FB is extracted, endoscopy should be repeated to assess the esophagus for any injury or underlying cause such as a stricture or mass.\\n```',\n", " 'md': 'The majority of swallowed foreign bodies (FB) will pass into the stomach without difficulty; however, approximately 10-20% of them will need to be removed. Nearly all impacted FB can be removed with endoscopy, with only 1-2% requiring surgery for extraction. Disc batteries contain a high concentration of alkali solution that is released and may cause severe caustic injury to the esophagus — thus they should be removed urgently! Emergency removal of other impacted foreign bodies is less critical, but earlier extraction decreases the risk of esophageal injury (pressure necrosis and perforation).\\n\\nAs mentioned above, the overwhelming majority of ingested FB will pass into the stomach, so some small, round, non-corrosive objects can be initially observed. Unfortunately, the amount of time one should wait for this to occur is not well defined. We would recommend that if a non-obstructive FB has not progressed distally or completely passed into the stomach within 12 hours, then endoscopy should be performed.\\n\\nThe goals of endoscopy should be to evaluate the esophagus, extract the FB, and perform a post-extraction evaluation of the esophagus for injury. Objects located in the hypopharynx can be removed with direct laryngoscopy and McGill forceps. Otherwise, flexible endoscopy is performed, and small particles or objects are removed with fenestrated forceps, a wire basket, or polyp net. We recommend this be performed with general anesthesia because it provides the optimal conditions for the procedure: a still patient, all the time you need, and airway protection to reduce the risk of aspiration.\\n\\nRigid esophagoscopy requires special expertise, but the rigid scopes come in different diameters and lengths to allow the use of larger graspers for FB extraction. With sharp objects, they should be extracted with the sharp edge as the trailing point. If extraction is not possible, some impactions can be pushed into the stomach. This should be done with caution as underlying esophageal pathology, if not known pre-operatively, can lead to complications with attempted advancement of the impaction. If any resistance is encountered, then advancement should be aborted and surgical extraction performed. Once the impacted FB is extracted, endoscopy should be repeated to assess the esophagus for any injury or underlying cause such as a stricture or mass.\\n```',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.78, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 224,\n", " 'text': ' Rarely (<1%), if the endoscopic extraction fails, is not feasible, or there\\nis an obvious associated perforation, then surgical removal is required.\\nThe surgical approach to removal is dependent on the location of the\\nimpaction and can be done with techniques described above for the\\nmanagement of esophageal perforations.\\n PERYA9014\\n Figure 15.5. Patient: “Doctor, I think I swallowed a small fish.” Surgeon: “I need a live bait\\n — get a night crawler stat!”\\n\\n Key points…\\n\\n • Round disc batteries should be promptly removed to prevent\\n corrosive damage to the esophagus.\\n • Nearly all FB ingestions and impactions can be treated\\n endoscopically.\\n • Surgeons should be skilled in the use of both a flexible and rigid\\n endoscope (yes, I know it is wishful thinking...).\\n • Post-extraction endoscopy should be performed to assess the\\n esophagus for injury or an underlying pathology.',\n", " 'md': \"```markdown\\n## Page Content\\n\\nRarely (<1%), if the endoscopic extraction fails, is not feasible, or there is an obvious associated perforation, then surgical removal is required. The surgical approach to removal is dependent on the location of the impaction and can be done with techniques described above for the management of esophageal perforations.\\n\\n### Figure 15.5\\n**Caption:** Patient: “Doctor, I think I swallowed a small fish.” Surgeon: “I need a live bait — get a night crawler stat!”\\n\\n**Description:** This figure likely depicts a humorous interaction between a patient and a surgeon regarding a potential foreign body ingestion. The image may illustrate the context of the conversation, possibly showing a patient expressing concern about swallowing a small fish and the surgeon's light-hearted response.\\n\\n### Key Points\\n- Round disc batteries should be promptly removed to prevent corrosive damage to the esophagus.\\n- Nearly all foreign body (FB) ingestions and impactions can be treated endoscopically.\\n- Surgeons should be skilled in the use of both a flexible and rigid endoscope (yes, I know it is wishful thinking...).\\n- Post-extraction endoscopy should be performed to assess the esophagus for injury or an underlying pathology.\\n```\",\n", " 'images': [{'name': 'img_p223_1.png',\n", " 'height': 574,\n", " 'width': 802,\n", " 'x': 108,\n", " 'y': 165.59999999999997,\n", " 'original_width': 1377,\n", " 'original_height': 985}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Rarely (<1%), if the endoscopic extraction fails, is not feasible, or there is an obvious associated perforation, then surgical removal is required. The surgical approach to removal is dependent on the location of the impaction and can be done with techniques described above for the management of esophageal perforations.',\n", " 'md': 'Rarely (<1%), if the endoscopic extraction fails, is not feasible, or there is an obvious associated perforation, then surgical removal is required. The surgical approach to removal is dependent on the location of the impaction and can be done with techniques described above for the management of esophageal perforations.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.35, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 15.5',\n", " 'md': '### Figure 15.5',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"**Caption:** Patient: “Doctor, I think I swallowed a small fish.” Surgeon: “I need a live bait — get a night crawler stat!”\\n\\n**Description:** This figure likely depicts a humorous interaction between a patient and a surgeon regarding a potential foreign body ingestion. The image may illustrate the context of the conversation, possibly showing a patient expressing concern about swallowing a small fish and the surgeon's light-hearted response.\",\n", " 'md': \"**Caption:** Patient: “Doctor, I think I swallowed a small fish.” Surgeon: “I need a live bait — get a night crawler stat!”\\n\\n**Description:** This figure likely depicts a humorous interaction between a patient and a surgeon regarding a potential foreign body ingestion. The image may illustrate the context of the conversation, possibly showing a patient expressing concern about swallowing a small fish and the surgeon's light-hearted response.\",\n", " 'bBox': {'x': 75, 'y': 481, 'w': 140.22, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key Points',\n", " 'md': '### Key Points',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Round disc batteries should be promptly removed to prevent corrosive damage to the esophagus.\\n- Nearly all foreign body (FB) ingestions and impactions can be treated endoscopically.\\n- Surgeons should be skilled in the use of both a flexible and rigid endoscope (yes, I know it is wishful thinking...).\\n- Post-extraction endoscopy should be performed to assess the esophagus for injury or an underlying pathology.\\n```',\n", " 'md': '- Round disc batteries should be promptly removed to prevent corrosive damage to the esophagus.\\n- Nearly all foreign body (FB) ingestions and impactions can be treated endoscopically.\\n- Surgeons should be skilled in the use of both a flexible and rigid endoscope (yes, I know it is wishful thinking...).\\n- Post-extraction endoscopy should be performed to assess the esophagus for injury or an underlying pathology.\\n```',\n", " 'bBox': {'x': 100, 'y': 589, 'w': 306, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 225,\n", " 'text': ' “The esophagus is a difficult surgical field… for its\\n inaccessibility, its lack of serous coat, and its enclosure\\n in structures where infection is especially dangerous and\\n rapid.”\\n Ivor Lewis\\n\\n1 Dr. Tom Horan contributed to this chapter in the previous editions.\\n2 For details about our use of T-tubes in such situations, see Chapter 6.2 by John Hunter in\\n Schein’s Common Sense Prevention and Management of Surgical Complications.\\n Shrewsbury, UK: tfm publishing, 2013.',\n", " 'md': '```markdown\\n# Page Content\\n\\n“The esophagus is a difficult surgical field… for its inaccessibility, its lack of serous coat, and its enclosure in structures where infection is especially dangerous and rapid.”\\n— Ivor Lewis\\n\\n1. Dr. Tom Horan contributed to this chapter in the previous editions.\\n2. For details about our use of T-tubes in such situations, see Chapter 6.2 by John Hunter in [Schein’s Common Sense Prevention and Management of Surgical Complications](https://www.tfm-publishing.com) Shrewsbury, UK: tfm publishing, 2013.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and formatted according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 251, 'y': 95, 'w': 9.21, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 251, 'y': 95, 'w': 9.21, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '“The esophagus is a difficult surgical field… for its inaccessibility, its lack of serous coat, and its enclosure in structures where infection is especially dangerous and rapid.”\\n— Ivor Lewis\\n\\n1. Dr. Tom Horan contributed to this chapter in the previous editions.\\n2. For details about our use of T-tubes in such situations, see Chapter 6.2 by John Hunter in [Schein’s Common Sense Prevention and Management of Surgical Complications](https://www.tfm-publishing.com) Shrewsbury, UK: tfm publishing, 2013.\\n```',\n", " 'md': '“The esophagus is a difficult surgical field… for its inaccessibility, its lack of serous coat, and its enclosure in structures where infection is especially dangerous and rapid.”\\n— Ivor Lewis\\n\\n1. Dr. Tom Horan contributed to this chapter in the previous editions.\\n2. For details about our use of T-tubes in such situations, see Chapter 6.2 by John Hunter in [Schein’s Common Sense Prevention and Management of Surgical Complications](https://www.tfm-publishing.com) Shrewsbury, UK: tfm publishing, 2013.\\n```',\n", " 'bBox': {'x': 73, 'y': 95, 'w': 459.09, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and formatted according to the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and formatted according to the requirements.',\n", " 'bBox': {'x': 226, 'y': 95, 'w': 22.07, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}, {'text': '2'}]},\n", " {'page': 226,\n", " 'text': 'Chapter 16\\nDiaphragmatic emergencies\\nDanny Rosin\\n\\n The diaphragm is a muscular partition that separates\\n disorders of the chest from disorders of the bowels.\\n Ambrose Bierce\\n\\n The diaphragm normally separates the abdomen from the chest.\\nThe surgeon is interested when it fails in this function. When its\\nintegrity is disturbed, either acutely (trauma), chronically or congenitally\\n(herniation), the pressure differences between the two cavities cause the\\nabdominal organs to shift upwards. The diaphragm is also a powerful\\nmuscle that allows us to breathe — but this is not so interesting to us\\nright now.\\n\\n Most diaphragmatic operations are elective, so when discussing\\nemergency abdominal operations we are limited to only two situations:\\n\\n • Diaphragmatic laceration, which results from either penetrating\\n trauma (knife, bullet) or blunt trauma (rupture).\\n • Acute presentation of chronic or congenital diaphragmatic\\n hernia, due to incarceration or twisting of the herniated contents.\\n\\n Although this chapter is short and simple we still need some\\nbackground knowledge in order to understand the treatment options\\nwhen faced with a diaphragmatic emergency. Our aim is to treat the\\ncontents, preferably by just putting the organs back where they belong',\n", " 'md': '```markdown\\n# Chapter 16: Diaphragmatic Emergencies\\n**Author:** Danny Rosin\\n\\n> \"The diaphragm is a muscular partition that separates disorders of the chest from disorders of the bowels.\"\\n> — Ambrose Bierce\\n\\nThe diaphragm normally separates the abdomen from the chest. The surgeon is interested when it fails in this function. When its integrity is disturbed, either acutely (trauma), chronically, or congenitally (herniation), the pressure differences between the two cavities cause the abdominal organs to shift upwards. The diaphragm is also a powerful muscle that allows us to breathe — but this is not so interesting to us right now.\\n\\nMost diaphragmatic operations are elective, so when discussing emergency abdominal operations we are limited to only two situations:\\n\\n- **Diaphragmatic laceration**, which results from either penetrating trauma (knife, bullet) or blunt trauma (rupture).\\n- **Acute presentation of chronic or congenital diaphragmatic hernia**, due to incarceration or twisting of the herniated contents.\\n\\nAlthough this chapter is short and simple, we still need some background knowledge in order to understand the treatment options when faced with a diaphragmatic emergency. Our aim is to treat the contents, preferably by just putting the organs back where they belong.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 16: Diaphragmatic Emergencies',\n", " 'md': '# Chapter 16: Diaphragmatic Emergencies',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 250.85, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Danny Rosin\\n\\n> \"The diaphragm is a muscular partition that separates disorders of the chest from disorders of the bowels.\"\\n> — Ambrose Bierce\\n\\nThe diaphragm normally separates the abdomen from the chest. The surgeon is interested when it fails in this function. When its integrity is disturbed, either acutely (trauma), chronically, or congenitally (herniation), the pressure differences between the two cavities cause the abdominal organs to shift upwards. The diaphragm is also a powerful muscle that allows us to breathe — but this is not so interesting to us right now.\\n\\nMost diaphragmatic operations are elective, so when discussing emergency abdominal operations we are limited to only two situations:\\n\\n- **Diaphragmatic laceration**, which results from either penetrating trauma (knife, bullet) or blunt trauma (rupture).\\n- **Acute presentation of chronic or congenital diaphragmatic hernia**, due to incarceration or twisting of the herniated contents.\\n\\nAlthough this chapter is short and simple, we still need some background knowledge in order to understand the treatment options when faced with a diaphragmatic emergency. Our aim is to treat the contents, preferably by just putting the organs back where they belong.\\n```',\n", " 'md': '**Author:** Danny Rosin\\n\\n> \"The diaphragm is a muscular partition that separates disorders of the chest from disorders of the bowels.\"\\n> — Ambrose Bierce\\n\\nThe diaphragm normally separates the abdomen from the chest. The surgeon is interested when it fails in this function. When its integrity is disturbed, either acutely (trauma), chronically, or congenitally (herniation), the pressure differences between the two cavities cause the abdominal organs to shift upwards. The diaphragm is also a powerful muscle that allows us to breathe — but this is not so interesting to us right now.\\n\\nMost diaphragmatic operations are elective, so when discussing emergency abdominal operations we are limited to only two situations:\\n\\n- **Diaphragmatic laceration**, which results from either penetrating trauma (knife, bullet) or blunt trauma (rupture).\\n- **Acute presentation of chronic or congenital diaphragmatic hernia**, due to incarceration or twisting of the herniated contents.\\n\\nAlthough this chapter is short and simple, we still need some background knowledge in order to understand the treatment options when faced with a diaphragmatic emergency. Our aim is to treat the contents, preferably by just putting the organs back where they belong.\\n```',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 467.67, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 227,\n", " 'text': '(but resection is sometimes necessary), and restore diaphragmatic\\nintegrity, hopefully by a lasting repair.\\n\\n So let’s start with some definitions, to get familiar with the\\ncommon pathologies.\\n\\n Diaphragmatic hernia\\n\\n This can be congenital or acquired. Being a breach in the integrity of\\nthe diaphragm, the congenital hernias result from ‘non-closure’, while the\\nacquired arise from widening of an existing opening — the hiatus.\\n\\n There are two types of congenital hernias:\\n\\n • Bochdalek hernia is the more common, representing a congenital\\n posterolateral defect — usually on the left side. Its main effect is\\n respiratory, as the protrusion of the abdominal organs into the chest\\n cavity leads to pulmonary hypoplasia; the life-threatening\\n respiratory distress after birth makes it a neonatal emergency,\\n which is beyond the scope of this book.\\n • Morgagni hernia is a much less frequent form of congenital hernia,\\n defined by an anterior, retrosternal defect. Rarely, congenital hernias\\n are small and can go unnoticed, only to be diagnosed later in life,\\n presenting similarly to acquired hernias.\\n\\n Hiatal hernia\\n\\n Sliding hiatal hernia is an upward shift of the stomach (the\\ngastroesophageal junction migrates proximal to the hiatus) and,\\ntherefore, anatomically it is a ‘sliding’ hernia, without a hernia sac.\\nTherefore, there is no risk of acute complications (e.g.\\nincarceration, strangulation, obstruction) related to such herniation\\n(although reflux-induced esophagitis may result in upper GI bleeding —\\nbut that is not really a surgical emergency…).\\n\\n Paraesophageal hernia, on the other hand, is more relevant to our',\n", " 'md': '```markdown\\n## Diaphragmatic Hernia\\n\\nThis can be congenital or acquired. Being a breach in the integrity of the diaphragm, the congenital hernias result from ‘non-closure’, while the acquired arise from widening of an existing opening — the hiatus.\\n\\n### Types of Congenital Hernias\\n\\n1. **Bochdalek Hernia**:\\n- The more common type, representing a congenital posterolateral defect — usually on the left side. Its main effect is respiratory, as the protrusion of the abdominal organs into the chest cavity leads to pulmonary hypoplasia. The life-threatening respiratory distress after birth makes it a neonatal emergency, which is beyond the scope of this book.\\n\\n2. **Morgagni Hernia**:\\n- A much less frequent form of congenital hernia, defined by an anterior, retrosternal defect. Rarely, congenital hernias are small and can go unnoticed, only to be diagnosed later in life, presenting similarly to acquired hernias.\\n\\n### Hiatal Hernia\\n\\n- **Sliding Hiatal Hernia**: An upward shift of the stomach (the gastroesophageal junction migrates proximal to the hiatus) and, therefore, anatomically it is a ‘sliding’ hernia, without a hernia sac. There is no risk of acute complications (e.g., incarceration, strangulation, obstruction) related to such herniation (although reflux-induced esophagitis may result in upper GI bleeding — but that is not really a surgical emergency…).\\n\\n- **Paraesophageal Hernia**: On the other hand, is more relevant to our...\\n```\\n\\n### Image Identification and Description\\n- No images or figures were identified on this page.\\n\\n### Summary\\nThe text provides definitions and descriptions of diaphragmatic hernias, including congenital types (Bochdalek and Morgagni) and hiatal hernias (sliding and paraesophageal). It explains the implications of these conditions, particularly focusing on their anatomical and clinical significance.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diaphragmatic Hernia',\n", " 'md': '## Diaphragmatic Hernia',\n", " 'bBox': {'x': 86, 'y': 197, 'w': 169.2, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This can be congenital or acquired. Being a breach in the integrity of the diaphragm, the congenital hernias result from ‘non-closure’, while the acquired arise from widening of an existing opening — the hiatus.',\n", " 'md': 'This can be congenital or acquired. Being a breach in the integrity of the diaphragm, the congenital hernias result from ‘non-closure’, while the acquired arise from widening of an existing opening — the hiatus.',\n", " 'bBox': {'x': 72, 'y': 250, 'w': 467.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Types of Congenital Hernias',\n", " 'md': '### Types of Congenital Hernias',\n", " 'bBox': {'x': 313, 'y': 620, 'w': 17.58, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '1. **Bochdalek Hernia**:\\n- The more common type, representing a congenital posterolateral defect — usually on the left side. Its main effect is respiratory, as the protrusion of the abdominal organs into the chest cavity leads to pulmonary hypoplasia. The life-threatening respiratory distress after birth makes it a neonatal emergency, which is beyond the scope of this book.\\n\\n2. **Morgagni Hernia**:\\n- A much less frequent form of congenital hernia, defined by an anterior, retrosternal defect. Rarely, congenital hernias are small and can go unnoticed, only to be diagnosed later in life, presenting similarly to acquired hernias.',\n", " 'md': '1. **Bochdalek Hernia**:\\n- The more common type, representing a congenital posterolateral defect — usually on the left side. Its main effect is respiratory, as the protrusion of the abdominal organs into the chest cavity leads to pulmonary hypoplasia. The life-threatening respiratory distress after birth makes it a neonatal emergency, which is beyond the scope of this book.\\n\\n2. **Morgagni Hernia**:\\n- A much less frequent form of congenital hernia, defined by an anterior, retrosternal defect. Rarely, congenital hernias are small and can go unnoticed, only to be diagnosed later in life, presenting similarly to acquired hernias.',\n", " 'bBox': {'x': 100, 'y': 371, 'w': 437.68, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Hiatal Hernia',\n", " 'md': '### Hiatal Hernia',\n", " 'bBox': {'x': 86, 'y': 535, 'w': 99.31, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- **Sliding Hiatal Hernia**: An upward shift of the stomach (the gastroesophageal junction migrates proximal to the hiatus) and, therefore, anatomically it is a ‘sliding’ hernia, without a hernia sac. There is no risk of acute complications (e.g., incarceration, strangulation, obstruction) related to such herniation (although reflux-induced esophagitis may result in upper GI bleeding — but that is not really a surgical emergency…).\\n\\n- **Paraesophageal Hernia**: On the other hand, is more relevant to our...\\n```',\n", " 'md': '- **Sliding Hiatal Hernia**: An upward shift of the stomach (the gastroesophageal junction migrates proximal to the hiatus) and, therefore, anatomically it is a ‘sliding’ hernia, without a hernia sac. There is no risk of acute complications (e.g., incarceration, strangulation, obstruction) related to such herniation (although reflux-induced esophagitis may result in upper GI bleeding — but that is not really a surgical emergency…).\\n\\n- **Paraesophageal Hernia**: On the other hand, is more relevant to our...\\n```',\n", " 'bBox': {'x': 72, 'y': 387, 'w': 467.63, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.',\n", " 'md': '- No images or figures were identified on this page.',\n", " 'bBox': {'x': 209, 'y': 620, 'w': 21.58, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text provides definitions and descriptions of diaphragmatic hernias, including congenital types (Bochdalek and Morgagni) and hiatal hernias (sliding and paraesophageal). It explains the implications of these conditions, particularly focusing on their anatomical and clinical significance.',\n", " 'md': 'The text provides definitions and descriptions of diaphragmatic hernias, including congenital types (Bochdalek and Morgagni) and hiatal hernias (sliding and paraesophageal). It explains the implications of these conditions, particularly focusing on their anatomical and clinical significance.',\n", " 'bBox': {'x': 86, 'y': 197, 'w': 169.2, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 228,\n", " 'text': 'topic. The defect in the diaphragm is actually the hiatus itself, which\\nwidens and allows the passage of the stomach (and other organs, if big\\nenough) alongside the esophagus. This hernia is potentially the most\\nproblematic, as its symptoms are related to changes in the stomach\\nposition, and it has the potential to incarcerate.\\n\\n Much mental effort is sometimes expended in an attempt to accurately\\nclassify different types of hernia on an anatomical basis: true sliding, true\\nparaesophageal and mixed types. In practice, as you will read later, this\\ndoes not help in surgical decision-making.\\n\\n Diaphragmatic trauma (see also Chapter 32)\\n\\n Diaphragmatic rupture or laceration is the result of trauma, the\\nformer usually the result of blunt trauma and the latter associated with a\\npenetrating one. In diaphragmatic trauma the tear includes the\\nperitoneum, so there’s no hernia sac but direct shift of abdominal\\norgans into the pleural space. As in congenital and acquired hernias,\\nthe liver protects the right diaphragm, so problems are more common on\\nthe left — but it doesn’t mean that the right diaphragm is immune to\\ninjury, and we have seen herniation of the liver itself into the chest.\\n\\n In trauma patients, if you can’t see the liver, look for the hole in the diaphragm… Ari\\n\\n Diaphragmatic rupture is usually associated with other injuries,\\nand treated at the same time (primary repair by non-absorbable\\nsutures). While it may be obvious (you see the NG tube curling inside the\\nleft chest and you know the stomach is up there), it can sometimes be\\nmissed, even by a CT scan. When suspected, and there is no other\\nindication for laparotomy, it is one of the few conditions in abdominal\\ntrauma where laparoscopy may have a place (at least in penetrating left\\nthoracoabdominal wounds): explore the diaphragm, and repair if\\nnecessary.\\n\\n When not suspected, and consequently missed, a diaphragmatic\\nlaceration can slowly enlarge and present, even years later, as a\\ndiaphragmatic hernia, possibly with incarceration. The lack of a hernia',\n", " 'md': '```markdown\\n## Diaphragmatic Hernias\\n\\nThe defect in the diaphragm is actually the hiatus itself, which widens and allows the passage of the stomach (and other organs, if big enough) alongside the esophagus. This hernia is potentially the most problematic, as its symptoms are related to changes in the stomach position, and it has the potential to incarcerate.\\n\\nMuch mental effort is sometimes expended in an attempt to accurately classify different types of hernia on an anatomical basis: true sliding, true paraesophageal, and mixed types. In practice, as you will read later, this does not help in surgical decision-making.\\n\\n### Diaphragmatic Trauma\\n\\nDiaphragmatic rupture or laceration is the result of trauma, the former usually the result of blunt trauma and the latter associated with a penetrating one. In diaphragmatic trauma, the tear includes the peritoneum, so there’s no hernia sac but direct shift of abdominal organs into the pleural space. As in congenital and acquired hernias, the liver protects the right diaphragm, so problems are more common on the left — but it doesn’t mean that the right diaphragm is immune to injury, and we have seen herniation of the liver itself into the chest.\\n\\n> In trauma patients, if you can’t see the liver, look for the hole in the diaphragm… Ari\\n\\nDiaphragmatic rupture is usually associated with other injuries and treated at the same time (primary repair by non-absorbable sutures). While it may be obvious (you see the NG tube curling inside the left chest and you know the stomach is up there), it can sometimes be missed, even by a CT scan. When suspected, and there is no other indication for laparotomy, it is one of the few conditions in abdominal trauma where laparoscopy may have a place (at least in penetrating left thoracoabdominal wounds): explore the diaphragm, and repair if necessary.\\n\\nWhen not suspected, and consequently missed, a diaphragmatic laceration can slowly enlarge and present, even years later, as a diaphragmatic hernia, possibly with incarceration. The lack of a hernia...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diaphragmatic Hernias',\n", " 'md': '## Diaphragmatic Hernias',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The defect in the diaphragm is actually the hiatus itself, which widens and allows the passage of the stomach (and other organs, if big enough) alongside the esophagus. This hernia is potentially the most problematic, as its symptoms are related to changes in the stomach position, and it has the potential to incarcerate.\\n\\nMuch mental effort is sometimes expended in an attempt to accurately classify different types of hernia on an anatomical basis: true sliding, true paraesophageal, and mixed types. In practice, as you will read later, this does not help in surgical decision-making.',\n", " 'md': 'The defect in the diaphragm is actually the hiatus itself, which widens and allows the passage of the stomach (and other organs, if big enough) alongside the esophagus. This hernia is potentially the most problematic, as its symptoms are related to changes in the stomach position, and it has the potential to incarcerate.\\n\\nMuch mental effort is sometimes expended in an attempt to accurately classify different types of hernia on an anatomical basis: true sliding, true paraesophageal, and mixed types. In practice, as you will read later, this does not help in surgical decision-making.',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diaphragmatic Trauma',\n", " 'md': '### Diaphragmatic Trauma',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Diaphragmatic rupture or laceration is the result of trauma, the former usually the result of blunt trauma and the latter associated with a penetrating one. In diaphragmatic trauma, the tear includes the peritoneum, so there’s no hernia sac but direct shift of abdominal organs into the pleural space. As in congenital and acquired hernias, the liver protects the right diaphragm, so problems are more common on the left — but it doesn’t mean that the right diaphragm is immune to injury, and we have seen herniation of the liver itself into the chest.\\n\\n> In trauma patients, if you can’t see the liver, look for the hole in the diaphragm… Ari\\n\\nDiaphragmatic rupture is usually associated with other injuries and treated at the same time (primary repair by non-absorbable sutures). While it may be obvious (you see the NG tube curling inside the left chest and you know the stomach is up there), it can sometimes be missed, even by a CT scan. When suspected, and there is no other indication for laparotomy, it is one of the few conditions in abdominal trauma where laparoscopy may have a place (at least in penetrating left thoracoabdominal wounds): explore the diaphragm, and repair if necessary.\\n\\nWhen not suspected, and consequently missed, a diaphragmatic laceration can slowly enlarge and present, even years later, as a diaphragmatic hernia, possibly with incarceration. The lack of a hernia...\\n```',\n", " 'md': 'Diaphragmatic rupture or laceration is the result of trauma, the former usually the result of blunt trauma and the latter associated with a penetrating one. In diaphragmatic trauma, the tear includes the peritoneum, so there’s no hernia sac but direct shift of abdominal organs into the pleural space. As in congenital and acquired hernias, the liver protects the right diaphragm, so problems are more common on the left — but it doesn’t mean that the right diaphragm is immune to injury, and we have seen herniation of the liver itself into the chest.\\n\\n> In trauma patients, if you can’t see the liver, look for the hole in the diaphragm… Ari\\n\\nDiaphragmatic rupture is usually associated with other injuries and treated at the same time (primary repair by non-absorbable sutures). While it may be obvious (you see the NG tube curling inside the left chest and you know the stomach is up there), it can sometimes be missed, even by a CT scan. When suspected, and there is no other indication for laparotomy, it is one of the few conditions in abdominal trauma where laparoscopy may have a place (at least in penetrating left thoracoabdominal wounds): explore the diaphragm, and repair if necessary.\\n\\nWhen not suspected, and consequently missed, a diaphragmatic laceration can slowly enlarge and present, even years later, as a diaphragmatic hernia, possibly with incarceration. The lack of a hernia...\\n```',\n", " 'bBox': {'x': 72, 'y': 332, 'w': 468, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 229,\n", " 'text': 'sac, and the resultant adhesions to the thoracic organs, may make\\nsurgery difficult, and for this reason some surgeons prefer to approach\\nthese cases by thoracotomy.\\n\\n And now we come to the main item of this chapter… gastric volvulus!\\n\\n Gastric volvulus in a paraesophageal hernia\\n\\n Gastric volvulus, abnormal rotation of the stomach, is usually\\nassociated with a paraesophageal hernia, although it can rarely be seen\\nwithout any herniation — caused by what I call ‘general floppiness’ of the\\nstomach.\\n\\n The stomach can twist along two different (and perpendicular) axes. In\\norganoaxial volvulus — which is the more common variant — the\\nstomach rotates around the axis that connects the gastroesophageal\\njunction and the pylorus. The less common variant, mesenteroaxial\\nvolvulus, occurs around the more horizontal axis that runs from the\\ncenter of the greater curvature of the stomach to the lesser curvature,\\ntwisting around the ‘mesentery’ where the left gastric artery can be found\\n( Figure 16.1).',\n", " 'md': '```markdown\\n## Gastric Volvulus in a Paraesophageal Hernia\\n\\nGastric volvulus, abnormal rotation of the stomach, is usually associated with a paraesophageal hernia, although it can rarely be seen without any herniation — caused by what I call ‘general floppiness’ of the stomach.\\n\\nThe stomach can twist along two different (and perpendicular) axes. In organoaxial volvulus — which is the more common variant — the stomach rotates around the axis that connects the gastroesophageal junction and the pylorus. The less common variant, mesenteroaxial volvulus, occurs around the more horizontal axis that runs from the center of the greater curvature of the stomach to the lesser curvature, twisting around the ‘mesentery’ where the left gastric artery can be found (Figure 16.1).\\n\\n### Figure 16.1\\n*Description*: This figure illustrates the two different axes along which the stomach can twist in cases of gastric volvulus. The organoaxial volvulus is depicted as a rotation around the gastroesophageal junction and pylorus, while the mesenteroaxial volvulus is shown as a twist around the mesentery connecting the greater and lesser curvatures of the stomach.\\n\\n*Summary*: The figure provides a visual representation of the anatomical differences between organoaxial and mesenteroaxial volvulus, highlighting the critical areas involved in each type of gastric rotation.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Gastric Volvulus in a Paraesophageal Hernia',\n", " 'md': '## Gastric Volvulus in a Paraesophageal Hernia',\n", " 'bBox': {'x': 86, 'y': 197, 'w': 346.67, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Gastric volvulus, abnormal rotation of the stomach, is usually associated with a paraesophageal hernia, although it can rarely be seen without any herniation — caused by what I call ‘general floppiness’ of the stomach.\\n\\nThe stomach can twist along two different (and perpendicular) axes. In organoaxial volvulus — which is the more common variant — the stomach rotates around the axis that connects the gastroesophageal junction and the pylorus. The less common variant, mesenteroaxial volvulus, occurs around the more horizontal axis that runs from the center of the greater curvature of the stomach to the lesser curvature, twisting around the ‘mesentery’ where the left gastric artery can be found (Figure 16.1).',\n", " 'md': 'Gastric volvulus, abnormal rotation of the stomach, is usually associated with a paraesophageal hernia, although it can rarely be seen without any herniation — caused by what I call ‘general floppiness’ of the stomach.\\n\\nThe stomach can twist along two different (and perpendicular) axes. In organoaxial volvulus — which is the more common variant — the stomach rotates around the axis that connects the gastroesophageal junction and the pylorus. The less common variant, mesenteroaxial volvulus, occurs around the more horizontal axis that runs from the center of the greater curvature of the stomach to the lesser curvature, twisting around the ‘mesentery’ where the left gastric artery can be found (Figure 16.1).',\n", " 'bBox': {'x': 72, 'y': 250, 'w': 467.55, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 16.1',\n", " 'md': '### Figure 16.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*Description*: This figure illustrates the two different axes along which the stomach can twist in cases of gastric volvulus. The organoaxial volvulus is depicted as a rotation around the gastroesophageal junction and pylorus, while the mesenteroaxial volvulus is shown as a twist around the mesentery connecting the greater and lesser curvatures of the stomach.\\n\\n*Summary*: The figure provides a visual representation of the anatomical differences between organoaxial and mesenteroaxial volvulus, highlighting the critical areas involved in each type of gastric rotation.\\n```',\n", " 'md': '*Description*: This figure illustrates the two different axes along which the stomach can twist in cases of gastric volvulus. The organoaxial volvulus is depicted as a rotation around the gastroesophageal junction and pylorus, while the mesenteroaxial volvulus is shown as a twist around the mesentery connecting the greater and lesser curvatures of the stomach.\\n\\n*Summary*: The figure provides a visual representation of the anatomical differences between organoaxial and mesenteroaxial volvulus, highlighting the critical areas involved in each type of gastric rotation.\\n```',\n", " 'bBox': {'x': 72, 'y': 283, 'w': 58.39, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 230,\n", " 'text': 'Figure 16.1. X-ray of mesenteroaxial volvulus. Image courtesy of Dr. Victor Bruscagin.\\n\\n This classification is nice for the radiologists who interpret the CT scan\\n(or the good old barium swallow), but to you what matters is whether\\nthe stomach is obstructed, and if there is any possibility of gastric\\nischemia and necrosis, regardless of the exact axis.\\n\\n Clinical presentation',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\nFigure 16.1. X-ray of mesenteroaxial volvulus. Image courtesy of Dr. Victor Bruscagin.\\n\\nThis classification is nice for the radiologists who interpret the CT scan (or the good old barium swallow), but to you what matters is whether the stomach is obstructed, and if there is any possibility of gastric ischemia and necrosis, regardless of the exact axis.\\n\\n### Clinical presentation\\n\\n## Image Identification and Description\\n**Figure 16**: X-ray of mesenteroaxial volvulus. The image shows an X-ray that illustrates the condition of mesenteroaxial volvulus, which is a type of gastric volvulus. The X-ray is crucial for understanding the anatomical positioning and potential complications associated with this condition. The image is credited to Dr. Victor Bruscagin.\\n\\n### Summary\\nThe page discusses the importance of understanding the clinical implications of mesenteroaxial volvulus, particularly in relation to gastric obstruction and the risk of ischemia and necrosis, while also acknowledging the role of radiological classification in diagnosis.\\n```',\n", " 'images': [{'name': 'img_p229_1.png',\n", " 'height': 546,\n", " 'width': 460,\n", " 'x': 192.24,\n", " 'y': 82.80000000000001,\n", " 'original_width': 789,\n", " 'original_height': 937}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 16.1. X-ray of mesenteroaxial volvulus. Image courtesy of Dr. Victor Bruscagin.\\n\\nThis classification is nice for the radiologists who interpret the CT scan (or the good old barium swallow), but to you what matters is whether the stomach is obstructed, and if there is any possibility of gastric ischemia and necrosis, regardless of the exact axis.',\n", " 'md': 'Figure 16.1. X-ray of mesenteroaxial volvulus. Image courtesy of Dr. Victor Bruscagin.\\n\\nThis classification is nice for the radiologists who interpret the CT scan (or the good old barium swallow), but to you what matters is whether the stomach is obstructed, and if there is any possibility of gastric ischemia and necrosis, regardless of the exact axis.',\n", " 'bBox': {'x': 72, 'y': 373, 'w': 467.59, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Clinical presentation',\n", " 'md': '### Clinical presentation',\n", " 'bBox': {'x': 86, 'y': 512, 'w': 162.75, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 16**: X-ray of mesenteroaxial volvulus. The image shows an X-ray that illustrates the condition of mesenteroaxial volvulus, which is a type of gastric volvulus. The X-ray is crucial for understanding the anatomical positioning and potential complications associated with this condition. The image is credited to Dr. Victor Bruscagin.',\n", " 'md': '**Figure 16**: X-ray of mesenteroaxial volvulus. The image shows an X-ray that illustrates the condition of mesenteroaxial volvulus, which is a type of gastric volvulus. The X-ray is crucial for understanding the anatomical positioning and potential complications associated with this condition. The image is credited to Dr. Victor Bruscagin.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The page discusses the importance of understanding the clinical implications of mesenteroaxial volvulus, particularly in relation to gastric obstruction and the risk of ischemia and necrosis, while also acknowledging the role of radiological classification in diagnosis.\\n```',\n", " 'md': 'The page discusses the importance of understanding the clinical implications of mesenteroaxial volvulus, particularly in relation to gastric obstruction and the risk of ischemia and necrosis, while also acknowledging the role of radiological classification in diagnosis.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 231,\n", " 'text': ' Figure 16.2. Patient: “Please help me to vomit.” Doctor: “Your stomach is in the chest. I\\n am afraid of aspiration…”\\n\\n Many years ago Moritz Borchardt (1868-1948, a surgeon from Berlin who was later forced to\\n emigrate to Argentina, where he died) described the diagnostic triad of gastric volvulus:\\n\\n Epigastric/substernal pain.\\n Retching without vomiting.\\n Inability to pass a nasogastric tube.\\n\\n You will not be wakened at night by uncomplicated hiatal hernias, and\\neven those with complex reflux problems will be managed by the\\ngastroenterologist and his medications. The trouble lies with the\\nparaesophageal hernia and its ‘relatives’ — the missed\\ndiaphragmatic injury and the late-presenting congenital hernia —\\nthat act like real hernias and may lead to incarceration and even\\nstrangulation. Interestingly, until relatively recently every diagnosed\\nparaesophageal hernia was a clear indication for surgery, even the',\n", " 'md': \"```markdown\\n## Page Content\\n\\n**Figure 16.2**: Patient: “Please help me to vomit.” Doctor: “Your stomach is in the chest. I am afraid of aspiration…”\\n\\nMany years ago, Moritz Borchardt (1868-1948), a surgeon from Berlin who was later forced to emigrate to Argentina, where he died, described the diagnostic triad of gastric volvulus:\\n\\n- Epigastric/substernal pain.\\n- Retching without vomiting.\\n- Inability to pass a nasogastric tube.\\n\\nYou will not be wakened at night by uncomplicated hiatal hernias, and even those with complex reflux problems will be managed by the gastroenterologist and his medications. The trouble lies with the paraesophageal hernia and its ‘relatives’ — the missed diaphragmatic injury and the late-presenting congenital hernia — that act like real hernias and may lead to incarceration and even strangulation. Interestingly, until relatively recently, every diagnosed paraesophageal hernia was a clear indication for surgery, even the...\\n```\\n\\n### Image Description\\n- **Figure 16.2**: The image depicts a patient expressing distress about vomiting, with a doctor responding to the situation. The context suggests a medical scenario involving gastric issues, specifically related to the stomach's position and potential complications. The dialogue highlights the urgency and seriousness of the patient's condition.\\n\\n### Summary\\nThis page discusses the diagnostic criteria for gastric volvulus as described by Moritz Borchardt, along with the implications of various types of hernias, particularly paraesophageal hernias, and their management in a clinical setting.\",\n", " 'images': [{'name': 'img_p230_1.png',\n", " 'height': 555,\n", " 'width': 803,\n", " 'x': 107.27999999999975,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1380,\n", " 'original_height': 952}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 16.2**: Patient: “Please help me to vomit.” Doctor: “Your stomach is in the chest. I am afraid of aspiration…”\\n\\nMany years ago, Moritz Borchardt (1868-1948), a surgeon from Berlin who was later forced to emigrate to Argentina, where he died, described the diagnostic triad of gastric volvulus:\\n\\n- Epigastric/substernal pain.\\n- Retching without vomiting.\\n- Inability to pass a nasogastric tube.\\n\\nYou will not be wakened at night by uncomplicated hiatal hernias, and even those with complex reflux problems will be managed by the gastroenterologist and his medications. The trouble lies with the paraesophageal hernia and its ‘relatives’ — the missed diaphragmatic injury and the late-presenting congenital hernia — that act like real hernias and may lead to incarceration and even strangulation. Interestingly, until relatively recently, every diagnosed paraesophageal hernia was a clear indication for surgery, even the...\\n```',\n", " 'md': '**Figure 16.2**: Patient: “Please help me to vomit.” Doctor: “Your stomach is in the chest. I am afraid of aspiration…”\\n\\nMany years ago, Moritz Borchardt (1868-1948), a surgeon from Berlin who was later forced to emigrate to Argentina, where he died, described the diagnostic triad of gastric volvulus:\\n\\n- Epigastric/substernal pain.\\n- Retching without vomiting.\\n- Inability to pass a nasogastric tube.\\n\\nYou will not be wakened at night by uncomplicated hiatal hernias, and even those with complex reflux problems will be managed by the gastroenterologist and his medications. The trouble lies with the paraesophageal hernia and its ‘relatives’ — the missed diaphragmatic injury and the late-presenting congenital hernia — that act like real hernias and may lead to incarceration and even strangulation. Interestingly, until relatively recently, every diagnosed paraesophageal hernia was a clear indication for surgery, even the...\\n```',\n", " 'bBox': {'x': 72, 'y': 389, 'w': 456.27, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- **Figure 16.2**: The image depicts a patient expressing distress about vomiting, with a doctor responding to the situation. The context suggests a medical scenario involving gastric issues, specifically related to the stomach's position and potential complications. The dialogue highlights the urgency and seriousness of the patient's condition.\",\n", " 'md': \"- **Figure 16.2**: The image depicts a patient expressing distress about vomiting, with a doctor responding to the situation. The context suggests a medical scenario involving gastric issues, specifically related to the stomach's position and potential complications. The dialogue highlights the urgency and seriousness of the patient's condition.\",\n", " 'bBox': {'x': 259, 'y': 642, 'w': 29.57, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the diagnostic criteria for gastric volvulus as described by Moritz Borchardt, along with the implications of various types of hernias, particularly paraesophageal hernias, and their management in a clinical setting.',\n", " 'md': 'This page discusses the diagnostic criteria for gastric volvulus as described by Moritz Borchardt, along with the implications of various types of hernias, particularly paraesophageal hernias, and their management in a clinical setting.',\n", " 'bBox': {'x': 72, 'y': 642, 'w': 113.52, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 232,\n", " 'text': 'asymptomatic ones, because of the perceived risk of strangulation and\\nthe associated morbidity and mortality. Some surgeons stick to this\\napproach even today… But as the typical patient is usually old and\\nfrail we are more selective in offering surgery — to symptomatic\\npatients only.\\n\\n Presenting symptoms relate to a difficulty or pain with swallowing, as\\nthe herniated part of the stomach presses upon the esophagus which can\\nbe partially obstructed at the hernia neck. Acute obstruction will be\\nassociated with retrosternal pain (the abdomen is usually soft and non-\\ntender), and retching — as the incarcerated part of the stomach cannot\\nempty, even with forceful attempts to vomit ( Figure 16.2). A nasogastric\\ntube may be difficult to pass, or fails to decompress the incarcerated\\nstomach.\\n\\n Figure 16.3. Chest X-ray of an incarcerated paraesophageal hernia with a gastric bubble\\n in the mediastinum.\\n\\n Since the ascent of the stomach into the chest is rarely straight,\\nsome element of torsion is almost always present, but true acute\\ngastric volvulus may quite rapidly lead to gastric necrosis. As these\\npatients complain of retrosternal pain, and are usually in some respiratory',\n", " 'md': \"```markdown\\n## Page Content\\n\\nAsymptomatic ones, because of the perceived risk of strangulation and the associated morbidity and mortality. Some surgeons stick to this approach even today… But as the typical patient is usually old and frail we are more selective in offering surgery — to symptomatic patients only.\\n\\nPresenting symptoms relate to a difficulty or pain with swallowing, as the herniated part of the stomach presses upon the esophagus which can be partially obstructed at the hernia neck. Acute obstruction will be associated with retrosternal pain (the abdomen is usually soft and non-tender), and retching — as the incarcerated part of the stomach cannot empty, even with forceful attempts to vomit (Figure 16.2). A nasogastric tube may be difficult to pass, or fails to decompress the incarcerated stomach.\\n\\n### Figure 16.3\\n**Description:** Chest X-ray of an incarcerated paraesophageal hernia with a gastric bubble in the mediastinum. The image shows the stomach's position in the chest cavity, indicating the presence of a hernia.\\n\\nSince the ascent of the stomach into the chest is rarely straight, some element of torsion is almost always present, but true acute gastric volvulus may quite rapidly lead to gastric necrosis. As these patients complain of retrosternal pain, and are usually in some respiratory distress.\\n```\",\n", " 'images': [{'name': 'img_p231_1.png',\n", " 'height': 533,\n", " 'width': 466,\n", " 'x': 190.79999999999973,\n", " 'y': 316.79999999999995,\n", " 'original_width': 801,\n", " 'original_height': 916}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Asymptomatic ones, because of the perceived risk of strangulation and the associated morbidity and mortality. Some surgeons stick to this approach even today… But as the typical patient is usually old and frail we are more selective in offering surgery — to symptomatic patients only.\\n\\nPresenting symptoms relate to a difficulty or pain with swallowing, as the herniated part of the stomach presses upon the esophagus which can be partially obstructed at the hernia neck. Acute obstruction will be associated with retrosternal pain (the abdomen is usually soft and non-tender), and retching — as the incarcerated part of the stomach cannot empty, even with forceful attempts to vomit (Figure 16.2). A nasogastric tube may be difficult to pass, or fails to decompress the incarcerated stomach.',\n", " 'md': 'Asymptomatic ones, because of the perceived risk of strangulation and the associated morbidity and mortality. Some surgeons stick to this approach even today… But as the typical patient is usually old and frail we are more selective in offering surgery — to symptomatic patients only.\\n\\nPresenting symptoms relate to a difficulty or pain with swallowing, as the herniated part of the stomach presses upon the esophagus which can be partially obstructed at the hernia neck. Acute obstruction will be associated with retrosternal pain (the abdomen is usually soft and non-tender), and retching — as the incarcerated part of the stomach cannot empty, even with forceful attempts to vomit (Figure 16.2). A nasogastric tube may be difficult to pass, or fails to decompress the incarcerated stomach.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.98, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 16.3',\n", " 'md': '### Figure 16.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"**Description:** Chest X-ray of an incarcerated paraesophageal hernia with a gastric bubble in the mediastinum. The image shows the stomach's position in the chest cavity, indicating the presence of a hernia.\\n\\nSince the ascent of the stomach into the chest is rarely straight, some element of torsion is almost always present, but true acute gastric volvulus may quite rapidly lead to gastric necrosis. As these patients complain of retrosternal pain, and are usually in some respiratory distress.\\n```\",\n", " 'md': \"**Description:** Chest X-ray of an incarcerated paraesophageal hernia with a gastric bubble in the mediastinum. The image shows the stomach's position in the chest cavity, indicating the presence of a hernia.\\n\\nSince the ascent of the stomach into the chest is rarely straight, some element of torsion is almost always present, but true acute gastric volvulus may quite rapidly lead to gastric necrosis. As these patients complain of retrosternal pain, and are usually in some respiratory distress.\\n```\",\n", " 'bBox': {'x': 72, 'y': 612, 'w': 467.74, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'tube may be difficult to pass, or fails to decompress the incarcerated'}]},\n", " {'page': 233,\n", " 'text': 'distress, you can be sure that a chest X-ray will already be available\\nwhen you are called by the ER doc; but don’t trust him to have noted the\\ngastric air bubble up in the mediastinum — have a look yourself ( Figure\\n16.3).\\n\\n Figure 16.4. CT of gastric volvulus. In this mesoaxial rotation, the lower part of the\\n stomach is found high in the chest — after herniating through a paraesophageal defect.\\n The incarcerated part of the stomach still has a narrow connection with the intra-\\n abdominal part, allowing contrast to enter — but it is distended and compressing the lung\\n upward and the esophagus medially.\\n\\n Of course, nowadays a CT scan is an integral part of the\\ndiagnosis and decision-making in the ER ( Figures 16.4 and 16.5). It\\nwill also show you other structures that may be involved: the transverse\\ncolon may be stuck up there too, and you really don’t want to\\nprocrastinate when the colon is at risk of ischemia and perforation high\\nup in the chest.\\n\\n Although CT is diagnostic, these patients commonly land in the hands\\nof internists/gastroenterologists who feel obliged to insert an endoscope.\\nThe typical endoscopic features of gastric volvulus (organoaxial) are:\\na tortuous stomach, paraesophageal hernia (viewed by retroflexing the\\nscope) and an inability to locate, and pass through, the pylorus; evidence',\n", " 'md': '```markdown\\n## Page Content\\n\\nWhen you are called by the ER doc, you can be sure that a chest X-ray will already be available; but don’t trust him to have noted the gastric air bubble up in the mediastinum — have a look yourself (Figure 16.3).\\n\\n### Figure 16.4\\n**CT of gastric volvulus.** In this mesoaxial rotation, the lower part of the stomach is found high in the chest — after herniating through a paraesophageal defect. The incarcerated part of the stomach still has a narrow connection with the intra-abdominal part, allowing contrast to enter — but it is distended and compressing the lung upward and the esophagus medially.\\n\\nOf course, nowadays a CT scan is an integral part of the diagnosis and decision-making in the ER (Figures 16.4 and 16.5). It will also show you other structures that may be involved: the transverse colon may be stuck up there too, and you really don’t want to procrastinate when the colon is at risk of ischemia and perforation high up in the chest.\\n\\nAlthough CT is diagnostic, these patients commonly land in the hands of internists/gastroenterologists who feel obliged to insert an endoscope. The typical endoscopic features of gastric volvulus (organoaxial) are: a tortuous stomach, paraesophageal hernia (viewed by retroflexing the scope) and an inability to locate, and pass through, the pylorus; evidence .\\n```\\n\\n### Image Descriptions\\n- **Figure 16.3**: Description not provided in the text.\\n- **Figure 16.4**: A CT scan image showing gastric volvulus with the lower part of the stomach positioned high in the chest due to a paraesophageal defect. The image illustrates the distended stomach compressing the lung and esophagus.\\n- **Figure 16.5**: Description not provided in the text.',\n", " 'images': [{'name': 'img_p232_1.png',\n", " 'height': 512,\n", " 'width': 604,\n", " 'x': 156.96000000000004,\n", " 'y': 149.03999999999996,\n", " 'original_width': 1038,\n", " 'original_height': 880}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'When you are called by the ER doc, you can be sure that a chest X-ray will already be available; but don’t trust him to have noted the gastric air bubble up in the mediastinum — have a look yourself (Figure 16.3).',\n", " 'md': 'When you are called by the ER doc, you can be sure that a chest X-ray will already be available; but don’t trust him to have noted the gastric air bubble up in the mediastinum — have a look yourself (Figure 16.3).',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 36.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 16.4',\n", " 'md': '### Figure 16.4',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**CT of gastric volvulus.** In this mesoaxial rotation, the lower part of the stomach is found high in the chest — after herniating through a paraesophageal defect. The incarcerated part of the stomach still has a narrow connection with the intra-abdominal part, allowing contrast to enter — but it is distended and compressing the lung upward and the esophagus medially.\\n\\nOf course, nowadays a CT scan is an integral part of the diagnosis and decision-making in the ER (Figures 16.4 and 16.5). It will also show you other structures that may be involved: the transverse colon may be stuck up there too, and you really don’t want to procrastinate when the colon is at risk of ischemia and perforation high up in the chest.\\n\\nAlthough CT is diagnostic, these patients commonly land in the hands of internists/gastroenterologists who feel obliged to insert an endoscope. The typical endoscopic features of gastric volvulus (organoaxial) are: a tortuous stomach, paraesophageal hernia (viewed by retroflexing the scope) and an inability to locate, and pass through, the pylorus; evidence .\\n```',\n", " 'md': '**CT of gastric volvulus.** In this mesoaxial rotation, the lower part of the stomach is found high in the chest — after herniating through a paraesophageal defect. The incarcerated part of the stomach still has a narrow connection with the intra-abdominal part, allowing contrast to enter — but it is distended and compressing the lung upward and the esophagus medially.\\n\\nOf course, nowadays a CT scan is an integral part of the diagnosis and decision-making in the ER (Figures 16.4 and 16.5). It will also show you other structures that may be involved: the transverse colon may be stuck up there too, and you really don’t want to procrastinate when the colon is at risk of ischemia and perforation high up in the chest.\\n\\nAlthough CT is diagnostic, these patients commonly land in the hands of internists/gastroenterologists who feel obliged to insert an endoscope. The typical endoscopic features of gastric volvulus (organoaxial) are: a tortuous stomach, paraesophageal hernia (viewed by retroflexing the scope) and an inability to locate, and pass through, the pylorus; evidence .\\n```',\n", " 'bBox': {'x': 72, 'y': 435, 'w': 467.85, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Descriptions',\n", " 'md': '### Image Descriptions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 16.3**: Description not provided in the text.\\n- **Figure 16.4**: A CT scan image showing gastric volvulus with the lower part of the stomach positioned high in the chest due to a paraesophageal defect. The image illustrates the distended stomach compressing the lung and esophagus.\\n- **Figure 16.5**: Description not provided in the text.',\n", " 'md': '- **Figure 16.3**: Description not provided in the text.\\n- **Figure 16.4**: A CT scan image showing gastric volvulus with the lower part of the stomach positioned high in the chest due to a paraesophageal defect. The image illustrates the distended stomach compressing the lung and esophagus.\\n- **Figure 16.5**: Description not provided in the text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'gastric air bubble up in the mediastinum — have a look yourself ( Figure 16.3).'},\n", " {'text': 'will also show you other structures that may be involved: the transverse'},\n", " {'text': 'will also show you other structures that may be involved: the transverse'}]},\n", " {'page': 234,\n", " 'text': 'of gastric ischemia may be observed. There are reports of successful\\nendoscopic-guided insertion of a nasogastric tube and detorsion —\\nallowing a subsequent elective operation.\\n\\nFigure 16.5. CT of gastric volvulus — lateral view, which better delineated the posterior\\npressure on the heart.\\n\\n Management\\n\\n Inserting a nasogastric tube may change an emergency into an\\nelective problem, because if you succeed in decompressing the\\nstomach, and the stomach has not yet necrosed, you will be able to\\noperate in better conditions: these patients are commonly elderly and\\ndebilitated, and the added respiratory distress, together with the local\\nconditions of the edematous, incarcerated stomach, make an emergency',\n", " 'md': '```markdown\\n## Management of Gastric Ischemia\\n\\nGastric ischemia may be observed. There are reports of successful endoscopic-guided insertion of a nasogastric tube and detorsion — allowing a subsequent elective operation.\\n\\n### Figure 16.5\\n**Description:** CT of gastric volvulus — lateral view, which better delineated the posterior pressure on the heart.\\n\\nInserting a nasogastric tube may change an emergency into an elective problem, because if you succeed in decompressing the stomach, and the stomach has not yet necrosed, you will be able to operate in better conditions: these patients are commonly elderly and debilitated, and the added respiratory distress, together with the local conditions of the edematous, incarcerated stomach, make an emergency.\\n```',\n", " 'images': [{'name': 'img_p233_1.png',\n", " 'height': 757,\n", " 'width': 447,\n", " 'x': 195.8399999999997,\n", " 'y': 132.48000000000002,\n", " 'original_width': 768,\n", " 'original_height': 1300}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Gastric Ischemia',\n", " 'md': '## Management of Gastric Ischemia',\n", " 'bBox': {'x': 86, 'y': 594, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Gastric ischemia may be observed. There are reports of successful endoscopic-guided insertion of a nasogastric tube and detorsion — allowing a subsequent elective operation.',\n", " 'md': 'Gastric ischemia may be observed. There are reports of successful endoscopic-guided insertion of a nasogastric tube and detorsion — allowing a subsequent elective operation.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 263.09, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 16.5',\n", " 'md': '### Figure 16.5',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** CT of gastric volvulus — lateral view, which better delineated the posterior pressure on the heart.\\n\\nInserting a nasogastric tube may change an emergency into an elective problem, because if you succeed in decompressing the stomach, and the stomach has not yet necrosed, you will be able to operate in better conditions: these patients are commonly elderly and debilitated, and the added respiratory distress, together with the local conditions of the edematous, incarcerated stomach, make an emergency.\\n```',\n", " 'md': '**Description:** CT of gastric volvulus — lateral view, which better delineated the posterior pressure on the heart.\\n\\nInserting a nasogastric tube may change an emergency into an elective problem, because if you succeed in decompressing the stomach, and the stomach has not yet necrosed, you will be able to operate in better conditions: these patients are commonly elderly and debilitated, and the added respiratory distress, together with the local conditions of the edematous, incarcerated stomach, make an emergency.\\n```',\n", " 'bBox': {'x': 72, 'y': 539, 'w': 467.91, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 235,\n", " 'text': 'repair less favorable. Unfortunately, in true and complete gastric\\nvolvulus, you will not be able to place a tube and decompress.\\n\\n When surgery is unavoidable, with the imminent risk of gastric\\nnecrosis, you’d better act fast (obviously after having optimized the\\npatient and given broad-spectrum antibiotics). Access is through the\\nabdomen — to reduce the contents and, if needed, resect if it is too late.\\nUpper midline laparotomy is the classic approach, but laparoscopy may\\nallow you to achieve what you need to do — if you are familiar enough\\nwith this approach for this pathology.\\n\\n Reduction of the herniated viscera may be difficult, and sometimes\\nadding a thoracotomy is inevitable. Reduction may be aided by two\\nmaneuvers: inserting a wide tube through the diaphragmatic defect\\nabolishes the negative, ‘sucking’, thoracic pressure and then a\\nnasogastric tube may be manipulated into the distended stomach to\\nreduce its size. If still unsuccessful you can try and directly aspirate air\\nand fluid via a needle puncture, or even through a small gastrotomy —\\nbut be careful to avoid spillage and protect your patient from empyema.\\n\\n After a successful reduction of a viable stomach you should\\ncontinue with your diaphragmatic repair, completing all the familiar\\ncomponents you know from elective surgery: excise the hernia sac,\\nclose the defect by suturing the diaphragmatic crura, and complete a\\nfundoplication, or not, based on your beliefs (I do). Some surgeons will\\nrecommend gastropexy to prevent a recurrent volvulus, or even a tube\\ngastrostomy for both fixation and drainage, but these are rarely\\nnecessary if you complete the repair. If, however, the patient is not in\\n‘great shape’, and you need to get out of there quickly — forget the\\ndiaphragmatic repair and the fundoplication. Under unfavorable\\nconditions just fixing the reduced stomach to the abdominal wall is\\na good idea.\\n\\n If the patient, the ER doc or you have waited too long — which in real\\nlife is not a rare scenario — and you find a necrotic stomach, your\\noptions are more limited. In such dire circumstances the patient will\\nalso limit your options by his/her grave condition, and the eventual\\nmortality is high. Do what you really have to do: resect the',\n", " 'md': \"```markdown\\n## Surgical Management of Gastric Volvulus\\n\\nRepair is less favorable in cases of true and complete gastric volvulus, where tube placement for decompression is not possible.\\n\\nWhen surgery is unavoidable due to the imminent risk of gastric necrosis, it is crucial to act quickly after optimizing the patient and administering broad-spectrum antibiotics. Access is typically through the abdomen to reduce contents and, if necessary, perform a resection. The classic approach is an upper midline laparotomy, although laparoscopy may be an option if the surgeon is experienced with this technique for the specific pathology.\\n\\nReduction of herniated viscera can be challenging, and sometimes a thoracotomy may be required. Two maneuvers can assist in reduction: inserting a wide tube through the diaphragmatic defect to eliminate negative thoracic pressure, followed by manipulating a nasogastric tube into the distended stomach to reduce its size. If these methods fail, direct aspiration of air and fluid via needle puncture or a small gastrotomy may be attempted, but care must be taken to avoid spillage and protect the patient from empyema.\\n\\nAfter successfully reducing a viable stomach, the next step is to perform a diaphragmatic repair, completing all familiar components from elective surgery: excising the hernia sac, suturing the diaphragmatic crura to close the defect, and deciding whether to perform a fundoplication based on the surgeon's preference. Some surgeons may recommend gastropexy to prevent recurrent volvulus or a tube gastrostomy for fixation and drainage, although these are rarely necessary if the repair is completed. If the patient is not in optimal condition and a quick exit is needed, it may be advisable to forgo the diaphragmatic repair and fundoplication, opting instead to fix the reduced stomach to the abdominal wall.\\n\\nIn cases where the patient, the ER doctor, or the surgeon has delayed intervention—an unfortunate but not uncommon scenario—and a necrotic stomach is found, options become limited. The patient's grave condition will further restrict choices, and the eventual mortality rate is high. In such dire circumstances, it is essential to perform only the necessary procedures: resection of the necrotic stomach.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Management of Gastric Volvulus',\n", " 'md': '## Surgical Management of Gastric Volvulus',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"Repair is less favorable in cases of true and complete gastric volvulus, where tube placement for decompression is not possible.\\n\\nWhen surgery is unavoidable due to the imminent risk of gastric necrosis, it is crucial to act quickly after optimizing the patient and administering broad-spectrum antibiotics. Access is typically through the abdomen to reduce contents and, if necessary, perform a resection. The classic approach is an upper midline laparotomy, although laparoscopy may be an option if the surgeon is experienced with this technique for the specific pathology.\\n\\nReduction of herniated viscera can be challenging, and sometimes a thoracotomy may be required. Two maneuvers can assist in reduction: inserting a wide tube through the diaphragmatic defect to eliminate negative thoracic pressure, followed by manipulating a nasogastric tube into the distended stomach to reduce its size. If these methods fail, direct aspiration of air and fluid via needle puncture or a small gastrotomy may be attempted, but care must be taken to avoid spillage and protect the patient from empyema.\\n\\nAfter successfully reducing a viable stomach, the next step is to perform a diaphragmatic repair, completing all familiar components from elective surgery: excising the hernia sac, suturing the diaphragmatic crura to close the defect, and deciding whether to perform a fundoplication based on the surgeon's preference. Some surgeons may recommend gastropexy to prevent recurrent volvulus or a tube gastrostomy for fixation and drainage, although these are rarely necessary if the repair is completed. If the patient is not in optimal condition and a quick exit is needed, it may be advisable to forgo the diaphragmatic repair and fundoplication, opting instead to fix the reduced stomach to the abdominal wall.\\n\\nIn cases where the patient, the ER doctor, or the surgeon has delayed intervention—an unfortunate but not uncommon scenario—and a necrotic stomach is found, options become limited. The patient's grave condition will further restrict choices, and the eventual mortality rate is high. In such dire circumstances, it is essential to perform only the necessary procedures: resection of the necrotic stomach.\\n```\",\n", " 'md': \"Repair is less favorable in cases of true and complete gastric volvulus, where tube placement for decompression is not possible.\\n\\nWhen surgery is unavoidable due to the imminent risk of gastric necrosis, it is crucial to act quickly after optimizing the patient and administering broad-spectrum antibiotics. Access is typically through the abdomen to reduce contents and, if necessary, perform a resection. The classic approach is an upper midline laparotomy, although laparoscopy may be an option if the surgeon is experienced with this technique for the specific pathology.\\n\\nReduction of herniated viscera can be challenging, and sometimes a thoracotomy may be required. Two maneuvers can assist in reduction: inserting a wide tube through the diaphragmatic defect to eliminate negative thoracic pressure, followed by manipulating a nasogastric tube into the distended stomach to reduce its size. If these methods fail, direct aspiration of air and fluid via needle puncture or a small gastrotomy may be attempted, but care must be taken to avoid spillage and protect the patient from empyema.\\n\\nAfter successfully reducing a viable stomach, the next step is to perform a diaphragmatic repair, completing all familiar components from elective surgery: excising the hernia sac, suturing the diaphragmatic crura to close the defect, and deciding whether to perform a fundoplication based on the surgeon's preference. Some surgeons may recommend gastropexy to prevent recurrent volvulus or a tube gastrostomy for fixation and drainage, although these are rarely necessary if the repair is completed. If the patient is not in optimal condition and a quick exit is needed, it may be advisable to forgo the diaphragmatic repair and fundoplication, opting instead to fix the reduced stomach to the abdominal wall.\\n\\nIn cases where the patient, the ER doctor, or the surgeon has delayed intervention—an unfortunate but not uncommon scenario—and a necrotic stomach is found, options become limited. The patient's grave condition will further restrict choices, and the eventual mortality rate is high. In such dire circumstances, it is essential to perform only the necessary procedures: resection of the necrotic stomach.\\n```\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 236,\n", " 'text': 'gangrenous portion of the stomach, clean the mediastinum of spilled\\ncontents if perforation has already occurred, and close the stomach if you\\ncan. If total gastrectomy and reconstruction are needed — make sure the\\npatient is in a condition to withstand such a long and difficult procedure. If\\nnot — consider staging: insert a nasogastric tube to drain the distal\\nesophagus, close the duodenal stump and place a tube jejunostomy.\\nRoux-en-Y jejunoesophagostomy will be performed once the patient is\\nstabilized and ready for a major reintervention.\\n\\n We recall some cases presented in the M & M meeting with a storyline like this: an old thin lady\\n with vague chest pain, hours in the ER ‘ruling out heart attack’, admission to medicine for\\n dyspepsia, interns or even nurses failing to insert a nasogastric tube, gastroenterologists\\n scoping the patient and failing to realize what they see. At operation the next day, or even later,\\n the whole stomach is dead. Very few survive! We hope you will do better. The Editors\\n\\n Remember: Presentation may be vague and a delay in treatment is disastrous.\\n Think about it — suspect — proceed rapidly with diagnostic steps and treat accordingly.',\n", " 'md': '```markdown\\n## Surgical Considerations for Gastrectomy\\n\\n- **Gangrenous Portion of the Stomach**: Clean the mediastinum of spilled contents if perforation has already occurred, and close the stomach if possible.\\n- **Total Gastrectomy and Reconstruction**: Ensure the patient is in a condition to withstand such a long and difficult procedure. If not, consider staging:\\n- Insert a nasogastric tube to drain the distal esophagus.\\n- Close the duodenal stump and place a tube jejunostomy.\\n- Roux-en-Y jejunoesophagostomy will be performed once the patient is stabilized and ready for a major reintervention.\\n\\n### Case Reflection\\nWe recall some cases presented in the M & M meeting with a storyline like this: an old thin lady with vague chest pain, hours in the ER ‘ruling out heart attack’, admission to medicine for dyspepsia, interns or even nurses failing to insert a nasogastric tube, gastroenterologists scoping the patient and failing to realize what they see. At operation the next day, or even later, the whole stomach is dead. Very few survive! We hope you will do better. The Editors.\\n\\n### Key Reminder\\n- **Presentation may be vague**: A delay in treatment is disastrous. Think about it — suspect — proceed rapidly with diagnostic steps and treat accordingly.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Considerations for Gastrectomy',\n", " 'md': '## Surgical Considerations for Gastrectomy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Gangrenous Portion of the Stomach**: Clean the mediastinum of spilled contents if perforation has already occurred, and close the stomach if possible.\\n- **Total Gastrectomy and Reconstruction**: Ensure the patient is in a condition to withstand such a long and difficult procedure. If not, consider staging:\\n- Insert a nasogastric tube to drain the distal esophagus.\\n- Close the duodenal stump and place a tube jejunostomy.\\n- Roux-en-Y jejunoesophagostomy will be performed once the patient is stabilized and ready for a major reintervention.',\n", " 'md': '- **Gangrenous Portion of the Stomach**: Clean the mediastinum of spilled contents if perforation has already occurred, and close the stomach if possible.\\n- **Total Gastrectomy and Reconstruction**: Ensure the patient is in a condition to withstand such a long and difficult procedure. If not, consider staging:\\n- Insert a nasogastric tube to drain the distal esophagus.\\n- Close the duodenal stump and place a tube jejunostomy.\\n- Roux-en-Y jejunoesophagostomy will be performed once the patient is stabilized and ready for a major reintervention.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 466.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Case Reflection',\n", " 'md': '### Case Reflection',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'We recall some cases presented in the M & M meeting with a storyline like this: an old thin lady with vague chest pain, hours in the ER ‘ruling out heart attack’, admission to medicine for dyspepsia, interns or even nurses failing to insert a nasogastric tube, gastroenterologists scoping the patient and failing to realize what they see. At operation the next day, or even later, the whole stomach is dead. Very few survive! We hope you will do better. The Editors.',\n", " 'md': 'We recall some cases presented in the M & M meeting with a storyline like this: an old thin lady with vague chest pain, hours in the ER ‘ruling out heart attack’, admission to medicine for dyspepsia, interns or even nurses failing to insert a nasogastric tube, gastroenterologists scoping the patient and failing to realize what they see. At operation the next day, or even later, the whole stomach is dead. Very few survive! We hope you will do better. The Editors.',\n", " 'bBox': {'x': 77, 'y': 242, 'w': 457.37, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key Reminder',\n", " 'md': '### Key Reminder',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Presentation may be vague**: A delay in treatment is disastrous. Think about it — suspect — proceed rapidly with diagnostic steps and treat accordingly.\\n```',\n", " 'md': '- **Presentation may be vague**: A delay in treatment is disastrous. Think about it — suspect — proceed rapidly with diagnostic steps and treat accordingly.\\n```',\n", " 'bBox': {'x': 79, 'y': 395, 'w': 452.97, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 237,\n", " 'text': 'Chapter 17\\nUpper gastrointestinal bleeding\\nMoshe Schein\\n\\n I wasn’t sure I remembered what or where the stomach\\n was, but refreshed my memory on Wikipedia. Yes, I do\\n recall an operation or two on that organ, but I had thought\\n maybe humans had lost it thru some rapid evolution, since I\\n never get stomach consults anymore. I think my partner\\n explored an upper GI bleeder after a 10-unit bleed not long\\n ago. I don’t know whether GI or IR is seeing these patients\\n at our hospital, assuming they still exist. Haven’t been\\n consulted for varices in 20 years.\\n John Kennedy\\n\\n This tongue-in-cheek comment by our colleague from Atlanta\\nreflects the emerging paradigm — surgery for upper gastrointestinal\\nbleeding (UGIB) is becoming (or has become) a rarity in many parts\\nof the world.\\n\\n During my residency in the 1980s not a week passed without a few\\noperations for bleeding duodenal or gastric ulcers. Emergency\\ngastrectomies, antrectomies, truncal vagotomies, and highly selective\\nvagotomies were our daily bread and butter. But gradually things started\\nto change. First the ħ2 antagonists appeared, followed by proton pump\\ninhibitors (PPIs), and then anti-Helicobacter therapy emerged. In\\naddition, novel methods of achieving endoscopic hemostasis appeared.\\nAs a result, operations for UGIB have become a rarity and our approach',\n", " 'md': '# Chapter 17: Upper Gastrointestinal Bleeding\\n\\n**Author:** Moshe Schein\\n\\nI wasn’t sure I remembered what or where the stomach was, but refreshed my memory on Wikipedia. Yes, I do recall an operation or two on that organ, but I had thought maybe humans had lost it through some rapid evolution, since I never get stomach consults anymore. I think my partner explored an upper GI bleeder after a 10-unit bleed not long ago. I don’t know whether GI or IR is seeing these patients at our hospital, assuming they still exist. Haven’t been consulted for varices in 20 years.\\n— John Kennedy\\n\\nThis tongue-in-cheek comment by our colleague from Atlanta reflects the emerging paradigm — surgery for upper gastrointestinal bleeding (UGIB) is becoming (or has become) a rarity in many parts of the world.\\n\\nDuring my residency in the 1980s, not a week passed without a few operations for bleeding duodenal or gastric ulcers. Emergency gastrectomies, antrectomies, truncal vagotomies, and highly selective vagotomies were our daily bread and butter. But gradually things started to change. First, the \\\\( H_2 \\\\) antagonists appeared, followed by proton pump inhibitors (PPIs), and then anti-Helicobacter therapy emerged. In addition, novel methods of achieving endoscopic hemostasis appeared. As a result, operations for UGIB have become a rarity and our approach...',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 17: Upper Gastrointestinal Bleeding',\n", " 'md': '# Chapter 17: Upper Gastrointestinal Bleeding',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 277.76, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Moshe Schein\\n\\nI wasn’t sure I remembered what or where the stomach was, but refreshed my memory on Wikipedia. Yes, I do recall an operation or two on that organ, but I had thought maybe humans had lost it through some rapid evolution, since I never get stomach consults anymore. I think my partner explored an upper GI bleeder after a 10-unit bleed not long ago. I don’t know whether GI or IR is seeing these patients at our hospital, assuming they still exist. Haven’t been consulted for varices in 20 years.\\n— John Kennedy\\n\\nThis tongue-in-cheek comment by our colleague from Atlanta reflects the emerging paradigm — surgery for upper gastrointestinal bleeding (UGIB) is becoming (or has become) a rarity in many parts of the world.\\n\\nDuring my residency in the 1980s, not a week passed without a few operations for bleeding duodenal or gastric ulcers. Emergency gastrectomies, antrectomies, truncal vagotomies, and highly selective vagotomies were our daily bread and butter. But gradually things started to change. First, the \\\\( H_2 \\\\) antagonists appeared, followed by proton pump inhibitors (PPIs), and then anti-Helicobacter therapy emerged. In addition, novel methods of achieving endoscopic hemostasis appeared. As a result, operations for UGIB have become a rarity and our approach...',\n", " 'md': '**Author:** Moshe Schein\\n\\nI wasn’t sure I remembered what or where the stomach was, but refreshed my memory on Wikipedia. Yes, I do recall an operation or two on that organ, but I had thought maybe humans had lost it through some rapid evolution, since I never get stomach consults anymore. I think my partner explored an upper GI bleeder after a 10-unit bleed not long ago. I don’t know whether GI or IR is seeing these patients at our hospital, assuming they still exist. Haven’t been consulted for varices in 20 years.\\n— John Kennedy\\n\\nThis tongue-in-cheek comment by our colleague from Atlanta reflects the emerging paradigm — surgery for upper gastrointestinal bleeding (UGIB) is becoming (or has become) a rarity in many parts of the world.\\n\\nDuring my residency in the 1980s, not a week passed without a few operations for bleeding duodenal or gastric ulcers. Emergency gastrectomies, antrectomies, truncal vagotomies, and highly selective vagotomies were our daily bread and butter. But gradually things started to change. First, the \\\\( H_2 \\\\) antagonists appeared, followed by proton pump inhibitors (PPIs), and then anti-Helicobacter therapy emerged. In addition, novel methods of achieving endoscopic hemostasis appeared. As a result, operations for UGIB have become a rarity and our approach...',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.69, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 238,\n", " 'text': 'to them has been radically modified. ħowever, if you work somewhere in\\nthe so-called developing world, where modern anti-ulcer medications are\\nnot freely available — or where expertise with endoscopic/radiologic\\nmanagement options are lacking — you may still be exposed to the old\\npattern of UGIB and the traditional methods of dealing with it.\\n\\n How common are operations for UGIB?\\n\\n From a non-formal poll we conducted among the international\\ngroup of surgeons linked on SURGINET, it appears that the average\\nactive general surgeon does not operate for UGIB more than once a\\nyear — or even less. Large urban academic centers may deal with up to\\na case per month but such experience is divided among many surgeons\\n— not only because of a lower incidence but also because better non-\\noperative management is available for the ‘serious’ cases, as described\\nbelow.\\n\\n So the pattern of etiology of the bleeding has shifted, and, in addition,\\nfailed, repeated attempts at non-operative management leave us\\nwith sicker patients who then present with more complex surgical\\nanatomy (e.g. the duodenum repeatedly tortured by the endoscopist is\\npristine no more). As a result, the cases you are called to save, after the\\nothers have failed, are becoming more demanding, while you, in all\\nlikelihood, are less and less familiar and skilled in the operative\\nmanagement of UGIB. (Confess — on how many cases of bleeding\\nduodenal ulcer did you operate during your residency? ħow many partial\\ngastrectomies have you done?). Therefore, you need to listen to us…\\n\\n What about bleeding esophageal varices?\\n\\n We do not know of a surgeon anywhere around the world who still\\noperates on acute variceal bleeding in patients with portal\\nhypertension. Anybody who remembers the bloody-morbid emergency\\ndevascularization procedures, or the no less exasperating portocaval\\nshunts, must be relieved that modern endoscopic and radiological\\napproaches have replaced the old butchery. ħence, we have moved the\\nsection on bleeding varices from this chapter to Chapter 25.',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nTo them has been radically modified. However, if you work somewhere in the so-called developing world, where modern anti-ulcer medications are not freely available — or where expertise with endoscopic/radiologic management options are lacking — you may still be exposed to the old pattern of UGIB and the traditional methods of dealing with it.\\n\\nHow common are operations for UGIB?\\n\\nFrom a non-formal poll we conducted among the international group of surgeons linked on SURGINET, it appears that the average active general surgeon does not operate for UGIB more than once a year — or even less. Large urban academic centers may deal with up to a case per month but such experience is divided among many surgeons — not only because of a lower incidence but also because better non-operative management is available for the ‘serious’ cases, as described below.\\n\\nSo the pattern of etiology of the bleeding has shifted, and, in addition, failed, repeated attempts at non-operative management leave us with sicker patients who then present with more complex surgical anatomy (e.g. the duodenum repeatedly tortured by the endoscopist is pristine no more). As a result, the cases you are called to save, after the others have failed, are becoming more demanding, while you, in all likelihood, are less and less familiar and skilled in the operative management of UGIB. (Confess — on how many cases of bleeding duodenal ulcer did you operate during your residency? How many partial gastrectomies have you done?). Therefore, you need to listen to us…\\n\\nWhat about bleeding esophageal varices?\\n\\nWe do not know of a surgeon anywhere around the world who still operates on acute variceal bleeding in patients with portal hypertension. Anybody who remembers the bloody-morbid emergency devascularization procedures, or the no less exasperating portocaval shunts, must be relieved that modern endoscopic and radiological approaches have replaced the old butchery. Hence, we have moved the section on bleeding varices from this chapter to Chapter 25.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted without any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'To them has been radically modified. However, if you work somewhere in the so-called developing world, where modern anti-ulcer medications are not freely available — or where expertise with endoscopic/radiologic management options are lacking — you may still be exposed to the old pattern of UGIB and the traditional methods of dealing with it.\\n\\nHow common are operations for UGIB?\\n\\nFrom a non-formal poll we conducted among the international group of surgeons linked on SURGINET, it appears that the average active general surgeon does not operate for UGIB more than once a year — or even less. Large urban academic centers may deal with up to a case per month but such experience is divided among many surgeons — not only because of a lower incidence but also because better non-operative management is available for the ‘serious’ cases, as described below.\\n\\nSo the pattern of etiology of the bleeding has shifted, and, in addition, failed, repeated attempts at non-operative management leave us with sicker patients who then present with more complex surgical anatomy (e.g. the duodenum repeatedly tortured by the endoscopist is pristine no more). As a result, the cases you are called to save, after the others have failed, are becoming more demanding, while you, in all likelihood, are less and less familiar and skilled in the operative management of UGIB. (Confess — on how many cases of bleeding duodenal ulcer did you operate during your residency? How many partial gastrectomies have you done?). Therefore, you need to listen to us…\\n\\nWhat about bleeding esophageal varices?\\n\\nWe do not know of a surgeon anywhere around the world who still operates on acute variceal bleeding in patients with portal hypertension. Anybody who remembers the bloody-morbid emergency devascularization procedures, or the no less exasperating portocaval shunts, must be relieved that modern endoscopic and radiological approaches have replaced the old butchery. Hence, we have moved the section on bleeding varices from this chapter to Chapter 25.\\n```',\n", " 'md': 'To them has been radically modified. However, if you work somewhere in the so-called developing world, where modern anti-ulcer medications are not freely available — or where expertise with endoscopic/radiologic management options are lacking — you may still be exposed to the old pattern of UGIB and the traditional methods of dealing with it.\\n\\nHow common are operations for UGIB?\\n\\nFrom a non-formal poll we conducted among the international group of surgeons linked on SURGINET, it appears that the average active general surgeon does not operate for UGIB more than once a year — or even less. Large urban academic centers may deal with up to a case per month but such experience is divided among many surgeons — not only because of a lower incidence but also because better non-operative management is available for the ‘serious’ cases, as described below.\\n\\nSo the pattern of etiology of the bleeding has shifted, and, in addition, failed, repeated attempts at non-operative management leave us with sicker patients who then present with more complex surgical anatomy (e.g. the duodenum repeatedly tortured by the endoscopist is pristine no more). As a result, the cases you are called to save, after the others have failed, are becoming more demanding, while you, in all likelihood, are less and less familiar and skilled in the operative management of UGIB. (Confess — on how many cases of bleeding duodenal ulcer did you operate during your residency? How many partial gastrectomies have you done?). Therefore, you need to listen to us…\\n\\nWhat about bleeding esophageal varices?\\n\\nWe do not know of a surgeon anywhere around the world who still operates on acute variceal bleeding in patients with portal hypertension. Anybody who remembers the bloody-morbid emergency devascularization procedures, or the no less exasperating portocaval shunts, must be relieved that modern endoscopic and radiological approaches have replaced the old butchery. Hence, we have moved the section on bleeding varices from this chapter to Chapter 25.\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.93, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted without any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted without any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 239,\n", " 'text': ' Now let us go back to some basics…\\n\\n The problem\\n\\n UGIB implies a source of bleeding proximal to the ligament of\\nTreitz. What is the etiology of bleeding in need of your surgical\\nattention?\\n\\n • Chronic duodenal (DU) or gastric ulcers (GU), while much less\\n prevalent than before (do you know anyone who is not munching\\n Zantac® or chewing a PPI? Our friend Angus of Ontario even claims\\n that there is some PPI in the local water supply), are still\\n predominant among the cases you are called upon to operate for\\n bleeding. You will see more DUs than GUs.\\n • Bleeding gastrointestinal stromal tumors (GISTs) requiring\\n surgical hemostasis have been mentioned by members of\\n SURGINET.\\n • Dieulafoy’s lesion, a manifestation of a gastric submucosal\\n vascular abnormality, has also emerged as a relatively frequent\\n indication for an emergency operation.\\n • Rare causes are seen from time to time, e.g. necrotic gastric cancer\\n after chemotherapy or aorto-enteric fistula ( Chapter 34).\\n • Acute gastric mucosal lesions (e.g. stress ulcers, erosive gastritis\\n and other terms that mean more or less the same) are usually due\\n to ingestion of analgesics and/or alcohol (aspirin for the hangover).\\n With the routine use of anti-ulcer prophylaxis in hospitalized\\n ‘stressed’ patients, significant UGIB from mucosal lesions is now\\n extremely rare — luckily, you will never be called upon to operate on\\n such cases. In practice nowadays, hemorrhage in stressed patients\\n often originates from reactivated chronic peptic ulcers.\\n\\n Presentation\\n\\n These days you usually see these patients only after they have passed\\nthrough the skilled hands of your medical friends. But again, we want you\\nto know the basics.',\n", " 'md': '```markdown\\n## The Problem\\n\\nUGIB implies a source of bleeding proximal to the ligament of Treitz. What is the etiology of bleeding in need of your surgical attention?\\n\\n- Chronic duodenal (DU) or gastric ulcers (GU), while much less prevalent than before (do you know anyone who is not munching Zantac® or chewing a PPI? Our friend Angus of Ontario even claims that there is some PPI in the local water supply), are still predominant among the cases you are called upon to operate for bleeding. You will see more DUs than GUs.\\n- Bleeding gastrointestinal stromal tumors (GISTs) requiring surgical hemostasis have been mentioned by members of SURGINET.\\n- Dieulafoy’s lesion, a manifestation of a gastric submucosal vascular abnormality, has also emerged as a relatively frequent indication for an emergency operation.\\n- Rare causes are seen from time to time, e.g. necrotic gastric cancer after chemotherapy or aorto-enteric fistula (Chapter 34).\\n- Acute gastric mucosal lesions (e.g. stress ulcers, erosive gastritis and other terms that mean more or less the same) are usually due to ingestion of analgesics and/or alcohol (aspirin for the hangover). With the routine use of anti-ulcer prophylaxis in hospitalized ‘stressed’ patients, significant UGIB from mucosal lesions is now extremely rare — luckily, you will never be called upon to operate on such cases. In practice nowadays, hemorrhage in stressed patients often originates from reactivated chronic peptic ulcers.\\n\\n## Presentation\\n\\nThese days you usually see these patients only after they have passed through the skilled hands of your medical friends. But again, we want you to know the basics.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Problem',\n", " 'md': '## The Problem',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 99.31, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'UGIB implies a source of bleeding proximal to the ligament of Treitz. What is the etiology of bleeding in need of your surgical attention?\\n\\n- Chronic duodenal (DU) or gastric ulcers (GU), while much less prevalent than before (do you know anyone who is not munching Zantac® or chewing a PPI? Our friend Angus of Ontario even claims that there is some PPI in the local water supply), are still predominant among the cases you are called upon to operate for bleeding. You will see more DUs than GUs.\\n- Bleeding gastrointestinal stromal tumors (GISTs) requiring surgical hemostasis have been mentioned by members of SURGINET.\\n- Dieulafoy’s lesion, a manifestation of a gastric submucosal vascular abnormality, has also emerged as a relatively frequent indication for an emergency operation.\\n- Rare causes are seen from time to time, e.g. necrotic gastric cancer after chemotherapy or aorto-enteric fistula (Chapter 34).\\n- Acute gastric mucosal lesions (e.g. stress ulcers, erosive gastritis and other terms that mean more or less the same) are usually due to ingestion of analgesics and/or alcohol (aspirin for the hangover). With the routine use of anti-ulcer prophylaxis in hospitalized ‘stressed’ patients, significant UGIB from mucosal lesions is now extremely rare — luckily, you will never be called upon to operate on such cases. In practice nowadays, hemorrhage in stressed patients often originates from reactivated chronic peptic ulcers.',\n", " 'md': 'UGIB implies a source of bleeding proximal to the ligament of Treitz. What is the etiology of bleeding in need of your surgical attention?\\n\\n- Chronic duodenal (DU) or gastric ulcers (GU), while much less prevalent than before (do you know anyone who is not munching Zantac® or chewing a PPI? Our friend Angus of Ontario even claims that there is some PPI in the local water supply), are still predominant among the cases you are called upon to operate for bleeding. You will see more DUs than GUs.\\n- Bleeding gastrointestinal stromal tumors (GISTs) requiring surgical hemostasis have been mentioned by members of SURGINET.\\n- Dieulafoy’s lesion, a manifestation of a gastric submucosal vascular abnormality, has also emerged as a relatively frequent indication for an emergency operation.\\n- Rare causes are seen from time to time, e.g. necrotic gastric cancer after chemotherapy or aorto-enteric fistula (Chapter 34).\\n- Acute gastric mucosal lesions (e.g. stress ulcers, erosive gastritis and other terms that mean more or less the same) are usually due to ingestion of analgesics and/or alcohol (aspirin for the hangover). With the routine use of anti-ulcer prophylaxis in hospitalized ‘stressed’ patients, significant UGIB from mucosal lesions is now extremely rare — luckily, you will never be called upon to operate on such cases. In practice nowadays, hemorrhage in stressed patients often originates from reactivated chronic peptic ulcers.',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 437.34, 'h': 17.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Presentation',\n", " 'md': '## Presentation',\n", " 'bBox': {'x': 86, 'y': 641, 'w': 100.24, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'These days you usually see these patients only after they have passed through the skilled hands of your medical friends. But again, we want you to know the basics.\\n```',\n", " 'md': 'These days you usually see these patients only after they have passed through the skilled hands of your medical friends. But again, we want you to know the basics.\\n```',\n", " 'bBox': {'x': 72, 'y': 677, 'w': 467.52, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 240,\n", " 'text': ' Patients present either with hematemesis, vomiting fresh blood or\\n‘coffee ground’ (melenemesis) or melena (passage of black stool per\\nrectum). Hematochezia (passage of fresh or altered non-black blood per\\nrectum) usually originates from a source below the ligament of Treitz.\\nNevertheless, with massive UGIB and rapid intestinal transit,\\nunaltered blood, producing loose stool, may appear in the rectum.\\n\\n Remember:\\n\\n Melena is black, sticky and very smelly.\\n Maroon feces are not melena.\\n Red feces are not UGI bleeding.\\n Black blood per rectum almost always means UGIB.\\n Fresh, red blood per rectum in a hemodynamically stable patient means that\\n the source is NOT in the UGI tract.\\n Any type of blood — fresh or old, vomited or retrieved through the nasogastric\\n tube — means that the source is in the UGI tract.\\n The character of blood originating from the small bowel depends on the amount\\n of bleeding and the location of the source: often it is maroon.\\n\\n You do not need panendoscopy to diagnose UGIB — contrary to the gastroenterologists’\\n credo. A finger, a nasogastric tube and a set of eyes are just as good.\\n\\n Key issues: Is the hemorrhage ‘serious’? When should\\n you be alarmed?\\n\\n These are key issues because the seriousness of hemorrhage\\ndetermines your diagnostic-therapeutic steps and the patient’s outcome.\\nIn general, the larger the bleeding vessel, the more ‘serious’ the\\nhemorrhage. The more ‘serious’ the hemorrhage, the less likely it is\\nto stop without an intervention, and the more likely it is to recur\\nafter it has stopped — spontaneously or after endoscopic\\nhemostasis.\\n\\n Massive bleeding from a large vessel requires your immediate',\n", " 'md': '```markdown\\n## Page Content\\n\\nPatients present either with hematemesis, vomiting fresh blood or ‘coffee ground’ (melenemesis) or melena (passage of black stool per rectum). Hematochezia (passage of fresh or altered non-black blood per rectum) usually originates from a source below the ligament of Treitz. Nevertheless, with massive UGIB and rapid intestinal transit, unaltered blood, producing loose stool, may appear in the rectum.\\n\\n### Remember:\\n- Melena is black, sticky and very smelly.\\n- Maroon feces are not melena.\\n- Red feces are not UGI bleeding.\\n- Black blood per rectum almost always means UGIB.\\n- Fresh, red blood per rectum in a hemodynamically stable patient means that the source is NOT in the UGI tract.\\n- Any type of blood — fresh or old, vomited or retrieved through the nasogastric tube — means that the source is in the UGI tract.\\n- The character of blood originating from the small bowel depends on the amount of bleeding and the location of the source: often it is maroon.\\n\\nYou do not need panendoscopy to diagnose UGIB — contrary to the gastroenterologists’ credo. A finger, a nasogastric tube and a set of eyes are just as good.\\n\\n### Key issues: Is the hemorrhage ‘serious’? When should you be alarmed?\\nThese are key issues because the seriousness of hemorrhage determines your diagnostic-therapeutic steps and the patient’s outcome. In general, the larger the bleeding vessel, the more ‘serious’ the hemorrhage. The more ‘serious’ the hemorrhage, the less likely it is to stop without an intervention, and the more likely it is to recur after it has stopped — spontaneously or after endoscopic hemostasis.\\n\\nMassive bleeding from a large vessel requires your immediate attention.\\n```\\n\\n### Image Identification and Description\\n- No images, graphs, or tables were identified on this page.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Patients present either with hematemesis, vomiting fresh blood or ‘coffee ground’ (melenemesis) or melena (passage of black stool per rectum). Hematochezia (passage of fresh or altered non-black blood per rectum) usually originates from a source below the ligament of Treitz. Nevertheless, with massive UGIB and rapid intestinal transit, unaltered blood, producing loose stool, may appear in the rectum.',\n", " 'md': 'Patients present either with hematemesis, vomiting fresh blood or ‘coffee ground’ (melenemesis) or melena (passage of black stool per rectum). Hematochezia (passage of fresh or altered non-black blood per rectum) usually originates from a source below the ligament of Treitz. Nevertheless, with massive UGIB and rapid intestinal transit, unaltered blood, producing loose stool, may appear in the rectum.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 466.84, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Remember:',\n", " 'md': '### Remember:',\n", " 'bBox': {'x': 79, 'y': 216, 'w': 91.06, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Melena is black, sticky and very smelly.\\n- Maroon feces are not melena.\\n- Red feces are not UGI bleeding.\\n- Black blood per rectum almost always means UGIB.\\n- Fresh, red blood per rectum in a hemodynamically stable patient means that the source is NOT in the UGI tract.\\n- Any type of blood — fresh or old, vomited or retrieved through the nasogastric tube — means that the source is in the UGI tract.\\n- The character of blood originating from the small bowel depends on the amount of bleeding and the location of the source: often it is maroon.\\n\\nYou do not need panendoscopy to diagnose UGIB — contrary to the gastroenterologists’ credo. A finger, a nasogastric tube and a set of eyes are just as good.',\n", " 'md': '- Melena is black, sticky and very smelly.\\n- Maroon feces are not melena.\\n- Red feces are not UGI bleeding.\\n- Black blood per rectum almost always means UGIB.\\n- Fresh, red blood per rectum in a hemodynamically stable patient means that the source is NOT in the UGI tract.\\n- Any type of blood — fresh or old, vomited or retrieved through the nasogastric tube — means that the source is in the UGI tract.\\n- The character of blood originating from the small bowel depends on the amount of bleeding and the location of the source: often it is maroon.\\n\\nYou do not need panendoscopy to diagnose UGIB — contrary to the gastroenterologists’ credo. A finger, a nasogastric tube and a set of eyes are just as good.',\n", " 'bBox': {'x': 79, 'y': 252, 'w': 444.18, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key issues: Is the hemorrhage ‘serious’? When should you be alarmed?',\n", " 'md': '### Key issues: Is the hemorrhage ‘serious’? When should you be alarmed?',\n", " 'bBox': {'x': 86, 'y': 511, 'w': 452.85, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'These are key issues because the seriousness of hemorrhage determines your diagnostic-therapeutic steps and the patient’s outcome. In general, the larger the bleeding vessel, the more ‘serious’ the hemorrhage. The more ‘serious’ the hemorrhage, the less likely it is to stop without an intervention, and the more likely it is to recur after it has stopped — spontaneously or after endoscopic hemostasis.\\n\\nMassive bleeding from a large vessel requires your immediate attention.\\n```',\n", " 'md': 'These are key issues because the seriousness of hemorrhage determines your diagnostic-therapeutic steps and the patient’s outcome. In general, the larger the bleeding vessel, the more ‘serious’ the hemorrhage. The more ‘serious’ the hemorrhage, the less likely it is to stop without an intervention, and the more likely it is to recur after it has stopped — spontaneously or after endoscopic hemostasis.\\n\\nMassive bleeding from a large vessel requires your immediate attention.\\n```',\n", " 'bBox': {'x': 72, 'y': 583, 'w': 467.73, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.',\n", " 'md': '- No images, graphs, or tables were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 241,\n", " 'text': 'attention and intervention. A small ooze from a tiny vessel is usually self-\\nlimiting and of minor significance at least for the moment; you can\\ninvestigate it electively. For most patients, however, the emergence of\\nany quantity of blood from any bodily orifice is alarming!\\n\\n The literature contains various formulas, usually based on\\nhemodynamic parameters and the volume of blood transfusion required,\\nto distinguish between ‘massive’ versus ‘non-massive’ UGIB. We\\nsuggest, however, that you use your common sense and consider\\nthe clinical paradigm consisting of the following:\\n\\n • Is the vomited blood (or the aspirate in the nasogastric tube) fresh\\n or ‘coffee ground’?\\n • Are the rectal contents fresh, juicy melena, or old dry melena?\\n • Is, or was, the patient hemodynamically compromised?\\n • Is the patient requiring a blood transfusion to maintain stability?\\n • Is there laboratory evidence of severe bleeding (hemoglobin/\\n hematocrit)?\\n • Is the patient over 60 years of age? Bleeding in elderly patients\\n merits greater concern because they are less likely to withstand a\\n prolonged hemorrhage.\\n • What is the patient’s overall physiological status? We find the\\n APACħE II 1 scoring system ( Chapter 6) useful in this situation as\\n it reflects the acute physiological compromise inflicted on the patient\\n by the bleeding, while taking into account age and comorbidity.\\n\\n What is true in acute surgery in general is true for UGIB: the volume of bleeding, the\\n degree of physiological compromise, the number of units transfused — all correlate\\n with morbidity, the risk of rebleeding, the need for surgery and mortality rates.\\n\\n Stratification\\n\\n These considerations should place your patients somewhere on the',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nA small ooze from a tiny vessel is usually self-limiting and of minor significance at least for the moment; you can investigate it electively. For most patients, however, the emergence of any quantity of blood from any bodily orifice is alarming!\\n\\nThe literature contains various formulas, usually based on hemodynamic parameters and the volume of blood transfusion required, to distinguish between ‘massive’ versus ‘non-massive’ UGIB. We suggest, however, that you use your common sense and consider the clinical paradigm consisting of the following:\\n\\n- Is the vomited blood (or the aspirate in the nasogastric tube) fresh or ‘coffee ground’?\\n- Are the rectal contents fresh, juicy melena, or old dry melena?\\n- Is, or was, the patient hemodynamically compromised?\\n- Is the patient requiring a blood transfusion to maintain stability?\\n- Is there laboratory evidence of severe bleeding (hemoglobin/hematocrit)?\\n- Is the patient over 60 years of age? Bleeding in elderly patients merits greater concern because they are less likely to withstand a prolonged hemorrhage.\\n- What is the patient’s overall physiological status? We find the APACHE II scoring system (Chapter 6) useful in this situation as it reflects the acute physiological compromise inflicted on the patient by the bleeding, while taking into account age and comorbidity.\\n\\nWhat is true in acute surgery in general is true for UGIB: the volume of bleeding, the degree of physiological compromise, the number of units transfused — all correlate with morbidity, the risk of rebleeding, the need for surgery and mortality rates.\\n\\n### Stratification\\n\\nThese considerations should place your patients somewhere on the...\\n```\\n\\n## Image Identification and Description\\n\\n*No images or figures were identified on this page.*\\n\\n## Formula Extraction\\n\\n- APACHE II scoring system: \\n\\n*Note: No specific formulas were provided in the text that could be converted into LaTeX MathJax notation.*\\n\\n## Table Extraction\\n\\n*No tables were identified on this page.*\\n\\n```\\n\\nThis markdown text captures the relevant information from the provided content while adhering to the specified output instructions.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 523, 'y': 170, 'w': 16.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'A small ooze from a tiny vessel is usually self-limiting and of minor significance at least for the moment; you can investigate it electively. For most patients, however, the emergence of any quantity of blood from any bodily orifice is alarming!\\n\\nThe literature contains various formulas, usually based on hemodynamic parameters and the volume of blood transfusion required, to distinguish between ‘massive’ versus ‘non-massive’ UGIB. We suggest, however, that you use your common sense and consider the clinical paradigm consisting of the following:\\n\\n- Is the vomited blood (or the aspirate in the nasogastric tube) fresh or ‘coffee ground’?\\n- Are the rectal contents fresh, juicy melena, or old dry melena?\\n- Is, or was, the patient hemodynamically compromised?\\n- Is the patient requiring a blood transfusion to maintain stability?\\n- Is there laboratory evidence of severe bleeding (hemoglobin/hematocrit)?\\n- Is the patient over 60 years of age? Bleeding in elderly patients merits greater concern because they are less likely to withstand a prolonged hemorrhage.\\n- What is the patient’s overall physiological status? We find the APACHE II scoring system (Chapter 6) useful in this situation as it reflects the acute physiological compromise inflicted on the patient by the bleeding, while taking into account age and comorbidity.\\n\\nWhat is true in acute surgery in general is true for UGIB: the volume of bleeding, the degree of physiological compromise, the number of units transfused — all correlate with morbidity, the risk of rebleeding, the need for surgery and mortality rates.',\n", " 'md': 'A small ooze from a tiny vessel is usually self-limiting and of minor significance at least for the moment; you can investigate it electively. For most patients, however, the emergence of any quantity of blood from any bodily orifice is alarming!\\n\\nThe literature contains various formulas, usually based on hemodynamic parameters and the volume of blood transfusion required, to distinguish between ‘massive’ versus ‘non-massive’ UGIB. We suggest, however, that you use your common sense and consider the clinical paradigm consisting of the following:\\n\\n- Is the vomited blood (or the aspirate in the nasogastric tube) fresh or ‘coffee ground’?\\n- Are the rectal contents fresh, juicy melena, or old dry melena?\\n- Is, or was, the patient hemodynamically compromised?\\n- Is the patient requiring a blood transfusion to maintain stability?\\n- Is there laboratory evidence of severe bleeding (hemoglobin/hematocrit)?\\n- Is the patient over 60 years of age? Bleeding in elderly patients merits greater concern because they are less likely to withstand a prolonged hemorrhage.\\n- What is the patient’s overall physiological status? We find the APACHE II scoring system (Chapter 6) useful in this situation as it reflects the acute physiological compromise inflicted on the patient by the bleeding, while taking into account age and comorbidity.\\n\\nWhat is true in acute surgery in general is true for UGIB: the volume of bleeding, the degree of physiological compromise, the number of units transfused — all correlate with morbidity, the risk of rebleeding, the need for surgery and mortality rates.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.63, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Stratification',\n", " 'md': '### Stratification',\n", " 'bBox': {'x': 86, 'y': 170, 'w': 453.01, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'These considerations should place your patients somewhere on the...\\n```',\n", " 'md': 'These considerations should place your patients somewhere on the...\\n```',\n", " 'bBox': {'x': 523, 'y': 170, 'w': 16.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 523, 'y': 170, 'w': 16.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*',\n", " 'md': '*No images or figures were identified on this page.*',\n", " 'bBox': {'x': 523, 'y': 170, 'w': 16.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formula Extraction',\n", " 'md': '## Formula Extraction',\n", " 'bBox': {'x': 523, 'y': 170, 'w': 16.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- APACHE II scoring system: \\n\\n*Note: No specific formulas were provided in the text that could be converted into LaTeX MathJax notation.*',\n", " 'md': '- APACHE II scoring system: \\n\\n*Note: No specific formulas were provided in the text that could be converted into LaTeX MathJax notation.*',\n", " 'bBox': {'x': 86, 'y': 170, 'w': 28.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table Extraction',\n", " 'md': '## Table Extraction',\n", " 'bBox': {'x': 523, 'y': 170, 'w': 16.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '*No tables were identified on this page.*\\n\\n```\\n\\nThis markdown text captures the relevant information from the provided content while adhering to the specified output instructions.',\n", " 'md': '*No tables were identified on this page.*\\n\\n```\\n\\nThis markdown text captures the relevant information from the provided content while adhering to the specified output instructions.',\n", " 'bBox': {'x': 86, 'y': 170, 'w': 28.79, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'APACħE II 1'},\n", " {'text': 'it reflects the acute physiological compromise inflicted on the patient'}]},\n", " {'page': 242,\n", " 'text': 'large spectrum of UGIB ‘seriousness’:\\n\\n • At one extreme, the patient presenting in shock, with fresh blood\\n pouring from his stomach, belongs to the serious group.\\n • At the other, the stable patient, with a little coffee ground and old,\\n hard melena is definitively not serious.\\n • Many patients, however, belong to the potentially serious group;\\n the problem here is to distinguish between those who continue\\n to ooze, or will rebleed, and those who have stopped bleeding\\n and whose chance of rebleeding is low. This distinction requires\\n active observation and endoscopy.\\n\\n Approach\\n\\n As introduced above, in many parts of the world, patients presenting\\nwith UGIB are initially seen by internists and/or gastroenterologists. We\\nsurgeons are usually called to take part in the management only when\\nthese specialists believe that they cannot stop the bleeding without our\\nhelp — and this may be too late — which means that they may call you\\n‘to operate’ when the patient is already unsalvageable. Oh yes, even in\\ntoday’s era of fancy endoscopic hemostasis and intensive care\\nunits, patients can die from bleeding ulcers — I recall a young man\\nadmitted to a New York teaching hospital and undergoing two attempts at\\nendoscopic control of his bleeding DU. ħe continued rebleeding in the\\nICU; when I was called he had bled out. I operated but too late — his life\\nwas lost because a simple hemostatic stitch to block the pumping\\ngastroduodenal artery was not inserted in time. We have to know\\nbetter how to manage these patients and encourage the early\\ninvolvement of surgeons in their management.\\n\\n What to do if you are taking care of the bleeding patient?',\n", " 'md': '```markdown\\n## Large Spectrum of UGIB ‘Seriousness’\\n\\n- At one extreme, the patient presenting in shock, with fresh blood pouring from his stomach, belongs to the serious group.\\n- At the other, the stable patient, with a little coffee ground and old, hard melena is definitively not serious.\\n- Many patients, however, belong to the potentially serious group; the problem here is to distinguish between those who continue to ooze, or will rebleed, and those who have stopped bleeding and whose chance of rebleeding is low. This distinction requires active observation and endoscopy.\\n\\n### Approach\\n\\nAs introduced above, in many parts of the world, patients presenting with UGIB are initially seen by internists and/or gastroenterologists. We surgeons are usually called to take part in the management only when these specialists believe that they cannot stop the bleeding without our help — and this may be too late — which means that they may call you ‘to operate’ when the patient is already unsalvageable.\\n\\nOh yes, even in today’s era of fancy endoscopic hemostasis and intensive care units, patients can die from bleeding ulcers — I recall a young man admitted to a New York teaching hospital and undergoing two attempts at endoscopic control of his bleeding DU. He continued rebleeding in the ICU; when I was called he had bled out. I operated but too late — his life was lost because a simple hemostatic stitch to block the pumping gastroduodenal artery was not inserted in time. We have to know better how to manage these patients and encourage the early involvement of surgeons in their management.\\n\\n### What to do if you are taking care of the bleeding patient?\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Large Spectrum of UGIB ‘Seriousness’',\n", " 'md': '## Large Spectrum of UGIB ‘Seriousness’',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- At one extreme, the patient presenting in shock, with fresh blood pouring from his stomach, belongs to the serious group.\\n- At the other, the stable patient, with a little coffee ground and old, hard melena is definitively not serious.\\n- Many patients, however, belong to the potentially serious group; the problem here is to distinguish between those who continue to ooze, or will rebleed, and those who have stopped bleeding and whose chance of rebleeding is low. This distinction requires active observation and endoscopy.',\n", " 'md': '- At one extreme, the patient presenting in shock, with fresh blood pouring from his stomach, belongs to the serious group.\\n- At the other, the stable patient, with a little coffee ground and old, hard melena is definitively not serious.\\n- Many patients, however, belong to the potentially serious group; the problem here is to distinguish between those who continue to ooze, or will rebleed, and those who have stopped bleeding and whose chance of rebleeding is low. This distinction requires active observation and endoscopy.',\n", " 'bBox': {'x': 100, 'y': 138, 'w': 437.42, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Approach',\n", " 'md': '### Approach',\n", " 'bBox': {'x': 86, 'y': 305, 'w': 77.26, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As introduced above, in many parts of the world, patients presenting with UGIB are initially seen by internists and/or gastroenterologists. We surgeons are usually called to take part in the management only when these specialists believe that they cannot stop the bleeding without our help — and this may be too late — which means that they may call you ‘to operate’ when the patient is already unsalvageable.\\n\\nOh yes, even in today’s era of fancy endoscopic hemostasis and intensive care units, patients can die from bleeding ulcers — I recall a young man admitted to a New York teaching hospital and undergoing two attempts at endoscopic control of his bleeding DU. He continued rebleeding in the ICU; when I was called he had bled out. I operated but too late — his life was lost because a simple hemostatic stitch to block the pumping gastroduodenal artery was not inserted in time. We have to know better how to manage these patients and encourage the early involvement of surgeons in their management.',\n", " 'md': 'As introduced above, in many parts of the world, patients presenting with UGIB are initially seen by internists and/or gastroenterologists. We surgeons are usually called to take part in the management only when these specialists believe that they cannot stop the bleeding without our help — and this may be too late — which means that they may call you ‘to operate’ when the patient is already unsalvageable.\\n\\nOh yes, even in today’s era of fancy endoscopic hemostasis and intensive care units, patients can die from bleeding ulcers — I recall a young man admitted to a New York teaching hospital and undergoing two attempts at endoscopic control of his bleeding DU. He continued rebleeding in the ICU; when I was called he had bled out. I operated but too late — his life was lost because a simple hemostatic stitch to block the pumping gastroduodenal artery was not inserted in time. We have to know better how to manage these patients and encourage the early involvement of surgeons in their management.',\n", " 'bBox': {'x': 72, 'y': 407, 'w': 467.8, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'What to do if you are taking care of the bleeding patient?',\n", " 'md': '### What to do if you are taking care of the bleeding patient?',\n", " 'bBox': {'x': 86, 'y': 616, 'w': 446.81, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 243,\n", " 'text': ' F28A8iy\\nFigure 17.1. “This is a ‘serious’ UGI hemorrhage.”\\n\\n • Check vital signs. Aggressive management of hypovolemic\\n shock is the first priority. Do not over-transfuse (!) as there is\\n evidence that excessive blood product administration exacerbates\\n bleeding and results in a higher incidence of rebleeding.\\n • With resuscitation underway, take a history. Previous peptic\\n ulceration? Dyspepsia? Anti-ulcer medications? (Remember,\\n bleeding patients do not have pain because blood is alkaline and\\n serves as an anti-acid.) Recent consumption of analgesics or\\n alcohol? Severe vomiting or retching (Mallory-Weiss)? Chronic liver\\n disease and/or varices? Nose bleed (swallowed blood)?\\n Coagulopathy? Amount of blood vomited or passed per rectum\\n (extremely inaccurate)? Full medical history (operative risk factors)?\\n • Pass a large-bore nasogastric tube, flush the stomach with 50ml\\n of water, and aspirate: fresh blood indicates active or a very recent\\n hemorrhage; coffee ground denotes recent bleeding which has\\n stopped; clean aspirate or bile means no recent hemorrhage. Note:\\n very rarely, a bleeding DU is associated with pyloric spasm with no',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Figure 17.1\\n“This is a ‘serious’ UGI hemorrhage.”\\n\\n- Check vital signs. Aggressive management of hypovolemic shock is the first priority. Do not over-transfuse (!) as there is evidence that excessive blood product administration exacerbates bleeding and results in a higher incidence of rebleeding.\\n- With resuscitation underway, take a history. Previous peptic ulceration? Dyspepsia? Anti-ulcer medications? (Remember, bleeding patients do not have pain because blood is alkaline and serves as an anti-acid.) Recent consumption of analgesics or alcohol? Severe vomiting or retching (Mallory-Weiss)? Chronic liver disease and/or varices? Nose bleed (swallowed blood)? Coagulopathy? Amount of blood vomited or passed per rectum (extremely inaccurate)? Full medical history (operative risk factors)?\\n- Pass a large-bore nasogastric tube, flush the stomach with 50ml of water, and aspirate: fresh blood indicates active or a very recent hemorrhage; coffee ground denotes recent bleeding which has stopped; clean aspirate or bile means no recent hemorrhage. Note: very rarely, a bleeding DU is associated with pyloric spasm with no.\\n\\n## Summary\\nThis page discusses the management of a serious upper gastrointestinal (UGI) hemorrhage, emphasizing the importance of vital sign monitoring, history taking, and nasogastric tube insertion for assessment of bleeding. It highlights the risks of over-transfusion and provides a checklist of potential causes and considerations in the context of UGI bleeding.\\n```',\n", " 'images': [{'name': 'img_p242_1.png',\n", " 'height': 591,\n", " 'width': 792,\n", " 'x': 110.15999999999985,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1360,\n", " 'original_height': 1016}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 17.1',\n", " 'md': '## Figure 17.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '“This is a ‘serious’ UGI hemorrhage.”\\n\\n- Check vital signs. Aggressive management of hypovolemic shock is the first priority. Do not over-transfuse (!) as there is evidence that excessive blood product administration exacerbates bleeding and results in a higher incidence of rebleeding.\\n- With resuscitation underway, take a history. Previous peptic ulceration? Dyspepsia? Anti-ulcer medications? (Remember, bleeding patients do not have pain because blood is alkaline and serves as an anti-acid.) Recent consumption of analgesics or alcohol? Severe vomiting or retching (Mallory-Weiss)? Chronic liver disease and/or varices? Nose bleed (swallowed blood)? Coagulopathy? Amount of blood vomited or passed per rectum (extremely inaccurate)? Full medical history (operative risk factors)?\\n- Pass a large-bore nasogastric tube, flush the stomach with 50ml of water, and aspirate: fresh blood indicates active or a very recent hemorrhage; coffee ground denotes recent bleeding which has stopped; clean aspirate or bile means no recent hemorrhage. Note: very rarely, a bleeding DU is associated with pyloric spasm with no.',\n", " 'md': '“This is a ‘serious’ UGI hemorrhage.”\\n\\n- Check vital signs. Aggressive management of hypovolemic shock is the first priority. Do not over-transfuse (!) as there is evidence that excessive blood product administration exacerbates bleeding and results in a higher incidence of rebleeding.\\n- With resuscitation underway, take a history. Previous peptic ulceration? Dyspepsia? Anti-ulcer medications? (Remember, bleeding patients do not have pain because blood is alkaline and serves as an anti-acid.) Recent consumption of analgesics or alcohol? Severe vomiting or retching (Mallory-Weiss)? Chronic liver disease and/or varices? Nose bleed (swallowed blood)? Coagulopathy? Amount of blood vomited or passed per rectum (extremely inaccurate)? Full medical history (operative risk factors)?\\n- Pass a large-bore nasogastric tube, flush the stomach with 50ml of water, and aspirate: fresh blood indicates active or a very recent hemorrhage; coffee ground denotes recent bleeding which has stopped; clean aspirate or bile means no recent hemorrhage. Note: very rarely, a bleeding DU is associated with pyloric spasm with no.',\n", " 'bBox': {'x': 100, 'y': 492, 'w': 437.62, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the management of a serious upper gastrointestinal (UGI) hemorrhage, emphasizing the importance of vital sign monitoring, history taking, and nasogastric tube insertion for assessment of bleeding. It highlights the risks of over-transfusion and provides a checklist of potential causes and considerations in the context of UGI bleeding.\\n```',\n", " 'md': 'This page discusses the management of a serious upper gastrointestinal (UGI) hemorrhage, emphasizing the importance of vital sign monitoring, history taking, and nasogastric tube insertion for assessment of bleeding. It highlights the risks of over-transfusion and provides a checklist of potential causes and considerations in the context of UGI bleeding.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 244,\n", " 'text': ' blood refluxing into the stomach; a bile-stained aspirate excludes\\n this possibility.\\n • Perform a rectal examination: fresh blood or juicy soft melena\\n indicates active or very recent bleeding, while dry and solid melena\\n signifies a non-recent UGIB ( Figure 17.1).\\n\\n How to proceed?\\n\\n Now, with all the above information in mind you can classify the\\npatients into one of the three groups mentioned above ( Table 17.1).\\n\\n The ‘non-serious bleeders’\\n\\n These patients have suffered a minor hemorrhage, which has stopped.\\nDo not rush to endoscopy in the middle of the night. Semi-elective\\ninvestigation suffices, and is more accurate and safer. Note that a very\\nlow hematocrit/hemoglobin in patients belonging to this group\\nresults from a chronic or intermittent ooze. The very anemic patient\\nwill tolerate endoscopy better after his general condition is improved.\\nThese patients do not require an emergency operation and therefore they\\nwon’t be discussed further.',\n", " 'md': \"```markdown\\n### Text Extraction\\n\\n- Blood refluxing into the stomach; a bile-stained aspirate excludes this possibility.\\n- Perform a rectal examination: fresh blood or juicy soft melena indicates active or very recent bleeding, while dry and solid melena signifies a non-recent UGIB (Figure 17.1).\\n- How to proceed?\\n- Now, with all the above information in mind you can classify the patients into one of the three groups mentioned above (Table 17.1).\\n- The ‘non-serious bleeders’\\n- These patients have suffered a minor hemorrhage, which has stopped. Do not rush to endoscopy in the middle of the night. Semi-elective investigation suffices, and is more accurate and safer. Note that a very low hematocrit/hemoglobin in patients belonging to this group results from a chronic or intermittent ooze. The very anemic patient will tolerate endoscopy better after his general condition is improved. These patients do not require an emergency operation and therefore they won’t be discussed further.\\n\\n### Figure Identification and Description\\n\\n**Figure 17.1**: This figure likely illustrates the classification of upper gastrointestinal bleeding (UGIB) based on the characteristics of the blood observed during a rectal examination. The figure may include visual indicators of fresh blood versus melena, but the specific content is not extractable from the text provided.\\n\\n### Table Identification\\n\\n**Table 17.1**: This table presumably categorizes patients into three groups based on their bleeding status. The specific structure and content of the table are not provided in the text, but it is referenced as a key element in classifying patients.\\n\\n### Summary\\n\\nThe text discusses the assessment of patients with upper gastrointestinal bleeding, emphasizing the importance of rectal examination findings in determining the urgency of intervention. It categorizes patients into groups based on the severity of their condition and suggests a more measured approach to treatment for those classified as 'non-serious bleeders'.\\n```\",\n", " 'images': [{'name': 'img_p243_1.png',\n", " 'height': 12,\n", " 'width': 12,\n", " 'x': 425.52,\n", " 'y': 243.36}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text Extraction',\n", " 'md': '### Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Blood refluxing into the stomach; a bile-stained aspirate excludes this possibility.\\n- Perform a rectal examination: fresh blood or juicy soft melena indicates active or very recent bleeding, while dry and solid melena signifies a non-recent UGIB (Figure 17.1).\\n- How to proceed?\\n- Now, with all the above information in mind you can classify the patients into one of the three groups mentioned above (Table 17.1).\\n- The ‘non-serious bleeders’\\n- These patients have suffered a minor hemorrhage, which has stopped. Do not rush to endoscopy in the middle of the night. Semi-elective investigation suffices, and is more accurate and safer. Note that a very low hematocrit/hemoglobin in patients belonging to this group results from a chronic or intermittent ooze. The very anemic patient will tolerate endoscopy better after his general condition is improved. These patients do not require an emergency operation and therefore they won’t be discussed further.',\n", " 'md': '- Blood refluxing into the stomach; a bile-stained aspirate excludes this possibility.\\n- Perform a rectal examination: fresh blood or juicy soft melena indicates active or very recent bleeding, while dry and solid melena signifies a non-recent UGIB (Figure 17.1).\\n- How to proceed?\\n- Now, with all the above information in mind you can classify the patients into one of the three groups mentioned above (Table 17.1).\\n- The ‘non-serious bleeders’\\n- These patients have suffered a minor hemorrhage, which has stopped. Do not rush to endoscopy in the middle of the night. Semi-elective investigation suffices, and is more accurate and safer. Note that a very low hematocrit/hemoglobin in patients belonging to this group results from a chronic or intermittent ooze. The very anemic patient will tolerate endoscopy better after his general condition is improved. These patients do not require an emergency operation and therefore they won’t be discussed further.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.69, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Identification and Description',\n", " 'md': '### Figure Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 17.1**: This figure likely illustrates the classification of upper gastrointestinal bleeding (UGIB) based on the characteristics of the blood observed during a rectal examination. The figure may include visual indicators of fresh blood versus melena, but the specific content is not extractable from the text provided.',\n", " 'md': '**Figure 17.1**: This figure likely illustrates the classification of upper gastrointestinal bleeding (UGIB) based on the characteristics of the blood observed during a rectal examination. The figure may include visual indicators of fresh blood versus melena, but the specific content is not extractable from the text provided.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table Identification',\n", " 'md': '### Table Identification',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Table 17.1**: This table presumably categorizes patients into three groups based on their bleeding status. The specific structure and content of the table are not provided in the text, but it is referenced as a key element in classifying patients.',\n", " 'md': '**Table 17.1**: This table presumably categorizes patients into three groups based on their bleeding status. The specific structure and content of the table are not provided in the text, but it is referenced as a key element in classifying patients.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"The text discusses the assessment of patients with upper gastrointestinal bleeding, emphasizing the importance of rectal examination findings in determining the urgency of intervention. It categorizes patients into groups based on the severity of their condition and suggests a more measured approach to treatment for those classified as 'non-serious bleeders'.\\n```\",\n", " 'md': \"The text discusses the assessment of patients with upper gastrointestinal bleeding, emphasizing the importance of rectal examination findings in determining the urgency of intervention. It categorizes patients into groups based on the severity of their condition and suggests a more measured approach to treatment for those classified as 'non-serious bleeders'.\\n```\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 245,\n", " 'text': ' Table 17.1. Stratification and management of patients with upper\\n gastrointestinal hemorrhage:\\n Serious Potentially serious Not serious\\n Vomiting or Fresh blood Coffee ground/fresh Nothing/coffee\\n nasogastric tube ground\\n Per rectum Fresh melena/blood Fresh melena Old melena\\n Hemodynamically Compromised Responded to Stable\\n resuscitation/stable\\n Hemoglobin/ 9/27 Use your common >9/27\\n hematocrit sense\\n Approach Endoscopy now Endoscopy soon Endoscopy tomorrow\\n Prognosis Requires hemostasis Variable Self-limiting\\n The ‘serious bleeders’\\n\\n In a minority of patients belonging to this group, fresh blood is\\npouring torrentially from the stomach; they are virtually\\nexsanguinating! You have to move fast. Esophageal or gastric varices\\noften bleed this way — like an open tap. In such cases a previous history\\nof portal hypertension or clinical stigmata of chronic liver disease often\\ncoexist, suggesting the diagnosis. Remember — you do not want to\\noperate on varices (see Chapter 25).\\n\\n In any event, you should transfer the exsanguinating patient to a critical\\ncare facility or the operating room. Intubate and sedate him/her to\\nfacilitate gastric lavage and subsequent endoscopy, and, most\\nimportantly, to reduce the risk of aspiration of the gastric contents\\nin the shocked, obtunded, bleeding patient. You should attempt\\nendoscopy because, even if gastroduodenal visualization is totally\\nobscured by blood, fresh bleeding from esophageal varices (usually at',\n", " 'md': '```markdown\\n## Table 17.1. Stratification and management of patients with upper gastrointestinal hemorrhage\\n\\n| Serious | Potentially serious | Not serious |\\n|-----------------------------|-----------------------------------|---------------------------|\\n| Vomiting or nasogastric tube| Fresh blood | Coffee ground/fresh |\\n| Per rectum | Fresh melena/blood | Fresh melena |\\n| Hemodynamically compromised | Responded to resuscitation/stable | Stable |\\n| Hemoglobin/hematocrit | 9/27 | Use your common sense |\\n| Approach | Endoscopy now | Endoscopy soon |\\n| Prognosis | Requires hemostasis | Self-limiting |\\n\\n### The ‘serious bleeders’\\n\\nIn a minority of patients belonging to this group, fresh blood is pouring torrentially from the stomach; they are virtually exsanguinating! You have to move fast. Esophageal or gastric varices often bleed this way — like an open tap. In such cases, a previous history of portal hypertension or clinical stigmata of chronic liver disease often coexist, suggesting the diagnosis. Remember — you do not want to operate on varices (see Chapter 25).\\n\\nIn any event, you should transfer the exsanguinating patient to a critical care facility or the operating room. Intubate and sedate him/her to facilitate gastric lavage and subsequent endoscopy, and, most importantly, to reduce the risk of aspiration of the gastric contents in the shocked, obtunded, bleeding patient. You should attempt endoscopy because, even if gastroduodenal visualization is totally obscured by blood, fresh bleeding from esophageal varices (usually at...\\n```',\n", " 'images': [{'name': 'img_p244_1.png',\n", " 'height': 667,\n", " 'width': 834,\n", " 'x': 100.07999999999993,\n", " 'y': 72,\n", " 'original_width': 1432,\n", " 'original_height': 1144}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 17.1. Stratification and management of patients with upper gastrointestinal hemorrhage',\n", " 'md': '## Table 17.1. Stratification and management of patients with upper gastrointestinal hemorrhage',\n", " 'bBox': {'x': 105.52, 'y': 74.47, 'w': 407.61, 'h': 20.27}},\n", " {'type': 'table',\n", " 'rows': [['Serious', 'Potentially serious', 'Not serious'],\n", " ['Vomiting or nasogastric tube', 'Fresh blood', 'Coffee ground/fresh'],\n", " ['Per rectum', 'Fresh melena/blood', 'Fresh melena'],\n", " ['Hemodynamically compromised',\n", " 'Responded to resuscitation/stable',\n", " 'Stable'],\n", " ['Hemoglobin/hematocrit', '9/27', 'Use your common sense'],\n", " ['Approach', 'Endoscopy now', 'Endoscopy soon'],\n", " ['Prognosis', 'Requires hemostasis', 'Self-limiting']],\n", " 'md': '| Serious | Potentially serious | Not serious |\\n|-----------------------------|-----------------------------------|---------------------------|\\n| Vomiting or nasogastric tube| Fresh blood | Coffee ground/fresh |\\n| Per rectum | Fresh melena/blood | Fresh melena |\\n| Hemodynamically compromised | Responded to resuscitation/stable | Stable |\\n| Hemoglobin/hematocrit | 9/27 | Use your common sense |\\n| Approach | Endoscopy now | Endoscopy soon |\\n| Prognosis | Requires hemostasis | Self-limiting |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Serious\",\"Potentially serious\",\"Not serious\"\\n\"Vomiting or nasogastric tube\",\"Fresh blood\",\"Coffee ground/fresh\"\\n\"Per rectum\",\"Fresh melena/blood\",\"Fresh melena\"\\n\"Hemodynamically compromised\",\"Responded to resuscitation/stable\",\"Stable\"\\n\"Hemoglobin/hematocrit\",\"9/27\",\"Use your common sense\"\\n\"Approach\",\"Endoscopy now\",\"Endoscopy soon\"\\n\"Prognosis\",\"Requires hemostasis\",\"Self-limiting\"',\n", " 'bBox': {'x': 105.03, 'y': 115.01, 'w': 193.42, 'h': 16.31}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The ‘serious bleeders’',\n", " 'md': '### The ‘serious bleeders’',\n", " 'bBox': {'x': 86, 'y': 115.51, 'w': 174.73, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In a minority of patients belonging to this group, fresh blood is pouring torrentially from the stomach; they are virtually exsanguinating! You have to move fast. Esophageal or gastric varices often bleed this way — like an open tap. In such cases, a previous history of portal hypertension or clinical stigmata of chronic liver disease often coexist, suggesting the diagnosis. Remember — you do not want to operate on varices (see Chapter 25).\\n\\nIn any event, you should transfer the exsanguinating patient to a critical care facility or the operating room. Intubate and sedate him/her to facilitate gastric lavage and subsequent endoscopy, and, most importantly, to reduce the risk of aspiration of the gastric contents in the shocked, obtunded, bleeding patient. You should attempt endoscopy because, even if gastroduodenal visualization is totally obscured by blood, fresh bleeding from esophageal varices (usually at...\\n```',\n", " 'md': 'In a minority of patients belonging to this group, fresh blood is pouring torrentially from the stomach; they are virtually exsanguinating! You have to move fast. Esophageal or gastric varices often bleed this way — like an open tap. In such cases, a previous history of portal hypertension or clinical stigmata of chronic liver disease often coexist, suggesting the diagnosis. Remember — you do not want to operate on varices (see Chapter 25).\\n\\nIn any event, you should transfer the exsanguinating patient to a critical care facility or the operating room. Intubate and sedate him/her to facilitate gastric lavage and subsequent endoscopy, and, most importantly, to reduce the risk of aspiration of the gastric contents in the shocked, obtunded, bleeding patient. You should attempt endoscopy because, even if gastroduodenal visualization is totally obscured by blood, fresh bleeding from esophageal varices (usually at...\\n```',\n", " 'bBox': {'x': 72, 'y': 150.11, 'w': 467.39, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 246,\n", " 'text': '40cm from the teeth, at the gastroesophageal junction) can always be\\ndetected, mandating a subsequent non-operative approach. In the\\nabsence of varices you should MYA 2 rapidly: to surgery or\\nangiography.\\n\\n We use a large-lumen irrigation endoscope that is capable of suctioning clots rapidly and\\n irrigating with high force. Ari\\n\\n The serious patients who are not exsanguinating should undergo\\nan emergency endoscopy, as should the ‘potentially serious’\\nbleeders.\\n\\n Emergency endoscopy for UGIB\\n\\n This should be done only after you have resuscitated the patient\\nand are in a controlled environment. Endoscopy induces hypoxemia\\nand vagal stimulation; we have seen it cause cardiac arrest in unstable\\nand poorly oxygenated patients (in addition, closed cardiac massage on\\na patient with a stomach ballooned with blood may lead to gastric\\nrupture). Ideally, you — the surgeon — should be the one who\\nperforms the procedure. Unfortunately, because of political and fiscal\\nconsiderations, in many hospitals you are denied this access to\\nendoscopy. If this is the case — at least try to be present at the\\nendoscopy to visualize the findings first hand. Do not entirely trust the\\ngastroenterologist; he’ll be going home soon, leaving you with the patient\\nand any problems resulting from a poorly identified bleeding site.\\n\\n To improve the diagnostic yield the stomach should be prepared\\nfor endoscopy. Pass the largest nasogastric tube you can find and flush\\nthe stomach rapidly and repeatedly, aspirating as many clots as possible.\\nA common ritual is to use ice-cold saline (with or without a\\nvasoconstricting agent) for this purpose. These methods have not been\\nproven to be therapeutic. Tap water is just as good, much cheaper, and\\ndoes not aggravate hypothermia which may impede clotting.\\n\\n At endoscopy, attempt to visualize the potential sources of bleeding,',\n", " 'md': '```markdown\\n## Emergency Endoscopy for Upper Gastrointestinal Bleeding (UGIB)\\n\\n- **Detection**: A lesion located 40 cm from the teeth, at the gastroesophageal junction, can always be detected, mandating a subsequent non-operative approach. In the absence of varices, you should MYA 2 rapidly: to surgery or angiography.\\n\\n- **Equipment**: We use a large-lumen irrigation endoscope that is capable of suctioning clots rapidly and irrigating with high force.\\n\\n- **Patient Management**: Serious patients who are not exsanguinating should undergo an emergency endoscopy, as should the ‘potentially serious’ bleeders.\\n\\n### Procedure Guidelines\\n- Emergency endoscopy for UGIB should be performed only after resuscitating the patient and ensuring a controlled environment.\\n- Endoscopy can induce hypoxemia and vagal stimulation; it has been observed to cause cardiac arrest in unstable and poorly oxygenated patients.\\n- Closed cardiac massage on a patient with a stomach ballooned with blood may lead to gastric rupture.\\n- Ideally, the surgeon should perform the procedure. However, due to political and fiscal considerations, access to endoscopy may be denied in many hospitals. If this is the case, try to be present at the endoscopy to visualize the findings firsthand. Do not entirely trust the gastroenterologist, as they may leave you with the patient and any problems resulting from a poorly identified bleeding site.\\n\\n### Preparation for Endoscopy\\n- To improve the diagnostic yield, the stomach should be prepared for endoscopy.\\n- Pass the largest nasogastric tube available and flush the stomach rapidly and repeatedly, aspirating as many clots as possible.\\n- A common ritual is to use ice-cold saline (with or without a vasoconstricting agent) for this purpose. However, these methods have not been proven to be therapeutic. Tap water is just as effective, much cheaper, and does not aggravate hypothermia, which may impede clotting.\\n\\n- At endoscopy, attempt to visualize the potential sources of bleeding.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Emergency Endoscopy for Upper Gastrointestinal Bleeding (UGIB)',\n", " 'md': '## Emergency Endoscopy for Upper Gastrointestinal Bleeding (UGIB)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Detection**: A lesion located 40 cm from the teeth, at the gastroesophageal junction, can always be detected, mandating a subsequent non-operative approach. In the absence of varices, you should MYA 2 rapidly: to surgery or angiography.\\n\\n- **Equipment**: We use a large-lumen irrigation endoscope that is capable of suctioning clots rapidly and irrigating with high force.\\n\\n- **Patient Management**: Serious patients who are not exsanguinating should undergo an emergency endoscopy, as should the ‘potentially serious’ bleeders.',\n", " 'md': '- **Detection**: A lesion located 40 cm from the teeth, at the gastroesophageal junction, can always be detected, mandating a subsequent non-operative approach. In the absence of varices, you should MYA 2 rapidly: to surgery or angiography.\\n\\n- **Equipment**: We use a large-lumen irrigation endoscope that is capable of suctioning clots rapidly and irrigating with high force.\\n\\n- **Patient Management**: Serious patients who are not exsanguinating should undergo an emergency endoscopy, as should the ‘potentially serious’ bleeders.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 90, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Procedure Guidelines',\n", " 'md': '### Procedure Guidelines',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Emergency endoscopy for UGIB should be performed only after resuscitating the patient and ensuring a controlled environment.\\n- Endoscopy can induce hypoxemia and vagal stimulation; it has been observed to cause cardiac arrest in unstable and poorly oxygenated patients.\\n- Closed cardiac massage on a patient with a stomach ballooned with blood may lead to gastric rupture.\\n- Ideally, the surgeon should perform the procedure. However, due to political and fiscal considerations, access to endoscopy may be denied in many hospitals. If this is the case, try to be present at the endoscopy to visualize the findings firsthand. Do not entirely trust the gastroenterologist, as they may leave you with the patient and any problems resulting from a poorly identified bleeding site.',\n", " 'md': '- Emergency endoscopy for UGIB should be performed only after resuscitating the patient and ensuring a controlled environment.\\n- Endoscopy can induce hypoxemia and vagal stimulation; it has been observed to cause cardiac arrest in unstable and poorly oxygenated patients.\\n- Closed cardiac massage on a patient with a stomach ballooned with blood may lead to gastric rupture.\\n- Ideally, the surgeon should perform the procedure. However, due to political and fiscal considerations, access to endoscopy may be denied in many hospitals. If this is the case, try to be present at the endoscopy to visualize the findings firsthand. Do not entirely trust the gastroenterologist, as they may leave you with the patient and any problems resulting from a poorly identified bleeding site.',\n", " 'bBox': {'x': 72, 'y': 315, 'w': 410.98, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Preparation for Endoscopy',\n", " 'md': '### Preparation for Endoscopy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- To improve the diagnostic yield, the stomach should be prepared for endoscopy.\\n- Pass the largest nasogastric tube available and flush the stomach rapidly and repeatedly, aspirating as many clots as possible.\\n- A common ritual is to use ice-cold saline (with or without a vasoconstricting agent) for this purpose. However, these methods have not been proven to be therapeutic. Tap water is just as effective, much cheaper, and does not aggravate hypothermia, which may impede clotting.\\n\\n- At endoscopy, attempt to visualize the potential sources of bleeding.\\n```',\n", " 'md': '- To improve the diagnostic yield, the stomach should be prepared for endoscopy.\\n- Pass the largest nasogastric tube available and flush the stomach rapidly and repeatedly, aspirating as many clots as possible.\\n- A common ritual is to use ice-cold saline (with or without a vasoconstricting agent) for this purpose. However, these methods have not been proven to be therapeutic. Tap water is just as effective, much cheaper, and does not aggravate hypothermia, which may impede clotting.\\n\\n- At endoscopy, attempt to visualize the potential sources of bleeding.\\n```',\n", " 'bBox': {'x': 72, 'y': 602, 'w': 468, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 247,\n", " 'text': 'mentioned above. Look also for the following prognostic stigmata:\\n\\n • Active bleeding from lesion.\\n • A ‘visible vessel’ in the ulcer’s base, indicating that the bleeding\\n originated from a large vessel and that there is a high chance of\\n further hemorrhage.\\n according to Classification\\n Table 17.2. of endoscopic findings in UGIB\\n Forrest: Forrest JA, Finlayson ND; Shearman DJ: Endoscopy in\\n gastrointestinal bleeding: Lancet 1974; 2: 394-7.\\n Acute hemorrhage:\\n Forrest Ia (spurting hemorrhage):\\n Forrest Ib (oozing hemorrhage):\\n Signs of recent hemorrhage:\\n Forrest Ila (visible vessel)\\n Forrest Ilb (adherent clot):\\n Forrest Ilc (flat pigmented [haematin] on [peptic ulcer/ulcer] base):\\n Lesions without active bleeding:\\n Forrest III (lesions without signs of recent hemorrhage or fibrin-covered clean\\n ulcer base):\\n • A clot adherent to the ulcer’s base, signifying a recent hemorrhage.\\n You may like to classify the findings according to the Forrest\\nclassification as presented in Table 17.2.\\n\\n Endoscopic management\\n\\n ħaving visualized the lesion you should now treat it endoscopically in',\n", " 'md': '```markdown\\n## Endoscopic Findings in UGIB\\n\\nLook also for the following prognostic stigmata:\\n\\n- Active bleeding from lesion.\\n- A ‘visible vessel’ in the ulcer’s base, indicating that the bleeding originated from a large vessel and that there is a high chance of further hemorrhage.\\n\\n### Classification of Endoscopic Findings in UGIB\\n\\nAccording to Forrest classification:\\n\\n- **Acute hemorrhage:**\\n- Forrest Ia (spurting hemorrhage)\\n- Forrest Ib (oozing hemorrhage)\\n\\n- **Signs of recent hemorrhage:**\\n- Forrest Ila (visible vessel)\\n- Forrest Ilb (adherent clot)\\n- Forrest Ilc (flat pigmented [haematin] on [peptic ulcer/ulcer] base)\\n\\n- **Lesions without active bleeding:**\\n- Forrest III (lesions without signs of recent hemorrhage or fibrin-covered clean ulcer base)\\n\\n- A clot adherent to the ulcer’s base, signifying a recent hemorrhage.\\n\\nYou may like to classify the findings according to the Forrest classification as presented in Table 17.2.\\n\\n### Endoscopic Management\\n\\nHaving visualized the lesion you should now treat it endoscopically.\\n```',\n", " 'images': [{'name': 'img_p246_1.png',\n", " 'height': 665,\n", " 'width': 819,\n", " 'x': 103.67999999999938,\n", " 'y': 205.20000000000005,\n", " 'original_width': 1407,\n", " 'original_height': 1141}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Endoscopic Findings in UGIB',\n", " 'md': '## Endoscopic Findings in UGIB',\n", " 'bBox': {'x': 471.92, 'y': 212.13, 'w': 35.64, 'h': 14.84}},\n", " {'type': 'text',\n", " 'value': 'Look also for the following prognostic stigmata:\\n\\n- Active bleeding from lesion.\\n- A ‘visible vessel’ in the ulcer’s base, indicating that the bleeding originated from a large vessel and that there is a high chance of further hemorrhage.',\n", " 'md': 'Look also for the following prognostic stigmata:\\n\\n- Active bleeding from lesion.\\n- A ‘visible vessel’ in the ulcer’s base, indicating that the bleeding originated from a large vessel and that there is a high chance of further hemorrhage.',\n", " 'bBox': {'x': 100, 'y': 121, 'w': 175.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Classification of Endoscopic Findings in UGIB',\n", " 'md': '### Classification of Endoscopic Findings in UGIB',\n", " 'bBox': {'x': 471.92, 'y': 212.13, 'w': 35.64, 'h': 14.84}},\n", " {'type': 'text',\n", " 'value': 'According to Forrest classification:\\n\\n- **Acute hemorrhage:**\\n- Forrest Ia (spurting hemorrhage)\\n- Forrest Ib (oozing hemorrhage)\\n\\n- **Signs of recent hemorrhage:**\\n- Forrest Ila (visible vessel)\\n- Forrest Ilb (adherent clot)\\n- Forrest Ilc (flat pigmented [haematin] on [peptic ulcer/ulcer] base)\\n\\n- **Lesions without active bleeding:**\\n- Forrest III (lesions without signs of recent hemorrhage or fibrin-covered clean ulcer base)\\n\\n- A clot adherent to the ulcer’s base, signifying a recent hemorrhage.\\n\\nYou may like to classify the findings according to the Forrest classification as presented in Table 17.2.',\n", " 'md': 'According to Forrest classification:\\n\\n- **Acute hemorrhage:**\\n- Forrest Ia (spurting hemorrhage)\\n- Forrest Ib (oozing hemorrhage)\\n\\n- **Signs of recent hemorrhage:**\\n- Forrest Ila (visible vessel)\\n- Forrest Ilb (adherent clot)\\n- Forrest Ilc (flat pigmented [haematin] on [peptic ulcer/ulcer] base)\\n\\n- **Lesions without active bleeding:**\\n- Forrest III (lesions without signs of recent hemorrhage or fibrin-covered clean ulcer base)\\n\\n- A clot adherent to the ulcer’s base, signifying a recent hemorrhage.\\n\\nYou may like to classify the findings according to the Forrest classification as presented in Table 17.2.',\n", " 'bBox': {'x': 100, 'y': 211.14, 'w': 426.45, 'h': 19.79}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Endoscopic Management',\n", " 'md': '### Endoscopic Management',\n", " 'bBox': {'x': 86, 'y': 673, 'w': 200.49, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Having visualized the lesion you should now treat it endoscopically.\\n```',\n", " 'md': 'Having visualized the lesion you should now treat it endoscopically.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 248,\n", " 'text': 'order to achieve hemostasis and to reduce the risk of further\\nhemorrhage. In broad terms, endoscopic therapy has a better chance of\\nsuccess in shallow lesions, which contain small vessels. ħowever, you\\nshould also attempt endoscopic hemostasis in deeper, large vessel-\\ncontaining lesions, with the aim of achieving at least temporary cessation\\nof bleeding. This will permit a safer, semi-elective, definitive operation to\\nbe performed in a better-prepared patient. The specific method of\\nendoscopic hemostasis, be it a ‘hot’ probe, clips, rubber bands, injection\\nwith adrenaline or a sclerosant, or even glue (frankly, it could be that\\neven injection of Coca Cola may be effective in stopping bleeding, which\\nin the old days would stop spontaneously…), depends on local skills and\\nfacilities. In fact, some experts claim that single-mode endoscopic\\ntreatment has no role and advocate ‘triple endoRx’. Since it will be\\nperformed in most places by the gastroenterologists we will not concern\\nourselves here with technique.\\n\\n Nevertheless, our standard approach is adrenalin plus fibrin glue for actively bleeding ulcers.\\n With a Dieulafoy’s lesion we use clips (plus angioembolization as needed) and with gastric\\n fundus varices we use special glue. Ari\\n\\n Post-endoscopy decision-making\\n\\n At the end of endoscopy you, or the ‘other endoscopist’, are left with\\nthe following categories of patients:\\n\\n • Actively bleeding: failed endoscopic hemostasis! The source is\\n usually a chronic ulcer and emergency operation is indicated. But\\n if you have a readily available and skilled angiographer, you may\\n wish to consult him…\\n • Bleeding (apparently) stopped: e.g. chronic ulcer with a ‘visible\\n vessel’ or adherent clot visualized. The chances of further\\n hemorrhage, usually within 48-72 hours, are substantial. Treat\\n conservatively but observe closely — you may be sitting on a time\\n bomb!',\n", " 'md': '```markdown\\n## Endoscopic Therapy for Hemostasis\\n\\nIn order to achieve hemostasis and to reduce the risk of further hemorrhage, endoscopic therapy has a better chance of success in shallow lesions, which contain small vessels. However, you should also attempt endoscopic hemostasis in deeper, large vessel-containing lesions, with the aim of achieving at least temporary cessation of bleeding. This will permit a safer, semi-elective, definitive operation to be performed in a better-prepared patient.\\n\\nThe specific method of endoscopic hemostasis, be it a ‘hot’ probe, clips, rubber bands, injection with adrenaline or a sclerosant, or even glue (frankly, it could be that even injection of Coca Cola may be effective in stopping bleeding, which in the old days would stop spontaneously…), depends on local skills and facilities. In fact, some experts claim that single-mode endoscopic treatment has no role and advocate ‘triple endoRx’. Since it will be performed in most places by the gastroenterologists, we will not concern ourselves here with technique.\\n\\nNevertheless, our standard approach is adrenaline plus fibrin glue for actively bleeding ulcers. With a Dieulafoy’s lesion, we use clips (plus angioembolization as needed) and with gastric fundus varices, we use special glue.\\n\\n### Post-endoscopy Decision-Making\\n\\nAt the end of endoscopy, you, or the ‘other endoscopist’, are left with the following categories of patients:\\n\\n- **Actively bleeding:** failed endoscopic hemostasis! The source is usually a chronic ulcer and emergency operation is indicated. But if you have a readily available and skilled angiographer, you may wish to consult him…\\n- **Bleeding (apparently) stopped:** e.g. chronic ulcer with a ‘visible vessel’ or adherent clot visualized. The chances of further hemorrhage, usually within 48-72 hours, are substantial. Treat conservatively but observe closely — you may be sitting on a time bomb!\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Endoscopic Therapy for Hemostasis',\n", " 'md': '## Endoscopic Therapy for Hemostasis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In order to achieve hemostasis and to reduce the risk of further hemorrhage, endoscopic therapy has a better chance of success in shallow lesions, which contain small vessels. However, you should also attempt endoscopic hemostasis in deeper, large vessel-containing lesions, with the aim of achieving at least temporary cessation of bleeding. This will permit a safer, semi-elective, definitive operation to be performed in a better-prepared patient.\\n\\nThe specific method of endoscopic hemostasis, be it a ‘hot’ probe, clips, rubber bands, injection with adrenaline or a sclerosant, or even glue (frankly, it could be that even injection of Coca Cola may be effective in stopping bleeding, which in the old days would stop spontaneously…), depends on local skills and facilities. In fact, some experts claim that single-mode endoscopic treatment has no role and advocate ‘triple endoRx’. Since it will be performed in most places by the gastroenterologists, we will not concern ourselves here with technique.\\n\\nNevertheless, our standard approach is adrenaline plus fibrin glue for actively bleeding ulcers. With a Dieulafoy’s lesion, we use clips (plus angioembolization as needed) and with gastric fundus varices, we use special glue.',\n", " 'md': 'In order to achieve hemostasis and to reduce the risk of further hemorrhage, endoscopic therapy has a better chance of success in shallow lesions, which contain small vessels. However, you should also attempt endoscopic hemostasis in deeper, large vessel-containing lesions, with the aim of achieving at least temporary cessation of bleeding. This will permit a safer, semi-elective, definitive operation to be performed in a better-prepared patient.\\n\\nThe specific method of endoscopic hemostasis, be it a ‘hot’ probe, clips, rubber bands, injection with adrenaline or a sclerosant, or even glue (frankly, it could be that even injection of Coca Cola may be effective in stopping bleeding, which in the old days would stop spontaneously…), depends on local skills and facilities. In fact, some experts claim that single-mode endoscopic treatment has no role and advocate ‘triple endoRx’. Since it will be performed in most places by the gastroenterologists, we will not concern ourselves here with technique.\\n\\nNevertheless, our standard approach is adrenaline plus fibrin glue for actively bleeding ulcers. With a Dieulafoy’s lesion, we use clips (plus angioembolization as needed) and with gastric fundus varices, we use special glue.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Post-endoscopy Decision-Making',\n", " 'md': '### Post-endoscopy Decision-Making',\n", " 'bBox': {'x': 86, 'y': 448, 'w': 263.93, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'At the end of endoscopy, you, or the ‘other endoscopist’, are left with the following categories of patients:\\n\\n- **Actively bleeding:** failed endoscopic hemostasis! The source is usually a chronic ulcer and emergency operation is indicated. But if you have a readily available and skilled angiographer, you may wish to consult him…\\n- **Bleeding (apparently) stopped:** e.g. chronic ulcer with a ‘visible vessel’ or adherent clot visualized. The chances of further hemorrhage, usually within 48-72 hours, are substantial. Treat conservatively but observe closely — you may be sitting on a time bomb!\\n```',\n", " 'md': 'At the end of endoscopy, you, or the ‘other endoscopist’, are left with the following categories of patients:\\n\\n- **Actively bleeding:** failed endoscopic hemostasis! The source is usually a chronic ulcer and emergency operation is indicated. But if you have a readily available and skilled angiographer, you may wish to consult him…\\n- **Bleeding (apparently) stopped:** e.g. chronic ulcer with a ‘visible vessel’ or adherent clot visualized. The chances of further hemorrhage, usually within 48-72 hours, are substantial. Treat conservatively but observe closely — you may be sitting on a time bomb!\\n```',\n", " 'bBox': {'x': 72, 'y': 501, 'w': 437.31, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 249,\n", " 'text': ' Our policy in the high-risk group — if the bleeding apparently has stopped — is to repeat\\n gastroscopy the next day. We Finns do not like to sit on bombs. Ari\\n\\n • Bleeding stopped: e.g. acute shallow lesion or chronic ulcer\\n without the aforementioned stigmata. In these patients further\\n hemorrhage is unlikely; treat conservatively and relax.\\n\\n Conservative treatment\\n\\n The mainstay of conservative treatment comprises completion\\nand maintenance of resuscitative measures, and observation for\\nfurther hemorrhage. In earlier editions of this book we decried the use\\nof proton pump inhibitors (PPIs) as a useless intervention in acute UGIB.\\nWe have changed our opinion. (“When the facts change, I change my\\nmind. What do you do, sir?” John Maynard Keynes.) There is now good\\nevidence that the administration of high-dose PPIs in patients with peptic\\nulceration reduces the incidence of rebleeding and the need for surgery\\nfollowing endoscopic haemostasis. Obviously, correct coagulopathies if\\npresent. All you need to do is to sustain the patient’s organ systems,\\nand watch for rebleeding, which usually occurs within 48-72 hours\\nand can be massive and lethal. Careful monitoring of vital signs,\\nobservation of the number and character of melena stools and\\nserial hematocrit measurements will detect episodes of further\\nhemorrhage. A nasogastric tube on suction is often advocated to provide\\nearly warning. In our experience, however, it is often blocked by clots, is\\nof great discomfort to the patient and is therefore worse than useless. If,\\nnonetheless, you choose to use it, flush it frequently.\\n\\n The management of rebleeding\\n\\n The patient has bled again! What now? Re-endoscopic treatment?\\nRush to the operating room? Transfer to the arteriography suite?\\nWell, it all depends…\\n\\n We do not suggest that you use cookbook recipes or formulas, as they\\nare of little help in the individual patient. Instead, use clinical judgment.',\n", " 'md': '```markdown\\n## Conservative Treatment in High-Risk Group\\n\\nOur policy in the high-risk group — if the bleeding apparently has stopped — is to repeat gastroscopy the next day. We Finns do not like to sit on bombs.\\n\\n- **Bleeding stopped**: e.g. acute shallow lesion or chronic ulcer without the aforementioned stigmata. In these patients, further hemorrhage is unlikely; treat conservatively and relax.\\n\\n### Conservative Treatment\\n\\nThe mainstay of conservative treatment comprises completion and maintenance of resuscitative measures, and observation for further hemorrhage. In earlier editions of this book, we decried the use of proton pump inhibitors (PPIs) as a useless intervention in acute UGIB. We have changed our opinion. (“When the facts change, I change my mind. What do you do, sir?” John Maynard Keynes.) There is now good evidence that the administration of high-dose PPIs in patients with peptic ulceration reduces the incidence of rebleeding and the need for surgery following endoscopic haemostasis.\\n\\nObviously, correct coagulopathies if present. All you need to do is to sustain the patient’s organ systems, and watch for rebleeding, which usually occurs within 48-72 hours and can be massive and lethal. Careful monitoring of vital signs, observation of the number and character of melena stools, and serial hematocrit measurements will detect episodes of further hemorrhage. A nasogastric tube on suction is often advocated to provide early warning. In our experience, however, it is often blocked by clots, is of great discomfort to the patient, and is therefore worse than useless. If, nonetheless, you choose to use it, flush it frequently.\\n\\n### Management of Rebleeding\\n\\nThe patient has bled again! What now? Re-endoscopic treatment? Rush to the operating room? Transfer to the arteriography suite? Well, it all depends…\\n\\nWe do not suggest that you use cookbook recipes or formulas, as they are of little help in the individual patient. Instead, use clinical judgment.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Conservative Treatment in High-Risk Group',\n", " 'md': '## Conservative Treatment in High-Risk Group',\n", " 'bBox': {'x': 86, 'y': 233, 'w': 183.94, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Our policy in the high-risk group — if the bleeding apparently has stopped — is to repeat gastroscopy the next day. We Finns do not like to sit on bombs.\\n\\n- **Bleeding stopped**: e.g. acute shallow lesion or chronic ulcer without the aforementioned stigmata. In these patients, further hemorrhage is unlikely; treat conservatively and relax.',\n", " 'md': 'Our policy in the high-risk group — if the bleeding apparently has stopped — is to repeat gastroscopy the next day. We Finns do not like to sit on bombs.\\n\\n- **Bleeding stopped**: e.g. acute shallow lesion or chronic ulcer without the aforementioned stigmata. In these patients, further hemorrhage is unlikely; treat conservatively and relax.',\n", " 'bBox': {'x': 100, 'y': 188, 'w': 343, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Conservative Treatment',\n", " 'md': '### Conservative Treatment',\n", " 'bBox': {'x': 86, 'y': 233, 'w': 183.94, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The mainstay of conservative treatment comprises completion and maintenance of resuscitative measures, and observation for further hemorrhage. In earlier editions of this book, we decried the use of proton pump inhibitors (PPIs) as a useless intervention in acute UGIB. We have changed our opinion. (“When the facts change, I change my mind. What do you do, sir?” John Maynard Keynes.) There is now good evidence that the administration of high-dose PPIs in patients with peptic ulceration reduces the incidence of rebleeding and the need for surgery following endoscopic haemostasis.\\n\\nObviously, correct coagulopathies if present. All you need to do is to sustain the patient’s organ systems, and watch for rebleeding, which usually occurs within 48-72 hours and can be massive and lethal. Careful monitoring of vital signs, observation of the number and character of melena stools, and serial hematocrit measurements will detect episodes of further hemorrhage. A nasogastric tube on suction is often advocated to provide early warning. In our experience, however, it is often blocked by clots, is of great discomfort to the patient, and is therefore worse than useless. If, nonetheless, you choose to use it, flush it frequently.',\n", " 'md': 'The mainstay of conservative treatment comprises completion and maintenance of resuscitative measures, and observation for further hemorrhage. In earlier editions of this book, we decried the use of proton pump inhibitors (PPIs) as a useless intervention in acute UGIB. We have changed our opinion. (“When the facts change, I change my mind. What do you do, sir?” John Maynard Keynes.) There is now good evidence that the administration of high-dose PPIs in patients with peptic ulceration reduces the incidence of rebleeding and the need for surgery following endoscopic haemostasis.\\n\\nObviously, correct coagulopathies if present. All you need to do is to sustain the patient’s organ systems, and watch for rebleeding, which usually occurs within 48-72 hours and can be massive and lethal. Careful monitoring of vital signs, observation of the number and character of melena stools, and serial hematocrit measurements will detect episodes of further hemorrhage. A nasogastric tube on suction is often advocated to provide early warning. In our experience, however, it is often blocked by clots, is of great discomfort to the patient, and is therefore worse than useless. If, nonetheless, you choose to use it, flush it frequently.',\n", " 'bBox': {'x': 72, 'y': 233, 'w': 467.91, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management of Rebleeding',\n", " 'md': '### Management of Rebleeding',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The patient has bled again! What now? Re-endoscopic treatment? Rush to the operating room? Transfer to the arteriography suite? Well, it all depends…\\n\\nWe do not suggest that you use cookbook recipes or formulas, as they are of little help in the individual patient. Instead, use clinical judgment.\\n```',\n", " 'md': 'The patient has bled again! What now? Re-endoscopic treatment? Rush to the operating room? Transfer to the arteriography suite? Well, it all depends…\\n\\nWe do not suggest that you use cookbook recipes or formulas, as they are of little help in the individual patient. Instead, use clinical judgment.\\n```',\n", " 'bBox': {'x': 72, 'y': 630, 'w': 467, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 250,\n", " 'text': 'That the exsanguinating patient, and the one who continues to bleed\\nafter endoscopic hemostasis fails, need an emergency operation is clear\\nand has been discussed above. But what to do with recurrent\\nhemorrhage? Factors that may or may not modify your decision to\\noperate include the magnitude of recurrent hemorrhage, its source, and\\nthe age and general condition of the patient.\\n\\n In general terms, recurrent hemorrhage is an ominous sign,\\nmeaning that bleeding will continue or, if stopped again, may well recur!\\n\\n So our advice is:\\n\\n • If hemodynamically significant you have to operate!\\n • If rebleeding seems of mild or moderate magnitude you may\\n elect to continue conservative treatment or retreat endoscopically.\\n • The source of the bleeding may influence your decisions: e.g. a\\n chronic, giant ulcer may tilt the scale towards surgery; a superficial,\\n acute source may guide you to avoid an operation.\\n\\n Gastroenterologists are nowadays very keen to repeat\\nendoscopic therapy in rebleeding patients — all of them, even those\\nwho squirt it out in a pulsatile stream — and even to do so a few times.\\nCommonly, those patients ‘belong’ to them and you cannot interfere, but\\nyou should watch them ‘from the side’ and be ready to act. After repeated\\nendoscopic maneuvers sometimes not much will be left of the first part of\\nthe duodenum when you eventually operate.\\n\\n Well, let’s not exaggerate… Danny\\n\\n A colleague of mine said this:\\n\\n Why are gastroenterologists more imaginative and\\n courageous than we surgeons in employing new and\\n bizarre invasive therapeutic modalities? Because they have\\n somebody (us) to bail them out!\\n Eli Mavor',\n", " 'md': '```markdown\\n## Recurrent Hemorrhage Management\\n\\nThat the exsanguinating patient, and the one who continues to bleed after endoscopic hemostasis fails, need an emergency operation is clear and has been discussed above. But what to do with recurrent hemorrhage? Factors that may or may not modify your decision to operate include the magnitude of recurrent hemorrhage, its source, and the age and general condition of the patient.\\n\\nIn general terms, recurrent hemorrhage is an ominous sign, meaning that bleeding will continue or, if stopped again, may well recur!\\n\\nSo our advice is:\\n\\n- If hemodynamically significant you have to operate!\\n- If rebleeding seems of mild or moderate magnitude you may elect to continue conservative treatment or retreat endoscopically.\\n- The source of the bleeding may influence your decisions: e.g. a chronic, giant ulcer may tilt the scale towards surgery; a superficial, acute source may guide you to avoid an operation.\\n\\nGastroenterologists are nowadays very keen to repeat endoscopic therapy in rebleeding patients — all of them, even those who squirt it out in a pulsatile stream — and even to do so a few times. Commonly, those patients ‘belong’ to them and you cannot interfere, but you should watch them ‘from the side’ and be ready to act. After repeated endoscopic maneuvers sometimes not much will be left of the first part of the duodenum when you eventually operate.\\n\\nWell, let’s not exaggerate… Danny\\n\\nA colleague of mine said this:\\n\\n> Why are gastroenterologists more imaginative and courageous than we surgeons in employing new and bizarre invasive therapeutic modalities? Because they have somebody (us) to bail them out!\\n> — Eli Mavor\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Recurrent Hemorrhage Management',\n", " 'md': '## Recurrent Hemorrhage Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'That the exsanguinating patient, and the one who continues to bleed after endoscopic hemostasis fails, need an emergency operation is clear and has been discussed above. But what to do with recurrent hemorrhage? Factors that may or may not modify your decision to operate include the magnitude of recurrent hemorrhage, its source, and the age and general condition of the patient.\\n\\nIn general terms, recurrent hemorrhage is an ominous sign, meaning that bleeding will continue or, if stopped again, may well recur!\\n\\nSo our advice is:\\n\\n- If hemodynamically significant you have to operate!\\n- If rebleeding seems of mild or moderate magnitude you may elect to continue conservative treatment or retreat endoscopically.\\n- The source of the bleeding may influence your decisions: e.g. a chronic, giant ulcer may tilt the scale towards surgery; a superficial, acute source may guide you to avoid an operation.\\n\\nGastroenterologists are nowadays very keen to repeat endoscopic therapy in rebleeding patients — all of them, even those who squirt it out in a pulsatile stream — and even to do so a few times. Commonly, those patients ‘belong’ to them and you cannot interfere, but you should watch them ‘from the side’ and be ready to act. After repeated endoscopic maneuvers sometimes not much will be left of the first part of the duodenum when you eventually operate.\\n\\nWell, let’s not exaggerate… Danny\\n\\nA colleague of mine said this:\\n\\n> Why are gastroenterologists more imaginative and courageous than we surgeons in employing new and bizarre invasive therapeutic modalities? Because they have somebody (us) to bail them out!\\n> — Eli Mavor\\n```',\n", " 'md': 'That the exsanguinating patient, and the one who continues to bleed after endoscopic hemostasis fails, need an emergency operation is clear and has been discussed above. But what to do with recurrent hemorrhage? Factors that may or may not modify your decision to operate include the magnitude of recurrent hemorrhage, its source, and the age and general condition of the patient.\\n\\nIn general terms, recurrent hemorrhage is an ominous sign, meaning that bleeding will continue or, if stopped again, may well recur!\\n\\nSo our advice is:\\n\\n- If hemodynamically significant you have to operate!\\n- If rebleeding seems of mild or moderate magnitude you may elect to continue conservative treatment or retreat endoscopically.\\n- The source of the bleeding may influence your decisions: e.g. a chronic, giant ulcer may tilt the scale towards surgery; a superficial, acute source may guide you to avoid an operation.\\n\\nGastroenterologists are nowadays very keen to repeat endoscopic therapy in rebleeding patients — all of them, even those who squirt it out in a pulsatile stream — and even to do so a few times. Commonly, those patients ‘belong’ to them and you cannot interfere, but you should watch them ‘from the side’ and be ready to act. After repeated endoscopic maneuvers sometimes not much will be left of the first part of the duodenum when you eventually operate.\\n\\nWell, let’s not exaggerate… Danny\\n\\nA colleague of mine said this:\\n\\n> Why are gastroenterologists more imaginative and courageous than we surgeons in employing new and bizarre invasive therapeutic modalities? Because they have somebody (us) to bail them out!\\n> — Eli Mavor\\n```',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.86, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 251,\n", " 'text': ' But, whatever you do, remember that old and chronically ill patients poorly tolerate\\n repeated episodes of bleeding; do not mess around with them. As a rough guide, when\\n the transfusion requirement exceeds 4 units of blood in a patient over 65 years of age,\\n consider surgery (or angiography). Yes, we know it is a rough guide but surgical\\n decisions are rough.\\n\\n Angiographic transarterial management?\\n\\n As mentioned above, in some centers therapeutic arteriography is the\\nnext stop for patients failing endoscopic hemostasis. Not surprisingly,\\nassessing the results of various management options in such patients is\\ndifficult, but it seems that embolization is associated with a higher rate of\\nrebleeding than surgery, and ischemic complications at the target organs\\nare not uncommon. Of course, as everything in life, it depends — in this\\ncase on your local expertise. We would consider this option as an\\nalternative to an operation in special circumstances — for example, a\\nbleeding DU when the risk of operative intervention would be prohibitive\\n(e.g. after myocardial infarction) or UGIB from a pseudoaneurysm of the\\nsplenic artery associated with chronic or acute pancreatitis. But again, in\\nsome ‘high-tech’ centers angiotherapy has become the default — not the\\nalternative treatment.\\n\\n So practically, these days we are, sorry to say, ‘allowed to operate’\\nonly on patients who ‘have failed everything’: they bled and bled —\\nneeded lots of blood; they have been endoscoped, injected, clipped over\\nand over again; lost more blood, and then dispatched for angiography.\\nWe are operating on a smaller number of patients who are sicker and\\nwith more demanding surgical pathology — no wonder that postoperative\\nmortality and morbidity in such patients remains high. But this is typical\\nof modern medicine: two steps forward, one back — like a frog in a\\nwell.\\n\\n Not in our center. Having expert angiographers available at all times, not only do we operate\\n much less, but very rarely do we see mortality any more from peptic bleeding (I am not talking\\n about varices and end-stage liver failure). I certainly don’t miss operating on the ‘bleeders’ with',\n", " 'md': '```markdown\\n## Page Content\\n\\nBut, whatever you do, remember that old and chronically ill patients poorly tolerate repeated episodes of bleeding; do not mess around with them. As a rough guide, when the transfusion requirement exceeds 4 units of blood in a patient over 65 years of age, consider surgery (or angiography). Yes, we know it is a rough guide but surgical decisions are rough.\\n\\n### Angiographic transarterial management?\\n\\nAs mentioned above, in some centers therapeutic arteriography is the next stop for patients failing endoscopic hemostasis. Not surprisingly, assessing the results of various management options in such patients is difficult, but it seems that embolization is associated with a higher rate of rebleeding than surgery, and ischemic complications at the target organs are not uncommon. Of course, as everything in life, it depends — in this case on your local expertise. We would consider this option as an alternative to an operation in special circumstances — for example, a bleeding DU when the risk of operative intervention would be prohibitive (e.g. after myocardial infarction) or UGIB from a pseudoaneurysm of the splenic artery associated with chronic or acute pancreatitis. But again, in some ‘high-tech’ centers angiotherapy has become the default — not the alternative treatment.\\n\\nSo practically, these days we are, sorry to say, ‘allowed to operate’ only on patients who ‘have failed everything’: they bled and bled — needed lots of blood; they have been endoscoped, injected, clipped over and over again; lost more blood, and then dispatched for angiography. We are operating on a smaller number of patients who are sicker and with more demanding surgical pathology — no wonder that postoperative mortality and morbidity in such patients remains high. But this is typical of modern medicine: two steps forward, one back — like a frog in a well.\\n\\nNot in our center. Having expert angiographers available at all times, not only do we operate much less, but very rarely do we see mortality any more from peptic bleeding (I am not talking about varices and end-stage liver failure). I certainly don’t miss operating on the ‘bleeders’ with\\n```\\n\\n### Image Identification and Description\\n- No images, graphs, or tables were identified on this page.\\n\\n### Summary\\nThe text discusses the management of old and chronically ill patients who experience bleeding, emphasizing the importance of careful decision-making regarding surgery and angiographic interventions. It highlights the challenges of treating patients who have undergone multiple procedures and the evolving practices in modern medicine regarding surgical interventions for bleeding.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'But, whatever you do, remember that old and chronically ill patients poorly tolerate repeated episodes of bleeding; do not mess around with them. As a rough guide, when the transfusion requirement exceeds 4 units of blood in a patient over 65 years of age, consider surgery (or angiography). Yes, we know it is a rough guide but surgical decisions are rough.',\n", " 'md': 'But, whatever you do, remember that old and chronically ill patients poorly tolerate repeated episodes of bleeding; do not mess around with them. As a rough guide, when the transfusion requirement exceeds 4 units of blood in a patient over 65 years of age, consider surgery (or angiography). Yes, we know it is a rough guide but surgical decisions are rough.',\n", " 'bBox': {'x': 79, 'y': 93, 'w': 453.54, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Angiographic transarterial management?',\n", " 'md': '### Angiographic transarterial management?',\n", " 'bBox': {'x': 86, 'y': 224, 'w': 323.69, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As mentioned above, in some centers therapeutic arteriography is the next stop for patients failing endoscopic hemostasis. Not surprisingly, assessing the results of various management options in such patients is difficult, but it seems that embolization is associated with a higher rate of rebleeding than surgery, and ischemic complications at the target organs are not uncommon. Of course, as everything in life, it depends — in this case on your local expertise. We would consider this option as an alternative to an operation in special circumstances — for example, a bleeding DU when the risk of operative intervention would be prohibitive (e.g. after myocardial infarction) or UGIB from a pseudoaneurysm of the splenic artery associated with chronic or acute pancreatitis. But again, in some ‘high-tech’ centers angiotherapy has become the default — not the alternative treatment.\\n\\nSo practically, these days we are, sorry to say, ‘allowed to operate’ only on patients who ‘have failed everything’: they bled and bled — needed lots of blood; they have been endoscoped, injected, clipped over and over again; lost more blood, and then dispatched for angiography. We are operating on a smaller number of patients who are sicker and with more demanding surgical pathology — no wonder that postoperative mortality and morbidity in such patients remains high. But this is typical of modern medicine: two steps forward, one back — like a frog in a well.\\n\\nNot in our center. Having expert angiographers available at all times, not only do we operate much less, but very rarely do we see mortality any more from peptic bleeding (I am not talking about varices and end-stage liver failure). I certainly don’t miss operating on the ‘bleeders’ with\\n```',\n", " 'md': 'As mentioned above, in some centers therapeutic arteriography is the next stop for patients failing endoscopic hemostasis. Not surprisingly, assessing the results of various management options in such patients is difficult, but it seems that embolization is associated with a higher rate of rebleeding than surgery, and ischemic complications at the target organs are not uncommon. Of course, as everything in life, it depends — in this case on your local expertise. We would consider this option as an alternative to an operation in special circumstances — for example, a bleeding DU when the risk of operative intervention would be prohibitive (e.g. after myocardial infarction) or UGIB from a pseudoaneurysm of the splenic artery associated with chronic or acute pancreatitis. But again, in some ‘high-tech’ centers angiotherapy has become the default — not the alternative treatment.\\n\\nSo practically, these days we are, sorry to say, ‘allowed to operate’ only on patients who ‘have failed everything’: they bled and bled — needed lots of blood; they have been endoscoped, injected, clipped over and over again; lost more blood, and then dispatched for angiography. We are operating on a smaller number of patients who are sicker and with more demanding surgical pathology — no wonder that postoperative mortality and morbidity in such patients remains high. But this is typical of modern medicine: two steps forward, one back — like a frog in a well.\\n\\nNot in our center. Having expert angiographers available at all times, not only do we operate much less, but very rarely do we see mortality any more from peptic bleeding (I am not talking about varices and end-stage liver failure). I certainly don’t miss operating on the ‘bleeders’ with\\n```',\n", " 'bBox': {'x': 72, 'y': 260, 'w': 467.98, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.',\n", " 'md': '- No images, graphs, or tables were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the management of old and chronically ill patients who experience bleeding, emphasizing the importance of careful decision-making regarding surgery and angiographic interventions. It highlights the challenges of treating patients who have undergone multiple procedures and the evolving practices in modern medicine regarding surgical interventions for bleeding.',\n", " 'md': 'The text discusses the management of old and chronically ill patients who experience bleeding, emphasizing the importance of careful decision-making regarding surgery and angiographic interventions. It highlights the challenges of treating patients who have undergone multiple procedures and the evolving practices in modern medicine regarding surgical interventions for bleeding.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 252,\n", " 'text': ' the associated M & M that I still remember. Danny\\n\\n Operative management\\n\\n So finally, you decided to take the (optimally resuscitated, we hope)\\npatient to the OR. Consider repeating the endoscopy!\\n\\n It is crucial that you know the exact location in the UGI tract from where\\nthe patient is bleeding. If the initial endoscopy was not done by you, or in\\nyour presence; play it again Sam! In an anesthetized patient it will not\\ntake you more than 5 minutes to insert and remove the endoscope. Do\\nnot trust blindly the 2-day-old endoscopy report that the “source of\\nhemorrhage appeared to be in the duodenum”. This could lead you to\\nstart with an unnecessary duodenotomy while the source lies high in the\\nstomach. Oy vey iz mir…\\n\\n Exploration\\n\\n Through a midline upper abdominal incision! No laparoscopy is\\nadvised in such patients, except in special circumstances (e.g. bleeding\\ngastric GIST). A paraxyphoid extension and forceful upward sternal\\nretraction lets you deal with anything in the foregut. In obese patients with\\na wide costal angle, however, a transverse chevron-type incision may\\ntake a few more minutes but affords a more comfortable exposure. In\\naddition, a generous reverse-Trendelenburg tilt of the patient will\\nbring the upper stomach almost into your nose.\\n\\n Start by searching for external visual or palpable features of chronic\\nulceration. The latter are invariably associated with serosal inflammatory\\nchanges. Look for evidence of chronic ulcers from the duodenum to the\\ngastric cardia. Duodenal ‘Kocherization’ (Theodor Kocher is perhaps the\\nonly surgeon in history to have his name used as a verb) will be\\nnecessary to reveal the now almost extinct post-bulbar ulcer in the\\nsecond portion of the duodenum. Occasionally, a posterior or lesser\\ncurvature gastric ulcer will become palpable only through the lesser\\nsac. Acute superficial mucosal lesions are unfortunately not',\n", " 'md': '```markdown\\n# Operative Management\\n\\nSo finally, you decided to take the (optimally resuscitated, we hope) patient to the OR. Consider repeating the endoscopy!\\n\\nIt is crucial that you know the exact location in the UGI tract from where the patient is bleeding. If the initial endoscopy was not done by you, or in your presence; play it again Sam! In an anesthetized patient, it will not take you more than 5 minutes to insert and remove the endoscope. Do not trust blindly the 2-day-old endoscopy report that the “source of hemorrhage appeared to be in the duodenum”. This could lead you to start with an unnecessary duodenotomy while the source lies high in the stomach. Oy vey iz mir…\\n\\n## Exploration\\n\\nThrough a midline upper abdominal incision! No laparoscopy is advised in such patients, except in special circumstances (e.g., bleeding gastric GIST). A paraxyphoid extension and forceful upward sternal retraction lets you deal with anything in the foregut. In obese patients with a wide costal angle, however, a transverse chevron-type incision may take a few more minutes but affords a more comfortable exposure. In addition, a generous reverse-Trendelenburg tilt of the patient will bring the upper stomach almost into your nose.\\n\\nStart by searching for external visual or palpable features of chronic ulceration. The latter are invariably associated with serosal inflammatory changes. Look for evidence of chronic ulcers from the duodenum to the gastric cardia. Duodenal ‘Kocherization’ (Theodor Kocher is perhaps the only surgeon in history to have his name used as a verb) will be necessary to reveal the now almost extinct post-bulbar ulcer in the second portion of the duodenum. Occasionally, a posterior or lesser curvature gastric ulcer will become palpable only through the lesser sac. Acute superficial mucosal lesions are unfortunately not .\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Operative Management',\n", " 'md': '# Operative Management',\n", " 'bBox': {'x': 86, 'y': 137, 'w': 183.02, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'So finally, you decided to take the (optimally resuscitated, we hope) patient to the OR. Consider repeating the endoscopy!\\n\\nIt is crucial that you know the exact location in the UGI tract from where the patient is bleeding. If the initial endoscopy was not done by you, or in your presence; play it again Sam! In an anesthetized patient, it will not take you more than 5 minutes to insert and remove the endoscope. Do not trust blindly the 2-day-old endoscopy report that the “source of hemorrhage appeared to be in the duodenum”. This could lead you to start with an unnecessary duodenotomy while the source lies high in the stomach. Oy vey iz mir…',\n", " 'md': 'So finally, you decided to take the (optimally resuscitated, we hope) patient to the OR. Consider repeating the endoscopy!\\n\\nIt is crucial that you know the exact location in the UGI tract from where the patient is bleeding. If the initial endoscopy was not done by you, or in your presence; play it again Sam! In an anesthetized patient, it will not take you more than 5 minutes to insert and remove the endoscope. Do not trust blindly the 2-day-old endoscopy report that the “source of hemorrhage appeared to be in the duodenum”. This could lead you to start with an unnecessary duodenotomy while the source lies high in the stomach. Oy vey iz mir…',\n", " 'bBox': {'x': 72, 'y': 190, 'w': 467.92, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Exploration',\n", " 'md': '## Exploration',\n", " 'bBox': {'x': 86, 'y': 384, 'w': 91.03, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Through a midline upper abdominal incision! No laparoscopy is advised in such patients, except in special circumstances (e.g., bleeding gastric GIST). A paraxyphoid extension and forceful upward sternal retraction lets you deal with anything in the foregut. In obese patients with a wide costal angle, however, a transverse chevron-type incision may take a few more minutes but affords a more comfortable exposure. In addition, a generous reverse-Trendelenburg tilt of the patient will bring the upper stomach almost into your nose.\\n\\nStart by searching for external visual or palpable features of chronic ulceration. The latter are invariably associated with serosal inflammatory changes. Look for evidence of chronic ulcers from the duodenum to the gastric cardia. Duodenal ‘Kocherization’ (Theodor Kocher is perhaps the only surgeon in history to have his name used as a verb) will be necessary to reveal the now almost extinct post-bulbar ulcer in the second portion of the duodenum. Occasionally, a posterior or lesser curvature gastric ulcer will become palpable only through the lesser sac. Acute superficial mucosal lesions are unfortunately not .\\n```',\n", " 'md': 'Through a midline upper abdominal incision! No laparoscopy is advised in such patients, except in special circumstances (e.g., bleeding gastric GIST). A paraxyphoid extension and forceful upward sternal retraction lets you deal with anything in the foregut. In obese patients with a wide costal angle, however, a transverse chevron-type incision may take a few more minutes but affords a more comfortable exposure. In addition, a generous reverse-Trendelenburg tilt of the patient will bring the upper stomach almost into your nose.\\n\\nStart by searching for external visual or palpable features of chronic ulceration. The latter are invariably associated with serosal inflammatory changes. Look for evidence of chronic ulcers from the duodenum to the gastric cardia. Duodenal ‘Kocherization’ (Theodor Kocher is perhaps the only surgeon in history to have his name used as a verb) will be necessary to reveal the now almost extinct post-bulbar ulcer in the second portion of the duodenum. Occasionally, a posterior or lesser curvature gastric ulcer will become palpable only through the lesser sac. Acute superficial mucosal lesions are unfortunately not .\\n```',\n", " 'bBox': {'x': 72, 'y': 470, 'w': 467.78, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 253,\n", " 'text': 'identifiable from the outside, although a Mallory-Weiss lesion may be\\nnaturally ‘tattooed’ by the blood with bluish serosal staining at the\\ngastroesophageal junction.\\n\\n The finding of a chronic ulcer in accordance with the pre-operative\\nendoscopic finding tells you where the trouble is; but what is to be done\\nin the absence of any external evidence of pathology? Yes, a rare\\nsituation but plausible. You have a few options:\\n\\n • Proceed according to the endoscopist’s findings — if you trust\\n them… but they will not always be correct.\\n • Surgical exploration.\\n • Intra-operative endoscopy.\\n\\n Intra-operative endoscopy\\n\\n ħaving endoscopically visualized, with your own eyes, an actively\\nbleeding DU, you should not have any doubts. A doubtful endoscopic\\nreport, however, may promote a negative duodenotomy, extending it —\\npiecemeal — proximally, until the high gastric lesion is found. All that\\nwas needed was a small gastrotomy and suture ligation of the\\nlesion; instead you are left with a very long, messy and\\nunnecessary duodenogastrotomy to repair. To obviate such a mini-\\ndisaster we would unscrub for a moment and shove in an\\nendoscope. On rare occasions, when the stomach is distended with\\nhuge clots, we would place a purse-string suture at the anterior wall of\\nthe antrum, perform a small gastrotomy, and with a large sucker remove\\nand irrigate all clots. An endoscope is then inserted through the\\ngastrotomy with the purse-string tightened to allow gastric insufflation;\\nthis offers an excellent and controlled view of the stomach and\\nduodenum. We call it ‘intra-operative retrograde gastroscopy’. One day\\nthis maneuver may save your butt!\\n\\n Philosophy of surgical management',\n", " 'md': '```markdown\\n## Intra-operative Endoscopy\\n\\nIdentifiable from the outside, although a Mallory-Weiss lesion may be naturally ‘tattooed’ by the blood with bluish serosal staining at the gastroesophageal junction.\\n\\nThe finding of a chronic ulcer in accordance with the pre-operative endoscopic finding tells you where the trouble is; but what is to be done in the absence of any external evidence of pathology? Yes, a rare situation but plausible. You have a few options:\\n\\n- Proceed according to the endoscopist’s findings — if you trust them… but they will not always be correct.\\n- Surgical exploration.\\n- Intra-operative endoscopy.\\n\\n### Intra-operative Endoscopy\\n\\nHaving endoscopically visualized, with your own eyes, an actively bleeding DU, you should not have any doubts. A doubtful endoscopic report, however, may promote a negative duodenotomy, extending it — piecemeal — proximally, until the high gastric lesion is found. All that was needed was a small gastrotomy and suture ligation of the lesion; instead, you are left with a very long, messy, and unnecessary duodenogastrotomy to repair. To obviate such a mini-disaster we would unscrub for a moment and shove in an endoscope. On rare occasions, when the stomach is distended with huge clots, we would place a purse-string suture at the anterior wall of the antrum, perform a small gastrotomy, and with a large sucker remove and irrigate all clots. An endoscope is then inserted through the gastrotomy with the purse-string tightened to allow gastric insufflation; this offers an excellent and controlled view of the stomach and duodenum. We call it ‘intra-operative retrograde gastroscopy’. One day this maneuver may save your butt!\\n\\n### Philosophy of Surgical Management\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Intra-operative Endoscopy',\n", " 'md': '## Intra-operative Endoscopy',\n", " 'bBox': {'x': 86, 'y': 358, 'w': 206.91, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Identifiable from the outside, although a Mallory-Weiss lesion may be naturally ‘tattooed’ by the blood with bluish serosal staining at the gastroesophageal junction.\\n\\nThe finding of a chronic ulcer in accordance with the pre-operative endoscopic finding tells you where the trouble is; but what is to be done in the absence of any external evidence of pathology? Yes, a rare situation but plausible. You have a few options:\\n\\n- Proceed according to the endoscopist’s findings — if you trust them… but they will not always be correct.\\n- Surgical exploration.\\n- Intra-operative endoscopy.',\n", " 'md': 'Identifiable from the outside, although a Mallory-Weiss lesion may be naturally ‘tattooed’ by the blood with bluish serosal staining at the gastroesophageal junction.\\n\\nThe finding of a chronic ulcer in accordance with the pre-operative endoscopic finding tells you where the trouble is; but what is to be done in the absence of any external evidence of pathology? Yes, a rare situation but plausible. You have a few options:\\n\\n- Proceed according to the endoscopist’s findings — if you trust them… but they will not always be correct.\\n- Surgical exploration.\\n- Intra-operative endoscopy.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 466.54, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Intra-operative Endoscopy',\n", " 'md': '### Intra-operative Endoscopy',\n", " 'bBox': {'x': 86, 'y': 358, 'w': 206.91, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Having endoscopically visualized, with your own eyes, an actively bleeding DU, you should not have any doubts. A doubtful endoscopic report, however, may promote a negative duodenotomy, extending it — piecemeal — proximally, until the high gastric lesion is found. All that was needed was a small gastrotomy and suture ligation of the lesion; instead, you are left with a very long, messy, and unnecessary duodenogastrotomy to repair. To obviate such a mini-disaster we would unscrub for a moment and shove in an endoscope. On rare occasions, when the stomach is distended with huge clots, we would place a purse-string suture at the anterior wall of the antrum, perform a small gastrotomy, and with a large sucker remove and irrigate all clots. An endoscope is then inserted through the gastrotomy with the purse-string tightened to allow gastric insufflation; this offers an excellent and controlled view of the stomach and duodenum. We call it ‘intra-operative retrograde gastroscopy’. One day this maneuver may save your butt!',\n", " 'md': 'Having endoscopically visualized, with your own eyes, an actively bleeding DU, you should not have any doubts. A doubtful endoscopic report, however, may promote a negative duodenotomy, extending it — piecemeal — proximally, until the high gastric lesion is found. All that was needed was a small gastrotomy and suture ligation of the lesion; instead, you are left with a very long, messy, and unnecessary duodenogastrotomy to repair. To obviate such a mini-disaster we would unscrub for a moment and shove in an endoscope. On rare occasions, when the stomach is distended with huge clots, we would place a purse-string suture at the anterior wall of the antrum, perform a small gastrotomy, and with a large sucker remove and irrigate all clots. An endoscope is then inserted through the gastrotomy with the purse-string tightened to allow gastric insufflation; this offers an excellent and controlled view of the stomach and duodenum. We call it ‘intra-operative retrograde gastroscopy’. One day this maneuver may save your butt!',\n", " 'bBox': {'x': 72, 'y': 493, 'w': 467.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Philosophy of Surgical Management',\n", " 'md': '### Philosophy of Surgical Management',\n", " 'bBox': {'x': 86, 'y': 685, 'w': 284.13, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 254,\n", " 'text': ' I remember in the late 1970s, in my medical school in Jerusalem, the\\nProfessors of Surgery quarrelling for hours about which is better:\\nHofmeister’s partial gastrectomy or the Polya one? The duels about\\nwhich pyloroplasty should be done in a specific case — the Heineke-\\nMikulicz? A Finney? And what about a Jaboulay? — were endless.\\nToday, a young surgeon who can recognize even one of those names, let\\nalone pronounce them correctly, is considered a doyen of history. The\\ntimes they are a-changin’, eh?\\n\\n A friend of ours, Asher ħirshberg, aptly stated: “In the era of\\nHelicobacter pylori, doing a gastrectomy for peptic ulcer is like\\ndoing a lobectomy for pneumonia.” Clearly, where potent anti-ulcer\\ndrugs are available, elective ulcer surgery has disappeared and definitive\\nanti-ulcer procedures during emergency surgery for complications of\\nulcers are disappearing rapidly (nay, they have totally vanished) as well.\\nWhy do a surgical vagotomy when proton pump inhibitors offer a\\n‘medical vagotomy’?\\n\\n The general philosophy is that the role of the surgeon is to\\nprevent the patient dying of blood loss. This is the main\\nconsideration in severely ill patients. Other considerations are\\nsecondary.\\n\\n Are there any situations left when adding a definitive anti-ulcer\\nprocedure would be reasonably indicated? While in the previous\\neditions we mentioned it as a viable option in ‘selected patients’ we now\\nbelieve that such procedures are indicated only if dictated by\\nanatomical constraints, as discussed below. ħowever, in the\\n‘developing world’, when proper anti-ulcer medications are not readily\\navailable, one could consider adding an anti-ulcer procedure for chronic\\nulcers in reasonably stable patients (e.g. a homeless patient in St.\\nPetersburg — or the uninsured hobo in Florida — with a chronic gastric\\nulcer and a history of recurrent UGIB).\\n\\n That is — if you still know how to do it. BTW: when was the last\\ntime you performed, or watched, a vagotomy?',\n", " 'md': '```markdown\\n# Page Content\\n\\nI remember in the late 1970s, in my medical school in Jerusalem, the Professors of Surgery quarrelling for hours about which is better: Hofmeister’s partial gastrectomy or the Polya one? The duels about which pyloroplasty should be done in a specific case — the Heineke-Mikulicz? A Finney? And what about a Jaboulay? — were endless. Today, a young surgeon who can recognize even one of those names, let alone pronounce them correctly, is considered a doyen of history. The times they are a-changin’, eh?\\n\\nA friend of ours, Asher ħirshberg, aptly stated: “In the era of Helicobacter pylori, doing a gastrectomy for peptic ulcer is like doing a lobectomy for pneumonia.” Clearly, where potent anti-ulcer drugs are available, elective ulcer surgery has disappeared and definitive anti-ulcer procedures during emergency surgery for complications of ulcers are disappearing rapidly (nay, they have totally vanished) as well. Why do a surgical vagotomy when proton pump inhibitors offer a ‘medical vagotomy’?\\n\\nThe general philosophy is that the role of the surgeon is to prevent the patient dying of blood loss. This is the main consideration in severely ill patients. Other considerations are secondary.\\n\\nAre there any situations left when adding a definitive anti-ulcer procedure would be reasonably indicated? While in the previous editions we mentioned it as a viable option in ‘selected patients’ we now believe that such procedures are indicated only if dictated by anatomical constraints, as discussed below. However, in the ‘developing world’, when proper anti-ulcer medications are not readily available, one could consider adding an anti-ulcer procedure for chronic ulcers in reasonably stable patients (e.g. a homeless patient in St. Petersburg — or the uninsured hobo in Florida — with a chronic gastric ulcer and a history of recurrent UGIB).\\n\\nThat is — if you still know how to do it. BTW: when was the last time you performed, or watched, a vagotomy?\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'I remember in the late 1970s, in my medical school in Jerusalem, the Professors of Surgery quarrelling for hours about which is better: Hofmeister’s partial gastrectomy or the Polya one? The duels about which pyloroplasty should be done in a specific case — the Heineke-Mikulicz? A Finney? And what about a Jaboulay? — were endless. Today, a young surgeon who can recognize even one of those names, let alone pronounce them correctly, is considered a doyen of history. The times they are a-changin’, eh?\\n\\nA friend of ours, Asher ħirshberg, aptly stated: “In the era of Helicobacter pylori, doing a gastrectomy for peptic ulcer is like doing a lobectomy for pneumonia.” Clearly, where potent anti-ulcer drugs are available, elective ulcer surgery has disappeared and definitive anti-ulcer procedures during emergency surgery for complications of ulcers are disappearing rapidly (nay, they have totally vanished) as well. Why do a surgical vagotomy when proton pump inhibitors offer a ‘medical vagotomy’?\\n\\nThe general philosophy is that the role of the surgeon is to prevent the patient dying of blood loss. This is the main consideration in severely ill patients. Other considerations are secondary.\\n\\nAre there any situations left when adding a definitive anti-ulcer procedure would be reasonably indicated? While in the previous editions we mentioned it as a viable option in ‘selected patients’ we now believe that such procedures are indicated only if dictated by anatomical constraints, as discussed below. However, in the ‘developing world’, when proper anti-ulcer medications are not readily available, one could consider adding an anti-ulcer procedure for chronic ulcers in reasonably stable patients (e.g. a homeless patient in St. Petersburg — or the uninsured hobo in Florida — with a chronic gastric ulcer and a history of recurrent UGIB).\\n\\nThat is — if you still know how to do it. BTW: when was the last time you performed, or watched, a vagotomy?\\n```',\n", " 'md': 'I remember in the late 1970s, in my medical school in Jerusalem, the Professors of Surgery quarrelling for hours about which is better: Hofmeister’s partial gastrectomy or the Polya one? The duels about which pyloroplasty should be done in a specific case — the Heineke-Mikulicz? A Finney? And what about a Jaboulay? — were endless. Today, a young surgeon who can recognize even one of those names, let alone pronounce them correctly, is considered a doyen of history. The times they are a-changin’, eh?\\n\\nA friend of ours, Asher ħirshberg, aptly stated: “In the era of Helicobacter pylori, doing a gastrectomy for peptic ulcer is like doing a lobectomy for pneumonia.” Clearly, where potent anti-ulcer drugs are available, elective ulcer surgery has disappeared and definitive anti-ulcer procedures during emergency surgery for complications of ulcers are disappearing rapidly (nay, they have totally vanished) as well. Why do a surgical vagotomy when proton pump inhibitors offer a ‘medical vagotomy’?\\n\\nThe general philosophy is that the role of the surgeon is to prevent the patient dying of blood loss. This is the main consideration in severely ill patients. Other considerations are secondary.\\n\\nAre there any situations left when adding a definitive anti-ulcer procedure would be reasonably indicated? While in the previous editions we mentioned it as a viable option in ‘selected patients’ we now believe that such procedures are indicated only if dictated by anatomical constraints, as discussed below. However, in the ‘developing world’, when proper anti-ulcer medications are not readily available, one could consider adding an anti-ulcer procedure for chronic ulcers in reasonably stable patients (e.g. a homeless patient in St. Petersburg — or the uninsured hobo in Florida — with a chronic gastric ulcer and a history of recurrent UGIB).\\n\\nThat is — if you still know how to do it. BTW: when was the last time you performed, or watched, a vagotomy?\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 255,\n", " 'text': ' Specific sources of bleeding\\n\\n Duodenal ulcer (DU)\\n If anyone should consider removing half of my good\\n stomach to cure a small ulcer in my duodenum, I would run\\n faster than he.\\n Charles H. Mayo\\n\\n About gastrectomy for duodenal ulcer: in this operation… a\\n segment of an essentially normal stomach is removed to\\n treat the disease next door in the duodenum. It is like taking\\n out the engine to decrease noise in the gear box.\\n Francis D. Moore\\n\\n The source of bleeding is always the gastroduodenal artery at the\\nbase of a posterior ulcer. ħemostasis is accomplished through an\\nanterior, longitudinal duodenotomy, underrunning the base (and bleeding\\nvessel) with two or three (2-0 or 0, a monofilament or Vicryl®) deeply\\nplaced sutures — each placed on a different axis. When bleeding is\\nactive, successful ligation of the vessel will be evident; in its absence you\\nmay want to abrade the ulcer’s base, dislodging the clot and inducing\\nbleeding. Otherwise, just underrun the base, deeply, and in a few\\ndirections. The theoretical danger of underrunning a nearby common\\nbile duct has been mentioned but we are unaware of even a single\\nreport of such a case — however, never say never; s**t can happen!\\nOthers have described ligating the gastroduodenal artery from the\\noutside, above and behind the duodenum. We have no experience with\\nthis and would be anxious fishing for the artery at the base of the\\ngastrohepatic omentum which would be inflamed by the adjacent\\nulcerating process. Now carefully close the duodenotomy without\\nconstricting the lumen, and get out. Local hemostasis can be achieved\\neven in the base of giant ulcers or when the duodenum is extremely\\ninflamed or scarred. When simple closure of the duodenotomy\\nappears to compromise the lumen or pyloroplasty is deemed\\notherwise unsatisfactory, just close the duodenum and do a\\nposterior gastroenterostomy (GE). Of course, this is an ‘ulcerogenic',\n", " 'md': '```markdown\\n# Specific sources of bleeding\\n\\n## Duodenal ulcer (DU)\\n\\n> \"If anyone should consider removing half of my good stomach to cure a small ulcer in my duodenum, I would run faster than he.\"\\n> — Charles H. Mayo\\n\\n> \"About gastrectomy for duodenal ulcer: in this operation… a segment of an essentially normal stomach is removed to treat the disease next door in the duodenum. It is like taking out the engine to decrease noise in the gear box.\"\\n> — Francis D. Moore\\n\\nThe source of bleeding is always the gastroduodenal artery at the base of a posterior ulcer. Hemostasis is accomplished through an anterior, longitudinal duodenotomy, underrunning the base (and bleeding vessel) with two or three (2-0 or 0, a monofilament or Vicryl®) deeply placed sutures — each placed on a different axis. When bleeding is active, successful ligation of the vessel will be evident; in its absence, you may want to abrade the ulcer’s base, dislodging the clot and inducing bleeding. Otherwise, just underrun the base, deeply, and in a few directions.\\n\\nThe theoretical danger of underrunning a nearby common bile duct has been mentioned but we are unaware of even a single report of such a case — however, never say never; s**t can happen! Others have described ligating the gastroduodenal artery from the outside, above and behind the duodenum. We have no experience with this and would be anxious fishing for the artery at the base of the gastrohepatic omentum which would be inflamed by the adjacent ulcerating process.\\n\\nNow carefully close the duodenotomy without constricting the lumen, and get out. Local hemostasis can be achieved even in the base of giant ulcers or when the duodenum is extremely inflamed or scarred. When simple closure of the duodenotomy appears to compromise the lumen or pyloroplasty is deemed otherwise unsatisfactory, just close the duodenum and do a posterior gastroenterostomy (GE). Of course, this is an ‘ulcerogenic...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Specific sources of bleeding',\n", " 'md': '# Specific sources of bleeding',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 224.36, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Duodenal ulcer (DU)',\n", " 'md': '## Duodenal ulcer (DU)',\n", " 'bBox': {'x': 86, 'y': 132, 'w': 159.08, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '> \"If anyone should consider removing half of my good stomach to cure a small ulcer in my duodenum, I would run faster than he.\"\\n> — Charles H. Mayo\\n\\n> \"About gastrectomy for duodenal ulcer: in this operation… a segment of an essentially normal stomach is removed to treat the disease next door in the duodenum. It is like taking out the engine to decrease noise in the gear box.\"\\n> — Francis D. Moore\\n\\nThe source of bleeding is always the gastroduodenal artery at the base of a posterior ulcer. Hemostasis is accomplished through an anterior, longitudinal duodenotomy, underrunning the base (and bleeding vessel) with two or three (2-0 or 0, a monofilament or Vicryl®) deeply placed sutures — each placed on a different axis. When bleeding is active, successful ligation of the vessel will be evident; in its absence, you may want to abrade the ulcer’s base, dislodging the clot and inducing bleeding. Otherwise, just underrun the base, deeply, and in a few directions.\\n\\nThe theoretical danger of underrunning a nearby common bile duct has been mentioned but we are unaware of even a single report of such a case — however, never say never; s**t can happen! Others have described ligating the gastroduodenal artery from the outside, above and behind the duodenum. We have no experience with this and would be anxious fishing for the artery at the base of the gastrohepatic omentum which would be inflamed by the adjacent ulcerating process.\\n\\nNow carefully close the duodenotomy without constricting the lumen, and get out. Local hemostasis can be achieved even in the base of giant ulcers or when the duodenum is extremely inflamed or scarred. When simple closure of the duodenotomy appears to compromise the lumen or pyloroplasty is deemed otherwise unsatisfactory, just close the duodenum and do a posterior gastroenterostomy (GE). Of course, this is an ‘ulcerogenic...\\n```',\n", " 'md': '> \"If anyone should consider removing half of my good stomach to cure a small ulcer in my duodenum, I would run faster than he.\"\\n> — Charles H. Mayo\\n\\n> \"About gastrectomy for duodenal ulcer: in this operation… a segment of an essentially normal stomach is removed to treat the disease next door in the duodenum. It is like taking out the engine to decrease noise in the gear box.\"\\n> — Francis D. Moore\\n\\nThe source of bleeding is always the gastroduodenal artery at the base of a posterior ulcer. Hemostasis is accomplished through an anterior, longitudinal duodenotomy, underrunning the base (and bleeding vessel) with two or three (2-0 or 0, a monofilament or Vicryl®) deeply placed sutures — each placed on a different axis. When bleeding is active, successful ligation of the vessel will be evident; in its absence, you may want to abrade the ulcer’s base, dislodging the clot and inducing bleeding. Otherwise, just underrun the base, deeply, and in a few directions.\\n\\nThe theoretical danger of underrunning a nearby common bile duct has been mentioned but we are unaware of even a single report of such a case — however, never say never; s**t can happen! Others have described ligating the gastroduodenal artery from the outside, above and behind the duodenum. We have no experience with this and would be anxious fishing for the artery at the base of the gastrohepatic omentum which would be inflamed by the adjacent ulcerating process.\\n\\nNow carefully close the duodenotomy without constricting the lumen, and get out. Local hemostasis can be achieved even in the base of giant ulcers or when the duodenum is extremely inflamed or scarred. When simple closure of the duodenotomy appears to compromise the lumen or pyloroplasty is deemed otherwise unsatisfactory, just close the duodenum and do a posterior gastroenterostomy (GE). Of course, this is an ‘ulcerogenic...\\n```',\n", " 'bBox': {'x': 72, 'y': 180, 'w': 467.68, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 256,\n", " 'text': 'anastomosis’! But such patients will receive proton pump inhibitors for\\nlife; that is if vagotomy is not added. The eventual cure of the ulcer is\\nleft to acid-reducing drugs and anti-Helicobacter agents.\\n Stomach\\n Ulcer\\n PeRYA2oly\\n Figure 17.2. Gastroduodenostomy: note that the posterior aspect of the anastomosis is\\n performed with ‘heavy’ (e.g. Vicryl® 2-0) interrupted sutures, taking ‘big bites’ in the\\n posterior ‘lip’ of the duodenum (which is adherent to the pancreas) — well into the scar\\n tissue at the base of the (now excluded) ulcer.\\n\\n Which definitive procedure should you select in the rare patient?\\nObviously, this is considered only in a patient who is stable\\nhemodynamically and otherwise in a reasonable shape! Our choice\\nwould be adding a truncal vagotomy (TV), extending the\\nduodenotomy across the pylorus, and closing it to form a Heineke-\\nMikulicz pyloroplasty. When and if the duodenum is extremely scarred\\nand friable we would do a gastroenterostomy rather than pyloroplasty\\n— just patch the duodenotomy the best you can and hook a proximal\\nloop of jejunum, side to side, to the antrum.\\n\\n Is there any indication for an antrectomy? The proponents of\\nantrectomy plus vagotomy for bleeding DUs claim an increased incidence\\nof rehemorrhage when gastric resection is avoided. In over 100',\n", " 'md': \"```markdown\\n## Page Content\\n\\nAnastomosis! But such patients will receive proton pump inhibitors for life; that is if vagotomy is not added. The eventual cure of the ulcer is left to acid-reducing drugs and anti-Helicobacter agents.\\n\\n### Stomach Ulcer\\n\\n**Figure 17.2**. Gastroduodenostomy: note that the posterior aspect of the anastomosis is performed with ‘heavy’ (e.g. Vicryl® 2-0) interrupted sutures, taking ‘big bites’ in the posterior ‘lip’ of the duodenum (which is adherent to the pancreas) — well into the scar tissue at the base of the (now excluded) ulcer.\\n\\nWhich definitive procedure should you select in the rare patient? Obviously, this is considered only in a patient who is stable hemodynamically and otherwise in a reasonable shape! Our choice would be adding a truncal vagotomy (TV), extending the duodenotomy across the pylorus, and closing it to form a Heineke-Mikulicz pyloroplasty. When and if the duodenum is extremely scarred and friable we would do a gastroenterostomy rather than pyloroplasty — just patch the duodenotomy the best you can and hook a proximal loop of jejunum, side to side, to the antrum.\\n\\nIs there any indication for an antrectomy? The proponents of antrectomy plus vagotomy for bleeding DUs claim an increased incidence of rehemorrhage when gastric resection is avoided. In over 100...\\n\\n## Image Description\\n\\n**Figure 17.2**: The image illustrates the surgical procedure of gastroduodenostomy. It shows the posterior aspect of the anastomosis, highlighting the use of heavy interrupted sutures (e.g., Vicryl® 2-0) and the technique of taking 'big bites' in the posterior lip of the duodenum, which is adherent to the pancreas. The image captures the surgical approach well into the scar tissue at the base of the excluded ulcer.\\n\\n### Summary\\nThe figure provides a visual representation of the surgical technique used in gastroduodenostomy, emphasizing the importance of suturing and the anatomical considerations involved in the procedure.\\n```\",\n", " 'images': [{'name': 'img_p255_1.png',\n", " 'height': 539,\n", " 'width': 501,\n", " 'x': 182.15999999999985,\n", " 'y': 132.48000000000002,\n", " 'original_width': 1148,\n", " 'original_height': 1236}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Anastomosis! But such patients will receive proton pump inhibitors for life; that is if vagotomy is not added. The eventual cure of the ulcer is left to acid-reducing drugs and anti-Helicobacter agents.',\n", " 'md': 'Anastomosis! But such patients will receive proton pump inhibitors for life; that is if vagotomy is not added. The eventual cure of the ulcer is left to acid-reducing drugs and anti-Helicobacter agents.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.29, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Stomach Ulcer',\n", " 'md': '### Stomach Ulcer',\n", " 'bBox': {'x': 299.82, 'y': 217, 'w': 97.39, 'h': 11.86}},\n", " {'type': 'text',\n", " 'value': '**Figure 17.2**. Gastroduodenostomy: note that the posterior aspect of the anastomosis is performed with ‘heavy’ (e.g. Vicryl® 2-0) interrupted sutures, taking ‘big bites’ in the posterior ‘lip’ of the duodenum (which is adherent to the pancreas) — well into the scar tissue at the base of the (now excluded) ulcer.\\n\\nWhich definitive procedure should you select in the rare patient? Obviously, this is considered only in a patient who is stable hemodynamically and otherwise in a reasonable shape! Our choice would be adding a truncal vagotomy (TV), extending the duodenotomy across the pylorus, and closing it to form a Heineke-Mikulicz pyloroplasty. When and if the duodenum is extremely scarred and friable we would do a gastroenterostomy rather than pyloroplasty — just patch the duodenotomy the best you can and hook a proximal loop of jejunum, side to side, to the antrum.\\n\\nIs there any indication for an antrectomy? The proponents of antrectomy plus vagotomy for bleeding DUs claim an increased incidence of rehemorrhage when gastric resection is avoided. In over 100...',\n", " 'md': '**Figure 17.2**. Gastroduodenostomy: note that the posterior aspect of the anastomosis is performed with ‘heavy’ (e.g. Vicryl® 2-0) interrupted sutures, taking ‘big bites’ in the posterior ‘lip’ of the duodenum (which is adherent to the pancreas) — well into the scar tissue at the base of the (now excluded) ulcer.\\n\\nWhich definitive procedure should you select in the rare patient? Obviously, this is considered only in a patient who is stable hemodynamically and otherwise in a reasonable shape! Our choice would be adding a truncal vagotomy (TV), extending the duodenotomy across the pylorus, and closing it to form a Heineke-Mikulicz pyloroplasty. When and if the duodenum is extremely scarred and friable we would do a gastroenterostomy rather than pyloroplasty — just patch the duodenotomy the best you can and hook a proximal loop of jejunum, side to side, to the antrum.\\n\\nIs there any indication for an antrectomy? The proponents of antrectomy plus vagotomy for bleeding DUs claim an increased incidence of rehemorrhage when gastric resection is avoided. In over 100...',\n", " 'bBox': {'x': 72, 'y': 311.4, 'w': 467.97, 'h': 14.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Description',\n", " 'md': '## Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"**Figure 17.2**: The image illustrates the surgical procedure of gastroduodenostomy. It shows the posterior aspect of the anastomosis, highlighting the use of heavy interrupted sutures (e.g., Vicryl® 2-0) and the technique of taking 'big bites' in the posterior lip of the duodenum, which is adherent to the pancreas. The image captures the surgical approach well into the scar tissue at the base of the excluded ulcer.\",\n", " 'md': \"**Figure 17.2**: The image illustrates the surgical procedure of gastroduodenostomy. It shows the posterior aspect of the anastomosis, highlighting the use of heavy interrupted sutures (e.g., Vicryl® 2-0) and the technique of taking 'big bites' in the posterior lip of the duodenum, which is adherent to the pancreas. The image captures the surgical approach well into the scar tissue at the base of the excluded ulcer.\",\n", " 'bBox': {'x': 299.82, 'y': 311.4, 'w': 27.68, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The figure provides a visual representation of the surgical technique used in gastroduodenostomy, emphasizing the importance of suturing and the anatomical considerations involved in the procedure.\\n```',\n", " 'md': 'The figure provides a visual representation of the surgical technique used in gastroduodenostomy, emphasizing the importance of suturing and the anatomical considerations involved in the procedure.\\n```',\n", " 'bBox': {'x': 215, 'y': 554, 'w': 21.59, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 257,\n", " 'text': 'emergency operations for bleeding DUs, this has not been our\\nexperience and we believe that there is no sense in removing a healthy\\nstomach, producing a gastric cripple, for benign duodenal disease —\\nwhich in any case can be subsequently cured with medications. When,\\nhowever, the duodenum is virtually replaced by a huge ulcer involving the\\nanterior and posterior wall of the duodenal cap-bulb (‘kissing ulcers’), one\\nessentially is forced to perform an antrectomy (plus/minus a truncal\\nvagotomy). In this situation, to avoid creating a duodenal stump which\\ncan be difficult to close and can leak, we prefer a Billroth I\\ngastroduodenostomy as depicted in Figure 17.2).\\n\\n Gastric ulcer (GU)\\n\\n In the previous editions we bored the hell out of our readers with a\\ncomplex classification of gastric ulcers, recommending different definitive\\nanti-ulcer procedures, based on the specific type of the GU. This has\\nbecome irrelevant as, irrespective of the location and type of the\\nulcer, your aim is to achieve hemostasis by the simplest possible\\nmaneuver. In most cases all that is required is simple underrunning\\nof the lesion through a small gastrotomy. In large chronic gastric\\nulcers we first underrun the bleeding point with an absorbable suture;\\nwith a heavy absorbable suture we then obliterate the ulcer’s base. UGIB\\nfrom a malignant ulcer very rarely requires an emergency operation. We\\nwould, however, take tissue from the ulcer’s edges for histology. For\\nbleeding ulcers situated at the greater curvature, wedge resection of the\\nbleeding ulcer may appear more practical. Partial gastrectomy becomes\\nnecessary only in cases of a giant GU on the lesser curvature with direct\\ninvolvement of the left gastric or splenic arteries.\\n\\n Juxtacardial lesser curvature GUs and the so-called ‘riding GU’\\n A riding GU, also called a ‘Cameron ulcer’ is a variant of a high GU\\nassociated with a sliding hiatal hernia, produced by injury to the herniated\\nstomach, ‘riding’ against the diaphragm. Typically, such ulcers are\\nmultiple and shallow, and present clinically with chronic UGIB and\\nassociated iron deficiency anemia. ħowever, solitary, deeper ones can\\npresent as life-threatening UGIB. Rarely, when conservative/endoscopic\\ntherapy fails, an operation may be indicated: it comprises reduction of the',\n", " 'md': \"```markdown\\n## Emergency Operations for Bleeding DUs\\n\\nIn the context of emergency operations for bleeding duodenal ulcers (DUs), it has not been our experience to remove a healthy stomach, which would result in a gastric cripple, for benign duodenal disease. This condition can typically be treated with medications. However, when the duodenum is largely replaced by a significant ulcer affecting both the anterior and posterior walls of the duodenal cap-bulb (known as ‘kissing ulcers’), it becomes necessary to perform an antrectomy (with or without a truncal vagotomy). To prevent the creation of a duodenal stump that can be challenging to close and may leak, we prefer a Billroth I gastroduodenostomy as depicted in **Figure 17.2**.\\n\\n### Gastric Ulcer (GU)\\n\\nIn previous editions, we provided an extensive classification of gastric ulcers, suggesting various definitive anti-ulcer procedures based on the specific type of GU. This approach has become less relevant, as the primary goal is to achieve hemostasis through the simplest possible maneuver, regardless of the ulcer's location and type. In most cases, simple underrunning of the lesion through a small gastrotomy is sufficient. For large chronic gastric ulcers, we first underrun the bleeding point with an absorbable suture, and then obliterate the ulcer’s base with a heavy absorbable suture.\\n\\nUpper gastrointestinal bleeding (UGIB) from a malignant ulcer rarely necessitates an emergency operation; however, we would take tissue from the ulcer’s edges for histological examination. For bleeding ulcers located at the greater curvature, wedge resection of the bleeding ulcer may be more practical. Partial gastrectomy is only required in cases of a giant GU on the lesser curvature that directly involves the left gastric or splenic arteries.\\n\\n### Juxtacardial Lesser Curvature GUs and the ‘Riding GU’\\n\\nA riding GU, also known as a ‘Cameron ulcer’, is a variant of a high gastric ulcer associated with a sliding hiatal hernia, resulting from injury to the herniated stomach that is ‘riding’ against the diaphragm. Typically, these ulcers are multiple and shallow, presenting clinically with chronic UGIB and associated iron deficiency anemia. However, solitary, deeper ulcers can present as life-threatening UGIB. Rarely, when conservative or endoscopic therapy fails, surgical intervention may be indicated, which involves the reduction of the hernia.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Emergency Operations for Bleeding DUs',\n", " 'md': '## Emergency Operations for Bleeding DUs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In the context of emergency operations for bleeding duodenal ulcers (DUs), it has not been our experience to remove a healthy stomach, which would result in a gastric cripple, for benign duodenal disease. This condition can typically be treated with medications. However, when the duodenum is largely replaced by a significant ulcer affecting both the anterior and posterior walls of the duodenal cap-bulb (known as ‘kissing ulcers’), it becomes necessary to perform an antrectomy (with or without a truncal vagotomy). To prevent the creation of a duodenal stump that can be challenging to close and may leak, we prefer a Billroth I gastroduodenostomy as depicted in **Figure 17.2**.',\n", " 'md': 'In the context of emergency operations for bleeding duodenal ulcers (DUs), it has not been our experience to remove a healthy stomach, which would result in a gastric cripple, for benign duodenal disease. This condition can typically be treated with medications. However, when the duodenum is largely replaced by a significant ulcer affecting both the anterior and posterior walls of the duodenal cap-bulb (known as ‘kissing ulcers’), it becomes necessary to perform an antrectomy (with or without a truncal vagotomy). To prevent the creation of a duodenal stump that can be challenging to close and may leak, we prefer a Billroth I gastroduodenostomy as depicted in **Figure 17.2**.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Gastric Ulcer (GU)',\n", " 'md': '### Gastric Ulcer (GU)',\n", " 'bBox': {'x': 86, 'y': 278, 'w': 141.59, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': \"In previous editions, we provided an extensive classification of gastric ulcers, suggesting various definitive anti-ulcer procedures based on the specific type of GU. This approach has become less relevant, as the primary goal is to achieve hemostasis through the simplest possible maneuver, regardless of the ulcer's location and type. In most cases, simple underrunning of the lesion through a small gastrotomy is sufficient. For large chronic gastric ulcers, we first underrun the bleeding point with an absorbable suture, and then obliterate the ulcer’s base with a heavy absorbable suture.\\n\\nUpper gastrointestinal bleeding (UGIB) from a malignant ulcer rarely necessitates an emergency operation; however, we would take tissue from the ulcer’s edges for histological examination. For bleeding ulcers located at the greater curvature, wedge resection of the bleeding ulcer may be more practical. Partial gastrectomy is only required in cases of a giant GU on the lesser curvature that directly involves the left gastric or splenic arteries.\",\n", " 'md': \"In previous editions, we provided an extensive classification of gastric ulcers, suggesting various definitive anti-ulcer procedures based on the specific type of GU. This approach has become less relevant, as the primary goal is to achieve hemostasis through the simplest possible maneuver, regardless of the ulcer's location and type. In most cases, simple underrunning of the lesion through a small gastrotomy is sufficient. For large chronic gastric ulcers, we first underrun the bleeding point with an absorbable suture, and then obliterate the ulcer’s base with a heavy absorbable suture.\\n\\nUpper gastrointestinal bleeding (UGIB) from a malignant ulcer rarely necessitates an emergency operation; however, we would take tissue from the ulcer’s edges for histological examination. For bleeding ulcers located at the greater curvature, wedge resection of the bleeding ulcer may be more practical. Partial gastrectomy is only required in cases of a giant GU on the lesser curvature that directly involves the left gastric or splenic arteries.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Juxtacardial Lesser Curvature GUs and the ‘Riding GU’',\n", " 'md': '### Juxtacardial Lesser Curvature GUs and the ‘Riding GU’',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A riding GU, also known as a ‘Cameron ulcer’, is a variant of a high gastric ulcer associated with a sliding hiatal hernia, resulting from injury to the herniated stomach that is ‘riding’ against the diaphragm. Typically, these ulcers are multiple and shallow, presenting clinically with chronic UGIB and associated iron deficiency anemia. However, solitary, deeper ulcers can present as life-threatening UGIB. Rarely, when conservative or endoscopic therapy fails, surgical intervention may be indicated, which involves the reduction of the hernia.\\n```',\n", " 'md': 'A riding GU, also known as a ‘Cameron ulcer’, is a variant of a high gastric ulcer associated with a sliding hiatal hernia, resulting from injury to the herniated stomach that is ‘riding’ against the diaphragm. Typically, these ulcers are multiple and shallow, presenting clinically with chronic UGIB and associated iron deficiency anemia. However, solitary, deeper ulcers can present as life-threatening UGIB. Rarely, when conservative or endoscopic therapy fails, surgical intervention may be indicated, which involves the reduction of the hernia.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 258,\n", " 'text': 'stomach by pinching the ulcer away from the adherent diaphragm, local\\nhemostasis, and crural repair. This may be easier said than done since\\noccasionally the huge riding ulcer adheres to mediastinal structures and\\nmay require major resective surgery.\\n\\n In conclusion, the generation of surgeons raised on the dogma that a complicated GU\\n has to be resected is busy retiring or dying off (this includes us…). The modern surgeon\\n should attack the bleeding GU with the simplest procedure possible, as dictated by the\\n specific anatomy encountered.\\n\\n Anastomotic (stomal) ulcer\\n\\n This ulcer develops on the jejunal side of the gastrojejunal\\nanastomosis following a previous vagotomy (or when vagotomy was\\nomitted or is ‘incomplete’) and gastroenterostomy or Billroth II\\ngastrectomy. Because stomal ulcers almost never involve a large\\nblood vessel, hemorrhage is usually self-limiting or amenable to\\nendoscopic therapy. Remember also that all stomal ulcers will heal on\\nmodern acid-suppressing medications. Persisting or recurrent\\nhemorrhage, however, will force you, rarely, to operate. In the high-risk\\npatient do the minimum: through a small gastrotomy, perpendicular to the\\nanastomosis, examine the stoma and ulcer; underrun the latter with a few\\ndeeply placed absorbable sutures; close the gastrotomy and put the\\npatient on ħ2 antagonists or PPIs for life.\\n\\n The role of a definitive procedure is limited, following the above\\nstated philosophy. If the previous operation was a vagotomy plus GE,\\nlook for a missed vagal nerve or add an antrectomy. In the case of a\\nprevious Billroth II gastrectomy, add TV or consider a higher gastrectomy\\n(do not forget to rule out Zollinger-Ellison syndrome later on). Remember\\n— hemorrhage from a stomal ulcer can be arrested with a simple\\nsurgical maneuver (underrunning); try to stay out of trouble by not\\nescalating the emergency procedure into complicated\\nreconstructive gastric surgery, which may kill your bleeding patient.',\n", " 'md': '```markdown\\n## Stomal Ulcer Management\\n\\nThe management of a stomal ulcer involves several key considerations:\\n\\n- **Surgical Approach**: The ulcer can be addressed by pinching it away from the adherent diaphragm, ensuring local hemostasis, and performing crural repair. However, this can be challenging if the ulcer adheres to mediastinal structures, potentially necessitating major resective surgery.\\n\\n- **Modern Surgical Philosophy**: The traditional belief that complicated gastric ulcers (GU) must be resected is becoming outdated. Contemporary surgeons are encouraged to manage bleeding GUs with the least invasive procedures based on the specific anatomy encountered.\\n\\n### Anastomotic (Stomal) Ulcer\\n\\n- **Definition**: This type of ulcer occurs on the jejunal side of the gastrojejunal anastomosis after a previous vagotomy or when vagotomy is incomplete, as well as following gastroenterostomy or Billroth II gastrectomy.\\n\\n- **Characteristics**: Stomal ulcers rarely involve large blood vessels, leading to self-limiting hemorrhage or bleeding that can be managed with endoscopic therapy. All stomal ulcers are expected to heal with modern acid-suppressing medications.\\n\\n- **Management of Hemorrhage**: In cases of persistent or recurrent hemorrhage, surgical intervention may be necessary. For high-risk patients, a minimal approach is recommended:\\n- Perform a small gastrotomy perpendicular to the anastomosis.\\n- Examine the stoma and ulcer.\\n- Underrun the ulcer with a few deep absorbable sutures.\\n- Close the gastrotomy and initiate lifelong treatment with H2 antagonists or PPIs.\\n\\n- **Definitive Procedures**: The role of definitive surgical procedures is limited. If the previous operation involved vagotomy and gastroenterostomy, check for a missed vagal nerve or consider antrectomy. In cases of prior Billroth II gastrectomy, consider adding a truncal vagotomy or a higher gastrectomy. It is crucial to rule out Zollinger-Ellison syndrome later.\\n\\n- **Surgical Caution**: Hemorrhage from a stomal ulcer can often be controlled with simple surgical techniques (e.g., underrunning). Surgeons should avoid escalating the situation into complex reconstructive gastric surgery, which poses significant risks to the patient.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Stomal Ulcer Management',\n", " 'md': '## Stomal Ulcer Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The management of a stomal ulcer involves several key considerations:\\n\\n- **Surgical Approach**: The ulcer can be addressed by pinching it away from the adherent diaphragm, ensuring local hemostasis, and performing crural repair. However, this can be challenging if the ulcer adheres to mediastinal structures, potentially necessitating major resective surgery.\\n\\n- **Modern Surgical Philosophy**: The traditional belief that complicated gastric ulcers (GU) must be resected is becoming outdated. Contemporary surgeons are encouraged to manage bleeding GUs with the least invasive procedures based on the specific anatomy encountered.',\n", " 'md': 'The management of a stomal ulcer involves several key considerations:\\n\\n- **Surgical Approach**: The ulcer can be addressed by pinching it away from the adherent diaphragm, ensuring local hemostasis, and performing crural repair. However, this can be challenging if the ulcer adheres to mediastinal structures, potentially necessitating major resective surgery.\\n\\n- **Modern Surgical Philosophy**: The traditional belief that complicated gastric ulcers (GU) must be resected is becoming outdated. Contemporary surgeons are encouraged to manage bleeding GUs with the least invasive procedures based on the specific anatomy encountered.',\n", " 'bBox': {'x': 72, 'y': 240, 'w': 165.23, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Anastomotic (Stomal) Ulcer',\n", " 'md': '### Anastomotic (Stomal) Ulcer',\n", " 'bBox': {'x': 86, 'y': 292, 'w': 213.33, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- **Definition**: This type of ulcer occurs on the jejunal side of the gastrojejunal anastomosis after a previous vagotomy or when vagotomy is incomplete, as well as following gastroenterostomy or Billroth II gastrectomy.\\n\\n- **Characteristics**: Stomal ulcers rarely involve large blood vessels, leading to self-limiting hemorrhage or bleeding that can be managed with endoscopic therapy. All stomal ulcers are expected to heal with modern acid-suppressing medications.\\n\\n- **Management of Hemorrhage**: In cases of persistent or recurrent hemorrhage, surgical intervention may be necessary. For high-risk patients, a minimal approach is recommended:\\n- Perform a small gastrotomy perpendicular to the anastomosis.\\n- Examine the stoma and ulcer.\\n- Underrun the ulcer with a few deep absorbable sutures.\\n- Close the gastrotomy and initiate lifelong treatment with H2 antagonists or PPIs.\\n\\n- **Definitive Procedures**: The role of definitive surgical procedures is limited. If the previous operation involved vagotomy and gastroenterostomy, check for a missed vagal nerve or consider antrectomy. In cases of prior Billroth II gastrectomy, consider adding a truncal vagotomy or a higher gastrectomy. It is crucial to rule out Zollinger-Ellison syndrome later.\\n\\n- **Surgical Caution**: Hemorrhage from a stomal ulcer can often be controlled with simple surgical techniques (e.g., underrunning). Surgeons should avoid escalating the situation into complex reconstructive gastric surgery, which poses significant risks to the patient.\\n\\n```',\n", " 'md': '- **Definition**: This type of ulcer occurs on the jejunal side of the gastrojejunal anastomosis after a previous vagotomy or when vagotomy is incomplete, as well as following gastroenterostomy or Billroth II gastrectomy.\\n\\n- **Characteristics**: Stomal ulcers rarely involve large blood vessels, leading to self-limiting hemorrhage or bleeding that can be managed with endoscopic therapy. All stomal ulcers are expected to heal with modern acid-suppressing medications.\\n\\n- **Management of Hemorrhage**: In cases of persistent or recurrent hemorrhage, surgical intervention may be necessary. For high-risk patients, a minimal approach is recommended:\\n- Perform a small gastrotomy perpendicular to the anastomosis.\\n- Examine the stoma and ulcer.\\n- Underrun the ulcer with a few deep absorbable sutures.\\n- Close the gastrotomy and initiate lifelong treatment with H2 antagonists or PPIs.\\n\\n- **Definitive Procedures**: The role of definitive surgical procedures is limited. If the previous operation involved vagotomy and gastroenterostomy, check for a missed vagal nerve or consider antrectomy. In cases of prior Billroth II gastrectomy, consider adding a truncal vagotomy or a higher gastrectomy. It is crucial to rule out Zollinger-Ellison syndrome later.\\n\\n- **Surgical Caution**: Hemorrhage from a stomal ulcer can often be controlled with simple surgical techniques (e.g., underrunning). Surgeons should avoid escalating the situation into complex reconstructive gastric surgery, which poses significant risks to the patient.\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 427, 'w': 112.77, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 259,\n", " 'text': ' UGIB after gastric bypass procedures for morbid obesity\\n\\n This not uncommon entity should be addressed as any stomal ulcer. If\\nendoscopic hemostasis fails, just overrun the bleeding ulcer through a\\ngastrotomy in the ‘gastric pouch’ immediately above the anastomosis.\\n\\n However, bleeding ulcers may develop in the distal, excluded\\nstomach or the duodenum — locations which are not accessible to\\nconventional endoscopy. Angiography (diagnostic/therapeutic) is a\\nreasonable option; percutaneous, lap-assisted endoscopy has been\\ndescribed as well. If forced to operate you may want to resect the\\nexcluded, ulcerated stomach.\\n\\n Dieulafoy’s lesion\\n\\n This small, solitary and difficult to diagnose gastric vascular\\nmalformation typically causes a recurrent ‘obscure’ massive UGIB.\\nIf not controlled by endoscopic maneuvers (or angio), they have become\\nthese days not an uncommon indication for UGIB surgery. Surgeons\\ncontinue to debate what to do after the lesion has been exposed through\\nan anterior gastrotomy: local excision?; underrunning?; do it through a\\nlaparoscope? Well, just stop dithering and deal with the bleeding the best\\nyou can!\\n\\n Acute superficial mucosal lesions\\n\\n Due to effective anti-ulcer prophylaxis in critically ill patients, you may\\nnever be called upon to operate on such lesions. In the remote past we\\nhad to intervene in a few such cases whose diffuse bleeding from ‘stress\\ngastritis’ persisted despite management with PPIs and vasopressin. Of\\ncourse, endoscopic treatments are useless in this situation as the\\ninvolved gastric mucosa looks and behaves like a blood-soaked and\\ndripping sponge. Surgical options mentioned by the standard textbooks\\ninclude TV and drainage or total gastrectomy. The former is associated\\nwith a very high rate of rebleeding and the latter with a prohibitive\\nmortality rate. In this situation we have carried out gastric\\ndevascularization by ligating the two gastroepiploic, and left and',\n", " 'md': '```markdown\\n# UGIB after Gastric Bypass Procedures for Morbid Obesity\\n\\nThis not uncommon entity should be addressed as any stomal ulcer. If endoscopic hemostasis fails, just overrun the bleeding ulcer through a gastrotomy in the ‘gastric pouch’ immediately above the anastomosis.\\n\\nHowever, bleeding ulcers may develop in the distal, excluded stomach or the duodenum — locations which are not accessible to conventional endoscopy. Angiography (diagnostic/therapeutic) is a reasonable option; percutaneous, lap-assisted endoscopy has been described as well. If forced to operate you may want to resect the excluded, ulcerated stomach.\\n\\n## Dieulafoy’s Lesion\\n\\nThis small, solitary and difficult to diagnose gastric vascular malformation typically causes a recurrent ‘obscure’ massive UGIB. If not controlled by endoscopic maneuvers (or angio), they have become these days not an uncommon indication for UGIB surgery. Surgeons continue to debate what to do after the lesion has been exposed through an anterior gastrotomy: local excision?; underrunning?; do it through a laparoscope? Well, just stop dithering and deal with the bleeding the best you can!\\n\\n## Acute Superficial Mucosal Lesions\\n\\nDue to effective anti-ulcer prophylaxis in critically ill patients, you may never be called upon to operate on such lesions. In the remote past we had to intervene in a few such cases whose diffuse bleeding from ‘stress gastritis’ persisted despite management with PPIs and vasopressin. Of course, endoscopic treatments are useless in this situation as the involved gastric mucosa looks and behaves like a blood-soaked and dripping sponge. Surgical options mentioned by the standard textbooks include TV and drainage or total gastrectomy. The former is associated with a very high rate of rebleeding and the latter with a prohibitive mortality rate. In this situation we have carried out gastric devascularization by ligating the two gastroepiploic, and left and right gastric arteries.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'UGIB after Gastric Bypass Procedures for Morbid Obesity',\n", " 'md': '# UGIB after Gastric Bypass Procedures for Morbid Obesity',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 446.89, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This not uncommon entity should be addressed as any stomal ulcer. If endoscopic hemostasis fails, just overrun the bleeding ulcer through a gastrotomy in the ‘gastric pouch’ immediately above the anastomosis.\\n\\nHowever, bleeding ulcers may develop in the distal, excluded stomach or the duodenum — locations which are not accessible to conventional endoscopy. Angiography (diagnostic/therapeutic) is a reasonable option; percutaneous, lap-assisted endoscopy has been described as well. If forced to operate you may want to resect the excluded, ulcerated stomach.',\n", " 'md': 'This not uncommon entity should be addressed as any stomal ulcer. If endoscopic hemostasis fails, just overrun the bleeding ulcer through a gastrotomy in the ‘gastric pouch’ immediately above the anastomosis.\\n\\nHowever, bleeding ulcers may develop in the distal, excluded stomach or the duodenum — locations which are not accessible to conventional endoscopy. Angiography (diagnostic/therapeutic) is a reasonable option; percutaneous, lap-assisted endoscopy has been described as well. If forced to operate you may want to resect the excluded, ulcerated stomach.',\n", " 'bBox': {'x': 72, 'y': 124, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Dieulafoy’s Lesion',\n", " 'md': '## Dieulafoy’s Lesion',\n", " 'bBox': {'x': 86, 'y': 318, 'w': 140.07, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This small, solitary and difficult to diagnose gastric vascular malformation typically causes a recurrent ‘obscure’ massive UGIB. If not controlled by endoscopic maneuvers (or angio), they have become these days not an uncommon indication for UGIB surgery. Surgeons continue to debate what to do after the lesion has been exposed through an anterior gastrotomy: local excision?; underrunning?; do it through a laparoscope? Well, just stop dithering and deal with the bleeding the best you can!',\n", " 'md': 'This small, solitary and difficult to diagnose gastric vascular malformation typically causes a recurrent ‘obscure’ massive UGIB. If not controlled by endoscopic maneuvers (or angio), they have become these days not an uncommon indication for UGIB surgery. Surgeons continue to debate what to do after the lesion has been exposed through an anterior gastrotomy: local excision?; underrunning?; do it through a laparoscope? Well, just stop dithering and deal with the bleeding the best you can!',\n", " 'bBox': {'x': 72, 'y': 387, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Acute Superficial Mucosal Lesions',\n", " 'md': '## Acute Superficial Mucosal Lesions',\n", " 'bBox': {'x': 86, 'y': 513, 'w': 266.67, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Due to effective anti-ulcer prophylaxis in critically ill patients, you may never be called upon to operate on such lesions. In the remote past we had to intervene in a few such cases whose diffuse bleeding from ‘stress gastritis’ persisted despite management with PPIs and vasopressin. Of course, endoscopic treatments are useless in this situation as the involved gastric mucosa looks and behaves like a blood-soaked and dripping sponge. Surgical options mentioned by the standard textbooks include TV and drainage or total gastrectomy. The former is associated with a very high rate of rebleeding and the latter with a prohibitive mortality rate. In this situation we have carried out gastric devascularization by ligating the two gastroepiploic, and left and right gastric arteries.\\n```',\n", " 'md': 'Due to effective anti-ulcer prophylaxis in critically ill patients, you may never be called upon to operate on such lesions. In the remote past we had to intervene in a few such cases whose diffuse bleeding from ‘stress gastritis’ persisted despite management with PPIs and vasopressin. Of course, endoscopic treatments are useless in this situation as the involved gastric mucosa looks and behaves like a blood-soaked and dripping sponge. Surgical options mentioned by the standard textbooks include TV and drainage or total gastrectomy. The former is associated with a very high rate of rebleeding and the latter with a prohibitive mortality rate. In this situation we have carried out gastric devascularization by ligating the two gastroepiploic, and left and right gastric arteries.\\n```',\n", " 'bBox': {'x': 72, 'y': 549, 'w': 467.63, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 260,\n", " 'text': 'right gastric arteries near the stomach’s wall. In our experience, this\\nrelatively simple and well-tolerated procedure results in an\\nimmediate drying of the gastric sponge.\\n\\n To recap…\\n\\n Admit patients with UGIB to your surgical service. Do not leave them to\\nthe internists who will call you when the patient is almost dead. After\\nresuscitation diagnose the source of hemorrhage and stage it. Give\\nendoscopic treatment a chance but do not delay an indicated operation.\\nAt surgery the goal is to stop the bleeding — remembering that\\nmost ulcers can be cured later on by medication. Life comes first.\\n\\n Perhaps this rhyme will help you to remember…\\n\\n When the blood is fresh and pink and the patient is old\\n It is time to be active and bold.\\n When the patient is young and the blood is dark and old\\n You can relax and put your knife on hold.\\n\\n1 Acute Physiology and Chronic Health Evaluation II.\\n2 Move your ass.',\n", " 'md': '```markdown\\n## Text Extraction\\n\\n- Right gastric arteries near the stomach’s wall. In our experience, this relatively simple and well-tolerated procedure results in an immediate drying of the gastric sponge.\\n\\n### Summary Points\\n- Admit patients with UGIB to your surgical service. Do not leave them to the internists who will call you when the patient is almost dead.\\n- After resuscitation, diagnose the source of hemorrhage and stage it.\\n- Give endoscopic treatment a chance but do not delay an indicated operation.\\n- At surgery, the goal is to stop the bleeding — remembering that most ulcers can be cured later on by medication. Life comes first.\\n\\n### Rhyme for Memory Aid\\n- When the blood is fresh and pink and the patient is old, it is time to be active and bold.\\n- When the patient is young and the blood is dark and old, you can relax and put your knife on hold.\\n\\n### References\\n1. Acute Physiology and Chronic Health Evaluation II.\\n2. Move your ass.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Right gastric arteries near the stomach’s wall. In our experience, this relatively simple and well-tolerated procedure results in an immediate drying of the gastric sponge.',\n", " 'md': '- Right gastric arteries near the stomach’s wall. In our experience, this relatively simple and well-tolerated procedure results in an immediate drying of the gastric sponge.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.66, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary Points',\n", " 'md': '### Summary Points',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Admit patients with UGIB to your surgical service. Do not leave them to the internists who will call you when the patient is almost dead.\\n- After resuscitation, diagnose the source of hemorrhage and stage it.\\n- Give endoscopic treatment a chance but do not delay an indicated operation.\\n- At surgery, the goal is to stop the bleeding — remembering that most ulcers can be cured later on by medication. Life comes first.',\n", " 'md': '- Admit patients with UGIB to your surgical service. Do not leave them to the internists who will call you when the patient is almost dead.\\n- After resuscitation, diagnose the source of hemorrhage and stage it.\\n- Give endoscopic treatment a chance but do not delay an indicated operation.\\n- At surgery, the goal is to stop the bleeding — remembering that most ulcers can be cured later on by medication. Life comes first.',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.32, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Rhyme for Memory Aid',\n", " 'md': '### Rhyme for Memory Aid',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- When the blood is fresh and pink and the patient is old, it is time to be active and bold.\\n- When the patient is young and the blood is dark and old, you can relax and put your knife on hold.',\n", " 'md': '- When the blood is fresh and pink and the patient is old, it is time to be active and bold.\\n- When the patient is young and the blood is dark and old, you can relax and put your knife on hold.',\n", " 'bBox': {'x': 79, 'y': 363, 'w': 440.37, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'References',\n", " 'md': '### References',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. Acute Physiology and Chronic Health Evaluation II.\\n2. Move your ass.\\n```',\n", " 'md': '1. Acute Physiology and Chronic Health Evaluation II.\\n2. Move your ass.\\n```',\n", " 'bBox': {'x': 73, 'y': 486, 'w': 243.4, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured according to the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured according to the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 261,\n", " 'text': 'Chapter 18\\nPerforated peptic ulcer\\nMoshe Schein\\n\\n There’s a hole in my bucket… How should I mend it? Just\\n patch it!\\n A folk song\\n\\n Every doctor, faced with a perforated ulcer of the stomach\\n or intestine, must consider opening the abdomen, sewing\\n up the hole, and averting a possible or actual inflammation\\n by careful cleansing of the abdominal cavity.\\n Johan Mikulicz-Radecki\\n\\n Thanks to effective, modern anti-ulcer drug management the incidence\\nof perforated peptic ulcers has decreased drastically (some say that the\\nincidence and ‘virulence’ of peptic ulcers started to decline even before\\nsuch drugs became available and Helicobacter pylori discovered) — but\\nnot everywhere. Perforated ulcers are still common in socioeconomically\\ndisadvantaged or stressed populations worldwide. Usually, perforations\\ndevelop against a background of chronic symptomatic ulceration but for a\\npatient to present with a perforation ‘out of the blue’, without previous\\nhistory of peptic ulcer disease whatsoever, is not uncommon. In the\\nWestern World perforated duodenal ulcers (DUs) are much more\\ncommon than perforated gastric ulcers (GUs), which are seen more in\\nlower socioeconomic groups.\\n\\n In the back of your mind you have to remember that not all perforations',\n", " 'md': '```markdown\\n# Chapter 18: Perforated Peptic Ulcer\\n**Author:** Moshe Schein\\n\\n> “There’s a hole in my bucket… How should I mend it? Just patch it!”\\n> — A folk song\\n\\nEvery doctor, faced with a perforated ulcer of the stomach or intestine, must consider opening the abdomen, sewing up the hole, and averting a possible or actual inflammation by careful cleansing of the abdominal cavity.\\n— Johan Mikulicz-Radecki\\n\\nThanks to effective, modern anti-ulcer drug management, the incidence of perforated peptic ulcers has decreased drastically (some say that the incidence and ‘virulence’ of peptic ulcers started to decline even before such drugs became available and Helicobacter pylori discovered) — but not everywhere. Perforated ulcers are still common in socioeconomically disadvantaged or stressed populations worldwide. Usually, perforations develop against a background of chronic symptomatic ulceration, but for a patient to present with a perforation ‘out of the blue’, without previous history of peptic ulcer disease whatsoever, is not uncommon. In the Western World, perforated duodenal ulcers (DUs) are much more common than perforated gastric ulcers (GUs), which are seen more in lower socioeconomic groups.\\n\\nIn the back of your mind, you have to remember that not all perforations...\\n```\\n\\n*Note: There are no figures, tables, or images identified on this page.*',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 18: Perforated Peptic Ulcer',\n", " 'md': '# Chapter 18: Perforated Peptic Ulcer',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 202.69, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Moshe Schein\\n\\n> “There’s a hole in my bucket… How should I mend it? Just patch it!”\\n> — A folk song\\n\\nEvery doctor, faced with a perforated ulcer of the stomach or intestine, must consider opening the abdomen, sewing up the hole, and averting a possible or actual inflammation by careful cleansing of the abdominal cavity.\\n— Johan Mikulicz-Radecki\\n\\nThanks to effective, modern anti-ulcer drug management, the incidence of perforated peptic ulcers has decreased drastically (some say that the incidence and ‘virulence’ of peptic ulcers started to decline even before such drugs became available and Helicobacter pylori discovered) — but not everywhere. Perforated ulcers are still common in socioeconomically disadvantaged or stressed populations worldwide. Usually, perforations develop against a background of chronic symptomatic ulceration, but for a patient to present with a perforation ‘out of the blue’, without previous history of peptic ulcer disease whatsoever, is not uncommon. In the Western World, perforated duodenal ulcers (DUs) are much more common than perforated gastric ulcers (GUs), which are seen more in lower socioeconomic groups.\\n\\nIn the back of your mind, you have to remember that not all perforations...\\n```\\n\\n*Note: There are no figures, tables, or images identified on this page.*',\n", " 'md': '**Author:** Moshe Schein\\n\\n> “There’s a hole in my bucket… How should I mend it? Just patch it!”\\n> — A folk song\\n\\nEvery doctor, faced with a perforated ulcer of the stomach or intestine, must consider opening the abdomen, sewing up the hole, and averting a possible or actual inflammation by careful cleansing of the abdominal cavity.\\n— Johan Mikulicz-Radecki\\n\\nThanks to effective, modern anti-ulcer drug management, the incidence of perforated peptic ulcers has decreased drastically (some say that the incidence and ‘virulence’ of peptic ulcers started to decline even before such drugs became available and Helicobacter pylori discovered) — but not everywhere. Perforated ulcers are still common in socioeconomically disadvantaged or stressed populations worldwide. Usually, perforations develop against a background of chronic symptomatic ulceration, but for a patient to present with a perforation ‘out of the blue’, without previous history of peptic ulcer disease whatsoever, is not uncommon. In the Western World, perforated duodenal ulcers (DUs) are much more common than perforated gastric ulcers (GUs), which are seen more in lower socioeconomic groups.\\n\\nIn the back of your mind, you have to remember that not all perforations...\\n```\\n\\n*Note: There are no figures, tables, or images identified on this page.*',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.93, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 262,\n", " 'text': 'arise in peptic ulcers: rarely, a gastric adenocarcinoma or lymphoma\\ncan perforate as well.\\n\\n Natural history\\n\\n In perforated peptic ulcers: “It must be remembered that the exudate in\\nthe early cases is sterile or nearly so, and the peritoneal reaction is a\\nresponse to chemical irritation by the gastric and duodenal contents\\nrather than the result of bacterial invasion” (John Blair Deaver).\\n\\n Classically, the abdominal pain caused by a peptic perforation\\ndevelops very suddenly in the upper abdomen. Most patients can\\naccurately time the dramatic onset of symptoms. The natural history of\\nsuch an episode can be divided into three phases:\\n\\n • Chemical peritonitis/contamination. Initially, the perforation leads\\n to chemical peritonitis, with or without contamination with micro-\\n organisms (note that the presence of acid sterilizes gastroduodenal\\n contents; it is when gastric acid is reduced by acid-reducing\\n treatment or disease, e.g. achlorhydria of gastric cancer, that\\n bacteria and fungi are present in the stomach and duodenum).\\n Spillage of gastroduodenal contents is usually diffuse but may be\\n localized in the upper abdomen by adhesions or the omentum.\\n Spillage along the right gutter into the right lower quadrant,\\n mimicking acute appendicitis, is mentioned in every textbook but is\\n almost never seen in clinical practice (see Chapter 23 about the\\n ‘Valentino appendix’).\\n • Intermediate stage. After 6 to 12 hours, many patients obtain some\\n spontaneous relief from the pain. This is probably due to the dilution\\n of the irritating gastroduodenal contents by the ensuing peritoneal\\n exudate.\\n • Intra-abdominal infection. If the patient initially escapes the\\n scalpel, then intra-abdominal infection supervenes 12 to 24 hours\\n later. The exact point in time in the individual patient when\\n contaminating micro-organisms become invasive/infective is\\n unknown. Therefore, you should consider any perforation\\n operated upon with a delay of more than 12 hours as infection',\n", " 'md': '```markdown\\n## Natural History of Perforated Peptic Ulcers\\n\\nIn perforated peptic ulcers: “It must be remembered that the exudate in the early cases is sterile or nearly so, and the peritoneal reaction is a response to chemical irritation by the gastric and duodenal contents rather than the result of bacterial invasion” (John Blair Deaver).\\n\\nClassically, the abdominal pain caused by a peptic perforation develops very suddenly in the upper abdomen. Most patients can accurately time the dramatic onset of symptoms. The natural history of such an episode can be divided into three phases:\\n\\n1. **Chemical peritonitis/contamination.** Initially, the perforation leads to chemical peritonitis, with or without contamination with microorganisms (note that the presence of acid sterilizes gastroduodenal contents; it is when gastric acid is reduced by acid-reducing treatment or disease, e.g., achlorhydria of gastric cancer, that bacteria and fungi are present in the stomach and duodenum). Spillage of gastroduodenal contents is usually diffuse but may be localized in the upper abdomen by adhesions or the omentum. Spillage along the right gutter into the right lower quadrant, mimicking acute appendicitis, is mentioned in every textbook but is almost never seen in clinical practice (see Chapter 23 about the ‘Valentino appendix’).\\n\\n2. **Intermediate stage.** After 6 to 12 hours, many patients obtain some spontaneous relief from the pain. This is probably due to the dilution of the irritating gastroduodenal contents by the ensuing peritoneal exudate.\\n\\n3. **Intra-abdominal infection.** If the patient initially escapes the scalpel, then intra-abdominal infection supervenes 12 to 24 hours later. The exact point in time in the individual patient when contaminating microorganisms become invasive/infective is unknown. Therefore, you should consider any perforation operated upon with a delay of more than 12 hours as infection.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Natural History of Perforated Peptic Ulcers',\n", " 'md': '## Natural History of Perforated Peptic Ulcers',\n", " 'bBox': {'x': 86, 'y': 145, 'w': 116.78, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In perforated peptic ulcers: “It must be remembered that the exudate in the early cases is sterile or nearly so, and the peritoneal reaction is a response to chemical irritation by the gastric and duodenal contents rather than the result of bacterial invasion” (John Blair Deaver).\\n\\nClassically, the abdominal pain caused by a peptic perforation develops very suddenly in the upper abdomen. Most patients can accurately time the dramatic onset of symptoms. The natural history of such an episode can be divided into three phases:\\n\\n1. **Chemical peritonitis/contamination.** Initially, the perforation leads to chemical peritonitis, with or without contamination with microorganisms (note that the presence of acid sterilizes gastroduodenal contents; it is when gastric acid is reduced by acid-reducing treatment or disease, e.g., achlorhydria of gastric cancer, that bacteria and fungi are present in the stomach and duodenum). Spillage of gastroduodenal contents is usually diffuse but may be localized in the upper abdomen by adhesions or the omentum. Spillage along the right gutter into the right lower quadrant, mimicking acute appendicitis, is mentioned in every textbook but is almost never seen in clinical practice (see Chapter 23 about the ‘Valentino appendix’).\\n\\n2. **Intermediate stage.** After 6 to 12 hours, many patients obtain some spontaneous relief from the pain. This is probably due to the dilution of the irritating gastroduodenal contents by the ensuing peritoneal exudate.\\n\\n3. **Intra-abdominal infection.** If the patient initially escapes the scalpel, then intra-abdominal infection supervenes 12 to 24 hours later. The exact point in time in the individual patient when contaminating microorganisms become invasive/infective is unknown. Therefore, you should consider any perforation operated upon with a delay of more than 12 hours as infection.\\n```',\n", " 'md': 'In perforated peptic ulcers: “It must be remembered that the exudate in the early cases is sterile or nearly so, and the peritoneal reaction is a response to chemical irritation by the gastric and duodenal contents rather than the result of bacterial invasion” (John Blair Deaver).\\n\\nClassically, the abdominal pain caused by a peptic perforation develops very suddenly in the upper abdomen. Most patients can accurately time the dramatic onset of symptoms. The natural history of such an episode can be divided into three phases:\\n\\n1. **Chemical peritonitis/contamination.** Initially, the perforation leads to chemical peritonitis, with or without contamination with microorganisms (note that the presence of acid sterilizes gastroduodenal contents; it is when gastric acid is reduced by acid-reducing treatment or disease, e.g., achlorhydria of gastric cancer, that bacteria and fungi are present in the stomach and duodenum). Spillage of gastroduodenal contents is usually diffuse but may be localized in the upper abdomen by adhesions or the omentum. Spillage along the right gutter into the right lower quadrant, mimicking acute appendicitis, is mentioned in every textbook but is almost never seen in clinical practice (see Chapter 23 about the ‘Valentino appendix’).\\n\\n2. **Intermediate stage.** After 6 to 12 hours, many patients obtain some spontaneous relief from the pain. This is probably due to the dilution of the irritating gastroduodenal contents by the ensuing peritoneal exudate.\\n\\n3. **Intra-abdominal infection.** If the patient initially escapes the scalpel, then intra-abdominal infection supervenes 12 to 24 hours later. The exact point in time in the individual patient when contaminating microorganisms become invasive/infective is unknown. Therefore, you should consider any perforation operated upon with a delay of more than 12 hours as infection.\\n```',\n", " 'bBox': {'x': 72, 'y': 145, 'w': 467.02, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 263,\n", " 'text': ' rather than contamination. This bears on your postoperative\\n antibiotic therapy as discussed below. Neglected patients may\\n present a few days after the perforation in septic shock. Shock in the\\n earlier stages is very rare, although quoted commonly by medical\\n students, but when confronted with a combination of shock and\\n abdominal pain, think about ruptured aortic aneurysm,\\n mesenteric ischemia or severe acute pancreatitis. Untreated\\n perforation can lead eventually to an early ‘septic’ death from\\n peritonitis or the development of an intra-abdominal abscess.\\n\\n Diagnosis\\n\\n The vast majority of patients present with signs of diffuse or\\nlocalized peritoneal irritation; most lie still, groaning, and have a\\nboard-like abdomen as described in textbooks (some call it\\n‘textbook peritonitis’). Spontaneous ‘sealing off’ of the perforation, or\\nlocalization of the spill or leakage into the lesser sac, causes an atypical\\nand delayed presentation. We had a patient who reperforated his\\nduodenal ulcer a few years after receiving an omental patch. The second\\nperforation was thus diverted backwards into the retroperitoneum —\\nbehind the pancreas, the left colon and into the scrotum — while the\\nabdomen remained soft.\\n\\n In a patient with an abrupt onset of upper abdominal pain and diffuse\\nperitonitis, the diagnosis is simple. It can be summarized in the following\\nformulas:\\n\\n Sudden onset peritonitis + free gas = perforated viscus\\n\\n Sudden onset peritonitis + no free gas + normal amylase/lipase =\\nperforated viscus\\n\\n There is free gas under the diaphragm in about two-thirds of\\nperforated patients. Remember, free gas is visualized better on an\\nupright chest X-ray than on plain abdominal radiographs ( Chapters 4\\nand 5). If your patient can’t stand, or sit up, order a left lateral decubitus\\nabdominal film. Remember that free gas without clinical peritonitis is',\n", " 'md': '```markdown\\n## Diagnosis\\n\\nThe vast majority of patients present with signs of diffuse or localized peritoneal irritation; most lie still, groaning, and have a board-like abdomen as described in textbooks (some call it ‘textbook peritonitis’). Spontaneous ‘sealing off’ of the perforation, or localization of the spill or leakage into the lesser sac, causes an atypical and delayed presentation. We had a patient who reperforated his duodenal ulcer a few years after receiving an omental patch. The second perforation was thus diverted backwards into the retroperitoneum — behind the pancreas, the left colon and into the scrotum — while the abdomen remained soft.\\n\\nIn a patient with an abrupt onset of upper abdominal pain and diffuse peritonitis, the diagnosis is simple. It can be summarized in the following formulas:\\n\\n- Sudden onset peritonitis + free gas = perforated viscus\\n- Sudden onset peritonitis + no free gas + normal amylase/lipase = perforated viscus\\n\\nThere is free gas under the diaphragm in about two-thirds of perforated patients. Remember, free gas is visualized better on an upright chest X-ray than on plain abdominal radiographs. If your patient can’t stand, or sit up, order a left lateral decubitus abdominal film. Remember that free gas without clinical peritonitis is .\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnosis',\n", " 'md': '## Diagnosis',\n", " 'bBox': {'x': 86, 'y': 263, 'w': 79.09, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The vast majority of patients present with signs of diffuse or localized peritoneal irritation; most lie still, groaning, and have a board-like abdomen as described in textbooks (some call it ‘textbook peritonitis’). Spontaneous ‘sealing off’ of the perforation, or localization of the spill or leakage into the lesser sac, causes an atypical and delayed presentation. We had a patient who reperforated his duodenal ulcer a few years after receiving an omental patch. The second perforation was thus diverted backwards into the retroperitoneum — behind the pancreas, the left colon and into the scrotum — while the abdomen remained soft.\\n\\nIn a patient with an abrupt onset of upper abdominal pain and diffuse peritonitis, the diagnosis is simple. It can be summarized in the following formulas:\\n\\n- Sudden onset peritonitis + free gas = perforated viscus\\n- Sudden onset peritonitis + no free gas + normal amylase/lipase = perforated viscus\\n\\nThere is free gas under the diaphragm in about two-thirds of perforated patients. Remember, free gas is visualized better on an upright chest X-ray than on plain abdominal radiographs. If your patient can’t stand, or sit up, order a left lateral decubitus abdominal film. Remember that free gas without clinical peritonitis is .\\n```',\n", " 'md': 'The vast majority of patients present with signs of diffuse or localized peritoneal irritation; most lie still, groaning, and have a board-like abdomen as described in textbooks (some call it ‘textbook peritonitis’). Spontaneous ‘sealing off’ of the perforation, or localization of the spill or leakage into the lesser sac, causes an atypical and delayed presentation. We had a patient who reperforated his duodenal ulcer a few years after receiving an omental patch. The second perforation was thus diverted backwards into the retroperitoneum — behind the pancreas, the left colon and into the scrotum — while the abdomen remained soft.\\n\\nIn a patient with an abrupt onset of upper abdominal pain and diffuse peritonitis, the diagnosis is simple. It can be summarized in the following formulas:\\n\\n- Sudden onset peritonitis + free gas = perforated viscus\\n- Sudden onset peritonitis + no free gas + normal amylase/lipase = perforated viscus\\n\\nThere is free gas under the diaphragm in about two-thirds of perforated patients. Remember, free gas is visualized better on an upright chest X-ray than on plain abdominal radiographs. If your patient can’t stand, or sit up, order a left lateral decubitus abdominal film. Remember that free gas without clinical peritonitis is .\\n```',\n", " 'bBox': {'x': 72, 'y': 168, 'w': 467.57, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'and 5). If your patient can’t stand, or sit up, order a left lateral decubitus'},\n", " {'text': 'abdominal film. '}]},\n", " {'page': 264,\n", " 'text': 'NOT an indication for an emergency laparotomy. As mentioned in\\nChapter 4, there is a long list of ‘non-operative’ conditions that may\\nproduce free intraperitoneal gas. Free gas in a ‘soft’ abdomen may also\\nmean that the perforation has been spontaneously sealed and is thus\\namenable to non-operative therapy as discussed below.\\n\\n In the absence of free air, acute pancreatitis — the ‘great\\nsimulator’ — should be considered and excluded ( Chapter 19).\\nNormal pancreatic enzyme levels would support a diagnosis of a\\nperforation, while very elevated levels in a ‘susceptible’ patient (e.g.\\nalcohol, gallstones) would indicate acute pancreatitis. The ‘border-line’\\npatient with atypical presentation and marginal elevation of\\namylase/lipase remains a problem because a perforated ulcer may cause\\nhyperamylasemia. In the good old days, before imaging techniques\\nreplaced clinical skills, our decision to operate or observe would have\\ndepended on the whole clinical picture. Rarely, a Gastrografin® contrast\\nstudy was performed to demonstrate or exclude leakage. Faced with\\nsuch a patient today we would advise you to obtain a CT scan of the\\nabdomen, looking for free gas, extraluminal Gastrografin® and free\\nperitoneal fluid. CT is excellent at picking up minute amounts of free\\nintraperitoneal gas and is thus a valuable tool in clarifying the diagnosis\\nin patients with an ambiguous clinical picture — is it acute diverticulitis to\\nbe managed non-operatively or perforated ulcer to operate upon? Those\\nof you who are lucky to practice in the United States know that in most\\nsuch patients a CT is obtained even before you have a chance to see\\nthem. From a self-interested point of view this is not such a bad idea.\\nImagine the 13th edition of this book (2049?) — this whole chapter will\\nconsist of one sentence: “Obtain a CT; seal the perforation with CT-\\nguided injection of glue.” But perhaps, before then, perforated peptic\\nulcers will disappear completely.\\n\\n Philosophy of treatment\\n\\n “The primary goal of treatment is to save the patient’s life by\\neliminating the source of infection and cleaning the abdominal\\ncavity. The secondary goal is to cure, if possible, the ulcer diathesis. The\\nformer goal is achieved by simple closure of the ulcer; the latter requires',\n", " 'md': '```markdown\\n## Page Content\\n\\nNOT an indication for an emergency laparotomy. As mentioned in Chapter 4, there is a long list of ‘non-operative’ conditions that may produce free intraperitoneal gas. Free gas in a ‘soft’ abdomen may also mean that the perforation has been spontaneously sealed and is thus amenable to non-operative therapy as discussed below.\\n\\nIn the absence of free air, acute pancreatitis — the ‘great simulator’ — should be considered and excluded (Chapter 19). Normal pancreatic enzyme levels would support a diagnosis of a perforation, while very elevated levels in a ‘susceptible’ patient (e.g. alcohol, gallstones) would indicate acute pancreatitis. The ‘border-line’ patient with atypical presentation and marginal elevation of amylase/lipase remains a problem because a perforated ulcer may cause hyperamylasemia. In the good old days, before imaging techniques replaced clinical skills, our decision to operate or observe would have depended on the whole clinical picture. Rarely, a Gastrografin® contrast study was performed to demonstrate or exclude leakage. Faced with such a patient today we would advise you to obtain a CT scan of the abdomen, looking for free gas, extraluminal Gastrografin® and free peritoneal fluid. CT is excellent at picking up minute amounts of free intraperitoneal gas and is thus a valuable tool in clarifying the diagnosis in patients with an ambiguous clinical picture — is it acute diverticulitis to be managed non-operatively or perforated ulcer to operate upon? Those of you who are lucky to practice in the United States know that in most such patients a CT is obtained even before you have a chance to see them. From a self-interested point of view this is not such a bad idea. Imagine the 13th edition of this book (2049?) — this whole chapter will consist of one sentence: “Obtain a CT; seal the perforation with CT-guided injection of glue.” But perhaps, before then, perforated peptic ulcers will disappear completely.\\n\\n### Philosophy of treatment\\n\\n“The primary goal of treatment is to save the patient’s life by eliminating the source of infection and cleaning the abdominal cavity. The secondary goal is to cure, if possible, the ulcer diathesis. The former goal is achieved by simple closure of the ulcer; the latter requires\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted while excluding any diagonal text, headers, and footers.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'NOT an indication for an emergency laparotomy. As mentioned in Chapter 4, there is a long list of ‘non-operative’ conditions that may produce free intraperitoneal gas. Free gas in a ‘soft’ abdomen may also mean that the perforation has been spontaneously sealed and is thus amenable to non-operative therapy as discussed below.\\n\\nIn the absence of free air, acute pancreatitis — the ‘great simulator’ — should be considered and excluded (Chapter 19). Normal pancreatic enzyme levels would support a diagnosis of a perforation, while very elevated levels in a ‘susceptible’ patient (e.g. alcohol, gallstones) would indicate acute pancreatitis. The ‘border-line’ patient with atypical presentation and marginal elevation of amylase/lipase remains a problem because a perforated ulcer may cause hyperamylasemia. In the good old days, before imaging techniques replaced clinical skills, our decision to operate or observe would have depended on the whole clinical picture. Rarely, a Gastrografin® contrast study was performed to demonstrate or exclude leakage. Faced with such a patient today we would advise you to obtain a CT scan of the abdomen, looking for free gas, extraluminal Gastrografin® and free peritoneal fluid. CT is excellent at picking up minute amounts of free intraperitoneal gas and is thus a valuable tool in clarifying the diagnosis in patients with an ambiguous clinical picture — is it acute diverticulitis to be managed non-operatively or perforated ulcer to operate upon? Those of you who are lucky to practice in the United States know that in most such patients a CT is obtained even before you have a chance to see them. From a self-interested point of view this is not such a bad idea. Imagine the 13th edition of this book (2049?) — this whole chapter will consist of one sentence: “Obtain a CT; seal the perforation with CT-guided injection of glue.” But perhaps, before then, perforated peptic ulcers will disappear completely.',\n", " 'md': 'NOT an indication for an emergency laparotomy. As mentioned in Chapter 4, there is a long list of ‘non-operative’ conditions that may produce free intraperitoneal gas. Free gas in a ‘soft’ abdomen may also mean that the perforation has been spontaneously sealed and is thus amenable to non-operative therapy as discussed below.\\n\\nIn the absence of free air, acute pancreatitis — the ‘great simulator’ — should be considered and excluded (Chapter 19). Normal pancreatic enzyme levels would support a diagnosis of a perforation, while very elevated levels in a ‘susceptible’ patient (e.g. alcohol, gallstones) would indicate acute pancreatitis. The ‘border-line’ patient with atypical presentation and marginal elevation of amylase/lipase remains a problem because a perforated ulcer may cause hyperamylasemia. In the good old days, before imaging techniques replaced clinical skills, our decision to operate or observe would have depended on the whole clinical picture. Rarely, a Gastrografin® contrast study was performed to demonstrate or exclude leakage. Faced with such a patient today we would advise you to obtain a CT scan of the abdomen, looking for free gas, extraluminal Gastrografin® and free peritoneal fluid. CT is excellent at picking up minute amounts of free intraperitoneal gas and is thus a valuable tool in clarifying the diagnosis in patients with an ambiguous clinical picture — is it acute diverticulitis to be managed non-operatively or perforated ulcer to operate upon? Those of you who are lucky to practice in the United States know that in most such patients a CT is obtained even before you have a chance to see them. From a self-interested point of view this is not such a bad idea. Imagine the 13th edition of this book (2049?) — this whole chapter will consist of one sentence: “Obtain a CT; seal the perforation with CT-guided injection of glue.” But perhaps, before then, perforated peptic ulcers will disappear completely.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.84, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Philosophy of treatment',\n", " 'md': '### Philosophy of treatment',\n", " 'bBox': {'x': 86, 'y': 270, 'w': 453, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '“The primary goal of treatment is to save the patient’s life by eliminating the source of infection and cleaning the abdominal cavity. The secondary goal is to cure, if possible, the ulcer diathesis. The former goal is achieved by simple closure of the ulcer; the latter requires\\n```',\n", " 'md': '“The primary goal of treatment is to save the patient’s life by eliminating the source of infection and cleaning the abdominal cavity. The secondary goal is to cure, if possible, the ulcer diathesis. The former goal is achieved by simple closure of the ulcer; the latter requires\\n```',\n", " 'bBox': {'x': 72, 'y': 270, 'w': 467.57, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted while excluding any diagonal text, headers, and footers.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted while excluding any diagonal text, headers, and footers.',\n", " 'bBox': {'x': 338, 'y': 270, 'w': 28, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 4, there is a long list of ‘non-operative’ conditions that may produce free intraperitoneal gas. Free gas in a ‘soft’ abdomen may also'},\n", " {'text': 'Normal pancreatic enzyme levels would support a diagnosis of a'}]},\n", " {'page': 265,\n", " 'text': 'a definitive ulcer operation. So what should you do and when?”\\n\\n That is what we wrote in the previous editions of this book, but is\\nit still relevant today? Not only are these perforations less frequent and\\n(perhaps) less nasty, but such ulcers can now be healed in the long term\\n(abolishing the ulcer diathesis) in most patients by modern anti-acid\\ndrugs and the eradication of the causative Helicobacter pylori bacteria.\\nThis being so, is there any place today for definitive anti-ulcer\\noperations?\\n\\n To find out about the current (2015) practice concerning perforated\\nulcers worldwide we polled the international membership of SURGINET\\n(an online general surgical discussion group). And here is what we found:\\n\\n • How common is the problem? It is very rare in developed\\n countries. Surgeons in the US, UK or Australia do not deal with\\n more than one or two cases per year. When western lifestyle and\\n availability of medications reaches a previously developing region,\\n perforated ulcers become rare (e.g. Odessa, Ukraine). On the other\\n hand, perforated ulcers are still common in indigent\\n populations, as in South Africa, India or even Russia, where\\n some surgeons report as many as 25 cases per month! A surgeon\\n from St. Petersburg (Russia) reported operating on 10 perforated\\n DUs last year.\\n • What is the site of perforated ulcers? The vast majority are\\n situated in the duodenum. A few are pre-pyloric or gastric\\n (associated with NSAID use). Because gastric resections for benign\\n disease are so rarely performed, perforated anastomotic ulcers have\\n almost disappeared, although they are resurfacing following bariatric\\n gastric operations.\\n • Which operation? All responders would use a simple closure as\\n the preferred operative treatment. Some would add, very rarely, and\\n in special circumstances — only if ‘forced to do’ — a definitive anti-\\n ulcer procedure, as described below.\\n • Open procedure vs. laparoscopy? The laparoscopic approach\\n seems to be increasingly popular at least in the hands of ‘advanced\\n laparoscopists’ (or those who wish they were…). But even the latter\\n (or those who are smart) would opt for open surgery in very ill, septic',\n", " 'md': '```markdown\\n## Current Practice on Perforated Ulcers\\n\\nA definitive ulcer operation. So what should you do and when?\\n\\nThat is what we wrote in the previous editions of this book, but is it still relevant today? Not only are these perforations less frequent and (perhaps) less nasty, but such ulcers can now be healed in the long term (abolishing the ulcer diathesis) in most patients by modern anti-acid drugs and the eradication of the causative *Helicobacter pylori* bacteria. This being so, is there any place today for definitive anti-ulcer operations?\\n\\nTo find out about the current (2015) practice concerning perforated ulcers worldwide, we polled the international membership of SURGINET (an online general surgical discussion group). And here is what we found:\\n\\n- **How common is the problem?** It is very rare in developed countries. Surgeons in the US, UK, or Australia do not deal with more than one or two cases per year. When western lifestyle and availability of medications reaches a previously developing region, perforated ulcers become rare (e.g. Odessa, Ukraine). On the other hand, perforated ulcers are still common in indigent populations, as in South Africa, India, or even Russia, where some surgeons report as many as 25 cases per month! A surgeon from St. Petersburg (Russia) reported operating on 10 perforated DUs last year.\\n\\n- **What is the site of perforated ulcers?** The vast majority are situated in the duodenum. A few are pre-pyloric or gastric (associated with NSAID use). Because gastric resections for benign disease are so rarely performed, perforated anastomotic ulcers have almost disappeared, although they are resurfacing following bariatric gastric operations.\\n\\n- **Which operation?** All responders would use a simple closure as the preferred operative treatment. Some would add, very rarely, and in special circumstances — only if ‘forced to do’ — a definitive anti-ulcer procedure, as described below.\\n\\n- **Open procedure vs. laparoscopy?** The laparoscopic approach seems to be increasingly popular at least in the hands of ‘advanced laparoscopists’ (or those who wish they were…). But even the latter (or those who are smart) would opt for open surgery in very ill, septic patients.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Practice on Perforated Ulcers',\n", " 'md': '## Current Practice on Perforated Ulcers',\n", " 'bBox': {'x': 154, 'y': 407, 'w': 75.15, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'A definitive ulcer operation. So what should you do and when?\\n\\nThat is what we wrote in the previous editions of this book, but is it still relevant today? Not only are these perforations less frequent and (perhaps) less nasty, but such ulcers can now be healed in the long term (abolishing the ulcer diathesis) in most patients by modern anti-acid drugs and the eradication of the causative *Helicobacter pylori* bacteria. This being so, is there any place today for definitive anti-ulcer operations?\\n\\nTo find out about the current (2015) practice concerning perforated ulcers worldwide, we polled the international membership of SURGINET (an online general surgical discussion group). And here is what we found:\\n\\n- **How common is the problem?** It is very rare in developed countries. Surgeons in the US, UK, or Australia do not deal with more than one or two cases per year. When western lifestyle and availability of medications reaches a previously developing region, perforated ulcers become rare (e.g. Odessa, Ukraine). On the other hand, perforated ulcers are still common in indigent populations, as in South Africa, India, or even Russia, where some surgeons report as many as 25 cases per month! A surgeon from St. Petersburg (Russia) reported operating on 10 perforated DUs last year.\\n\\n- **What is the site of perforated ulcers?** The vast majority are situated in the duodenum. A few are pre-pyloric or gastric (associated with NSAID use). Because gastric resections for benign disease are so rarely performed, perforated anastomotic ulcers have almost disappeared, although they are resurfacing following bariatric gastric operations.\\n\\n- **Which operation?** All responders would use a simple closure as the preferred operative treatment. Some would add, very rarely, and in special circumstances — only if ‘forced to do’ — a definitive anti-ulcer procedure, as described below.\\n\\n- **Open procedure vs. laparoscopy?** The laparoscopic approach seems to be increasingly popular at least in the hands of ‘advanced laparoscopists’ (or those who wish they were…). But even the latter (or those who are smart) would opt for open surgery in very ill, septic patients.\\n```',\n", " 'md': 'A definitive ulcer operation. So what should you do and when?\\n\\nThat is what we wrote in the previous editions of this book, but is it still relevant today? Not only are these perforations less frequent and (perhaps) less nasty, but such ulcers can now be healed in the long term (abolishing the ulcer diathesis) in most patients by modern anti-acid drugs and the eradication of the causative *Helicobacter pylori* bacteria. This being so, is there any place today for definitive anti-ulcer operations?\\n\\nTo find out about the current (2015) practice concerning perforated ulcers worldwide, we polled the international membership of SURGINET (an online general surgical discussion group). And here is what we found:\\n\\n- **How common is the problem?** It is very rare in developed countries. Surgeons in the US, UK, or Australia do not deal with more than one or two cases per year. When western lifestyle and availability of medications reaches a previously developing region, perforated ulcers become rare (e.g. Odessa, Ukraine). On the other hand, perforated ulcers are still common in indigent populations, as in South Africa, India, or even Russia, where some surgeons report as many as 25 cases per month! A surgeon from St. Petersburg (Russia) reported operating on 10 perforated DUs last year.\\n\\n- **What is the site of perforated ulcers?** The vast majority are situated in the duodenum. A few are pre-pyloric or gastric (associated with NSAID use). Because gastric resections for benign disease are so rarely performed, perforated anastomotic ulcers have almost disappeared, although they are resurfacing following bariatric gastric operations.\\n\\n- **Which operation?** All responders would use a simple closure as the preferred operative treatment. Some would add, very rarely, and in special circumstances — only if ‘forced to do’ — a definitive anti-ulcer procedure, as described below.\\n\\n- **Open procedure vs. laparoscopy?** The laparoscopic approach seems to be increasingly popular at least in the hands of ‘advanced laparoscopists’ (or those who wish they were…). But even the latter (or those who are smart) would opt for open surgery in very ill, septic patients.\\n```',\n", " 'bBox': {'x': 72, 'y': 121, 'w': 467.59, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 266,\n", " 'text': ' patients.\\n\\n Management\\n\\n There is no need to repeat how important it is to optimize these\\npatients along the lines discussed in Chapter 6.\\n\\n Antibiotics\\n\\n As soon as the diagnosis of perforation is made, and the patient is\\nbooked in for an operation, administer a dose of broad-spectrum\\nantibiotics. The vast majority of patients present for treatment within\\n12 hours of perforation and therefore suffer from peritoneal\\ncontamination rather than infection. In many of them, in fact, the\\nperitonitis is chemical and does not contain any micro-organisms.\\nAntibiotics in this group will serve for prophylaxis. Prolonged\\npostoperative therapeutic antibiotics are not needed. Those who present\\nlater than 12 hours may suffer from an established intra-abdominal\\ninfection; here antibiotics should be continued in the postoperative phase\\n( Chapter 44). The antibiotics given, either in the form of monotherapy\\nor combination therapy, should ‘cover’, empirically, Gram-negatives and\\nanaerobes. Routine culturing of the peritoneal fluid in perforated patients\\nis not indicated ( Chapter 13).\\n\\n But you may be crucified by the infection disease specialist and probably by your boss if you fail\\n to comply with their guidelines. Danny\\n\\n Candida, often cultured from the peritoneum in these cases, is a\\ncontaminant and does not need specific therapy.\\n\\n Operative treatment\\n\\n Open surgery versus laparoscopy?\\n Omentopexy and peritoneal toilet can be executed laparoscopically.',\n", " 'md': '```markdown\\n# Management of Patients with Perforation\\n\\n## Antibiotics\\n\\nAs soon as the diagnosis of perforation is made, and the patient is booked in for an operation, administer a dose of broad-spectrum antibiotics. The vast majority of patients present for treatment within 12 hours of perforation and therefore suffer from peritoneal contamination rather than infection. In many of them, in fact, the peritonitis is chemical and does not contain any micro-organisms. Antibiotics in this group will serve for prophylaxis. Prolonged postoperative therapeutic antibiotics are not needed. Those who present later than 12 hours may suffer from an established intra-abdominal infection; here antibiotics should be continued in the postoperative phase (see Chapter 44). The antibiotics given, either in the form of monotherapy or combination therapy, should ‘cover’, empirically, Gram-negatives and anaerobes. Routine culturing of the peritoneal fluid in perforated patients is not indicated (see Chapter 13).\\n\\n> But you may be crucified by the infection disease specialist and probably by your boss if you fail to comply with their guidelines. - Danny\\n\\nCandida, often cultured from the peritoneum in these cases, is a contaminant and does not need specific therapy.\\n\\n## Operative Treatment\\n\\n### Open Surgery versus Laparoscopy?\\n\\nOmentopexy and peritoneal toilet can be executed laparoscopically.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management of Patients with Perforation',\n", " 'md': '# Management of Patients with Perforation',\n", " 'bBox': {'x': 86, 'y': 131, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Antibiotics',\n", " 'md': '## Antibiotics',\n", " 'bBox': {'x': 86, 'y': 227, 'w': 85.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As soon as the diagnosis of perforation is made, and the patient is booked in for an operation, administer a dose of broad-spectrum antibiotics. The vast majority of patients present for treatment within 12 hours of perforation and therefore suffer from peritoneal contamination rather than infection. In many of them, in fact, the peritonitis is chemical and does not contain any micro-organisms. Antibiotics in this group will serve for prophylaxis. Prolonged postoperative therapeutic antibiotics are not needed. Those who present later than 12 hours may suffer from an established intra-abdominal infection; here antibiotics should be continued in the postoperative phase (see Chapter 44). The antibiotics given, either in the form of monotherapy or combination therapy, should ‘cover’, empirically, Gram-negatives and anaerobes. Routine culturing of the peritoneal fluid in perforated patients is not indicated (see Chapter 13).\\n\\n> But you may be crucified by the infection disease specialist and probably by your boss if you fail to comply with their guidelines. - Danny\\n\\nCandida, often cultured from the peritoneum in these cases, is a contaminant and does not need specific therapy.',\n", " 'md': 'As soon as the diagnosis of perforation is made, and the patient is booked in for an operation, administer a dose of broad-spectrum antibiotics. The vast majority of patients present for treatment within 12 hours of perforation and therefore suffer from peritoneal contamination rather than infection. In many of them, in fact, the peritonitis is chemical and does not contain any micro-organisms. Antibiotics in this group will serve for prophylaxis. Prolonged postoperative therapeutic antibiotics are not needed. Those who present later than 12 hours may suffer from an established intra-abdominal infection; here antibiotics should be continued in the postoperative phase (see Chapter 44). The antibiotics given, either in the form of monotherapy or combination therapy, should ‘cover’, empirically, Gram-negatives and anaerobes. Routine culturing of the peritoneal fluid in perforated patients is not indicated (see Chapter 13).\\n\\n> But you may be crucified by the infection disease specialist and probably by your boss if you fail to comply with their guidelines. - Danny\\n\\nCandida, often cultured from the peritoneum in these cases, is a contaminant and does not need specific therapy.',\n", " 'bBox': {'x': 72, 'y': 227, 'w': 467.78, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Operative Treatment',\n", " 'md': '## Operative Treatment',\n", " 'bBox': {'x': 86, 'y': 641, 'w': 156.33, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Open Surgery versus Laparoscopy?',\n", " 'md': '### Open Surgery versus Laparoscopy?',\n", " 'bBox': {'x': 86, 'y': 680, 'w': 241.44, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Omentopexy and peritoneal toilet can be executed laparoscopically.\\n```',\n", " 'md': 'Omentopexy and peritoneal toilet can be executed laparoscopically.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'or combination therapy, should ‘cover’, empirically, Gram-negatives and'},\n", " {'text': ''}]},\n", " {'page': 267,\n", " 'text': 'We suggest that a laparoscopic procedure is a reasonable option in\\nstable and well-resuscitated patients and when the perforation can\\nbe promptly and securely closed. Conversely, a prolonged\\npneumoperitoneum will be poorly tolerated in the high-risk or severely\\nseptic patients. And, of course, you must be a skilled laparoscopist (do\\nyou know any surgeon who does not consider himself ‘skilled in\\neverything’?) to be able to perform a safe, watertight laparoscopic\\nomentopexy.\\n Peeya Qal4\\nFigure 18.1. “How should we mend it?”\\n\\n By the way, the laparotomy for omentopexy need not always be a\\nmacrolaparotomy. Instead, with accurate pre-operative diagnosis on CT,\\nyou can repair the perforation and suck out the free peritoneal fluid\\nthrough a limited transverse right subcostal incision or a short midline\\nepigastric incision which are easier on the patient than the traditional long\\nmidline approach ( Chapter 10).\\n\\n Some surgeons would opt for a ‘lap-assisted’ procedure: the',\n", " 'md': '```markdown\\nWe suggest that a laparoscopic procedure is a reasonable option in stable and well-resuscitated patients and when the perforation can be promptly and securely closed. Conversely, a prolonged pneumoperitoneum will be poorly tolerated in the high-risk or severely septic patients. And, of course, you must be a skilled laparoscopist (do you know any surgeon who does not consider himself ‘skilled in everything’?) to be able to perform a safe, watertight laparoscopic omentopexy.\\n\\n**Figure 18.1**: “How should we mend it?”\\n\\nBy the way, the laparotomy for omentopexy need not always be a macrolaparotomy. Instead, with accurate pre-operative diagnosis on CT, you can repair the perforation and suck out the free peritoneal fluid through a limited transverse right subcostal incision or a short midline epigastric incision which are easier on the patient than the traditional long midline approach (Chapter 10).\\n\\nSome surgeons would opt for a ‘lap-assisted’ procedure:\\n```',\n", " 'images': [{'name': 'img_p266_1.png',\n", " 'height': 620,\n", " 'width': 806,\n", " 'x': 106.55999999999995,\n", " 'y': 215.28000000000003,\n", " 'original_width': 1384,\n", " 'original_height': 1064}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nWe suggest that a laparoscopic procedure is a reasonable option in stable and well-resuscitated patients and when the perforation can be promptly and securely closed. Conversely, a prolonged pneumoperitoneum will be poorly tolerated in the high-risk or severely septic patients. And, of course, you must be a skilled laparoscopist (do you know any surgeon who does not consider himself ‘skilled in everything’?) to be able to perform a safe, watertight laparoscopic omentopexy.\\n\\n**Figure 18.1**: “How should we mend it?”\\n\\nBy the way, the laparotomy for omentopexy need not always be a macrolaparotomy. Instead, with accurate pre-operative diagnosis on CT, you can repair the perforation and suck out the free peritoneal fluid through a limited transverse right subcostal incision or a short midline epigastric incision which are easier on the patient than the traditional long midline approach (Chapter 10).\\n\\nSome surgeons would opt for a ‘lap-assisted’ procedure:\\n```',\n", " 'md': '```markdown\\nWe suggest that a laparoscopic procedure is a reasonable option in stable and well-resuscitated patients and when the perforation can be promptly and securely closed. Conversely, a prolonged pneumoperitoneum will be poorly tolerated in the high-risk or severely septic patients. And, of course, you must be a skilled laparoscopist (do you know any surgeon who does not consider himself ‘skilled in everything’?) to be able to perform a safe, watertight laparoscopic omentopexy.\\n\\n**Figure 18.1**: “How should we mend it?”\\n\\nBy the way, the laparotomy for omentopexy need not always be a macrolaparotomy. Instead, with accurate pre-operative diagnosis on CT, you can repair the perforation and suck out the free peritoneal fluid through a limited transverse right subcostal incision or a short midline epigastric incision which are easier on the patient than the traditional long midline approach (Chapter 10).\\n\\nSome surgeons would opt for a ‘lap-assisted’ procedure:\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.67, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 268,\n", " 'text': 'diagnosis is confirmed at laparoscopy, the peritoneal cavity is cleansed; a\\nsmall incision is then placed just on top of the perforation and the hole is\\nfixed.\\n\\n In sum, do what is absolutely safe in your hands — even if open\\nsurgery seems to you not so ‘sexy’ it is still considered ‘OK’.\\n\\n Simple closure of the perforation ( Figure 18.1)\\n\\n The key word is OMENTOPEXY! Classically, simple closure of the ulcer is best achieved by\\n an omental patch (termed Graham’s patch, although described earlier in 1929 by\\n Cellan-Jones — well, the Russians claim that it was V. A. Oppel who first described the\\n operation in 1925), also called omentopexy. Place a few ‘through-all-layers’ interrupted sutures\\n (we use 2-0 Vicryl®, but monofilament is OK) through both edges of the perforation\\n (longitudinal to the axis of the duodenum in order not to narrow the lumen), and leave them\\n untied; fashion a fat pedicle of the greater omentum and flip it up and over the perforation; then\\n gently tie the sutures over the omentum in order not to strangulate it ( Figure 18.2). At this\\n stage ask the anesthetist to inject saline, with or without dye, through the nasogastric tube to\\n ascertain that the patch is waterproof. If it is not then do it again! If the omentum is flimsy or\\n absent for some reason, you can do the same with a mobilized falciform ligament,\\n flipping it down over the perforation.\\n\\n More than a few surgeons misunderstand this operation; they\\ninitially suture-close the perforation and only then cover the suture line\\nwith the omentum. Some, mainly inexperienced laparoscopic surgeons,\\n‘cut corners’ and avoid the patch altogether — it is easier in their hands\\nto suture-close the perforation. But this is a recipe for disaster! This is\\nhow postoperative leaks occur! The approximation of the edematous,\\nfriable edges of perforation can be troublesome. It may be successful in\\nsmall perforations when the edges of the defect are fresh, but in all cases\\nof postoperative duodenal fistula witnessed by us, simple suture-\\nclosure of a perforated DU was the causative mechanism. Be smarter,\\ndo not stitch the perforation but plug it with viable omentum.',\n", " 'md': '```markdown\\n## Surgical Procedure for Perforated Ulcer\\n\\nDiagnosis is confirmed at laparoscopy, the peritoneal cavity is cleansed; a small incision is then placed just on top of the perforation and the hole is fixed.\\n\\nIn sum, do what is absolutely safe in your hands — even if open surgery seems to you not so ‘sexy’ it is still considered ‘OK’.\\n\\n### Simple Closure of the Perforation (Figure 18.1)\\n\\nThe key word is **OMENTOPEXY**! Classically, simple closure of the ulcer is best achieved by an omental patch (termed Graham’s patch, although described earlier in 1929 by Cellan-Jones — well, the Russians claim that it was V. A. Oppel who first described the operation in 1925), also called omentopexy.\\n\\nPlace a few ‘through-all-layers’ interrupted sutures (we use 2-0 Vicryl®, but monofilament is OK) through both edges of the perforation (longitudinal to the axis of the duodenum in order not to narrow the lumen), and leave them untied; fashion a fat pedicle of the greater omentum and flip it up and over the perforation; then gently tie the sutures over the omentum in order not to strangulate it (Figure 18.2).\\n\\nAt this stage, ask the anesthetist to inject saline, with or without dye, through the nasogastric tube to ascertain that the patch is waterproof. If it is not, then do it again! If the omentum is flimsy or absent for some reason, you can do the same with a mobilized falciform ligament, flipping it down over the perforation.\\n\\nMore than a few surgeons misunderstand this operation; they initially suture-close the perforation and only then cover the suture line with the omentum. Some, mainly inexperienced laparoscopic surgeons, ‘cut corners’ and avoid the patch altogether — it is easier in their hands to suture-close the perforation. But this is a recipe for disaster! This is how postoperative leaks occur!\\n\\nThe approximation of the edematous, friable edges of perforation can be troublesome. It may be successful in small perforations when the edges of the defect are fresh, but in all cases of postoperative duodenal fistula witnessed by us, simple suture-closure of a perforated DU was the causative mechanism. Be smarter, do not stitch the perforation but plug it with viable omentum.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Procedure for Perforated Ulcer',\n", " 'md': '## Surgical Procedure for Perforated Ulcer',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Diagnosis is confirmed at laparoscopy, the peritoneal cavity is cleansed; a small incision is then placed just on top of the perforation and the hole is fixed.\\n\\nIn sum, do what is absolutely safe in your hands — even if open surgery seems to you not so ‘sexy’ it is still considered ‘OK’.',\n", " 'md': 'Diagnosis is confirmed at laparoscopy, the peritoneal cavity is cleansed; a small incision is then placed just on top of the perforation and the hole is fixed.\\n\\nIn sum, do what is absolutely safe in your hands — even if open surgery seems to you not so ‘sexy’ it is still considered ‘OK’.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.57, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Simple Closure of the Perforation (Figure 18.1)',\n", " 'md': '### Simple Closure of the Perforation (Figure 18.1)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The key word is **OMENTOPEXY**! Classically, simple closure of the ulcer is best achieved by an omental patch (termed Graham’s patch, although described earlier in 1929 by Cellan-Jones — well, the Russians claim that it was V. A. Oppel who first described the operation in 1925), also called omentopexy.\\n\\nPlace a few ‘through-all-layers’ interrupted sutures (we use 2-0 Vicryl®, but monofilament is OK) through both edges of the perforation (longitudinal to the axis of the duodenum in order not to narrow the lumen), and leave them untied; fashion a fat pedicle of the greater omentum and flip it up and over the perforation; then gently tie the sutures over the omentum in order not to strangulate it (Figure 18.2).\\n\\nAt this stage, ask the anesthetist to inject saline, with or without dye, through the nasogastric tube to ascertain that the patch is waterproof. If it is not, then do it again! If the omentum is flimsy or absent for some reason, you can do the same with a mobilized falciform ligament, flipping it down over the perforation.\\n\\nMore than a few surgeons misunderstand this operation; they initially suture-close the perforation and only then cover the suture line with the omentum. Some, mainly inexperienced laparoscopic surgeons, ‘cut corners’ and avoid the patch altogether — it is easier in their hands to suture-close the perforation. But this is a recipe for disaster! This is how postoperative leaks occur!\\n\\nThe approximation of the edematous, friable edges of perforation can be troublesome. It may be successful in small perforations when the edges of the defect are fresh, but in all cases of postoperative duodenal fistula witnessed by us, simple suture-closure of a perforated DU was the causative mechanism. Be smarter, do not stitch the perforation but plug it with viable omentum.\\n```',\n", " 'md': 'The key word is **OMENTOPEXY**! Classically, simple closure of the ulcer is best achieved by an omental patch (termed Graham’s patch, although described earlier in 1929 by Cellan-Jones — well, the Russians claim that it was V. A. Oppel who first described the operation in 1925), also called omentopexy.\\n\\nPlace a few ‘through-all-layers’ interrupted sutures (we use 2-0 Vicryl®, but monofilament is OK) through both edges of the perforation (longitudinal to the axis of the duodenum in order not to narrow the lumen), and leave them untied; fashion a fat pedicle of the greater omentum and flip it up and over the perforation; then gently tie the sutures over the omentum in order not to strangulate it (Figure 18.2).\\n\\nAt this stage, ask the anesthetist to inject saline, with or without dye, through the nasogastric tube to ascertain that the patch is waterproof. If it is not, then do it again! If the omentum is flimsy or absent for some reason, you can do the same with a mobilized falciform ligament, flipping it down over the perforation.\\n\\nMore than a few surgeons misunderstand this operation; they initially suture-close the perforation and only then cover the suture line with the omentum. Some, mainly inexperienced laparoscopic surgeons, ‘cut corners’ and avoid the patch altogether — it is easier in their hands to suture-close the perforation. But this is a recipe for disaster! This is how postoperative leaks occur!\\n\\nThe approximation of the edematous, friable edges of perforation can be troublesome. It may be successful in small perforations when the edges of the defect are fresh, but in all cases of postoperative duodenal fistula witnessed by us, simple suture-closure of a perforated DU was the causative mechanism. Be smarter, do not stitch the perforation but plug it with viable omentum.\\n```',\n", " 'bBox': {'x': 72, 'y': 276, 'w': 467.92, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 269,\n", " 'text': ' Omentalflap\\n Duodenum Duodenum\\n Wrong Correct\\n Figure 18.2. Simple closure. Note: the omental patch should ‘plug’ the hole with the\\n sutures tied over it. Suturing the hole first and then sticking omentum over the repair is\\n wrong.\\n\\n Should you leave a drain behind? Some surgeons do. We don’t — a\\nperfect, tested omental patch does not leak and makes drains\\nobsolete.\\n\\n I leave a periduodenal drain after open repair when there is more than 24 hours’ delay from the\\n onset of pain to surgery. This detects early leaks and sometimes is sufficient to keep the\\n ensuing fistula ‘controlled’. Ari\\n\\n It appears that drains are left more often after laparoscopic repairs —\\nthis makes sense: the lap surgeons suspect that their repair is not always\\nfantastic…\\n\\n Simple surgical drainage (in ‘difficult’ circumstances)\\n In the absence of basic anesthetic facilities (e.g. somewhere in the\\nbush or remote India) and when confronted with a patient who clearly\\nneeds an operation, there is a viable (and well-described) option. Under',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Omental Flap\\n\\n### Figure 18.2\\n**Description:** This figure illustrates the concept of omental flap closure in relation to the duodenum. It contrasts a \"Wrong\" method with a \"Correct\" method of closure. The correct technique involves using the omental patch to effectively \"plug\" the hole, with sutures tied over it. The incorrect method is suturing the hole first and then placing the omentum over the repair.\\n\\n**Caption:** Simple closure. Note: the omental patch should ‘plug’ the hole with the sutures tied over it. Suturing the hole first and then sticking omentum over the repair is wrong.\\n\\n### Surgical Drainage Considerations\\n- **Drain Usage:** Some surgeons opt to leave a drain behind, but the author does not, asserting that a well-tested omental patch does not leak and makes drains unnecessary.\\n- **Periduodenal Drain:** The author mentions leaving a periduodenal drain after open repair if there is more than a 24-hour delay from the onset of pain to surgery. This is to detect early leaks and sometimes helps in controlling the ensuing fistula.\\n- **Laparoscopic Repairs:** It is noted that drains are left more often after laparoscopic repairs, as surgeons suspect that their repairs may not always be optimal.\\n\\n### Simple Surgical Drainage\\nIn situations where basic anesthetic facilities are lacking (e.g., in remote areas), there exists a viable option for surgical drainage when faced with a patient in need of an operation.\\n\\n```',\n", " 'images': [{'name': 'img_p268_1.png',\n", " 'height': 510,\n", " 'width': 641,\n", " 'x': 147.5999999999999,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1100,\n", " 'original_height': 876}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Omental Flap',\n", " 'md': '## Omental Flap',\n", " 'bBox': {'x': 254.35, 'y': 86.26, 'w': 66.72, 'h': 16.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 18.2',\n", " 'md': '### Figure 18.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure illustrates the concept of omental flap closure in relation to the duodenum. It contrasts a \"Wrong\" method with a \"Correct\" method of closure. The correct technique involves using the omental patch to effectively \"plug\" the hole, with sutures tied over it. The incorrect method is suturing the hole first and then placing the omentum over the repair.\\n\\n**Caption:** Simple closure. Note: the omental patch should ‘plug’ the hole with the sutures tied over it. Suturing the hole first and then sticking omentum over the repair is wrong.',\n", " 'md': '**Description:** This figure illustrates the concept of omental flap closure in relation to the duodenum. It contrasts a \"Wrong\" method with a \"Correct\" method of closure. The correct technique involves using the omental patch to effectively \"plug\" the hole, with sutures tied over it. The incorrect method is suturing the hole first and then placing the omentum over the repair.\\n\\n**Caption:** Simple closure. Note: the omental patch should ‘plug’ the hole with the sutures tied over it. Suturing the hole first and then sticking omentum over the repair is wrong.',\n", " 'bBox': {'x': 75, 'y': 86.26, 'w': 460.57, 'h': 17.79}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Surgical Drainage Considerations',\n", " 'md': '### Surgical Drainage Considerations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Drain Usage:** Some surgeons opt to leave a drain behind, but the author does not, asserting that a well-tested omental patch does not leak and makes drains unnecessary.\\n- **Periduodenal Drain:** The author mentions leaving a periduodenal drain after open repair if there is more than a 24-hour delay from the onset of pain to surgery. This is to detect early leaks and sometimes helps in controlling the ensuing fistula.\\n- **Laparoscopic Repairs:** It is noted that drains are left more often after laparoscopic repairs, as surgeons suspect that their repairs may not always be optimal.',\n", " 'md': '- **Drain Usage:** Some surgeons opt to leave a drain behind, but the author does not, asserting that a well-tested omental patch does not leak and makes drains unnecessary.\\n- **Periduodenal Drain:** The author mentions leaving a periduodenal drain after open repair if there is more than a 24-hour delay from the onset of pain to surgery. This is to detect early leaks and sometimes helps in controlling the ensuing fistula.\\n- **Laparoscopic Repairs:** It is noted that drains are left more often after laparoscopic repairs, as surgeons suspect that their repairs may not always be optimal.',\n", " 'bBox': {'x': 254.35, 'y': 87.74, 'w': 46.46, 'h': 12.85}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Simple Surgical Drainage',\n", " 'md': '### Simple Surgical Drainage',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In situations where basic anesthetic facilities are lacking (e.g., in remote areas), there exists a viable option for surgical drainage when faced with a patient in need of an operation.\\n\\n```',\n", " 'md': 'In situations where basic anesthetic facilities are lacking (e.g., in remote areas), there exists a viable option for surgical drainage when faced with a patient in need of an operation.\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 270,\n", " 'text': 'local anesthesia the upper abdomen may be entered through a limited\\nincision and, after aspiration of as much muck and pus as possible, a\\nlarge drain can be left under the liver in the region of the duodenum. If\\nthe perforation seals spontaneously the drain helps to control the\\nassociated abscess; if not, then it forms a life-saving controlled duodenal\\nfistula, to be dealt with — conservatively or operatively — later and\\nelsewhere (not in the bush!). Our friend, Dr. Kuldip Pandey, a surgeon in\\nrural India told us: “In moribund patients, if conditions don’t permit for\\nlaparotomy, I generally put in a drain under vision (under local\\nanesthesia). Quite often I do it bedside or in the minor OR cum dressing\\nroom attached to my ward. In quite a number of cases only this much has\\nled to great improvement in the general condition of the patient who were\\nlater operated [upon] and discharged successfully.”\\n\\n Operative treatment: definitive surgery?\\n So is there any indication left to add a definitive ulcer procedure?\\n\\n It is, according to Dr. Alex Berzoy of Odessa, Ukraine: “The patient\\nwho would buy vodka instead of a proton pump inhibitor.” And he is right!\\nThe very patients who are susceptible to perforation also suffer from\\nsubstandard access to medical care and reduced compliance, both\\nadversely affecting successful medical anti-ulcer therapies. This is\\nobviously much more common in the developing world. Consequently, if\\nthe operation for a perforated ulcer can kill two birds with one stone\\n(especially if the environment around you cannot ensure optimal medical\\nmanagement and follow-up of your patient), why not add a definitive\\nprocedure? — that is, if you know how to do it. While intractability as a\\nreal issue seems to be limited to the developing world, other special\\nproblems which could indicate a definitive procedure may be\\npresent anywhere (see below).\\n In which patients is a definitive procedure safe?\\n Well, you certainly do not want to embark on a lengthy definitive\\nprocedure in a critically ill and septic patient. ħowever, over the years we\\nhave encountered surgeons who omitted a definitive procedure because\\nof ‘severe contamination’, often quoting a myth that vagotomy in a\\nperforated patient may “spread the infection into the mediastinum”. The\\nħong Kong group showed that when the following three factors are',\n", " 'md': '```markdown\\n## Local Anesthesia and Operative Treatment\\n\\nLocal anesthesia in the upper abdomen may be entered through a limited incision and, after aspiration of as much muck and pus as possible, a large drain can be left under the liver in the region of the duodenum. If the perforation seals spontaneously, the drain helps to control the associated abscess; if not, then it forms a life-saving controlled duodenal fistula, to be dealt with — conservatively or operatively — later and elsewhere (not in the bush!).\\n\\nOur friend, Dr. Kuldip Pandey, a surgeon in rural India, told us: “In moribund patients, if conditions don’t permit for laparotomy, I generally put in a drain under vision (under local anesthesia). Quite often I do it bedside or in the minor OR cum dressing room attached to my ward. In quite a number of cases only this much has led to great improvement in the general condition of the patient who were later operated [upon] and discharged successfully.”\\n\\n### Operative Treatment: Definitive Surgery?\\n\\nSo is there any indication left to add a definitive ulcer procedure?\\n\\nIt is, according to Dr. Alex Berzoy of Odessa, Ukraine: “The patient who would buy vodka instead of a proton pump inhibitor.” And he is right! The very patients who are susceptible to perforation also suffer from substandard access to medical care and reduced compliance, both adversely affecting successful medical anti-ulcer therapies. This is obviously much more common in the developing world. Consequently, if the operation for a perforated ulcer can kill two birds with one stone (especially if the environment around you cannot ensure optimal medical management and follow-up of your patient), why not add a definitive procedure? — that is, if you know how to do it.\\n\\nWhile intractability as a real issue seems to be limited to the developing world, other special problems which could indicate a definitive procedure may be present anywhere (see below).\\n\\n### In Which Patients is a Definitive Procedure Safe?\\n\\nWell, you certainly do not want to embark on a lengthy definitive procedure in a critically ill and septic patient. However, over the years we have encountered surgeons who omitted a definitive procedure because of ‘severe contamination’, often quoting a myth that vagotomy in a perforated patient may “spread the infection into the mediastinum”. The Hong Kong group showed that when the following three factors are...\\n```\\n\\n*Note: The text has been transcribed accurately, and no images or tables were identified in the provided content.*',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Local Anesthesia and Operative Treatment',\n", " 'md': '## Local Anesthesia and Operative Treatment',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Local anesthesia in the upper abdomen may be entered through a limited incision and, after aspiration of as much muck and pus as possible, a large drain can be left under the liver in the region of the duodenum. If the perforation seals spontaneously, the drain helps to control the associated abscess; if not, then it forms a life-saving controlled duodenal fistula, to be dealt with — conservatively or operatively — later and elsewhere (not in the bush!).\\n\\nOur friend, Dr. Kuldip Pandey, a surgeon in rural India, told us: “In moribund patients, if conditions don’t permit for laparotomy, I generally put in a drain under vision (under local anesthesia). Quite often I do it bedside or in the minor OR cum dressing room attached to my ward. In quite a number of cases only this much has led to great improvement in the general condition of the patient who were later operated [upon] and discharged successfully.”',\n", " 'md': 'Local anesthesia in the upper abdomen may be entered through a limited incision and, after aspiration of as much muck and pus as possible, a large drain can be left under the liver in the region of the duodenum. If the perforation seals spontaneously, the drain helps to control the associated abscess; if not, then it forms a life-saving controlled duodenal fistula, to be dealt with — conservatively or operatively — later and elsewhere (not in the bush!).\\n\\nOur friend, Dr. Kuldip Pandey, a surgeon in rural India, told us: “In moribund patients, if conditions don’t permit for laparotomy, I generally put in a drain under vision (under local anesthesia). Quite often I do it bedside or in the minor OR cum dressing room attached to my ward. In quite a number of cases only this much has led to great improvement in the general condition of the patient who were later operated [upon] and discharged successfully.”',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Operative Treatment: Definitive Surgery?',\n", " 'md': '### Operative Treatment: Definitive Surgery?',\n", " 'bBox': {'x': 86, 'y': 323, 'w': 273.41, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'So is there any indication left to add a definitive ulcer procedure?\\n\\nIt is, according to Dr. Alex Berzoy of Odessa, Ukraine: “The patient who would buy vodka instead of a proton pump inhibitor.” And he is right! The very patients who are susceptible to perforation also suffer from substandard access to medical care and reduced compliance, both adversely affecting successful medical anti-ulcer therapies. This is obviously much more common in the developing world. Consequently, if the operation for a perforated ulcer can kill two birds with one stone (especially if the environment around you cannot ensure optimal medical management and follow-up of your patient), why not add a definitive procedure? — that is, if you know how to do it.\\n\\nWhile intractability as a real issue seems to be limited to the developing world, other special problems which could indicate a definitive procedure may be present anywhere (see below).',\n", " 'md': 'So is there any indication left to add a definitive ulcer procedure?\\n\\nIt is, according to Dr. Alex Berzoy of Odessa, Ukraine: “The patient who would buy vodka instead of a proton pump inhibitor.” And he is right! The very patients who are susceptible to perforation also suffer from substandard access to medical care and reduced compliance, both adversely affecting successful medical anti-ulcer therapies. This is obviously much more common in the developing world. Consequently, if the operation for a perforated ulcer can kill two birds with one stone (especially if the environment around you cannot ensure optimal medical management and follow-up of your patient), why not add a definitive procedure? — that is, if you know how to do it.\\n\\nWhile intractability as a real issue seems to be limited to the developing world, other special problems which could indicate a definitive procedure may be present anywhere (see below).',\n", " 'bBox': {'x': 72, 'y': 344, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'In Which Patients is a Definitive Procedure Safe?',\n", " 'md': '### In Which Patients is a Definitive Procedure Safe?',\n", " 'bBox': {'x': 82, 'y': 608, 'w': 245.68, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': 'Well, you certainly do not want to embark on a lengthy definitive procedure in a critically ill and septic patient. However, over the years we have encountered surgeons who omitted a definitive procedure because of ‘severe contamination’, often quoting a myth that vagotomy in a perforated patient may “spread the infection into the mediastinum”. The Hong Kong group showed that when the following three factors are...\\n```\\n\\n*Note: The text has been transcribed accurately, and no images or tables were identified in the provided content.*',\n", " 'md': 'Well, you certainly do not want to embark on a lengthy definitive procedure in a critically ill and septic patient. However, over the years we have encountered surgeons who omitted a definitive procedure because of ‘severe contamination’, often quoting a myth that vagotomy in a perforated patient may “spread the infection into the mediastinum”. The Hong Kong group showed that when the following three factors are...\\n```\\n\\n*Note: The text has been transcribed accurately, and no images or tables were identified in the provided content.*',\n", " 'bBox': {'x': 72, 'y': 661, 'w': 467.74, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 271,\n", " 'text': 'present, an anti-ulcer procedure can be safely performed: blood\\npressure >90mmHg, operation within 48 hours of perforation, and\\nlack of associated medical illnesses. We found the APACħE II 1\\nscoring system ( Chapter 6) useful in this situation as patients with\\nperforated ulcers with scores of less than 11 can tolerate a definitive\\nprocedure of any magnitude. Conversely, in patients with higher APACħE\\nII scores, the simplest operation should be performed.\\n Which definitive procedure?\\n Ideally, in an emergency you should choose the anti-ulcer procedure\\nwith which you are most familiar in the elective situation. The problem is\\nthat today you and other young surgeons are deprived of experience with\\nelective anti-ulcer operations. Based on our philosophy to avoid, if\\npossible, a gastric resection for a benign process, and on results of\\nelective ulcer operations (good old history!), we recommend an operative\\npolicy which tailors the definitive procedure to the special situation as\\ndiscussed in the following section. Whatever you do please remember\\nthat if your patient is sick and you are not a skilled gastroduodenal\\nsurgeon — forget about the definitive procedure. Just patch the\\nhole and get out! Anyway, it seems that in a few years no surgeon able\\nto do a vagotomy will be still practicing. So perhaps in future editions of\\nthis book there will be no chapter dedicated to perforated peptic ulcer; or\\nthe only operative option mentioned will be omentopexy. In fact, a few of\\nmy co-editors suggested that I remove this section altogether. But not\\nyet…\\n\\n Special problems\\n\\n These are the situations which may require more than simple\\nclosure:\\n\\n • ‘Kissing’ ulcers: coexisting active UGI bleeding suggests the\\n possibility of ‘kissing’ ulcers — the anterior perforated, the\\n posterior bleeding. Simple closure of the former, without\\n hemostasis for the latter, could lead to a severe postoperative\\n hemorrhage. In such circumstances enlarge the duodenal\\n perforation into a duodenotomy and explore the inside of the\\n duodenum. If a bleeding posterior ulcer is found, suture-transfix its',\n", " 'md': '```markdown\\n# Page Content\\n\\nAn anti-ulcer procedure can be safely performed under the following conditions: blood pressure > 90 mmHg, operation within 48 hours of perforation, and lack of associated medical illnesses. We found the APACħE II scoring system (Chapter 6) useful in this situation, as patients with perforated ulcers with scores of less than 11 can tolerate a definitive procedure of any magnitude. Conversely, in patients with higher APACħE II scores, the simplest operation should be performed.\\n\\n## Which definitive procedure?\\n\\nIdeally, in an emergency, you should choose the anti-ulcer procedure with which you are most familiar in the elective situation. The problem is that today you and other young surgeons are deprived of experience with elective anti-ulcer operations. Based on our philosophy to avoid, if possible, a gastric resection for a benign process, and on results of elective ulcer operations (good old history!), we recommend an operative policy that tailors the definitive procedure to the special situation as discussed in the following section. Whatever you do, please remember that if your patient is sick and you are not a skilled gastroduodenal surgeon — forget about the definitive procedure. Just patch the hole and get out! Anyway, it seems that in a few years no surgeon able to do a vagotomy will be still practicing. So perhaps in future editions of this book, there will be no chapter dedicated to perforated peptic ulcer; or the only operative option mentioned will be omentopexy. In fact, a few of my co-editors suggested that I remove this section altogether. But not yet…\\n\\n## Special problems\\n\\nThese are the situations which may require more than simple closure:\\n\\n- **‘Kissing’ ulcers**: Coexisting active UGI bleeding suggests the possibility of ‘kissing’ ulcers — the anterior perforated, the posterior bleeding. Simple closure of the former, without hemostasis for the latter, could lead to a severe postoperative hemorrhage. In such circumstances, enlarge the duodenal perforation into a duodenotomy and explore the inside of the duodenum. If a bleeding posterior ulcer is found, suture-transfix its...\\n```\\n\\n### Notes:\\n- No images or figures were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'An anti-ulcer procedure can be safely performed under the following conditions: blood pressure > 90 mmHg, operation within 48 hours of perforation, and lack of associated medical illnesses. We found the APACħE II scoring system (Chapter 6) useful in this situation, as patients with perforated ulcers with scores of less than 11 can tolerate a definitive procedure of any magnitude. Conversely, in patients with higher APACħE II scores, the simplest operation should be performed.',\n", " 'md': 'An anti-ulcer procedure can be safely performed under the following conditions: blood pressure > 90 mmHg, operation within 48 hours of perforation, and lack of associated medical illnesses. We found the APACħE II scoring system (Chapter 6) useful in this situation, as patients with perforated ulcers with scores of less than 11 can tolerate a definitive procedure of any magnitude. Conversely, in patients with higher APACħE II scores, the simplest operation should be performed.',\n", " 'bBox': {'x': 72, 'y': 170, 'w': 467.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Which definitive procedure?',\n", " 'md': '## Which definitive procedure?',\n", " 'bBox': {'x': 82, 'y': 217, 'w': 145.03, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': 'Ideally, in an emergency, you should choose the anti-ulcer procedure with which you are most familiar in the elective situation. The problem is that today you and other young surgeons are deprived of experience with elective anti-ulcer operations. Based on our philosophy to avoid, if possible, a gastric resection for a benign process, and on results of elective ulcer operations (good old history!), we recommend an operative policy that tailors the definitive procedure to the special situation as discussed in the following section. Whatever you do, please remember that if your patient is sick and you are not a skilled gastroduodenal surgeon — forget about the definitive procedure. Just patch the hole and get out! Anyway, it seems that in a few years no surgeon able to do a vagotomy will be still practicing. So perhaps in future editions of this book, there will be no chapter dedicated to perforated peptic ulcer; or the only operative option mentioned will be omentopexy. In fact, a few of my co-editors suggested that I remove this section altogether. But not yet…',\n", " 'md': 'Ideally, in an emergency, you should choose the anti-ulcer procedure with which you are most familiar in the elective situation. The problem is that today you and other young surgeons are deprived of experience with elective anti-ulcer operations. Based on our philosophy to avoid, if possible, a gastric resection for a benign process, and on results of elective ulcer operations (good old history!), we recommend an operative policy that tailors the definitive procedure to the special situation as discussed in the following section. Whatever you do, please remember that if your patient is sick and you are not a skilled gastroduodenal surgeon — forget about the definitive procedure. Just patch the hole and get out! Anyway, it seems that in a few years no surgeon able to do a vagotomy will be still practicing. So perhaps in future editions of this book, there will be no chapter dedicated to perforated peptic ulcer; or the only operative option mentioned will be omentopexy. In fact, a few of my co-editors suggested that I remove this section altogether. But not yet…',\n", " 'bBox': {'x': 72, 'y': 253, 'w': 467.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Special problems',\n", " 'md': '## Special problems',\n", " 'bBox': {'x': 86, 'y': 528, 'w': 137.02, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'These are the situations which may require more than simple closure:\\n\\n- **‘Kissing’ ulcers**: Coexisting active UGI bleeding suggests the possibility of ‘kissing’ ulcers — the anterior perforated, the posterior bleeding. Simple closure of the former, without hemostasis for the latter, could lead to a severe postoperative hemorrhage. In such circumstances, enlarge the duodenal perforation into a duodenotomy and explore the inside of the duodenum. If a bleeding posterior ulcer is found, suture-transfix its...\\n```',\n", " 'md': 'These are the situations which may require more than simple closure:\\n\\n- **‘Kissing’ ulcers**: Coexisting active UGI bleeding suggests the possibility of ‘kissing’ ulcers — the anterior perforated, the posterior bleeding. Simple closure of the former, without hemostasis for the latter, could lead to a severe postoperative hemorrhage. In such circumstances, enlarge the duodenal perforation into a duodenotomy and explore the inside of the duodenum. If a bleeding posterior ulcer is found, suture-transfix its...\\n```',\n", " 'bBox': {'x': 72, 'y': 581, 'w': 85.57, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images or figures were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 442, 'y': 683, 'w': 23.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'perforated ulcers with scores of less than 11 can tolerate a definitive'}]},\n", " {'page': 272,\n", " 'text': ' base as described in the preceding Chapter 17.\\n• Perforated giant ulcers: while omentopexy can be used to repair\\n most perforated DUs, a giant perforated DU may create a huge\\n anterior bulbar-pyloric defect, which is not amenable to safe closure\\n and thus mandates partial gastrectomy. In our hands this would\\n be a Billroth I gastroduodenostomy as depicted in Figure 17.2 in\\n the previous chapter.\\n• Perforated gastric ulcers: these are usually larger than the\\n duodenal ones. For those positioned on the greater curvature of the\\n stomach, a wedge resection of the ulcer, hand sutured or stapled,\\n may be easier and safer than omentopexy. For chronic and large\\n lesser curvature ulcers, omentopexy is notoriously difficult and\\n unsafe; partial gastrectomy may serve the patient better.\\n Perforations of malignant gastric ulcers are very rare in the west (but\\n in India, for example, many gastric perforations are malignant). Be\\n that as it may, if we decide to patch a gastric perforation we would\\n take a few biopsies from its edges before closing it. If positive for\\n cancer, an elective reoperation for ‘oncological’ gastrectomy may be\\n necessary.\\n• Pyloric obstruction: perforated DUs are rarely associated with\\n chronic narrowing of the gastric outlet. But if the patient gives a\\n history of prolonged postprandial vomiting and/or at operation his\\n stomach appears dilated and thickened, consider that possibility.\\n Insert your index finger through the duodenal perforation and up the\\n pylorus, or feed in a Foley catheter and check whether the inflated\\n balloon (5cc) passes easily through the pylorus. Documented\\n pyloric stenosis would demand the addition of some form of\\n drainage procedure (pyloroplasty or gastrojejunostomy). Whether\\n you wish to add a truncal vagotomy is up to you.\\n• Intractable cases: selected patients with a clear history of chronicity\\n or intractability (e.g. a recurrent perforation), with no easy access to\\n healthcare and medications may benefit from a definitive anti-ulcer\\n procedure. That surgeons in London or ħouston no longer find\\n indications for acid-reducing procedures does not mean that there\\n are no patients in Tbilisi who would benefit from it.\\n\\n Non-operative management of perforated ulcers',\n", " 'md': '```markdown\\n## Non-operative Management of Perforated Ulcers\\n\\n- **Perforated giant ulcers**: While omentopexy can be used to repair most perforated duodenal ulcers (DUs), a giant perforated DU may create a huge anterior bulbar-pyloric defect, which is not amenable to safe closure and thus mandates partial gastrectomy. In our hands, this would be a Billroth I gastroduodenostomy as depicted in Figure 17.2 in the previous chapter.\\n\\n- **Perforated gastric ulcers**: These are usually larger than the duodenal ones. For those positioned on the greater curvature of the stomach, a wedge resection of the ulcer, hand sutured or stapled, may be easier and safer than omentopexy. For chronic and large lesser curvature ulcers, omentopexy is notoriously difficult and unsafe; partial gastrectomy may serve the patient better. Perforations of malignant gastric ulcers are very rare in the west (but in India, for example, many gastric perforations are malignant). Be that as it may, if we decide to patch a gastric perforation, we would take a few biopsies from its edges before closing it. If positive for cancer, an elective reoperation for ‘oncological’ gastrectomy may be necessary.\\n\\n- **Pyloric obstruction**: Perforated DUs are rarely associated with chronic narrowing of the gastric outlet. But if the patient gives a history of prolonged postprandial vomiting and/or at operation his stomach appears dilated and thickened, consider that possibility. Insert your index finger through the duodenal perforation and up the pylorus, or feed in a Foley catheter and check whether the inflated balloon (5cc) passes easily through the pylorus. Documented pyloric stenosis would demand the addition of some form of drainage procedure (pyloroplasty or gastrojejunostomy). Whether you wish to add a truncal vagotomy is up to you.\\n\\n- **Intractable cases**: Selected patients with a clear history of chronicity or intractability (e.g., a recurrent perforation), with no easy access to healthcare and medications may benefit from a definitive anti-ulcer procedure. That surgeons in London or Houston no longer find indications for acid-reducing procedures does not mean that there are no patients in Tbilisi who would benefit from it.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Non-operative Management of Perforated Ulcers',\n", " 'md': '## Non-operative Management of Perforated Ulcers',\n", " 'bBox': {'x': 86, 'y': 705, 'w': 377.95, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- **Perforated giant ulcers**: While omentopexy can be used to repair most perforated duodenal ulcers (DUs), a giant perforated DU may create a huge anterior bulbar-pyloric defect, which is not amenable to safe closure and thus mandates partial gastrectomy. In our hands, this would be a Billroth I gastroduodenostomy as depicted in Figure 17.2 in the previous chapter.\\n\\n- **Perforated gastric ulcers**: These are usually larger than the duodenal ones. For those positioned on the greater curvature of the stomach, a wedge resection of the ulcer, hand sutured or stapled, may be easier and safer than omentopexy. For chronic and large lesser curvature ulcers, omentopexy is notoriously difficult and unsafe; partial gastrectomy may serve the patient better. Perforations of malignant gastric ulcers are very rare in the west (but in India, for example, many gastric perforations are malignant). Be that as it may, if we decide to patch a gastric perforation, we would take a few biopsies from its edges before closing it. If positive for cancer, an elective reoperation for ‘oncological’ gastrectomy may be necessary.\\n\\n- **Pyloric obstruction**: Perforated DUs are rarely associated with chronic narrowing of the gastric outlet. But if the patient gives a history of prolonged postprandial vomiting and/or at operation his stomach appears dilated and thickened, consider that possibility. Insert your index finger through the duodenal perforation and up the pylorus, or feed in a Foley catheter and check whether the inflated balloon (5cc) passes easily through the pylorus. Documented pyloric stenosis would demand the addition of some form of drainage procedure (pyloroplasty or gastrojejunostomy). Whether you wish to add a truncal vagotomy is up to you.\\n\\n- **Intractable cases**: Selected patients with a clear history of chronicity or intractability (e.g., a recurrent perforation), with no easy access to healthcare and medications may benefit from a definitive anti-ulcer procedure. That surgeons in London or Houston no longer find indications for acid-reducing procedures does not mean that there are no patients in Tbilisi who would benefit from it.\\n```',\n", " 'md': '- **Perforated giant ulcers**: While omentopexy can be used to repair most perforated duodenal ulcers (DUs), a giant perforated DU may create a huge anterior bulbar-pyloric defect, which is not amenable to safe closure and thus mandates partial gastrectomy. In our hands, this would be a Billroth I gastroduodenostomy as depicted in Figure 17.2 in the previous chapter.\\n\\n- **Perforated gastric ulcers**: These are usually larger than the duodenal ones. For those positioned on the greater curvature of the stomach, a wedge resection of the ulcer, hand sutured or stapled, may be easier and safer than omentopexy. For chronic and large lesser curvature ulcers, omentopexy is notoriously difficult and unsafe; partial gastrectomy may serve the patient better. Perforations of malignant gastric ulcers are very rare in the west (but in India, for example, many gastric perforations are malignant). Be that as it may, if we decide to patch a gastric perforation, we would take a few biopsies from its edges before closing it. If positive for cancer, an elective reoperation for ‘oncological’ gastrectomy may be necessary.\\n\\n- **Pyloric obstruction**: Perforated DUs are rarely associated with chronic narrowing of the gastric outlet. But if the patient gives a history of prolonged postprandial vomiting and/or at operation his stomach appears dilated and thickened, consider that possibility. Insert your index finger through the duodenal perforation and up the pylorus, or feed in a Foley catheter and check whether the inflated balloon (5cc) passes easily through the pylorus. Documented pyloric stenosis would demand the addition of some form of drainage procedure (pyloroplasty or gastrojejunostomy). Whether you wish to add a truncal vagotomy is up to you.\\n\\n- **Intractable cases**: Selected patients with a clear history of chronicity or intractability (e.g., a recurrent perforation), with no easy access to healthcare and medications may benefit from a definitive anti-ulcer procedure. That surgeons in London or Houston no longer find indications for acid-reducing procedures does not mean that there are no patients in Tbilisi who would benefit from it.\\n```',\n", " 'bBox': {'x': 100, 'y': 138, 'w': 436.73, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 273,\n", " 'text': ' A non-operative approach consisting of nil per mouth, nasogastric\\nsuction, systemic antibiotics, and acid secretion inhibitors, has been\\nproven effective by a few enthusiastic groups. The sine qua non for\\nsuccess is the spontaneous sealing of the perforation by the omentum or\\nother adjacent structures; if this occurs, a non-operative approach would\\nbe successful in the majority of cases.\\n\\n Non-operative treatment may be of particular value for two types\\nof patients: the ‘late presenter’ and the ‘extremely sick’.\\n\\n • The ‘late presenter’ comes to you a day or more after the\\n perforation occurred, with an already improving clinical picture and\\n minimal abdominal findings. This, together with radiographic\\n evidence of free air, hints at a localized and spontaneously sealed\\n perforation. Non-operative treatment, following a Gastrografin® UGI\\n study, or contrast CT, to document that the perforation is sealed,\\n should be successful in most instances.\\n • The ‘extremely sick’ are the other candidates for conservative\\n therapy: those in whom the risk of any operation could be\\n prohibitive, such as the early post-massive myocardial infarct\\n patient, the COPD (chronic obstructive pulmonary disease) grade IV\\n patient, or the patient with an APACħE II score over 25. Also in this\\n group, however, conservative treatment may be successful only if\\n the perforation is sealed and radiographically proven to be so. Of\\n course, localized collections or abscesses developing at the site of\\n the sealed perforation can be drained percutaneously under CT\\n guidance ( Chapter 46).\\n\\n Leaks after the operation?\\n\\n If you have performed a proper omentopexy you do not need to\\nbother reading about how to deal with leaks. ħowever, series of\\npatients developing leaks from the perforation repair sites are being\\nreported — reflecting, as mentioned above, a faulty operative technique,\\nmostly laparoscopic but also ‘open’. Details on how to manage such\\nleaks you will find in our book on complications 2.',\n", " 'md': '```markdown\\n## Non-Operative Approach to Perforation Management\\n\\nA non-operative approach consisting of nil per mouth, nasogastric suction, systemic antibiotics, and acid secretion inhibitors has been proven effective by a few enthusiastic groups. The sine qua non for success is the spontaneous sealing of the perforation by the omentum or other adjacent structures; if this occurs, a non-operative approach would be successful in the majority of cases.\\n\\nNon-operative treatment may be of particular value for two types of patients: the ‘late presenter’ and the ‘extremely sick’.\\n\\n- The ‘late presenter’ comes to you a day or more after the perforation occurred, with an already improving clinical picture and minimal abdominal findings. This, together with radiographic evidence of free air, hints at a localized and spontaneously sealed perforation. Non-operative treatment, following a Gastrografin® UGI study, or contrast CT, to document that the perforation is sealed, should be successful in most instances.\\n\\n- The ‘extremely sick’ are the other candidates for conservative therapy: those in whom the risk of any operation could be prohibitive, such as the early post-massive myocardial infarct patient, the COPD (chronic obstructive pulmonary disease) grade IV patient, or the patient with an APACħE II score over 25. Also in this group, however, conservative treatment may be successful only if the perforation is sealed and radiographically proven to be so. Of course, localized collections or abscesses developing at the site of the sealed perforation can be drained percutaneously under CT guidance (Chapter 46).\\n\\n### Leaks after the Operation?\\n\\nIf you have performed a proper omentopexy you do not need to bother reading about how to deal with leaks. However, series of patients developing leaks from the perforation repair sites are being reported — reflecting, as mentioned above, a faulty operative technique, mostly laparoscopic but also ‘open’. Details on how to manage such leaks you will find in our book on complications.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Non-Operative Approach to Perforation Management',\n", " 'md': '## Non-Operative Approach to Perforation Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A non-operative approach consisting of nil per mouth, nasogastric suction, systemic antibiotics, and acid secretion inhibitors has been proven effective by a few enthusiastic groups. The sine qua non for success is the spontaneous sealing of the perforation by the omentum or other adjacent structures; if this occurs, a non-operative approach would be successful in the majority of cases.\\n\\nNon-operative treatment may be of particular value for two types of patients: the ‘late presenter’ and the ‘extremely sick’.\\n\\n- The ‘late presenter’ comes to you a day or more after the perforation occurred, with an already improving clinical picture and minimal abdominal findings. This, together with radiographic evidence of free air, hints at a localized and spontaneously sealed perforation. Non-operative treatment, following a Gastrografin® UGI study, or contrast CT, to document that the perforation is sealed, should be successful in most instances.\\n\\n- The ‘extremely sick’ are the other candidates for conservative therapy: those in whom the risk of any operation could be prohibitive, such as the early post-massive myocardial infarct patient, the COPD (chronic obstructive pulmonary disease) grade IV patient, or the patient with an APACħE II score over 25. Also in this group, however, conservative treatment may be successful only if the perforation is sealed and radiographically proven to be so. Of course, localized collections or abscesses developing at the site of the sealed perforation can be drained percutaneously under CT guidance (Chapter 46).',\n", " 'md': 'A non-operative approach consisting of nil per mouth, nasogastric suction, systemic antibiotics, and acid secretion inhibitors has been proven effective by a few enthusiastic groups. The sine qua non for success is the spontaneous sealing of the perforation by the omentum or other adjacent structures; if this occurs, a non-operative approach would be successful in the majority of cases.\\n\\nNon-operative treatment may be of particular value for two types of patients: the ‘late presenter’ and the ‘extremely sick’.\\n\\n- The ‘late presenter’ comes to you a day or more after the perforation occurred, with an already improving clinical picture and minimal abdominal findings. This, together with radiographic evidence of free air, hints at a localized and spontaneously sealed perforation. Non-operative treatment, following a Gastrografin® UGI study, or contrast CT, to document that the perforation is sealed, should be successful in most instances.\\n\\n- The ‘extremely sick’ are the other candidates for conservative therapy: those in whom the risk of any operation could be prohibitive, such as the early post-massive myocardial infarct patient, the COPD (chronic obstructive pulmonary disease) grade IV patient, or the patient with an APACħE II score over 25. Also in this group, however, conservative treatment may be successful only if the perforation is sealed and radiographically proven to be so. Of course, localized collections or abscesses developing at the site of the sealed perforation can be drained percutaneously under CT guidance (Chapter 46).',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.69, 'h': 17.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Leaks after the Operation?',\n", " 'md': '### Leaks after the Operation?',\n", " 'bBox': {'x': 86, 'y': 571, 'w': 206.9, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'If you have performed a proper omentopexy you do not need to bother reading about how to deal with leaks. However, series of patients developing leaks from the perforation repair sites are being reported — reflecting, as mentioned above, a faulty operative technique, mostly laparoscopic but also ‘open’. Details on how to manage such leaks you will find in our book on complications.\\n```',\n", " 'md': 'If you have performed a proper omentopexy you do not need to bother reading about how to deal with leaks. However, series of patients developing leaks from the perforation repair sites are being reported — reflecting, as mentioned above, a faulty operative technique, mostly laparoscopic but also ‘open’. Details on how to manage such leaks you will find in our book on complications.\\n```',\n", " 'bBox': {'x': 72, 'y': 657, 'w': 467.69, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'leaks you will find in our book on complications '}]},\n", " {'page': 274,\n", " 'text': ' Let us not forget:\\n\\n …a course of anti-Helicobacter antibiotics after the operation,\\ncombined with appropriate acid-reducing agents. ħigh-risk elderly\\npatients may need acid suppression for the rest of their lives. The\\nduration of such management in younger patients, and whether they will\\nbe re-infected with the ulcerogenic bacteria, is controversial.\\n\\n Final words…\\n\\n Patch a perforated ulcer if you can. In the vast majority of patients this\\nis possible, but if not then you must resect. Consider adding a definitive\\nanti-ulcer procedure on an extremely selective basis (almost never), and\\ndo not forget that a non-operative approach is possible, beneficial and\\nindicated in selected patients. Whatever you do, large studies show that\\none-third of these patients will be dead within 5 years — the same factors\\nwhich led to the perforation shorten their lives.\\n\\n “We have no responsibility to such patients but to save\\n their lives. Any procedure, which aims to do more than\\n this, can quite significantly be considered meddlesome\\n surgery. We have no responsibility during the surgery to\\n carry out any procedure to cure the patient of his\\n duodenal ulcer.”\\n Roscoe R. Graham\\n\\n 1 Acute Physiology and Chronic Health Evaluation II.\\n 2 Tang WH. Leaking gastrointestinal anastomoses — Stomach and duodenum. In: Schein’s\\n Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK:\\n tfm publishing, 2013; Chapter 6.3: 116.',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nLet us not forget:\\n\\n…a course of anti-Helicobacter antibiotics after the operation, combined with appropriate acid-reducing agents. High-risk elderly patients may need acid suppression for the rest of their lives. The duration of such management in younger patients, and whether they will be re-infected with the ulcerogenic bacteria, is controversial.\\n\\nFinal words…\\n\\nPatch a perforated ulcer if you can. In the vast majority of patients this is possible, but if not then you must resect. Consider adding a definitive anti-ulcer procedure on an extremely selective basis (almost never), and do not forget that a non-operative approach is possible, beneficial and indicated in selected patients. Whatever you do, large studies show that one-third of these patients will be dead within 5 years — the same factors which led to the perforation shorten their lives.\\n\\n“We have no responsibility to such patients but to save their lives. Any procedure, which aims to do more than this, can quite significantly be considered meddlesome surgery. We have no responsibility during the surgery to carry out any procedure to cure the patient of his duodenal ulcer.”\\nRoscoe R. Graham\\n\\n1. Acute Physiology and Chronic Health Evaluation II.\\n2. Tang WH. Leaking gastrointestinal anastomoses — Stomach and duodenum. In: Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013; Chapter 6.3: 116.\\n\\n## Hyperlinks\\n- Tang WH. Leaking gastrointestinal anastomoses — Stomach and duodenum. In: Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013; Chapter 6.3: 116.\\n\\n## Image Identification and Description\\n- No images or graphs were identified on this page.\\n\\n## Summary\\nThis page discusses the management of perforated ulcers, emphasizing the importance of anti-Helicobacter antibiotics and acid-reducing agents, particularly for high-risk elderly patients. It also highlights the necessity of surgical intervention in certain cases and the potential outcomes for patients with perforated ulcers. The quote from Roscoe R. Graham underscores the surgical philosophy regarding the treatment of duodenal ulcers.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Let us not forget:\\n\\n…a course of anti-Helicobacter antibiotics after the operation, combined with appropriate acid-reducing agents. High-risk elderly patients may need acid suppression for the rest of their lives. The duration of such management in younger patients, and whether they will be re-infected with the ulcerogenic bacteria, is controversial.\\n\\nFinal words…\\n\\nPatch a perforated ulcer if you can. In the vast majority of patients this is possible, but if not then you must resect. Consider adding a definitive anti-ulcer procedure on an extremely selective basis (almost never), and do not forget that a non-operative approach is possible, beneficial and indicated in selected patients. Whatever you do, large studies show that one-third of these patients will be dead within 5 years — the same factors which led to the perforation shorten their lives.\\n\\n“We have no responsibility to such patients but to save their lives. Any procedure, which aims to do more than this, can quite significantly be considered meddlesome surgery. We have no responsibility during the surgery to carry out any procedure to cure the patient of his duodenal ulcer.”\\nRoscoe R. Graham\\n\\n1. Acute Physiology and Chronic Health Evaluation II.\\n2. Tang WH. Leaking gastrointestinal anastomoses — Stomach and duodenum. In: Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013; Chapter 6.3: 116.',\n", " 'md': 'Let us not forget:\\n\\n…a course of anti-Helicobacter antibiotics after the operation, combined with appropriate acid-reducing agents. High-risk elderly patients may need acid suppression for the rest of their lives. The duration of such management in younger patients, and whether they will be re-infected with the ulcerogenic bacteria, is controversial.\\n\\nFinal words…\\n\\nPatch a perforated ulcer if you can. In the vast majority of patients this is possible, but if not then you must resect. Consider adding a definitive anti-ulcer procedure on an extremely selective basis (almost never), and do not forget that a non-operative approach is possible, beneficial and indicated in selected patients. Whatever you do, large studies show that one-third of these patients will be dead within 5 years — the same factors which led to the perforation shorten their lives.\\n\\n“We have no responsibility to such patients but to save their lives. Any procedure, which aims to do more than this, can quite significantly be considered meddlesome surgery. We have no responsibility during the surgery to carry out any procedure to cure the patient of his duodenal ulcer.”\\nRoscoe R. Graham\\n\\n1. Acute Physiology and Chronic Health Evaluation II.\\n2. Tang WH. Leaking gastrointestinal anastomoses — Stomach and duodenum. In: Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013; Chapter 6.3: 116.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.76, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Hyperlinks',\n", " 'md': '## Hyperlinks',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Tang WH. Leaking gastrointestinal anastomoses — Stomach and duodenum. In: Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013; Chapter 6.3: 116.',\n", " 'md': '- Tang WH. Leaking gastrointestinal anastomoses — Stomach and duodenum. In: Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013; Chapter 6.3: 116.',\n", " 'bBox': {'x': 73, 'y': 491, 'w': 244.63, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 508, 'y': 491, 'w': 23.91, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the management of perforated ulcers, emphasizing the importance of anti-Helicobacter antibiotics and acid-reducing agents, particularly for high-risk elderly patients. It also highlights the necessity of surgical intervention in certain cases and the potential outcomes for patients with perforated ulcers. The quote from Roscoe R. Graham underscores the surgical philosophy regarding the treatment of duodenal ulcers.\\n```',\n", " 'md': 'This page discusses the management of perforated ulcers, emphasizing the importance of anti-Helicobacter antibiotics and acid-reducing agents, particularly for high-risk elderly patients. It also highlights the necessity of surgical intervention in certain cases and the potential outcomes for patients with perforated ulcers. The quote from Roscoe R. Graham underscores the surgical philosophy regarding the treatment of duodenal ulcers.\\n```',\n", " 'bBox': {'x': 131, 'y': 491, 'w': 180.27, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 275,\n", " 'text': 'Chapter 19\\nAcute pancreatitis\\nAri Leppäniemi\\n\\n During millions of years of evolution the pancreas wandered\\n to the retroperitoneum for a reason; surgeons should think\\n twice before messing with it!\\n\\n In this chapter I will deal with acute pancreatitis, using alcoholic\\npancreatitis as the main example. For additional emphasis on gallstone-\\nbiliary pancreatitis read Chapter 20, Section 3. Abbreviations are listed\\nin Table 19.1.\\n\\n Now that you have memorized by heart all the abbreviations, you are allowed to continue. The\\n Editors\\n\\n The incidence of acute pancreatitis varies significantly and can be as\\nhigh as 102/100,000 population in countries such as Finland where\\nalcohol is the most common etiological factor (and the main source of fun\\nexcept sauna and fishing); gallstones are the next most common etiology.\\nFollowing these two causes (accounting for 70-80% of cases) there are\\nmany others: metabolic (hypercalcemia, hypertriglyceridemia), external or\\niatrogenic trauma (ERCP), many drugs (look at Google — you will be\\nsurprised to see how many drugs have been implicated in the etiology of\\nacute pancreatitis), infections, postoperative conditions (cardiac surgery),\\nanomalies (pancreas divisum), tumors, hereditary and autoimmune\\ndiseases. Oh yes, don’t forget snake bites!',\n", " 'md': '```markdown\\n# Chapter 19: Acute Pancreatitis\\n**Author:** Ari Leppäniemi\\n\\nDuring millions of years of evolution, the pancreas wandered to the retroperitoneum for a reason; surgeons should think twice before messing with it!\\n\\nIn this chapter, I will deal with acute pancreatitis, using alcoholic pancreatitis as the main example. For additional emphasis on gallstone-biliary pancreatitis, read Chapter 20, Section 3. Abbreviations are listed in Table 19.1.\\n\\nNow that you have memorized by heart all the abbreviations, you are allowed to continue. **The Editors**\\n\\nThe incidence of acute pancreatitis varies significantly and can be as high as 102/100,000 population in countries such as Finland, where alcohol is the most common etiological factor (and the main source of fun except sauna and fishing); gallstones are the next most common etiology. Following these two causes (accounting for 70-80% of cases), there are many others: metabolic (hypercalcemia, hypertriglyceridemia), external or iatrogenic trauma (ERCP), many drugs (look at Google — you will be surprised to see how many drugs have been implicated in the etiology of acute pancreatitis), infections, postoperative conditions (cardiac surgery), anomalies (pancreas divisum), tumors, hereditary and autoimmune diseases. Oh yes, don’t forget snake bites!\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 19: Acute Pancreatitis',\n", " 'md': '# Chapter 19: Acute Pancreatitis',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 160.14, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Ari Leppäniemi\\n\\nDuring millions of years of evolution, the pancreas wandered to the retroperitoneum for a reason; surgeons should think twice before messing with it!\\n\\nIn this chapter, I will deal with acute pancreatitis, using alcoholic pancreatitis as the main example. For additional emphasis on gallstone-biliary pancreatitis, read Chapter 20, Section 3. Abbreviations are listed in Table 19.1.\\n\\nNow that you have memorized by heart all the abbreviations, you are allowed to continue. **The Editors**\\n\\nThe incidence of acute pancreatitis varies significantly and can be as high as 102/100,000 population in countries such as Finland, where alcohol is the most common etiological factor (and the main source of fun except sauna and fishing); gallstones are the next most common etiology. Following these two causes (accounting for 70-80% of cases), there are many others: metabolic (hypercalcemia, hypertriglyceridemia), external or iatrogenic trauma (ERCP), many drugs (look at Google — you will be surprised to see how many drugs have been implicated in the etiology of acute pancreatitis), infections, postoperative conditions (cardiac surgery), anomalies (pancreas divisum), tumors, hereditary and autoimmune diseases. Oh yes, don’t forget snake bites!\\n```',\n", " 'md': '**Author:** Ari Leppäniemi\\n\\nDuring millions of years of evolution, the pancreas wandered to the retroperitoneum for a reason; surgeons should think twice before messing with it!\\n\\nIn this chapter, I will deal with acute pancreatitis, using alcoholic pancreatitis as the main example. For additional emphasis on gallstone-biliary pancreatitis, read Chapter 20, Section 3. Abbreviations are listed in Table 19.1.\\n\\nNow that you have memorized by heart all the abbreviations, you are allowed to continue. **The Editors**\\n\\nThe incidence of acute pancreatitis varies significantly and can be as high as 102/100,000 population in countries such as Finland, where alcohol is the most common etiological factor (and the main source of fun except sauna and fishing); gallstones are the next most common etiology. Following these two causes (accounting for 70-80% of cases), there are many others: metabolic (hypercalcemia, hypertriglyceridemia), external or iatrogenic trauma (ERCP), many drugs (look at Google — you will be surprised to see how many drugs have been implicated in the etiology of acute pancreatitis), infections, postoperative conditions (cardiac surgery), anomalies (pancreas divisum), tumors, hereditary and autoimmune diseases. Oh yes, don’t forget snake bites!\\n```',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.77, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 276,\n", " 'text': ' Table 19.1. Abbreviations.\\n AcS Abdominal compartment syndrome\\n ANC Acute necrotic collection\\n APACHE Il Acute Physiological and Chronic Health Evaluation (score)\\n APP Abdominal perfusion pressure (APP = MAP IAP)\\n CRP C-reactive protein\\n ERCP Endoscopic retrograde cholangiopancreatography\\n FNA Fine needle aspiration\\n IAH Intra-abdominal hypertension\\n IAP Intra-abdominal pressure\\n MAP Mean arterial pressure\\n MODS Multiple organ dysfunction syndrome\\n MOF Multiple organ failure\\n MRCP Magnetic resonance cholangiopancreatography\\n SIRS Systemic inflammatory response syndrome\\n SOFA Sequential Organ Failure Assessment (score)\\n SvOz Mixed venous oxygen saturation\\n WON Walled-off necrosis\\n In daily practice, out of those rare etiologies, post-ERCP pancreatitis\\nseems the most common. In all other cases ask again about alcohol\\nuse…J, and only then classify it as ‘idiopathic’, meaning you have\\nno idea what caused this attack of acute pancreatitis. However, in\\nolder patients it is important to rule out an underlying pancreatic\\nneoplasm with a follow-up CT when the inflammation has subsided.\\n\\n In a normal (Finnish) general hospital ED, about 3-4% of patients with\\nan acute abdomen have acute pancreatitis. For a differential diagnosis,\\nround up the usual suspects, such as perforated peptic ulcer, gastritis,\\nreflux esophagitis, biliary colic, acute cholecystitis, acute mesenteric\\nischemia, intestinal obstruction, acute hepatitis, ruptured abdominal aortic\\naneurysm, inferior myocardial infarct, basal pneumonia, etc., and\\nremember that the clinical picture of severe acute pancreatitis\\nresembles peritonitis. Often a CT (we do not use i.v. contrast in this\\nsituation — but if you do then check that renal function is adequate —\\ncontrast is used at a later stage to look for pancreatic necrosis) is needed\\nto exclude pancreatitis (and pinpoint another diagnosis) before operating\\non a patient with clinical peritonitis. But we’ll get to the diagnostics later',\n", " 'md': '```markdown\\n# Table 19.1. Abbreviations\\n\\n| Abbreviation | Description |\\n|--------------|--------------------------------------------------------------|\\n| AcS | Abdominal compartment syndrome |\\n| ANC | Acute necrotic collection |\\n| APACHE II | Acute Physiological and Chronic Health Evaluation (score) |\\n| APP | Abdominal perfusion pressure (APP = MAP - IAP) |\\n| CRP | C-reactive protein |\\n| ERCP | Endoscopic retrograde cholangiopancreatography |\\n| FNA | Fine needle aspiration |\\n| IAH | Intra-abdominal hypertension |\\n| IAP | Intra-abdominal pressure |\\n| MAP | Mean arterial pressure |\\n| MODS | Multiple organ dysfunction syndrome |\\n| MOF | Multiple organ failure |\\n| MRCP | Magnetic resonance cholangiopancreatography |\\n| SIRS | Systemic inflammatory response syndrome |\\n| SOFA | Sequential Organ Failure Assessment (score) |\\n| SvO2 | Mixed venous oxygen saturation |\\n| WON | Walled-off necrosis |\\n\\nIn daily practice, out of those rare etiologies, post-ERCP pancreatitis seems the most common. In all other cases ask again about alcohol use, and only then classify it as ‘idiopathic’, meaning you have no idea what caused this attack of acute pancreatitis. However, in older patients, it is important to rule out an underlying pancreatic neoplasm with a follow-up CT when the inflammation has subsided.\\n\\nIn a normal (Finnish) general hospital ED, about 3-4% of patients with an acute abdomen have acute pancreatitis. For a differential diagnosis, round up the usual suspects, such as perforated peptic ulcer, gastritis, reflux esophagitis, biliary colic, acute cholecystitis, acute mesenteric ischemia, intestinal obstruction, acute hepatitis, ruptured abdominal aortic aneurysm, inferior myocardial infarct, basal pneumonia, etc., and remember that the clinical picture of severe acute pancreatitis resembles peritonitis. Often a CT (we do not use i.v. contrast in this situation — but if you do then check that renal function is adequate — contrast is used at a later stage to look for pancreatic necrosis) is needed to exclude pancreatitis (and pinpoint another diagnosis) before operating on a patient with clinical peritonitis. But we’ll get to the diagnostics later.\\n```',\n", " 'images': [{'name': 'img_p275_1.png',\n", " 'height': 607,\n", " 'width': 815,\n", " 'x': 104.39999999999998,\n", " 'y': 72,\n", " 'original_width': 1401,\n", " 'original_height': 1042}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Table 19.1. Abbreviations',\n", " 'md': '# Table 19.1. Abbreviations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Abbreviation', 'Description'],\n", " ['AcS', 'Abdominal compartment syndrome'],\n", " ['ANC', 'Acute necrotic collection'],\n", " ['APACHE II',\n", " 'Acute Physiological and Chronic Health Evaluation (score)'],\n", " ['APP', 'Abdominal perfusion pressure (APP = MAP - IAP)'],\n", " ['CRP', 'C-reactive protein'],\n", " ['ERCP', 'Endoscopic retrograde cholangiopancreatography'],\n", " ['FNA', 'Fine needle aspiration'],\n", " ['IAH', 'Intra-abdominal hypertension'],\n", " ['IAP', 'Intra-abdominal pressure'],\n", " ['MAP', 'Mean arterial pressure'],\n", " ['MODS', 'Multiple organ dysfunction syndrome'],\n", " ['MOF', 'Multiple organ failure'],\n", " ['MRCP', 'Magnetic resonance cholangiopancreatography'],\n", " ['SIRS', 'Systemic inflammatory response syndrome'],\n", " ['SOFA', 'Sequential Organ Failure Assessment (score)'],\n", " ['SvO2', 'Mixed venous oxygen saturation'],\n", " ['WON', 'Walled-off necrosis']],\n", " 'md': '| Abbreviation | Description |\\n|--------------|--------------------------------------------------------------|\\n| AcS | Abdominal compartment syndrome |\\n| ANC | Acute necrotic collection |\\n| APACHE II | Acute Physiological and Chronic Health Evaluation (score) |\\n| APP | Abdominal perfusion pressure (APP = MAP - IAP) |\\n| CRP | C-reactive protein |\\n| ERCP | Endoscopic retrograde cholangiopancreatography |\\n| FNA | Fine needle aspiration |\\n| IAH | Intra-abdominal hypertension |\\n| IAP | Intra-abdominal pressure |\\n| MAP | Mean arterial pressure |\\n| MODS | Multiple organ dysfunction syndrome |\\n| MOF | Multiple organ failure |\\n| MRCP | Magnetic resonance cholangiopancreatography |\\n| SIRS | Systemic inflammatory response syndrome |\\n| SOFA | Sequential Organ Failure Assessment (score) |\\n| SvO2 | Mixed venous oxygen saturation |\\n| WON | Walled-off necrosis |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Abbreviation\",\"Description\"\\n\"AcS\",\"Abdominal compartment syndrome\"\\n\"ANC\",\"Acute necrotic collection\"\\n\"APACHE II\",\"Acute Physiological and Chronic Health Evaluation (score)\"\\n\"APP\",\"Abdominal perfusion pressure (APP = MAP - IAP)\"\\n\"CRP\",\"C-reactive protein\"\\n\"ERCP\",\"Endoscopic retrograde cholangiopancreatography\"\\n\"FNA\",\"Fine needle aspiration\"\\n\"IAH\",\"Intra-abdominal hypertension\"\\n\"IAP\",\"Intra-abdominal pressure\"\\n\"MAP\",\"Mean arterial pressure\"\\n\"MODS\",\"Multiple organ dysfunction syndrome\"\\n\"MOF\",\"Multiple organ failure\"\\n\"MRCP\",\"Magnetic resonance cholangiopancreatography\"\\n\"SIRS\",\"Systemic inflammatory response syndrome\"\\n\"SOFA\",\"Sequential Organ Failure Assessment (score)\"\\n\"SvO2\",\"Mixed venous oxygen saturation\"\\n\"WON\",\"Walled-off necrosis\"',\n", " 'bBox': {'x': 109.35, 'y': 115.53, 'w': 256.27, 'h': 15.83}},\n", " {'type': 'text',\n", " 'value': 'In daily practice, out of those rare etiologies, post-ERCP pancreatitis seems the most common. In all other cases ask again about alcohol use, and only then classify it as ‘idiopathic’, meaning you have no idea what caused this attack of acute pancreatitis. However, in older patients, it is important to rule out an underlying pancreatic neoplasm with a follow-up CT when the inflammation has subsided.\\n\\nIn a normal (Finnish) general hospital ED, about 3-4% of patients with an acute abdomen have acute pancreatitis. For a differential diagnosis, round up the usual suspects, such as perforated peptic ulcer, gastritis, reflux esophagitis, biliary colic, acute cholecystitis, acute mesenteric ischemia, intestinal obstruction, acute hepatitis, ruptured abdominal aortic aneurysm, inferior myocardial infarct, basal pneumonia, etc., and remember that the clinical picture of severe acute pancreatitis resembles peritonitis. Often a CT (we do not use i.v. contrast in this situation — but if you do then check that renal function is adequate — contrast is used at a later stage to look for pancreatic necrosis) is needed to exclude pancreatitis (and pinpoint another diagnosis) before operating on a patient with clinical peritonitis. But we’ll get to the diagnostics later.\\n```',\n", " 'md': 'In daily practice, out of those rare etiologies, post-ERCP pancreatitis seems the most common. In all other cases ask again about alcohol use, and only then classify it as ‘idiopathic’, meaning you have no idea what caused this attack of acute pancreatitis. However, in older patients, it is important to rule out an underlying pancreatic neoplasm with a follow-up CT when the inflammation has subsided.\\n\\nIn a normal (Finnish) general hospital ED, about 3-4% of patients with an acute abdomen have acute pancreatitis. For a differential diagnosis, round up the usual suspects, such as perforated peptic ulcer, gastritis, reflux esophagitis, biliary colic, acute cholecystitis, acute mesenteric ischemia, intestinal obstruction, acute hepatitis, ruptured abdominal aortic aneurysm, inferior myocardial infarct, basal pneumonia, etc., and remember that the clinical picture of severe acute pancreatitis resembles peritonitis. Often a CT (we do not use i.v. contrast in this situation — but if you do then check that renal function is adequate — contrast is used at a later stage to look for pancreatic necrosis) is needed to exclude pancreatitis (and pinpoint another diagnosis) before operating on a patient with clinical peritonitis. But we’ll get to the diagnostics later.\\n```',\n", " 'bBox': {'x': 72, 'y': 130.37, 'w': 467.86, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 277,\n", " 'text': 'on…\\n\\n Natural history\\n\\n Following the initial triggering factor causing acinar cell injury and\\nintrapancreatic activation of the pancreatic proenzymes, a local\\ninflammation of the pancreas activates inflammatory cells and the release\\nof inflammatory mediators. If this process is not localized, a SIRS\\ndevelops. This is when patients arrive at your emergency room. In most\\ncases, the disease is self-limited, requiring only supportive and\\nsymptomatic treatment, but in about 15-20% a more severe form of\\npancreatitis develops leading to MODS characterized by dysfunction\\nof the pulmonary, cardiovascular, renal and other organ systems. In the\\nsevere forms the peripancreatic fat tissue and sometimes the pancreas\\nitself undergoes necrosis — necrotizing pancreatitis; and if the necrotic\\ntissue is invaded by microbes (believed to migrate transmurally from the\\nadjacent colon), causing infected pancreatic necrosis, the prognosis\\ngets instantly much worse, and the patient often requires surgical\\nintervention.\\n\\n Clinical presentation and diagnosis\\n\\n Clinical features\\n\\n A history is important. A typical patient with acute pancreatitis in\\nFinland presents with a history of drinking a bottle of vodka (have\\nyou heard about the vodka called Finlandia which in Finland costs more\\nthan double what it costs in the USA?) a day for the last 3 weeks, and\\nthen he got so much pain that he could drink no more. Most such patients\\nhave so-called ‘darts-habitus’— you know the big guys in the pub\\nthrowing darts with their jeans lying low and showing the hairy lower\\nback…. Of course there are also guys who “only had a couple of beers”,\\nso ask again.\\n\\n The other typical patient is a dame (as ħumphrey Bogart would\\nsay…) with intolerance to certain foodstuffs (greasy food, apples, etc.)',\n", " 'md': '```markdown\\n# Natural History\\n\\nFollowing the initial triggering factor causing acinar cell injury and intrapancreatic activation of the pancreatic proenzymes, a local inflammation of the pancreas activates inflammatory cells and the release of inflammatory mediators. If this process is not localized, a SIRS develops. This is when patients arrive at your emergency room. In most cases, the disease is self-limited, requiring only supportive and symptomatic treatment, but in about 15-20% a more severe form of pancreatitis develops leading to MODS characterized by dysfunction of the pulmonary, cardiovascular, renal and other organ systems. In the severe forms, the peripancreatic fat tissue and sometimes the pancreas itself undergoes necrosis — necrotizing pancreatitis; and if the necrotic tissue is invaded by microbes (believed to migrate transmurally from the adjacent colon), causing infected pancreatic necrosis, the prognosis gets instantly much worse, and the patient often requires surgical intervention.\\n\\n# Clinical Presentation and Diagnosis\\n\\n## Clinical Features\\n\\nA history is important. A typical patient with acute pancreatitis in Finland presents with a history of drinking a bottle of vodka (have you heard about the vodka called Finlandia which in Finland costs more than double what it costs in the USA?) a day for the last 3 weeks, and then he got so much pain that he could drink no more. Most such patients have so-called ‘darts-habitus’— you know the big guys in the pub throwing darts with their jeans lying low and showing the hairy lower back…. Of course there are also guys who “only had a couple of beers”, so ask again.\\n\\nThe other typical patient is a dame (as Humphrey Bogart would say…) with intolerance to certain foodstuffs (greasy food, apples, etc.)\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Natural History',\n", " 'md': '# Natural History',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 116.78, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Following the initial triggering factor causing acinar cell injury and intrapancreatic activation of the pancreatic proenzymes, a local inflammation of the pancreas activates inflammatory cells and the release of inflammatory mediators. If this process is not localized, a SIRS develops. This is when patients arrive at your emergency room. In most cases, the disease is self-limited, requiring only supportive and symptomatic treatment, but in about 15-20% a more severe form of pancreatitis develops leading to MODS characterized by dysfunction of the pulmonary, cardiovascular, renal and other organ systems. In the severe forms, the peripancreatic fat tissue and sometimes the pancreas itself undergoes necrosis — necrotizing pancreatitis; and if the necrotic tissue is invaded by microbes (believed to migrate transmurally from the adjacent colon), causing infected pancreatic necrosis, the prognosis gets instantly much worse, and the patient often requires surgical intervention.',\n", " 'md': 'Following the initial triggering factor causing acinar cell injury and intrapancreatic activation of the pancreatic proenzymes, a local inflammation of the pancreas activates inflammatory cells and the release of inflammatory mediators. If this process is not localized, a SIRS develops. This is when patients arrive at your emergency room. In most cases, the disease is self-limited, requiring only supportive and symptomatic treatment, but in about 15-20% a more severe form of pancreatitis develops leading to MODS characterized by dysfunction of the pulmonary, cardiovascular, renal and other organ systems. In the severe forms, the peripancreatic fat tissue and sometimes the pancreas itself undergoes necrosis — necrotizing pancreatitis; and if the necrotic tissue is invaded by microbes (believed to migrate transmurally from the adjacent colon), causing infected pancreatic necrosis, the prognosis gets instantly much worse, and the patient often requires surgical intervention.',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Clinical Presentation and Diagnosis',\n", " 'md': '# Clinical Presentation and Diagnosis',\n", " 'bBox': {'x': 86, 'y': 440, 'w': 278.6, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Features',\n", " 'md': '## Clinical Features',\n", " 'bBox': {'x': 86, 'y': 483, 'w': 127.82, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A history is important. A typical patient with acute pancreatitis in Finland presents with a history of drinking a bottle of vodka (have you heard about the vodka called Finlandia which in Finland costs more than double what it costs in the USA?) a day for the last 3 weeks, and then he got so much pain that he could drink no more. Most such patients have so-called ‘darts-habitus’— you know the big guys in the pub throwing darts with their jeans lying low and showing the hairy lower back…. Of course there are also guys who “only had a couple of beers”, so ask again.\\n\\nThe other typical patient is a dame (as Humphrey Bogart would say…) with intolerance to certain foodstuffs (greasy food, apples, etc.)\\n```',\n", " 'md': 'A history is important. A typical patient with acute pancreatitis in Finland presents with a history of drinking a bottle of vodka (have you heard about the vodka called Finlandia which in Finland costs more than double what it costs in the USA?) a day for the last 3 weeks, and then he got so much pain that he could drink no more. Most such patients have so-called ‘darts-habitus’— you know the big guys in the pub throwing darts with their jeans lying low and showing the hairy lower back…. Of course there are also guys who “only had a couple of beers”, so ask again.\\n\\nThe other typical patient is a dame (as Humphrey Bogart would say…) with intolerance to certain foodstuffs (greasy food, apples, etc.)\\n```',\n", " 'bBox': {'x': 72, 'y': 552, 'w': 467.76, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 278,\n", " 'text': 'causing colicky upper abdominal pain but this time it is different, and\\nfeels like a belt around the epigastrium. The problem: a tiny gallstone\\nmigrates to the common bile duct causing at least temporary outflow\\nobstruction of the bile (and pancreatic juice); the stone itself usually\\npasses spontaneously through the papilla to the duodenum and signs of\\nbiliary stasis are minimal and transient (mild elevation of liver enzymes,\\nno dilated bile ducts on ultrasound).\\n\\n In addition to epigastric pain, patients often suffer nausea and\\nvomiting; fever is uncommon unless there is accompanying cholangitis.\\nAlcohol-induced pancreatitis is often associated with mental restlessness\\nand sometimes even delirium.\\n\\n Besides assessing the vital signs and reacting to severe physiological\\nderangement (as in all severely ill patients), physical examination\\ntypically reveals a distended abdomen, epigastric or generalized\\ntenderness and absent bowel sounds indicating paralytic ileus. In more\\nsevere cases, the abdomen might be filled with pancreatic ascites, and in\\npatients with a delayed presentation the typical signs of necrotizing\\npancreatitis with discoloration around the umbilicus (Cullen’s sign) or at\\nthe loins (Gray-Turner’s sign) can be seen.\\n\\n Lab work\\n\\n Elevated plasma amylase levels (pancreas-specific, three times upper\\nnormal limit) confirms the diagnosis but be aware that the amylase levels\\nmay have returned to normal if the symptoms have been present for\\nseveral days. Therefore, some also measure serum lipase levels that\\nstay elevated for a longer time. Other abdominal catastrophes can\\ncause mild elevation of the amylase levels, so when in doubt,\\nrequest a CT! CRP is usually significantly elevated in severe acute\\npancreatitis but it takes 24-48 hours before that happens. Other lab tests\\nsuch as blood count, liver tests, electrolytes, glucose and renal function\\n(creatinine) are important to complement the overall picture and helpful\\nwhen planning treatment. If you suspect hyperlipidemia as the cause,\\ncheck triglycerides. In really sick patients with suspected cellular\\nhypoperfusion, lactate levels and arterial blood gases are needed.',\n", " 'md': '```markdown\\n## Clinical Presentation of Gallstone Migration and Pancreatitis\\n\\nThe patient presents with colicky upper abdominal pain, described as feeling like a belt around the epigastrium. The underlying issue is a tiny gallstone that migrates to the common bile duct, causing temporary outflow obstruction of bile and pancreatic juice. Typically, the stone passes spontaneously through the papilla to the duodenum, resulting in minimal and transient signs of biliary stasis, such as mild elevation of liver enzymes, with no dilated bile ducts observed on ultrasound.\\n\\nIn addition to epigastric pain, patients often experience nausea and vomiting. Fever is uncommon unless there is accompanying cholangitis. Alcohol-induced pancreatitis is frequently associated with mental restlessness and, in some cases, delirium.\\n\\n### Physical Examination Findings\\n\\n- **Vital Signs**: Assessment of vital signs is crucial, especially in severely ill patients.\\n- **Abdominal Examination**:\\n- Distended abdomen\\n- Epigastric or generalized tenderness\\n- Absent bowel sounds indicating paralytic ileus\\n- In more severe cases, the abdomen may contain pancreatic ascites. In patients with delayed presentation, typical signs of necrotizing pancreatitis may be observed, including discoloration around the umbilicus (Cullen’s sign) or at the loins (Gray-Turner’s sign).\\n\\n### Laboratory Work\\n\\n- **Elevated Plasma Amylase Levels**: A pancreas-specific elevation of amylase levels (three times the upper normal limit) confirms the diagnosis. However, it is important to note that amylase levels may return to normal if symptoms have persisted for several days.\\n- **Serum Lipase Levels**: Some clinicians also measure serum lipase levels, which remain elevated for a longer duration.\\n- **CT Scan**: In cases of uncertainty, a CT scan is recommended, as other abdominal conditions can also cause mild elevations in amylase levels.\\n- **CRP Levels**: C-reactive protein (CRP) is usually significantly elevated in severe acute pancreatitis, but this elevation takes 24-48 hours to manifest.\\n- **Additional Lab Tests**: Blood count, liver tests, electrolytes, glucose, and renal function (creatinine) are important for a comprehensive assessment and treatment planning.\\n- **Hyperlipidemia**: If hyperlipidemia is suspected as the cause, triglyceride levels should be checked.\\n- **Severe Cases**: In critically ill patients with suspected cellular hypoperfusion, lactate levels and arterial blood gases are necessary.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Presentation of Gallstone Migration and Pancreatitis',\n", " 'md': '## Clinical Presentation of Gallstone Migration and Pancreatitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The patient presents with colicky upper abdominal pain, described as feeling like a belt around the epigastrium. The underlying issue is a tiny gallstone that migrates to the common bile duct, causing temporary outflow obstruction of bile and pancreatic juice. Typically, the stone passes spontaneously through the papilla to the duodenum, resulting in minimal and transient signs of biliary stasis, such as mild elevation of liver enzymes, with no dilated bile ducts observed on ultrasound.\\n\\nIn addition to epigastric pain, patients often experience nausea and vomiting. Fever is uncommon unless there is accompanying cholangitis. Alcohol-induced pancreatitis is frequently associated with mental restlessness and, in some cases, delirium.',\n", " 'md': 'The patient presents with colicky upper abdominal pain, described as feeling like a belt around the epigastrium. The underlying issue is a tiny gallstone that migrates to the common bile duct, causing temporary outflow obstruction of bile and pancreatic juice. Typically, the stone passes spontaneously through the papilla to the duodenum, resulting in minimal and transient signs of biliary stasis, such as mild elevation of liver enzymes, with no dilated bile ducts observed on ultrasound.\\n\\nIn addition to epigastric pain, patients often experience nausea and vomiting. Fever is uncommon unless there is accompanying cholangitis. Alcohol-induced pancreatitis is frequently associated with mental restlessness and, in some cases, delirium.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Physical Examination Findings',\n", " 'md': '### Physical Examination Findings',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Vital Signs**: Assessment of vital signs is crucial, especially in severely ill patients.\\n- **Abdominal Examination**:\\n- Distended abdomen\\n- Epigastric or generalized tenderness\\n- Absent bowel sounds indicating paralytic ileus\\n- In more severe cases, the abdomen may contain pancreatic ascites. In patients with delayed presentation, typical signs of necrotizing pancreatitis may be observed, including discoloration around the umbilicus (Cullen’s sign) or at the loins (Gray-Turner’s sign).',\n", " 'md': '- **Vital Signs**: Assessment of vital signs is crucial, especially in severely ill patients.\\n- **Abdominal Examination**:\\n- Distended abdomen\\n- Epigastric or generalized tenderness\\n- Absent bowel sounds indicating paralytic ileus\\n- In more severe cases, the abdomen may contain pancreatic ascites. In patients with delayed presentation, typical signs of necrotizing pancreatitis may be observed, including discoloration around the umbilicus (Cullen’s sign) or at the loins (Gray-Turner’s sign).',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Laboratory Work',\n", " 'md': '### Laboratory Work',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Elevated Plasma Amylase Levels**: A pancreas-specific elevation of amylase levels (three times the upper normal limit) confirms the diagnosis. However, it is important to note that amylase levels may return to normal if symptoms have persisted for several days.\\n- **Serum Lipase Levels**: Some clinicians also measure serum lipase levels, which remain elevated for a longer duration.\\n- **CT Scan**: In cases of uncertainty, a CT scan is recommended, as other abdominal conditions can also cause mild elevations in amylase levels.\\n- **CRP Levels**: C-reactive protein (CRP) is usually significantly elevated in severe acute pancreatitis, but this elevation takes 24-48 hours to manifest.\\n- **Additional Lab Tests**: Blood count, liver tests, electrolytes, glucose, and renal function (creatinine) are important for a comprehensive assessment and treatment planning.\\n- **Hyperlipidemia**: If hyperlipidemia is suspected as the cause, triglyceride levels should be checked.\\n- **Severe Cases**: In critically ill patients with suspected cellular hypoperfusion, lactate levels and arterial blood gases are necessary.\\n\\n```',\n", " 'md': '- **Elevated Plasma Amylase Levels**: A pancreas-specific elevation of amylase levels (three times the upper normal limit) confirms the diagnosis. However, it is important to note that amylase levels may return to normal if symptoms have persisted for several days.\\n- **Serum Lipase Levels**: Some clinicians also measure serum lipase levels, which remain elevated for a longer duration.\\n- **CT Scan**: In cases of uncertainty, a CT scan is recommended, as other abdominal conditions can also cause mild elevations in amylase levels.\\n- **CRP Levels**: C-reactive protein (CRP) is usually significantly elevated in severe acute pancreatitis, but this elevation takes 24-48 hours to manifest.\\n- **Additional Lab Tests**: Blood count, liver tests, electrolytes, glucose, and renal function (creatinine) are important for a comprehensive assessment and treatment planning.\\n- **Hyperlipidemia**: If hyperlipidemia is suspected as the cause, triglyceride levels should be checked.\\n- **Severe Cases**: In critically ill patients with suspected cellular hypoperfusion, lactate levels and arterial blood gases are necessary.\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 279,\n", " 'text': ' Imaging\\n\\n If CT is available in your hospital, forget plain abdominal X-rays; they\\nare not helpful except in some cases to rule out mechanical bowel\\nobstruction or perforation (if you believe the absence of free air is enough\\nto rule out perforation — I don’t…). Of course, plain films and CT may\\nshow pancreatic calcifications in patients suffering from acute-on-\\nchronic pancreatitis. Chest X-rays are helpful in a later phase to assess\\npulmonary congestion and possible pleural effusion.\\n\\n Abdominal CT is the best diagnostic tool available. It detects even\\nmild acute pancreatitis (some edema around the pancreas, sometimes\\nonly confined to the head or tail). We have stopped using oral contrast\\nand use mostly tap water as a contrast medium. As I mention above, we\\ndo not use intravenous contrast in the initial phase to avoid damage to\\nthe already stressed kidneys. If severe (necrotizing) pancreatitis is\\nsuspected, a later CT scan with i.v. contrast to assess pancreatic\\nenhancement and vitality can be used after volume restoration and\\nconfirmation of normal renal function.\\n\\n Ultrasonography is used early as a complementary study to identify\\nor rule out cholelithiasis (CT is not reliable in detecting gallstones) and a\\ndilated common bile duct, but it is not helpful in diagnosing pancreatitis. If\\nthe liver enzymes are elevated and ultrasound shows the presence of\\ngallstones and/or a dilated common bile duct, we usually perform MRCP\\nto see if the stone is still present or has passed though spontaneously. In\\nmost cases when a persistent stone causes biliary stasis, especially\\nwhen associated with a high fever (cholangitis), ERCP and\\nsphincterotomy are indicated to clear the common bile duct.\\n\\n Estimation of severity and classification\\n\\n Although a continuum — ranging from edematous acute pancreatitis,\\nwith mild symptoms lasting a couple of days, to a critical, severe form of\\nnecrotizing pancreatitis, with MODS — for everyday clinical purposes\\nacute pancreatitis can be divided into mild, intermediate, severe and\\ncritical forms.',\n", " 'md': '```markdown\\n# Imaging\\n\\nIf CT is available in your hospital, forget plain abdominal X-rays; they are not helpful except in some cases to rule out mechanical bowel obstruction or perforation (if you believe the absence of free air is enough to rule out perforation — I don’t…). Of course, plain films and CT may show pancreatic calcifications in patients suffering from acute-on-chronic pancreatitis. Chest X-rays are helpful in a later phase to assess pulmonary congestion and possible pleural effusion.\\n\\nAbdominal CT is the best diagnostic tool available. It detects even mild acute pancreatitis (some edema around the pancreas, sometimes only confined to the head or tail). We have stopped using oral contrast and use mostly tap water as a contrast medium. As I mention above, we do not use intravenous contrast in the initial phase to avoid damage to the already stressed kidneys. If severe (necrotizing) pancreatitis is suspected, a later CT scan with i.v. contrast to assess pancreatic enhancement and vitality can be used after volume restoration and confirmation of normal renal function.\\n\\nUltrasonography is used early as a complementary study to identify or rule out cholelithiasis (CT is not reliable in detecting gallstones) and a dilated common bile duct, but it is not helpful in diagnosing pancreatitis. If the liver enzymes are elevated and ultrasound shows the presence of gallstones and/or a dilated common bile duct, we usually perform MRCP to see if the stone is still present or has passed through spontaneously. In most cases when a persistent stone causes biliary stasis, especially when associated with a high fever (cholangitis), ERCP and sphincterotomy are indicated to clear the common bile duct.\\n\\n## Estimation of Severity and Classification\\n\\nAlthough a continuum — ranging from edematous acute pancreatitis, with mild symptoms lasting a couple of days, to a critical, severe form of necrotizing pancreatitis, with MODS — for everyday clinical purposes acute pancreatitis can be divided into mild, intermediate, severe, and critical forms.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Imaging',\n", " 'md': '# Imaging',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 63.44, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'If CT is available in your hospital, forget plain abdominal X-rays; they are not helpful except in some cases to rule out mechanical bowel obstruction or perforation (if you believe the absence of free air is enough to rule out perforation — I don’t…). Of course, plain films and CT may show pancreatic calcifications in patients suffering from acute-on-chronic pancreatitis. Chest X-rays are helpful in a later phase to assess pulmonary congestion and possible pleural effusion.\\n\\nAbdominal CT is the best diagnostic tool available. It detects even mild acute pancreatitis (some edema around the pancreas, sometimes only confined to the head or tail). We have stopped using oral contrast and use mostly tap water as a contrast medium. As I mention above, we do not use intravenous contrast in the initial phase to avoid damage to the already stressed kidneys. If severe (necrotizing) pancreatitis is suspected, a later CT scan with i.v. contrast to assess pancreatic enhancement and vitality can be used after volume restoration and confirmation of normal renal function.\\n\\nUltrasonography is used early as a complementary study to identify or rule out cholelithiasis (CT is not reliable in detecting gallstones) and a dilated common bile duct, but it is not helpful in diagnosing pancreatitis. If the liver enzymes are elevated and ultrasound shows the presence of gallstones and/or a dilated common bile duct, we usually perform MRCP to see if the stone is still present or has passed through spontaneously. In most cases when a persistent stone causes biliary stasis, especially when associated with a high fever (cholangitis), ERCP and sphincterotomy are indicated to clear the common bile duct.',\n", " 'md': 'If CT is available in your hospital, forget plain abdominal X-rays; they are not helpful except in some cases to rule out mechanical bowel obstruction or perforation (if you believe the absence of free air is enough to rule out perforation — I don’t…). Of course, plain films and CT may show pancreatic calcifications in patients suffering from acute-on-chronic pancreatitis. Chest X-rays are helpful in a later phase to assess pulmonary congestion and possible pleural effusion.\\n\\nAbdominal CT is the best diagnostic tool available. It detects even mild acute pancreatitis (some edema around the pancreas, sometimes only confined to the head or tail). We have stopped using oral contrast and use mostly tap water as a contrast medium. As I mention above, we do not use intravenous contrast in the initial phase to avoid damage to the already stressed kidneys. If severe (necrotizing) pancreatitis is suspected, a later CT scan with i.v. contrast to assess pancreatic enhancement and vitality can be used after volume restoration and confirmation of normal renal function.\\n\\nUltrasonography is used early as a complementary study to identify or rule out cholelithiasis (CT is not reliable in detecting gallstones) and a dilated common bile duct, but it is not helpful in diagnosing pancreatitis. If the liver enzymes are elevated and ultrasound shows the presence of gallstones and/or a dilated common bile duct, we usually perform MRCP to see if the stone is still present or has passed through spontaneously. In most cases when a persistent stone causes biliary stasis, especially when associated with a high fever (cholangitis), ERCP and sphincterotomy are indicated to clear the common bile duct.',\n", " 'bBox': {'x': 72, 'y': 124, 'w': 467.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Estimation of Severity and Classification',\n", " 'md': '## Estimation of Severity and Classification',\n", " 'bBox': {'x': 86, 'y': 542, 'w': 453, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Although a continuum — ranging from edematous acute pancreatitis, with mild symptoms lasting a couple of days, to a critical, severe form of necrotizing pancreatitis, with MODS — for everyday clinical purposes acute pancreatitis can be divided into mild, intermediate, severe, and critical forms.\\n```',\n", " 'md': 'Although a continuum — ranging from edematous acute pancreatitis, with mild symptoms lasting a couple of days, to a critical, severe form of necrotizing pancreatitis, with MODS — for everyday clinical purposes acute pancreatitis can be divided into mild, intermediate, severe, and critical forms.\\n```',\n", " 'bBox': {'x': 72, 'y': 542, 'w': 467.33, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 280,\n", " 'text': ' It is not always clear in the early stages (when you are in the\\nemergency room) into which category the patient belongs, i.e. what\\nnatural course the disease will take.\\n\\n So how do we assess the severity of the disease?\\n\\n • The amount or progression of amylase levels does not correlate with\\n severity; CRP is better (150mg/L is some kind of threshold for\\n severe acute pancreatitis), but manifests a couple of days too late;\\n other potential markers (procalcitonin, interleukin 10, etc.) are not\\n (yet) in clinical use.\\n • Clinical scoring systems such as those described by the late\\n Ranson, USA, or Imrie, Scotland (you probably do not remember the\\n time when medical students knew all Ranson’s criteria by heart), are\\n inaccurate and not used anymore. The APACHE II score ( see\\n Chapter 6) measures nicely the severity of the disease — a score\\n higher than 8 indicates significant physiological derangement. In our\\n hospital we use the SOFA 1 score routinely to monitor the degree of\\n organ dysfunction; we rely especially on the cardiovascular,\\n pulmonary and renal components of this score (and also\\n measurement of the intra-abdominal pressure [IAP] — see\\n Chapter 33) to determine if the patient should go to the ICU directly\\n from the emergency room.\\n • At the end of the day we classify the severity of acute\\n pancreatitis by combining the local and systemic determinants\\n of severity. The local determinants are related to the presence or\\n absence of peripancreatic and pancreatic necrosis and whether it is\\n sterile or infected. The systemic determinant is related to whether\\n there is organ failure or not and, if present, whether it is transient or\\n persistent. These factors are connected, and the relationship\\n between necrosis, be it infected or not, and the development of\\n organ dysfunction has been established in multiple studies. The key\\n is the development of persistent organ failure. The mortality in acute\\n pancreatitis is mainly associated with MOF whereas the risk of dying\\n is minimal in patients with no or transient organ dysfunction.\\n\\n So in this day and age patients rarely die from the early-acute manifestation of acute',\n", " 'md': '```markdown\\n## Assessment of Disease Severity\\n\\nIt is not always clear in the early stages (when you are in the emergency room) into which category the patient belongs, i.e., what natural course the disease will take.\\n\\n### How do we assess the severity of the disease?\\n\\n- The amount or progression of amylase levels does not correlate with severity; CRP is better (150 mg/L is some kind of threshold for severe acute pancreatitis), but manifests a couple of days too late; other potential markers (procalcitonin, interleukin 10, etc.) are not (yet) in clinical use.\\n- Clinical scoring systems such as those described by the late Ranson, USA, or Imrie, Scotland (you probably do not remember the time when medical students knew all Ranson’s criteria by heart), are inaccurate and not used anymore. The APACHE II score (see Chapter 6) measures nicely the severity of the disease — a score higher than 8 indicates significant physiological derangement. In our hospital, we use the SOFA score routinely to monitor the degree of organ dysfunction; we rely especially on the cardiovascular, pulmonary, and renal components of this score (and also measurement of the intra-abdominal pressure [IAP] — see Chapter 33) to determine if the patient should go to the ICU directly from the emergency room.\\n- At the end of the day, we classify the severity of acute pancreatitis by combining the local and systemic determinants of severity. The local determinants are related to the presence or absence of peripancreatic and pancreatic necrosis and whether it is sterile or infected. The systemic determinant is related to whether there is organ failure or not and, if present, whether it is transient or persistent. These factors are connected, and the relationship between necrosis, be it infected or not, and the development of organ dysfunction has been established in multiple studies. The key is the development of persistent organ failure. The mortality in acute pancreatitis is mainly associated with multiple organ failure (MOF) whereas the risk of dying is minimal in patients with no or transient organ dysfunction.\\n\\nSo in this day and age, patients rarely die from the early-acute manifestation of acute pancreatitis.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Assessment of Disease Severity',\n", " 'md': '## Assessment of Disease Severity',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'It is not always clear in the early stages (when you are in the emergency room) into which category the patient belongs, i.e., what natural course the disease will take.',\n", " 'md': 'It is not always clear in the early stages (when you are in the emergency room) into which category the patient belongs, i.e., what natural course the disease will take.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 245, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'How do we assess the severity of the disease?',\n", " 'md': '### How do we assess the severity of the disease?',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The amount or progression of amylase levels does not correlate with severity; CRP is better (150 mg/L is some kind of threshold for severe acute pancreatitis), but manifests a couple of days too late; other potential markers (procalcitonin, interleukin 10, etc.) are not (yet) in clinical use.\\n- Clinical scoring systems such as those described by the late Ranson, USA, or Imrie, Scotland (you probably do not remember the time when medical students knew all Ranson’s criteria by heart), are inaccurate and not used anymore. The APACHE II score (see Chapter 6) measures nicely the severity of the disease — a score higher than 8 indicates significant physiological derangement. In our hospital, we use the SOFA score routinely to monitor the degree of organ dysfunction; we rely especially on the cardiovascular, pulmonary, and renal components of this score (and also measurement of the intra-abdominal pressure [IAP] — see Chapter 33) to determine if the patient should go to the ICU directly from the emergency room.\\n- At the end of the day, we classify the severity of acute pancreatitis by combining the local and systemic determinants of severity. The local determinants are related to the presence or absence of peripancreatic and pancreatic necrosis and whether it is sterile or infected. The systemic determinant is related to whether there is organ failure or not and, if present, whether it is transient or persistent. These factors are connected, and the relationship between necrosis, be it infected or not, and the development of organ dysfunction has been established in multiple studies. The key is the development of persistent organ failure. The mortality in acute pancreatitis is mainly associated with multiple organ failure (MOF) whereas the risk of dying is minimal in patients with no or transient organ dysfunction.\\n\\nSo in this day and age, patients rarely die from the early-acute manifestation of acute pancreatitis.\\n```',\n", " 'md': '- The amount or progression of amylase levels does not correlate with severity; CRP is better (150 mg/L is some kind of threshold for severe acute pancreatitis), but manifests a couple of days too late; other potential markers (procalcitonin, interleukin 10, etc.) are not (yet) in clinical use.\\n- Clinical scoring systems such as those described by the late Ranson, USA, or Imrie, Scotland (you probably do not remember the time when medical students knew all Ranson’s criteria by heart), are inaccurate and not used anymore. The APACHE II score (see Chapter 6) measures nicely the severity of the disease — a score higher than 8 indicates significant physiological derangement. In our hospital, we use the SOFA score routinely to monitor the degree of organ dysfunction; we rely especially on the cardiovascular, pulmonary, and renal components of this score (and also measurement of the intra-abdominal pressure [IAP] — see Chapter 33) to determine if the patient should go to the ICU directly from the emergency room.\\n- At the end of the day, we classify the severity of acute pancreatitis by combining the local and systemic determinants of severity. The local determinants are related to the presence or absence of peripancreatic and pancreatic necrosis and whether it is sterile or infected. The systemic determinant is related to whether there is organ failure or not and, if present, whether it is transient or persistent. These factors are connected, and the relationship between necrosis, be it infected or not, and the development of organ dysfunction has been established in multiple studies. The key is the development of persistent organ failure. The mortality in acute pancreatitis is mainly associated with multiple organ failure (MOF) whereas the risk of dying is minimal in patients with no or transient organ dysfunction.\\n\\nSo in this day and age, patients rarely die from the early-acute manifestation of acute pancreatitis.\\n```',\n", " 'bBox': {'x': 100, 'y': 190, 'w': 437.02, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'higher than 8 indicates significant physiological derangement. In our'},\n", " {'text': ' '},\n", " {'text': 'from the emergency room.'}]},\n", " {'page': 281,\n", " 'text': ' pancreatitis (e.g. hypovolemia) but from its late sequelae (e.g. SIRS, sepsis, MOF). But\\n beware of the patient coming in with early ACS-induced renal and respiratory failure\\n after undergoing massive fluid resuscitation. Measure the IAP, the patient might need\\n early decompressive surgery!\\n\\n The 4-week approach to the management of acute\\n pancreatitis ( Figure 19.1)\\n\\n 1st week: inflammation\\n\\n About 85% of patients with acute pancreatitis have the mild form of the\\ndisease. In the past we used to admit these patients to the ward, keeping\\nthem starved and inserting a nasogastric tube, and treating the pain,\\nnausea and delirium with medications. In most cases, the patient\\nrecovered within a few days and was discharged. These days we treat\\nthe symptoms with medications, start oral feeding as soon as the patient\\ntolerates it, and look for signs of severe acute pancreatitis hoping to\\nrecognize it early. If all is going well, the patient has mild acute\\npancreatitis (a ‘1-week disease’) where the inflammation has resolved\\nwithout major systemic or local complications.\\n\\n Any signs of continuous severe pain, restlessness, respiratory distress,\\ndecreasing urine output, greatly distended abdomen, increasing CRP\\nlevels, or increasing IAP could indicate that the inflammatory process\\ncontinues and the patient will progress to the second stage: necrosis (see\\nbelow ‘2nd week’). Remember: mild acute pancreatitis is maximally a\\n7-day disease. Anything that lasts longer is not so mild…\\n\\n OK, time for a little theory: MOF is a consequence of excessive\\nactivation of a systemic inflammatory response cascade, where\\ninflammatory mediators induce end-organ endothelial cell activation\\nleading to increased permeability. Leaking microvessels cause a loss of\\nintravascular fluid and in conjunction with vasodilatation lead to\\nhypotension and shock. Accumulation of inflammatory cells in tissues,\\nincreased interstitial fluid and activation of coagulation with microvascular\\nthrombosis further impair oxygen supply of tissues (OK, now you can',\n", " 'md': '```markdown\\n# Management of Acute Pancreatitis\\n\\nThe 4-week approach to the management of acute pancreatitis (Figure 19.1)\\n\\n## 1st Week: Inflammation\\n\\nAbout 85% of patients with acute pancreatitis have the mild form of the disease. In the past, we used to admit these patients to the ward, keeping them starved and inserting a nasogastric tube, and treating the pain, nausea, and delirium with medications. In most cases, the patient recovered within a few days and was discharged. These days, we treat the symptoms with medications, start oral feeding as soon as the patient tolerates it, and look for signs of severe acute pancreatitis hoping to recognize it early. If all is going well, the patient has mild acute pancreatitis (a ‘1-week disease’) where the inflammation has resolved without major systemic or local complications.\\n\\nAny signs of continuous severe pain, restlessness, respiratory distress, decreasing urine output, greatly distended abdomen, increasing CRP levels, or increasing IAP could indicate that the inflammatory process continues and the patient will progress to the second stage: necrosis (see below ‘2nd week’). Remember: mild acute pancreatitis is maximally a 7-day disease. Anything that lasts longer is not so mild…\\n\\nOK, time for a little theory: MOF is a consequence of excessive activation of a systemic inflammatory response cascade, where inflammatory mediators induce end-organ endothelial cell activation leading to increased permeability. Leaking microvessels cause a loss of intravascular fluid and in conjunction with vasodilatation lead to hypotension and shock. Accumulation of inflammatory cells in tissues, increased interstitial fluid, and activation of coagulation with microvascular thrombosis further impair oxygen supply of tissues.\\n\\n## Figure 19.1 Description\\n- **Figure 19.1**: This figure likely illustrates the 4-week management approach for acute pancreatitis, detailing the progression of the disease and treatment strategies over time. The specific content of the figure is not provided in the text, but it is an important visual aid for understanding the management timeline.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management of Acute Pancreatitis',\n", " 'md': '# Management of Acute Pancreatitis',\n", " 'bBox': {'x': 351, 'y': 197, 'w': 102.1, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The 4-week approach to the management of acute pancreatitis (Figure 19.1)',\n", " 'md': 'The 4-week approach to the management of acute pancreatitis (Figure 19.1)',\n", " 'bBox': {'x': 86, 'y': 197, 'w': 102.98, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': '1st Week: Inflammation',\n", " 'md': '## 1st Week: Inflammation',\n", " 'bBox': {'x': 86, 'y': 260, 'w': 182.06, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'About 85% of patients with acute pancreatitis have the mild form of the disease. In the past, we used to admit these patients to the ward, keeping them starved and inserting a nasogastric tube, and treating the pain, nausea, and delirium with medications. In most cases, the patient recovered within a few days and was discharged. These days, we treat the symptoms with medications, start oral feeding as soon as the patient tolerates it, and look for signs of severe acute pancreatitis hoping to recognize it early. If all is going well, the patient has mild acute pancreatitis (a ‘1-week disease’) where the inflammation has resolved without major systemic or local complications.\\n\\nAny signs of continuous severe pain, restlessness, respiratory distress, decreasing urine output, greatly distended abdomen, increasing CRP levels, or increasing IAP could indicate that the inflammatory process continues and the patient will progress to the second stage: necrosis (see below ‘2nd week’). Remember: mild acute pancreatitis is maximally a 7-day disease. Anything that lasts longer is not so mild…\\n\\nOK, time for a little theory: MOF is a consequence of excessive activation of a systemic inflammatory response cascade, where inflammatory mediators induce end-organ endothelial cell activation leading to increased permeability. Leaking microvessels cause a loss of intravascular fluid and in conjunction with vasodilatation lead to hypotension and shock. Accumulation of inflammatory cells in tissues, increased interstitial fluid, and activation of coagulation with microvascular thrombosis further impair oxygen supply of tissues.',\n", " 'md': 'About 85% of patients with acute pancreatitis have the mild form of the disease. In the past, we used to admit these patients to the ward, keeping them starved and inserting a nasogastric tube, and treating the pain, nausea, and delirium with medications. In most cases, the patient recovered within a few days and was discharged. These days, we treat the symptoms with medications, start oral feeding as soon as the patient tolerates it, and look for signs of severe acute pancreatitis hoping to recognize it early. If all is going well, the patient has mild acute pancreatitis (a ‘1-week disease’) where the inflammation has resolved without major systemic or local complications.\\n\\nAny signs of continuous severe pain, restlessness, respiratory distress, decreasing urine output, greatly distended abdomen, increasing CRP levels, or increasing IAP could indicate that the inflammatory process continues and the patient will progress to the second stage: necrosis (see below ‘2nd week’). Remember: mild acute pancreatitis is maximally a 7-day disease. Anything that lasts longer is not so mild…\\n\\nOK, time for a little theory: MOF is a consequence of excessive activation of a systemic inflammatory response cascade, where inflammatory mediators induce end-organ endothelial cell activation leading to increased permeability. Leaking microvessels cause a loss of intravascular fluid and in conjunction with vasodilatation lead to hypotension and shock. Accumulation of inflammatory cells in tissues, increased interstitial fluid, and activation of coagulation with microvascular thrombosis further impair oxygen supply of tissues.',\n", " 'bBox': {'x': 72, 'y': 197, 'w': 467.78, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 19.1 Description',\n", " 'md': '## Figure 19.1 Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 19.1**: This figure likely illustrates the 4-week management approach for acute pancreatitis, detailing the progression of the disease and treatment strategies over time. The specific content of the figure is not provided in the text, but it is an important visual aid for understanding the management timeline.\\n```',\n", " 'md': '- **Figure 19.1**: This figure likely illustrates the 4-week management approach for acute pancreatitis, detailing the progression of the disease and treatment strategies over time. The specific content of the figure is not provided in the text, but it is an important visual aid for understanding the management timeline.\\n```',\n", " 'bBox': {'x': 86, 'y': 197, 'w': 102.1, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 282,\n", " 'text': 'wake up!).\\n INFLAMMATIONFirst week Support organs\\n Second week Be patient_\\n NECROSIS\\n Third week Be ready\\n INFECTION\\n ACTI Fourth week\\n ACTION BEGINSI\\n Figure 19.1. Severe acute pancreatitis: week by week.\\n\\n The clinical manifestation of all this is MODS that develops early\\nduring the course of acute pancreatitis. Over half of patients with\\nsevere acute pancreatitis have signs of organ dysfunction on admission\\n— most developing within the first 4 days. So, when that happens, get\\nyour patient to the ICU!\\n\\n Besides monitoring and supporting organ dysfunction as in all\\nICU patients, below are some specific comments about patients\\nwith severe acute pancreatitis in the ICU.\\n\\n Fluid resuscitation\\n In the past, aggressive fluid therapy during the early phase of acute\\npancreatitis was one of the dogmas we followed religiously (God have\\nmercy on the resident who had not ordered at least 5-10L of fluid for the\\npatient). Of course the rationale behind fluid resuscitation is sound: to\\ncorrect hypovolemia caused by ‘third space’ fluid loss; however, or to put\\nit simply: too little fluid leads to hypovolemia and organ dysfunction,',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Figure 19.1\\n**Description:** This figure illustrates the progression of severe acute pancreatitis over a four-week period. It outlines the stages of inflammation, necrosis, and infection, with specific actions recommended for each week.\\n\\n- **Week 1:** Inflammation - Support organs\\n- **Week 2:** Necrosis - Be patient\\n- **Week 3:** Infection - Be ready\\n- **Week 4:** Action begins\\n\\n**Summary:** The figure emphasizes the critical timeline of severe acute pancreatitis and the necessary interventions at each stage.\\n\\n----\\n\\nThe clinical manifestation of all this is MODS (Multiple Organ Dysfunction Syndrome) that develops early during the course of acute pancreatitis. Over half of patients with severe acute pancreatitis have signs of organ dysfunction on admission, most developing within the first 4 days. So, when that happens, get your patient to the ICU!\\n\\nBesides monitoring and supporting organ dysfunction as in all ICU patients, below are some specific comments about patients with severe acute pancreatitis in the ICU.\\n\\n### Fluid Resuscitation\\nIn the past, aggressive fluid therapy during the early phase of acute pancreatitis was one of the dogmas we followed religiously (God have mercy on the resident who had not ordered at least 5-10L of fluid for the patient). Of course, the rationale behind fluid resuscitation is sound: to correct hypovolemia caused by ‘third space’ fluid loss; however, or to put it simply: too little fluid leads to hypovolemia and organ dysfunction.\\n```',\n", " 'images': [{'name': 'img_p281_1.png',\n", " 'height': 552,\n", " 'width': 761,\n", " 'x': 118.07999999999993,\n", " 'y': 99.36000000000001,\n", " 'original_width': 1308,\n", " 'original_height': 949}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 19.1',\n", " 'md': '## Figure 19.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure illustrates the progression of severe acute pancreatitis over a four-week period. It outlines the stages of inflammation, necrosis, and infection, with specific actions recommended for each week.\\n\\n- **Week 1:** Inflammation - Support organs\\n- **Week 2:** Necrosis - Be patient\\n- **Week 3:** Infection - Be ready\\n- **Week 4:** Action begins\\n\\n**Summary:** The figure emphasizes the critical timeline of severe acute pancreatitis and the necessary interventions at each stage.\\n\\n----\\n\\nThe clinical manifestation of all this is MODS (Multiple Organ Dysfunction Syndrome) that develops early during the course of acute pancreatitis. Over half of patients with severe acute pancreatitis have signs of organ dysfunction on admission, most developing within the first 4 days. So, when that happens, get your patient to the ICU!\\n\\nBesides monitoring and supporting organ dysfunction as in all ICU patients, below are some specific comments about patients with severe acute pancreatitis in the ICU.',\n", " 'md': '**Description:** This figure illustrates the progression of severe acute pancreatitis over a four-week period. It outlines the stages of inflammation, necrosis, and infection, with specific actions recommended for each week.\\n\\n- **Week 1:** Inflammation - Support organs\\n- **Week 2:** Necrosis - Be patient\\n- **Week 3:** Infection - Be ready\\n- **Week 4:** Action begins\\n\\n**Summary:** The figure emphasizes the critical timeline of severe acute pancreatitis and the necessary interventions at each stage.\\n\\n----\\n\\nThe clinical manifestation of all this is MODS (Multiple Organ Dysfunction Syndrome) that develops early during the course of acute pancreatitis. Over half of patients with severe acute pancreatitis have signs of organ dysfunction on admission, most developing within the first 4 days. So, when that happens, get your patient to the ICU!\\n\\nBesides monitoring and supporting organ dysfunction as in all ICU patients, below are some specific comments about patients with severe acute pancreatitis in the ICU.',\n", " 'bBox': {'x': 72, 'y': 114.68, 'w': 467.97, 'h': 25.21}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Fluid Resuscitation',\n", " 'md': '### Fluid Resuscitation',\n", " 'bBox': {'x': 86, 'y': 612, 'w': 127.88, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'In the past, aggressive fluid therapy during the early phase of acute pancreatitis was one of the dogmas we followed religiously (God have mercy on the resident who had not ordered at least 5-10L of fluid for the patient). Of course, the rationale behind fluid resuscitation is sound: to correct hypovolemia caused by ‘third space’ fluid loss; however, or to put it simply: too little fluid leads to hypovolemia and organ dysfunction.\\n```',\n", " 'md': 'In the past, aggressive fluid therapy during the early phase of acute pancreatitis was one of the dogmas we followed religiously (God have mercy on the resident who had not ordered at least 5-10L of fluid for the patient). Of course, the rationale behind fluid resuscitation is sound: to correct hypovolemia caused by ‘third space’ fluid loss; however, or to put it simply: too little fluid leads to hypovolemia and organ dysfunction.\\n```',\n", " 'bBox': {'x': 72, 'y': 612, 'w': 467.54, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 283,\n", " 'text': 'too much fluid can cause tissue edema and intra-abdominal\\nhypertension (IAH). Our current fluid resuscitation goals are\\nsummarized in Table 19.2.\\n Table 19.2. Summary of early treatment of severe acute\\n pancreatitis _\\n Early admission to ICU or high dependency unit_\\n Goals for fluid resuscitation with crystalloids:\\n MAP >65mmHg;\\n SvOz >65% (requires pulmonary artery catheter);\\n normal lactate;\\n urine output >Iml/kg/hr (about 50-10Oml/hr);\\n routine measurement of IAP (goal <25mmHg);\\n APP (MAP-IAP) >6OmmHg;\\n norepinephrine and/or dobutamine in cardiovascular failure\\n Analgesia, sedation, lung-protective ventilation:\\n Normoglycemia.\\n Thrombosis prophylaxis_\\n Early enteral feeding, prophylactic antibiotics_\\n Early biliary decompression; if obstruction.\\n Enteral nutrition\\n Fasting does not help, and it does not alleviate the inflammatory\\nresponse or ‘put the pancreas to rest’. Enteral feeding (a product of\\nmillions of years of evolution) is superior to parenteral feeding,\\nprevents bacterial overgrowth in the intestine and reduces bacterial\\ntranslocation, reduces the risk of systemic infections, organ\\ndysfunction and mortality. The only contraindication is an inability\\nto eat because of the associated ileus or gastric outlet obstruction.\\nSo, offer food to a conscious patient if it is tolerated without vomiting or\\naggravating pain.\\n\\n In a ventilated and sedated patient this is what we do:\\n\\n • Try a nasogastric tube first and start feeding.\\n If gastric residual is >250ml/6hr, insert a self-advancing nasojejunal',\n", " 'md': '```markdown\\n## Summary of Early Treatment of Severe Acute Pancreatitis\\n\\nToo much fluid can cause tissue edema and intra-abdominal hypertension (IAH). Our current fluid resuscitation goals are summarized in Table 19.2.\\n\\n### Table 19.2: Summary of Early Treatment of Severe Acute Pancreatitis\\n\\n| Treatment Goals | Details |\\n|-----------------|---------|\\n| Early admission to ICU or high dependency unit | - |\\n| Goals for fluid resuscitation with crystalloids: | - MAP > 65 mmHg\\n- SvO2 > 65% (requires pulmonary artery catheter)\\n- Normal lactate\\n- Urine output > 1 ml/kg/hr (about 50-100 ml/hr)\\n- Routine measurement of IAP (goal < 25 mmHg)\\n- APP (MAP - IAP) > 60 mmHg\\n- Norepinephrine and/or dobutamine in cardiovascular failure |\\n| Analgesia, sedation, lung-protective ventilation | Normoglycemia |\\n| Thrombosis prophylaxis | - |\\n| Early enteral feeding, prophylactic antibiotics | - |\\n| Early biliary decompression; if obstruction | - |\\n\\n### Enteral Nutrition\\n\\nFasting does not help, and it does not alleviate the inflammatory response or ‘put the pancreas to rest’. Enteral feeding (a product of millions of years of evolution) is superior to parenteral feeding, prevents bacterial overgrowth in the intestine and reduces bacterial translocation, reduces the risk of systemic infections, organ dysfunction, and mortality. The only contraindication is an inability to eat because of the associated ileus or gastric outlet obstruction. So, offer food to a conscious patient if it is tolerated without vomiting or aggravating pain.\\n\\nIn a ventilated and sedated patient, this is what we do:\\n\\n- Try a nasogastric tube first and start feeding. If gastric residual is > 250 ml/6 hr, insert a self-advancing nasojejunal tube.\\n```',\n", " 'images': [{'name': 'img_p282_1.png',\n", " 'height': 590,\n", " 'width': 819,\n", " 'x': 103.67999999999984,\n", " 'y': 132.48000000000002,\n", " 'original_width': 1407,\n", " 'original_height': 1012}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary of Early Treatment of Severe Acute Pancreatitis',\n", " 'md': '## Summary of Early Treatment of Severe Acute Pancreatitis',\n", " 'bBox': {'x': 325.42, 'y': 138.41, 'w': 90.08, 'h': 15.82}},\n", " {'type': 'text',\n", " 'value': 'Too much fluid can cause tissue edema and intra-abdominal hypertension (IAH). Our current fluid resuscitation goals are summarized in Table 19.2.',\n", " 'md': 'Too much fluid can cause tissue edema and intra-abdominal hypertension (IAH). Our current fluid resuscitation goals are summarized in Table 19.2.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 94.32, 'h': 15.82}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 19.2: Summary of Early Treatment of Severe Acute Pancreatitis',\n", " 'md': '### Table 19.2: Summary of Early Treatment of Severe Acute Pancreatitis',\n", " 'bBox': {'x': 110.61, 'y': 138.41, 'w': 90.08, 'h': 15.82}},\n", " {'type': 'table',\n", " 'rows': [['Treatment Goals', 'Details'],\n", " ['Early admission to ICU or high dependency unit', '-'],\n", " ['Goals for fluid resuscitation with crystalloids:']],\n", " 'md': '| Treatment Goals | Details |\\n|-----------------|---------|\\n| Early admission to ICU or high dependency unit | - |\\n| Goals for fluid resuscitation with crystalloids: | - MAP > 65 mmHg',\n", " 'isPerfectTable': False,\n", " 'csv': '\"Treatment Goals\",\"Details\"\\n\"Early admission to ICU or high dependency unit\",\"-\"\\n\"Goals for fluid resuscitation with crystalloids:\"',\n", " 'bBox': {'x': 152.18, 'y': 102, 'w': 262.58, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- SvO2 > 65% (requires pulmonary artery catheter)\\n- Normal lactate\\n- Urine output > 1 ml/kg/hr (about 50-100 ml/hr)\\n- Routine measurement of IAP (goal < 25 mmHg)\\n- APP (MAP - IAP) > 60 mmHg\\n- Norepinephrine and/or dobutamine in cardiovascular failure |',\n", " 'md': '- SvO2 > 65% (requires pulmonary artery catheter)\\n- Normal lactate\\n- Urine output > 1 ml/kg/hr (about 50-100 ml/hr)\\n- Routine measurement of IAP (goal < 25 mmHg)\\n- APP (MAP - IAP) > 60 mmHg\\n- Norepinephrine and/or dobutamine in cardiovascular failure |',\n", " 'bBox': {'x': 159.11, 'y': 306.95, 'w': 272.22, 'h': 13.34}},\n", " {'type': 'table',\n", " 'rows': [['Analgesia, sedation, lung-protective ventilation',\n", " 'Normoglycemia'],\n", " ['Early enteral feeding, prophylactic antibiotics', '-'],\n", " ['Early biliary decompression; if obstruction', '-']],\n", " 'md': '| Analgesia, sedation, lung-protective ventilation | Normoglycemia |\\n| Thrombosis prophylaxis | - |\\n| Early enteral feeding, prophylactic antibiotics | - |\\n| Early biliary decompression; if obstruction | - |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Analgesia, sedation, lung-protective ventilation\",\"Normoglycemia\"\\n\"Early enteral feeding, prophylactic antibiotics\",\"-\"\\n\"Early biliary decompression; if obstruction\",\"-\"',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Enteral Nutrition',\n", " 'md': '### Enteral Nutrition',\n", " 'bBox': {'x': 86, 'y': 460, 'w': 111.09, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Fasting does not help, and it does not alleviate the inflammatory response or ‘put the pancreas to rest’. Enteral feeding (a product of millions of years of evolution) is superior to parenteral feeding, prevents bacterial overgrowth in the intestine and reduces bacterial translocation, reduces the risk of systemic infections, organ dysfunction, and mortality. The only contraindication is an inability to eat because of the associated ileus or gastric outlet obstruction. So, offer food to a conscious patient if it is tolerated without vomiting or aggravating pain.\\n\\nIn a ventilated and sedated patient, this is what we do:\\n\\n- Try a nasogastric tube first and start feeding. If gastric residual is > 250 ml/6 hr, insert a self-advancing nasojejunal tube.\\n```',\n", " 'md': 'Fasting does not help, and it does not alleviate the inflammatory response or ‘put the pancreas to rest’. Enteral feeding (a product of millions of years of evolution) is superior to parenteral feeding, prevents bacterial overgrowth in the intestine and reduces bacterial translocation, reduces the risk of systemic infections, organ dysfunction, and mortality. The only contraindication is an inability to eat because of the associated ileus or gastric outlet obstruction. So, offer food to a conscious patient if it is tolerated without vomiting or aggravating pain.\\n\\nIn a ventilated and sedated patient, this is what we do:\\n\\n- Try a nasogastric tube first and start feeding. If gastric residual is > 250 ml/6 hr, insert a self-advancing nasojejunal tube.\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.86, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 284,\n", " 'text': ' • tube or ask your endoscopy friend to insert one.\\n • Then start feeding with 10ml/hr and increase gradually until caloric\\n needs are met.\\n • Avoid exceeding 60ml/hr.\\n Enteral feeding is probably more beneficial in reducing the risk of\\ninfectious complications than prophylactic antibiotics, so use it!\\n\\n Prophylactic antibiotics\\n There are many randomized controlled trials and probably even more\\nmeta-analyses (BTW — “Meta-analysis is to analysis as metaphysics to\\nphysics” said ħ. ħarlan Stone) and systematic reviews, that try to\\nconvince us that prophylactic antibiotics do not benefit patients with acute\\npancreatitis. Acknowledging the limitations of the trials and that\\npatients with organ failure are susceptible to infections, we believe\\n(not evidence but maybe error-based medicine) that the use of\\nprophylactic antibiotics in patients with severe pancreatitis is\\njustified. We base our indication for starting antibiotics on clinical\\njudgment taking into account the presence of SIRS, IAħ, hyperglycemia,\\nlow plasma calcium, high creatinine or other signs of organ dysfunction. If\\nit turns out that the patient has mild acute pancreatitis, it is quite OK to\\nterminate the antibiotics, no harm done. We start with cefuroxime unless\\ncontraindicated (allergy). You can use your local soup du jour.\\n\\n Who needs surgery on week 1?\\n Apart from surgical or endoscopic interventions required for gallstone-\\nassociated pancreatitis (see Chapter 20, Section 3), there are very\\nfew reasons to operate on patients with severe acute pancreatitis in\\nthe early stage:\\n\\n • Abdominal compartment syndrome (ACS). The combination of\\n excessive fluid resuscitation and capillary leakage leads to tissue\\n edema of the abdominal and retroperitoneal organs, and ascites\\n formation. Intestinal paralysis (ileus) usually adds to the increase of\\n the intra-abdominal volume leading to IAħ. For general diagnosis\\n and management of IAħ and ACS, see Chapter 33. When IAħ',\n", " 'md': '```markdown\\n### Enteral Feeding and Prophylactic Antibiotics\\n\\n- Tube or ask your endoscopy friend to insert one.\\n- Then start feeding with \\\\(10 \\\\, \\\\text{ml/hr}\\\\) and increase gradually until caloric needs are met.\\n- Avoid exceeding \\\\(60 \\\\, \\\\text{ml/hr}\\\\).\\n\\nEnteral feeding is probably more beneficial in reducing the risk of infectious complications than prophylactic antibiotics, so use it!\\n\\n#### Prophylactic Antibiotics\\n\\nThere are many randomized controlled trials and probably even more meta-analyses (BTW — “Meta-analysis is to analysis as metaphysics to physics” said ħ. ħarlan Stone) and systematic reviews, that try to convince us that prophylactic antibiotics do not benefit patients with acute pancreatitis. Acknowledging the limitations of the trials and that patients with organ failure are susceptible to infections, we believe (not evidence but maybe error-based medicine) that the use of prophylactic antibiotics in patients with severe pancreatitis is justified. We base our indication for starting antibiotics on clinical judgment taking into account the presence of SIRS, IAħ, hyperglycemia, low plasma calcium, high creatinine or other signs of organ dysfunction. If it turns out that the patient has mild acute pancreatitis, it is quite OK to terminate the antibiotics, no harm done. We start with cefuroxime unless contraindicated (allergy). You can use your local soup du jour.\\n\\n#### Who Needs Surgery on Week 1?\\n\\nApart from surgical or endoscopic interventions required for gallstone-associated pancreatitis (see Chapter 20, Section 3), there are very few reasons to operate on patients with severe acute pancreatitis in the early stage:\\n\\n- Abdominal compartment syndrome (ACS). The combination of excessive fluid resuscitation and capillary leakage leads to tissue edema of the abdominal and retroperitoneal organs, and ascites formation. Intestinal paralysis (ileus) usually adds to the increase of the intra-abdominal volume leading to IAħ. For general diagnosis and management of IAħ and ACS, see Chapter 33. When IAħ\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Enteral Feeding and Prophylactic Antibiotics',\n", " 'md': '### Enteral Feeding and Prophylactic Antibiotics',\n", " 'bBox': {'x': 86, 'y': 250, 'w': 162.26, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- Tube or ask your endoscopy friend to insert one.\\n- Then start feeding with \\\\(10 \\\\, \\\\text{ml/hr}\\\\) and increase gradually until caloric needs are met.\\n- Avoid exceeding \\\\(60 \\\\, \\\\text{ml/hr}\\\\).\\n\\nEnteral feeding is probably more beneficial in reducing the risk of infectious complications than prophylactic antibiotics, so use it!',\n", " 'md': '- Tube or ask your endoscopy friend to insert one.\\n- Then start feeding with \\\\(10 \\\\, \\\\text{ml/hr}\\\\) and increase gradually until caloric needs are met.\\n- Avoid exceeding \\\\(60 \\\\, \\\\text{ml/hr}\\\\).\\n\\nEnteral feeding is probably more beneficial in reducing the risk of infectious complications than prophylactic antibiotics, so use it!',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.42, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Prophylactic Antibiotics',\n", " 'md': '#### Prophylactic Antibiotics',\n", " 'bBox': {'x': 86, 'y': 250, 'w': 162.26, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'There are many randomized controlled trials and probably even more meta-analyses (BTW — “Meta-analysis is to analysis as metaphysics to physics” said ħ. ħarlan Stone) and systematic reviews, that try to convince us that prophylactic antibiotics do not benefit patients with acute pancreatitis. Acknowledging the limitations of the trials and that patients with organ failure are susceptible to infections, we believe (not evidence but maybe error-based medicine) that the use of prophylactic antibiotics in patients with severe pancreatitis is justified. We base our indication for starting antibiotics on clinical judgment taking into account the presence of SIRS, IAħ, hyperglycemia, low plasma calcium, high creatinine or other signs of organ dysfunction. If it turns out that the patient has mild acute pancreatitis, it is quite OK to terminate the antibiotics, no harm done. We start with cefuroxime unless contraindicated (allergy). You can use your local soup du jour.',\n", " 'md': 'There are many randomized controlled trials and probably even more meta-analyses (BTW — “Meta-analysis is to analysis as metaphysics to physics” said ħ. ħarlan Stone) and systematic reviews, that try to convince us that prophylactic antibiotics do not benefit patients with acute pancreatitis. Acknowledging the limitations of the trials and that patients with organ failure are susceptible to infections, we believe (not evidence but maybe error-based medicine) that the use of prophylactic antibiotics in patients with severe pancreatitis is justified. We base our indication for starting antibiotics on clinical judgment taking into account the presence of SIRS, IAħ, hyperglycemia, low plasma calcium, high creatinine or other signs of organ dysfunction. If it turns out that the patient has mild acute pancreatitis, it is quite OK to terminate the antibiotics, no harm done. We start with cefuroxime unless contraindicated (allergy). You can use your local soup du jour.',\n", " 'bBox': {'x': 72, 'y': 250, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Who Needs Surgery on Week 1?',\n", " 'md': '#### Who Needs Surgery on Week 1?',\n", " 'bBox': {'x': 86, 'y': 525, 'w': 215.03, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Apart from surgical or endoscopic interventions required for gallstone-associated pancreatitis (see Chapter 20, Section 3), there are very few reasons to operate on patients with severe acute pancreatitis in the early stage:\\n\\n- Abdominal compartment syndrome (ACS). The combination of excessive fluid resuscitation and capillary leakage leads to tissue edema of the abdominal and retroperitoneal organs, and ascites formation. Intestinal paralysis (ileus) usually adds to the increase of the intra-abdominal volume leading to IAħ. For general diagnosis and management of IAħ and ACS, see Chapter 33. When IAħ\\n```',\n", " 'md': 'Apart from surgical or endoscopic interventions required for gallstone-associated pancreatitis (see Chapter 20, Section 3), there are very few reasons to operate on patients with severe acute pancreatitis in the early stage:\\n\\n- Abdominal compartment syndrome (ACS). The combination of excessive fluid resuscitation and capillary leakage leads to tissue edema of the abdominal and retroperitoneal organs, and ascites formation. Intestinal paralysis (ileus) usually adds to the increase of the intra-abdominal volume leading to IAħ. For general diagnosis and management of IAħ and ACS, see Chapter 33. When IAħ\\n```',\n", " 'bBox': {'x': 72, 'y': 546, 'w': 467.87, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'few reasons to operate on patients with severe acute pancreatitis in'},\n", " {'text': ''}]},\n", " {'page': 285,\n", " 'text': ' (defined as IAP ≥12mmħg) develops, non-operative methods to\\n decrease IAP should be tried first to prevent progression to a full-\\n blown ACS. If non-operative management, including\\n percutaneous drainage of pancreatic ascites, fails to reduce the\\n IAP (goal APP >60mmHg), surgical decompression is indicated.\\n Unlike some other indications for an open abdomen (trauma,\\n peritonitis, bowel ischemia), in acute pancreatitis surgical\\n decompression usually leads to an open abdomen of several weeks’\\n duration. ħowever, with the new methods of open abdomen\\n management, such as the vacuum-assisted closure (VAC) with\\n mesh-mediated fascial traction, the delayed fascial closure rates\\n approach 90% with a very low enteric fistula rate.\\n• Bleeding. Bleeding — usually from the necrotic process around the\\n pancreas eroding an artery — is a rare complication in severe acute\\n pancreatitis, but when it occurs it requires prompt management,\\n preferably by angiographic embolization. Sometimes, however, you\\n are forced to go in and pack the bleeding leaving the abdomen open\\n and then do a reoperation 2 days later to remove the packs.\\n Obviously, hemorrhage in need of hemostasis may develop during\\n the subsequent weeks.\\n• Colon necrosis (actually, this complication is more common later\\n on…). Necrosis of a part of the transverse colon in acute\\n pancreatitis is associated with high mortality and is difficult to\\n diagnose until perforation occurs. Gas bubbles in the colonic wall\\n seen on CT can be a useful hint. Colon necrosis is probably caused\\n by retroperitoneal spread of the necrotizing process to the colon with\\n fat necrosis and pericolitis. Usually, the inner layers of the colon\\n remain viable longer. The commonest site of colon necrosis is the\\n adjacent transverse colon — caused by thrombosis of the middle\\n colic artery branches involved in the peripancreatic necrosis (\\n Figure 19.2). We have also seen cecal perforations — probably\\n aggravated by colonic dilatation ( Figure 19.3). Try to identify any\\n necrosis (gas bubbles and other signs of necrosis in the colon\\n wall on CT) before it progresses to frank perforation and\\n contamination of the peritoneal cavity. At surgery removal of the\\n affected segment is performed. Primary colonic anastomosis under\\n these circumstances is risky, and a colostomy is a better option.',\n", " 'md': '```markdown\\n## Management of Intra-Abdominal Pressure (IAP) in Acute Pancreatitis\\n\\n- When IAP is defined as \\\\( IAP \\\\geq 12 \\\\, \\\\text{mmHg} \\\\), non-operative methods to decrease IAP should be tried first to prevent progression to a full-blown Abdominal Compartment Syndrome (ACS). If non-operative management, including percutaneous drainage of pancreatic ascites, fails to reduce the IAP (goal APP > 60 mmHg), surgical decompression is indicated.\\n- Unlike some other indications for an open abdomen (trauma, peritonitis, bowel ischemia), in acute pancreatitis, surgical decompression usually leads to an open abdomen of several weeks’ duration. However, with the new methods of open abdomen management, such as the vacuum-assisted closure (VAC) with mesh-mediated fascial traction, the delayed fascial closure rates approach 90% with a very low enteric fistula rate.\\n\\n### Complications in Severe Acute Pancreatitis\\n\\n- **Bleeding**:\\n- Bleeding, usually from the necrotic process around the pancreas eroding an artery, is a rare complication in severe acute pancreatitis. When it occurs, it requires prompt management, preferably by angiographic embolization. Sometimes, however, you are forced to go in and pack the bleeding, leaving the abdomen open and then doing a reoperation 2 days later to remove the packs. Obviously, hemorrhage in need of hemostasis may develop during the subsequent weeks.\\n\\n- **Colon Necrosis**:\\n- Necrosis of a part of the transverse colon in acute pancreatitis is associated with high mortality and is difficult to diagnose until perforation occurs. Gas bubbles in the colonic wall seen on CT can be a useful hint. Colon necrosis is probably caused by retroperitoneal spread of the necrotizing process to the colon with fat necrosis and pericolitis. Usually, the inner layers of the colon remain viable longer. The commonest site of colon necrosis is the adjacent transverse colon, caused by thrombosis of the middle colic artery branches involved in the peripancreatic necrosis (Figure 19.2). We have also seen cecal perforations, probably aggravated by colonic dilatation (Figure 19.3).\\n\\n### Recommendations\\n- Try to identify any necrosis (gas bubbles and other signs of necrosis in the colon wall on CT) before it progresses to frank perforation and contamination of the peritoneal cavity. At surgery, removal of the affected segment is performed. Primary colonic anastomosis under these circumstances is risky, and a colostomy is a better option.\\n\\n### Figures\\n- **Figure 19.2**: Depicts the common site of colon necrosis associated with thrombosis of the middle colic artery branches involved in peripancreatic necrosis.\\n- **Figure 19.3**: Illustrates cecal perforations, likely aggravated by colonic dilatation.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Intra-Abdominal Pressure (IAP) in Acute Pancreatitis',\n", " 'md': '## Management of Intra-Abdominal Pressure (IAP) in Acute Pancreatitis',\n", " 'bBox': {'x': 318, 'y': 185, 'w': 39.19, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- When IAP is defined as \\\\( IAP \\\\geq 12 \\\\, \\\\text{mmHg} \\\\), non-operative methods to decrease IAP should be tried first to prevent progression to a full-blown Abdominal Compartment Syndrome (ACS). If non-operative management, including percutaneous drainage of pancreatic ascites, fails to reduce the IAP (goal APP > 60 mmHg), surgical decompression is indicated.\\n- Unlike some other indications for an open abdomen (trauma, peritonitis, bowel ischemia), in acute pancreatitis, surgical decompression usually leads to an open abdomen of several weeks’ duration. However, with the new methods of open abdomen management, such as the vacuum-assisted closure (VAC) with mesh-mediated fascial traction, the delayed fascial closure rates approach 90% with a very low enteric fistula rate.',\n", " 'md': '- When IAP is defined as \\\\( IAP \\\\geq 12 \\\\, \\\\text{mmHg} \\\\), non-operative methods to decrease IAP should be tried first to prevent progression to a full-blown Abdominal Compartment Syndrome (ACS). If non-operative management, including percutaneous drainage of pancreatic ascites, fails to reduce the IAP (goal APP > 60 mmHg), surgical decompression is indicated.\\n- Unlike some other indications for an open abdomen (trauma, peritonitis, bowel ischemia), in acute pancreatitis, surgical decompression usually leads to an open abdomen of several weeks’ duration. However, with the new methods of open abdomen management, such as the vacuum-assisted closure (VAC) with mesh-mediated fascial traction, the delayed fascial closure rates approach 90% with a very low enteric fistula rate.',\n", " 'bBox': {'x': 100, 'y': 119, 'w': 436.47, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Complications in Severe Acute Pancreatitis',\n", " 'md': '### Complications in Severe Acute Pancreatitis',\n", " 'bBox': {'x': 318, 'y': 185, 'w': 39.19, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Bleeding**:\\n- Bleeding, usually from the necrotic process around the pancreas eroding an artery, is a rare complication in severe acute pancreatitis. When it occurs, it requires prompt management, preferably by angiographic embolization. Sometimes, however, you are forced to go in and pack the bleeding, leaving the abdomen open and then doing a reoperation 2 days later to remove the packs. Obviously, hemorrhage in need of hemostasis may develop during the subsequent weeks.\\n\\n- **Colon Necrosis**:\\n- Necrosis of a part of the transverse colon in acute pancreatitis is associated with high mortality and is difficult to diagnose until perforation occurs. Gas bubbles in the colonic wall seen on CT can be a useful hint. Colon necrosis is probably caused by retroperitoneal spread of the necrotizing process to the colon with fat necrosis and pericolitis. Usually, the inner layers of the colon remain viable longer. The commonest site of colon necrosis is the adjacent transverse colon, caused by thrombosis of the middle colic artery branches involved in the peripancreatic necrosis (Figure 19.2). We have also seen cecal perforations, probably aggravated by colonic dilatation (Figure 19.3).',\n", " 'md': '- **Bleeding**:\\n- Bleeding, usually from the necrotic process around the pancreas eroding an artery, is a rare complication in severe acute pancreatitis. When it occurs, it requires prompt management, preferably by angiographic embolization. Sometimes, however, you are forced to go in and pack the bleeding, leaving the abdomen open and then doing a reoperation 2 days later to remove the packs. Obviously, hemorrhage in need of hemostasis may develop during the subsequent weeks.\\n\\n- **Colon Necrosis**:\\n- Necrosis of a part of the transverse colon in acute pancreatitis is associated with high mortality and is difficult to diagnose until perforation occurs. Gas bubbles in the colonic wall seen on CT can be a useful hint. Colon necrosis is probably caused by retroperitoneal spread of the necrotizing process to the colon with fat necrosis and pericolitis. Usually, the inner layers of the colon remain viable longer. The commonest site of colon necrosis is the adjacent transverse colon, caused by thrombosis of the middle colic artery branches involved in the peripancreatic necrosis (Figure 19.2). We have also seen cecal perforations, probably aggravated by colonic dilatation (Figure 19.3).',\n", " 'bBox': {'x': 100, 'y': 119, 'w': 436.5, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Recommendations',\n", " 'md': '### Recommendations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Try to identify any necrosis (gas bubbles and other signs of necrosis in the colon wall on CT) before it progresses to frank perforation and contamination of the peritoneal cavity. At surgery, removal of the affected segment is performed. Primary colonic anastomosis under these circumstances is risky, and a colostomy is a better option.',\n", " 'md': '- Try to identify any necrosis (gas bubbles and other signs of necrosis in the colon wall on CT) before it progresses to frank perforation and contamination of the peritoneal cavity. At surgery, removal of the affected segment is performed. Primary colonic anastomosis under these circumstances is risky, and a colostomy is a better option.',\n", " 'bBox': {'x': 100, 'y': 185, 'w': 437.02, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 19.2**: Depicts the common site of colon necrosis associated with thrombosis of the middle colic artery branches involved in peripancreatic necrosis.\\n- **Figure 19.3**: Illustrates cecal perforations, likely aggravated by colonic dilatation.\\n```',\n", " 'md': '- **Figure 19.2**: Depicts the common site of colon necrosis associated with thrombosis of the middle colic artery branches involved in peripancreatic necrosis.\\n- **Figure 19.3**: Illustrates cecal perforations, likely aggravated by colonic dilatation.\\n```',\n", " 'bBox': {'x': 318, 'y': 185, 'w': 15.2, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'aggravated by colonic dilatation ('},\n", " {'text': 'necrosis (gas bubbles and other signs of necrosis in the colon'}]},\n", " {'page': 286,\n", " 'text': ' Figure 19.2. Necrosis of the transverse colon. The necrotic area is between my (on the\\n left) and my assistant’s thumbs.\\n\\n Figure 19.3. Patchy necrosis of the cecum.\\n\\n 2nd week: necrosis\\n\\n The necrotic process in and around the pancreas starts to manifest by\\nthe end of the first week, and the severity (and the prognosis) depends\\non the quantity and extent of the necrotic tissue. A CT scan (with i.v.',\n", " 'md': \"```markdown\\n## Page Content\\n\\n### Text\\n- Necrosis of the transverse colon. The necrotic area is between my (on the left) and my assistant’s thumbs.\\n- Patchy necrosis of the cecum.\\n- 2nd week: necrosis\\n- The necrotic process in and around the pancreas starts to manifest by the end of the first week, and the severity (and the prognosis) depends on the quantity and extent of the necrotic tissue. A CT scan (with i.v.\\n\\n### Figures\\n- **Figure 19.2**: This image depicts necrosis of the transverse colon, with the necrotic area indicated between the thumbs of the presenter and their assistant. The image illustrates the physical manifestation of necrosis in this specific region of the colon.\\n\\n- **Figure 19.3**: This image shows patchy necrosis of the cecum. The visual representation highlights the irregular areas of necrosis present in the cecum, which is crucial for understanding the condition's progression.\\n\\n### Summary\\nThe text discusses the necrotic processes occurring in the colon and pancreas, emphasizing the timeline and severity of necrosis. The figures provide visual evidence of necrosis in specific areas, aiding in the understanding of the condition's impact on the gastrointestinal system.\\n```\",\n", " 'images': [{'name': 'img_p285_1.png',\n", " 'height': 431,\n", " 'width': 597,\n", " 'x': 158.39999999999964,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1368,\n", " 'original_height': 988},\n", " {'name': 'img_p285_2.png',\n", " 'height': 428,\n", " 'width': 597,\n", " 'x': 158.39999999999964,\n", " 'y': 353.52,\n", " 'original_width': 1371,\n", " 'original_height': 982}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Necrosis of the transverse colon. The necrotic area is between my (on the left) and my assistant’s thumbs.\\n- Patchy necrosis of the cecum.\\n- 2nd week: necrosis\\n- The necrotic process in and around the pancreas starts to manifest by the end of the first week, and the severity (and the prognosis) depends on the quantity and extent of the necrotic tissue. A CT scan (with i.v.',\n", " 'md': '- Necrosis of the transverse colon. The necrotic area is between my (on the left) and my assistant’s thumbs.\\n- Patchy necrosis of the cecum.\\n- 2nd week: necrosis\\n- The necrotic process in and around the pancreas starts to manifest by the end of the first week, and the severity (and the prognosis) depends on the quantity and extent of the necrotic tissue. A CT scan (with i.v.',\n", " 'bBox': {'x': 75, 'y': 328, 'w': 453.3, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- **Figure 19.2**: This image depicts necrosis of the transverse colon, with the necrotic area indicated between the thumbs of the presenter and their assistant. The image illustrates the physical manifestation of necrosis in this specific region of the colon.\\n\\n- **Figure 19.3**: This image shows patchy necrosis of the cecum. The visual representation highlights the irregular areas of necrosis present in the cecum, which is crucial for understanding the condition's progression.\",\n", " 'md': \"- **Figure 19.2**: This image depicts necrosis of the transverse colon, with the necrotic area indicated between the thumbs of the presenter and their assistant. The image illustrates the physical manifestation of necrosis in this specific region of the colon.\\n\\n- **Figure 19.3**: This image shows patchy necrosis of the cecum. The visual representation highlights the irregular areas of necrosis present in the cecum, which is crucial for understanding the condition's progression.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"The text discusses the necrotic processes occurring in the colon and pancreas, emphasizing the timeline and severity of necrosis. The figures provide visual evidence of necrosis in specific areas, aiding in the understanding of the condition's impact on the gastrointestinal system.\\n```\",\n", " 'md': \"The text discusses the necrotic processes occurring in the colon and pancreas, emphasizing the timeline and severity of necrosis. The figures provide visual evidence of necrosis in specific areas, aiding in the understanding of the condition's impact on the gastrointestinal system.\\n```\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 287,\n", " 'text': 'contrast now if the renal function is normal) can show the extent of\\nthe necrosis. There are classification systems based on the CT\\nevaluation (the first one developed in Finland by the radiologist Leena\\nKivisaari), such as the Balthazar classification (look it up), but the\\nphysiological state and organ functions are better determinants of\\nseverity. Fluid collections around the pancreas and in the lesser sac are\\ncommon. We used to call them pseudocysts, but acute\\nperipancreatic fluid collection is a more accurate term. They may\\nresolve spontaneously and as such require no treatment. If the\\nnecrotic collections remain sterile, there is no reason to operate at\\nthis early stage. So, be patient even if the intensivists give you the\\ntypical look (while thinking): “Why is he not going to operate, we are\\ntired and bored of this…” (see Figure 19.4).\\n PeRyAD\\nFigure 19.4. Assistant: “Prof, let’s operate for God’s sake! His pancreas is dead!”\\nProfessor: “Are you an imbecile or what? Be patient! We’ll operate perhaps next month.\\nNow get me some more vino!”\\n\\n 3rd week: infection\\n\\n The diagnosis of infected necrosis is difficult. Even fine-needle\\naspiration (FNA) of the necrosis, usually performed with ultrasound\\nguidance, has a false-negative rate of 20-25%.',\n", " 'md': \"```markdown\\n## Page Content\\n\\nContrast now if the renal function is normal can show the extent of the necrosis. There are classification systems based on the CT evaluation (the first one developed in Finland by the radiologist Leena Kivisaari), such as the Balthazar classification (look it up), but the physiological state and organ functions are better determinants of severity. Fluid collections around the pancreas and in the lesser sac are common. We used to call them pseudocysts, but acute peripancreatic fluid collection is a more accurate term. They may resolve spontaneously and as such require no treatment. If the necrotic collections remain sterile, there is no reason to operate at this early stage. So, be patient even if the intensivists give you the typical look (while thinking): “Why is he not going to operate, we are tired and bored of this…” (see Figure 19.4).\\n\\n**Figure 19.4.** Assistant: “Prof, let’s operate for God’s sake! His pancreas is dead!”\\nProfessor: “Are you an imbecile or what? Be patient! We’ll operate perhaps next month. Now get me some more vino!”\\n\\n### 3rd week: infection\\n\\nThe diagnosis of infected necrosis is difficult. Even fine-needle aspiration (FNA) of the necrosis, usually performed with ultrasound guidance, has a false-negative rate of 20-25%.\\n```\\n\\n### Image Identification and Description\\n\\n- **Figure 19.4**: This figure likely depicts a humorous dialogue between an assistant and a professor regarding the urgency of operating on a patient with necrotic pancreas. The image may include caricatures or illustrations of the characters involved in the conversation, emphasizing the tension between the urgency of the assistant and the calm demeanor of the professor. The caption reflects the humorous nature of the dialogue, highlighting the professor's nonchalant attitude towards the situation.\\n\\n### Summary\\nThe page discusses the classification of pancreatic necrosis and the management of fluid collections, emphasizing the importance of patience in treatment decisions. It also touches on the challenges of diagnosing infected necrosis.\",\n", " 'images': [{'name': 'img_p286_1.png',\n", " 'height': 447,\n", " 'width': 603,\n", " 'x': 156.96000000000004,\n", " 'y': 298.08000000000004,\n", " 'original_width': 1383,\n", " 'original_height': 1027}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Contrast now if the renal function is normal can show the extent of the necrosis. There are classification systems based on the CT evaluation (the first one developed in Finland by the radiologist Leena Kivisaari), such as the Balthazar classification (look it up), but the physiological state and organ functions are better determinants of severity. Fluid collections around the pancreas and in the lesser sac are common. We used to call them pseudocysts, but acute peripancreatic fluid collection is a more accurate term. They may resolve spontaneously and as such require no treatment. If the necrotic collections remain sterile, there is no reason to operate at this early stage. So, be patient even if the intensivists give you the typical look (while thinking): “Why is he not going to operate, we are tired and bored of this…” (see Figure 19.4).\\n\\n**Figure 19.4.** Assistant: “Prof, let’s operate for God’s sake! His pancreas is dead!”\\nProfessor: “Are you an imbecile or what? Be patient! We’ll operate perhaps next month. Now get me some more vino!”',\n", " 'md': 'Contrast now if the renal function is normal can show the extent of the necrosis. There are classification systems based on the CT evaluation (the first one developed in Finland by the radiologist Leena Kivisaari), such as the Balthazar classification (look it up), but the physiological state and organ functions are better determinants of severity. Fluid collections around the pancreas and in the lesser sac are common. We used to call them pseudocysts, but acute peripancreatic fluid collection is a more accurate term. They may resolve spontaneously and as such require no treatment. If the necrotic collections remain sterile, there is no reason to operate at this early stage. So, be patient even if the intensivists give you the typical look (while thinking): “Why is he not going to operate, we are tired and bored of this…” (see Figure 19.4).\\n\\n**Figure 19.4.** Assistant: “Prof, let’s operate for God’s sake! His pancreas is dead!”\\nProfessor: “Are you an imbecile or what? Be patient! We’ll operate perhaps next month. Now get me some more vino!”',\n", " 'bBox': {'x': 72, 'y': 168, 'w': 467.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': '3rd week: infection',\n", " 'md': '### 3rd week: infection',\n", " 'bBox': {'x': 86, 'y': 618, 'w': 149.88, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The diagnosis of infected necrosis is difficult. Even fine-needle aspiration (FNA) of the necrosis, usually performed with ultrasound guidance, has a false-negative rate of 20-25%.\\n```',\n", " 'md': 'The diagnosis of infected necrosis is difficult. Even fine-needle aspiration (FNA) of the necrosis, usually performed with ultrasound guidance, has a false-negative rate of 20-25%.\\n```',\n", " 'bBox': {'x': 72, 'y': 687, 'w': 297.47, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- **Figure 19.4**: This figure likely depicts a humorous dialogue between an assistant and a professor regarding the urgency of operating on a patient with necrotic pancreas. The image may include caricatures or illustrations of the characters involved in the conversation, emphasizing the tension between the urgency of the assistant and the calm demeanor of the professor. The caption reflects the humorous nature of the dialogue, highlighting the professor's nonchalant attitude towards the situation.\",\n", " 'md': \"- **Figure 19.4**: This figure likely depicts a humorous dialogue between an assistant and a professor regarding the urgency of operating on a patient with necrotic pancreas. The image may include caricatures or illustrations of the characters involved in the conversation, emphasizing the tension between the urgency of the assistant and the calm demeanor of the professor. The caption reflects the humorous nature of the dialogue, highlighting the professor's nonchalant attitude towards the situation.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The page discusses the classification of pancreatic necrosis and the management of fluid collections, emphasizing the importance of patience in treatment decisions. It also touches on the challenges of diagnosing infected necrosis.',\n", " 'md': 'The page discusses the classification of pancreatic necrosis and the management of fluid collections, emphasizing the importance of patience in treatment decisions. It also touches on the challenges of diagnosing infected necrosis.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 288,\n", " 'text': ' Clinical signs of sepsis are too non-specific for definitive diagnosis,\\nalthough a new increase in the CRP value without any other good\\nexplanation might alert you to look for infected necrosis. Get a new CT! If\\nyou are lucky, gas bubbles in the CT scan means infection but\\nunfortunately, they are present in less than 10% of cases.\\n\\n 4th week: the (surgical) action really starts now\\n\\n What do you see on CT?\\n\\nFigure 19.5. Abdominal CT showing walled-off necrosis (WON). Note the encapsulated\\ncollection of pancreatic and/or peripancreatic necrosis with a well-defined, enhancing\\ninflammatory wall.\\n\\n According to the updated Atlanta classification 2012:\\n\\n • Peripancreatic collections associated with necrosis are termed\\n acute necrotic collection (ANC) and walled-off necrosis (WON).\\n In the early phase poorly demarcated acute peripancreatic fluid\\n collections are commonly seen on CT scan. They are\\n homogeneous, confined to normal fascial planes, can be multiple,\\n usually remain sterile and resolve spontaneously without\\n intervention. So, don’t worry about them.\\n • Pancreatic pseudocyst refers to a well-defined fluid collection\\n containing no solid material. The development of pancreatic\\n pseudocyst is rare in acute pancreatitis, and is often confused with',\n", " 'md': '```markdown\\n## Clinical Signs of Sepsis\\n\\nClinical signs of sepsis are too non-specific for definitive diagnosis, although a new increase in the CRP value without any other good explanation might alert you to look for infected necrosis. Get a new CT! If you are lucky, gas bubbles in the CT scan means infection but unfortunately, they are present in less than 10% of cases.\\n\\n### 4th Week: The (Surgical) Action Really Starts Now\\n\\nWhat do you see on CT?\\n\\n### Figure 19.5\\n**Description:** Abdominal CT showing walled-off necrosis (WON). Note the encapsulated collection of pancreatic and/or peripancreatic necrosis with a well-defined, enhancing inflammatory wall.\\n\\nAccording to the updated Atlanta classification 2012:\\n\\n- Peripancreatic collections associated with necrosis are termed acute necrotic collection (ANC) and walled-off necrosis (WON). In the early phase, poorly demarcated acute peripancreatic fluid collections are commonly seen on CT scan. They are homogeneous, confined to normal fascial planes, can be multiple, usually remain sterile, and resolve spontaneously without intervention. So, don’t worry about them.\\n- Pancreatic pseudocyst refers to a well-defined fluid collection containing no solid material. The development of pancreatic pseudocyst is rare in acute pancreatitis and is often confused with .\\n```',\n", " 'images': [{'name': 'img_p287_1.png',\n", " 'height': 361,\n", " 'width': 416,\n", " 'x': 203.03999999999996,\n", " 'y': 244.79999999999995,\n", " 'original_width': 1144,\n", " 'original_height': 992}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Signs of Sepsis',\n", " 'md': '## Clinical Signs of Sepsis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Clinical signs of sepsis are too non-specific for definitive diagnosis, although a new increase in the CRP value without any other good explanation might alert you to look for infected necrosis. Get a new CT! If you are lucky, gas bubbles in the CT scan means infection but unfortunately, they are present in less than 10% of cases.',\n", " 'md': 'Clinical signs of sepsis are too non-specific for definitive diagnosis, although a new increase in the CRP value without any other good explanation might alert you to look for infected necrosis. Get a new CT! If you are lucky, gas bubbles in the CT scan means infection but unfortunately, they are present in less than 10% of cases.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 466.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': '4th Week: The (Surgical) Action Really Starts Now',\n", " 'md': '### 4th Week: The (Surgical) Action Really Starts Now',\n", " 'bBox': {'x': 86, 'y': 195, 'w': 372.39, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'What do you see on CT?',\n", " 'md': 'What do you see on CT?',\n", " 'bBox': {'x': 86, 'y': 231, 'w': 167.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 19.5',\n", " 'md': '### Figure 19.5',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** Abdominal CT showing walled-off necrosis (WON). Note the encapsulated collection of pancreatic and/or peripancreatic necrosis with a well-defined, enhancing inflammatory wall.\\n\\nAccording to the updated Atlanta classification 2012:\\n\\n- Peripancreatic collections associated with necrosis are termed acute necrotic collection (ANC) and walled-off necrosis (WON). In the early phase, poorly demarcated acute peripancreatic fluid collections are commonly seen on CT scan. They are homogeneous, confined to normal fascial planes, can be multiple, usually remain sterile, and resolve spontaneously without intervention. So, don’t worry about them.\\n- Pancreatic pseudocyst refers to a well-defined fluid collection containing no solid material. The development of pancreatic pseudocyst is rare in acute pancreatitis and is often confused with .\\n```',\n", " 'md': '**Description:** Abdominal CT showing walled-off necrosis (WON). Note the encapsulated collection of pancreatic and/or peripancreatic necrosis with a well-defined, enhancing inflammatory wall.\\n\\nAccording to the updated Atlanta classification 2012:\\n\\n- Peripancreatic collections associated with necrosis are termed acute necrotic collection (ANC) and walled-off necrosis (WON). In the early phase, poorly demarcated acute peripancreatic fluid collections are commonly seen on CT scan. They are homogeneous, confined to normal fascial planes, can be multiple, usually remain sterile, and resolve spontaneously without intervention. So, don’t worry about them.\\n- Pancreatic pseudocyst refers to a well-defined fluid collection containing no solid material. The development of pancreatic pseudocyst is rare in acute pancreatitis and is often confused with .\\n```',\n", " 'bBox': {'x': 75, 'y': 455, 'w': 460.13, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 289,\n", " 'text': ' ANC. ħowever, it may form many weeks after operative\\n necrosectomy due to localized leakage of a disconnected duct (see\\n below) in the necrosectomy cavity.\\n • ANC (‘early’) is a collection seen during the first 4 weeks and\\n containing variable amounts of fluid and necrotic tissue involving the\\n pancreatic parenchyma and/or peripancreatic tissues.\\n • WON (‘late’) is a mature, encapsulated collection of pancreatic\\n and/or peripancreatic necrosis with a well-defined, enhancing\\n inflammatory wall ( Figure 19.5). The maturation takes usually 4\\n weeks or more after the onset of acute pancreatitis. (If you have\\n problems remembering these, think about Nelson Mandela and\\n “ANC won in 40 years”.)\\n\\n Indications and timing for interventions\\n\\n According to the International Association of Pancreatology and the\\nAmerican Pancreatic Association evidence-based guidelines for the\\nmanagement of acute pancreatitis 2, the indications for intervention\\n(surgical, radiological or endoscopic) in necrotizing pancreatitis are:\\n\\n • Clinically suspected or documented infected necrosis with\\n clinical deterioration, or ongoing organ failure for several\\n weeks.\\n • Ongoing gastric outlet, intestinal, or biliary obstruction due to mass\\n effect of WON.\\n • Patient not getting better with WON but no infection (after 8 weeks).\\n • Disconnected duct syndrome (full transection of the pancreatic duct)\\n with persisting symptomatic collection with necrosis without signs of\\n infection (>8 weeks).\\n\\n So you see that the timing of intervention is usually postponed until at least 4 weeks\\n after the initial presentation to allow the WON to be formed. As listed above,\\n recommendation for some of the other indications is more than 8 weeks. This requires\\n lots of patience!',\n", " 'md': \"```markdown\\n## Text Extraction\\n\\n- ANC ('early') is a collection seen during the first 4 weeks and containing variable amounts of fluid and necrotic tissue involving the pancreatic parenchyma and/or peripancreatic tissues.\\n- WON ('late') is a mature, encapsulated collection of pancreatic and/or peripancreatic necrosis with a well-defined, enhancing inflammatory wall (Figure 19.5). The maturation takes usually 4 weeks or more after the onset of acute pancreatitis. (If you have problems remembering these, think about Nelson Mandela and “ANC won in 40 years”.)\\n\\n### Indications and Timing for Interventions\\n\\nAccording to the International Association of Pancreatology and the American Pancreatic Association evidence-based guidelines for the management of acute pancreatitis, the indications for intervention (surgical, radiological or endoscopic) in necrotizing pancreatitis are:\\n\\n- Clinically suspected or documented infected necrosis with clinical deterioration, or ongoing organ failure for several weeks.\\n- Ongoing gastric outlet, intestinal, or biliary obstruction due to mass effect of WON.\\n- Patient not getting better with WON but no infection (after 8 weeks).\\n- Disconnected duct syndrome (full transection of the pancreatic duct) with persisting symptomatic collection with necrosis without signs of infection (>8 weeks).\\n\\nSo you see that the timing of intervention is usually postponed until at least 4 weeks after the initial presentation to allow the WON to be formed. As listed above, recommendation for some of the other indications is more than 8 weeks. This requires lots of patience!\\n\\n## Image Identification and Description\\n\\n### Figure 19.5\\n- **Description**: This figure illustrates the concept of WON (Walled-off Necrosis) in the context of necrotizing pancreatitis. It likely shows a diagram or imaging result that highlights the encapsulated nature of the necrotic tissue and the inflammatory wall surrounding it.\\n- **Summary**: The figure serves to visually represent the late-stage complications of acute pancreatitis, emphasizing the importance of recognizing WON for appropriate management.\\n\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- ANC ('early') is a collection seen during the first 4 weeks and containing variable amounts of fluid and necrotic tissue involving the pancreatic parenchyma and/or peripancreatic tissues.\\n- WON ('late') is a mature, encapsulated collection of pancreatic and/or peripancreatic necrosis with a well-defined, enhancing inflammatory wall (Figure 19.5). The maturation takes usually 4 weeks or more after the onset of acute pancreatitis. (If you have problems remembering these, think about Nelson Mandela and “ANC won in 40 years”.)\",\n", " 'md': \"- ANC ('early') is a collection seen during the first 4 weeks and containing variable amounts of fluid and necrotic tissue involving the pancreatic parenchyma and/or peripancreatic tissues.\\n- WON ('late') is a mature, encapsulated collection of pancreatic and/or peripancreatic necrosis with a well-defined, enhancing inflammatory wall (Figure 19.5). The maturation takes usually 4 weeks or more after the onset of acute pancreatitis. (If you have problems remembering these, think about Nelson Mandela and “ANC won in 40 years”.)\",\n", " 'bBox': {'x': 100, 'y': 86, 'w': 436.98, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Indications and Timing for Interventions',\n", " 'md': '### Indications and Timing for Interventions',\n", " 'bBox': {'x': 86, 'y': 319, 'w': 310.74, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'According to the International Association of Pancreatology and the American Pancreatic Association evidence-based guidelines for the management of acute pancreatitis, the indications for intervention (surgical, radiological or endoscopic) in necrotizing pancreatitis are:\\n\\n- Clinically suspected or documented infected necrosis with clinical deterioration, or ongoing organ failure for several weeks.\\n- Ongoing gastric outlet, intestinal, or biliary obstruction due to mass effect of WON.\\n- Patient not getting better with WON but no infection (after 8 weeks).\\n- Disconnected duct syndrome (full transection of the pancreatic duct) with persisting symptomatic collection with necrosis without signs of infection (>8 weeks).\\n\\nSo you see that the timing of intervention is usually postponed until at least 4 weeks after the initial presentation to allow the WON to be formed. As listed above, recommendation for some of the other indications is more than 8 weeks. This requires lots of patience!',\n", " 'md': 'According to the International Association of Pancreatology and the American Pancreatic Association evidence-based guidelines for the management of acute pancreatitis, the indications for intervention (surgical, radiological or endoscopic) in necrotizing pancreatitis are:\\n\\n- Clinically suspected or documented infected necrosis with clinical deterioration, or ongoing organ failure for several weeks.\\n- Ongoing gastric outlet, intestinal, or biliary obstruction due to mass effect of WON.\\n- Patient not getting better with WON but no infection (after 8 weeks).\\n- Disconnected duct syndrome (full transection of the pancreatic duct) with persisting symptomatic collection with necrosis without signs of infection (>8 weeks).\\n\\nSo you see that the timing of intervention is usually postponed until at least 4 weeks after the initial presentation to allow the WON to be formed. As listed above, recommendation for some of the other indications is more than 8 weeks. This requires lots of patience!',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 19.5',\n", " 'md': '### Figure 19.5',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure illustrates the concept of WON (Walled-off Necrosis) in the context of necrotizing pancreatitis. It likely shows a diagram or imaging result that highlights the encapsulated nature of the necrotic tissue and the inflammatory wall surrounding it.\\n- **Summary**: The figure serves to visually represent the late-stage complications of acute pancreatitis, emphasizing the importance of recognizing WON for appropriate management.\\n\\n```',\n", " 'md': '- **Description**: This figure illustrates the concept of WON (Walled-off Necrosis) in the context of necrotizing pancreatitis. It likely shows a diagram or imaging result that highlights the encapsulated nature of the necrotic tissue and the inflammatory wall surrounding it.\\n- **Summary**: The figure serves to visually represent the late-stage complications of acute pancreatitis, emphasizing the importance of recognizing WON for appropriate management.\\n\\n```',\n", " 'bBox': {'x': 224, 'y': 86, 'w': 11.19, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'weeks or more after the onset of acute pancreatitis. (If you have'},\n", " {'text': '2'}]},\n", " {'page': 290,\n", " 'text': ' Treatment\\n\\n In patients with suspected or confirmed infected necrotic pancreatic\\ntissue, the Dutch 3 have shown that by using the so-called ‘step-up’\\nstrategy consisting of initial percutaneous drainage followed, if\\nnecessary, by minimally invasive retroperitoneal necrosectomy,\\nopen surgical procedures can be avoided in about one-third of\\npatients.\\n\\n Normally we leave the early fluid collections alone for the first 2-3\\nweeks unless causing major obstructive problems by compression. If we\\nsuspect that they are infected, we then use the step-up procedure and\\nask our ultrasonographers to put a drain into the collection. We take\\nbacterial samples and, if positive, we keep the drain and if necessary\\nproceed to necrosectomy later on, if the drainage procedure is\\ninadequate (as judged by deteriorating infection and organ function). If it\\nis sterile, we remove the drain after a few days to avoid drain-induced\\ncontamination/infection of the necrotic collection. We have one or two\\npatients like this in the ICU at any given time, and we follow the plan\\ndescribed above and wait for the bacterial result.\\n\\n How to do a necrosectomy\\n\\n Of course, there are several ways of doing a necrosectomy ranging\\nfrom minimally invasive to ‘maximally invasive’ techniques, the choice\\ndepending on the size and location of the WON, the presence or absence\\nof a disconnected duct, and the expertise available. So ask: open or\\nminimal access pancreatic necrosectomy? Transperitoneal or\\nretroperitoneal? Close the abdomen or leave it open? In reality, you\\ndo what you know best but if possible, tailor the procedure to that\\nwhich benefits the patient most. It is always useful to have more\\nthan one option.\\n\\n Endoscopic variations for the management of peripancreatic necrotic\\ncollections have been introduced and include endoscopic retroperitoneal\\ndrainage or lumboscopic necrosectomy, and percutaneous necrosectomy\\nand sinus tract endoscopy. The value of these techniques is still under',\n", " 'md': '```markdown\\n# Treatment\\n\\nIn patients with suspected or confirmed infected necrotic pancreatic tissue, the Dutch have shown that by using the so-called ‘step-up’ strategy consisting of initial percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy, open surgical procedures can be avoided in about one-third of patients.\\n\\nNormally we leave the early fluid collections alone for the first 2-3 weeks unless causing major obstructive problems by compression. If we suspect that they are infected, we then use the step-up procedure and ask our ultrasonographers to put a drain into the collection. We take bacterial samples and, if positive, we keep the drain and if necessary proceed to necrosectomy later on, if the drainage procedure is inadequate (as judged by deteriorating infection and organ function). If it is sterile, we remove the drain after a few days to avoid drain-induced contamination/infection of the necrotic collection. We have one or two patients like this in the ICU at any given time, and we follow the plan described above and wait for the bacterial result.\\n\\n## How to do a necrosectomy\\n\\nOf course, there are several ways of doing a necrosectomy ranging from minimally invasive to ‘maximally invasive’ techniques, the choice depending on the size and location of the WON, the presence or absence of a disconnected duct, and the expertise available. So ask: open or minimal access pancreatic necrosectomy? Transperitoneal or retroperitoneal? Close the abdomen or leave it open? In reality, you do what you know best but if possible, tailor the procedure to that which benefits the patient most. It is always useful to have more than one option.\\n\\nEndoscopic variations for the management of peripancreatic necrotic collections have been introduced and include endoscopic retroperitoneal drainage or lumboscopic necrosectomy, and percutaneous necrosectomy and sinus tract endoscopy. The value of these techniques is still under .\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Treatment',\n", " 'md': '# Treatment',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 79.1, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In patients with suspected or confirmed infected necrotic pancreatic tissue, the Dutch have shown that by using the so-called ‘step-up’ strategy consisting of initial percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy, open surgical procedures can be avoided in about one-third of patients.\\n\\nNormally we leave the early fluid collections alone for the first 2-3 weeks unless causing major obstructive problems by compression. If we suspect that they are infected, we then use the step-up procedure and ask our ultrasonographers to put a drain into the collection. We take bacterial samples and, if positive, we keep the drain and if necessary proceed to necrosectomy later on, if the drainage procedure is inadequate (as judged by deteriorating infection and organ function). If it is sterile, we remove the drain after a few days to avoid drain-induced contamination/infection of the necrotic collection. We have one or two patients like this in the ICU at any given time, and we follow the plan described above and wait for the bacterial result.',\n", " 'md': 'In patients with suspected or confirmed infected necrotic pancreatic tissue, the Dutch have shown that by using the so-called ‘step-up’ strategy consisting of initial percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy, open surgical procedures can be avoided in about one-third of patients.\\n\\nNormally we leave the early fluid collections alone for the first 2-3 weeks unless causing major obstructive problems by compression. If we suspect that they are infected, we then use the step-up procedure and ask our ultrasonographers to put a drain into the collection. We take bacterial samples and, if positive, we keep the drain and if necessary proceed to necrosectomy later on, if the drainage procedure is inadequate (as judged by deteriorating infection and organ function). If it is sterile, we remove the drain after a few days to avoid drain-induced contamination/infection of the necrotic collection. We have one or two patients like this in the ICU at any given time, and we follow the plan described above and wait for the bacterial result.',\n", " 'bBox': {'x': 72, 'y': 209, 'w': 467.72, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'How to do a necrosectomy',\n", " 'md': '## How to do a necrosectomy',\n", " 'bBox': {'x': 86, 'y': 453, 'w': 210.58, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Of course, there are several ways of doing a necrosectomy ranging from minimally invasive to ‘maximally invasive’ techniques, the choice depending on the size and location of the WON, the presence or absence of a disconnected duct, and the expertise available. So ask: open or minimal access pancreatic necrosectomy? Transperitoneal or retroperitoneal? Close the abdomen or leave it open? In reality, you do what you know best but if possible, tailor the procedure to that which benefits the patient most. It is always useful to have more than one option.\\n\\nEndoscopic variations for the management of peripancreatic necrotic collections have been introduced and include endoscopic retroperitoneal drainage or lumboscopic necrosectomy, and percutaneous necrosectomy and sinus tract endoscopy. The value of these techniques is still under .\\n```',\n", " 'md': 'Of course, there are several ways of doing a necrosectomy ranging from minimally invasive to ‘maximally invasive’ techniques, the choice depending on the size and location of the WON, the presence or absence of a disconnected duct, and the expertise available. So ask: open or minimal access pancreatic necrosectomy? Transperitoneal or retroperitoneal? Close the abdomen or leave it open? In reality, you do what you know best but if possible, tailor the procedure to that which benefits the patient most. It is always useful to have more than one option.\\n\\nEndoscopic variations for the management of peripancreatic necrotic collections have been introduced and include endoscopic retroperitoneal drainage or lumboscopic necrosectomy, and percutaneous necrosectomy and sinus tract endoscopy. The value of these techniques is still under .\\n```',\n", " 'bBox': {'x': 72, 'y': 522, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 291,\n", " 'text': 'assessment, but many centers use them as a primary option. We did a\\nfew minimal access necrosectomies a couple years ago but found it\\ncumbersome and it left a nasty feeling of not doing enough. So we\\naborted the experiment…\\n\\n Open necrosectomy\\n\\n When you do open necrosectomy for the right indications at the right\\ntime, removing the black clay-like stuff by scooping with your fingers is\\neasy. Getting through the gastrocolic ligament (yes, I prefer not to go\\nthrough the transverse mesocolon), opening the correct tissue planes\\nwith blunt dissection and utilizing the ħarmonic Scalpel® or old-fashioned\\nligatures gives good exposure.\\n\\n Usually the necrosis is mostly found around the pancreas while\\nthe pancreas itself is firm and protrudes like a transverse ridge.\\nLeave it alone! If on the other hand (and pre-operative CT helps) the\\nnecrotizing process has destroyed the pancreas (the disconnected duct\\nsyndrome), you can squeeze it out distally with gentle finger dissection,\\nbut be careful with the splenic vessels and leave the spleen alone. Once\\nyou have removed the dead distal pancreas ( Figure 19.6) (sometimes\\nonly a small proximal remnant is left), you can try to find the divided\\npancreatic duct and ligate it. Usually you don’t see it, and a pancreatic\\nfistula occurs, but you can deal with that later on. Pack the area for a few\\nminutes and check hemostasis. Deal with clear bleeders, don’t worry\\nabout minor oozing. Draining the peripancreatic area with a couple of\\nwell-placed drains (one coming behind the left colon into the pancreatic\\narea if the necrosis is mainly on the left side) completes the procedure.\\nUsually, in 80-90% of cases, we close the abdomen after\\nnecrosectomy unless the IAP was clearly elevated prior to surgery\\nor if there is considerable intestinal oedema. Obviously, in a patient\\nalready with an ‘open abdomen’ (for ACS for example), and who, later on,\\nneeds necrosectomy, we almost always leave the abdomen open and\\ncontinue with the mesh-mediated VAC system.\\n\\n The vacuum and mesh-mediated fascial traction is a temporary\\nabdominal closure (TAC) method described by our Swedish colleagues',\n", " 'md': '```markdown\\n## Open Necrosectomy\\n\\nWhen you do open necrosectomy for the right indications at the right time, removing the black clay-like stuff by scooping with your fingers is easy. Getting through the gastrocolic ligament (yes, I prefer not to go through the transverse mesocolon), opening the correct tissue planes with blunt dissection and utilizing the harmonic Scalpel® or old-fashioned ligatures gives good exposure.\\n\\nUsually, the necrosis is mostly found around the pancreas while the pancreas itself is firm and protrudes like a transverse ridge. Leave it alone! If on the other hand (and pre-operative CT helps) the necrotizing process has destroyed the pancreas (the disconnected duct syndrome), you can squeeze it out distally with gentle finger dissection, but be careful with the splenic vessels and leave the spleen alone. Once you have removed the dead distal pancreas (Figure 19.6) (sometimes only a small proximal remnant is left), you can try to find the divided pancreatic duct and ligate it. Usually, you don’t see it, and a pancreatic fistula occurs, but you can deal with that later on. Pack the area for a few minutes and check hemostasis. Deal with clear bleeders, don’t worry about minor oozing. Draining the peripancreatic area with a couple of well-placed drains (one coming behind the left colon into the pancreatic area if the necrosis is mainly on the left side) completes the procedure. Usually, in 80-90% of cases, we close the abdomen after necrosectomy unless the IAP was clearly elevated prior to surgery or if there is considerable intestinal oedema. Obviously, in a patient already with an ‘open abdomen’ (for ACS for example), and who, later on, needs necrosectomy, we almost always leave the abdomen open and continue with the mesh-mediated VAC system.\\n\\nThe vacuum and mesh-mediated fascial traction is a temporary abdominal closure (TAC) method described by our Swedish colleagues.\\n```\\n\\n### Figure 19.6 Description\\n- **Figure 19.6**: This figure likely depicts the anatomical considerations and surgical approach during an open necrosectomy, particularly focusing on the pancreas and surrounding structures. The image may illustrate the necrotic tissue removal process and the anatomical landmarks to be aware of during the procedure.\\n- **Summary**: The figure serves as a visual guide for surgeons performing necrosectomy, emphasizing the importance of careful dissection and the management of pancreatic necrosis.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Open Necrosectomy',\n", " 'md': '## Open Necrosectomy',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 159.11, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'When you do open necrosectomy for the right indications at the right time, removing the black clay-like stuff by scooping with your fingers is easy. Getting through the gastrocolic ligament (yes, I prefer not to go through the transverse mesocolon), opening the correct tissue planes with blunt dissection and utilizing the harmonic Scalpel® or old-fashioned ligatures gives good exposure.\\n\\nUsually, the necrosis is mostly found around the pancreas while the pancreas itself is firm and protrudes like a transverse ridge. Leave it alone! If on the other hand (and pre-operative CT helps) the necrotizing process has destroyed the pancreas (the disconnected duct syndrome), you can squeeze it out distally with gentle finger dissection, but be careful with the splenic vessels and leave the spleen alone. Once you have removed the dead distal pancreas (Figure 19.6) (sometimes only a small proximal remnant is left), you can try to find the divided pancreatic duct and ligate it. Usually, you don’t see it, and a pancreatic fistula occurs, but you can deal with that later on. Pack the area for a few minutes and check hemostasis. Deal with clear bleeders, don’t worry about minor oozing. Draining the peripancreatic area with a couple of well-placed drains (one coming behind the left colon into the pancreatic area if the necrosis is mainly on the left side) completes the procedure. Usually, in 80-90% of cases, we close the abdomen after necrosectomy unless the IAP was clearly elevated prior to surgery or if there is considerable intestinal oedema. Obviously, in a patient already with an ‘open abdomen’ (for ACS for example), and who, later on, needs necrosectomy, we almost always leave the abdomen open and continue with the mesh-mediated VAC system.\\n\\nThe vacuum and mesh-mediated fascial traction is a temporary abdominal closure (TAC) method described by our Swedish colleagues.\\n```',\n", " 'md': 'When you do open necrosectomy for the right indications at the right time, removing the black clay-like stuff by scooping with your fingers is easy. Getting through the gastrocolic ligament (yes, I prefer not to go through the transverse mesocolon), opening the correct tissue planes with blunt dissection and utilizing the harmonic Scalpel® or old-fashioned ligatures gives good exposure.\\n\\nUsually, the necrosis is mostly found around the pancreas while the pancreas itself is firm and protrudes like a transverse ridge. Leave it alone! If on the other hand (and pre-operative CT helps) the necrotizing process has destroyed the pancreas (the disconnected duct syndrome), you can squeeze it out distally with gentle finger dissection, but be careful with the splenic vessels and leave the spleen alone. Once you have removed the dead distal pancreas (Figure 19.6) (sometimes only a small proximal remnant is left), you can try to find the divided pancreatic duct and ligate it. Usually, you don’t see it, and a pancreatic fistula occurs, but you can deal with that later on. Pack the area for a few minutes and check hemostasis. Deal with clear bleeders, don’t worry about minor oozing. Draining the peripancreatic area with a couple of well-placed drains (one coming behind the left colon into the pancreatic area if the necrosis is mainly on the left side) completes the procedure. Usually, in 80-90% of cases, we close the abdomen after necrosectomy unless the IAP was clearly elevated prior to surgery or if there is considerable intestinal oedema. Obviously, in a patient already with an ‘open abdomen’ (for ACS for example), and who, later on, needs necrosectomy, we almost always leave the abdomen open and continue with the mesh-mediated VAC system.\\n\\nThe vacuum and mesh-mediated fascial traction is a temporary abdominal closure (TAC) method described by our Swedish colleagues.\\n```',\n", " 'bBox': {'x': 72, 'y': 178, 'w': 468.01, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 19.6 Description',\n", " 'md': '### Figure 19.6 Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 19.6**: This figure likely depicts the anatomical considerations and surgical approach during an open necrosectomy, particularly focusing on the pancreas and surrounding structures. The image may illustrate the necrotic tissue removal process and the anatomical landmarks to be aware of during the procedure.\\n- **Summary**: The figure serves as a visual guide for surgeons performing necrosectomy, emphasizing the importance of careful dissection and the management of pancreatic necrosis.',\n", " 'md': '- **Figure 19.6**: This figure likely depicts the anatomical considerations and surgical approach during an open necrosectomy, particularly focusing on the pancreas and surrounding structures. The image may illustrate the necrotic tissue removal process and the anatomical landmarks to be aware of during the procedure.\\n- **Summary**: The figure serves as a visual guide for surgeons performing necrosectomy, emphasizing the importance of careful dissection and the management of pancreatic necrosis.',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 159.11, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'only a small proximal remnant is left), you can try to find the divided'}]},\n", " {'page': 292,\n", " 'text': '4. It combines the vacuum effect with mechanical traction induced by a\\nmesh. The intra-abdominal contents are first covered by a polyethylene\\nsheet followed by suturing of an oval-shaped polypropylene mesh to the\\nfascial edges. A polyurethane sponge is then placed on the mesh and\\ncovered with an airtight occlusive plastic sheet. A vacuum is introduced\\nby connecting the dressing to a suction apparatus creating continuous\\nnegative pressure (usually minus 125mmħg). TAC changes are\\nperformed every 2-3 days in the operating theatre or at the bedside\\nin the ICU. During the TAC changes, fascial edges are approximated\\nby tightening the mesh by suturing it in the midline (the mesh is\\ndivided at the midline during the first change to allow changing of the\\nunderlying plastic sheet). When the gap between the fascial edges has\\nbeen reduced to about 5cm, the mesh is removed, and the fascia\\nand skin are closed with sutures. Using this method the delayed\\nfascial closure rate is about 80-90%, higher than with any other TAC\\nmethod published. Furthermore, the enteral fistula rate is also the lowest\\namong TAC methods.\\n\\n Figure 19.6. Removed dead pancreas.\\n\\n About two out of three cases need only a single procedure\\n(probably because we do it late enough and can do a fairly complete\\nnecrosectomy). These days reoperations are not ‘planned’ but\\nperformed ‘on demand’ for complications such as disconnected\\nduct syndrome (see above).\\n\\n Complications after necrosectomy',\n", " 'md': '```markdown\\n4. It combines the vacuum effect with mechanical traction induced by a mesh. The intra-abdominal contents are first covered by a polyethylene sheet followed by suturing of an oval-shaped polypropylene mesh to the fascial edges. A polyurethane sponge is then placed on the mesh and covered with an airtight occlusive plastic sheet. A vacuum is introduced by connecting the dressing to a suction apparatus creating continuous negative pressure (usually minus 125 mmHg). TAC changes are performed every 2-3 days in the operating theatre or at the bedside in the ICU. During the TAC changes, fascial edges are approximated by tightening the mesh by suturing it in the midline (the mesh is divided at the midline during the first change to allow changing of the underlying plastic sheet). When the gap between the fascial edges has been reduced to about 5 cm, the mesh is removed, and the fascia and skin are closed with sutures. Using this method the delayed fascial closure rate is about 80-90%, higher than with any other TAC method published. Furthermore, the enteral fistula rate is also the lowest among TAC methods.\\n\\n**Figure 19.6.** Removed dead pancreas.\\n\\nAbout two out of three cases need only a single procedure (probably because we do it late enough and can do a fairly complete necrosectomy). These days reoperations are not ‘planned’ but performed ‘on demand’ for complications such as disconnected duct syndrome (see above).\\n\\nComplications after necrosectomy\\n```\\n\\n### Image Description\\n- **Figure 19.6**: This image depicts the removed dead pancreas. The specific details of the image content are not provided, but it is likely to show the anatomical structure of the pancreas post-necrosectomy. The image serves to illustrate the surgical outcome of the procedure discussed in the text.',\n", " 'images': [{'name': 'img_p291_1.png',\n", " 'height': 336,\n", " 'width': 670,\n", " 'x': 140.39999999999964,\n", " 'y': 366.47999999999996,\n", " 'original_width': 1149,\n", " 'original_height': 577}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\n4. It combines the vacuum effect with mechanical traction induced by a mesh. The intra-abdominal contents are first covered by a polyethylene sheet followed by suturing of an oval-shaped polypropylene mesh to the fascial edges. A polyurethane sponge is then placed on the mesh and covered with an airtight occlusive plastic sheet. A vacuum is introduced by connecting the dressing to a suction apparatus creating continuous negative pressure (usually minus 125 mmHg). TAC changes are performed every 2-3 days in the operating theatre or at the bedside in the ICU. During the TAC changes, fascial edges are approximated by tightening the mesh by suturing it in the midline (the mesh is divided at the midline during the first change to allow changing of the underlying plastic sheet). When the gap between the fascial edges has been reduced to about 5 cm, the mesh is removed, and the fascia and skin are closed with sutures. Using this method the delayed fascial closure rate is about 80-90%, higher than with any other TAC method published. Furthermore, the enteral fistula rate is also the lowest among TAC methods.\\n\\n**Figure 19.6.** Removed dead pancreas.\\n\\nAbout two out of three cases need only a single procedure (probably because we do it late enough and can do a fairly complete necrosectomy). These days reoperations are not ‘planned’ but performed ‘on demand’ for complications such as disconnected duct syndrome (see above).\\n\\nComplications after necrosectomy\\n```',\n", " 'md': '```markdown\\n4. It combines the vacuum effect with mechanical traction induced by a mesh. The intra-abdominal contents are first covered by a polyethylene sheet followed by suturing of an oval-shaped polypropylene mesh to the fascial edges. A polyurethane sponge is then placed on the mesh and covered with an airtight occlusive plastic sheet. A vacuum is introduced by connecting the dressing to a suction apparatus creating continuous negative pressure (usually minus 125 mmHg). TAC changes are performed every 2-3 days in the operating theatre or at the bedside in the ICU. During the TAC changes, fascial edges are approximated by tightening the mesh by suturing it in the midline (the mesh is divided at the midline during the first change to allow changing of the underlying plastic sheet). When the gap between the fascial edges has been reduced to about 5 cm, the mesh is removed, and the fascia and skin are closed with sutures. Using this method the delayed fascial closure rate is about 80-90%, higher than with any other TAC method published. Furthermore, the enteral fistula rate is also the lowest among TAC methods.\\n\\n**Figure 19.6.** Removed dead pancreas.\\n\\nAbout two out of three cases need only a single procedure (probably because we do it late enough and can do a fairly complete necrosectomy). These days reoperations are not ‘planned’ but performed ‘on demand’ for complications such as disconnected duct syndrome (see above).\\n\\nComplications after necrosectomy\\n```',\n", " 'bBox': {'x': 72, 'y': 121, 'w': 467.73, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 19.6**: This image depicts the removed dead pancreas. The specific details of the image content are not provided, but it is likely to show the anatomical structure of the pancreas post-necrosectomy. The image serves to illustrate the surgical outcome of the procedure discussed in the text.',\n", " 'md': '- **Figure 19.6**: This image depicts the removed dead pancreas. The specific details of the image content are not provided, but it is likely to show the anatomical structure of the pancreas post-necrosectomy. The image serves to illustrate the surgical outcome of the procedure discussed in the text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '4'}]},\n", " {'page': 293,\n", " 'text': ' After necrosectomy, don’t expect everything to go smoothly...\\n\\n Postoperative bleeding is common so don’t panic! The drainage fluid\\ntends to be bloody in the first couple of days; it then turns brown and\\nugly, and finally grey-brown or pus-like. But if the blood in the drainage\\nbag is ‘pure’ or the patient becomes hemodynamically unstable and\\nrequires multiple blood transfusions, don’t hesitate to go in, evacuate the\\nblood and clots, stop any bleeding from visible sources or just pack the\\narea and leave the abdomen open. Angio-embolization is an\\nalternative to reoperation — if it is readily available.\\n\\n Residual necrosis after ‘incomplete’ necrosectomy is more common if\\nyou do the initial necrosectomy too early. Completing the necrosectomy\\nin a second (or more) operation is acceptable, so don’t try to remove\\nevery tiny bit of necrosis at the first operation if it causes more harm\\n(usually bleeding).\\n\\n Pancreatic fistula is common especially after necrosectomy that\\ninvolves distal pancreatectomy. You cannot measure amylase levels from\\nthe drains if the secretion is thick but eventually you will find out that\\nthere is a fistula. Keep the drains and, when feasible, ask your\\nendoscopist friends to insert a stent into the pancreatic duct. Some use\\noctreotide, we routinely do not.\\n\\n Bile-stained secretion from the drains is a bad sign. Accidental\\ninjury to the duodenum during necrosectomy sometimes happens. If\\nthe duodenal fistula is controlled (bile not floating all over the place) and\\nthe patient is not septic, have patience. Closing the duodenum at this\\nstage is virtually impossible; it is better to have a controlled fistula and\\ndeal with the duodenum later (if necessary).\\n\\n Please note:\\n In managing patients with severe acute pancreatitis, the emphasis is EARLY and\\n AGGRESSIVE supportive management, and LATE and MEASURED surgical\\n treatment.\\n These patients are best treated in centers which can provide long-term ICU',\n", " 'md': '```markdown\\n## Postoperative Management After Necrosectomy\\n\\nAfter necrosectomy, don’t expect everything to go smoothly...\\n\\nPostoperative bleeding is common so don’t panic! The drainage fluid tends to be bloody in the first couple of days; it then turns brown and ugly, and finally grey-brown or pus-like. But if the blood in the drainage bag is ‘pure’ or the patient becomes hemodynamically unstable and requires multiple blood transfusions, don’t hesitate to go in, evacuate the blood and clots, stop any bleeding from visible sources or just pack the area and leave the abdomen open. Angio-embolization is an alternative to reoperation — if it is readily available.\\n\\nResidual necrosis after ‘incomplete’ necrosectomy is more common if you do the initial necrosectomy too early. Completing the necrosectomy in a second (or more) operation is acceptable, so don’t try to remove every tiny bit of necrosis at the first operation if it causes more harm (usually bleeding).\\n\\nPancreatic fistula is common especially after necrosectomy that involves distal pancreatectomy. You cannot measure amylase levels from the drains if the secretion is thick but eventually you will find out that there is a fistula. Keep the drains and, when feasible, ask your endoscopist friends to insert a stent into the pancreatic duct. Some use octreotide, we routinely do not.\\n\\nBile-stained secretion from the drains is a bad sign. Accidental injury to the duodenum during necrosectomy sometimes happens. If the duodenal fistula is controlled (bile not floating all over the place) and the patient is not septic, have patience. Closing the duodenum at this stage is virtually impossible; it is better to have a controlled fistula and deal with the duodenum later (if necessary).\\n\\n### Important Note:\\nIn managing patients with severe acute pancreatitis, the emphasis is **EARLY** and **AGGRESSIVE** supportive management, and **LATE** and **MEASURED** surgical treatment. These patients are best treated in centers which can provide long-term ICU.\\n```',\n", " 'images': [{'name': 'img_p292_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 642.24},\n", " {'name': 'img_p292_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 701.28}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Postoperative Management After Necrosectomy',\n", " 'md': '## Postoperative Management After Necrosectomy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'After necrosectomy, don’t expect everything to go smoothly...\\n\\nPostoperative bleeding is common so don’t panic! The drainage fluid tends to be bloody in the first couple of days; it then turns brown and ugly, and finally grey-brown or pus-like. But if the blood in the drainage bag is ‘pure’ or the patient becomes hemodynamically unstable and requires multiple blood transfusions, don’t hesitate to go in, evacuate the blood and clots, stop any bleeding from visible sources or just pack the area and leave the abdomen open. Angio-embolization is an alternative to reoperation — if it is readily available.\\n\\nResidual necrosis after ‘incomplete’ necrosectomy is more common if you do the initial necrosectomy too early. Completing the necrosectomy in a second (or more) operation is acceptable, so don’t try to remove every tiny bit of necrosis at the first operation if it causes more harm (usually bleeding).\\n\\nPancreatic fistula is common especially after necrosectomy that involves distal pancreatectomy. You cannot measure amylase levels from the drains if the secretion is thick but eventually you will find out that there is a fistula. Keep the drains and, when feasible, ask your endoscopist friends to insert a stent into the pancreatic duct. Some use octreotide, we routinely do not.\\n\\nBile-stained secretion from the drains is a bad sign. Accidental injury to the duodenum during necrosectomy sometimes happens. If the duodenal fistula is controlled (bile not floating all over the place) and the patient is not septic, have patience. Closing the duodenum at this stage is virtually impossible; it is better to have a controlled fistula and deal with the duodenum later (if necessary).',\n", " 'md': 'After necrosectomy, don’t expect everything to go smoothly...\\n\\nPostoperative bleeding is common so don’t panic! The drainage fluid tends to be bloody in the first couple of days; it then turns brown and ugly, and finally grey-brown or pus-like. But if the blood in the drainage bag is ‘pure’ or the patient becomes hemodynamically unstable and requires multiple blood transfusions, don’t hesitate to go in, evacuate the blood and clots, stop any bleeding from visible sources or just pack the area and leave the abdomen open. Angio-embolization is an alternative to reoperation — if it is readily available.\\n\\nResidual necrosis after ‘incomplete’ necrosectomy is more common if you do the initial necrosectomy too early. Completing the necrosectomy in a second (or more) operation is acceptable, so don’t try to remove every tiny bit of necrosis at the first operation if it causes more harm (usually bleeding).\\n\\nPancreatic fistula is common especially after necrosectomy that involves distal pancreatectomy. You cannot measure amylase levels from the drains if the secretion is thick but eventually you will find out that there is a fistula. Keep the drains and, when feasible, ask your endoscopist friends to insert a stent into the pancreatic duct. Some use octreotide, we routinely do not.\\n\\nBile-stained secretion from the drains is a bad sign. Accidental injury to the duodenum during necrosectomy sometimes happens. If the duodenal fistula is controlled (bile not floating all over the place) and the patient is not septic, have patience. Closing the duodenum at this stage is virtually impossible; it is better to have a controlled fistula and deal with the duodenum later (if necessary).',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.84, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Important Note:',\n", " 'md': '### Important Note:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In managing patients with severe acute pancreatitis, the emphasis is **EARLY** and **AGGRESSIVE** supportive management, and **LATE** and **MEASURED** surgical treatment. These patients are best treated in centers which can provide long-term ICU.\\n```',\n", " 'md': 'In managing patients with severe acute pancreatitis, the emphasis is **EARLY** and **AGGRESSIVE** supportive management, and **LATE** and **MEASURED** surgical treatment. These patients are best treated in centers which can provide long-term ICU.\\n```',\n", " 'bBox': {'x': 132, 'y': 692, 'w': 48.54, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 294,\n", " 'text': ' support, combined with radiological, endoscopic and surgical expertise — by\\n people who remember and understand all the acronyms used in this chapter (!) —\\n not in the small ‘high-care unit’ in your little community hospital. So ship them out to\\n the experts…\\n\\n Let me conclude with some Finnish wisdom…\\n\\n Remember — we Finns drink a lot so we see tons of these cases.\\n\\n When our hospital in ħelsinki was built (about 1965), the mortality rate\\nfor severe acute pancreatitis was over 90%. When I started my surgical\\nresidency (early 1980s), it was still around 50%. Gradually it came\\ndown to 20% with highly improved intensive care and early surgical\\nconservatism. The last 10 years have seen tremendous progress in our\\nunderstanding of this very complex disease. Recognizing and treating the\\nACS associated with aggressive fluid resuscitation and tissue edema has\\nfurther improved the prognosis, especially when we have been more\\naggressive in opening the abdomen and leaving it open. We see about\\n20 patients like this every year, and with modern temporary abdominal\\nclosure methods, such as the mesh-mediated vacuum-assisted closure\\ntechnique, we can close the fascia (and skin) in about 90% of patients.\\nOnly a small proportion end up with skin grafting and subsequent\\nabdominal wall reconstruction.\\n\\n So, until a ‘magic pill’ is invented that stops the inflammatory cascade\\nat its beginning, we still need — with the help of our intensivists — to\\ntreat these patients as ‘surgical’ patients.\\n\\n The proper management of severe acute pancreatitis requires that you\\nunderstand its natural history and be armed with lots of patience. During\\nthe early phases of the disease “our patience will achieve more than our\\nforce” (Edmund Burke); later on, when called to operate on necrotic and\\ninfected complications, remember that “patience and diligence, like faith,\\nremove mountains” (William Penn).\\n\\n I wish to conclude with some wise words from the famous pancreatic',\n", " 'md': \"```markdown\\n## Text Extraction\\n\\nSupport, combined with radiological, endoscopic, and surgical expertise — by people who remember and understand all the acronyms used in this chapter (!) — not in the small ‘high-care unit’ in your little community hospital. So ship them out to the experts…\\n\\nLet me conclude with some Finnish wisdom…\\n\\nRemember — we Finns drink a lot so we see tons of these cases.\\n\\nWhen our hospital in Helsinki was built (about 1965), the mortality rate for severe acute pancreatitis was over 90%. When I started my surgical residency (early 1980s), it was still around 50%. Gradually it came down to 20% with highly improved intensive care and early surgical conservatism. The last 10 years have seen tremendous progress in our understanding of this very complex disease. Recognizing and treating the ACS associated with aggressive fluid resuscitation and tissue edema has further improved the prognosis, especially when we have been more aggressive in opening the abdomen and leaving it open. We see about 20 patients like this every year, and with modern temporary abdominal closure methods, such as the mesh-mediated vacuum-assisted closure technique, we can close the fascia (and skin) in about 90% of patients. Only a small proportion end up with skin grafting and subsequent abdominal wall reconstruction.\\n\\nSo, until a ‘magic pill’ is invented that stops the inflammatory cascade at its beginning, we still need — with the help of our intensivists — to treat these patients as ‘surgical’ patients.\\n\\nThe proper management of severe acute pancreatitis requires that you understand its natural history and be armed with lots of patience. During the early phases of the disease “our patience will achieve more than our force” (Edmund Burke); later on, when called to operate on necrotic and infected complications, remember that “patience and diligence, like faith, remove mountains” (William Penn).\\n\\nI wish to conclude with some wise words from the famous pancreatic...\\n\\n## Image Identification and Description\\n\\n*No images or figures were identified on this page.*\\n\\n## Summary\\n\\nThis page discusses the management of severe acute pancreatitis, highlighting the importance of surgical expertise and the evolution of treatment methods over the years. It emphasizes the need for patience and understanding of the disease's natural history, quoting notable figures to reinforce the message.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Support, combined with radiological, endoscopic, and surgical expertise — by people who remember and understand all the acronyms used in this chapter (!) — not in the small ‘high-care unit’ in your little community hospital. So ship them out to the experts…\\n\\nLet me conclude with some Finnish wisdom…\\n\\nRemember — we Finns drink a lot so we see tons of these cases.\\n\\nWhen our hospital in Helsinki was built (about 1965), the mortality rate for severe acute pancreatitis was over 90%. When I started my surgical residency (early 1980s), it was still around 50%. Gradually it came down to 20% with highly improved intensive care and early surgical conservatism. The last 10 years have seen tremendous progress in our understanding of this very complex disease. Recognizing and treating the ACS associated with aggressive fluid resuscitation and tissue edema has further improved the prognosis, especially when we have been more aggressive in opening the abdomen and leaving it open. We see about 20 patients like this every year, and with modern temporary abdominal closure methods, such as the mesh-mediated vacuum-assisted closure technique, we can close the fascia (and skin) in about 90% of patients. Only a small proportion end up with skin grafting and subsequent abdominal wall reconstruction.\\n\\nSo, until a ‘magic pill’ is invented that stops the inflammatory cascade at its beginning, we still need — with the help of our intensivists — to treat these patients as ‘surgical’ patients.\\n\\nThe proper management of severe acute pancreatitis requires that you understand its natural history and be armed with lots of patience. During the early phases of the disease “our patience will achieve more than our force” (Edmund Burke); later on, when called to operate on necrotic and infected complications, remember that “patience and diligence, like faith, remove mountains” (William Penn).\\n\\nI wish to conclude with some wise words from the famous pancreatic...',\n", " 'md': 'Support, combined with radiological, endoscopic, and surgical expertise — by people who remember and understand all the acronyms used in this chapter (!) — not in the small ‘high-care unit’ in your little community hospital. So ship them out to the experts…\\n\\nLet me conclude with some Finnish wisdom…\\n\\nRemember — we Finns drink a lot so we see tons of these cases.\\n\\nWhen our hospital in Helsinki was built (about 1965), the mortality rate for severe acute pancreatitis was over 90%. When I started my surgical residency (early 1980s), it was still around 50%. Gradually it came down to 20% with highly improved intensive care and early surgical conservatism. The last 10 years have seen tremendous progress in our understanding of this very complex disease. Recognizing and treating the ACS associated with aggressive fluid resuscitation and tissue edema has further improved the prognosis, especially when we have been more aggressive in opening the abdomen and leaving it open. We see about 20 patients like this every year, and with modern temporary abdominal closure methods, such as the mesh-mediated vacuum-assisted closure technique, we can close the fascia (and skin) in about 90% of patients. Only a small proportion end up with skin grafting and subsequent abdominal wall reconstruction.\\n\\nSo, until a ‘magic pill’ is invented that stops the inflammatory cascade at its beginning, we still need — with the help of our intensivists — to treat these patients as ‘surgical’ patients.\\n\\nThe proper management of severe acute pancreatitis requires that you understand its natural history and be armed with lots of patience. During the early phases of the disease “our patience will achieve more than our force” (Edmund Burke); later on, when called to operate on necrotic and infected complications, remember that “patience and diligence, like faith, remove mountains” (William Penn).\\n\\nI wish to conclude with some wise words from the famous pancreatic...',\n", " 'bBox': {'x': 72, 'y': 104, 'w': 467.76, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*',\n", " 'md': '*No images or figures were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"This page discusses the management of severe acute pancreatitis, highlighting the importance of surgical expertise and the evolution of treatment methods over the years. It emphasizes the need for patience and understanding of the disease's natural history, quoting notable figures to reinforce the message.\\n```\",\n", " 'md': \"This page discusses the management of severe acute pancreatitis, highlighting the importance of surgical expertise and the evolution of treatment methods over the years. It emphasizes the need for patience and understanding of the disease's natural history, quoting notable figures to reinforce the message.\\n```\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 295,\n", " 'text': 'surgeon Kenneth W. Warren (1911-2001).\\n\\n “The most common errors in the surgical treatment of\\n acute pancreatitis are to operate too early in the course\\n of the disease and to do too much, or in the secondary or\\n septic phase of the disease to operate too late and to do\\n too little.”\\n Kenneth W. Warren\\n\\n1 http://clincalc.com/IcuMortality/SOFA.aspx.\\n2 IAP/APA evidence-based guidelines for the management of acute pancreatitis.\\n Pancreatology 2013; 13(4 Suppl 2): 1-15.\\n3 van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open\\n necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362: 1491-502.\\n4 Peterson U, Acosta S, Björck M. Vacuum-assisted wound closure and mesh-mediated\\n fascial traction — a novel technique for late closure of the open abdomen. World J Surg\\n 2007; 31: 2133-7.',\n", " 'md': '```markdown\\n## Page Content\\n\\nSurgeon Kenneth W. Warren (1911-2001).\\n\\n> “The most common errors in the surgical treatment of acute pancreatitis are to operate too early in the course of the disease and to do too much, or in the secondary or septic phase of the disease to operate too late and to do too little.”\\n> — Kenneth W. Warren\\n\\n### References\\n1. [http://clincalc.com/IcuMortality/SOFA.aspx](http://clincalc.com/IcuMortality/SOFA.aspx)\\n2. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13(4 Suppl 2): 1-15.\\n3. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362: 1491-502.\\n4. Peterson U, Acosta S, Björck M. Vacuum-assisted wound closure and mesh-mediated fascial traction — a novel technique for late closure of the open abdomen. World J Surg 2007; 31: 2133-7.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Surgeon Kenneth W. Warren (1911-2001).\\n\\n> “The most common errors in the surgical treatment of acute pancreatitis are to operate too early in the course of the disease and to do too much, or in the secondary or septic phase of the disease to operate too late and to do too little.”\\n> — Kenneth W. Warren',\n", " 'md': 'Surgeon Kenneth W. Warren (1911-2001).\\n\\n> “The most common errors in the surgical treatment of acute pancreatitis are to operate too early in the course of the disease and to do too much, or in the secondary or septic phase of the disease to operate too late and to do too little.”\\n> — Kenneth W. Warren',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 453.6, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'References',\n", " 'md': '### References',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. [http://clincalc.com/IcuMortality/SOFA.aspx](http://clincalc.com/IcuMortality/SOFA.aspx)\\n2. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13(4 Suppl 2): 1-15.\\n3. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362: 1491-502.\\n4. Peterson U, Acosta S, Björck M. Vacuum-assisted wound closure and mesh-mediated fascial traction — a novel technique for late closure of the open abdomen. World J Surg 2007; 31: 2133-7.\\n```',\n", " 'md': '1. [http://clincalc.com/IcuMortality/SOFA.aspx](http://clincalc.com/IcuMortality/SOFA.aspx)\\n2. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13(4 Suppl 2): 1-15.\\n3. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362: 1491-502.\\n4. Peterson U, Acosta S, Björck M. Vacuum-assisted wound closure and mesh-mediated fascial traction — a novel technique for late closure of the open abdomen. World J Surg 2007; 31: 2133-7.\\n```',\n", " 'bBox': {'x': 73, 'y': 306, 'w': 372.5, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'},\n", " {'url': 'http://clincalc.com/IcuMortality/SOFA.aspx',\n", " 'text': 'http://clincalc.com/IcuMortality/SOFA.aspx.'},\n", " {'text': '2'},\n", " {'text': '3'},\n", " {'text': '4'}]},\n", " {'page': 296,\n", " 'text': 'Chapter 20\\nGallbladder and biliary emergency surgery\\nDanny Rosin, Moshe Schein and B. Ramana\\n\\n This chapter has been subdivided into the following three\\n sections:\\n\\n 1. The acute gallbladder.\\n 2. Bile duct emergencies.\\n 3. Biliary pancreatitis.\\n\\n The acute gallbladder\\n1 Danny Rosin and Moshe Schein\\n In dropsy of the gallbladder… and in gallstones we should\\n not wait ‘til the patient’s strength is exhausted, or ‘til the\\n blood becomes poisoned with bile, producing hemorrhage;\\n we should make an early abdominal incision, ascertain the\\n true nature of the disease, and then carry out the surgical\\n treatment that necessities of the case demand.\\n James Marion Sims\\n\\n Biliary surgery, and especially gallbladder surgery, is considered as\\none of the pillars of ‘general surgery’. Yet you will find a great diversity of',\n", " 'md': '```markdown\\n# Chapter 20: Gallbladder and Biliary Emergency Surgery\\n**Authors:** Danny Rosin, Moshe Schein, and B. Ramana\\n\\nThis chapter has been subdivided into the following three sections:\\n\\n1. The acute gallbladder.\\n2. Bile duct emergencies.\\n3. Biliary pancreatitis.\\n\\n## The Acute Gallbladder\\n> \"In dropsy of the gallbladder… and in gallstones we should not wait ‘til the patient’s strength is exhausted, or ‘til the blood becomes poisoned with bile, producing hemorrhage; we should make an early abdominal incision, ascertain the true nature of the disease, and then carry out the surgical treatment that necessities of the case demand.\"\\n> — James Marion Sims\\n\\nBiliary surgery, and especially gallbladder surgery, is considered as one of the pillars of ‘general surgery’. Yet you will find a great diversity of...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 20: Gallbladder and Biliary Emergency Surgery',\n", " 'md': '# Chapter 20: Gallbladder and Biliary Emergency Surgery',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 378.51, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Danny Rosin, Moshe Schein, and B. Ramana\\n\\nThis chapter has been subdivided into the following three sections:\\n\\n1. The acute gallbladder.\\n2. Bile duct emergencies.\\n3. Biliary pancreatitis.',\n", " 'md': '**Authors:** Danny Rosin, Moshe Schein, and B. Ramana\\n\\nThis chapter has been subdivided into the following three sections:\\n\\n1. The acute gallbladder.\\n2. Bile duct emergencies.\\n3. Biliary pancreatitis.',\n", " 'bBox': {'x': 79, 'y': 319, 'w': 453.27, 'h': 18.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Acute Gallbladder',\n", " 'md': '## The Acute Gallbladder',\n", " 'bBox': {'x': 100, 'y': 492, 'w': 170.12, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '> \"In dropsy of the gallbladder… and in gallstones we should not wait ‘til the patient’s strength is exhausted, or ‘til the blood becomes poisoned with bile, producing hemorrhage; we should make an early abdominal incision, ascertain the true nature of the disease, and then carry out the surgical treatment that necessities of the case demand.\"\\n> — James Marion Sims\\n\\nBiliary surgery, and especially gallbladder surgery, is considered as one of the pillars of ‘general surgery’. Yet you will find a great diversity of...\\n```',\n", " 'md': '> \"In dropsy of the gallbladder… and in gallstones we should not wait ‘til the patient’s strength is exhausted, or ‘til the blood becomes poisoned with bile, producing hemorrhage; we should make an early abdominal incision, ascertain the true nature of the disease, and then carry out the surgical treatment that necessities of the case demand.\"\\n> — James Marion Sims\\n\\nBiliary surgery, and especially gallbladder surgery, is considered as one of the pillars of ‘general surgery’. Yet you will find a great diversity of...\\n```',\n", " 'bBox': {'x': 72, 'y': 548, 'w': 467.91, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 297,\n", " 'text': 'clinical presentations, treatment options and local customs and dogmas\\n— that will all affect the selected approach. In acute biliary surgery the\\ndisagreements are even greater, and the debate between non-\\noperative treatment and endoscopic, radiologic and surgical\\ninterventions is more heated. Therefore, in this chapter we will try to\\nsimplify this maze for you, and lead you through a common-sense\\napproach, focusing on problem areas. As always, you will be able to find\\nin the literature a large spectrum of views and approaches which\\ncontradicts ours — but by now you know who is right... We trust you to\\nknow the basics (and more) from your medical school, surgical training\\nand practice.\\n\\n For the sake of simplicity we will divide the chapter between\\ngallbladder emergencies and bile duct emergencies — but you should\\nremember that the clinical picture may be ‘mixed’ — it’s the patient with\\nacute cholecystitis and simultaneous elevation of bilirubin and amylase\\nthat will force you to think hard about the next step.\\n\\n Acute cholecystitis\\n\\n Acute cholecystitis (AC) is either calculous or, much less commonly,\\nacalculous. Since the clinical picture of these two entities differs they are\\ndiscussed separately. We will start with the calculous entity.\\n\\n Obstruction of the gallbladder outlet by a stone is by far the most\\ncommon etiology for acute cholecystitis (AC). It is a spectrum:\\n\\n • Short-term obstruction with spontaneous dislodgment of the\\n obstructing stone causes a biliary colic.\\n • Impaction of the stone at the neck of the gallbladder will lead to\\n distension, pressure elevation, ischemic changes and, if left to\\n progress, secondary bacterial infection — AC. Untreated, it may\\n progress to complications such as necrosis, perforation,\\n empyema, liver abscess, peritonitis and systemic sepsis.\\n\\n How do you know where the patient is along this spectrum? You\\nuse all the information you can gather from history, physical examination,',\n", " 'md': '```markdown\\n# Clinical Presentations and Treatment Options\\n\\nClinical presentations, treatment options, and local customs and dogmas will all affect the selected approach. In acute biliary surgery, the disagreements are even greater, and the debate between non-operative treatment and endoscopic, radiologic, and surgical interventions is more heated. Therefore, in this chapter, we will try to simplify this maze for you and lead you through a common-sense approach, focusing on problem areas. As always, you will be able to find in the literature a large spectrum of views and approaches which contradict ours — but by now you know who is right... We trust you to know the basics (and more) from your medical school, surgical training, and practice.\\n\\nFor the sake of simplicity, we will divide the chapter between gallbladder emergencies and bile duct emergencies — but you should remember that the clinical picture may be ‘mixed’ — it’s the patient with acute cholecystitis and simultaneous elevation of bilirubin and amylase that will force you to think hard about the next step.\\n\\n## Acute Cholecystitis\\n\\nAcute cholecystitis (AC) is either calculous or, much less commonly, acalculous. Since the clinical picture of these two entities differs, they are discussed separately. We will start with the calculous entity.\\n\\nObstruction of the gallbladder outlet by a stone is by far the most common etiology for acute cholecystitis (AC). It is a spectrum:\\n\\n- Short-term obstruction with spontaneous dislodgment of the obstructing stone causes biliary colic.\\n- Impaction of the stone at the neck of the gallbladder will lead to distension, pressure elevation, ischemic changes, and, if left to progress, secondary bacterial infection — AC. Untreated, it may progress to complications such as necrosis, perforation, empyema, liver abscess, peritonitis, and systemic sepsis.\\n\\nHow do you know where the patient is along this spectrum? You use all the information you can gather from history, physical examination.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Clinical Presentations and Treatment Options',\n", " 'md': '# Clinical Presentations and Treatment Options',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Clinical presentations, treatment options, and local customs and dogmas will all affect the selected approach. In acute biliary surgery, the disagreements are even greater, and the debate between non-operative treatment and endoscopic, radiologic, and surgical interventions is more heated. Therefore, in this chapter, we will try to simplify this maze for you and lead you through a common-sense approach, focusing on problem areas. As always, you will be able to find in the literature a large spectrum of views and approaches which contradict ours — but by now you know who is right... We trust you to know the basics (and more) from your medical school, surgical training, and practice.\\n\\nFor the sake of simplicity, we will divide the chapter between gallbladder emergencies and bile duct emergencies — but you should remember that the clinical picture may be ‘mixed’ — it’s the patient with acute cholecystitis and simultaneous elevation of bilirubin and amylase that will force you to think hard about the next step.',\n", " 'md': 'Clinical presentations, treatment options, and local customs and dogmas will all affect the selected approach. In acute biliary surgery, the disagreements are even greater, and the debate between non-operative treatment and endoscopic, radiologic, and surgical interventions is more heated. Therefore, in this chapter, we will try to simplify this maze for you and lead you through a common-sense approach, focusing on problem areas. As always, you will be able to find in the literature a large spectrum of views and approaches which contradict ours — but by now you know who is right... We trust you to know the basics (and more) from your medical school, surgical training, and practice.\\n\\nFor the sake of simplicity, we will divide the chapter between gallbladder emergencies and bile duct emergencies — but you should remember that the clinical picture may be ‘mixed’ — it’s the patient with acute cholecystitis and simultaneous elevation of bilirubin and amylase that will force you to think hard about the next step.',\n", " 'bBox': {'x': 72, 'y': 185, 'w': 467.69, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Acute Cholecystitis',\n", " 'md': '## Acute Cholecystitis',\n", " 'bBox': {'x': 86, 'y': 396, 'w': 150.82, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Acute cholecystitis (AC) is either calculous or, much less commonly, acalculous. Since the clinical picture of these two entities differs, they are discussed separately. We will start with the calculous entity.\\n\\nObstruction of the gallbladder outlet by a stone is by far the most common etiology for acute cholecystitis (AC). It is a spectrum:\\n\\n- Short-term obstruction with spontaneous dislodgment of the obstructing stone causes biliary colic.\\n- Impaction of the stone at the neck of the gallbladder will lead to distension, pressure elevation, ischemic changes, and, if left to progress, secondary bacterial infection — AC. Untreated, it may progress to complications such as necrosis, perforation, empyema, liver abscess, peritonitis, and systemic sepsis.\\n\\nHow do you know where the patient is along this spectrum? You use all the information you can gather from history, physical examination.\\n```',\n", " 'md': 'Acute cholecystitis (AC) is either calculous or, much less commonly, acalculous. Since the clinical picture of these two entities differs, they are discussed separately. We will start with the calculous entity.\\n\\nObstruction of the gallbladder outlet by a stone is by far the most common etiology for acute cholecystitis (AC). It is a spectrum:\\n\\n- Short-term obstruction with spontaneous dislodgment of the obstructing stone causes biliary colic.\\n- Impaction of the stone at the neck of the gallbladder will lead to distension, pressure elevation, ischemic changes, and, if left to progress, secondary bacterial infection — AC. Untreated, it may progress to complications such as necrosis, perforation, empyema, liver abscess, peritonitis, and systemic sepsis.\\n\\nHow do you know where the patient is along this spectrum? You use all the information you can gather from history, physical examination.\\n```',\n", " 'bBox': {'x': 72, 'y': 396, 'w': 466.86, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 298,\n", " 'text': 'laboratory results and imaging studies. Biliary colic is self-limited and\\nof short duration: the pain — typically in the epigastrium, but maybe in\\nthe right upper quadrant, radiating to the right loin, back and/or shoulder\\nand associated with nausea/vomiting — lasts no more than a few hours,\\nand there are no clinical/laboratory markers of inflammation. In contrast,\\nAC will last longer, as a persisting pain, and will be associated with\\nlocal (tenderness — hey, you don’t want to hear again about Murphy’s\\nsign, eh? — peritoneal signs, a mass — denoting a palpable gallbladder)\\nas well as systemic (fever, leukocytosis) inflammatory signs. Remember:\\ninflammation alone cannot always differentiate between the ‘early’,\\nmechanical/chemical acute cholecystitis and the ‘late’, bacterial\\nphase. Often at surgery, we are surprised by how advanced the AC is,\\nwhich clinically had been assessed as ‘mild’. More advanced forms, such\\nas gangrenous cholecystitis or gallbladder empyema, will be associated\\nwith higher levels of inflammation, greater leukocytosis, and more\\nsystemic manifestations of sepsis.\\n\\n Diagnosis\\n\\n Diagnosis is not considered complete without supporting\\nimaging.\\n\\n Ultrasound\\n\\n Ultrasound is your best friend: available, cheap, simple, radiation free,\\nand usually accurate. It will demonstrate the stones, the distended\\ngallbladder with its thickened walls, and provide information about\\nassociated findings such as pericholecystic fluid collection, bile duct\\ndilatation and the nearby structures — liver, kidney and pancreas. Note,\\nhowever, that often, ultrasonographic features of AC lag behind the\\nclinical picture — a patient can have an advanced AC even if the wall of\\nthe gallbladder is not thickened and/or the gallbladder is not surrounded\\nwith fluid. Remember also that an almost constant feature of AC is a\\ndilated gallbladder (a feature which is sometimes not mentioned by\\nthe radiologist) — so: a non-distended gallbladder on imaging is\\nusually not AC!',\n", " 'md': '```markdown\\n## Laboratory Results and Imaging Studies\\n\\nBiliary colic is self-limited and of short duration: the pain — typically in the epigastrium, but maybe in the right upper quadrant, radiating to the right loin, back and/or shoulder and associated with nausea/vomiting — lasts no more than a few hours, and there are no clinical/laboratory markers of inflammation. In contrast, acute cholecystitis (AC) will last longer, as a persisting pain, and will be associated with local (tenderness — hey, you don’t want to hear again about Murphy’s sign, eh? — peritoneal signs, a mass — denoting a palpable gallbladder) as well as systemic (fever, leukocytosis) inflammatory signs.\\n\\nRemember: inflammation alone cannot always differentiate between the ‘early’, mechanical/chemical acute cholecystitis and the ‘late’, bacterial phase. Often at surgery, we are surprised by how advanced the AC is, which clinically had been assessed as ‘mild’. More advanced forms, such as gangrenous cholecystitis or gallbladder empyema, will be associated with higher levels of inflammation, greater leukocytosis, and more systemic manifestations of sepsis.\\n\\n### Diagnosis\\n\\nDiagnosis is not considered complete without supporting imaging.\\n\\n#### Ultrasound\\n\\nUltrasound is your best friend: available, cheap, simple, radiation-free, and usually accurate. It will demonstrate the stones, the distended gallbladder with its thickened walls, and provide information about associated findings such as pericholecystic fluid collection, bile duct dilatation, and the nearby structures — liver, kidney, and pancreas.\\n\\nNote, however, that often, ultrasonographic features of AC lag behind the clinical picture — a patient can have an advanced AC even if the wall of the gallbladder is not thickened and/or the gallbladder is not surrounded with fluid. Remember also that an almost constant feature of AC is a dilated gallbladder (a feature which is sometimes not mentioned by the radiologist) — so: a non-distended gallbladder on imaging is usually not AC!\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Laboratory Results and Imaging Studies',\n", " 'md': '## Laboratory Results and Imaging Studies',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Biliary colic is self-limited and of short duration: the pain — typically in the epigastrium, but maybe in the right upper quadrant, radiating to the right loin, back and/or shoulder and associated with nausea/vomiting — lasts no more than a few hours, and there are no clinical/laboratory markers of inflammation. In contrast, acute cholecystitis (AC) will last longer, as a persisting pain, and will be associated with local (tenderness — hey, you don’t want to hear again about Murphy’s sign, eh? — peritoneal signs, a mass — denoting a palpable gallbladder) as well as systemic (fever, leukocytosis) inflammatory signs.\\n\\nRemember: inflammation alone cannot always differentiate between the ‘early’, mechanical/chemical acute cholecystitis and the ‘late’, bacterial phase. Often at surgery, we are surprised by how advanced the AC is, which clinically had been assessed as ‘mild’. More advanced forms, such as gangrenous cholecystitis or gallbladder empyema, will be associated with higher levels of inflammation, greater leukocytosis, and more systemic manifestations of sepsis.',\n", " 'md': 'Biliary colic is self-limited and of short duration: the pain — typically in the epigastrium, but maybe in the right upper quadrant, radiating to the right loin, back and/or shoulder and associated with nausea/vomiting — lasts no more than a few hours, and there are no clinical/laboratory markers of inflammation. In contrast, acute cholecystitis (AC) will last longer, as a persisting pain, and will be associated with local (tenderness — hey, you don’t want to hear again about Murphy’s sign, eh? — peritoneal signs, a mass — denoting a palpable gallbladder) as well as systemic (fever, leukocytosis) inflammatory signs.\\n\\nRemember: inflammation alone cannot always differentiate between the ‘early’, mechanical/chemical acute cholecystitis and the ‘late’, bacterial phase. Often at surgery, we are surprised by how advanced the AC is, which clinically had been assessed as ‘mild’. More advanced forms, such as gangrenous cholecystitis or gallbladder empyema, will be associated with higher levels of inflammation, greater leukocytosis, and more systemic manifestations of sepsis.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diagnosis',\n", " 'md': '### Diagnosis',\n", " 'bBox': {'x': 86, 'y': 377, 'w': 79.09, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Diagnosis is not considered complete without supporting imaging.',\n", " 'md': 'Diagnosis is not considered complete without supporting imaging.',\n", " 'bBox': {'x': 72, 'y': 377, 'w': 93.09, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Ultrasound',\n", " 'md': '#### Ultrasound',\n", " 'bBox': {'x': 86, 'y': 473, 'w': 87.36, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Ultrasound is your best friend: available, cheap, simple, radiation-free, and usually accurate. It will demonstrate the stones, the distended gallbladder with its thickened walls, and provide information about associated findings such as pericholecystic fluid collection, bile duct dilatation, and the nearby structures — liver, kidney, and pancreas.\\n\\nNote, however, that often, ultrasonographic features of AC lag behind the clinical picture — a patient can have an advanced AC even if the wall of the gallbladder is not thickened and/or the gallbladder is not surrounded with fluid. Remember also that an almost constant feature of AC is a dilated gallbladder (a feature which is sometimes not mentioned by the radiologist) — so: a non-distended gallbladder on imaging is usually not AC!\\n```',\n", " 'md': 'Ultrasound is your best friend: available, cheap, simple, radiation-free, and usually accurate. It will demonstrate the stones, the distended gallbladder with its thickened walls, and provide information about associated findings such as pericholecystic fluid collection, bile duct dilatation, and the nearby structures — liver, kidney, and pancreas.\\n\\nNote, however, that often, ultrasonographic features of AC lag behind the clinical picture — a patient can have an advanced AC even if the wall of the gallbladder is not thickened and/or the gallbladder is not surrounded with fluid. Remember also that an almost constant feature of AC is a dilated gallbladder (a feature which is sometimes not mentioned by the radiologist) — so: a non-distended gallbladder on imaging is usually not AC!\\n```',\n", " 'bBox': {'x': 72, 'y': 473, 'w': 467.55, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 299,\n", " 'text': ' CT\\n\\n Many patients will already have had a CT scan of the abdomen when\\nyou are called for a consult, and a distended, thick-walled gallbladder\\nwith surrounding fat stranding will support the diagnosis, even when the\\nUS is ‘not diagnostic’. ħowever, the US is more accurate in this situation\\nand will show stones missed by the CT. Often we ask for an US to\\nconfirm the CT diagnosis. You may be correct if you call this a ‘defensive\\napproach’…\\n\\n HIDA scan\\n\\n In doubtful cases you can still use the old and trusted HIDA (hepatic\\nimino-diacetic acid) radionuclide scan. It is highly sensitive for non-\\nvisualization of the gallbladder in cases of cystic duct obstruction (a\\ntypical feature of AC), although specificity is affected by impaired hepatic\\nbile secretion with hyperbilirubinemia. A negative scan (i.e.\\nvisualization of the gallbladder) will exclude the diagnosis of AC\\nand make you think again.\\n\\n Again, remember that some findings may be lacking, without\\nexcluding the diagnosis. We have seen AC without gallbladder\\ndistension (due to chronic changes), with a thin wall (about to burst) or\\nwith stones so small that they are easily missed by imaging. Don’t rush to\\nlabel the condition as ‘acalculous cholecystitis’, as this rare diagnosis is\\nusually limited to sick, ICU patients — but to make our life complex, seen\\noccasionally in otherwise perfectly healthy patients.\\n\\n You may also get confused by some abnormal associated\\nparameters. For example, mild jaundice (bilirubin levels of up to\\n5mg/dL [85mmol/L]) and minimal elevation of liver enzymes can\\naccompany AC, even without choledocholithiasis and cholangitis.\\nWhether this is caused by pressure on the bile ducts, reactive\\ninflammation around the gallbladder or absorption of bile from the\\ngallbladder through its pressurized, ischemic wall, does not really matter.\\nWhat matters is that you know to differentiate this condition from\\nascending cholangitis (see below) that merits a different plan of',\n", " 'md': '```markdown\\n# CT and HIDA Scan in Diagnosing Acute Cholecystitis\\n\\nMany patients will already have had a CT scan of the abdomen when you are called for a consult, and a distended, thick-walled gallbladder with surrounding fat stranding will support the diagnosis, even when the US is ‘not diagnostic’. However, the US is more accurate in this situation and will show stones missed by the CT. Often we ask for an US to confirm the CT diagnosis. You may be correct if you call this a ‘defensive approach’…\\n\\n## HIDA Scan\\n\\nIn doubtful cases, you can still use the old and trusted HIDA (hepatic imino-diacetic acid) radionuclide scan. It is highly sensitive for non-visualization of the gallbladder in cases of cystic duct obstruction (a typical feature of AC), although specificity is affected by impaired hepatic bile secretion with hyperbilirubinemia. A negative scan (i.e. visualization of the gallbladder) will exclude the diagnosis of AC and make you think again.\\n\\nAgain, remember that some findings may be lacking, without excluding the diagnosis. We have seen AC without gallbladder distension (due to chronic changes), with a thin wall (about to burst) or with stones so small that they are easily missed by imaging. Don’t rush to label the condition as ‘acalculous cholecystitis’, as this rare diagnosis is usually limited to sick, ICU patients — but to make our life complex, seen occasionally in otherwise perfectly healthy patients.\\n\\nYou may also get confused by some abnormal associated parameters. For example, mild jaundice (bilirubin levels of up to \\\\(5 \\\\text{ mg/dL} \\\\, [85 \\\\text{ mmol/L}]\\\\)) and minimal elevation of liver enzymes can accompany AC, even without choledocholithiasis and cholangitis. Whether this is caused by pressure on the bile ducts, reactive inflammation around the gallbladder or absorption of bile from the gallbladder through its pressurized, ischemic wall, does not really matter. What matters is that you know to differentiate this condition from ascending cholangitis (see below) that merits a different plan of action.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'CT and HIDA Scan in Diagnosing Acute Cholecystitis',\n", " 'md': '# CT and HIDA Scan in Diagnosing Acute Cholecystitis',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 82.16, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Many patients will already have had a CT scan of the abdomen when you are called for a consult, and a distended, thick-walled gallbladder with surrounding fat stranding will support the diagnosis, even when the US is ‘not diagnostic’. However, the US is more accurate in this situation and will show stones missed by the CT. Often we ask for an US to confirm the CT diagnosis. You may be correct if you call this a ‘defensive approach’…',\n", " 'md': 'Many patients will already have had a CT scan of the abdomen when you are called for a consult, and a distended, thick-walled gallbladder with surrounding fat stranding will support the diagnosis, even when the US is ‘not diagnostic’. However, the US is more accurate in this situation and will show stones missed by the CT. Often we ask for an US to confirm the CT diagnosis. You may be correct if you call this a ‘defensive approach’…',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.92, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'HIDA Scan',\n", " 'md': '## HIDA Scan',\n", " 'bBox': {'x': 86, 'y': 266, 'w': 82.16, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In doubtful cases, you can still use the old and trusted HIDA (hepatic imino-diacetic acid) radionuclide scan. It is highly sensitive for non-visualization of the gallbladder in cases of cystic duct obstruction (a typical feature of AC), although specificity is affected by impaired hepatic bile secretion with hyperbilirubinemia. A negative scan (i.e. visualization of the gallbladder) will exclude the diagnosis of AC and make you think again.\\n\\nAgain, remember that some findings may be lacking, without excluding the diagnosis. We have seen AC without gallbladder distension (due to chronic changes), with a thin wall (about to burst) or with stones so small that they are easily missed by imaging. Don’t rush to label the condition as ‘acalculous cholecystitis’, as this rare diagnosis is usually limited to sick, ICU patients — but to make our life complex, seen occasionally in otherwise perfectly healthy patients.\\n\\nYou may also get confused by some abnormal associated parameters. For example, mild jaundice (bilirubin levels of up to \\\\(5 \\\\text{ mg/dL} \\\\, [85 \\\\text{ mmol/L}]\\\\)) and minimal elevation of liver enzymes can accompany AC, even without choledocholithiasis and cholangitis. Whether this is caused by pressure on the bile ducts, reactive inflammation around the gallbladder or absorption of bile from the gallbladder through its pressurized, ischemic wall, does not really matter. What matters is that you know to differentiate this condition from ascending cholangitis (see below) that merits a different plan of action.\\n```',\n", " 'md': 'In doubtful cases, you can still use the old and trusted HIDA (hepatic imino-diacetic acid) radionuclide scan. It is highly sensitive for non-visualization of the gallbladder in cases of cystic duct obstruction (a typical feature of AC), although specificity is affected by impaired hepatic bile secretion with hyperbilirubinemia. A negative scan (i.e. visualization of the gallbladder) will exclude the diagnosis of AC and make you think again.\\n\\nAgain, remember that some findings may be lacking, without excluding the diagnosis. We have seen AC without gallbladder distension (due to chronic changes), with a thin wall (about to burst) or with stones so small that they are easily missed by imaging. Don’t rush to label the condition as ‘acalculous cholecystitis’, as this rare diagnosis is usually limited to sick, ICU patients — but to make our life complex, seen occasionally in otherwise perfectly healthy patients.\\n\\nYou may also get confused by some abnormal associated parameters. For example, mild jaundice (bilirubin levels of up to \\\\(5 \\\\text{ mg/dL} \\\\, [85 \\\\text{ mmol/L}]\\\\)) and minimal elevation of liver enzymes can accompany AC, even without choledocholithiasis and cholangitis. Whether this is caused by pressure on the bile ducts, reactive inflammation around the gallbladder or absorption of bile from the gallbladder through its pressurized, ischemic wall, does not really matter. What matters is that you know to differentiate this condition from ascending cholangitis (see below) that merits a different plan of action.\\n```',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.91, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 300,\n", " 'text': 'action. The trick is not to jump to conclusions but hold to your guns and\\nremeasure liver functions a day later: if improving, go ahead with your\\ngallbladder operation; if deteriorating, you have to image the duct —\\npreferably with magnetic resonance cholangiopancreatography (MRCP)\\nas discussed below.\\n\\n Management\\n Have you ever popped a potato out of the oven in your\\n mouth? What happens? And what if you let it cool and then\\n enjoy it!\\n Amjad Siraj Memon\\n\\n ħere lies the main dissociation between what’s recommended in the\\nliterature and what is practiced in many places around the globe. The\\nsimple, ‘correct’ management of acute cholecystitis is surgery, and\\nnowadays it means laparoscopic cholecystectomy. So why isn’t it\\nalways practiced?\\n\\n Non-operative management\\n\\n Conservative management will be successful in most cases to\\nrelieve the acute episode. Antibiotics, to cover Gram-negative\\nenteric bacteria (adding anti-anaerobe agents in sicker patients),\\nalong with i.v. fluids, analgesics and anti-emetics, will make more\\nthan 90% of your patients better within a few days. The price for this\\napproach is prolonged hospital stay, a defined risk of failure — which in\\nturn may necessitate a more invasive approach in worse conditions —\\nand a risk of recurrent episodes during the waiting period of 6-8 weeks\\nfor the ‘interval’ cholecystectomy that is necessary anyway.\\n\\n So why not ‘just take it out’? The reasons vary, but the most\\ncommon around the world is the lack of an immediate OR/surgeon\\navailability. If you are lucky to work in a system where early\\ncholecystectomy is feasible (next day is OK, even the day after\\ntomorrow is fine) — then go for it! You will find the operation easier,\\nwith the gallbladder wall edema allowing you a relatively easy',\n", " 'md': '```markdown\\n## Management of Acute Cholecystitis\\n\\nThe trick is not to jump to conclusions but hold to your guns and remeasure liver functions a day later: if improving, go ahead with your gallbladder operation; if deteriorating, you have to image the duct — preferably with magnetic resonance cholangiopancreatography (MRCP) as discussed below.\\n\\n### Non-operative Management\\n\\nConservative management will be successful in most cases to relieve the acute episode. Antibiotics, to cover Gram-negative enteric bacteria (adding anti-anaerobe agents in sicker patients), along with i.v. fluids, analgesics, and anti-emetics, will make more than 90% of your patients better within a few days. The price for this approach is prolonged hospital stay, a defined risk of failure — which in turn may necessitate a more invasive approach in worse conditions — and a risk of recurrent episodes during the waiting period of 6-8 weeks for the ‘interval’ cholecystectomy that is necessary anyway.\\n\\nSo why not ‘just take it out’? The reasons vary, but the most common around the world is the lack of an immediate OR/surgeon availability. If you are lucky to work in a system where early cholecystectomy is feasible (next day is OK, even the day after tomorrow is fine) — then go for it! You will find the operation easier, with the gallbladder wall edema allowing you a relatively easy.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Acute Cholecystitis',\n", " 'md': '## Management of Acute Cholecystitis',\n", " 'bBox': {'x': 86, 'y': 195, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The trick is not to jump to conclusions but hold to your guns and remeasure liver functions a day later: if improving, go ahead with your gallbladder operation; if deteriorating, you have to image the duct — preferably with magnetic resonance cholangiopancreatography (MRCP) as discussed below.',\n", " 'md': 'The trick is not to jump to conclusions but hold to your guns and remeasure liver functions a day later: if improving, go ahead with your gallbladder operation; if deteriorating, you have to image the duct — preferably with magnetic resonance cholangiopancreatography (MRCP) as discussed below.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 127.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Non-operative Management',\n", " 'md': '### Non-operative Management',\n", " 'bBox': {'x': 86, 'y': 195, 'w': 217.96, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Conservative management will be successful in most cases to relieve the acute episode. Antibiotics, to cover Gram-negative enteric bacteria (adding anti-anaerobe agents in sicker patients), along with i.v. fluids, analgesics, and anti-emetics, will make more than 90% of your patients better within a few days. The price for this approach is prolonged hospital stay, a defined risk of failure — which in turn may necessitate a more invasive approach in worse conditions — and a risk of recurrent episodes during the waiting period of 6-8 weeks for the ‘interval’ cholecystectomy that is necessary anyway.\\n\\nSo why not ‘just take it out’? The reasons vary, but the most common around the world is the lack of an immediate OR/surgeon availability. If you are lucky to work in a system where early cholecystectomy is feasible (next day is OK, even the day after tomorrow is fine) — then go for it! You will find the operation easier, with the gallbladder wall edema allowing you a relatively easy.\\n```',\n", " 'md': 'Conservative management will be successful in most cases to relieve the acute episode. Antibiotics, to cover Gram-negative enteric bacteria (adding anti-anaerobe agents in sicker patients), along with i.v. fluids, analgesics, and anti-emetics, will make more than 90% of your patients better within a few days. The price for this approach is prolonged hospital stay, a defined risk of failure — which in turn may necessitate a more invasive approach in worse conditions — and a risk of recurrent episodes during the waiting period of 6-8 weeks for the ‘interval’ cholecystectomy that is necessary anyway.\\n\\nSo why not ‘just take it out’? The reasons vary, but the most common around the world is the lack of an immediate OR/surgeon availability. If you are lucky to work in a system where early cholecystectomy is feasible (next day is OK, even the day after tomorrow is fine) — then go for it! You will find the operation easier, with the gallbladder wall edema allowing you a relatively easy.\\n```',\n", " 'bBox': {'x': 72, 'y': 195, 'w': 467.43, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 301,\n", " 'text': 'dissection, before fibrosis ensues and makes anatomy unclear and\\nsurgery more difficult and dangerous.\\n\\n Delaying cholecystectomy may be justified also in other specific\\nsituations. If the patient presents late, after a few days of disease, the\\noperation may prove difficult, with a higher rate of conversion and higher\\nrisk of complications. You are probably familiar with the ‘golden 72 hours’,\\nalthough you should not take it too literally — some patients have an\\n‘easy gallbladder’ even later, while others will have a horrendous,\\ngangrenous one after 24 hours. Medically unfit patients may also\\nbenefit from delayed surgery, after optimization, proper evaluation and\\npreparation. However, this is a double-edged sword, as these frail\\npatients can also succumb more easily to an untreated septic\\nsource. So use your judgment — good judgment comes from\\nexperience; experience comes from bad judgment. And so it goes.\\n\\n Gallbladder drainage\\n\\n Gallbladder drainage is another option to temporize the acute\\ncondition, by relieving the intra-gallbladder pressure and draining\\nthe infected bile. It is an effective solution for the high-risk patient\\n(e.g. acute cholecystitis a few days after an acute MI), and for failed\\n‘conservative’ treatment a few more days into the disease process.\\n\\n Performed percutaneously, transhepatically, under imaging (US or CT)\\nby the interventional radiologist, or rarely — if the latter option is not\\navailable — under local anesthesia as an open procedure by you, it will\\nusually bring the condition under control, with rapid clinical improvement.\\nIn many cases it will also lead to dislodgment of the obstructing stone,\\nand if bile starts to flow down the tube, and a tube cholecystogram a few\\ndays later shows free flow of contrast to the common bile duct (CBD) and\\nduodenum, you can safely cork the tube until interval cholecystectomy, 6-\\n8 weeks later. Don’t expect it to be an easy case!\\n\\n As a ‘footnote’ one has to mention here that it is not written in the ‘Bible of Surgery’ that all\\n patients treated conservatively, or after successful percutaneous drainage, must undergo an',\n", " 'md': '```markdown\\n## Gallbladder Management\\n\\nDissection, before fibrosis ensues and makes anatomy unclear and surgery more difficult and dangerous.\\n\\nDelaying cholecystectomy may be justified also in other specific situations. If the patient presents late, after a few days of disease, the operation may prove difficult, with a higher rate of conversion and higher risk of complications. You are probably familiar with the ‘golden 72 hours’, although you should not take it too literally — some patients have an ‘easy gallbladder’ even later, while others will have a horrendous, gangrenous one after 24 hours. Medically unfit patients may also benefit from delayed surgery, after optimization, proper evaluation, and preparation. However, this is a double-edged sword, as these frail patients can also succumb more easily to an untreated septic source. So use your judgment — good judgment comes from experience; experience comes from bad judgment. And so it goes.\\n\\n### Gallbladder Drainage\\n\\nGallbladder drainage is another option to temporize the acute condition, by relieving the intra-gallbladder pressure and draining the infected bile. It is an effective solution for the high-risk patient (e.g., acute cholecystitis a few days after an acute MI), and for failed ‘conservative’ treatment a few more days into the disease process.\\n\\nPerformed percutaneously, transhepatically, under imaging (US or CT) by the interventional radiologist, or rarely — if the latter option is not available — under local anesthesia as an open procedure by you, it will usually bring the condition under control, with rapid clinical improvement. In many cases, it will also lead to dislodgment of the obstructing stone, and if bile starts to flow down the tube, and a tube cholecystogram a few days later shows free flow of contrast to the common bile duct (CBD) and duodenum, you can safely cork the tube until interval cholecystectomy, 6-8 weeks later. Don’t expect it to be an easy case!\\n\\nAs a ‘footnote’ one has to mention here that it is not written in the ‘Bible of Surgery’ that all patients treated conservatively, or after successful percutaneous drainage, must undergo an...\\n```\\n\\n### Notes:\\n- The text has been extracted and structured into markdown format.\\n- No images, graphs, or tables were identified in the provided text. If there are any images or figures on the page, please provide the relevant details for further extraction.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Gallbladder Management',\n", " 'md': '## Gallbladder Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Dissection, before fibrosis ensues and makes anatomy unclear and surgery more difficult and dangerous.\\n\\nDelaying cholecystectomy may be justified also in other specific situations. If the patient presents late, after a few days of disease, the operation may prove difficult, with a higher rate of conversion and higher risk of complications. You are probably familiar with the ‘golden 72 hours’, although you should not take it too literally — some patients have an ‘easy gallbladder’ even later, while others will have a horrendous, gangrenous one after 24 hours. Medically unfit patients may also benefit from delayed surgery, after optimization, proper evaluation, and preparation. However, this is a double-edged sword, as these frail patients can also succumb more easily to an untreated septic source. So use your judgment — good judgment comes from experience; experience comes from bad judgment. And so it goes.',\n", " 'md': 'Dissection, before fibrosis ensues and makes anatomy unclear and surgery more difficult and dangerous.\\n\\nDelaying cholecystectomy may be justified also in other specific situations. If the patient presents late, after a few days of disease, the operation may prove difficult, with a higher rate of conversion and higher risk of complications. You are probably familiar with the ‘golden 72 hours’, although you should not take it too literally — some patients have an ‘easy gallbladder’ even later, while others will have a horrendous, gangrenous one after 24 hours. Medically unfit patients may also benefit from delayed surgery, after optimization, proper evaluation, and preparation. However, this is a double-edged sword, as these frail patients can also succumb more easily to an untreated septic source. So use your judgment — good judgment comes from experience; experience comes from bad judgment. And so it goes.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Gallbladder Drainage',\n", " 'md': '### Gallbladder Drainage',\n", " 'bBox': {'x': 86, 'y': 363, 'w': 164.59, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Gallbladder drainage is another option to temporize the acute condition, by relieving the intra-gallbladder pressure and draining the infected bile. It is an effective solution for the high-risk patient (e.g., acute cholecystitis a few days after an acute MI), and for failed ‘conservative’ treatment a few more days into the disease process.\\n\\nPerformed percutaneously, transhepatically, under imaging (US or CT) by the interventional radiologist, or rarely — if the latter option is not available — under local anesthesia as an open procedure by you, it will usually bring the condition under control, with rapid clinical improvement. In many cases, it will also lead to dislodgment of the obstructing stone, and if bile starts to flow down the tube, and a tube cholecystogram a few days later shows free flow of contrast to the common bile duct (CBD) and duodenum, you can safely cork the tube until interval cholecystectomy, 6-8 weeks later. Don’t expect it to be an easy case!\\n\\nAs a ‘footnote’ one has to mention here that it is not written in the ‘Bible of Surgery’ that all patients treated conservatively, or after successful percutaneous drainage, must undergo an...\\n```',\n", " 'md': 'Gallbladder drainage is another option to temporize the acute condition, by relieving the intra-gallbladder pressure and draining the infected bile. It is an effective solution for the high-risk patient (e.g., acute cholecystitis a few days after an acute MI), and for failed ‘conservative’ treatment a few more days into the disease process.\\n\\nPerformed percutaneously, transhepatically, under imaging (US or CT) by the interventional radiologist, or rarely — if the latter option is not available — under local anesthesia as an open procedure by you, it will usually bring the condition under control, with rapid clinical improvement. In many cases, it will also lead to dislodgment of the obstructing stone, and if bile starts to flow down the tube, and a tube cholecystogram a few days later shows free flow of contrast to the common bile duct (CBD) and duodenum, you can safely cork the tube until interval cholecystectomy, 6-8 weeks later. Don’t expect it to be an easy case!\\n\\nAs a ‘footnote’ one has to mention here that it is not written in the ‘Bible of Surgery’ that all patients treated conservatively, or after successful percutaneous drainage, must undergo an...\\n```',\n", " 'bBox': {'x': 72, 'y': 363, 'w': 467.91, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text has been extracted and structured into markdown format.\\n- No images, graphs, or tables were identified in the provided text. If there are any images or figures on the page, please provide the relevant details for further extraction.',\n", " 'md': '- The text has been extracted and structured into markdown format.\\n- No images, graphs, or tables were identified in the provided text. If there are any images or figures on the page, please provide the relevant details for further extraction.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 302,\n", " 'text': ' interval LC. Be selective: you can leave the old, frail, high risk and asymptomatic alone!\\n Longitudinal studies and audits reveal that many patients allowed to ‘cool down’ never come to\\n surgery, for a variety of reasons. Recurrent problems are not inevitable.\\n\\n Operative management\\n\\n Emergency cholecystectomy is rarely a true emergency, requiring\\nyou to rush to the OR, unless you are dealing with the rare free\\nperforation with bile peritonitis, or with Clostridium-induced,\\nemphysematous cholecystitis. Remember that even with these\\nconditions, a brief resuscitation is a must.\\n\\n Early cholecystectomy, as mentioned above, is the preferred\\napproach for most cases of acute cholecystitis. The definition of ‘early’\\nmay differ between surgeons and systems, but operating in the next\\navailable OR list, or after-hours in the ‘emergency’ list, is acceptable as\\nlong as it is done within a day or two. Operating after 72 hours is not\\nrecommended — but still possible. Some patients will improve quickly\\nafter the initial non-operative therapy; this may mean that they had a\\n‘protracted biliary colic’ and not a true inflammation, but nevertheless — if\\nyou can get rid of the source and send them home without a gallbladder,\\nthey may benefit.\\n\\n The algorithm on the facing page summarizes our recommended\\napproach ( Figure 20.1).',\n", " 'md': '```markdown\\n## Operative Management\\n\\nEmergency cholecystectomy is rarely a true emergency, requiring you to rush to the OR, unless you are dealing with the rare free perforation with bile peritonitis, or with Clostridium-induced, emphysematous cholecystitis. Remember that even with these conditions, a brief resuscitation is a must.\\n\\nEarly cholecystectomy, as mentioned above, is the preferred approach for most cases of acute cholecystitis. The definition of ‘early’ may differ between surgeons and systems, but operating in the next available OR list, or after-hours in the ‘emergency’ list, is acceptable as long as it is done within a day or two. Operating after 72 hours is not recommended — but still possible. Some patients will improve quickly after the initial non-operative therapy; this may mean that they had a ‘protracted biliary colic’ and not a true inflammation, but nevertheless — if you can get rid of the source and send them home without a gallbladder, they may benefit.\\n\\nThe algorithm on the facing page summarizes our recommended approach (Figure 20.1).\\n\\n### Figure 20.1\\n*Description*: The algorithm summarizes the recommended approach for managing acute cholecystitis. It visually outlines the steps and decision points in the management process, providing a clear pathway for clinicians to follow.\\n\\n*Summary*: This figure serves as a guideline for the operative management of acute cholecystitis, illustrating the preferred timing and conditions under which cholecystectomy should be performed.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Operative Management',\n", " 'md': '## Operative Management',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 183.02, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Emergency cholecystectomy is rarely a true emergency, requiring you to rush to the OR, unless you are dealing with the rare free perforation with bile peritonitis, or with Clostridium-induced, emphysematous cholecystitis. Remember that even with these conditions, a brief resuscitation is a must.\\n\\nEarly cholecystectomy, as mentioned above, is the preferred approach for most cases of acute cholecystitis. The definition of ‘early’ may differ between surgeons and systems, but operating in the next available OR list, or after-hours in the ‘emergency’ list, is acceptable as long as it is done within a day or two. Operating after 72 hours is not recommended — but still possible. Some patients will improve quickly after the initial non-operative therapy; this may mean that they had a ‘protracted biliary colic’ and not a true inflammation, but nevertheless — if you can get rid of the source and send them home without a gallbladder, they may benefit.\\n\\nThe algorithm on the facing page summarizes our recommended approach (Figure 20.1).',\n", " 'md': 'Emergency cholecystectomy is rarely a true emergency, requiring you to rush to the OR, unless you are dealing with the rare free perforation with bile peritonitis, or with Clostridium-induced, emphysematous cholecystitis. Remember that even with these conditions, a brief resuscitation is a must.\\n\\nEarly cholecystectomy, as mentioned above, is the preferred approach for most cases of acute cholecystitis. The definition of ‘early’ may differ between surgeons and systems, but operating in the next available OR list, or after-hours in the ‘emergency’ list, is acceptable as long as it is done within a day or two. Operating after 72 hours is not recommended — but still possible. Some patients will improve quickly after the initial non-operative therapy; this may mean that they had a ‘protracted biliary colic’ and not a true inflammation, but nevertheless — if you can get rid of the source and send them home without a gallbladder, they may benefit.\\n\\nThe algorithm on the facing page summarizes our recommended approach (Figure 20.1).',\n", " 'bBox': {'x': 72, 'y': 247, 'w': 467.89, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 20.1',\n", " 'md': '### Figure 20.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*Description*: The algorithm summarizes the recommended approach for managing acute cholecystitis. It visually outlines the steps and decision points in the management process, providing a clear pathway for clinicians to follow.\\n\\n*Summary*: This figure serves as a guideline for the operative management of acute cholecystitis, illustrating the preferred timing and conditions under which cholecystectomy should be performed.\\n```',\n", " 'md': '*Description*: The algorithm summarizes the recommended approach for managing acute cholecystitis. It visually outlines the steps and decision points in the management process, providing a clear pathway for clinicians to follow.\\n\\n*Summary*: This figure serves as a guideline for the operative management of acute cholecystitis, illustrating the preferred timing and conditions under which cholecystectomy should be performed.\\n```',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 183.02, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 303,\n", " 'text': ' Acute calculous cholecystitis\\n USICTIHIDA\\n perforated\\n Very ill, septicOR available?\\n gallbladder Early presentation?\\n Fit for surgery?\\n Yes No\\n Emergency\\n cholecystectomy Failure to improve. Conservative\\n management\\n Early cholecystectomy\\n (within 72 hours) Percutaneous\\n cholecystostomy\\n Consider elective interval\\n cholecystectomy: or never\\n weeks or later after 6\\n Figure 20.1. Algorithm for the treatment of acute calculous cholecystitis.\\n\\n The operation\\n\\n Laparoscopic cholecystectomy (LC) is the standard approach,\\nalthough the rate of conversion is higher than in elective cases.\\nSome still prefer an open approach from the start for acute cases.',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Acute Calculous Cholecystitis\\n\\n### Figure 20.1\\n**Description:** This figure presents an algorithm for the treatment of acute calculous cholecystitis. It outlines the decision-making process for managing patients with this condition, including considerations for emergency cholecystectomy and conservative management options.\\n\\n- **Key Points:**\\n- Patients may present as very ill and septic.\\n- The algorithm asks if the patient is fit for surgery, with options for \"Yes\" or \"No.\"\\n- If \"Yes,\" an emergency cholecystectomy is indicated.\\n- If \"No,\" conservative management is suggested.\\n- Early cholecystectomy is recommended within 72 hours.\\n- Percutaneous cholecystostomy is also an option.\\n- Consideration for elective interval cholecystectomy is mentioned, with a timeframe of weeks or later after 6 weeks.\\n\\n### The Operation\\nLaparoscopic cholecystectomy (LC) is the standard approach for treating acute calculous cholecystitis, although the rate of conversion to open surgery is higher than in elective cases. Some surgeons prefer to start with an open approach for acute cases.\\n\\n```',\n", " 'images': [{'name': 'img_p302_1.png',\n", " 'height': 978,\n", " 'width': 734,\n", " 'x': 124.55999999999995,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1260,\n", " 'original_height': 1679}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Acute Calculous Cholecystitis',\n", " 'md': '## Acute Calculous Cholecystitis',\n", " 'bBox': {'x': 232.34, 'y': 103.58, 'w': 156.23, 'h': 14.84}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 20.1',\n", " 'md': '### Figure 20.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure presents an algorithm for the treatment of acute calculous cholecystitis. It outlines the decision-making process for managing patients with this condition, including considerations for emergency cholecystectomy and conservative management options.\\n\\n- **Key Points:**\\n- Patients may present as very ill and septic.\\n- The algorithm asks if the patient is fit for surgery, with options for \"Yes\" or \"No.\"\\n- If \"Yes,\" an emergency cholecystectomy is indicated.\\n- If \"No,\" conservative management is suggested.\\n- Early cholecystectomy is recommended within 72 hours.\\n- Percutaneous cholecystostomy is also an option.\\n- Consideration for elective interval cholecystectomy is mentioned, with a timeframe of weeks or later after 6 weeks.',\n", " 'md': '**Description:** This figure presents an algorithm for the treatment of acute calculous cholecystitis. It outlines the decision-making process for managing patients with this condition, including considerations for emergency cholecystectomy and conservative management options.\\n\\n- **Key Points:**\\n- Patients may present as very ill and septic.\\n- The algorithm asks if the patient is fit for surgery, with options for \"Yes\" or \"No.\"\\n- If \"Yes,\" an emergency cholecystectomy is indicated.\\n- If \"No,\" conservative management is suggested.\\n- Early cholecystectomy is recommended within 72 hours.\\n- Percutaneous cholecystostomy is also an option.\\n- Consideration for elective interval cholecystectomy is mentioned, with a timeframe of weeks or later after 6 weeks.',\n", " 'bBox': {'x': 135.44, 'y': 103.58, 'w': 253.13, 'h': 15.34}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Operation',\n", " 'md': '### The Operation',\n", " 'bBox': {'x': 86, 'y': 641, 'w': 109.42, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Laparoscopic cholecystectomy (LC) is the standard approach for treating acute calculous cholecystitis, although the rate of conversion to open surgery is higher than in elective cases. Some surgeons prefer to start with an open approach for acute cases.\\n\\n```',\n", " 'md': 'Laparoscopic cholecystectomy (LC) is the standard approach for treating acute calculous cholecystitis, although the rate of conversion to open surgery is higher than in elective cases. Some surgeons prefer to start with an open approach for acute cases.\\n\\n```',\n", " 'bBox': {'x': 137.41, 'y': 103.58, 'w': 251.15, 'h': 14.84}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 304,\n", " 'text': 'So, how should you decide how to proceed?\\n\\n It is rare nowadays to start with open surgery, unless the patient is very\\nunwell and you do not think it a great idea to pump his tummy with gas;\\nbut then think again if surgery is what he needs now. The need to\\nconvert a lap approach to an open procedure is related to local\\ninflammatory conditions and inversely related to your own\\nexpertise, but what should really guide you is the progress of the\\noperation.\\n\\n Struggling without making progress (45-60 minutes of no real progress is an acceptable\\n rule of thumb) means that your chance of harming the patient increases, and you\\n should change strategy — calling for help is one such possible change.\\n\\n With the decreasing exposure of young surgeons to open\\ncholecystectomy, opening up is not always a safe option (what we call\\nthe ‘unlearning curve’), and finding a grey-haired surgeon to assist you is\\nnot a bad idea. Yes, sometimes one of those ‘old farts’ may prove useful!\\n\\n There are some technical ‘tricks’ that you may use to improve\\nyour chances of successfully and safely completing a difficult LC:\\n\\n • Decompress the distended gallbladder (you may use the Veress\\n needle inserted through the abdominal wall or a special ‘needle-\\n trocar’). After aspiration of the contents, grasping the ‘eggplant’\\n becomes easier...\\n • Add a fifth or even sixth trocar to improve retraction of structures\\n that obliterate your view, especially in obese patients.\\n • Use gravity: make sure, before the operation, the patient is well\\n secured to the OR table, and make your anesthetist give you a\\n steep reverse-Trendelenburg and left-tilt position.\\n • Use the suction tip liberally; it is a good dissection tool, especially\\n for the ‘wet’, edematous gallbladder.\\n • In difficult-to-grasp gallbladders try to milk the stone back up from\\n ħartmann’s pouch into the fundus, or just push the gallbladder up\\n with an open instrument.',\n", " 'md': '```markdown\\n## Surgical Decision-Making in Laparoscopic Cholecystectomy\\n\\nSo, how should you decide how to proceed?\\n\\nIt is rare nowadays to start with open surgery, unless the patient is very unwell and you do not think it a great idea to pump his tummy with gas; but then think again if surgery is what he needs now. The need to convert a lap approach to an open procedure is related to local inflammatory conditions and inversely related to your own expertise, but what should really guide you is the progress of the operation.\\n\\nStruggling without making progress (45-60 minutes of no real progress is an acceptable rule of thumb) means that your chance of harming the patient increases, and you should change strategy — calling for help is one such possible change.\\n\\nWith the decreasing exposure of young surgeons to open cholecystectomy, opening up is not always a safe option (what we call the ‘unlearning curve’), and finding a grey-haired surgeon to assist you is not a bad idea. Yes, sometimes one of those ‘old farts’ may prove useful!\\n\\nThere are some technical ‘tricks’ that you may use to improve your chances of successfully and safely completing a difficult laparoscopic cholecystectomy (LC):\\n\\n- Decompress the distended gallbladder (you may use the Veress needle inserted through the abdominal wall or a special ‘needle-trocar’). After aspiration of the contents, grasping the ‘eggplant’ becomes easier...\\n- Add a fifth or even sixth trocar to improve retraction of structures that obliterate your view, especially in obese patients.\\n- Use gravity: make sure, before the operation, the patient is well secured to the OR table, and make your anesthetist give you a steep reverse-Trendelenburg and left-tilt position.\\n- Use the suction tip liberally; it is a good dissection tool, especially for the ‘wet’, edematous gallbladder.\\n- In difficult-to-grasp gallbladders try to milk the stone back up from Hartmann’s pouch into the fundus, or just push the gallbladder up with an open instrument.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Decision-Making in Laparoscopic Cholecystectomy',\n", " 'md': '## Surgical Decision-Making in Laparoscopic Cholecystectomy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'So, how should you decide how to proceed?\\n\\nIt is rare nowadays to start with open surgery, unless the patient is very unwell and you do not think it a great idea to pump his tummy with gas; but then think again if surgery is what he needs now. The need to convert a lap approach to an open procedure is related to local inflammatory conditions and inversely related to your own expertise, but what should really guide you is the progress of the operation.\\n\\nStruggling without making progress (45-60 minutes of no real progress is an acceptable rule of thumb) means that your chance of harming the patient increases, and you should change strategy — calling for help is one such possible change.\\n\\nWith the decreasing exposure of young surgeons to open cholecystectomy, opening up is not always a safe option (what we call the ‘unlearning curve’), and finding a grey-haired surgeon to assist you is not a bad idea. Yes, sometimes one of those ‘old farts’ may prove useful!\\n\\nThere are some technical ‘tricks’ that you may use to improve your chances of successfully and safely completing a difficult laparoscopic cholecystectomy (LC):\\n\\n- Decompress the distended gallbladder (you may use the Veress needle inserted through the abdominal wall or a special ‘needle-trocar’). After aspiration of the contents, grasping the ‘eggplant’ becomes easier...\\n- Add a fifth or even sixth trocar to improve retraction of structures that obliterate your view, especially in obese patients.\\n- Use gravity: make sure, before the operation, the patient is well secured to the OR table, and make your anesthetist give you a steep reverse-Trendelenburg and left-tilt position.\\n- Use the suction tip liberally; it is a good dissection tool, especially for the ‘wet’, edematous gallbladder.\\n- In difficult-to-grasp gallbladders try to milk the stone back up from Hartmann’s pouch into the fundus, or just push the gallbladder up with an open instrument.\\n```',\n", " 'md': 'So, how should you decide how to proceed?\\n\\nIt is rare nowadays to start with open surgery, unless the patient is very unwell and you do not think it a great idea to pump his tummy with gas; but then think again if surgery is what he needs now. The need to convert a lap approach to an open procedure is related to local inflammatory conditions and inversely related to your own expertise, but what should really guide you is the progress of the operation.\\n\\nStruggling without making progress (45-60 minutes of no real progress is an acceptable rule of thumb) means that your chance of harming the patient increases, and you should change strategy — calling for help is one such possible change.\\n\\nWith the decreasing exposure of young surgeons to open cholecystectomy, opening up is not always a safe option (what we call the ‘unlearning curve’), and finding a grey-haired surgeon to assist you is not a bad idea. Yes, sometimes one of those ‘old farts’ may prove useful!\\n\\nThere are some technical ‘tricks’ that you may use to improve your chances of successfully and safely completing a difficult laparoscopic cholecystectomy (LC):\\n\\n- Decompress the distended gallbladder (you may use the Veress needle inserted through the abdominal wall or a special ‘needle-trocar’). After aspiration of the contents, grasping the ‘eggplant’ becomes easier...\\n- Add a fifth or even sixth trocar to improve retraction of structures that obliterate your view, especially in obese patients.\\n- Use gravity: make sure, before the operation, the patient is well secured to the OR table, and make your anesthetist give you a steep reverse-Trendelenburg and left-tilt position.\\n- Use the suction tip liberally; it is a good dissection tool, especially for the ‘wet’, edematous gallbladder.\\n- In difficult-to-grasp gallbladders try to milk the stone back up from Hartmann’s pouch into the fundus, or just push the gallbladder up with an open instrument.\\n```',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 305,\n", " 'text': ' • Adhering to the principles of a ‘critical view of safety’ (CVS) is\\n even more important in acute conditions, when anatomy tends to be\\n distorted. If it’s not easy — go higher and find the plane between the\\n liver and the gallbladder, and try to come back down from there. This\\n is the equivalent of the open ‘fundus-down’ technique, which is less\\n suitable for laparoscopic performance. Achieving a CVS is probably\\n more difficult when operating on a hot gallbladder, but not less\\n important, so make sure you really have it. Dictating that you did is\\n not enough...\\n • While uncontrolled bleeding should make you convert quickly,\\n remember that you don’t have to panic, as most hemorrhage can be\\n controlled, at least partially, by pressure. Instead of frantic and\\n dangerous hemostatic attempts, insert a gauze and apply pressure,\\n wait a few minutes and reassess.\\n\\n We hope that there is no need to explain the ‘critical view of safety’. But if you are not familiar\\n with this term please do read Chapter 16 in Schein’s Common Sense Prevention and\\n Management of Surgical Complications, for an in-depth discussion on how to avoid problems\\n (and manage them) in gallbladder and biliary surgery. The Editors\\n\\n Conversion, and open cholecystectomy\\n\\n Apart from non-progression ( Figure 20.2), and difficulty in defining\\nanatomy, you may need to convert for bleeding, or — and this means you\\ndid not convert early enough — for bile duct injury (clear bile is suddenly\\naccumulating in your surgical field? Something is wrong!).\\n\\n Don’t expect the conversion to easily solve your problems, and\\ncontinue to be alert, suspicious and careful. You need the best\\npossible working conditions — exposure and lighting, so make sure you\\nhave good assistance, proper retraction, and accessories such as a\\nhead-light, if needed. The most important thing is changing your\\nmindset: this is no longer minimal access, so act accordingly. Forget\\nabout ‘connecting the dots’ (if they do not fit) between your trocars,\\nresulting in a strange and inconvenient incision — make a proper\\nsubcostal incision that will allow you to work comfortably. Forget about',\n", " 'md': '```markdown\\n## Text Extraction\\n\\n- Adhering to the principles of a ‘critical view of safety’ (CVS) is even more important in acute conditions, when anatomy tends to be distorted. If it’s not easy — go higher and find the plane between the liver and the gallbladder, and try to come back down from there. This is the equivalent of the open ‘fundus-down’ technique, which is less suitable for laparoscopic performance. Achieving a CVS is probably more difficult when operating on a hot gallbladder, but not less important, so make sure you really have it. Dictating that you did is not enough...\\n- While uncontrolled bleeding should make you convert quickly, remember that you don’t have to panic, as most hemorrhage can be controlled, at least partially, by pressure. Instead of frantic and dangerous hemostatic attempts, insert a gauze and apply pressure, wait a few minutes and reassess.\\n\\nWe hope that there is no need to explain the ‘critical view of safety’. But if you are not familiar with this term please do read Chapter 16 in Schein’s Common Sense Prevention and Management of Surgical Complications, for an in-depth discussion on how to avoid problems (and manage them) in gallbladder and biliary surgery. The Editors\\n\\nConversion, and open cholecystectomy\\n\\nApart from non-progression (Figure 20.2), and difficulty in defining anatomy, you may need to convert for bleeding, or — and this means you did not convert early enough — for bile duct injury (clear bile is suddenly accumulating in your surgical field? Something is wrong!).\\n\\nDon’t expect the conversion to easily solve your problems, and continue to be alert, suspicious and careful. You need the best possible working conditions — exposure and lighting, so make sure you have good assistance, proper retraction, and accessories such as a head-light, if needed. The most important thing is changing your mindset: this is no longer minimal access, so act accordingly. Forget about ‘connecting the dots’ (if they do not fit) between your trocars, resulting in a strange and inconvenient incision — make a proper subcostal incision that will allow you to work comfortably.\\n\\n## Image Identification and Description\\n\\n### Figure 20.2\\n- **Description**: This figure illustrates the concept of non-progression in surgical procedures, particularly in the context of gallbladder surgery. It visually represents the challenges faced when anatomy is not clearly defined, emphasizing the importance of recognizing when to convert to open surgery.\\n- **Summary**: The image serves as a visual aid to understand the implications of non-progression during surgery and the critical decision-making involved in converting to open cholecystectomy when necessary.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Adhering to the principles of a ‘critical view of safety’ (CVS) is even more important in acute conditions, when anatomy tends to be distorted. If it’s not easy — go higher and find the plane between the liver and the gallbladder, and try to come back down from there. This is the equivalent of the open ‘fundus-down’ technique, which is less suitable for laparoscopic performance. Achieving a CVS is probably more difficult when operating on a hot gallbladder, but not less important, so make sure you really have it. Dictating that you did is not enough...\\n- While uncontrolled bleeding should make you convert quickly, remember that you don’t have to panic, as most hemorrhage can be controlled, at least partially, by pressure. Instead of frantic and dangerous hemostatic attempts, insert a gauze and apply pressure, wait a few minutes and reassess.\\n\\nWe hope that there is no need to explain the ‘critical view of safety’. But if you are not familiar with this term please do read Chapter 16 in Schein’s Common Sense Prevention and Management of Surgical Complications, for an in-depth discussion on how to avoid problems (and manage them) in gallbladder and biliary surgery. The Editors\\n\\nConversion, and open cholecystectomy\\n\\nApart from non-progression (Figure 20.2), and difficulty in defining anatomy, you may need to convert for bleeding, or — and this means you did not convert early enough — for bile duct injury (clear bile is suddenly accumulating in your surgical field? Something is wrong!).\\n\\nDon’t expect the conversion to easily solve your problems, and continue to be alert, suspicious and careful. You need the best possible working conditions — exposure and lighting, so make sure you have good assistance, proper retraction, and accessories such as a head-light, if needed. The most important thing is changing your mindset: this is no longer minimal access, so act accordingly. Forget about ‘connecting the dots’ (if they do not fit) between your trocars, resulting in a strange and inconvenient incision — make a proper subcostal incision that will allow you to work comfortably.',\n", " 'md': '- Adhering to the principles of a ‘critical view of safety’ (CVS) is even more important in acute conditions, when anatomy tends to be distorted. If it’s not easy — go higher and find the plane between the liver and the gallbladder, and try to come back down from there. This is the equivalent of the open ‘fundus-down’ technique, which is less suitable for laparoscopic performance. Achieving a CVS is probably more difficult when operating on a hot gallbladder, but not less important, so make sure you really have it. Dictating that you did is not enough...\\n- While uncontrolled bleeding should make you convert quickly, remember that you don’t have to panic, as most hemorrhage can be controlled, at least partially, by pressure. Instead of frantic and dangerous hemostatic attempts, insert a gauze and apply pressure, wait a few minutes and reassess.\\n\\nWe hope that there is no need to explain the ‘critical view of safety’. But if you are not familiar with this term please do read Chapter 16 in Schein’s Common Sense Prevention and Management of Surgical Complications, for an in-depth discussion on how to avoid problems (and manage them) in gallbladder and biliary surgery. The Editors\\n\\nConversion, and open cholecystectomy\\n\\nApart from non-progression (Figure 20.2), and difficulty in defining anatomy, you may need to convert for bleeding, or — and this means you did not convert early enough — for bile duct injury (clear bile is suddenly accumulating in your surgical field? Something is wrong!).\\n\\nDon’t expect the conversion to easily solve your problems, and continue to be alert, suspicious and careful. You need the best possible working conditions — exposure and lighting, so make sure you have good assistance, proper retraction, and accessories such as a head-light, if needed. The most important thing is changing your mindset: this is no longer minimal access, so act accordingly. Forget about ‘connecting the dots’ (if they do not fit) between your trocars, resulting in a strange and inconvenient incision — make a proper subcostal incision that will allow you to work comfortably.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.6, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 20.2',\n", " 'md': '### Figure 20.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure illustrates the concept of non-progression in surgical procedures, particularly in the context of gallbladder surgery. It visually represents the challenges faced when anatomy is not clearly defined, emphasizing the importance of recognizing when to convert to open surgery.\\n- **Summary**: The image serves as a visual aid to understand the implications of non-progression during surgery and the critical decision-making involved in converting to open cholecystectomy when necessary.\\n```',\n", " 'md': '- **Description**: This figure illustrates the concept of non-progression in surgical procedures, particularly in the context of gallbladder surgery. It visually represents the challenges faced when anatomy is not clearly defined, emphasizing the importance of recognizing when to convert to open surgery.\\n- **Summary**: The image serves as a visual aid to understand the implications of non-progression during surgery and the critical decision-making involved in converting to open cholecystectomy when necessary.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'anatomy, you may need to convert for bleeding, or — and this means you'}]},\n", " {'page': 306,\n", " 'text': '‘mini-cholecystectomy’ unless you have your own experience with this\\nprocedure — this is not the time to save a few centimeters but to make\\nsure you complete the procedure quickly and safely. Unlike laparoscopy,\\nafter you have converted, the retrograde ‘dome-down‘ cholecystectomy is\\nthe one we recommend — staying near the gallbladder wall and\\nprogressing toward the cystic duct and artery, to be disconnected last.\\nWhat about a drain? Probably not if you feel the cystic duct was well\\nsecured, but leaving one is not a sin.\\n +\\n PERY44\\n Figure 20.2. “I never convert…”\\n\\n Again, we have never seen a patient dying because he was converted to open; we have seen\\n them dying because they were not converted.\\n\\n Alternative approaches to avoid zures 1\\n In some cases you need to act differently in order save you (and\\nthe patient…) from big troubles. This is commonly the situation in',\n", " 'md': '```markdown\\n## Page Content\\n\\n‘mini-cholecystectomy’ unless you have your own experience with this procedure — this is not the time to save a few centimeters but to make sure you complete the procedure quickly and safely. Unlike laparoscopy, after you have converted, the retrograde ‘dome-down‘ cholecystectomy is the one we recommend — staying near the gallbladder wall and progressing toward the cystic duct and artery, to be disconnected last. What about a drain? Probably not if you feel the cystic duct was well secured, but leaving one is not a sin.\\n\\n**Figure 20.2**: “I never convert…”\\n\\nAgain, we have never seen a patient dying because he was converted to open; we have seen them dying because they were not converted.\\n\\n### Alternative approaches to avoid zures\\nIn some cases you need to act differently in order to save you (and the patient…) from big troubles. This is commonly the situation in\\n```\\n\\n### Image Identification and Description\\n- **Figure 20.2**: The image is referenced but not described in detail. It likely contains a visual representation related to the discussion of conversion in surgical procedures. The caption suggests a statement or quote regarding the conversion from laparoscopic to open surgery. The content of the image is not identifiable from the text provided.\\n\\n### Summary\\nThe text discusses the approach to mini-cholecystectomy, emphasizing the importance of completing the procedure safely and efficiently. It also touches on the decision-making process regarding the use of drains and the implications of converting to open surgery.',\n", " 'images': [{'name': 'img_p305_1.png',\n", " 'height': 572,\n", " 'width': 812,\n", " 'x': 105.11999999999989,\n", " 'y': 215.28000000000003,\n", " 'original_width': 1395,\n", " 'original_height': 982}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '‘mini-cholecystectomy’ unless you have your own experience with this procedure — this is not the time to save a few centimeters but to make sure you complete the procedure quickly and safely. Unlike laparoscopy, after you have converted, the retrograde ‘dome-down‘ cholecystectomy is the one we recommend — staying near the gallbladder wall and progressing toward the cystic duct and artery, to be disconnected last. What about a drain? Probably not if you feel the cystic duct was well secured, but leaving one is not a sin.\\n\\n**Figure 20.2**: “I never convert…”\\n\\nAgain, we have never seen a patient dying because he was converted to open; we have seen them dying because they were not converted.',\n", " 'md': '‘mini-cholecystectomy’ unless you have your own experience with this procedure — this is not the time to save a few centimeters but to make sure you complete the procedure quickly and safely. Unlike laparoscopy, after you have converted, the retrograde ‘dome-down‘ cholecystectomy is the one we recommend — staying near the gallbladder wall and progressing toward the cystic duct and artery, to be disconnected last. What about a drain? Probably not if you feel the cystic duct was well secured, but leaving one is not a sin.\\n\\n**Figure 20.2**: “I never convert…”\\n\\nAgain, we have never seen a patient dying because he was converted to open; we have seen them dying because they were not converted.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Alternative approaches to avoid zures',\n", " 'md': '### Alternative approaches to avoid zures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In some cases you need to act differently in order to save you (and the patient…) from big troubles. This is commonly the situation in\\n```',\n", " 'md': 'In some cases you need to act differently in order to save you (and the patient…) from big troubles. This is commonly the situation in\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 20.2**: The image is referenced but not described in detail. It likely contains a visual representation related to the discussion of conversion in surgical procedures. The caption suggests a statement or quote regarding the conversion from laparoscopic to open surgery. The content of the image is not identifiable from the text provided.',\n", " 'md': '- **Figure 20.2**: The image is referenced but not described in detail. It likely contains a visual representation related to the discussion of conversion in surgical procedures. The caption suggests a statement or quote regarding the conversion from laparoscopic to open surgery. The content of the image is not identifiable from the text provided.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the approach to mini-cholecystectomy, emphasizing the importance of completing the procedure safely and efficiently. It also touches on the decision-making process regarding the use of drains and the implications of converting to open surgery.',\n", " 'md': 'The text discusses the approach to mini-cholecystectomy, emphasizing the importance of completing the procedure safely and efficiently. It also touches on the decision-making process regarding the use of drains and the implications of converting to open surgery.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 307,\n", " 'text': '‘neglected’ cases, operated late in the disease process, with a lot of\\npathology and little normal anatomy. Sometimes even ‘cooled down’\\ncases, operated weeks after the acute infection, may be surprisingly\\nchallenging — with a chronically contracted, thick-walled gallbladder,\\ncommonly described by the pathologist as ‘xanthogranulomatous’.\\nInterestingly, some ‘chronic gallbladders’ with a clear hydrops (mucocele)\\nor even frank empyema can be clinically silent. Your initial surprise\\nshould be quickly transformed into a decision about how to\\nprogress safely with a low risk of complications.\\n\\n Subtotal (partial) cholecystectomy\\n Our old friend, Asher ħirshberg, summarized it aptly: “It is better to\\nremove 95% of the gallbladder (i.e. subtotal cholecystectomy) than\\n101% (i.e. together with a piece of the bile duct).”\\n\\n And yes, yes, yes — any weathered surgeon will tell you that this is\\nthe procedure to use, in order to avoid misery in problematic\\nsituations such as a scarred, ‘impossible’ triangle of Calot — when\\ninflammatory changes obscure the anatomy in such a way that the\\nrisk of bile duct injury is significant. It is also useful in cases where\\nthe risk of bleeding from the liver is significant, as in cirrhosis or\\ncoagulopathy.\\n\\n Partial or subtotal cholecystectomy has been popularized in the United\\nStates by Max Thorek (1880-1960) and thus some call it the Thorek\\nprocedure. Thorek, by the way, was a keen aphorist and also said:\\n“…how old is our newest knowledge, how painfully and proudly we\\nstruggle to discoveries, which, instead of being new truth, are only\\nrediscoveries of lost knowledge.”\\n\\n ħow should you perform a partial or subtotal cholecystectomy? It\\nseems to us that this most valuable technique, which has saved our butt\\nnumerous times, is not well known to the new generation of surgeons.\\nħence, we will go into details below.\\n\\n During open cholecystectomy\\n Open the gallbladder at the fundus, empty it from all contents. Now\\nstart carving out the gallbladder (we do it with the diathermy) leaving its',\n", " 'md': '```markdown\\n## Text Extraction\\n\\n‘Neglected’ cases, operated late in the disease process, with a lot of pathology and little normal anatomy. Sometimes even ‘cooled down’ cases, operated weeks after the acute infection, may be surprisingly challenging — with a chronically contracted, thick-walled gallbladder, commonly described by the pathologist as ‘xanthogranulomatous’. Interestingly, some ‘chronic gallbladders’ with a clear hydrops (mucocele) or even frank empyema can be clinically silent. Your initial surprise should be quickly transformed into a decision about how to progress safely with a low risk of complications.\\n\\n### Subtotal (Partial) Cholecystectomy\\n\\nOur old friend, Asher Hirshberg, summarized it aptly: “It is better to remove 95% of the gallbladder (i.e. subtotal cholecystectomy) than 101% (i.e. together with a piece of the bile duct).”\\n\\nAnd yes, yes, yes — any weathered surgeon will tell you that this is the procedure to use, in order to avoid misery in problematic situations such as a scarred, ‘impossible’ triangle of Calot — when inflammatory changes obscure the anatomy in such a way that the risk of bile duct injury is significant. It is also useful in cases where the risk of bleeding from the liver is significant, as in cirrhosis or coagulopathy.\\n\\nPartial or subtotal cholecystectomy has been popularized in the United States by Max Thorek (1880-1960) and thus some call it the Thorek procedure. Thorek, by the way, was a keen aphorist and also said: “…how old is our newest knowledge, how painfully and proudly we struggle to discoveries, which, instead of being new truth, are only rediscoveries of lost knowledge.”\\n\\nHow should you perform a partial or subtotal cholecystectomy? It seems to us that this most valuable technique, which has saved our butt numerous times, is not well known to the new generation of surgeons. Hence, we will go into details below.\\n\\n### During Open Cholecystectomy\\n\\nOpen the gallbladder at the fundus, empty it from all contents. Now start carving out the gallbladder (we do it with the diathermy) leaving its...\\n```\\n\\n### Notes\\n- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and structured without any headers or footers.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '‘Neglected’ cases, operated late in the disease process, with a lot of pathology and little normal anatomy. Sometimes even ‘cooled down’ cases, operated weeks after the acute infection, may be surprisingly challenging — with a chronically contracted, thick-walled gallbladder, commonly described by the pathologist as ‘xanthogranulomatous’. Interestingly, some ‘chronic gallbladders’ with a clear hydrops (mucocele) or even frank empyema can be clinically silent. Your initial surprise should be quickly transformed into a decision about how to progress safely with a low risk of complications.',\n", " 'md': '‘Neglected’ cases, operated late in the disease process, with a lot of pathology and little normal anatomy. Sometimes even ‘cooled down’ cases, operated weeks after the acute infection, may be surprisingly challenging — with a chronically contracted, thick-walled gallbladder, commonly described by the pathologist as ‘xanthogranulomatous’. Interestingly, some ‘chronic gallbladders’ with a clear hydrops (mucocele) or even frank empyema can be clinically silent. Your initial surprise should be quickly transformed into a decision about how to progress safely with a low risk of complications.',\n", " 'bBox': {'x': 72, 'y': 168, 'w': 466.8, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Subtotal (Partial) Cholecystectomy',\n", " 'md': '### Subtotal (Partial) Cholecystectomy',\n", " 'bBox': {'x': 86, 'y': 257, 'w': 235.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Our old friend, Asher Hirshberg, summarized it aptly: “It is better to remove 95% of the gallbladder (i.e. subtotal cholecystectomy) than 101% (i.e. together with a piece of the bile duct).”\\n\\nAnd yes, yes, yes — any weathered surgeon will tell you that this is the procedure to use, in order to avoid misery in problematic situations such as a scarred, ‘impossible’ triangle of Calot — when inflammatory changes obscure the anatomy in such a way that the risk of bile duct injury is significant. It is also useful in cases where the risk of bleeding from the liver is significant, as in cirrhosis or coagulopathy.\\n\\nPartial or subtotal cholecystectomy has been popularized in the United States by Max Thorek (1880-1960) and thus some call it the Thorek procedure. Thorek, by the way, was a keen aphorist and also said: “…how old is our newest knowledge, how painfully and proudly we struggle to discoveries, which, instead of being new truth, are only rediscoveries of lost knowledge.”\\n\\nHow should you perform a partial or subtotal cholecystectomy? It seems to us that this most valuable technique, which has saved our butt numerous times, is not well known to the new generation of surgeons. Hence, we will go into details below.',\n", " 'md': 'Our old friend, Asher Hirshberg, summarized it aptly: “It is better to remove 95% of the gallbladder (i.e. subtotal cholecystectomy) than 101% (i.e. together with a piece of the bile duct).”\\n\\nAnd yes, yes, yes — any weathered surgeon will tell you that this is the procedure to use, in order to avoid misery in problematic situations such as a scarred, ‘impossible’ triangle of Calot — when inflammatory changes obscure the anatomy in such a way that the risk of bile duct injury is significant. It is also useful in cases where the risk of bleeding from the liver is significant, as in cirrhosis or coagulopathy.\\n\\nPartial or subtotal cholecystectomy has been popularized in the United States by Max Thorek (1880-1960) and thus some call it the Thorek procedure. Thorek, by the way, was a keen aphorist and also said: “…how old is our newest knowledge, how painfully and proudly we struggle to discoveries, which, instead of being new truth, are only rediscoveries of lost knowledge.”\\n\\nHow should you perform a partial or subtotal cholecystectomy? It seems to us that this most valuable technique, which has saved our butt numerous times, is not well known to the new generation of surgeons. Hence, we will go into details below.',\n", " 'bBox': {'x': 72, 'y': 294, 'w': 467.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'During Open Cholecystectomy',\n", " 'md': '### During Open Cholecystectomy',\n", " 'bBox': {'x': 82, 'y': 679, 'w': 154.04, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': 'Open the gallbladder at the fundus, empty it from all contents. Now start carving out the gallbladder (we do it with the diathermy) leaving its...\\n```',\n", " 'md': 'Open the gallbladder at the fundus, empty it from all contents. Now start carving out the gallbladder (we do it with the diathermy) leaving its...\\n```',\n", " 'bBox': {'x': 72, 'y': 715, 'w': 467.64, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and structured without any headers or footers.',\n", " 'md': '- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and structured without any headers or footers.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 308,\n", " 'text': 'posterior wall attached to the liver. ħemostasis of the rim of the remnant\\nis achieved with the diathermy and clips or Vicryl® 3-0 sutures. When you\\nreach the level of the ħartmann’s pouch, make sure that all impacted\\nstones have been evacuated — now you can insert your index finger, or\\ninstrument tip, all the way down to the internal opening of the cystic duct,\\nwhich can be often visualized from within. The accurate placement of a\\npurse-string suture around this opening, as depicted by artists’ drawings,\\nis not satisfactory, because the suture tends to tear out of the inflamed\\nand friable tissues. A better option is to leave a 1cm rim of\\nHartmann’s pouch tissue and suture-buttress it over the opening of\\nthe cystic duct (we use 2-0 Vicryl®). The exposed mucosa of the\\nposterior gallbladder wall is fried with diathermy (some say until you smell\\nfried liver…) and the omentum is brought into the area. Finally, leave a\\ndrain below the gallbladder remnant; usually you won’t see even a drop\\nof bile in the drain because in such cases the cystic duct is obstructed\\ndue to the inflammatory process. ħowever, in the rare case when a bile\\nleak develops, the drain will solve the problem.\\n\\n What to do if you find that it is impossible to close the cystic\\nduct/gallbladder remnant? Don’t panic: it is absolutely safe just to\\nleave a suction drain and bail out. The drain will be producing bile\\nfor a few days, up to 2 weeks, but eventually it will dry out!\\n During laparoscopic cholecystectomy\\n The gallbladder is opened at a ‘safe and comfortable’ location, at\\nħartmann’s pouch or above, and the contents evacuated. Have your\\nsuction ready, and place a specimen collection bag inside —\\nthrough an added port if needed — to collect the stones before they\\nspill. At this point you can easily look inside towards the gallbladder\\noutlet and make sure you clear all stones obstructing the cystic duct.\\nComplete the transection of ħartmann’s pouch, and close the remnant\\n(you can suture the cystic duct from within, or suture-close the remnant\\nfrom outside, or simply place an Endoloop® around it). Now complete the\\nremoval of the body and fundus — you can leave the posterior wall on\\nthe liver and fulgurate the mucosa if the risk of bleeding is high. Leave a\\ndrain. The end result is depicted in Figure 20.3.',\n", " 'md': '```markdown\\n## Surgical Procedure Overview\\n\\nThe posterior wall is attached to the liver. Hemostasis of the rim of the remnant is achieved with diathermy and clips or Vicryl® 3-0 sutures. When you reach the level of Hartmann’s pouch, ensure that all impacted stones have been evacuated. You can insert your index finger or instrument tip all the way down to the internal opening of the cystic duct, which can often be visualized from within.\\n\\nThe accurate placement of a purse-string suture around this opening, as depicted by artists’ drawings, is not satisfactory because the suture tends to tear out of the inflamed and friable tissues. A better option is to leave a 1 cm rim of Hartmann’s pouch tissue and suture-buttress it over the opening of the cystic duct (we use 2-0 Vicryl®). The exposed mucosa of the posterior gallbladder wall is fried with diathermy (some say until you smell fried liver…) and the omentum is brought into the area. Finally, leave a drain below the gallbladder remnant; usually, you won’t see even a drop of bile in the drain because, in such cases, the cystic duct is obstructed due to the inflammatory process. However, in the rare case when a bile leak develops, the drain will solve the problem.\\n\\n### What to Do if Closure is Impossible\\n\\nIf you find that it is impossible to close the cystic duct/gallbladder remnant, don’t panic: it is absolutely safe just to leave a suction drain and bail out. The drain will be producing bile for a few days, up to 2 weeks, but eventually, it will dry out!\\n\\n### During Laparoscopic Cholecystectomy\\n\\nThe gallbladder is opened at a ‘safe and comfortable’ location, at Hartmann’s pouch or above, and the contents evacuated. Have your suction ready, and place a specimen collection bag inside — through an added port if needed — to collect the stones before they spill. At this point, you can easily look inside towards the gallbladder outlet and make sure you clear all stones obstructing the cystic duct.\\n\\nComplete the transection of Hartmann’s pouch, and close the remnant (you can suture the cystic duct from within, or suture-close the remnant from outside, or simply place an Endoloop® around it). Now complete the removal of the body and fundus — you can leave the posterior wall on the liver and fulgurate the mucosa if the risk of bleeding is high. Leave a drain. The end result is depicted in **Figure 20.3**.\\n```\\n\\n### Image Identification and Description\\n- **Figure 20.3**: This figure illustrates the end result of the surgical procedure described. It likely includes a visual representation of the gallbladder remnant and the surrounding anatomy post-operation. The details of the figure are not provided in the text, but it serves as a visual aid to understand the surgical outcome.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Procedure Overview',\n", " 'md': '## Surgical Procedure Overview',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The posterior wall is attached to the liver. Hemostasis of the rim of the remnant is achieved with diathermy and clips or Vicryl® 3-0 sutures. When you reach the level of Hartmann’s pouch, ensure that all impacted stones have been evacuated. You can insert your index finger or instrument tip all the way down to the internal opening of the cystic duct, which can often be visualized from within.\\n\\nThe accurate placement of a purse-string suture around this opening, as depicted by artists’ drawings, is not satisfactory because the suture tends to tear out of the inflamed and friable tissues. A better option is to leave a 1 cm rim of Hartmann’s pouch tissue and suture-buttress it over the opening of the cystic duct (we use 2-0 Vicryl®). The exposed mucosa of the posterior gallbladder wall is fried with diathermy (some say until you smell fried liver…) and the omentum is brought into the area. Finally, leave a drain below the gallbladder remnant; usually, you won’t see even a drop of bile in the drain because, in such cases, the cystic duct is obstructed due to the inflammatory process. However, in the rare case when a bile leak develops, the drain will solve the problem.',\n", " 'md': 'The posterior wall is attached to the liver. Hemostasis of the rim of the remnant is achieved with diathermy and clips or Vicryl® 3-0 sutures. When you reach the level of Hartmann’s pouch, ensure that all impacted stones have been evacuated. You can insert your index finger or instrument tip all the way down to the internal opening of the cystic duct, which can often be visualized from within.\\n\\nThe accurate placement of a purse-string suture around this opening, as depicted by artists’ drawings, is not satisfactory because the suture tends to tear out of the inflamed and friable tissues. A better option is to leave a 1 cm rim of Hartmann’s pouch tissue and suture-buttress it over the opening of the cystic duct (we use 2-0 Vicryl®). The exposed mucosa of the posterior gallbladder wall is fried with diathermy (some say until you smell fried liver…) and the omentum is brought into the area. Finally, leave a drain below the gallbladder remnant; usually, you won’t see even a drop of bile in the drain because, in such cases, the cystic duct is obstructed due to the inflammatory process. However, in the rare case when a bile leak develops, the drain will solve the problem.',\n", " 'bBox': {'x': 72, 'y': 187, 'w': 467.82, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'What to Do if Closure is Impossible',\n", " 'md': '### What to Do if Closure is Impossible',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'If you find that it is impossible to close the cystic duct/gallbladder remnant, don’t panic: it is absolutely safe just to leave a suction drain and bail out. The drain will be producing bile for a few days, up to 2 weeks, but eventually, it will dry out!',\n", " 'md': 'If you find that it is impossible to close the cystic duct/gallbladder remnant, don’t panic: it is absolutely safe just to leave a suction drain and bail out. The drain will be producing bile for a few days, up to 2 weeks, but eventually, it will dry out!',\n", " 'bBox': {'x': 72, 'y': 423, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'During Laparoscopic Cholecystectomy',\n", " 'md': '### During Laparoscopic Cholecystectomy',\n", " 'bBox': {'x': 82, 'y': 470, 'w': 194.8, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': 'The gallbladder is opened at a ‘safe and comfortable’ location, at Hartmann’s pouch or above, and the contents evacuated. Have your suction ready, and place a specimen collection bag inside — through an added port if needed — to collect the stones before they spill. At this point, you can easily look inside towards the gallbladder outlet and make sure you clear all stones obstructing the cystic duct.\\n\\nComplete the transection of Hartmann’s pouch, and close the remnant (you can suture the cystic duct from within, or suture-close the remnant from outside, or simply place an Endoloop® around it). Now complete the removal of the body and fundus — you can leave the posterior wall on the liver and fulgurate the mucosa if the risk of bleeding is high. Leave a drain. The end result is depicted in **Figure 20.3**.\\n```',\n", " 'md': 'The gallbladder is opened at a ‘safe and comfortable’ location, at Hartmann’s pouch or above, and the contents evacuated. Have your suction ready, and place a specimen collection bag inside — through an added port if needed — to collect the stones before they spill. At this point, you can easily look inside towards the gallbladder outlet and make sure you clear all stones obstructing the cystic duct.\\n\\nComplete the transection of Hartmann’s pouch, and close the remnant (you can suture the cystic duct from within, or suture-close the remnant from outside, or simply place an Endoloop® around it). Now complete the removal of the body and fundus — you can leave the posterior wall on the liver and fulgurate the mucosa if the risk of bleeding is high. Leave a drain. The end result is depicted in **Figure 20.3**.\\n```',\n", " 'bBox': {'x': 72, 'y': 539, 'w': 467.85, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 20.3**: This figure illustrates the end result of the surgical procedure described. It likely includes a visual representation of the gallbladder remnant and the surrounding anatomy post-operation. The details of the figure are not provided in the text, but it serves as a visual aid to understand the surgical outcome.',\n", " 'md': '- **Figure 20.3**: This figure illustrates the end result of the surgical procedure described. It likely includes a visual representation of the gallbladder remnant and the surrounding anatomy post-operation. The details of the figure are not provided in the text, but it serves as a visual aid to understand the surgical outcome.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 309,\n", " 'text': ' In conclusion: in this operation, the structures in Calot’s triangle are not dissected out and\\n bleeding from the hepatic bed is avoided; it is a fast and safe procedure having the advantages\\n of both cholecystectomy and cholecystostomy.\\n\\n There is a caveat: a rare (so rare as to deserve being published as\\nisolated case reports) complication of subtotal cholecystectomy is the\\nlate enlargement of the gallbladder remnant presenting as\\nsymptomatic cholelithiasis, with ultrasound reporting “stones within the\\ngallbladder”. The most common cause is faulty technique, and failure to\\nevacuate the stones completely. Differential diagnosis would include late\\nenlargement of the cystic duct remnant and a duplication of the\\ngallbladder (one of which was missed during the initial operation). This\\ncomplication has been also described following ‘conventional’ LC, where\\nthe surgeon divided and occluded ħartmann’s pouch instead of the cystic\\nduct. Whatever the specific cause, the treatment is a ‘re-\\ncholecystectomy’ (open or lap) with pre-operative bile duct imaging,\\nproviding a road map for the biliary anatomy. So when doing a subtotal\\ncholecystectomy always make a detailed operative report justifying\\nwhat was done and why, and explain it to the patient — thus pre-\\nemptively suppressing any future lawsuit. (“ħe did not tell me that\\npart of my gallbladder is still inside…”).',\n", " 'md': '```markdown\\n## Conclusion\\n\\nIn this operation, the structures in Calot’s triangle are not dissected out and bleeding from the hepatic bed is avoided; it is a fast and safe procedure having the advantages of both cholecystectomy and cholecystostomy.\\n\\nThere is a caveat: a rare (so rare as to deserve being published as isolated case reports) complication of subtotal cholecystectomy is the late enlargement of the gallbladder remnant presenting as symptomatic cholelithiasis, with ultrasound reporting “stones within the gallbladder”. The most common cause is faulty technique, and failure to evacuate the stones completely. Differential diagnosis would include late enlargement of the cystic duct remnant and a duplication of the gallbladder (one of which was missed during the initial operation). This complication has been also described following ‘conventional’ LC, where the surgeon divided and occluded Hartmann’s pouch instead of the cystic duct.\\n\\nWhatever the specific cause, the treatment is a ‘re-cholecystectomy’ (open or lap) with pre-operative bile duct imaging, providing a road map for the biliary anatomy. So when doing a subtotal cholecystectomy always make a detailed operative report justifying what was done and why, and explain it to the patient — thus preemptively suppressing any future lawsuit. (“He did not tell me that part of my gallbladder is still inside…”).\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Conclusion',\n", " 'md': '## Conclusion',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In this operation, the structures in Calot’s triangle are not dissected out and bleeding from the hepatic bed is avoided; it is a fast and safe procedure having the advantages of both cholecystectomy and cholecystostomy.\\n\\nThere is a caveat: a rare (so rare as to deserve being published as isolated case reports) complication of subtotal cholecystectomy is the late enlargement of the gallbladder remnant presenting as symptomatic cholelithiasis, with ultrasound reporting “stones within the gallbladder”. The most common cause is faulty technique, and failure to evacuate the stones completely. Differential diagnosis would include late enlargement of the cystic duct remnant and a duplication of the gallbladder (one of which was missed during the initial operation). This complication has been also described following ‘conventional’ LC, where the surgeon divided and occluded Hartmann’s pouch instead of the cystic duct.\\n\\nWhatever the specific cause, the treatment is a ‘re-cholecystectomy’ (open or lap) with pre-operative bile duct imaging, providing a road map for the biliary anatomy. So when doing a subtotal cholecystectomy always make a detailed operative report justifying what was done and why, and explain it to the patient — thus preemptively suppressing any future lawsuit. (“He did not tell me that part of my gallbladder is still inside…”).\\n```',\n", " 'md': 'In this operation, the structures in Calot’s triangle are not dissected out and bleeding from the hepatic bed is avoided; it is a fast and safe procedure having the advantages of both cholecystectomy and cholecystostomy.\\n\\nThere is a caveat: a rare (so rare as to deserve being published as isolated case reports) complication of subtotal cholecystectomy is the late enlargement of the gallbladder remnant presenting as symptomatic cholelithiasis, with ultrasound reporting “stones within the gallbladder”. The most common cause is faulty technique, and failure to evacuate the stones completely. Differential diagnosis would include late enlargement of the cystic duct remnant and a duplication of the gallbladder (one of which was missed during the initial operation). This complication has been also described following ‘conventional’ LC, where the surgeon divided and occluded Hartmann’s pouch instead of the cystic duct.\\n\\nWhatever the specific cause, the treatment is a ‘re-cholecystectomy’ (open or lap) with pre-operative bile duct imaging, providing a road map for the biliary anatomy. So when doing a subtotal cholecystectomy always make a detailed operative report justifying what was done and why, and explain it to the patient — thus preemptively suppressing any future lawsuit. (“He did not tell me that part of my gallbladder is still inside…”).\\n```',\n", " 'bBox': {'x': 72, 'y': 113, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 310,\n", " 'text': ' Figure 20.3. Subtotal cholecystectomy. The end result of subtotal cholecystectomy, be it\\n laparoscopic or open. The blue arrow points to the ‘rim’ of the gallbladder remnant. The\\n black arrow points to the inside of the remnant and down to the Hartmann’s pouch, which\\n is now clear of stones and towards the inner opening of the cystic duct. If you can close\\n the remnant with sutures then do it; but sometimes, as in this case, it is impossible... so\\n just leave a drain. Do not worry — everything will be alright! Image courtesy of Dr. Kristoffer\\n Lassen, Oslo, Norway.\\n\\n Surgical cholecystostomy\\n Another option to bail out in difficult situations is to do a\\ncholecystostomy. This procedure is rarely performed nowadays, as\\npercutaneous techniques prevail, but occasionally you may find yourself\\nalone with a patient in such an extreme condition, that he will be best\\nserved by a short procedure under local anesthesia. Another plausible\\nsituation can arise during a planned LC when the gallbladder appears\\n‘impossible’ — say, an obliterated gallbladder in a morbidly obese patient:\\nyou do not want to convert and you are not comfortable with laparoscopic\\nsubtotal cholecystectomy. Whatever the situation, expose the fundus of\\nthe gallbladder, place a purse-string suture, and incise it. Suck out the\\ncontents; evacuate stones if you can but your purpose is drainage, not a\\ncomplete surgical solution. Then insert a Foley catheter into the\\ngallbladder and inflate the balloon and tie the purse-string, which is\\neasier done during an open procedure.',\n", " 'md': \"```markdown\\n# Page Content\\n\\n## Figure 20.3\\n**Description:** The image depicts the end result of a subtotal cholecystectomy, which can be performed laparoscopically or through an open approach. The blue arrow indicates the 'rim' of the gallbladder remnant, while the black arrow points to the inside of the remnant and down to Hartmann’s pouch, which is free of stones and leads to the inner opening of the cystic duct. The text suggests that if it is possible to close the remnant with sutures, it should be done; however, in some cases, like the one shown, it may be impossible, and a drain should be left in place. The image is credited to Dr. Kristoffer Lassen from Oslo, Norway.\\n\\n**Caption:** Subtotal cholecystectomy.\\n\\n----\\n\\n## Surgical Cholecystostomy\\nAnother option to consider in difficult situations is to perform a cholecystostomy. This procedure is rarely performed nowadays due to the prevalence of percutaneous techniques, but there may be instances where a patient is in such an extreme condition that a short procedure under local anesthesia is the best option.\\n\\nA plausible scenario can occur during a planned laparoscopic cholecystectomy (LC) when the gallbladder appears 'impossible' to manage, such as in the case of an obliterated gallbladder in a morbidly obese patient. In such situations, conversion to open surgery may not be desirable, and the surgeon may not feel comfortable performing a laparoscopic subtotal cholecystectomy.\\n\\nRegardless of the situation, the steps to perform a cholecystostomy include:\\n1. Expose the fundus of the gallbladder.\\n2. Place a purse-string suture and incise it.\\n3. Suck out the contents and evacuate stones if possible, keeping in mind that the primary goal is drainage rather than a complete surgical solution.\\n4. Insert a Foley catheter into the gallbladder, inflate the balloon, and tie the purse-string, which is easier to accomplish during an open procedure.\\n```\",\n", " 'images': [{'name': 'img_p309_1.png',\n", " 'height': 467,\n", " 'width': 678,\n", " 'x': 138.23999999999978,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1164,\n", " 'original_height': 802}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 20.3',\n", " 'md': '## Figure 20.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"**Description:** The image depicts the end result of a subtotal cholecystectomy, which can be performed laparoscopically or through an open approach. The blue arrow indicates the 'rim' of the gallbladder remnant, while the black arrow points to the inside of the remnant and down to Hartmann’s pouch, which is free of stones and leads to the inner opening of the cystic duct. The text suggests that if it is possible to close the remnant with sutures, it should be done; however, in some cases, like the one shown, it may be impossible, and a drain should be left in place. The image is credited to Dr. Kristoffer Lassen from Oslo, Norway.\\n\\n**Caption:** Subtotal cholecystectomy.\\n\\n----\",\n", " 'md': \"**Description:** The image depicts the end result of a subtotal cholecystectomy, which can be performed laparoscopically or through an open approach. The blue arrow indicates the 'rim' of the gallbladder remnant, while the black arrow points to the inside of the remnant and down to Hartmann’s pouch, which is free of stones and leads to the inner opening of the cystic duct. The text suggests that if it is possible to close the remnant with sutures, it should be done; however, in some cases, like the one shown, it may be impossible, and a drain should be left in place. The image is credited to Dr. Kristoffer Lassen from Oslo, Norway.\\n\\n**Caption:** Subtotal cholecystectomy.\\n\\n----\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Cholecystostomy',\n", " 'md': '## Surgical Cholecystostomy',\n", " 'bBox': {'x': 86, 'y': 458, 'w': 178.28, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': \"Another option to consider in difficult situations is to perform a cholecystostomy. This procedure is rarely performed nowadays due to the prevalence of percutaneous techniques, but there may be instances where a patient is in such an extreme condition that a short procedure under local anesthesia is the best option.\\n\\nA plausible scenario can occur during a planned laparoscopic cholecystectomy (LC) when the gallbladder appears 'impossible' to manage, such as in the case of an obliterated gallbladder in a morbidly obese patient. In such situations, conversion to open surgery may not be desirable, and the surgeon may not feel comfortable performing a laparoscopic subtotal cholecystectomy.\\n\\nRegardless of the situation, the steps to perform a cholecystostomy include:\\n1. Expose the fundus of the gallbladder.\\n2. Place a purse-string suture and incise it.\\n3. Suck out the contents and evacuate stones if possible, keeping in mind that the primary goal is drainage rather than a complete surgical solution.\\n4. Insert a Foley catheter into the gallbladder, inflate the balloon, and tie the purse-string, which is easier to accomplish during an open procedure.\\n```\",\n", " 'md': \"Another option to consider in difficult situations is to perform a cholecystostomy. This procedure is rarely performed nowadays due to the prevalence of percutaneous techniques, but there may be instances where a patient is in such an extreme condition that a short procedure under local anesthesia is the best option.\\n\\nA plausible scenario can occur during a planned laparoscopic cholecystectomy (LC) when the gallbladder appears 'impossible' to manage, such as in the case of an obliterated gallbladder in a morbidly obese patient. In such situations, conversion to open surgery may not be desirable, and the surgeon may not feel comfortable performing a laparoscopic subtotal cholecystectomy.\\n\\nRegardless of the situation, the steps to perform a cholecystostomy include:\\n1. Expose the fundus of the gallbladder.\\n2. Place a purse-string suture and incise it.\\n3. Suck out the contents and evacuate stones if possible, keeping in mind that the primary goal is drainage rather than a complete surgical solution.\\n4. Insert a Foley catheter into the gallbladder, inflate the balloon, and tie the purse-string, which is easier to accomplish during an open procedure.\\n```\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 311,\n", " 'text': ' You may want to know how to insert the Foley catheter into the\\ngallbladder during a laparoscopic procedure. Well, insert a 5mm\\ngrasper through the epigastric port and bring it to lie within the tip of the\\nlateral subcostal trocar. Now remove the latter while ‘pushing’ the grasper\\nto follow the retracting trocar, through the skin incision. Lubricate a Foley\\ncatheter (16Fr will do), grasp it with the grasper and pull it into the\\nabdomen.\\n\\n With regard to the management of the cholecystostomy tube, a\\ntube cholangiogram performed a week later will tell you whether the\\ncystic duct is patent; and if so whether the bile duct is free of stones. The\\ntube can be safely capped if all is well, and left as a safety valve until\\nelective surgery; another attack is simply treated by opening the tube.\\nWhether an interval cholecystectomy is subsequently indicated is\\ncontroversial, but is usually performed (see above). Cystic duct\\nobstruction would usually mandate interval cholecystectomy.\\n\\n Other considerations\\n\\n Intra-operative cholangiogram (IOC)\\n Without jumping into this never-ending discussion again, an IOC has\\nbeen mentioned as a way to delineate unclear anatomy in cases of acute\\ncholecystitis. It may be enough to say that “the authors have not\\nfound the need for this measure in their experience...”; we also find it\\ndifficult to perform in acute disease, where the cystic duct is obstructed\\nand the tissues are edematous and friable. Transcholecystic needle\\ncholangiography has been described, but rarely used. It is best to define\\nthe surgical anatomy by proper dissection, using the above-mentioned\\nprinciples, and if you can’t — then avoid this area and resort to subtotal\\ncholecystectomy. Again: in emergency surgery, simple is beautiful. Why\\ncomplicate your life?!\\n\\n [An] intra-operative cholangiogram is a religion — not\\n science.\\n Nathaniel J. Soper\\n\\n Antibiotic treatment',\n", " 'md': '```markdown\\n## Insertion of Foley Catheter into Gallbladder\\n\\nYou may want to know how to insert the Foley catheter into the gallbladder during a laparoscopic procedure. Well, insert a 5mm grasper through the epigastric port and bring it to lie within the tip of the lateral subcostal trocar. Now remove the latter while ‘pushing’ the grasper to follow the retracting trocar, through the skin incision. Lubricate a Foley catheter (16Fr will do), grasp it with the grasper and pull it into the abdomen.\\n\\n### Management of Cholecystostomy Tube\\n\\nWith regard to the management of the cholecystostomy tube, a tube cholangiogram performed a week later will tell you whether the cystic duct is patent; and if so whether the bile duct is free of stones. The tube can be safely capped if all is well, and left as a safety valve until elective surgery; another attack is simply treated by opening the tube. Whether an interval cholecystectomy is subsequently indicated is controversial, but is usually performed (see above). Cystic duct obstruction would usually mandate interval cholecystectomy.\\n\\n### Other Considerations\\n\\n#### Intra-operative Cholangiogram (IOC)\\n\\nWithout jumping into this never-ending discussion again, an IOC has been mentioned as a way to delineate unclear anatomy in cases of acute cholecystitis. It may be enough to say that “the authors have not found the need for this measure in their experience...”; we also find it difficult to perform in acute disease, where the cystic duct is obstructed and the tissues are edematous and friable. Transcholecystic needle cholangiography has been described, but rarely used. It is best to define the surgical anatomy by proper dissection, using the above-mentioned principles, and if you can’t — then avoid this area and resort to subtotal cholecystectomy. Again: in emergency surgery, simple is beautiful. Why complicate your life?!\\n\\n> “An intra-operative cholangiogram is a religion — not science.”\\n> — Nathaniel J. Soper\\n\\n### Antibiotic Treatment\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Insertion of Foley Catheter into Gallbladder',\n", " 'md': '## Insertion of Foley Catheter into Gallbladder',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'You may want to know how to insert the Foley catheter into the gallbladder during a laparoscopic procedure. Well, insert a 5mm grasper through the epigastric port and bring it to lie within the tip of the lateral subcostal trocar. Now remove the latter while ‘pushing’ the grasper to follow the retracting trocar, through the skin incision. Lubricate a Foley catheter (16Fr will do), grasp it with the grasper and pull it into the abdomen.',\n", " 'md': 'You may want to know how to insert the Foley catheter into the gallbladder during a laparoscopic procedure. Well, insert a 5mm grasper through the epigastric port and bring it to lie within the tip of the lateral subcostal trocar. Now remove the latter while ‘pushing’ the grasper to follow the retracting trocar, through the skin incision. Lubricate a Foley catheter (16Fr will do), grasp it with the grasper and pull it into the abdomen.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.85, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management of Cholecystostomy Tube',\n", " 'md': '### Management of Cholecystostomy Tube',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'With regard to the management of the cholecystostomy tube, a tube cholangiogram performed a week later will tell you whether the cystic duct is patent; and if so whether the bile duct is free of stones. The tube can be safely capped if all is well, and left as a safety valve until elective surgery; another attack is simply treated by opening the tube. Whether an interval cholecystectomy is subsequently indicated is controversial, but is usually performed (see above). Cystic duct obstruction would usually mandate interval cholecystectomy.',\n", " 'md': 'With regard to the management of the cholecystostomy tube, a tube cholangiogram performed a week later will tell you whether the cystic duct is patent; and if so whether the bile duct is free of stones. The tube can be safely capped if all is well, and left as a safety valve until elective surgery; another attack is simply treated by opening the tube. Whether an interval cholecystectomy is subsequently indicated is controversial, but is usually performed (see above). Cystic duct obstruction would usually mandate interval cholecystectomy.',\n", " 'bBox': {'x': 72, 'y': 253, 'w': 467.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Other Considerations',\n", " 'md': '### Other Considerations',\n", " 'bBox': {'x': 86, 'y': 379, 'w': 166.44, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Intra-operative Cholangiogram (IOC)',\n", " 'md': '#### Intra-operative Cholangiogram (IOC)',\n", " 'bBox': {'x': 86, 'y': 419, 'w': 246.19, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Without jumping into this never-ending discussion again, an IOC has been mentioned as a way to delineate unclear anatomy in cases of acute cholecystitis. It may be enough to say that “the authors have not found the need for this measure in their experience...”; we also find it difficult to perform in acute disease, where the cystic duct is obstructed and the tissues are edematous and friable. Transcholecystic needle cholangiography has been described, but rarely used. It is best to define the surgical anatomy by proper dissection, using the above-mentioned principles, and if you can’t — then avoid this area and resort to subtotal cholecystectomy. Again: in emergency surgery, simple is beautiful. Why complicate your life?!\\n\\n> “An intra-operative cholangiogram is a religion — not science.”\\n> — Nathaniel J. Soper',\n", " 'md': 'Without jumping into this never-ending discussion again, an IOC has been mentioned as a way to delineate unclear anatomy in cases of acute cholecystitis. It may be enough to say that “the authors have not found the need for this measure in their experience...”; we also find it difficult to perform in acute disease, where the cystic duct is obstructed and the tissues are edematous and friable. Transcholecystic needle cholangiography has been described, but rarely used. It is best to define the surgical anatomy by proper dissection, using the above-mentioned principles, and if you can’t — then avoid this area and resort to subtotal cholecystectomy. Again: in emergency surgery, simple is beautiful. Why complicate your life?!\\n\\n> “An intra-operative cholangiogram is a religion — not science.”\\n> — Nathaniel J. Soper',\n", " 'bBox': {'x': 72, 'y': 456, 'w': 467.68, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Antibiotic Treatment',\n", " 'md': '### Antibiotic Treatment',\n", " 'bBox': {'x': 86, 'y': 715, 'w': 135.88, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 312,\n", " 'text': ' The role of antibiotics in treating acute cholecystitis appears to be\\ntrivial, but it is not. It seems that over-treatment is the rule, by type as well\\nas by dosage. The common pathogens are enteric Gram-negative\\nbacteria, secondarily infecting an obstructed gallbladder. So, as\\nmentioned above, the early phase of acute cholecystitis is probably\\nsterile. Not every case of 12-hour RUQ pain with some ultrasonographic\\nsigns of distension and wall-thickening mandates antibiotics. And if they\\nare prescribed, the coverage should not automatically include anaerobes,\\nwhich are not common pathogens. ħowever, we would add anti-\\nanaerobe coverage when necrotizing AC is suspected clinically or found\\nat operation. If surgery is carried out, the peri-operative antibiotic\\ncoverage for acute cholecystitis should be short, as for ‘resectable\\ninfection’ ( Chapters 7 and 44), and extended only for complicated\\ncases of empyema, gangrene or perforation.\\n\\n Acalculous cholecystitis\\n We briefly mentioned this condition above as it is relatively rare, and\\noften mistakenly diagnosed when small stones are simply missed. This\\nentity is a manifestation of disturbed gallbladder circulation in a critically\\nill patient, usually the outcome of multiple etiologic factors: gallbladder\\ndistension due to fasting, a low-flow state, and vasospasm due to the use\\nof amine vasopressors. The result is a distended gallbladder, with an\\nischemic wall and secondary infection that risks the patient’s life.\\n(ħaving said this, there has been a growing number of cases developing\\n‘out of the blue’ in otherwise healthy individuals, even young patients,\\nwithout any of the known predisposing factors.)\\n\\n The diagnosis may be obscured by the patient’s general condition and\\nunderlying critical disease, and clinical signs may not be obvious in the\\nsedated patient, but bedside US (or a trip to the CT) will quickly reveal\\nthe distended gallbladder, surrounded by fluid, that will explain the septic\\ndeterioration and the elevated liver enzymes — if you were suspicious\\nenough to order the study. Questionable cases and unclear studies may\\nrequire the definitive ħIDA scan — but this is difficult to perform in the\\ntypical ICU patient, so you may need to act empirically if suspicion is high\\nenough.\\n\\n Although this condition may lead to necrosis and perforation, most',\n", " 'md': '```markdown\\n# The Role of Antibiotics in Treating Acute Cholecystitis\\n\\nThe role of antibiotics in treating acute cholecystitis appears to be trivial, but it is not. It seems that over-treatment is the rule, by type as well as by dosage. The common pathogens are enteric Gram-negative bacteria, secondarily infecting an obstructed gallbladder. So, as mentioned above, the early phase of acute cholecystitis is probably sterile. Not every case of 12-hour RUQ pain with some ultrasonographic signs of distension and wall-thickening mandates antibiotics. And if they are prescribed, the coverage should not automatically include anaerobes, which are not common pathogens. However, we would add anti-anaerobe coverage when necrotizing AC is suspected clinically or found at operation. If surgery is carried out, the peri-operative antibiotic coverage for acute cholecystitis should be short, as for ‘resectable infection’ (Chapters 7 and 44), and extended only for complicated cases of empyema, gangrene, or perforation.\\n\\n## Acalculous Cholecystitis\\n\\nWe briefly mentioned this condition above as it is relatively rare, and often mistakenly diagnosed when small stones are simply missed. This entity is a manifestation of disturbed gallbladder circulation in a critically ill patient, usually the outcome of multiple etiologic factors: gallbladder distension due to fasting, a low-flow state, and vasospasm due to the use of amine vasopressors. The result is a distended gallbladder, with an ischemic wall and secondary infection that risks the patient’s life. Having said this, there has been a growing number of cases developing ‘out of the blue’ in otherwise healthy individuals, even young patients, without any of the known predisposing factors.\\n\\nThe diagnosis may be obscured by the patient’s general condition and underlying critical disease, and clinical signs may not be obvious in the sedated patient, but bedside US (or a trip to the CT) will quickly reveal the distended gallbladder, surrounded by fluid, that will explain the septic deterioration and the elevated liver enzymes — if you were suspicious enough to order the study. Questionable cases and unclear studies may require the definitive HIDA scan — but this is difficult to perform in the typical ICU patient, so you may need to act empirically if suspicion is high enough.\\n\\nAlthough this condition may lead to necrosis and perforation, most...\\n```\\n\\n*Note: There were no figures, tables, or images identified in the provided text.*',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'The Role of Antibiotics in Treating Acute Cholecystitis',\n", " 'md': '# The Role of Antibiotics in Treating Acute Cholecystitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The role of antibiotics in treating acute cholecystitis appears to be trivial, but it is not. It seems that over-treatment is the rule, by type as well as by dosage. The common pathogens are enteric Gram-negative bacteria, secondarily infecting an obstructed gallbladder. So, as mentioned above, the early phase of acute cholecystitis is probably sterile. Not every case of 12-hour RUQ pain with some ultrasonographic signs of distension and wall-thickening mandates antibiotics. And if they are prescribed, the coverage should not automatically include anaerobes, which are not common pathogens. However, we would add anti-anaerobe coverage when necrotizing AC is suspected clinically or found at operation. If surgery is carried out, the peri-operative antibiotic coverage for acute cholecystitis should be short, as for ‘resectable infection’ (Chapters 7 and 44), and extended only for complicated cases of empyema, gangrene, or perforation.',\n", " 'md': 'The role of antibiotics in treating acute cholecystitis appears to be trivial, but it is not. It seems that over-treatment is the rule, by type as well as by dosage. The common pathogens are enteric Gram-negative bacteria, secondarily infecting an obstructed gallbladder. So, as mentioned above, the early phase of acute cholecystitis is probably sterile. Not every case of 12-hour RUQ pain with some ultrasonographic signs of distension and wall-thickening mandates antibiotics. And if they are prescribed, the coverage should not automatically include anaerobes, which are not common pathogens. However, we would add anti-anaerobe coverage when necrotizing AC is suspected clinically or found at operation. If surgery is carried out, the peri-operative antibiotic coverage for acute cholecystitis should be short, as for ‘resectable infection’ (Chapters 7 and 44), and extended only for complicated cases of empyema, gangrene, or perforation.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.72, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Acalculous Cholecystitis',\n", " 'md': '## Acalculous Cholecystitis',\n", " 'bBox': {'x': 86, 'y': 340, 'w': 167.87, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'We briefly mentioned this condition above as it is relatively rare, and often mistakenly diagnosed when small stones are simply missed. This entity is a manifestation of disturbed gallbladder circulation in a critically ill patient, usually the outcome of multiple etiologic factors: gallbladder distension due to fasting, a low-flow state, and vasospasm due to the use of amine vasopressors. The result is a distended gallbladder, with an ischemic wall and secondary infection that risks the patient’s life. Having said this, there has been a growing number of cases developing ‘out of the blue’ in otherwise healthy individuals, even young patients, without any of the known predisposing factors.\\n\\nThe diagnosis may be obscured by the patient’s general condition and underlying critical disease, and clinical signs may not be obvious in the sedated patient, but bedside US (or a trip to the CT) will quickly reveal the distended gallbladder, surrounded by fluid, that will explain the septic deterioration and the elevated liver enzymes — if you were suspicious enough to order the study. Questionable cases and unclear studies may require the definitive HIDA scan — but this is difficult to perform in the typical ICU patient, so you may need to act empirically if suspicion is high enough.\\n\\nAlthough this condition may lead to necrosis and perforation, most...\\n```\\n\\n*Note: There were no figures, tables, or images identified in the provided text.*',\n", " 'md': 'We briefly mentioned this condition above as it is relatively rare, and often mistakenly diagnosed when small stones are simply missed. This entity is a manifestation of disturbed gallbladder circulation in a critically ill patient, usually the outcome of multiple etiologic factors: gallbladder distension due to fasting, a low-flow state, and vasospasm due to the use of amine vasopressors. The result is a distended gallbladder, with an ischemic wall and secondary infection that risks the patient’s life. Having said this, there has been a growing number of cases developing ‘out of the blue’ in otherwise healthy individuals, even young patients, without any of the known predisposing factors.\\n\\nThe diagnosis may be obscured by the patient’s general condition and underlying critical disease, and clinical signs may not be obvious in the sedated patient, but bedside US (or a trip to the CT) will quickly reveal the distended gallbladder, surrounded by fluid, that will explain the septic deterioration and the elevated liver enzymes — if you were suspicious enough to order the study. Questionable cases and unclear studies may require the definitive HIDA scan — but this is difficult to perform in the typical ICU patient, so you may need to act empirically if suspicion is high enough.\\n\\nAlthough this condition may lead to necrosis and perforation, most...\\n```\\n\\n*Note: There were no figures, tables, or images identified in the provided text.*',\n", " 'bBox': {'x': 72, 'y': 394, 'w': 467.93, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'cases of empyema, gangrene or perforation.'},\n", " {'text': 'cases of empyema, gangrene or perforation.'}]},\n", " {'page': 313,\n", " 'text': 'cases, despite old beliefs, will respond to percutaneous drainage. If the\\npatient does not improve, though, cholecystectomy may be required. In\\nnon-critically ill patients diagnosed with acalculous cholecystitis,\\nwe would proceed with LC, along the lines discussed above.\\n\\n For an in-depth discussion on the complications of cholecystectomy\\nread the relevant chapter in our twin book 2!\\n Beware of the easy-looking gallbladder and the\\n overconfident surgeon.\\n\\n Bile duct emergencies\\n 2 Danny Rosin\\n So a stone has passed into the CBD — how does it change your\\napproach?\\n\\n As in cholecystitis, the same mechanism is responsible for most of the\\nproblems — obstruction and build-up of pressure. Obstruction is caused\\nby a stone in most cases, but a stricture or external compression can\\nresult in a similar outcome — which can be one of three:\\n\\n • Non-infected: obstructive jaundice.\\n • Infected: acute (‘ascending’) cholangitis.\\n • Acute pancreatitis.\\n The exact mechanism may vary in different patients — for\\nexample:\\n\\n • The young, postpartum patient, who developed stones during\\n pregnancy (due to the progesterone effect on gallbladder\\n contractility), now starts to contract her gallbladder, expelling the\\n small stones through a somewhat wide cystic duct.\\n • The old man, 30 years after cholecystectomy, with a primary CBD\\n stone (or a chain of them).',\n", " 'md': '```markdown\\n## Bile Duct Emergencies\\n\\nSo a stone has passed into the CBD — how does it change your approach?\\n\\nAs in cholecystitis, the same mechanism is responsible for most of the problems — obstruction and build-up of pressure. Obstruction is caused by a stone in most cases, but a stricture or external compression can result in a similar outcome — which can be one of three:\\n\\n- **Non-infected:** obstructive jaundice.\\n- **Infected:** acute (‘ascending’) cholangitis.\\n- **Acute pancreatitis.**\\n\\nThe exact mechanism may vary in different patients — for example:\\n\\n- The young, postpartum patient, who developed stones during pregnancy (due to the progesterone effect on gallbladder contractility), now starts to contract her gallbladder, expelling the small stones through a somewhat wide cystic duct.\\n- The old man, 30 years after cholecystectomy, with a primary CBD stone (or a chain of them).\\n\\n### References\\nFor an in-depth discussion on the complications of cholecystectomy, read the relevant chapter in our twin book [2]().\\n\\n> **Note:** Beware of the easy-looking gallbladder and the overconfident surgeon.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Bile Duct Emergencies',\n", " 'md': '## Bile Duct Emergencies',\n", " 'bBox': {'x': 100, 'y': 275, 'w': 175.65, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'So a stone has passed into the CBD — how does it change your approach?\\n\\nAs in cholecystitis, the same mechanism is responsible for most of the problems — obstruction and build-up of pressure. Obstruction is caused by a stone in most cases, but a stricture or external compression can result in a similar outcome — which can be one of three:\\n\\n- **Non-infected:** obstructive jaundice.\\n- **Infected:** acute (‘ascending’) cholangitis.\\n- **Acute pancreatitis.**\\n\\nThe exact mechanism may vary in different patients — for example:\\n\\n- The young, postpartum patient, who developed stones during pregnancy (due to the progesterone effect on gallbladder contractility), now starts to contract her gallbladder, expelling the small stones through a somewhat wide cystic duct.\\n- The old man, 30 years after cholecystectomy, with a primary CBD stone (or a chain of them).',\n", " 'md': 'So a stone has passed into the CBD — how does it change your approach?\\n\\nAs in cholecystitis, the same mechanism is responsible for most of the problems — obstruction and build-up of pressure. Obstruction is caused by a stone in most cases, but a stricture or external compression can result in a similar outcome — which can be one of three:\\n\\n- **Non-infected:** obstructive jaundice.\\n- **Infected:** acute (‘ascending’) cholangitis.\\n- **Acute pancreatitis.**\\n\\nThe exact mechanism may vary in different patients — for example:\\n\\n- The young, postpartum patient, who developed stones during pregnancy (due to the progesterone effect on gallbladder contractility), now starts to contract her gallbladder, expelling the small stones through a somewhat wide cystic duct.\\n- The old man, 30 years after cholecystectomy, with a primary CBD stone (or a chain of them).',\n", " 'bBox': {'x': 72, 'y': 220, 'w': 467.46, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'References',\n", " 'md': '### References',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'For an in-depth discussion on the complications of cholecystectomy, read the relevant chapter in our twin book [2]().\\n\\n> **Note:** Beware of the easy-looking gallbladder and the overconfident surgeon.\\n```',\n", " 'md': 'For an in-depth discussion on the complications of cholecystectomy, read the relevant chapter in our twin book [2]().\\n\\n> **Note:** Beware of the easy-looking gallbladder and the overconfident surgeon.\\n```',\n", " 'bBox': {'x': 73, 'y': 220, 'w': 181.35, 'h': 28.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'read the relevant chapter in our twin book '}]},\n", " {'page': 314,\n", " 'text': ' • The 55-year-old athlete who suddenly turns yellow, due to his not-\\n yet diagnosed pancreatic head carcinoma (painless, and usually\\n non-infected unless we start to intervene).\\n\\n Of course, the list of etiologies doesn’t stop here, but you get the idea:\\nthere is an obstruction of the bile duct, hopefully benign, and it’s your job\\nto treat the resulting complication. The obstruction itself may resolve\\nspontaneously, and if not — it needs a specific intervention.\\n\\n We will leave the third scenario to our pancreatic experts (and\\nanyway, it’s rarely an emergency), and discuss the three stone-\\nrelated entities that are relevant to us as general surgeons, namely\\n— jaundice, cholangitis and pancreatitis. While separated for didactic\\nreasons, ‘mixed’ presentations do occur commonly in real life. The\\ncommon denominator for all these emergencies, though, is that\\nonly rarely do they require emergency surgery. Your goal, and\\nresponsibility, is to solve the acute problem, navigating between different\\nimaging modalities and interventional procedures, and lead the patient\\nsafely to an elective operation.\\n\\n Obstructive jaundice\\n\\n If the gallstones are small enough, and the cystic duct wide enough,\\nstones can migrate into the CBD. The sphincter of Oddi is the reason\\nwhy even small stones may get stuck, at least temporarily, but it is\\nsurprising to find even larger stones in the CBD, which make us wonder\\nhow the hell did they pass through the cystic duct… but the fact is they\\ndid, sometimes after being stuck in the gallbladder outlet for a few days\\n(you may remember Winnie the Pooh, stuck in Rabbit’s hole for a week\\n— but eventually he popped out). Of course, small stones that pass to\\nthe CBD and stay there can grow over time, but this is a slow process.\\n\\n Primary CBD stones are much less frequent, and are usually the\\nresult of longstanding bile stasis, which may be related to a stricture, or\\nthe elusive ‘sphincter of Oddi dysfunction’. We don’t have a good\\nexplanation why such a slow and quiet process suddenly leads to acute\\nobstruction of the CBD, but the outcome is the same, like that of a',\n", " 'md': '```markdown\\n# Page Content\\n\\nThe 55-year-old athlete who suddenly turns yellow, due to his not-yet diagnosed pancreatic head carcinoma (painless, and usually non-infected unless we start to intervene).\\n\\nOf course, the list of etiologies doesn’t stop here, but you get the idea: there is an obstruction of the bile duct, hopefully benign, and it’s your job to treat the resulting complication. The obstruction itself may resolve spontaneously, and if not — it needs a specific intervention.\\n\\nWe will leave the third scenario to our pancreatic experts (and anyway, it’s rarely an emergency), and discuss the three stone-related entities that are relevant to us as general surgeons, namely — jaundice, cholangitis and pancreatitis. While separated for didactic reasons, ‘mixed’ presentations do occur commonly in real life. The common denominator for all these emergencies, though, is that only rarely do they require emergency surgery. Your goal, and responsibility, is to solve the acute problem, navigating between different imaging modalities and interventional procedures, and lead the patient safely to an elective operation.\\n\\n## Obstructive Jaundice\\n\\nIf the gallstones are small enough, and the cystic duct wide enough, stones can migrate into the CBD. The sphincter of Oddi is the reason why even small stones may get stuck, at least temporarily, but it is surprising to find even larger stones in the CBD, which make us wonder how the hell did they pass through the cystic duct… but the fact is they did, sometimes after being stuck in the gallbladder outlet for a few days (you may remember Winnie the Pooh, stuck in Rabbit’s hole for a week — but eventually he popped out). Of course, small stones that pass to the CBD and stay there can grow over time, but this is a slow process.\\n\\nPrimary CBD stones are much less frequent, and are usually the result of longstanding bile stasis, which may be related to a stricture, or the elusive ‘sphincter of Oddi dysfunction’. We don’t have a good explanation why such a slow and quiet process suddenly leads to acute obstruction of the CBD, but the outcome is the same, like that of a...\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The 55-year-old athlete who suddenly turns yellow, due to his not-yet diagnosed pancreatic head carcinoma (painless, and usually non-infected unless we start to intervene).\\n\\nOf course, the list of etiologies doesn’t stop here, but you get the idea: there is an obstruction of the bile duct, hopefully benign, and it’s your job to treat the resulting complication. The obstruction itself may resolve spontaneously, and if not — it needs a specific intervention.\\n\\nWe will leave the third scenario to our pancreatic experts (and anyway, it’s rarely an emergency), and discuss the three stone-related entities that are relevant to us as general surgeons, namely — jaundice, cholangitis and pancreatitis. While separated for didactic reasons, ‘mixed’ presentations do occur commonly in real life. The common denominator for all these emergencies, though, is that only rarely do they require emergency surgery. Your goal, and responsibility, is to solve the acute problem, navigating between different imaging modalities and interventional procedures, and lead the patient safely to an elective operation.',\n", " 'md': 'The 55-year-old athlete who suddenly turns yellow, due to his not-yet diagnosed pancreatic head carcinoma (painless, and usually non-infected unless we start to intervene).\\n\\nOf course, the list of etiologies doesn’t stop here, but you get the idea: there is an obstruction of the bile duct, hopefully benign, and it’s your job to treat the resulting complication. The obstruction itself may resolve spontaneously, and if not — it needs a specific intervention.\\n\\nWe will leave the third scenario to our pancreatic experts (and anyway, it’s rarely an emergency), and discuss the three stone-related entities that are relevant to us as general surgeons, namely — jaundice, cholangitis and pancreatitis. While separated for didactic reasons, ‘mixed’ presentations do occur commonly in real life. The common denominator for all these emergencies, though, is that only rarely do they require emergency surgery. Your goal, and responsibility, is to solve the acute problem, navigating between different imaging modalities and interventional procedures, and lead the patient safely to an elective operation.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Obstructive Jaundice',\n", " 'md': '## Obstructive Jaundice',\n", " 'bBox': {'x': 86, 'y': 433, 'w': 163.68, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'If the gallstones are small enough, and the cystic duct wide enough, stones can migrate into the CBD. The sphincter of Oddi is the reason why even small stones may get stuck, at least temporarily, but it is surprising to find even larger stones in the CBD, which make us wonder how the hell did they pass through the cystic duct… but the fact is they did, sometimes after being stuck in the gallbladder outlet for a few days (you may remember Winnie the Pooh, stuck in Rabbit’s hole for a week — but eventually he popped out). Of course, small stones that pass to the CBD and stay there can grow over time, but this is a slow process.\\n\\nPrimary CBD stones are much less frequent, and are usually the result of longstanding bile stasis, which may be related to a stricture, or the elusive ‘sphincter of Oddi dysfunction’. We don’t have a good explanation why such a slow and quiet process suddenly leads to acute obstruction of the CBD, but the outcome is the same, like that of a...\\n```',\n", " 'md': 'If the gallstones are small enough, and the cystic duct wide enough, stones can migrate into the CBD. The sphincter of Oddi is the reason why even small stones may get stuck, at least temporarily, but it is surprising to find even larger stones in the CBD, which make us wonder how the hell did they pass through the cystic duct… but the fact is they did, sometimes after being stuck in the gallbladder outlet for a few days (you may remember Winnie the Pooh, stuck in Rabbit’s hole for a week — but eventually he popped out). Of course, small stones that pass to the CBD and stay there can grow over time, but this is a slow process.\\n\\nPrimary CBD stones are much less frequent, and are usually the result of longstanding bile stasis, which may be related to a stricture, or the elusive ‘sphincter of Oddi dysfunction’. We don’t have a good explanation why such a slow and quiet process suddenly leads to acute obstruction of the CBD, but the outcome is the same, like that of a...\\n```',\n", " 'bBox': {'x': 72, 'y': 519, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 315,\n", " 'text': 'passing stone: mechanical blockage of the flow.\\n\\n The presentation may be different though, as acute obstruction of\\na narrow duct by a small passing stone is usually painful\\n(‘choledochal colic’), while with obstructing stones in a chronically\\ndilated and hypokinetic CBD, symptoms tend to be ‘gradual’ or\\n‘minimal’— almost like the ‘silent jaundice’ of malignant\\nobstruction.\\n\\n The patient will tell you about his dark urine, and his loving wife about\\nhis yellow eyes, but obvious jaundice requires a bilirubin of 3mg%\\n(50μmol/L) or more. The liver function tests are sensitive, with direct\\nhyperbilirubinemia, moderately elevated transaminases, and the more\\nspecific elevated alkaline phosphatase and gamma-glutamyl transferase.\\nDon’t be surprised to see some amylase/lipase elevation as well — the\\n‘common channel’ brings along many variants of combined pathology of\\nthe biliary and pancreatic systems.\\n\\n Management\\n\\n As opposed to cholangitis (see next), obstructive jaundice is not a life-\\nthreatening emergency; but the patient is stressed, because of the pain, if\\npresent, and the altered appearance — with its frightening associations\\n(“yellow patients have cancer”). The mandatory ultrasound will\\nconfirm your diagnosis (gallstones? dilated vs. collapsed\\ngallbladder — remember Courvoisier’s sign? dilated CBD?\\nintrahepatic dilatation? pancreatic mass?), although the sensitivity\\nfor CBD stones is not more than 50%. If no gallstones are visible in\\nthe gallbladder, you have to investigate further for peri-ampullary\\nmalignancy — and CT is your next step.\\n\\n Benign obstructive jaundice is a fluctuating condition, and\\nspontaneous resolution is common. It usually means that the stone has\\npassed, but not necessarily so — stones may act like a ball-valve with\\nintermittent obstruction. In these cases you are likely to see that\\nnormalization of the hepatic enzymes is not complete. But even if all\\nlaboratory features normalize, you should still consider specific',\n", " 'md': '```markdown\\n## Obstructive Jaundice\\n\\n### Overview\\nPassing stone: mechanical blockage of the flow.\\n\\nThe presentation may be different though, as acute obstruction of a narrow duct by a small passing stone is usually painful (‘choledochal colic’), while with obstructing stones in a chronically dilated and hypokinetic CBD, symptoms tend to be ‘gradual’ or ‘minimal’—almost like the ‘silent jaundice’ of malignant obstruction.\\n\\nThe patient will tell you about his dark urine, and his loving wife about his yellow eyes, but obvious jaundice requires a bilirubin of 3 mg% (50 μmol/L) or more. The liver function tests are sensitive, with direct hyperbilirubinemia, moderately elevated transaminases, and the more specific elevated alkaline phosphatase and gamma-glutamyl transferase. Don’t be surprised to see some amylase/lipase elevation as well — the ‘common channel’ brings along many variants of combined pathology of the biliary and pancreatic systems.\\n\\n### Management\\nAs opposed to cholangitis (see next), obstructive jaundice is not a life-threatening emergency; but the patient is stressed, because of the pain, if present, and the altered appearance — with its frightening associations (“yellow patients have cancer”). The mandatory ultrasound will confirm your diagnosis (gallstones? dilated vs. collapsed gallbladder — remember Courvoisier’s sign? dilated CBD? intrahepatic dilatation? pancreatic mass?), although the sensitivity for CBD stones is not more than 50%. If no gallstones are visible in the gallbladder, you have to investigate further for peri-ampullary malignancy — and CT is your next step.\\n\\nBenign obstructive jaundice is a fluctuating condition, and spontaneous resolution is common. It usually means that the stone has passed, but not necessarily so — stones may act like a ball-valve with intermittent obstruction. In these cases, you are likely to see that normalization of the hepatic enzymes is not complete. But even if all laboratory features normalize, you should still consider specific...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Obstructive Jaundice',\n", " 'md': '## Obstructive Jaundice',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Overview',\n", " 'md': '### Overview',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Passing stone: mechanical blockage of the flow.\\n\\nThe presentation may be different though, as acute obstruction of a narrow duct by a small passing stone is usually painful (‘choledochal colic’), while with obstructing stones in a chronically dilated and hypokinetic CBD, symptoms tend to be ‘gradual’ or ‘minimal’—almost like the ‘silent jaundice’ of malignant obstruction.\\n\\nThe patient will tell you about his dark urine, and his loving wife about his yellow eyes, but obvious jaundice requires a bilirubin of 3 mg% (50 μmol/L) or more. The liver function tests are sensitive, with direct hyperbilirubinemia, moderately elevated transaminases, and the more specific elevated alkaline phosphatase and gamma-glutamyl transferase. Don’t be surprised to see some amylase/lipase elevation as well — the ‘common channel’ brings along many variants of combined pathology of the biliary and pancreatic systems.',\n", " 'md': 'Passing stone: mechanical blockage of the flow.\\n\\nThe presentation may be different though, as acute obstruction of a narrow duct by a small passing stone is usually painful (‘choledochal colic’), while with obstructing stones in a chronically dilated and hypokinetic CBD, symptoms tend to be ‘gradual’ or ‘minimal’—almost like the ‘silent jaundice’ of malignant obstruction.\\n\\nThe patient will tell you about his dark urine, and his loving wife about his yellow eyes, but obvious jaundice requires a bilirubin of 3 mg% (50 μmol/L) or more. The liver function tests are sensitive, with direct hyperbilirubinemia, moderately elevated transaminases, and the more specific elevated alkaline phosphatase and gamma-glutamyl transferase. Don’t be surprised to see some amylase/lipase elevation as well — the ‘common channel’ brings along many variants of combined pathology of the biliary and pancreatic systems.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management',\n", " 'md': '### Management',\n", " 'bBox': {'x': 86, 'y': 398, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As opposed to cholangitis (see next), obstructive jaundice is not a life-threatening emergency; but the patient is stressed, because of the pain, if present, and the altered appearance — with its frightening associations (“yellow patients have cancer”). The mandatory ultrasound will confirm your diagnosis (gallstones? dilated vs. collapsed gallbladder — remember Courvoisier’s sign? dilated CBD? intrahepatic dilatation? pancreatic mass?), although the sensitivity for CBD stones is not more than 50%. If no gallstones are visible in the gallbladder, you have to investigate further for peri-ampullary malignancy — and CT is your next step.\\n\\nBenign obstructive jaundice is a fluctuating condition, and spontaneous resolution is common. It usually means that the stone has passed, but not necessarily so — stones may act like a ball-valve with intermittent obstruction. In these cases, you are likely to see that normalization of the hepatic enzymes is not complete. But even if all laboratory features normalize, you should still consider specific...\\n```',\n", " 'md': 'As opposed to cholangitis (see next), obstructive jaundice is not a life-threatening emergency; but the patient is stressed, because of the pain, if present, and the altered appearance — with its frightening associations (“yellow patients have cancer”). The mandatory ultrasound will confirm your diagnosis (gallstones? dilated vs. collapsed gallbladder — remember Courvoisier’s sign? dilated CBD? intrahepatic dilatation? pancreatic mass?), although the sensitivity for CBD stones is not more than 50%. If no gallstones are visible in the gallbladder, you have to investigate further for peri-ampullary malignancy — and CT is your next step.\\n\\nBenign obstructive jaundice is a fluctuating condition, and spontaneous resolution is common. It usually means that the stone has passed, but not necessarily so — stones may act like a ball-valve with intermittent obstruction. In these cases, you are likely to see that normalization of the hepatic enzymes is not complete. But even if all laboratory features normalize, you should still consider specific...\\n```',\n", " 'bBox': {'x': 72, 'y': 187, 'w': 467.76, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 316,\n", " 'text': 'CBD imaging to rule out a CBD stone before deciding to remove the\\ngallbladder. MRCP availability has significantly increased in recent years\\nand is our preferred study, but endoscopic ultrasound (EUS) is also\\naccurate, albeit more invasive. Endoscopic retrograde\\ncholangiopancreatography (ERCP) as a diagnostic modality is not\\njustified in these cases.\\n\\n When the jaundice fails to resolve, or if your investigation proved\\nthe presence of a CBD stone — pre-operative ERCP with\\nsphincterotomy (ERCP+S) is the favoured approach in most places.\\n\\n After the CBD has been cleared, in the absence of infection, surgery\\n(laparoscopic cholecystectomy) should not be delayed too much. There\\nare some claims that pre-operative ERCP does induce some\\ninflammatory changes, which can make surgery more difficult, but we\\nhave no evidence that delaying surgery has a real advantage.\\n\\n We will not conclude without mentioning cholecystectomy with intra-\\noperative cholangiography, bile-duct exploration (transcystic if possible)\\nand stone removal. The proponents of this approach (laparoscopic, of\\ncourse), claim that this is the simplest, one-stage solution, but the fact is\\nthat the equipment and expertise required are beyond what’s commonly\\navailable, so this perfect solution is not so perfect… and thus not widely\\npracticed.\\n\\n Open CBD exploration is still a valid option but is usually saved for\\nfailed endoscopic attempts — we hope that you, or your mentors,\\nremember how to do it and are familiar with the management of T-\\ntubes…\\n\\n Acute (‘ascending’) cholangitis\\n\\n What is the source of infection in patients with\\ncholedocholithiasis? Is it really ‘ascending’ from the duodenum (which\\nis not so heavily colonized anyway)? Is it an infected stone that starts the\\nprocess? God knows… but complete obstruction, like a malignant one, is\\nprobably ‘protective’ against secondary infection until late into the',\n", " 'md': '```markdown\\n# CBD Imaging and Management\\n\\nCBD imaging is crucial to rule out a CBD stone before deciding to remove the gallbladder. MRCP availability has significantly increased in recent years and is our preferred study, but endoscopic ultrasound (EUS) is also accurate, albeit more invasive. Endoscopic retrograde cholangiopancreatography (ERCP) as a diagnostic modality is not justified in these cases.\\n\\nWhen jaundice fails to resolve, or if investigations prove the presence of a CBD stone, pre-operative ERCP with sphincterotomy (ERCP+S) is the favored approach in most places.\\n\\nAfter the CBD has been cleared, in the absence of infection, surgery (laparoscopic cholecystectomy) should not be delayed too much. There are claims that pre-operative ERCP induces some inflammatory changes, which can make surgery more difficult, but there is no evidence that delaying surgery has a real advantage.\\n\\nWe will not conclude without mentioning cholecystectomy with intra-operative cholangiography, bile-duct exploration (transcystic if possible), and stone removal. Proponents of this approach (laparoscopic, of course) claim that this is the simplest, one-stage solution, but the fact is that the equipment and expertise required are beyond what’s commonly available, so this perfect solution is not so perfect and thus not widely practiced.\\n\\nOpen CBD exploration is still a valid option but is usually saved for failed endoscopic attempts. We hope that you, or your mentors, remember how to do it and are familiar with the management of T-tubes.\\n\\n## Acute (‘Ascending’) Cholangitis\\n\\nWhat is the source of infection in patients with choledocholithiasis? Is it really ‘ascending’ from the duodenum (which is not so heavily colonized anyway)? Is it an infected stone that starts the process? God knows… but complete obstruction, like a malignant one, is probably ‘protective’ against secondary infection until late into the disease.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'CBD Imaging and Management',\n", " 'md': '# CBD Imaging and Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'CBD imaging is crucial to rule out a CBD stone before deciding to remove the gallbladder. MRCP availability has significantly increased in recent years and is our preferred study, but endoscopic ultrasound (EUS) is also accurate, albeit more invasive. Endoscopic retrograde cholangiopancreatography (ERCP) as a diagnostic modality is not justified in these cases.\\n\\nWhen jaundice fails to resolve, or if investigations prove the presence of a CBD stone, pre-operative ERCP with sphincterotomy (ERCP+S) is the favored approach in most places.\\n\\nAfter the CBD has been cleared, in the absence of infection, surgery (laparoscopic cholecystectomy) should not be delayed too much. There are claims that pre-operative ERCP induces some inflammatory changes, which can make surgery more difficult, but there is no evidence that delaying surgery has a real advantage.\\n\\nWe will not conclude without mentioning cholecystectomy with intra-operative cholangiography, bile-duct exploration (transcystic if possible), and stone removal. Proponents of this approach (laparoscopic, of course) claim that this is the simplest, one-stage solution, but the fact is that the equipment and expertise required are beyond what’s commonly available, so this perfect solution is not so perfect and thus not widely practiced.\\n\\nOpen CBD exploration is still a valid option but is usually saved for failed endoscopic attempts. We hope that you, or your mentors, remember how to do it and are familiar with the management of T-tubes.',\n", " 'md': 'CBD imaging is crucial to rule out a CBD stone before deciding to remove the gallbladder. MRCP availability has significantly increased in recent years and is our preferred study, but endoscopic ultrasound (EUS) is also accurate, albeit more invasive. Endoscopic retrograde cholangiopancreatography (ERCP) as a diagnostic modality is not justified in these cases.\\n\\nWhen jaundice fails to resolve, or if investigations prove the presence of a CBD stone, pre-operative ERCP with sphincterotomy (ERCP+S) is the favored approach in most places.\\n\\nAfter the CBD has been cleared, in the absence of infection, surgery (laparoscopic cholecystectomy) should not be delayed too much. There are claims that pre-operative ERCP induces some inflammatory changes, which can make surgery more difficult, but there is no evidence that delaying surgery has a real advantage.\\n\\nWe will not conclude without mentioning cholecystectomy with intra-operative cholangiography, bile-duct exploration (transcystic if possible), and stone removal. Proponents of this approach (laparoscopic, of course) claim that this is the simplest, one-stage solution, but the fact is that the equipment and expertise required are beyond what’s commonly available, so this perfect solution is not so perfect and thus not widely practiced.\\n\\nOpen CBD exploration is still a valid option but is usually saved for failed endoscopic attempts. We hope that you, or your mentors, remember how to do it and are familiar with the management of T-tubes.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Acute (‘Ascending’) Cholangitis',\n", " 'md': '## Acute (‘Ascending’) Cholangitis',\n", " 'bBox': {'x': 86, 'y': 601, 'w': 244.58, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'What is the source of infection in patients with choledocholithiasis? Is it really ‘ascending’ from the duodenum (which is not so heavily colonized anyway)? Is it an infected stone that starts the process? God knows… but complete obstruction, like a malignant one, is probably ‘protective’ against secondary infection until late into the disease.\\n```',\n", " 'md': 'What is the source of infection in patients with choledocholithiasis? Is it really ‘ascending’ from the duodenum (which is not so heavily colonized anyway)? Is it an infected stone that starts the process? God knows… but complete obstruction, like a malignant one, is probably ‘protective’ against secondary infection until late into the disease.\\n```',\n", " 'bBox': {'x': 72, 'y': 637, 'w': 467.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 317,\n", " 'text': 'disease process. Biliary intervention is probably the most common\\ncause of cholangitis, and once bacteria are introduced into the\\nsystem, the risk of recurrent infection is high until the problem is\\nsolved.\\n\\n The most important underlying factor is bile stasis, and the most\\nimportant element of the treatment is restoring the bile flow. Without it —\\nductal pressure will rise, and the risk of bacterial translocation from the\\nbile to the blood increases, resulting in bacteremia and sepsis.\\n\\n You are probably familiar with Charcot’s triad (Jean Martin Charcot of\\nParis, 1825-1893 — Figure 20.4):\\n\\n • Right upper quadrant (RUQ) pain.\\n • Fever (and rigors).\\n • Jaundice.\\n Add to that the two other elements — confusion and septic shock —\\nand you get Reynold’s pentad, which is associated with markedly\\nincreased mortality, and should make you move faster. Significant\\nleukocytosis (or even worse — leukopenia), and evidence of organ failure\\n(lungs, kidneys, liver) signifies rapid deterioration and mandates\\naggressive treatment.\\n\\n Management\\n\\n You already know how to diagnose jaundice in the laboratory, but\\nplease don’t forget to obtain blood cultures as well.\\n\\n The treatment comprises:\\n\\n • Fluid resuscitation and hemodynamic monitoring (and support, if\\n needed).\\n • Antibiotic treatment.',\n", " 'md': '```markdown\\n## Cholangitis and Management\\n\\nBiliary intervention is probably the most common cause of cholangitis, and once bacteria are introduced into the system, the risk of recurrent infection is high until the problem is solved.\\n\\nThe most important underlying factor is bile stasis, and the most important element of the treatment is restoring the bile flow. Without it, ductal pressure will rise, and the risk of bacterial translocation from the bile to the blood increases, resulting in bacteremia and sepsis.\\n\\nYou are probably familiar with Charcot’s triad (Jean Martin Charcot of Paris, 1825-1893 — Figure 20.4):\\n\\n- Right upper quadrant (RUQ) pain.\\n- Fever (and rigors).\\n- Jaundice.\\n\\nAdd to that the two other elements — confusion and septic shock — and you get Reynold’s pentad, which is associated with markedly increased mortality, and should make you move faster. Significant leukocytosis (or even worse — leukopenia), and evidence of organ failure (lungs, kidneys, liver) signifies rapid deterioration and mandates aggressive treatment.\\n\\n### Management\\n\\nYou already know how to diagnose jaundice in the laboratory, but please don’t forget to obtain blood cultures as well.\\n\\nThe treatment comprises:\\n\\n- Fluid resuscitation and hemodynamic monitoring (and support, if needed).\\n- Antibiotic treatment.\\n```\\n\\n### Figure Description\\n**Figure 20.4**: Charcot’s triad, which includes the symptoms of cholangitis: right upper quadrant pain, fever, and jaundice. This figure is crucial for understanding the clinical presentation of the disease.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Cholangitis and Management',\n", " 'md': '## Cholangitis and Management',\n", " 'bBox': {'x': 86, 'y': 536, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Biliary intervention is probably the most common cause of cholangitis, and once bacteria are introduced into the system, the risk of recurrent infection is high until the problem is solved.\\n\\nThe most important underlying factor is bile stasis, and the most important element of the treatment is restoring the bile flow. Without it, ductal pressure will rise, and the risk of bacterial translocation from the bile to the blood increases, resulting in bacteremia and sepsis.\\n\\nYou are probably familiar with Charcot’s triad (Jean Martin Charcot of Paris, 1825-1893 — Figure 20.4):\\n\\n- Right upper quadrant (RUQ) pain.\\n- Fever (and rigors).\\n- Jaundice.\\n\\nAdd to that the two other elements — confusion and septic shock — and you get Reynold’s pentad, which is associated with markedly increased mortality, and should make you move faster. Significant leukocytosis (or even worse — leukopenia), and evidence of organ failure (lungs, kidneys, liver) signifies rapid deterioration and mandates aggressive treatment.',\n", " 'md': 'Biliary intervention is probably the most common cause of cholangitis, and once bacteria are introduced into the system, the risk of recurrent infection is high until the problem is solved.\\n\\nThe most important underlying factor is bile stasis, and the most important element of the treatment is restoring the bile flow. Without it, ductal pressure will rise, and the risk of bacterial translocation from the bile to the blood increases, resulting in bacteremia and sepsis.\\n\\nYou are probably familiar with Charcot’s triad (Jean Martin Charcot of Paris, 1825-1893 — Figure 20.4):\\n\\n- Right upper quadrant (RUQ) pain.\\n- Fever (and rigors).\\n- Jaundice.\\n\\nAdd to that the two other elements — confusion and septic shock — and you get Reynold’s pentad, which is associated with markedly increased mortality, and should make you move faster. Significant leukocytosis (or even worse — leukopenia), and evidence of organ failure (lungs, kidneys, liver) signifies rapid deterioration and mandates aggressive treatment.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management',\n", " 'md': '### Management',\n", " 'bBox': {'x': 86, 'y': 536, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'You already know how to diagnose jaundice in the laboratory, but please don’t forget to obtain blood cultures as well.\\n\\nThe treatment comprises:\\n\\n- Fluid resuscitation and hemodynamic monitoring (and support, if needed).\\n- Antibiotic treatment.\\n```',\n", " 'md': 'You already know how to diagnose jaundice in the laboratory, but please don’t forget to obtain blood cultures as well.\\n\\nThe treatment comprises:\\n\\n- Fluid resuscitation and hemodynamic monitoring (and support, if needed).\\n- Antibiotic treatment.\\n```',\n", " 'bBox': {'x': 72, 'y': 589, 'w': 323.03, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Description',\n", " 'md': '### Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 20.4**: Charcot’s triad, which includes the symptoms of cholangitis: right upper quadrant pain, fever, and jaundice. This figure is crucial for understanding the clinical presentation of the disease.',\n", " 'md': '**Figure 20.4**: Charcot’s triad, which includes the symptoms of cholangitis: right upper quadrant pain, fever, and jaundice. This figure is crucial for understanding the clinical presentation of the disease.',\n", " 'bBox': {'x': 100, 'y': 364, 'w': 61.59, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 318,\n", " 'text': ' • Unplugging the duct.\\n The antibiotic treatment, started empirically, should cover enteric\\nGram-negative bacteria (typically E. coli and Klebsiella), and probably,\\nespecially in elderly patients, also anaerobes, which will grow in up to\\n20% of the cultures. In most cases of acute cholangitis there will be a\\nrelatively prompt response, with defervescence within 24 hours.\\nTherefore, interventional therapies should be used selectively, and saved\\nfor patients with persistent septic signs, deterioration of lab results\\n(increasing bilirubin), and diagnosis of non-resolving biliary obstruction.\\nOnly in a handful of patients, presenting in septic shock as a result\\nof pyogenic bile, is emergency ERCP+S at presentation justified.\\nMake sure that the extreme condition is not the result of an associated\\ncondition, like gangrenous cholecystitis.\\n aT\\n Der(A\\nFigure 20.4. “Oh the urine is dark… what do you call that triad? Charcoal triad?”\\n\\n ERCP+S is the modality of choice for biliary drainage. If possible\\nthe obstructing stone should be removed after sphincterotomy, but in a\\nseptic patient a shorter drainage procedure may suffice, by inserting a',\n", " 'md': '```markdown\\n## Page Content\\n\\n- Unplugging the duct.\\n- The antibiotic treatment, started empirically, should cover enteric Gram-negative bacteria (typically E. coli and Klebsiella), and probably, especially in elderly patients, also anaerobes, which will grow in up to 20% of the cultures. In most cases of acute cholangitis there will be a relatively prompt response, with defervescence within 24 hours. Therefore, interventional therapies should be used selectively, and saved for patients with persistent septic signs, deterioration of lab results (increasing bilirubin), and diagnosis of non-resolving biliary obstruction. Only in a handful of patients, presenting in septic shock as a result of pyogenic bile, is emergency ERCP+S at presentation justified. Make sure that the extreme condition is not the result of an associated condition, like gangrenous cholecystitis.\\n\\n### Figure 20.4\\n- **Caption**: “Oh the urine is dark… what do you call that triad? Charcoal triad?”\\n- **Description**: This figure likely illustrates the clinical signs associated with a specific condition, possibly related to cholangitis or another biliary issue. The term \"Charcoal triad\" suggests a focus on symptoms that may include dark urine, which is indicative of certain types of liver or biliary dysfunction. The exact graphical content is not identifiable from the text provided.\\n\\n### Additional Information\\n- ERCP+S is the modality of choice for biliary drainage. If possible, the obstructing stone should be removed after sphincterotomy, but in a septic patient, a shorter drainage procedure may suffice, by inserting a...\\n```',\n", " 'images': [{'name': 'img_p317_1.png',\n", " 'height': 579,\n", " 'width': 812,\n", " 'x': 105.11999999999898,\n", " 'y': 326.16,\n", " 'original_width': 1395,\n", " 'original_height': 994}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Unplugging the duct.\\n- The antibiotic treatment, started empirically, should cover enteric Gram-negative bacteria (typically E. coli and Klebsiella), and probably, especially in elderly patients, also anaerobes, which will grow in up to 20% of the cultures. In most cases of acute cholangitis there will be a relatively prompt response, with defervescence within 24 hours. Therefore, interventional therapies should be used selectively, and saved for patients with persistent septic signs, deterioration of lab results (increasing bilirubin), and diagnosis of non-resolving biliary obstruction. Only in a handful of patients, presenting in septic shock as a result of pyogenic bile, is emergency ERCP+S at presentation justified. Make sure that the extreme condition is not the result of an associated condition, like gangrenous cholecystitis.',\n", " 'md': '- Unplugging the duct.\\n- The antibiotic treatment, started empirically, should cover enteric Gram-negative bacteria (typically E. coli and Klebsiella), and probably, especially in elderly patients, also anaerobes, which will grow in up to 20% of the cultures. In most cases of acute cholangitis there will be a relatively prompt response, with defervescence within 24 hours. Therefore, interventional therapies should be used selectively, and saved for patients with persistent septic signs, deterioration of lab results (increasing bilirubin), and diagnosis of non-resolving biliary obstruction. Only in a handful of patients, presenting in septic shock as a result of pyogenic bile, is emergency ERCP+S at presentation justified. Make sure that the extreme condition is not the result of an associated condition, like gangrenous cholecystitis.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.92, 'h': 29.7}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 20.4',\n", " 'md': '### Figure 20.4',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Caption**: “Oh the urine is dark… what do you call that triad? Charcoal triad?”\\n- **Description**: This figure likely illustrates the clinical signs associated with a specific condition, possibly related to cholangitis or another biliary issue. The term \"Charcoal triad\" suggests a focus on symptoms that may include dark urine, which is indicative of certain types of liver or biliary dysfunction. The exact graphical content is not identifiable from the text provided.',\n", " 'md': '- **Caption**: “Oh the urine is dark… what do you call that triad? Charcoal triad?”\\n- **Description**: This figure likely illustrates the clinical signs associated with a specific condition, possibly related to cholangitis or another biliary issue. The term \"Charcoal triad\" suggests a focus on symptoms that may include dark urine, which is indicative of certain types of liver or biliary dysfunction. The exact graphical content is not identifiable from the text provided.',\n", " 'bBox': {'x': 154.1, 'y': 338.53, 'w': 45.52, 'h': 29.7}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Additional Information',\n", " 'md': '### Additional Information',\n", " 'bBox': {'x': 154.1, 'y': 338.53, 'w': 45.52, 'h': 29.7}},\n", " {'type': 'text',\n", " 'value': '- ERCP+S is the modality of choice for biliary drainage. If possible, the obstructing stone should be removed after sphincterotomy, but in a septic patient, a shorter drainage procedure may suffice, by inserting a...\\n```',\n", " 'md': '- ERCP+S is the modality of choice for biliary drainage. If possible, the obstructing stone should be removed after sphincterotomy, but in a septic patient, a shorter drainage procedure may suffice, by inserting a...\\n```',\n", " 'bBox': {'x': 154.1, 'y': 338.53, 'w': 45.52, 'h': 29.7}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 319,\n", " 'text': 'plastic stent.\\n\\n Failed or impossible ERCP (a gastric bypass patient, for example),\\nwill mandate an alternative procedure, like percutaneous transhepatic\\ndrainage. If the gallbladder is distended, a percutaneous\\ncholecystostomy may drain the CBD as well.\\n\\n Surgical solutions, as in obstructive jaundice, should be on an\\nelective basis, after solving the acute condition, except in rare conditions\\nthat mandate emergency surgery, like gallbladder perforation. Taking a\\nseptic patient for an emergency exploration of the CBD is a rare event\\nnowadays, but if deemed necessary (e.g. failed ERCP+S to remove large\\nCBD stones or an impacted Dormia® basket) — it should be kept to the\\nminimal possible — like a choledochotomy and T-tube insertion. Forget\\nabout complex biliary anastomoses in a septic patient.\\n\\n Biliary pancreatitis\\n3 B. Ramana\\n You can read about acute pancreatitis in general in Chapter 19.\\nHere we’ll focus on the approach to patients with gallstone\\npancreatitis.\\n\\n You should suspect gallstone pancreatitis in patients who present with\\nacute pancreatitis and are found (on US) to harbor stones in the\\ngallbladder. Suspect it also in non-alcoholic patients even if stones are\\nnot visualized as occasionally ‘idiopathic acute pancreatitis’ is caused by\\ntiny gallbladder stones or sludge (microlithiasis).\\n\\n Commonly, in addition to the elevated pancreatic enzymes, there is\\nsome degree of chemical liver dysfunction (similar to that described\\nabove in patients with ascending cholangitis). It is believed that biliary\\npancreatitis is caused by small stones dropping into the CBD from\\nthe gallbladder, and migrating distally through the papilla. More than\\n30 years ago Dr. John Acosta established his name in the ħall of Fame\\nof surgery by sifting through the feces of patients with suspected\\ngallstone pancreatitis, finding small stones in their feces within 10 days of',\n", " 'md': '```markdown\\n## Biliary Pancreatitis\\n\\nYou can read about acute pancreatitis in general in [Chapter 19](#). Here we’ll focus on the approach to patients with gallstone pancreatitis.\\n\\nYou should suspect gallstone pancreatitis in patients who present with acute pancreatitis and are found (on US) to harbor stones in the gallbladder. Suspect it also in non-alcoholic patients even if stones are not visualized as occasionally ‘idiopathic acute pancreatitis’ is caused by tiny gallbladder stones or sludge (microlithiasis).\\n\\nCommonly, in addition to the elevated pancreatic enzymes, there is some degree of chemical liver dysfunction (similar to that described above in patients with ascending cholangitis). It is believed that biliary pancreatitis is caused by small stones dropping into the CBD from the gallbladder, and migrating distally through the papilla. More than 30 years ago Dr. John Acosta established his name in the Hall of Fame of surgery by sifting through the feces of patients with suspected gallstone pancreatitis, finding small stones in their feces within 10 days of .\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Biliary Pancreatitis',\n", " 'md': '## Biliary Pancreatitis',\n", " 'bBox': {'x': 100, 'y': 362, 'w': 148.04, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'You can read about acute pancreatitis in general in [Chapter 19](#). Here we’ll focus on the approach to patients with gallstone pancreatitis.\\n\\nYou should suspect gallstone pancreatitis in patients who present with acute pancreatitis and are found (on US) to harbor stones in the gallbladder. Suspect it also in non-alcoholic patients even if stones are not visualized as occasionally ‘idiopathic acute pancreatitis’ is caused by tiny gallbladder stones or sludge (microlithiasis).\\n\\nCommonly, in addition to the elevated pancreatic enzymes, there is some degree of chemical liver dysfunction (similar to that described above in patients with ascending cholangitis). It is believed that biliary pancreatitis is caused by small stones dropping into the CBD from the gallbladder, and migrating distally through the papilla. More than 30 years ago Dr. John Acosta established his name in the Hall of Fame of surgery by sifting through the feces of patients with suspected gallstone pancreatitis, finding small stones in their feces within 10 days of .\\n```',\n", " 'md': 'You can read about acute pancreatitis in general in [Chapter 19](#). Here we’ll focus on the approach to patients with gallstone pancreatitis.\\n\\nYou should suspect gallstone pancreatitis in patients who present with acute pancreatitis and are found (on US) to harbor stones in the gallbladder. Suspect it also in non-alcoholic patients even if stones are not visualized as occasionally ‘idiopathic acute pancreatitis’ is caused by tiny gallbladder stones or sludge (microlithiasis).\\n\\nCommonly, in addition to the elevated pancreatic enzymes, there is some degree of chemical liver dysfunction (similar to that described above in patients with ascending cholangitis). It is believed that biliary pancreatitis is caused by small stones dropping into the CBD from the gallbladder, and migrating distally through the papilla. More than 30 years ago Dr. John Acosta established his name in the Hall of Fame of surgery by sifting through the feces of patients with suspected gallstone pancreatitis, finding small stones in their feces within 10 days of .\\n```',\n", " 'bBox': {'x': 72, 'y': 154, 'w': 467.99, 'h': 28.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Here we’ll focus on the approach to patients with gallstone'}]},\n", " {'page': 320,\n", " 'text': 'their admission ( Figure 20.5). In those patients who underwent a\\nlaparotomy, within 48 hours impacted stones in the papilla were found in\\nmore than two-thirds of individuals (and the morbidity/mortality was high);\\nin those who underwent a delayed operation no impacted stones were\\nfound and the M & M was minimal. From John Acosta (and the other\\nstool strainers who duplicated his findings and added more information)\\nwe learned:\\n\\n • The vast majority of CBD stones responsible for pancreatitis pass\\n spontaneously.\\n • Most of the so-called ‘impacted stones’ will pass into the duodenum\\n if you wait long enough.\\n • In most such patients pre-operative ERCP is negative for bile duct\\n stones.\\n • In most such patients (intra-operative) cholangiography during LC is\\n normal.\\n • Sifting through patients’ feces may change your life and make you\\n famous!\\n\\n This has taught us how to manage these patients…',\n", " 'md': '```markdown\\n## Page Content\\n\\nIn those patients who underwent a laparotomy, within 48 hours impacted stones in the papilla were found in more than two-thirds of individuals (and the morbidity/mortality was high); in those who underwent a delayed operation no impacted stones were found and the morbidity and mortality was minimal. From John Acosta (and the other stool strainers who duplicated his findings and added more information) we learned:\\n\\n- The vast majority of CBD stones responsible for pancreatitis pass spontaneously.\\n- Most of the so-called ‘impacted stones’ will pass into the duodenum if you wait long enough.\\n- In most such patients pre-operative ERCP is negative for bile duct stones.\\n- In most such patients (intra-operative) cholangiography during LC is normal.\\n- Sifting through patients’ feces may change your life and make you famous!\\n\\nThis has taught us how to manage these patients…\\n\\n### Figures\\n\\n**Figure 20.5**: This figure is referenced in the text but not described in the extracted content. Further details about the figure are needed to provide a complete description.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In those patients who underwent a laparotomy, within 48 hours impacted stones in the papilla were found in more than two-thirds of individuals (and the morbidity/mortality was high); in those who underwent a delayed operation no impacted stones were found and the morbidity and mortality was minimal. From John Acosta (and the other stool strainers who duplicated his findings and added more information) we learned:\\n\\n- The vast majority of CBD stones responsible for pancreatitis pass spontaneously.\\n- Most of the so-called ‘impacted stones’ will pass into the duodenum if you wait long enough.\\n- In most such patients pre-operative ERCP is negative for bile duct stones.\\n- In most such patients (intra-operative) cholangiography during LC is normal.\\n- Sifting through patients’ feces may change your life and make you famous!\\n\\nThis has taught us how to manage these patients…',\n", " 'md': 'In those patients who underwent a laparotomy, within 48 hours impacted stones in the papilla were found in more than two-thirds of individuals (and the morbidity/mortality was high); in those who underwent a delayed operation no impacted stones were found and the morbidity and mortality was minimal. From John Acosta (and the other stool strainers who duplicated his findings and added more information) we learned:\\n\\n- The vast majority of CBD stones responsible for pancreatitis pass spontaneously.\\n- Most of the so-called ‘impacted stones’ will pass into the duodenum if you wait long enough.\\n- In most such patients pre-operative ERCP is negative for bile duct stones.\\n- In most such patients (intra-operative) cholangiography during LC is normal.\\n- Sifting through patients’ feces may change your life and make you famous!\\n\\nThis has taught us how to manage these patients…',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.48, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 20.5**: This figure is referenced in the text but not described in the extracted content. Further details about the figure are needed to provide a complete description.\\n```',\n", " 'md': '**Figure 20.5**: This figure is referenced in the text but not described in the extracted content. Further details about the figure are needed to provide a complete description.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'laparotomy, within 48 hours impacted stones in the papilla were found in'}]},\n", " {'page': 321,\n", " 'text': ' LAB Re SULES\\n LiPA SE 25C\\n AMylase 89\\n BiLirvbin 2,5_\\n PeryA2014\\nFigure 20.5. “Eureka, we found it!”\\n\\n Start conservative treatment as described in Chapter 19. In most\\npatients resolution of the clinical features of pancreatitis occurs within a\\nfew days and is marked by normalization of white cell count and\\npancreatic and liver enzymes. It is then — within a week or so — that you\\nwant to go ahead with laparoscopic cholecystectomy — preventing\\nrecurrent biliary pancreatitis by removing the source of the problem.\\nThere is no need to wait longer — once signs of pancreatic inflammation\\nhave subsided and chemical cholestasis is improving — you can safely\\ngo ahead with surgery. The aim should be to perform\\ncholecystectomy during the same hospital admission as the\\nepisode of pancreatitis.\\n\\n What about ‘suspected’ CBD stones? How can you be sure that\\nthey have indeed migrated into the duodenum?\\n\\n • If the CBD is not dilated on US and liver enzymes are back to\\n normal there is no need for any pre-operative imaging of the CBD.',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Laboratory Results\\n- **LiPA SE**: 25C\\n- **Amylase**: 89\\n- **Bilirubin**: 2.5\\n\\n*Source: PeryA2014*\\n\\n## Figure 20.5\\n**Caption**: “Eureka, we found it!”\\n\\n## Clinical Management\\nStart conservative treatment as described in Chapter 19. In most patients, resolution of the clinical features of pancreatitis occurs within a few days and is marked by normalization of white cell count and pancreatic and liver enzymes. It is then — within a week or so — that you want to go ahead with laparoscopic cholecystectomy — preventing recurrent biliary pancreatitis by removing the source of the problem. There is no need to wait longer — once signs of pancreatic inflammation have subsided and chemical cholestasis is improving — you can safely go ahead with surgery. The aim should be to perform cholecystectomy during the same hospital admission as the episode of pancreatitis.\\n\\n## Suspected CBD Stones\\nWhat about ‘suspected’ CBD stones? How can you be sure that they have indeed migrated into the duodenum?\\n\\n- If the CBD is not dilated on US and liver enzymes are back to normal, there is no need for any pre-operative imaging of the CBD.\\n```\\n\\n### Image Description\\n- **Figure 20.5**: The image titled “Eureka, we found it!” is referenced but not described in detail. It likely illustrates a significant finding related to the clinical context discussed. Further details about the image content are not provided in the text.',\n", " 'images': [{'name': 'img_p320_1.png',\n", " 'height': 578,\n", " 'width': 814,\n", " 'x': 105.11999999999898,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1398,\n", " 'original_height': 994}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Laboratory Results',\n", " 'md': '## Laboratory Results',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **LiPA SE**: 25C\\n- **Amylase**: 89\\n- **Bilirubin**: 2.5\\n\\n*Source: PeryA2014*',\n", " 'md': '- **LiPA SE**: 25C\\n- **Amylase**: 89\\n- **Bilirubin**: 2.5\\n\\n*Source: PeryA2014*',\n", " 'bBox': {'x': 176.32, 'y': 100.11, 'w': 39.56, 'h': 18.79}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 20.5',\n", " 'md': '## Figure 20.5',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption**: “Eureka, we found it!”',\n", " 'md': '**Caption**: “Eureka, we found it!”',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Management',\n", " 'md': '## Clinical Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Start conservative treatment as described in Chapter 19. In most patients, resolution of the clinical features of pancreatitis occurs within a few days and is marked by normalization of white cell count and pancreatic and liver enzymes. It is then — within a week or so — that you want to go ahead with laparoscopic cholecystectomy — preventing recurrent biliary pancreatitis by removing the source of the problem. There is no need to wait longer — once signs of pancreatic inflammation have subsided and chemical cholestasis is improving — you can safely go ahead with surgery. The aim should be to perform cholecystectomy during the same hospital admission as the episode of pancreatitis.',\n", " 'md': 'Start conservative treatment as described in Chapter 19. In most patients, resolution of the clinical features of pancreatitis occurs within a few days and is marked by normalization of white cell count and pancreatic and liver enzymes. It is then — within a week or so — that you want to go ahead with laparoscopic cholecystectomy — preventing recurrent biliary pancreatitis by removing the source of the problem. There is no need to wait longer — once signs of pancreatic inflammation have subsided and chemical cholestasis is improving — you can safely go ahead with surgery. The aim should be to perform cholecystectomy during the same hospital admission as the episode of pancreatitis.',\n", " 'bBox': {'x': 72, 'y': 485, 'w': 467.76, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Suspected CBD Stones',\n", " 'md': '## Suspected CBD Stones',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'What about ‘suspected’ CBD stones? How can you be sure that they have indeed migrated into the duodenum?\\n\\n- If the CBD is not dilated on US and liver enzymes are back to normal, there is no need for any pre-operative imaging of the CBD.\\n```',\n", " 'md': 'What about ‘suspected’ CBD stones? How can you be sure that they have indeed migrated into the duodenum?\\n\\n- If the CBD is not dilated on US and liver enzymes are back to normal, there is no need for any pre-operative imaging of the CBD.\\n```',\n", " 'bBox': {'x': 72, 'y': 568, 'w': 323.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 20.5**: The image titled “Eureka, we found it!” is referenced but not described in detail. It likely illustrates a significant finding related to the clinical context discussed. Further details about the image content are not provided in the text.',\n", " 'md': '- **Figure 20.5**: The image titled “Eureka, we found it!” is referenced but not described in detail. It likely illustrates a significant finding related to the clinical context discussed. Further details about the image content are not provided in the text.',\n", " 'bBox': {'x': 272, 'y': 568, 'w': 29.57, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'patients resolution of the clinical features of pancreatitis occurs within a'}]},\n", " {'page': 322,\n", " 'text': ' Adding a routine intra-operative cholangiogram in this situation is\\n controversial. Cholangiography may indeed demonstrate small\\n stones, but stones which would pass spontaneously in most\\n instances.\\n • If the CBD is dilated and liver function is deteriorating you have\\n to suspect impacted CBD stones (often associated with cholangitis).\\n An urgent therapeutic ERCP may be needed and, if successful,\\n followed a day or so later by LC. Whether an early endoscopic\\n sphincterotomy to remove an impacted stone is beneficial in\\n aborting the episode of acute pancreatitis is controversial. Some\\n claim it is — if performed early enough (within a few hours…) — but\\n try and find a center where patients undergo ERCP within a few\\n hours after their pains have started?!\\n • Nowadays, MRCP is a good option, selecting which patients need\\n to undergo invasive ERCP before cholecystectomy. If normal you\\n can proceed with LC.\\n\\n What to do with patients with complicated acute pancreatitis? You\\nsurely do not want to operate on them. Treat conservatively as\\ndescribed in Chapter 19. Delay the cholecystectomy until pancreatitis\\nand its complications are resolved.\\n\\n What to do with patients who are not fit for LC? Clearly, you do not\\nhave to rush with LC in medically unfit patients. Let them recuperate from\\nthe acute disease and try to improve their general condition before\\nproceeding with cholecystectomy. Do note, however, that some patients\\nmay suffer recurrent acute pancreatitis during the waiting period.\\nAnother option (as in high-risk patients with cholangitis) is ERCP+S\\n— leaving the gallbladder in situ. Now the stones can enter the CBD\\nand rapidly fall into the duodenum without producing pancreatitis. This is\\na viable option on the very old, frail and medically unfit and it has been\\nshown to reduce the risk of recurrent acute pancreatitis.\\n\\n In short: in most patients let the pancreatic inflammation subside, wait for the CBD stones\\n to pass spontaneously and then remove the gallbladder. Some patients need bile duct imaging\\n and possibly ERCP and sphincterotomy. In a few patients you will have to wait longer for the',\n", " 'md': '```markdown\\n# Management of Complicated Acute Pancreatitis\\n\\nAdding a routine intra-operative cholangiogram in this situation is controversial. Cholangiography may indeed demonstrate small stones, but stones which would pass spontaneously in most instances.\\n\\n- If the CBD is dilated and liver function is deteriorating, you have to suspect impacted CBD stones (often associated with cholangitis). An urgent therapeutic ERCP may be needed and, if successful, followed a day or so later by LC. Whether an early endoscopic sphincterotomy to remove an impacted stone is beneficial in aborting the episode of acute pancreatitis is controversial. Some claim it is — if performed early enough (within a few hours…) — but try and find a center where patients undergo ERCP within a few hours after their pains have started?!\\n\\n- Nowadays, MRCP is a good option, selecting which patients need to undergo invasive ERCP before cholecystectomy. If normal, you can proceed with LC.\\n\\n## What to do with patients with complicated acute pancreatitis?\\n\\nYou surely do not want to operate on them. Treat conservatively as described in Chapter 19. Delay the cholecystectomy until pancreatitis and its complications are resolved.\\n\\n## What to do with patients who are not fit for LC?\\n\\nClearly, you do not have to rush with LC in medically unfit patients. Let them recuperate from the acute disease and try to improve their general condition before proceeding with cholecystectomy. Do note, however, that some patients may suffer recurrent acute pancreatitis during the waiting period.\\n\\nAnother option (as in high-risk patients with cholangitis) is ERCP+S — leaving the gallbladder in situ. Now the stones can enter the CBD and rapidly fall into the duodenum without producing pancreatitis. This is a viable option on the very old, frail, and medically unfit and it has been shown to reduce the risk of recurrent acute pancreatitis.\\n\\nIn short: in most patients let the pancreatic inflammation subside, wait for the CBD stones to pass spontaneously and then remove the gallbladder. Some patients need bile duct imaging and possibly ERCP and sphincterotomy. In a few patients, you will have to wait longer for the procedure.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management of Complicated Acute Pancreatitis',\n", " 'md': '# Management of Complicated Acute Pancreatitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Adding a routine intra-operative cholangiogram in this situation is controversial. Cholangiography may indeed demonstrate small stones, but stones which would pass spontaneously in most instances.\\n\\n- If the CBD is dilated and liver function is deteriorating, you have to suspect impacted CBD stones (often associated with cholangitis). An urgent therapeutic ERCP may be needed and, if successful, followed a day or so later by LC. Whether an early endoscopic sphincterotomy to remove an impacted stone is beneficial in aborting the episode of acute pancreatitis is controversial. Some claim it is — if performed early enough (within a few hours…) — but try and find a center where patients undergo ERCP within a few hours after their pains have started?!\\n\\n- Nowadays, MRCP is a good option, selecting which patients need to undergo invasive ERCP before cholecystectomy. If normal, you can proceed with LC.',\n", " 'md': 'Adding a routine intra-operative cholangiogram in this situation is controversial. Cholangiography may indeed demonstrate small stones, but stones which would pass spontaneously in most instances.\\n\\n- If the CBD is dilated and liver function is deteriorating, you have to suspect impacted CBD stones (often associated with cholangitis). An urgent therapeutic ERCP may be needed and, if successful, followed a day or so later by LC. Whether an early endoscopic sphincterotomy to remove an impacted stone is beneficial in aborting the episode of acute pancreatitis is controversial. Some claim it is — if performed early enough (within a few hours…) — but try and find a center where patients undergo ERCP within a few hours after their pains have started?!\\n\\n- Nowadays, MRCP is a good option, selecting which patients need to undergo invasive ERCP before cholecystectomy. If normal, you can proceed with LC.',\n", " 'bBox': {'x': 100, 'y': 135, 'w': 437.08, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'What to do with patients with complicated acute pancreatitis?',\n", " 'md': '## What to do with patients with complicated acute pancreatitis?',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'You surely do not want to operate on them. Treat conservatively as described in Chapter 19. Delay the cholecystectomy until pancreatitis and its complications are resolved.',\n", " 'md': 'You surely do not want to operate on them. Treat conservatively as described in Chapter 19. Delay the cholecystectomy until pancreatitis and its complications are resolved.',\n", " 'bBox': {'x': 72, 'y': 410, 'w': 370.86, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'What to do with patients who are not fit for LC?',\n", " 'md': '## What to do with patients who are not fit for LC?',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Clearly, you do not have to rush with LC in medically unfit patients. Let them recuperate from the acute disease and try to improve their general condition before proceeding with cholecystectomy. Do note, however, that some patients may suffer recurrent acute pancreatitis during the waiting period.\\n\\nAnother option (as in high-risk patients with cholangitis) is ERCP+S — leaving the gallbladder in situ. Now the stones can enter the CBD and rapidly fall into the duodenum without producing pancreatitis. This is a viable option on the very old, frail, and medically unfit and it has been shown to reduce the risk of recurrent acute pancreatitis.\\n\\nIn short: in most patients let the pancreatic inflammation subside, wait for the CBD stones to pass spontaneously and then remove the gallbladder. Some patients need bile duct imaging and possibly ERCP and sphincterotomy. In a few patients, you will have to wait longer for the procedure.\\n```',\n", " 'md': 'Clearly, you do not have to rush with LC in medically unfit patients. Let them recuperate from the acute disease and try to improve their general condition before proceeding with cholecystectomy. Do note, however, that some patients may suffer recurrent acute pancreatitis during the waiting period.\\n\\nAnother option (as in high-risk patients with cholangitis) is ERCP+S — leaving the gallbladder in situ. Now the stones can enter the CBD and rapidly fall into the duodenum without producing pancreatitis. This is a viable option on the very old, frail, and medically unfit and it has been shown to reduce the risk of recurrent acute pancreatitis.\\n\\nIn short: in most patients let the pancreatic inflammation subside, wait for the CBD stones to pass spontaneously and then remove the gallbladder. Some patients need bile duct imaging and possibly ERCP and sphincterotomy. In a few patients, you will have to wait longer for the procedure.\\n```',\n", " 'bBox': {'x': 72, 'y': 479, 'w': 467.66, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'and its complications are resolved.'}]},\n", " {'page': 323,\n", " 'text': ' acute pancreatitis to resolve.\\n\\n So this is the end of the long spiel. You surely understand that there\\nare many ways to catch the fish and one has to find the best option for\\nthe specific case scenario. This is what we did while writing the chapter\\n— debating the optimal approach…( Figure 20.6).\\n\\nFigure 20.6. Danny and Moshe in a typical biliary debate (with Pushkin snoozing on the\\nstairs).\\n\\n “The most important aim in this operation is to not injure\\n the CBD, the second most important aim is to relieve any\\n sepsis. The third — if it can be done safely — is to\\n remove the gallbladder.”\\n Kristoffer Lassen',\n", " 'md': \"```markdown\\n## Text\\nAcute pancreatitis to resolve.\\n\\nSo this is the end of the long spiel. You surely understand that there are many ways to catch the fish and one has to find the best option for the specific case scenario. This is what we did while writing the chapter — debating the optimal approach…(Figure 20.6).\\n\\n“The most important aim in this operation is to not injure the CBD, the second most important aim is to relieve any sepsis. The third — if it can be done safely — is to remove the gallbladder.”\\n— Kristoffer Lassen\\n\\n## Images\\n### Figure 20.6\\n**Description:** This image depicts Danny and Moshe engaged in a typical biliary debate, with Pushkin snoozing on the stairs. The scene captures a moment of discussion, likely related to medical or surgical topics concerning biliary issues.\\n\\n**Summary:** The image illustrates a casual yet focused debate between two individuals, highlighting the importance of dialogue in medical decision-making. Pushkin's presence adds a light-hearted touch to the serious nature of the discussion.\\n\\n```\",\n", " 'images': [{'name': 'img_p322_1.png',\n", " 'height': 578,\n", " 'width': 800,\n", " 'x': 108,\n", " 'y': 194.40000000000003,\n", " 'original_width': 1376,\n", " 'original_height': 992}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Acute pancreatitis to resolve.\\n\\nSo this is the end of the long spiel. You surely understand that there are many ways to catch the fish and one has to find the best option for the specific case scenario. This is what we did while writing the chapter — debating the optimal approach…(Figure 20.6).\\n\\n“The most important aim in this operation is to not injure the CBD, the second most important aim is to relieve any sepsis. The third — if it can be done safely — is to remove the gallbladder.”\\n— Kristoffer Lassen',\n", " 'md': 'Acute pancreatitis to resolve.\\n\\nSo this is the end of the long spiel. You surely understand that there are many ways to catch the fish and one has to find the best option for the specific case scenario. This is what we did while writing the chapter — debating the optimal approach…(Figure 20.6).\\n\\n“The most important aim in this operation is to not injure the CBD, the second most important aim is to relieve any sepsis. The third — if it can be done safely — is to remove the gallbladder.”\\n— Kristoffer Lassen',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.83, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 20.6',\n", " 'md': '### Figure 20.6',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"**Description:** This image depicts Danny and Moshe engaged in a typical biliary debate, with Pushkin snoozing on the stairs. The scene captures a moment of discussion, likely related to medical or surgical topics concerning biliary issues.\\n\\n**Summary:** The image illustrates a casual yet focused debate between two individuals, highlighting the importance of dialogue in medical decision-making. Pushkin's presence adds a light-hearted touch to the serious nature of the discussion.\\n\\n```\",\n", " 'md': \"**Description:** This image depicts Danny and Moshe engaged in a typical biliary debate, with Pushkin snoozing on the stairs. The scene captures a moment of discussion, likely related to medical or surgical topics concerning biliary issues.\\n\\n**Summary:** The image illustrates a casual yet focused debate between two individuals, highlighting the importance of dialogue in medical decision-making. Pushkin's presence adds a light-hearted touch to the serious nature of the discussion.\\n\\n```\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 324,\n", " 'text': '1 Troubles in Yiddish.\\n2 Schein’s Common Sense Prevention and Management of Surgical Complications.\\n Shrewsbury, UK: tfm publishing, 2013; Chapter 16: 315.',\n", " 'md': '```markdown\\n# Troubles in Yiddish\\n\\n## Schein’s Common Sense Prevention and Management of Surgical Complications\\nShrewsbury, UK: tfm publishing, 2013; Chapter 16: 315.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Troubles in Yiddish',\n", " 'md': '# Troubles in Yiddish',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Schein’s Common Sense Prevention and Management of Surgical Complications',\n", " 'md': '## Schein’s Common Sense Prevention and Management of Surgical Complications',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Shrewsbury, UK: tfm publishing, 2013; Chapter 16: 315.\\n```',\n", " 'md': 'Shrewsbury, UK: tfm publishing, 2013; Chapter 16: 315.\\n```',\n", " 'bBox': {'x': 73, 'y': 80, 'w': 265.94, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}, {'text': '2'}, {'text': ''}]},\n", " {'page': 325,\n", " 'text': 'Chapter 21\\nSmall bowel obstruction\\nMoshe Schein and Danny Rosin\\n\\n It is less dangerous to leap from the Clifton Suspension\\n Bridge than to suffer from acute intestinal obstruction and\\n decline operation.\\n Fredrick Treves\\n\\n By far, the most common causes of small bowel obstruction (SBO) are\\npostoperative adhesions and hernias. Other less common mechanical\\netiologies are bolus obstruction (e.g. bezoar), malignant or inflammatory\\n(e.g. Crohn’s disease) or intussusception. ħernias causing SBO are\\ndiscussed in the next chapter ( Chapter 22) while early postoperative\\nsmall bowel obstruction (EPSBO) and paralytic ileus are discussed\\nelsewhere ( Chapter 45). For SBO developing in the aftermath of\\nbariatric abdominal surgery please consult Chapter 23 in our book on\\nsurgical complications 1. Mention will be made below of SBO in the\\n‘virgin’ abdomen, intussusception, the cancer patient, radiation enteritis\\nand gallstone ileus. Peritoneal tuberculosis as a cause of SBO is\\nmentioned in the chapter covering abdominal emergencies in Asia (\\nChapter 38, Section 1). The bulk of this chapter is, however, devoted\\nto the most common type of SBO — adhesive SBO.\\n\\n Sir William Osler used to say that “intestinal adhesions are the refuge\\nof the diagnostically destitute” while the truth of the matter is that\\niatrogenic surgeon-made adhesions are responsible for more than two-\\nthirds of episodes of obstruction, whatever the exact mechanisms are,',\n", " 'md': '```markdown\\n# Chapter 21: Small Bowel Obstruction\\n**Authors:** Moshe Schein and Danny Rosin\\n\\n> \"It is less dangerous to leap from the Clifton Suspension Bridge than to suffer from acute intestinal obstruction and decline operation.\"\\n> — Fredrick Treves\\n\\n## Overview of Small Bowel Obstruction (SBO)\\n\\nBy far, the most common causes of small bowel obstruction (SBO) are postoperative adhesions and hernias. Other less common mechanical etiologies include:\\n\\n- **Bolus obstruction** (e.g., bezoar)\\n- **Malignant or inflammatory causes** (e.g., Crohn’s disease)\\n- **Intussusception**\\n\\nHernias causing SBO are discussed in the next chapter (Chapter 22), while early postoperative small bowel obstruction (EPSBO) and paralytic ileus are discussed elsewhere (Chapter 45). For SBO developing in the aftermath of bariatric abdominal surgery, please consult Chapter 23 in our book on surgical complications. Mention will be made below of SBO in the ‘virgin’ abdomen, intussusception, the cancer patient, radiation enteritis, and gallstone ileus. Peritoneal tuberculosis as a cause of SBO is mentioned in the chapter covering abdominal emergencies in Asia (Chapter 38, Section 1). The bulk of this chapter is, however, devoted to the most common type of SBO — adhesive SBO.\\n\\nSir William Osler used to say that “intestinal adhesions are the refuge of the diagnostically destitute,” while the truth of the matter is that iatrogenic surgeon-made adhesions are responsible for more than two-thirds of episodes of obstruction, whatever the exact mechanisms are.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 21: Small Bowel Obstruction',\n", " 'md': '# Chapter 21: Small Bowel Obstruction',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 212.78, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Moshe Schein and Danny Rosin\\n\\n> \"It is less dangerous to leap from the Clifton Suspension Bridge than to suffer from acute intestinal obstruction and decline operation.\"\\n> — Fredrick Treves',\n", " 'md': '**Authors:** Moshe Schein and Danny Rosin\\n\\n> \"It is less dangerous to leap from the Clifton Suspension Bridge than to suffer from acute intestinal obstruction and decline operation.\"\\n> — Fredrick Treves',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 205.53, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Overview of Small Bowel Obstruction (SBO)',\n", " 'md': '## Overview of Small Bowel Obstruction (SBO)',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 212.78, 'h': 20.16}},\n", " {'type': 'text',\n", " 'value': 'By far, the most common causes of small bowel obstruction (SBO) are postoperative adhesions and hernias. Other less common mechanical etiologies include:\\n\\n- **Bolus obstruction** (e.g., bezoar)\\n- **Malignant or inflammatory causes** (e.g., Crohn’s disease)\\n- **Intussusception**\\n\\nHernias causing SBO are discussed in the next chapter (Chapter 22), while early postoperative small bowel obstruction (EPSBO) and paralytic ileus are discussed elsewhere (Chapter 45). For SBO developing in the aftermath of bariatric abdominal surgery, please consult Chapter 23 in our book on surgical complications. Mention will be made below of SBO in the ‘virgin’ abdomen, intussusception, the cancer patient, radiation enteritis, and gallstone ileus. Peritoneal tuberculosis as a cause of SBO is mentioned in the chapter covering abdominal emergencies in Asia (Chapter 38, Section 1). The bulk of this chapter is, however, devoted to the most common type of SBO — adhesive SBO.\\n\\nSir William Osler used to say that “intestinal adhesions are the refuge of the diagnostically destitute,” while the truth of the matter is that iatrogenic surgeon-made adhesions are responsible for more than two-thirds of episodes of obstruction, whatever the exact mechanisms are.\\n```',\n", " 'md': 'By far, the most common causes of small bowel obstruction (SBO) are postoperative adhesions and hernias. Other less common mechanical etiologies include:\\n\\n- **Bolus obstruction** (e.g., bezoar)\\n- **Malignant or inflammatory causes** (e.g., Crohn’s disease)\\n- **Intussusception**\\n\\nHernias causing SBO are discussed in the next chapter (Chapter 22), while early postoperative small bowel obstruction (EPSBO) and paralytic ileus are discussed elsewhere (Chapter 45). For SBO developing in the aftermath of bariatric abdominal surgery, please consult Chapter 23 in our book on surgical complications. Mention will be made below of SBO in the ‘virgin’ abdomen, intussusception, the cancer patient, radiation enteritis, and gallstone ileus. Peritoneal tuberculosis as a cause of SBO is mentioned in the chapter covering abdominal emergencies in Asia (Chapter 38, Section 1). The bulk of this chapter is, however, devoted to the most common type of SBO — adhesive SBO.\\n\\nSir William Osler used to say that “intestinal adhesions are the refuge of the diagnostically destitute,” while the truth of the matter is that iatrogenic surgeon-made adhesions are responsible for more than two-thirds of episodes of obstruction, whatever the exact mechanisms are.\\n```',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 466.67, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'small bowel obstruction (EPSBO) and paralytic ileus are discussed'},\n", " {'text': 'bariatric abdominal surgery please consult Chapter 23 in our book on'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'Chapter 38, Section 1). to the most common type of SBO — adhesive SBO'}]},\n", " {'page': 326,\n", " 'text': 'but in the absence of obstruction they are NOT a cause of abdominal\\npain. Remember, however, that upper abdominal, supracolic\\nprocedures (e.g. cholecystectomy) are much less likely to be\\nassociated with small bowel adhesions than infracolic ones. Finally,\\nas you are not an internist, we scarcely need remind you that adhesions\\nalmost never (never say never in surgery) cause colonic obstruction.\\n\\n Please note that in this era of laparoscopic surgery some patients\\nmay not volunteer a history of previous surgery and the abdominal scar is\\noften almost invisible when the previous operation has been, say,\\nsomething as banal as laparoscopic tubal ligation. Banal — yes; but it\\ncould have created a single ‘band’ adhesion causing complete SBO. On\\nthe other hand the risk of adhesive obstruction is low after laparoscopy,\\nso assuming ‘adhesion’ (and treating conservatively) may lead to missed\\npathology. For this reason we prefer to consider SBO in patients with\\na history of laparoscopic surgery more like a ‘virgin abdomen’ and\\nlook for a diagnosis by CT scan — as discussed below.\\n\\n The dilemma\\n\\n The majority of adhesive SBO patients (at least half of them,\\nperhaps many more) respond to conservative (non-operative)\\ntreatment. But persevering with conservative management in SBO may\\ndelay the recognition of compromised (strangulated) bowel, leading to a\\npoor outcome. Faced with this dilemma, your task is to resolve the\\nfollowing issues.\\n\\n Which patients need an urgent laparotomy for impending or established bowel\\n strangulation? And when is initial, conservative treatment appropriate and safe?\\n Once instituted, how long should conservative treatment be continued before an\\n operation is deemed necessary? In other words, how do you avoid an\\n operation without risking intestinal compromise?\\n\\n All surgeons acknowledge that symptoms and signs suggesting\\nthat the bowel may be compromised call for an immediate',\n", " 'md': '```markdown\\n## Abdominal Pain and Adhesions\\n\\nIn the absence of obstruction, adhesions are NOT a cause of abdominal pain. However, it is important to remember that upper abdominal, supracolic procedures (e.g., cholecystectomy) are much less likely to be associated with small bowel adhesions than infracolic ones. Additionally, it should be noted that adhesions almost never (never say never in surgery) cause colonic obstruction.\\n\\nPlease note that in this era of laparoscopic surgery, some patients may not volunteer a history of previous surgery, and the abdominal scar is often almost invisible when the previous operation has been something as banal as laparoscopic tubal ligation. While this may seem trivial, it could have created a single ‘band’ adhesion causing complete small bowel obstruction (SBO). On the other hand, the risk of adhesive obstruction is low after laparoscopy, so assuming ‘adhesion’ (and treating conservatively) may lead to missed pathology. For this reason, we prefer to consider SBO in patients with a history of laparoscopic surgery more like a ‘virgin abdomen’ and look for a diagnosis by CT scan, as discussed below.\\n\\n### The Dilemma\\n\\nThe majority of adhesive SBO patients (at least half of them, perhaps many more) respond to conservative (non-operative) treatment. However, persevering with conservative management in SBO may delay the recognition of compromised (strangulated) bowel, leading to a poor outcome. Faced with this dilemma, your task is to resolve the following issues:\\n\\n- Which patients need an urgent laparotomy for impending or established bowel strangulation?\\n- When is initial, conservative treatment appropriate and safe?\\n- Once instituted, how long should conservative treatment be continued before an operation is deemed necessary?\\n- In other words, how do you avoid an operation without risking intestinal compromise?\\n\\nAll surgeons acknowledge that symptoms and signs suggesting that the bowel may be compromised call for an immediate response.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Pain and Adhesions',\n", " 'md': '## Abdominal Pain and Adhesions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In the absence of obstruction, adhesions are NOT a cause of abdominal pain. However, it is important to remember that upper abdominal, supracolic procedures (e.g., cholecystectomy) are much less likely to be associated with small bowel adhesions than infracolic ones. Additionally, it should be noted that adhesions almost never (never say never in surgery) cause colonic obstruction.\\n\\nPlease note that in this era of laparoscopic surgery, some patients may not volunteer a history of previous surgery, and the abdominal scar is often almost invisible when the previous operation has been something as banal as laparoscopic tubal ligation. While this may seem trivial, it could have created a single ‘band’ adhesion causing complete small bowel obstruction (SBO). On the other hand, the risk of adhesive obstruction is low after laparoscopy, so assuming ‘adhesion’ (and treating conservatively) may lead to missed pathology. For this reason, we prefer to consider SBO in patients with a history of laparoscopic surgery more like a ‘virgin abdomen’ and look for a diagnosis by CT scan, as discussed below.',\n", " 'md': 'In the absence of obstruction, adhesions are NOT a cause of abdominal pain. However, it is important to remember that upper abdominal, supracolic procedures (e.g., cholecystectomy) are much less likely to be associated with small bowel adhesions than infracolic ones. Additionally, it should be noted that adhesions almost never (never say never in surgery) cause colonic obstruction.\\n\\nPlease note that in this era of laparoscopic surgery, some patients may not volunteer a history of previous surgery, and the abdominal scar is often almost invisible when the previous operation has been something as banal as laparoscopic tubal ligation. While this may seem trivial, it could have created a single ‘band’ adhesion causing complete small bowel obstruction (SBO). On the other hand, the risk of adhesive obstruction is low after laparoscopy, so assuming ‘adhesion’ (and treating conservatively) may lead to missed pathology. For this reason, we prefer to consider SBO in patients with a history of laparoscopic surgery more like a ‘virgin abdomen’ and look for a diagnosis by CT scan, as discussed below.',\n", " 'bBox': {'x': 72, 'y': 168, 'w': 467.71, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Dilemma',\n", " 'md': '### The Dilemma',\n", " 'bBox': {'x': 86, 'y': 396, 'w': 101.15, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The majority of adhesive SBO patients (at least half of them, perhaps many more) respond to conservative (non-operative) treatment. However, persevering with conservative management in SBO may delay the recognition of compromised (strangulated) bowel, leading to a poor outcome. Faced with this dilemma, your task is to resolve the following issues:\\n\\n- Which patients need an urgent laparotomy for impending or established bowel strangulation?\\n- When is initial, conservative treatment appropriate and safe?\\n- Once instituted, how long should conservative treatment be continued before an operation is deemed necessary?\\n- In other words, how do you avoid an operation without risking intestinal compromise?\\n\\nAll surgeons acknowledge that symptoms and signs suggesting that the bowel may be compromised call for an immediate response.\\n```',\n", " 'md': 'The majority of adhesive SBO patients (at least half of them, perhaps many more) respond to conservative (non-operative) treatment. However, persevering with conservative management in SBO may delay the recognition of compromised (strangulated) bowel, leading to a poor outcome. Faced with this dilemma, your task is to resolve the following issues:\\n\\n- Which patients need an urgent laparotomy for impending or established bowel strangulation?\\n- When is initial, conservative treatment appropriate and safe?\\n- Once instituted, how long should conservative treatment be continued before an operation is deemed necessary?\\n- In other words, how do you avoid an operation without risking intestinal compromise?\\n\\nAll surgeons acknowledge that symptoms and signs suggesting that the bowel may be compromised call for an immediate response.\\n```',\n", " 'bBox': {'x': 72, 'y': 481, 'w': 468.01, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 327,\n", " 'text': 'operation. You know the signs — severe constant pain, peritoneal signs\\n(but remember that distended loops of small bowel can be tender),\\nclinical and laboratory features of SIRS, elevated lactic acid, and so forth.\\nħowever, surgeons across the world tend to offer a wide range of\\nopinions as to the duration of non-operative therapy before declaring that\\nit has failed. Some still preach the outdated dictum “never let the sun set\\nor rise over intestinal obstruction”, while others persist in avoiding an\\noperation seemingly until the next Ramadan season or Christmas.\\n\\n We aim to provide you with guidelines to answer these questions and\\nhelp you develop a common sense approach. But first we need to clarify\\nsome terminology.\\n\\n Definitions\\n\\n • Simple obstruction: the bowel is blocked, compressed or kinked,\\n but its vascular supply is not threatened.\\n • Strangulation obstruction: the vascular supply to the segment of\\n obstructed bowel is compromised.\\n • Closed-loop obstruction: a segment of bowel is obstructed at both\\n a proximal and distal point — typical examples would be a volvulus\\n or a loop of bowel incarcerated within a tight hernial defect.\\n Commonly, the involved bowel is strangulated.\\n\\n Understanding the terms ‘partial’ versus ‘complete’ obstruction is\\ncrucial to the planning of treatment. Some surgeons offer definitions\\nbased on symptoms (mild vs. severe) which are notoriously inaccurate.\\nOthers consider patients who pass flatus as having partial obstruction,\\nwhereas to us the sound of farting is a happy indication that the\\nobstruction has resolved or is resolving. We believe that the best way to\\ndistinguish between partial and complete SBO is radiology, starting with\\nthe humble plain abdominal X-ray, but better observed on the CT (\\nChapter 5):\\n\\n • Partial obstruction: there is gas seen in the colon, in addition to\\n small bowel distension with fluid levels.\\n Complete obstruction: no gas is seen in the colon.',\n", " 'md': '```markdown\\n## Guidelines for Non-Operative Therapy in Bowel Obstruction\\n\\nYou know the signs — severe constant pain, peritoneal signs (but remember that distended loops of small bowel can be tender), clinical and laboratory features of SIRS, elevated lactic acid, and so forth. However, surgeons across the world tend to offer a wide range of opinions as to the duration of non-operative therapy before declaring that it has failed. Some still preach the outdated dictum “never let the sun set or rise over intestinal obstruction”, while others persist in avoiding an operation seemingly until the next Ramadan season or Christmas.\\n\\nWe aim to provide you with guidelines to answer these questions and help you develop a common sense approach. But first, we need to clarify some terminology.\\n\\n### Definitions\\n\\n- **Simple obstruction**: the bowel is blocked, compressed, or kinked, but its vascular supply is not threatened.\\n- **Strangulation obstruction**: the vascular supply to the segment of obstructed bowel is compromised.\\n- **Closed-loop obstruction**: a segment of bowel is obstructed at both a proximal and distal point — typical examples would be a volvulus or a loop of bowel incarcerated within a tight hernial defect. Commonly, the involved bowel is strangulated.\\n\\nUnderstanding the terms ‘partial’ versus ‘complete’ obstruction is crucial to the planning of treatment. Some surgeons offer definitions based on symptoms (mild vs. severe) which are notoriously inaccurate. Others consider patients who pass flatus as having partial obstruction, whereas to us the sound of farting is a happy indication that the obstruction has resolved or is resolving. We believe that the best way to distinguish between partial and complete SBO is radiology, starting with the humble plain abdominal X-ray, but better observed on the CT (Chapter 5):\\n\\n- **Partial obstruction**: there is gas seen in the colon, in addition to small bowel distension with fluid levels.\\n- **Complete obstruction**: no gas is seen in the colon.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Guidelines for Non-Operative Therapy in Bowel Obstruction',\n", " 'md': '## Guidelines for Non-Operative Therapy in Bowel Obstruction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'You know the signs — severe constant pain, peritoneal signs (but remember that distended loops of small bowel can be tender), clinical and laboratory features of SIRS, elevated lactic acid, and so forth. However, surgeons across the world tend to offer a wide range of opinions as to the duration of non-operative therapy before declaring that it has failed. Some still preach the outdated dictum “never let the sun set or rise over intestinal obstruction”, while others persist in avoiding an operation seemingly until the next Ramadan season or Christmas.\\n\\nWe aim to provide you with guidelines to answer these questions and help you develop a common sense approach. But first, we need to clarify some terminology.',\n", " 'md': 'You know the signs — severe constant pain, peritoneal signs (but remember that distended loops of small bowel can be tender), clinical and laboratory features of SIRS, elevated lactic acid, and so forth. However, surgeons across the world tend to offer a wide range of opinions as to the duration of non-operative therapy before declaring that it has failed. Some still preach the outdated dictum “never let the sun set or rise over intestinal obstruction”, while others persist in avoiding an operation seemingly until the next Ramadan season or Christmas.\\n\\nWe aim to provide you with guidelines to answer these questions and help you develop a common sense approach. But first, we need to clarify some terminology.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.65, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Definitions',\n", " 'md': '### Definitions',\n", " 'bBox': {'x': 86, 'y': 313, 'w': 85.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- **Simple obstruction**: the bowel is blocked, compressed, or kinked, but its vascular supply is not threatened.\\n- **Strangulation obstruction**: the vascular supply to the segment of obstructed bowel is compromised.\\n- **Closed-loop obstruction**: a segment of bowel is obstructed at both a proximal and distal point — typical examples would be a volvulus or a loop of bowel incarcerated within a tight hernial defect. Commonly, the involved bowel is strangulated.\\n\\nUnderstanding the terms ‘partial’ versus ‘complete’ obstruction is crucial to the planning of treatment. Some surgeons offer definitions based on symptoms (mild vs. severe) which are notoriously inaccurate. Others consider patients who pass flatus as having partial obstruction, whereas to us the sound of farting is a happy indication that the obstruction has resolved or is resolving. We believe that the best way to distinguish between partial and complete SBO is radiology, starting with the humble plain abdominal X-ray, but better observed on the CT (Chapter 5):\\n\\n- **Partial obstruction**: there is gas seen in the colon, in addition to small bowel distension with fluid levels.\\n- **Complete obstruction**: no gas is seen in the colon.\\n```',\n", " 'md': '- **Simple obstruction**: the bowel is blocked, compressed, or kinked, but its vascular supply is not threatened.\\n- **Strangulation obstruction**: the vascular supply to the segment of obstructed bowel is compromised.\\n- **Closed-loop obstruction**: a segment of bowel is obstructed at both a proximal and distal point — typical examples would be a volvulus or a loop of bowel incarcerated within a tight hernial defect. Commonly, the involved bowel is strangulated.\\n\\nUnderstanding the terms ‘partial’ versus ‘complete’ obstruction is crucial to the planning of treatment. Some surgeons offer definitions based on symptoms (mild vs. severe) which are notoriously inaccurate. Others consider patients who pass flatus as having partial obstruction, whereas to us the sound of farting is a happy indication that the obstruction has resolved or is resolving. We believe that the best way to distinguish between partial and complete SBO is radiology, starting with the humble plain abdominal X-ray, but better observed on the CT (Chapter 5):\\n\\n- **Partial obstruction**: there is gas seen in the colon, in addition to small bowel distension with fluid levels.\\n- **Complete obstruction**: no gas is seen in the colon.\\n```',\n", " 'bBox': {'x': 72, 'y': 313, 'w': 467.82, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 5):'}]},\n", " {'page': 328,\n", " 'text': ' •\\n Most episodes of partial SBO will resolve without an operation,\\nwhile the majority of patients presenting with a complete\\nobstruction will require one.\\n\\n Clinical features ( Figure 21.1)\\n\\n The three important clinical manifestations of SBO are colicky\\nabdominal pain, vomiting and abdominal distension. Constipation\\nand absence of flatus are relatively late symptoms of SBO but essential\\nfor the diagnosis. We are always surprised how often non-surgeons omit\\nasking the patient “when was the last time your bowels moved and you\\npassed wind?” — calling you to “assess SBO” in patients with diarrhea,\\nonly because a few loops of small bowel were seen on the abdominal X-\\nray… Remember: a patient who continues to pass gas and/or move\\nhis bowel is not suffering from a mechanical SBO!\\n PeRYA 2014\\n Figure 21.1. “I suspect this is intestinal obstruction. Should we try Gastrografin®?”',\n", " 'md': '```markdown\\n## Clinical Features of Small Bowel Obstruction (SBO)\\n\\nMost episodes of partial SBO will resolve without an operation, while the majority of patients presenting with a complete obstruction will require one.\\n\\nThe three important clinical manifestations of SBO are:\\n- Colicky abdominal pain\\n- Vomiting\\n- Abdominal distension\\n\\nConstipation and absence of flatus are relatively late symptoms of SBO but essential for the diagnosis. We are always surprised how often non-surgeons omit asking the patient “when was the last time your bowels moved and you passed wind?” — calling you to “assess SBO” in patients with diarrhea, only because a few loops of small bowel were seen on the abdominal X-ray… Remember: a patient who continues to pass gas and/or move his bowel is not suffering from a mechanical SBO!\\n\\n*Source: PeRYA 2014*\\n\\n### Figure 21.1\\n**Caption:** “I suspect this is intestinal obstruction. Should we try Gastrografin®?”\\n\\n**Description:** Figure 21.1 likely depicts a clinical scenario or image related to intestinal obstruction, possibly showing an X-ray or a patient assessment context. The figure emphasizes the importance of clinical evaluation in diagnosing SBO, particularly in distinguishing between mechanical obstruction and other gastrointestinal issues.\\n\\n**Summary:** The figure serves to illustrate the clinical suspicion of intestinal obstruction and the consideration of using Gastrografin® as a diagnostic tool.\\n```',\n", " 'images': [{'name': 'img_p327_1.png',\n", " 'height': 530,\n", " 'width': 814,\n", " 'x': 105.11999999999989,\n", " 'y': 388.8,\n", " 'original_width': 1398,\n", " 'original_height': 910}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Features of Small Bowel Obstruction (SBO)',\n", " 'md': '## Clinical Features of Small Bowel Obstruction (SBO)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Most episodes of partial SBO will resolve without an operation, while the majority of patients presenting with a complete obstruction will require one.\\n\\nThe three important clinical manifestations of SBO are:\\n- Colicky abdominal pain\\n- Vomiting\\n- Abdominal distension\\n\\nConstipation and absence of flatus are relatively late symptoms of SBO but essential for the diagnosis. We are always surprised how often non-surgeons omit asking the patient “when was the last time your bowels moved and you passed wind?” — calling you to “assess SBO” in patients with diarrhea, only because a few loops of small bowel were seen on the abdominal X-ray… Remember: a patient who continues to pass gas and/or move his bowel is not suffering from a mechanical SBO!\\n\\n*Source: PeRYA 2014*',\n", " 'md': 'Most episodes of partial SBO will resolve without an operation, while the majority of patients presenting with a complete obstruction will require one.\\n\\nThe three important clinical manifestations of SBO are:\\n- Colicky abdominal pain\\n- Vomiting\\n- Abdominal distension\\n\\nConstipation and absence of flatus are relatively late symptoms of SBO but essential for the diagnosis. We are always surprised how often non-surgeons omit asking the patient “when was the last time your bowels moved and you passed wind?” — calling you to “assess SBO” in patients with diarrhea, only because a few loops of small bowel were seen on the abdominal X-ray… Remember: a patient who continues to pass gas and/or move his bowel is not suffering from a mechanical SBO!\\n\\n*Source: PeRYA 2014*',\n", " 'bBox': {'x': 72, 'y': 163, 'w': 467.84, 'h': 14.83}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 21.1',\n", " 'md': '### Figure 21.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** “I suspect this is intestinal obstruction. Should we try Gastrografin®?”\\n\\n**Description:** Figure 21.1 likely depicts a clinical scenario or image related to intestinal obstruction, possibly showing an X-ray or a patient assessment context. The figure emphasizes the importance of clinical evaluation in diagnosing SBO, particularly in distinguishing between mechanical obstruction and other gastrointestinal issues.\\n\\n**Summary:** The figure serves to illustrate the clinical suspicion of intestinal obstruction and the consideration of using Gastrografin® as a diagnostic tool.\\n```',\n", " 'md': '**Caption:** “I suspect this is intestinal obstruction. Should we try Gastrografin®?”\\n\\n**Description:** Figure 21.1 likely depicts a clinical scenario or image related to intestinal obstruction, possibly showing an X-ray or a patient assessment context. The figure emphasizes the importance of clinical evaluation in diagnosing SBO, particularly in distinguishing between mechanical obstruction and other gastrointestinal issues.\\n\\n**Summary:** The figure serves to illustrate the clinical suspicion of intestinal obstruction and the consideration of using Gastrografin® as a diagnostic tool.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 329,\n", " 'text': ' The pattern of these features depends on the site, cause and\\nduration of the obstruction. For example, in proximal obstruction,\\nvomiting is prominent while pain and distension are absent or mild; as the\\nlevel of obstruction descends, the crampy pain becomes more marked. In\\ndistal SBO, distension is a significant symptom with vomiting appearing\\nlater. Feculent vomiting is the hallmark of longstanding, distal, complete\\nSBO and is characteristic of massive bacterial overgrowth proximal to the\\nobstruction (remember — the main bulk of feces is made of bacteria). It\\nis a poor prognostic sign — the more thick and smelly the\\nnasogastric aspirate, the less chance there is that the obstruction\\nwill resolve spontaneously. When we see s***, sorry, feces coming\\nfrom the nasogastric (NG) tube we start preparing the patient for\\nsurgery!\\n\\n Is there strangulation?\\n\\n This is a crucial question. If it is “yes”, not only is an operation\\ncompulsory, but it also needs to be performed promptly. The most\\nimportant clinical feature of strangulation is continuous pain. Signs\\nof peritoneal irritation (guarding, rebound tenderness) may be present but\\nremember that:\\n\\n • Dead bowel can be present in a relatively ‘innocent’ abdomen.\\n • Signs of peritoneal irritation are rarely useful in differentiating\\n ‘simple’ obstruction from strangulation because they may also be\\n found in ‘simple’ SBO when the distension is severe. As we\\n mentioned above, dilated loops of intestine are tender — you must\\n surely have seen internists poking aggressively into distended\\n abdomens and diagnosing ‘peritonitis’ in patients suffering from\\n gastroenteritis?\\n\\n What about lab tests? Obviously, features of an inflammatory\\nresponse (leukocytosis, raised CRP) or indicators of tissue ischemia\\n(elevated lactate, negative base excess or metabolic acidosis) point to\\nthe existence of compromised bowel. But never use any such tests in\\nisolation. Look at the whole clinical picture — the leukocytosis and\\nacidosis may improve after the hypovolemic patient has received a few',\n", " 'md': '```markdown\\n## Page Content\\n\\nThe pattern of these features depends on the site, cause, and duration of the obstruction. For example, in proximal obstruction, vomiting is prominent while pain and distension are absent or mild; as the level of obstruction descends, the crampy pain becomes more marked. In distal SBO, distension is a significant symptom with vomiting appearing later. Feculent vomiting is the hallmark of longstanding, distal, complete SBO and is characteristic of massive bacterial overgrowth proximal to the obstruction (remember — the main bulk of feces is made of bacteria). It is a poor prognostic sign — the more thick and smelly the nasogastric aspirate, the less chance there is that the obstruction will resolve spontaneously. When we see s***, sorry, feces coming from the nasogastric (NG) tube we start preparing the patient for surgery!\\n\\n### Is there strangulation?\\n\\nThis is a crucial question. If it is “yes”, not only is an operation compulsory, but it also needs to be performed promptly. The most important clinical feature of strangulation is continuous pain. Signs of peritoneal irritation (guarding, rebound tenderness) may be present but remember that:\\n\\n- Dead bowel can be present in a relatively ‘innocent’ abdomen.\\n- Signs of peritoneal irritation are rarely useful in differentiating ‘simple’ obstruction from strangulation because they may also be found in ‘simple’ SBO when the distension is severe. As we mentioned above, dilated loops of intestine are tender — you must surely have seen internists poking aggressively into distended abdomens and diagnosing ‘peritonitis’ in patients suffering from gastroenteritis?\\n\\n### What about lab tests?\\n\\nObviously, features of an inflammatory response (leukocytosis, raised CRP) or indicators of tissue ischemia (elevated lactate, negative base excess or metabolic acidosis) point to the existence of compromised bowel. But never use any such tests in isolation. Look at the whole clinical picture — the leukocytosis and acidosis may improve after the hypovolemic patient has received a few...\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The pattern of these features depends on the site, cause, and duration of the obstruction. For example, in proximal obstruction, vomiting is prominent while pain and distension are absent or mild; as the level of obstruction descends, the crampy pain becomes more marked. In distal SBO, distension is a significant symptom with vomiting appearing later. Feculent vomiting is the hallmark of longstanding, distal, complete SBO and is characteristic of massive bacterial overgrowth proximal to the obstruction (remember — the main bulk of feces is made of bacteria). It is a poor prognostic sign — the more thick and smelly the nasogastric aspirate, the less chance there is that the obstruction will resolve spontaneously. When we see s***, sorry, feces coming from the nasogastric (NG) tube we start preparing the patient for surgery!',\n", " 'md': 'The pattern of these features depends on the site, cause, and duration of the obstruction. For example, in proximal obstruction, vomiting is prominent while pain and distension are absent or mild; as the level of obstruction descends, the crampy pain becomes more marked. In distal SBO, distension is a significant symptom with vomiting appearing later. Feculent vomiting is the hallmark of longstanding, distal, complete SBO and is characteristic of massive bacterial overgrowth proximal to the obstruction (remember — the main bulk of feces is made of bacteria). It is a poor prognostic sign — the more thick and smelly the nasogastric aspirate, the less chance there is that the obstruction will resolve spontaneously. When we see s***, sorry, feces coming from the nasogastric (NG) tube we start preparing the patient for surgery!',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Is there strangulation?',\n", " 'md': '### Is there strangulation?',\n", " 'bBox': {'x': 86, 'y': 327, 'w': 178.37, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is a crucial question. If it is “yes”, not only is an operation compulsory, but it also needs to be performed promptly. The most important clinical feature of strangulation is continuous pain. Signs of peritoneal irritation (guarding, rebound tenderness) may be present but remember that:\\n\\n- Dead bowel can be present in a relatively ‘innocent’ abdomen.\\n- Signs of peritoneal irritation are rarely useful in differentiating ‘simple’ obstruction from strangulation because they may also be found in ‘simple’ SBO when the distension is severe. As we mentioned above, dilated loops of intestine are tender — you must surely have seen internists poking aggressively into distended abdomens and diagnosing ‘peritonitis’ in patients suffering from gastroenteritis?',\n", " 'md': 'This is a crucial question. If it is “yes”, not only is an operation compulsory, but it also needs to be performed promptly. The most important clinical feature of strangulation is continuous pain. Signs of peritoneal irritation (guarding, rebound tenderness) may be present but remember that:\\n\\n- Dead bowel can be present in a relatively ‘innocent’ abdomen.\\n- Signs of peritoneal irritation are rarely useful in differentiating ‘simple’ obstruction from strangulation because they may also be found in ‘simple’ SBO when the distension is severe. As we mentioned above, dilated loops of intestine are tender — you must surely have seen internists poking aggressively into distended abdomens and diagnosing ‘peritonitis’ in patients suffering from gastroenteritis?',\n", " 'bBox': {'x': 72, 'y': 396, 'w': 467.66, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'What about lab tests?',\n", " 'md': '### What about lab tests?',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Obviously, features of an inflammatory response (leukocytosis, raised CRP) or indicators of tissue ischemia (elevated lactate, negative base excess or metabolic acidosis) point to the existence of compromised bowel. But never use any such tests in isolation. Look at the whole clinical picture — the leukocytosis and acidosis may improve after the hypovolemic patient has received a few...\\n\\n```',\n", " 'md': 'Obviously, features of an inflammatory response (leukocytosis, raised CRP) or indicators of tissue ischemia (elevated lactate, negative base excess or metabolic acidosis) point to the existence of compromised bowel. But never use any such tests in isolation. Look at the whole clinical picture — the leukocytosis and acidosis may improve after the hypovolemic patient has received a few...\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 680, 'w': 466.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 330,\n", " 'text': 'liters of fluids. And the lactate levels may not rise at all if any ischemic\\nsegment is short.\\n\\n Closed loop obstruction always equals strangulation! Here a loop of bowel is obstructed at\\n both ends (volvulus) and its blood supply is compromised. Plain abdominal X-ray is commonly\\n misleading in this situation. The intestine above the compromised loop may be full of liquid and\\n thus appears opaque — all one sees is a single dilated loop of bowel (but CT would be\\n diagnostic). Patients with this type of obstruction tend to cry out in pain — like a siren!\\n Agonizing abdominal pain may be the single most important clue you have.\\n\\n ħaving diagnosed strangulation, you will be congratulated for having\\nexpeditiously resuscitated and wheeled your patient to the operating\\nroom. ħowever, save yourself the embarrassment of explaining, the next\\nday, the presence of the long midline incision to deal with a knuckle of\\nischemic gut trapped in the groin! Never forget that a common cause\\nof strangulated bowel is an external hernia. The suspicion of\\nstrangulation must make you examine, or rather re-examine more\\ncarefully, the five external hernial orifices: two inguinal, two femoral and\\none umbilical ( Chapter 22). Oh yes, do pull off those tight jeans — see\\nthat the patient is undressed before examining him.\\n\\n Remember: No isolated clinical feature or laboratory finding can tell you if the intestine\\n is strangulated or dead. Only fools let themselves be guided by lactic acid levels. Do not wait\\n for fever, leukocytosis or acidosis to diagnose ischemic bowel, because when all these\\n systemic signs are present, the intestine is already dead!\\n\\n By now you understand that nothing, nothing can accurately distinguish\\nbetween ‘simple’ and ‘strangulating’ SBO. So how do you play it safe?\\nLet’s take a step back and discuss imaging…\\n\\n Imaging\\n\\n Plain abdominal X-rays',\n", " 'md': '```markdown\\n## Text Extraction\\n\\n- Liters of fluids. And the lactate levels may not rise at all if any ischemic segment is short.\\n- Closed loop obstruction always equals strangulation! Here a loop of bowel is obstructed at both ends (volvulus) and its blood supply is compromised. Plain abdominal X-ray is commonly misleading in this situation. The intestine above the compromised loop may be full of liquid and thus appears opaque — all one sees is a single dilated loop of bowel (but CT would be diagnostic). Patients with this type of obstruction tend to cry out in pain — like a siren! Agonizing abdominal pain may be the single most important clue you have.\\n- Having diagnosed strangulation, you will be congratulated for having expeditiously resuscitated and wheeled your patient to the operating room. However, save yourself the embarrassment of explaining, the next day, the presence of the long midline incision to deal with a knuckle of ischemic gut trapped in the groin! Never forget that a common cause of strangulated bowel is an external hernia. The suspicion of strangulation must make you examine, or rather re-examine more carefully, the five external hernial orifices: two inguinal, two femoral and one umbilical (Chapter 22). Oh yes, do pull off those tight jeans — see that the patient is undressed before examining him.\\n- Remember: No isolated clinical feature or laboratory finding can tell you if the intestine is strangulated or dead. Only fools let themselves be guided by lactic acid levels. Do not wait for fever, leukocytosis or acidosis to diagnose ischemic bowel, because when all these systemic signs are present, the intestine is already dead!\\n- By now you understand that nothing, nothing can accurately distinguish between ‘simple’ and ‘strangulating’ SBO. So how do you play it safe? Let’s take a step back and discuss imaging…\\n\\n## Section: Imaging\\n\\n### Plain abdominal X-rays\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Liters of fluids. And the lactate levels may not rise at all if any ischemic segment is short.\\n- Closed loop obstruction always equals strangulation! Here a loop of bowel is obstructed at both ends (volvulus) and its blood supply is compromised. Plain abdominal X-ray is commonly misleading in this situation. The intestine above the compromised loop may be full of liquid and thus appears opaque — all one sees is a single dilated loop of bowel (but CT would be diagnostic). Patients with this type of obstruction tend to cry out in pain — like a siren! Agonizing abdominal pain may be the single most important clue you have.\\n- Having diagnosed strangulation, you will be congratulated for having expeditiously resuscitated and wheeled your patient to the operating room. However, save yourself the embarrassment of explaining, the next day, the presence of the long midline incision to deal with a knuckle of ischemic gut trapped in the groin! Never forget that a common cause of strangulated bowel is an external hernia. The suspicion of strangulation must make you examine, or rather re-examine more carefully, the five external hernial orifices: two inguinal, two femoral and one umbilical (Chapter 22). Oh yes, do pull off those tight jeans — see that the patient is undressed before examining him.\\n- Remember: No isolated clinical feature or laboratory finding can tell you if the intestine is strangulated or dead. Only fools let themselves be guided by lactic acid levels. Do not wait for fever, leukocytosis or acidosis to diagnose ischemic bowel, because when all these systemic signs are present, the intestine is already dead!\\n- By now you understand that nothing, nothing can accurately distinguish between ‘simple’ and ‘strangulating’ SBO. So how do you play it safe? Let’s take a step back and discuss imaging…',\n", " 'md': '- Liters of fluids. And the lactate levels may not rise at all if any ischemic segment is short.\\n- Closed loop obstruction always equals strangulation! Here a loop of bowel is obstructed at both ends (volvulus) and its blood supply is compromised. Plain abdominal X-ray is commonly misleading in this situation. The intestine above the compromised loop may be full of liquid and thus appears opaque — all one sees is a single dilated loop of bowel (but CT would be diagnostic). Patients with this type of obstruction tend to cry out in pain — like a siren! Agonizing abdominal pain may be the single most important clue you have.\\n- Having diagnosed strangulation, you will be congratulated for having expeditiously resuscitated and wheeled your patient to the operating room. However, save yourself the embarrassment of explaining, the next day, the presence of the long midline incision to deal with a knuckle of ischemic gut trapped in the groin! Never forget that a common cause of strangulated bowel is an external hernia. The suspicion of strangulation must make you examine, or rather re-examine more carefully, the five external hernial orifices: two inguinal, two femoral and one umbilical (Chapter 22). Oh yes, do pull off those tight jeans — see that the patient is undressed before examining him.\\n- Remember: No isolated clinical feature or laboratory finding can tell you if the intestine is strangulated or dead. Only fools let themselves be guided by lactic acid levels. Do not wait for fever, leukocytosis or acidosis to diagnose ischemic bowel, because when all these systemic signs are present, the intestine is already dead!\\n- By now you understand that nothing, nothing can accurately distinguish between ‘simple’ and ‘strangulating’ SBO. So how do you play it safe? Let’s take a step back and discuss imaging…',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.46, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Section: Imaging',\n", " 'md': '## Section: Imaging',\n", " 'bBox': {'x': 86, 'y': 666, 'w': 63.44, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Plain abdominal X-rays',\n", " 'md': '### Plain abdominal X-rays',\n", " 'bBox': {'x': 86, 'y': 710, 'w': 182.06, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured according to the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured according to the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'that the patient is undressed before examining him.'}]},\n", " {'page': 331,\n", " 'text': ' The essential radiographic features seen on supine and erect\\nabdominal X-rays are: gaseous distension of the bowel proximal to the\\nobstruction, the presence of air-fluid levels and, in complete SBO, the\\nabsence of gas distal to the obstruction. The presence of parallel\\nstriations (caused by the valvulae conniventes) running transversely, right\\nacross the lumen, are chracteristic of distended small bowel. Colonic gas\\nshadows lack this pattern.\\n\\n Ultrasonography (US)\\n\\n US has been reported by enthusiasts to define accurately the site of\\nobstruction and establish whether strangulation is present. It requires\\naccess to an expert, which most institutions lack. We, and presumbly\\nyou, have no experience with it — so just forget ‘bout it!\\n\\n CT\\n\\n We have to admit — wherever CT is readily available, it has replaced\\nabdominal X-rays as the primary method of imaging of the abdomen.\\nMany of us are called to see patients suspected of having SBO only after\\na CT has been obtained. But even if you are not the one to order the\\nCT, try to educate those who do, to see to it that the ‘oral’ (per NG\\ntube) contrast used is water-soluble — the water-soluble contrast will\\nact like a ‘Gastrografin® challenge’ (to be discussed below).\\n\\n ħowever, if you need a ‘quick CT’ and do not have time to decompress\\nthe stomach, the oral contrast can be omitted — the fluid inside the bowel\\nlumen acting like ‘contrast’ and the i.v. contrast (given only if renal\\nfunction is OK) delineating the bowel wall.\\n\\n What you should look for on the CT is listed in Table 21.1.',\n", " 'md': '```markdown\\n## Radiographic Features of Abdominal X-rays\\n\\nThe essential radiographic features seen on supine and erect abdominal X-rays are:\\n- Gaseous distension of the bowel proximal to the obstruction.\\n- The presence of air-fluid levels.\\n- In complete small bowel obstruction (SBO), the absence of gas distal to the obstruction.\\n\\nThe presence of parallel striations (caused by the valvulae conniventes) running transversely, right across the lumen, are characteristic of distended small bowel. Colonic gas shadows lack this pattern.\\n\\n### Ultrasonography (US)\\n\\nUS has been reported by enthusiasts to define accurately the site of obstruction and establish whether strangulation is present. It requires access to an expert, which most institutions lack. We, and presumably you, have no experience with it — so just forget ‘bout it!\\n\\n### CT\\n\\nWe have to admit — wherever CT is readily available, it has replaced abdominal X-rays as the primary method of imaging of the abdomen. Many of us are called to see patients suspected of having SBO only after a CT has been obtained. But even if you are not the one to order the CT, try to educate those who do, to see to it that the ‘oral’ (per NG tube) contrast used is water-soluble — the water-soluble contrast will act like a ‘Gastrografin® challenge’ (to be discussed below).\\n\\nHowever, if you need a ‘quick CT’ and do not have time to decompress the stomach, the oral contrast can be omitted — the fluid inside the bowel lumen acting like ‘contrast’ and the intravenous (i.v.) contrast (given only if renal function is OK) delineating the bowel wall.\\n\\nWhat you should look for on the CT is listed in **Table 21.1**.\\n```\\n\\n### Note:\\n- There are no identifiable images or figures on this page.\\n- The text has been structured and formatted according to the requirements.',\n", " 'images': [{'name': 'img_p330_1.png',\n", " 'height': 12,\n", " 'width': 12,\n", " 'x': 383.03999999999996,\n", " 'y': 605.52}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Radiographic Features of Abdominal X-rays',\n", " 'md': '## Radiographic Features of Abdominal X-rays',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The essential radiographic features seen on supine and erect abdominal X-rays are:\\n- Gaseous distension of the bowel proximal to the obstruction.\\n- The presence of air-fluid levels.\\n- In complete small bowel obstruction (SBO), the absence of gas distal to the obstruction.\\n\\nThe presence of parallel striations (caused by the valvulae conniventes) running transversely, right across the lumen, are characteristic of distended small bowel. Colonic gas shadows lack this pattern.',\n", " 'md': 'The essential radiographic features seen on supine and erect abdominal X-rays are:\\n- Gaseous distension of the bowel proximal to the obstruction.\\n- The presence of air-fluid levels.\\n- In complete small bowel obstruction (SBO), the absence of gas distal to the obstruction.\\n\\nThe presence of parallel striations (caused by the valvulae conniventes) running transversely, right across the lumen, are characteristic of distended small bowel. Colonic gas shadows lack this pattern.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 466.87, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Ultrasonography (US)',\n", " 'md': '### Ultrasonography (US)',\n", " 'bBox': {'x': 86, 'y': 228, 'w': 171.04, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'US has been reported by enthusiasts to define accurately the site of obstruction and establish whether strangulation is present. It requires access to an expert, which most institutions lack. We, and presumably you, have no experience with it — so just forget ‘bout it!',\n", " 'md': 'US has been reported by enthusiasts to define accurately the site of obstruction and establish whether strangulation is present. It requires access to an expert, which most institutions lack. We, and presumably you, have no experience with it — so just forget ‘bout it!',\n", " 'bBox': {'x': 72, 'y': 314, 'w': 352.61, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'CT',\n", " 'md': '### CT',\n", " 'bBox': {'x': 86, 'y': 357, 'w': 22.08, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'We have to admit — wherever CT is readily available, it has replaced abdominal X-rays as the primary method of imaging of the abdomen. Many of us are called to see patients suspected of having SBO only after a CT has been obtained. But even if you are not the one to order the CT, try to educate those who do, to see to it that the ‘oral’ (per NG tube) contrast used is water-soluble — the water-soluble contrast will act like a ‘Gastrografin® challenge’ (to be discussed below).\\n\\nHowever, if you need a ‘quick CT’ and do not have time to decompress the stomach, the oral contrast can be omitted — the fluid inside the bowel lumen acting like ‘contrast’ and the intravenous (i.v.) contrast (given only if renal function is OK) delineating the bowel wall.\\n\\nWhat you should look for on the CT is listed in **Table 21.1**.\\n```',\n", " 'md': 'We have to admit — wherever CT is readily available, it has replaced abdominal X-rays as the primary method of imaging of the abdomen. Many of us are called to see patients suspected of having SBO only after a CT has been obtained. But even if you are not the one to order the CT, try to educate those who do, to see to it that the ‘oral’ (per NG tube) contrast used is water-soluble — the water-soluble contrast will act like a ‘Gastrografin® challenge’ (to be discussed below).\\n\\nHowever, if you need a ‘quick CT’ and do not have time to decompress the stomach, the oral contrast can be omitted — the fluid inside the bowel lumen acting like ‘contrast’ and the intravenous (i.v.) contrast (given only if renal function is OK) delineating the bowel wall.\\n\\nWhat you should look for on the CT is listed in **Table 21.1**.\\n```',\n", " 'bBox': {'x': 72, 'y': 357, 'w': 467.74, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Note:',\n", " 'md': '### Note:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- There are no identifiable images or figures on this page.\\n- The text has been structured and formatted according to the requirements.',\n", " 'md': '- There are no identifiable images or figures on this page.\\n- The text has been structured and formatted according to the requirements.',\n", " 'bBox': {'x': 86, 'y': 357, 'w': 22.08, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 332,\n", " 'text': \" Table 21.1. What should you look for on the CT?\\n Dilated loops with air-fluid levels (present in any SBO)\\n Oral contrast 'stacked' in the stomach suggesting advanced, complete\\n SBO\\n A transition point decompressed small bowel distal to dilated small bowel\\n (it is not an indication that conservative treatment will fail)\\n Thickened bowel wall\\n Findings suggestive of a closed loop obstruction single, isolated segment\\n of dilated small intestine (usually calls for an operation)\\n Small bowel feces sign gas bubbles and debris within the obstructed small\\n bowel lumen fecalization (indicates fixed prolonged obstruction)\\n Pneumatosis intestinalis (compromised bowell)\\n Mesenteric edema as defined by hazy fluid attenuation in the mesentery of\\n the involved intestinal segment and/or vascular engorgement or vascular\\n 'swirling' (suggests compromised intestine\\n The presence of free intraperitoneal fluid usually indicates advanced SBO\\n suspect compromised bowell\\n Free intraperitoneal air or portal venous gas you know what it means:\\n no need to explain\\n Surprise findings suggesting that it is not adhesive SBO the list islong;\\n just to mention a few examples: obstructing cecal carcinoma (causing distal\\n SBO), diverticular mass adherent to the small bowel, small bowel neoplasms,\\n intussusception_\\n While CT has been shown accurately to define the level of obstruction\\n(the ‘transition point’) and identify strangulated bowel segments, it does\\nnot mean that it is indicated in all cases of SBO. Take, for instance,\\nthe ‘frequent traveler’ who presents to the ER every other month with\\nadhesive SBO, responding to a day of NG decompression — CT-induced\\n‘radiotherapy’ has not been proven to be a valuable mode of treatment...\\n\\n CT, however, is a ‘must’ in the following circumstances:\\n\\n • ħistory of abdominal malignancy. A CT finding of diffuse\\n carcinomatosis indicates that symptomatic management is the\",\n", " 'md': \"```markdown\\n## Table 21.1. What should you look for on the CT?\\n\\n- **Dilated loops with air-fluid levels** (present in any SBO)\\n- **Oral contrast 'stacked' in the stomach** suggesting advanced, complete SBO\\n- **A transition point**: decompressed small bowel distal to dilated small bowel (it is not an indication that conservative treatment will fail)\\n- **Thickened bowel wall**\\n- **Findings suggestive of a closed loop obstruction**: single, isolated segment of dilated small intestine (usually calls for an operation)\\n- **Small bowel feces sign**: gas bubbles and debris within the obstructed small bowel lumen indicating fecalization (indicates fixed prolonged obstruction)\\n- **Pneumatosis intestinalis** (compromised bowel)\\n- **Mesenteric edema**: defined by hazy fluid attenuation in the mesentery of the involved intestinal segment and/or vascular engorgement or vascular 'swirling' (suggests compromised intestine)\\n- **The presence of free intraperitoneal fluid** usually indicates advanced SBO; suspect compromised bowel\\n- **Free intraperitoneal air or portal venous gas**: you know what it means; no need to explain\\n- **Surprise findings suggesting that it is not adhesive SBO**: the list is long; just to mention a few examples: obstructing cecal carcinoma (causing distal SBO), diverticular mass adherent to the small bowel, small bowel neoplasms, intussusception\\n\\nWhile CT has been shown accurately to define the level of obstruction (the ‘transition point’) and identify strangulated bowel segments, it does not mean that it is indicated in all cases of SBO. Take, for instance, the ‘frequent traveler’ who presents to the ER every other month with adhesive SBO, responding to a day of NG decompression — CT-induced ‘radiotherapy’ has not been proven to be a valuable mode of treatment...\\n\\nCT, however, is a ‘must’ in the following circumstances:\\n\\n- **History of abdominal malignancy**: A CT finding of diffuse carcinomatosis indicates that symptomatic management is the...\\n```\\n\\n### Notes:\\n- The text has been extracted and structured into a markdown format.\\n- No images or figures were identified in the provided text. If there are any images or graphs on the page, please provide the relevant details for further extraction.\",\n", " 'images': [{'name': 'img_p331_1.png',\n", " 'height': 879,\n", " 'width': 821,\n", " 'x': 102.96000000000004,\n", " 'y': 72,\n", " 'original_width': 1410,\n", " 'original_height': 1510}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 21.1. What should you look for on the CT?',\n", " 'md': '## Table 21.1. What should you look for on the CT?',\n", " 'bBox': {'x': 109.39, 'y': 78.43, 'w': 298.75, 'h': 17.81}},\n", " {'type': 'text',\n", " 'value': \"- **Dilated loops with air-fluid levels** (present in any SBO)\\n- **Oral contrast 'stacked' in the stomach** suggesting advanced, complete SBO\\n- **A transition point**: decompressed small bowel distal to dilated small bowel (it is not an indication that conservative treatment will fail)\\n- **Thickened bowel wall**\\n- **Findings suggestive of a closed loop obstruction**: single, isolated segment of dilated small intestine (usually calls for an operation)\\n- **Small bowel feces sign**: gas bubbles and debris within the obstructed small bowel lumen indicating fecalization (indicates fixed prolonged obstruction)\\n- **Pneumatosis intestinalis** (compromised bowel)\\n- **Mesenteric edema**: defined by hazy fluid attenuation in the mesentery of the involved intestinal segment and/or vascular engorgement or vascular 'swirling' (suggests compromised intestine)\\n- **The presence of free intraperitoneal fluid** usually indicates advanced SBO; suspect compromised bowel\\n- **Free intraperitoneal air or portal venous gas**: you know what it means; no need to explain\\n- **Surprise findings suggesting that it is not adhesive SBO**: the list is long; just to mention a few examples: obstructing cecal carcinoma (causing distal SBO), diverticular mass adherent to the small bowel, small bowel neoplasms, intussusception\\n\\nWhile CT has been shown accurately to define the level of obstruction (the ‘transition point’) and identify strangulated bowel segments, it does not mean that it is indicated in all cases of SBO. Take, for instance, the ‘frequent traveler’ who presents to the ER every other month with adhesive SBO, responding to a day of NG decompression — CT-induced ‘radiotherapy’ has not been proven to be a valuable mode of treatment...\\n\\nCT, however, is a ‘must’ in the following circumstances:\\n\\n- **History of abdominal malignancy**: A CT finding of diffuse carcinomatosis indicates that symptomatic management is the...\\n```\",\n", " 'md': \"- **Dilated loops with air-fluid levels** (present in any SBO)\\n- **Oral contrast 'stacked' in the stomach** suggesting advanced, complete SBO\\n- **A transition point**: decompressed small bowel distal to dilated small bowel (it is not an indication that conservative treatment will fail)\\n- **Thickened bowel wall**\\n- **Findings suggestive of a closed loop obstruction**: single, isolated segment of dilated small intestine (usually calls for an operation)\\n- **Small bowel feces sign**: gas bubbles and debris within the obstructed small bowel lumen indicating fecalization (indicates fixed prolonged obstruction)\\n- **Pneumatosis intestinalis** (compromised bowel)\\n- **Mesenteric edema**: defined by hazy fluid attenuation in the mesentery of the involved intestinal segment and/or vascular engorgement or vascular 'swirling' (suggests compromised intestine)\\n- **The presence of free intraperitoneal fluid** usually indicates advanced SBO; suspect compromised bowel\\n- **Free intraperitoneal air or portal venous gas**: you know what it means; no need to explain\\n- **Surprise findings suggesting that it is not adhesive SBO**: the list is long; just to mention a few examples: obstructing cecal carcinoma (causing distal SBO), diverticular mass adherent to the small bowel, small bowel neoplasms, intussusception\\n\\nWhile CT has been shown accurately to define the level of obstruction (the ‘transition point’) and identify strangulated bowel segments, it does not mean that it is indicated in all cases of SBO. Take, for instance, the ‘frequent traveler’ who presents to the ER every other month with adhesive SBO, responding to a day of NG decompression — CT-induced ‘radiotherapy’ has not been proven to be a valuable mode of treatment...\\n\\nCT, however, is a ‘must’ in the following circumstances:\\n\\n- **History of abdominal malignancy**: A CT finding of diffuse carcinomatosis indicates that symptomatic management is the...\\n```\",\n", " 'bBox': {'x': 72, 'y': 134.34, 'w': 467.55, 'h': 16.33}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text has been extracted and structured into a markdown format.\\n- No images or figures were identified in the provided text. If there are any images or graphs on the page, please provide the relevant details for further extraction.',\n", " 'md': '- The text has been extracted and structured into a markdown format.\\n- No images or figures were identified in the provided text. If there are any images or graphs on the page, please provide the relevant details for further extraction.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 333,\n", " 'text': ' correct option.\\n • The ‘virgin’ abdomen (see below).\\n • Clinical picture not consistent with the usual partial adhesive\\n SBO. Paralytic ileus may be easily confused with a partial SBO (\\n Chapter 45): there is air in the large bowel, the contrast may go\\n through but the patient remains symptomatic; fever and/or\\n leukocytosis may be present. CT will document the underlying cause\\n responsible for the paralytic ileus, such as acute appendicitis.\\n • Early postoperative SBO ( Chapter 45).\\n • Post-laparoscopic SBO ( Chapter 45).\\n\\n You should integrate the CT findings with the clinical picture in your little gray matter\\n laptop when making decisions.\\n\\n Management\\n\\n The timeline matters: a patient who has been puking for 3 days at\\nhome is different from the one rushed to the ER after the first\\nspasms of mid-abdominal colic! Intuitively, the former will require a\\nmore vigorous resuscitation but a shorter spell of non-operative\\nmanagement — “if he didn’t open up before now…”.\\n\\n Fluid and electrolytes\\n\\n There is hardly a need to remind you that SBO results in significant\\nlosses, or sequestration, of extracellular fluid and electrolytes (into the\\nlumen of the bowel, within its edematous wall, and — as the obstruction\\nprogresses — into the peritoneal cavity), which have to be replaced\\nintravenously. The aggressiveness of fluid management and\\nhemodynamic monitoring depends on the condition of the individual\\npatient. The fluid of choice is Ringer’s lactate. The charting of urine\\noutput — in a catheterized patient if indicated — is the minimal\\nmonitoring necessary. Oh, how often we find such patients on the',\n", " 'md': \"```markdown\\n## Management of Small Bowel Obstruction (SBO)\\n\\n- The ‘virgin’ abdomen (see below).\\n- Clinical picture not consistent with the usual partial adhesive SBO. Paralytic ileus may be easily confused with a partial SBO (Chapter 45): there is air in the large bowel, the contrast may go through but the patient remains symptomatic; fever and/or leukocytosis may be present. CT will document the underlying cause responsible for the paralytic ileus, such as acute appendicitis.\\n- Early postoperative SBO (Chapter 45).\\n- Post-laparoscopic SBO (Chapter 45).\\n\\nYou should integrate the CT findings with the clinical picture in your little gray matter laptop when making decisions.\\n\\n### Management\\n\\nThe timeline matters: a patient who has been puking for 3 days at home is different from the one rushed to the ER after the first spasms of mid-abdominal colic! Intuitively, the former will require a more vigorous resuscitation but a shorter spell of non-operative management — “if he didn’t open up before now…”.\\n\\n### Fluid and Electrolytes\\n\\nThere is hardly a need to remind you that SBO results in significant losses, or sequestration, of extracellular fluid and electrolytes (into the lumen of the bowel, within its edematous wall, and — as the obstruction progresses — into the peritoneal cavity), which have to be replaced intravenously. The aggressiveness of fluid management and hemodynamic monitoring depends on the condition of the individual patient. The fluid of choice is Ringer’s lactate. The charting of urine output — in a catheterized patient if indicated — is the minimal monitoring necessary. Oh, how often we find such patients on the...\\n```\\n\\n### Image Identification and Description\\n- **Figure 1**: The 'virgin' abdomen is referenced but not described in detail. Further context is needed to provide a full description.\\n- **Figure 2**: No images or graphs were identified on this page.\\n\\n### Note\\n- No formulas were present on this page.\\n- No tables were present on this page.\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Small Bowel Obstruction (SBO)',\n", " 'md': '## Management of Small Bowel Obstruction (SBO)',\n", " 'bBox': {'x': 86, 'y': 392, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- The ‘virgin’ abdomen (see below).\\n- Clinical picture not consistent with the usual partial adhesive SBO. Paralytic ileus may be easily confused with a partial SBO (Chapter 45): there is air in the large bowel, the contrast may go through but the patient remains symptomatic; fever and/or leukocytosis may be present. CT will document the underlying cause responsible for the paralytic ileus, such as acute appendicitis.\\n- Early postoperative SBO (Chapter 45).\\n- Post-laparoscopic SBO (Chapter 45).\\n\\nYou should integrate the CT findings with the clinical picture in your little gray matter laptop when making decisions.',\n", " 'md': '- The ‘virgin’ abdomen (see below).\\n- Clinical picture not consistent with the usual partial adhesive SBO. Paralytic ileus may be easily confused with a partial SBO (Chapter 45): there is air in the large bowel, the contrast may go through but the patient remains symptomatic; fever and/or leukocytosis may be present. CT will document the underlying cause responsible for the paralytic ileus, such as acute appendicitis.\\n- Early postoperative SBO (Chapter 45).\\n- Post-laparoscopic SBO (Chapter 45).\\n\\nYou should integrate the CT findings with the clinical picture in your little gray matter laptop when making decisions.',\n", " 'bBox': {'x': 79, 'y': 105, 'w': 457.34, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management',\n", " 'md': '### Management',\n", " 'bBox': {'x': 86, 'y': 392, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The timeline matters: a patient who has been puking for 3 days at home is different from the one rushed to the ER after the first spasms of mid-abdominal colic! Intuitively, the former will require a more vigorous resuscitation but a shorter spell of non-operative management — “if he didn’t open up before now…”.',\n", " 'md': 'The timeline matters: a patient who has been puking for 3 days at home is different from the one rushed to the ER after the first spasms of mid-abdominal colic! Intuitively, the former will require a more vigorous resuscitation but a shorter spell of non-operative management — “if he didn’t open up before now…”.',\n", " 'bBox': {'x': 72, 'y': 392, 'w': 467.28, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Fluid and Electrolytes',\n", " 'md': '### Fluid and Electrolytes',\n", " 'bBox': {'x': 86, 'y': 538, 'w': 170.1, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'There is hardly a need to remind you that SBO results in significant losses, or sequestration, of extracellular fluid and electrolytes (into the lumen of the bowel, within its edematous wall, and — as the obstruction progresses — into the peritoneal cavity), which have to be replaced intravenously. The aggressiveness of fluid management and hemodynamic monitoring depends on the condition of the individual patient. The fluid of choice is Ringer’s lactate. The charting of urine output — in a catheterized patient if indicated — is the minimal monitoring necessary. Oh, how often we find such patients on the...\\n```',\n", " 'md': 'There is hardly a need to remind you that SBO results in significant losses, or sequestration, of extracellular fluid and electrolytes (into the lumen of the bowel, within its edematous wall, and — as the obstruction progresses — into the peritoneal cavity), which have to be replaced intravenously. The aggressiveness of fluid management and hemodynamic monitoring depends on the condition of the individual patient. The fluid of choice is Ringer’s lactate. The charting of urine output — in a catheterized patient if indicated — is the minimal monitoring necessary. Oh, how often we find such patients on the...\\n```',\n", " 'bBox': {'x': 72, 'y': 392, 'w': 468, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 515, 'y': 640, 'w': 24, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': \"- **Figure 1**: The 'virgin' abdomen is referenced but not described in detail. Further context is needed to provide a full description.\\n- **Figure 2**: No images or graphs were identified on this page.\",\n", " 'md': \"- **Figure 1**: The 'virgin' abdomen is referenced but not described in detail. Further context is needed to provide a full description.\\n- **Figure 2**: No images or graphs were identified on this page.\",\n", " 'bBox': {'x': 177, 'y': 640, 'w': 28.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Note',\n", " 'md': '### Note',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No formulas were present on this page.\\n- No tables were present on this page.',\n", " 'md': '- No formulas were present on this page.\\n- No tables were present on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'through '}, {'text': ''}, {'text': ''}]},\n", " {'page': 334,\n", " 'text': '‘medical floors’ without a Foley catheter — nobody knowing the volume\\nof urine they have passed (sometimes even without a nasogastric tube).\\nIt seems that this will never change — sluggish internisits running\\naround, glued to their iPhones on which the entire corpus of medical\\nwisdom is loaded, nurses (sorry, ‘patient care attendants’) ever immersed\\nin the electronic medical record — and the poor old shriveled lady,\\nspewing, drying out, until you arrive!\\n\\n Even patients scheduled for urgent laparotomy for strangulation require\\nadequate pre-operative resuscitation ( Chapter 6). Patients with SBO\\nsometimes have intra-abdominal hypertension (we have seen patients\\nwith distal SBO presenting with a full-blown abdominal compartment\\nsyndrome), which may falsely raise their cardiac filling pressures (CVP,\\nwedge). These patients require even more aggressive fluid administration\\nto maintain an adequate cardiac output ( Chapter 33).\\n\\n Nasogastric (NG) aspiration\\n\\n “My work essentially has been that of plumber of the alimentary canal. I\\nhave worked on both ends, but largely in between”, wrote Owen ħ.\\nWangensteen, of Minneapolis. And indeed, by the 1930s he had\\nintroduced the NG tube as a crucial and indispensable aid in the\\nmanagement of SBO. So how sad and pathetic it is to find — 80 years\\nlater — patients admitted from the ER with the diagnosis of SBO, with\\ntheir abdomens distended, their pajamas stained in green, and no tube\\nsticking from their nose!\\n\\n A large NG tube (at least 18Fr in diameter) is needed. The NG tube\\nhas both therapeutic and diagnostic functions. It controls vomiting\\n(and reduces the risk of aspiration), but its main aim is to\\ndecompress the dilated stomach and gut proximal to the\\nobstruction. In a simple obstruction, decompression of the bowel results\\nin rapid pain relief and alleviates the distension. Essentially, the segment\\nof intestine proximal to the obstruction and distal to the gastroesophageal\\njunction behaves like a ‘closed loop’ — decompression of the stomach\\nwith a nasogastric tube converts it to a simple obstruction; pain, nausea\\nand vomiting are relieved. Note that in strangulation or closed-loop\\nobstruction, the pain persists despite nasogastric aspiration.',\n", " 'md': '```markdown\\n## Medical Management of SBO\\n\\n‘Medical floors’ without a Foley catheter — nobody knowing the volume of urine they have passed (sometimes even without a nasogastric tube). It seems that this will never change — sluggish internists running around, glued to their iPhones on which the entire corpus of medical wisdom is loaded, nurses (sorry, ‘patient care attendants’) ever immersed in the electronic medical record — and the poor old shriveled lady, spewing, drying out, until you arrive!\\n\\nEven patients scheduled for urgent laparotomy for strangulation require adequate pre-operative resuscitation (Chapter 6). Patients with SBO sometimes have intra-abdominal hypertension (we have seen patients with distal SBO presenting with a full-blown abdominal compartment syndrome), which may falsely raise their cardiac filling pressures (CVP, wedge). These patients require even more aggressive fluid administration to maintain an adequate cardiac output (Chapter 33).\\n\\n### Nasogastric (NG) Aspiration\\n\\n“My work essentially has been that of plumber of the alimentary canal. I have worked on both ends, but largely in between,” wrote Owen H. Wangensteen, of Minneapolis. And indeed, by the 1930s he had introduced the NG tube as a crucial and indispensable aid in the management of SBO. So how sad and pathetic it is to find — 80 years later — patients admitted from the ER with the diagnosis of SBO, with their abdomens distended, their pajamas stained in green, and no tube sticking from their nose!\\n\\nA large NG tube (at least 18Fr in diameter) is needed. The NG tube has both therapeutic and diagnostic functions. It controls vomiting (and reduces the risk of aspiration), but its main aim is to decompress the dilated stomach and gut proximal to the obstruction. In a simple obstruction, decompression of the bowel results in rapid pain relief and alleviates the distension. Essentially, the segment of intestine proximal to the obstruction and distal to the gastroesophageal junction behaves like a ‘closed loop’ — decompression of the stomach with a nasogastric tube converts it to a simple obstruction; pain, nausea, and vomiting are relieved. Note that in strangulation or closed-loop obstruction, the pain persists despite nasogastric aspiration.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Medical Management of SBO',\n", " 'md': '## Medical Management of SBO',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '‘Medical floors’ without a Foley catheter — nobody knowing the volume of urine they have passed (sometimes even without a nasogastric tube). It seems that this will never change — sluggish internists running around, glued to their iPhones on which the entire corpus of medical wisdom is loaded, nurses (sorry, ‘patient care attendants’) ever immersed in the electronic medical record — and the poor old shriveled lady, spewing, drying out, until you arrive!\\n\\nEven patients scheduled for urgent laparotomy for strangulation require adequate pre-operative resuscitation (Chapter 6). Patients with SBO sometimes have intra-abdominal hypertension (we have seen patients with distal SBO presenting with a full-blown abdominal compartment syndrome), which may falsely raise their cardiac filling pressures (CVP, wedge). These patients require even more aggressive fluid administration to maintain an adequate cardiac output (Chapter 33).',\n", " 'md': '‘Medical floors’ without a Foley catheter — nobody knowing the volume of urine they have passed (sometimes even without a nasogastric tube). It seems that this will never change — sluggish internists running around, glued to their iPhones on which the entire corpus of medical wisdom is loaded, nurses (sorry, ‘patient care attendants’) ever immersed in the electronic medical record — and the poor old shriveled lady, spewing, drying out, until you arrive!\\n\\nEven patients scheduled for urgent laparotomy for strangulation require adequate pre-operative resuscitation (Chapter 6). Patients with SBO sometimes have intra-abdominal hypertension (we have seen patients with distal SBO presenting with a full-blown abdominal compartment syndrome), which may falsely raise their cardiac filling pressures (CVP, wedge). These patients require even more aggressive fluid administration to maintain an adequate cardiac output (Chapter 33).',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.76, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Nasogastric (NG) Aspiration',\n", " 'md': '### Nasogastric (NG) Aspiration',\n", " 'bBox': {'x': 86, 'y': 363, 'w': 218.85, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '“My work essentially has been that of plumber of the alimentary canal. I have worked on both ends, but largely in between,” wrote Owen H. Wangensteen, of Minneapolis. And indeed, by the 1930s he had introduced the NG tube as a crucial and indispensable aid in the management of SBO. So how sad and pathetic it is to find — 80 years later — patients admitted from the ER with the diagnosis of SBO, with their abdomens distended, their pajamas stained in green, and no tube sticking from their nose!\\n\\nA large NG tube (at least 18Fr in diameter) is needed. The NG tube has both therapeutic and diagnostic functions. It controls vomiting (and reduces the risk of aspiration), but its main aim is to decompress the dilated stomach and gut proximal to the obstruction. In a simple obstruction, decompression of the bowel results in rapid pain relief and alleviates the distension. Essentially, the segment of intestine proximal to the obstruction and distal to the gastroesophageal junction behaves like a ‘closed loop’ — decompression of the stomach with a nasogastric tube converts it to a simple obstruction; pain, nausea, and vomiting are relieved. Note that in strangulation or closed-loop obstruction, the pain persists despite nasogastric aspiration.\\n```',\n", " 'md': '“My work essentially has been that of plumber of the alimentary canal. I have worked on both ends, but largely in between,” wrote Owen H. Wangensteen, of Minneapolis. And indeed, by the 1930s he had introduced the NG tube as a crucial and indispensable aid in the management of SBO. So how sad and pathetic it is to find — 80 years later — patients admitted from the ER with the diagnosis of SBO, with their abdomens distended, their pajamas stained in green, and no tube sticking from their nose!\\n\\nA large NG tube (at least 18Fr in diameter) is needed. The NG tube has both therapeutic and diagnostic functions. It controls vomiting (and reduces the risk of aspiration), but its main aim is to decompress the dilated stomach and gut proximal to the obstruction. In a simple obstruction, decompression of the bowel results in rapid pain relief and alleviates the distension. Essentially, the segment of intestine proximal to the obstruction and distal to the gastroesophageal junction behaves like a ‘closed loop’ — decompression of the stomach with a nasogastric tube converts it to a simple obstruction; pain, nausea, and vomiting are relieved. Note that in strangulation or closed-loop obstruction, the pain persists despite nasogastric aspiration.\\n```',\n", " 'bBox': {'x': 72, 'y': 399, 'w': 467.92, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'sometimes have intra-abdominal hypertension (we have seen patients'},\n", " {'text': ''}]},\n", " {'page': 335,\n", " 'text': ' Insertion of an NG tube is extremely unpleasant. Many patients\\nremember it as the most horrendous experience of their hospital stay\\n(and would certainly resist fiercely any attempt at re-insertion). The\\nprocedure can however be made much ‘kinder’ — soften the rigid tube by\\nimmersion for a minute or two in very hot water, spray the nostril of the\\npatient with a local anesthetic, and lubricate the tube. There is no\\nadvantage in connecting the NG tube to a suction apparatus; drainage by\\ngravity is as effective. (Long naso-intestinal tubes [Cantor, Linton, Moss\\n— you may have heard some of the names] are a gimmick with unproven\\nbenefits — requiring cumbersome manipulation and causing delay when\\noperation is necessary. Those who still mention them in your\\ndepartmental meetings tend to be senile.)\\n\\n When to operate?\\n\\n An hour or two of fluid replenishment is compulsory in the\\nmanagement of every patient. Reassess your resuscitated and NG\\ndecompressed patient. What is the pattern of pain now? Is there\\nimprovement on abdominal re-examination?\\n\\n Immediate operation is required in a minority of patients in whom\\nthe probability of strangulation or bowel compromise is high: those\\nwho do not improve, those who experience continuous pain, or those with\\nsignificant abdominal tenderness combined with the features stated\\nabove (e.g. fecal NG aspirate, SIRS). Of course, radiological features\\nshould also be taken into account.\\n\\n An initial non-operative approach is often possible because most\\npatients improve at first on the ‘drip-and-suck’ regimen. It would be safe\\nto bet, at this stage, that patients with radiological partial obstruction will\\neventually escape surgery, whereas those with complete obstruction will\\neventually visit the operating room. But how long is it safe to continue\\nwith conservative management?\\n\\n Some surgeons would abort the conservative trial at 24 hours if the\\npatient fails to ‘open up’, because of the nagging concern about\\nstrangulation even in a benign-looking abdomen. Others are prepared to',\n", " 'md': '```markdown\\n## Insertion of an NG Tube\\n\\nInsertion of an NG tube is extremely unpleasant. Many patients remember it as the most horrendous experience of their hospital stay (and would certainly resist fiercely any attempt at re-insertion). The procedure can however be made much ‘kinder’ — soften the rigid tube by immersion for a minute or two in very hot water, spray the nostril of the patient with a local anesthetic, and lubricate the tube. There is no advantage in connecting the NG tube to a suction apparatus; drainage by gravity is as effective. Long naso-intestinal tubes (Cantor, Linton, Moss — you may have heard some of the names) are a gimmick with unproven benefits — requiring cumbersome manipulation and causing delay when operation is necessary. Those who still mention them in your departmental meetings tend to be senile.\\n\\n### When to Operate?\\n\\nAn hour or two of fluid replenishment is compulsory in the management of every patient. Reassess your resuscitated and NG decompressed patient. What is the pattern of pain now? Is there improvement on abdominal re-examination?\\n\\nImmediate operation is required in a minority of patients in whom the probability of strangulation or bowel compromise is high: those who do not improve, those who experience continuous pain, or those with significant abdominal tenderness combined with the features stated above (e.g. fecal NG aspirate, SIRS). Of course, radiological features should also be taken into account.\\n\\nAn initial non-operative approach is often possible because most patients improve at first on the ‘drip-and-suck’ regimen. It would be safe to bet, at this stage, that patients with radiological partial obstruction will eventually escape surgery, whereas those with complete obstruction will eventually visit the operating room. But how long is it safe to continue with conservative management?\\n\\nSome surgeons would abort the conservative trial at 24 hours if the patient fails to ‘open up’, because of the nagging concern about strangulation even in a benign-looking abdomen. Others are prepared to...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Insertion of an NG Tube',\n", " 'md': '## Insertion of an NG Tube',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Insertion of an NG tube is extremely unpleasant. Many patients remember it as the most horrendous experience of their hospital stay (and would certainly resist fiercely any attempt at re-insertion). The procedure can however be made much ‘kinder’ — soften the rigid tube by immersion for a minute or two in very hot water, spray the nostril of the patient with a local anesthetic, and lubricate the tube. There is no advantage in connecting the NG tube to a suction apparatus; drainage by gravity is as effective. Long naso-intestinal tubes (Cantor, Linton, Moss — you may have heard some of the names) are a gimmick with unproven benefits — requiring cumbersome manipulation and causing delay when operation is necessary. Those who still mention them in your departmental meetings tend to be senile.',\n", " 'md': 'Insertion of an NG tube is extremely unpleasant. Many patients remember it as the most horrendous experience of their hospital stay (and would certainly resist fiercely any attempt at re-insertion). The procedure can however be made much ‘kinder’ — soften the rigid tube by immersion for a minute or two in very hot water, spray the nostril of the patient with a local anesthetic, and lubricate the tube. There is no advantage in connecting the NG tube to a suction apparatus; drainage by gravity is as effective. Long naso-intestinal tubes (Cantor, Linton, Moss — you may have heard some of the names) are a gimmick with unproven benefits — requiring cumbersome manipulation and causing delay when operation is necessary. Those who still mention them in your departmental meetings tend to be senile.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'When to Operate?',\n", " 'md': '### When to Operate?',\n", " 'bBox': {'x': 86, 'y': 311, 'w': 139.76, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'An hour or two of fluid replenishment is compulsory in the management of every patient. Reassess your resuscitated and NG decompressed patient. What is the pattern of pain now? Is there improvement on abdominal re-examination?\\n\\nImmediate operation is required in a minority of patients in whom the probability of strangulation or bowel compromise is high: those who do not improve, those who experience continuous pain, or those with significant abdominal tenderness combined with the features stated above (e.g. fecal NG aspirate, SIRS). Of course, radiological features should also be taken into account.\\n\\nAn initial non-operative approach is often possible because most patients improve at first on the ‘drip-and-suck’ regimen. It would be safe to bet, at this stage, that patients with radiological partial obstruction will eventually escape surgery, whereas those with complete obstruction will eventually visit the operating room. But how long is it safe to continue with conservative management?\\n\\nSome surgeons would abort the conservative trial at 24 hours if the patient fails to ‘open up’, because of the nagging concern about strangulation even in a benign-looking abdomen. Others are prepared to...\\n```',\n", " 'md': 'An hour or two of fluid replenishment is compulsory in the management of every patient. Reassess your resuscitated and NG decompressed patient. What is the pattern of pain now? Is there improvement on abdominal re-examination?\\n\\nImmediate operation is required in a minority of patients in whom the probability of strangulation or bowel compromise is high: those who do not improve, those who experience continuous pain, or those with significant abdominal tenderness combined with the features stated above (e.g. fecal NG aspirate, SIRS). Of course, radiological features should also be taken into account.\\n\\nAn initial non-operative approach is often possible because most patients improve at first on the ‘drip-and-suck’ regimen. It would be safe to bet, at this stage, that patients with radiological partial obstruction will eventually escape surgery, whereas those with complete obstruction will eventually visit the operating room. But how long is it safe to continue with conservative management?\\n\\nSome surgeons would abort the conservative trial at 24 hours if the patient fails to ‘open up’, because of the nagging concern about strangulation even in a benign-looking abdomen. Others are prepared to...\\n```',\n", " 'bBox': {'x': 72, 'y': 396, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 336,\n", " 'text': 'persevere, up to 5 days in a carefully monitored patient — especially in\\npatients who give a history of repeated episodes of adhesive SBO.\\n\\n In the absence of an immediate indication for operation, we favor the\\nuse of an oral water-soluble contrast medium (e.g. Gastrografin®) as\\nsoon as the diagnosis of SBO is made. Gastrografin®, a hyperosmolar\\nagent that promotes intestinal ‘hurry’, plays, we believe, two roles:\\ndiagnostic-prognostic and therapeutic.\\n\\n The ‘Gastrografin® challenge’\\n After the initial gastric decompression (an hour or two), instill 100ml\\nGastrografin® (make sure that your patient does not get barium —\\nChapter 4) via the NG tube which is then clamped. After 4-6 hours, a\\nplain abdominal X-ray is obtained. This is not a formal radiological\\nstudy under fluoroscopy.\\n\\n • The presence of contrast in the large bowel proves that the\\n obstruction is partial. In most of these instances, the Gastrografin® is\\n very soon passed per rectum as well. In partial SBO, Gastrografin®\\n is often therapeutic as it expedites the resolution of the obstructing\\n episode. On the other hand, failure of Gastrografin® to reach the\\n colon within 6 hours indicates a complete obstruction. The\\n probability of spontaneous resolution after a failed Gastrografin®\\n challenge is very low; most of these patients will require surgery\\n anyway so why not operate on them now?\\n • Another sign of a failed Gastrografin® challenge is the failure of the\\n contrast to evacuate from the stomach and enter the small bowel —\\n it signifies significant back pressure in the obstructed bowel. Thus, if\\n you see the stomach full of Gastrografin®, you know that further\\n delay is futile — you need to operate!\\n\\n These days a CT Gastrografin® challenge works the same way\\nand provides more information. So if we admit a patient during the\\nevening hours with a suspected adhesive SBO, and without features\\nmandating an immediate operation, we perform the Gastrografin®',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nIn the absence of an immediate indication for operation, we favor the use of an oral water-soluble contrast medium (e.g. Gastrografin®) as soon as the diagnosis of SBO is made. Gastrografin®, a hyperosmolar agent that promotes intestinal ‘hurry’, plays, we believe, two roles: diagnostic-prognostic and therapeutic.\\n\\n### The ‘Gastrografin® challenge’\\nAfter the initial gastric decompression (an hour or two), instill 100ml Gastrografin® (make sure that your patient does not get barium — Chapter 4) via the NG tube which is then clamped. After 4-6 hours, a plain abdominal X-ray is obtained. This is not a formal radiological study under fluoroscopy.\\n\\n- The presence of contrast in the large bowel proves that the obstruction is partial. In most of these instances, the Gastrografin® is very soon passed per rectum as well. In partial SBO, Gastrografin® is often therapeutic as it expedites the resolution of the obstructing episode. On the other hand, failure of Gastrografin® to reach the colon within 6 hours indicates a complete obstruction. The probability of spontaneous resolution after a failed Gastrografin® challenge is very low; most of these patients will require surgery anyway so why not operate on them now?\\n- Another sign of a failed Gastrografin® challenge is the failure of the contrast to evacuate from the stomach and enter the small bowel — it signifies significant back pressure in the obstructed bowel. Thus, if you see the stomach full of Gastrografin®, you know that further delay is futile — you need to operate!\\n\\nThese days a CT Gastrografin® challenge works the same way and provides more information. So if we admit a patient during the evening hours with a suspected adhesive SBO, and without features mandating an immediate operation, we perform the Gastrografin®.\\n\\n## Image Identification and Description\\n\\n*No images or graphs were identified on this page.*\\n\\n## Summary\\n\\nThis page discusses the use of Gastrografin® as a diagnostic and therapeutic agent in cases of small bowel obstruction (SBO). It outlines the procedure for the Gastrografin® challenge, the interpretation of results, and the implications for patient management.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In the absence of an immediate indication for operation, we favor the use of an oral water-soluble contrast medium (e.g. Gastrografin®) as soon as the diagnosis of SBO is made. Gastrografin®, a hyperosmolar agent that promotes intestinal ‘hurry’, plays, we believe, two roles: diagnostic-prognostic and therapeutic.',\n", " 'md': 'In the absence of an immediate indication for operation, we favor the use of an oral water-soluble contrast medium (e.g. Gastrografin®) as soon as the diagnosis of SBO is made. Gastrografin®, a hyperosmolar agent that promotes intestinal ‘hurry’, plays, we believe, two roles: diagnostic-prognostic and therapeutic.',\n", " 'bBox': {'x': 72, 'y': 137, 'w': 467.59, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The ‘Gastrografin® challenge’',\n", " 'md': '### The ‘Gastrografin® challenge’',\n", " 'bBox': {'x': 86, 'y': 246, 'w': 230.93, 'h': 22.56}},\n", " {'type': 'text',\n", " 'value': 'After the initial gastric decompression (an hour or two), instill 100ml Gastrografin® (make sure that your patient does not get barium — Chapter 4) via the NG tube which is then clamped. After 4-6 hours, a plain abdominal X-ray is obtained. This is not a formal radiological study under fluoroscopy.\\n\\n- The presence of contrast in the large bowel proves that the obstruction is partial. In most of these instances, the Gastrografin® is very soon passed per rectum as well. In partial SBO, Gastrografin® is often therapeutic as it expedites the resolution of the obstructing episode. On the other hand, failure of Gastrografin® to reach the colon within 6 hours indicates a complete obstruction. The probability of spontaneous resolution after a failed Gastrografin® challenge is very low; most of these patients will require surgery anyway so why not operate on them now?\\n- Another sign of a failed Gastrografin® challenge is the failure of the contrast to evacuate from the stomach and enter the small bowel — it signifies significant back pressure in the obstructed bowel. Thus, if you see the stomach full of Gastrografin®, you know that further delay is futile — you need to operate!\\n\\nThese days a CT Gastrografin® challenge works the same way and provides more information. So if we admit a patient during the evening hours with a suspected adhesive SBO, and without features mandating an immediate operation, we perform the Gastrografin®.',\n", " 'md': 'After the initial gastric decompression (an hour or two), instill 100ml Gastrografin® (make sure that your patient does not get barium — Chapter 4) via the NG tube which is then clamped. After 4-6 hours, a plain abdominal X-ray is obtained. This is not a formal radiological study under fluoroscopy.\\n\\n- The presence of contrast in the large bowel proves that the obstruction is partial. In most of these instances, the Gastrografin® is very soon passed per rectum as well. In partial SBO, Gastrografin® is often therapeutic as it expedites the resolution of the obstructing episode. On the other hand, failure of Gastrografin® to reach the colon within 6 hours indicates a complete obstruction. The probability of spontaneous resolution after a failed Gastrografin® challenge is very low; most of these patients will require surgery anyway so why not operate on them now?\\n- Another sign of a failed Gastrografin® challenge is the failure of the contrast to evacuate from the stomach and enter the small bowel — it signifies significant back pressure in the obstructed bowel. Thus, if you see the stomach full of Gastrografin®, you know that further delay is futile — you need to operate!\\n\\nThese days a CT Gastrografin® challenge works the same way and provides more information. So if we admit a patient during the evening hours with a suspected adhesive SBO, and without features mandating an immediate operation, we perform the Gastrografin®.',\n", " 'bBox': {'x': 72, 'y': 288, 'w': 467.1, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or graphs were identified on this page.*',\n", " 'md': '*No images or graphs were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the use of Gastrografin® as a diagnostic and therapeutic agent in cases of small bowel obstruction (SBO). It outlines the procedure for the Gastrografin® challenge, the interpretation of results, and the implications for patient management.\\n```',\n", " 'md': 'This page discusses the use of Gastrografin® as a diagnostic and therapeutic agent in cases of small bowel obstruction (SBO). It outlines the procedure for the Gastrografin® challenge, the interpretation of results, and the implications for patient management.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 4) via the NG tube which is then clamped. plain abdominal X-ray is obtained'}]},\n", " {'page': 337,\n", " 'text': 'challenge, and if by the morning the contrast has not reached the\\ncolon we would operate. If you see the contrast in the colon, expect the\\npatient to defecate very soon. If CT without Gastrografin® has been\\nobtained, we would order the challenge in the morning and plan to\\noperate early afternoon — that is if the obstruction is not relieved.\\n\\n Of course, the results of the Gastrografin® challenge test should be\\ncorrelated with the whole clinical picture. Note that Gastrografin® may\\npass across a chronic small bowel narrowing. Thus, for the obstructive\\nepisode to be considered ‘resolved’, the abdominal symptoms and signs\\nshould disappear as well.\\n\\n This approach has led us to modify that old aphorism; the new version\\nshould read: “Never let a patient with a complete intestinal\\nobstruction escape an operation for more than 24 hours.”\\n\\n The Gastrografin® challenge is safe. The most feared potential\\ncomplication is aspiration of the hyperosmolar Gastrografin® into the\\nlungs, causing edema and pneumonitis. ħowever, as long as your patient\\ncan protect his airways (he is not obtunded and the stomach has been\\ndecompressed beforehand), this should not happen.\\n\\n Antibiotics\\n\\n In animal models of SBO, systemic antibiotics delay intestinal\\ncompromise and decrease mortality. In clinical practice, there is no need\\nfor antibiotics in patients treated conservatively, and we operate\\nwhenever the suspicion of intestinal compromise is entertained. A pre-\\noperative dose of antibiotics is administered prophylactically; beyond this\\nthere is no need for postoperative antibiotics even if bowel resection has\\nbeen performed. The only indication for postoperative antibiotic\\nadministration would be longstanding bowel gangrene with\\nestablished intra-abdominal infection.\\n\\n The conduct of the operation',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nThe text discusses the management of intestinal obstruction, particularly focusing on the use of the Gastrografin® challenge test. Key points include:\\n\\n- If the contrast has not reached the colon by morning, an operation is planned.\\n- If contrast is seen in the colon, the patient is expected to defecate soon.\\n- If a CT scan without Gastrografin® is obtained, a challenge is ordered in the morning with plans for an early afternoon operation if obstruction persists.\\n- The results of the Gastrografin® challenge should correlate with the overall clinical picture, as Gastrografin® may pass through chronic small bowel narrowing.\\n- For an obstructive episode to be considered resolved, abdominal symptoms and signs must disappear.\\n- A modified aphorism is presented: “Never let a patient with a complete intestinal obstruction escape an operation for more than 24 hours.”\\n- The Gastrografin® challenge is deemed safe, with aspiration being the most feared complication, which can be mitigated if the patient can protect their airways.\\n\\n### Antibiotics\\n\\n- In animal models of small bowel obstruction (SBO), systemic antibiotics delay intestinal compromise and decrease mortality.\\n- In clinical practice, antibiotics are not needed for conservatively treated patients, and operations are performed when intestinal compromise is suspected.\\n- A pre-operative dose of antibiotics is given prophylactically, with no need for postoperative antibiotics unless there is longstanding bowel gangrene with established intra-abdominal infection.\\n\\n## Summary\\n\\nThe text outlines the protocol for managing intestinal obstruction, emphasizing the importance of the Gastrografin® challenge test and the judicious use of antibiotics in surgical practice.\\n\\n## Note\\n\\nNo images, graphs, or tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the management of intestinal obstruction, particularly focusing on the use of the Gastrografin® challenge test. Key points include:\\n\\n- If the contrast has not reached the colon by morning, an operation is planned.\\n- If contrast is seen in the colon, the patient is expected to defecate soon.\\n- If a CT scan without Gastrografin® is obtained, a challenge is ordered in the morning with plans for an early afternoon operation if obstruction persists.\\n- The results of the Gastrografin® challenge should correlate with the overall clinical picture, as Gastrografin® may pass through chronic small bowel narrowing.\\n- For an obstructive episode to be considered resolved, abdominal symptoms and signs must disappear.\\n- A modified aphorism is presented: “Never let a patient with a complete intestinal obstruction escape an operation for more than 24 hours.”\\n- The Gastrografin® challenge is deemed safe, with aspiration being the most feared complication, which can be mitigated if the patient can protect their airways.',\n", " 'md': 'The text discusses the management of intestinal obstruction, particularly focusing on the use of the Gastrografin® challenge test. Key points include:\\n\\n- If the contrast has not reached the colon by morning, an operation is planned.\\n- If contrast is seen in the colon, the patient is expected to defecate soon.\\n- If a CT scan without Gastrografin® is obtained, a challenge is ordered in the morning with plans for an early afternoon operation if obstruction persists.\\n- The results of the Gastrografin® challenge should correlate with the overall clinical picture, as Gastrografin® may pass through chronic small bowel narrowing.\\n- For an obstructive episode to be considered resolved, abdominal symptoms and signs must disappear.\\n- A modified aphorism is presented: “Never let a patient with a complete intestinal obstruction escape an operation for more than 24 hours.”\\n- The Gastrografin® challenge is deemed safe, with aspiration being the most feared complication, which can be mitigated if the patient can protect their airways.',\n", " 'bBox': {'x': 72, 'y': 328, 'w': 394.04, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Antibiotics',\n", " 'md': '### Antibiotics',\n", " 'bBox': {'x': 86, 'y': 477, 'w': 85.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- In animal models of small bowel obstruction (SBO), systemic antibiotics delay intestinal compromise and decrease mortality.\\n- In clinical practice, antibiotics are not needed for conservatively treated patients, and operations are performed when intestinal compromise is suspected.\\n- A pre-operative dose of antibiotics is given prophylactically, with no need for postoperative antibiotics unless there is longstanding bowel gangrene with established intra-abdominal infection.',\n", " 'md': '- In animal models of small bowel obstruction (SBO), systemic antibiotics delay intestinal compromise and decrease mortality.\\n- In clinical practice, antibiotics are not needed for conservatively treated patients, and operations are performed when intestinal compromise is suspected.\\n- A pre-operative dose of antibiotics is given prophylactically, with no need for postoperative antibiotics unless there is longstanding bowel gangrene with established intra-abdominal infection.',\n", " 'bBox': {'x': 72, 'y': 477, 'w': 258, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text outlines the protocol for managing intestinal obstruction, emphasizing the importance of the Gastrografin® challenge test and the judicious use of antibiotics in surgical practice.',\n", " 'md': 'The text outlines the protocol for managing intestinal obstruction, emphasizing the importance of the Gastrografin® challenge test and the judicious use of antibiotics in surgical practice.',\n", " 'bBox': {'x': 86, 'y': 477, 'w': 85.5, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Note',\n", " 'md': '## Note',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'No images, graphs, or tables were identified on this page.\\n```',\n", " 'md': 'No images, graphs, or tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 338,\n", " 'text': ' Most surgeons still prefer the open approach. About the\\nlaparoscopic one — please see the section below.\\n\\n ħere is our advice for the conduct of the operation:\\n\\n • The incision for abdominal re-entry has been discussed in\\n Chapter 10 but we need to remind you to be careful in avoiding\\n iatrogenic enterotomies with their associated postoperative\\n morbidity. Finding your way into the peritoneal cavity may take\\n time, but be patient, for this is the longest part of the\\n procedure. The rest is usually simpler. In this scenario the gentle\\n hand of the ‘slow’ surgeon is much preferred over that of the macho\\n cowboy — haste may open the gate to a nighmare.\\n • Find a loop of collapsed small bowel and follow it proximally. It\\n will lead you to the point of obstruction just distal to the dilated\\n obstructed intestine. Now deal with the cause of obstruction, be it a\\n simple band or a bowel kink. Mobilize the involved bowel segment\\n using sharp and blunt dissection with traction applied on the two\\n structures to be separated.\\n • Resect only when bowel is non-viable or it is impossible to free the\\n obstructed segment. Frequently, an ischemic-looking loop of bowel\\n is dusky after being released. Do not rush to resect; cover the bowel\\n with a warm, wet laparotomy pad and wait patiently; it will usually\\n pink up within 10 minutes. If not, it requires resection.\\n • Concentrate on the loop which is responsible for the obstruction;\\n there is no need to free the whole intestine by dividing all the\\n remaining innocent adhesions. This maneuver may be\\n cosmetically appealing, but adhesions lysed today will reform\\n tomorrow. As aptly stated by Timothy Fabian: “Lysis of all small\\n bowel adhesions is not required because I believe that the bowel is\\n ‘locked in the open position’ by these chronic adhesions.”\\n\\n We disagree slightly; if we have to perform a bowel resection, we free all the adhesions distal to\\n the anastomosis to prevent a second narrow part causing back pressure on the anastomosis\\n and then perhaps leading to a leak… Ari & Jon',\n", " 'md': '```markdown\\n## Surgical Advice for Laparoscopic Approach\\n\\nMost surgeons still prefer the open approach. About the laparoscopic one — please see the section below.\\n\\nHere is our advice for the conduct of the operation:\\n\\n- The incision for abdominal re-entry has been discussed in Chapter 10 but we need to remind you to be careful in avoiding iatrogenic enterotomies with their associated postoperative morbidity. Finding your way into the peritoneal cavity may take time, but be patient, for this is the longest part of the procedure. The rest is usually simpler. In this scenario, the gentle hand of the ‘slow’ surgeon is much preferred over that of the macho cowboy — haste may open the gate to a nightmare.\\n\\n- Find a loop of collapsed small bowel and follow it proximally. It will lead you to the point of obstruction just distal to the dilated obstructed intestine. Now deal with the cause of obstruction, be it a simple band or a bowel kink. Mobilize the involved bowel segment using sharp and blunt dissection with traction applied on the two structures to be separated.\\n\\n- Resect only when bowel is non-viable or it is impossible to free the obstructed segment. Frequently, an ischemic-looking loop of bowel is dusky after being released. Do not rush to resect; cover the bowel with a warm, wet laparotomy pad and wait patiently; it will usually pink up within 10 minutes. If not, it requires resection.\\n\\n- Concentrate on the loop which is responsible for the obstruction; there is no need to free the whole intestine by dividing all the remaining innocent adhesions. This maneuver may be cosmetically appealing, but adhesions lysed today will reform tomorrow. As aptly stated by Timothy Fabian: “Lysis of all small bowel adhesions is not required because I believe that the bowel is ‘locked in the open position’ by these chronic adhesions.”\\n\\nWe disagree slightly; if we have to perform a bowel resection, we free all the adhesions distal to the anastomosis to prevent a second narrow part causing back pressure on the anastomosis and then perhaps leading to a leak… Ari & Jon\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Advice for Laparoscopic Approach',\n", " 'md': '## Surgical Advice for Laparoscopic Approach',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Most surgeons still prefer the open approach. About the laparoscopic one — please see the section below.\\n\\nHere is our advice for the conduct of the operation:\\n\\n- The incision for abdominal re-entry has been discussed in Chapter 10 but we need to remind you to be careful in avoiding iatrogenic enterotomies with their associated postoperative morbidity. Finding your way into the peritoneal cavity may take time, but be patient, for this is the longest part of the procedure. The rest is usually simpler. In this scenario, the gentle hand of the ‘slow’ surgeon is much preferred over that of the macho cowboy — haste may open the gate to a nightmare.\\n\\n- Find a loop of collapsed small bowel and follow it proximally. It will lead you to the point of obstruction just distal to the dilated obstructed intestine. Now deal with the cause of obstruction, be it a simple band or a bowel kink. Mobilize the involved bowel segment using sharp and blunt dissection with traction applied on the two structures to be separated.\\n\\n- Resect only when bowel is non-viable or it is impossible to free the obstructed segment. Frequently, an ischemic-looking loop of bowel is dusky after being released. Do not rush to resect; cover the bowel with a warm, wet laparotomy pad and wait patiently; it will usually pink up within 10 minutes. If not, it requires resection.\\n\\n- Concentrate on the loop which is responsible for the obstruction; there is no need to free the whole intestine by dividing all the remaining innocent adhesions. This maneuver may be cosmetically appealing, but adhesions lysed today will reform tomorrow. As aptly stated by Timothy Fabian: “Lysis of all small bowel adhesions is not required because I believe that the bowel is ‘locked in the open position’ by these chronic adhesions.”\\n\\nWe disagree slightly; if we have to perform a bowel resection, we free all the adhesions distal to the anastomosis to prevent a second narrow part causing back pressure on the anastomosis and then perhaps leading to a leak… Ari & Jon\\n```',\n", " 'md': 'Most surgeons still prefer the open approach. About the laparoscopic one — please see the section below.\\n\\nHere is our advice for the conduct of the operation:\\n\\n- The incision for abdominal re-entry has been discussed in Chapter 10 but we need to remind you to be careful in avoiding iatrogenic enterotomies with their associated postoperative morbidity. Finding your way into the peritoneal cavity may take time, but be patient, for this is the longest part of the procedure. The rest is usually simpler. In this scenario, the gentle hand of the ‘slow’ surgeon is much preferred over that of the macho cowboy — haste may open the gate to a nightmare.\\n\\n- Find a loop of collapsed small bowel and follow it proximally. It will lead you to the point of obstruction just distal to the dilated obstructed intestine. Now deal with the cause of obstruction, be it a simple band or a bowel kink. Mobilize the involved bowel segment using sharp and blunt dissection with traction applied on the two structures to be separated.\\n\\n- Resect only when bowel is non-viable or it is impossible to free the obstructed segment. Frequently, an ischemic-looking loop of bowel is dusky after being released. Do not rush to resect; cover the bowel with a warm, wet laparotomy pad and wait patiently; it will usually pink up within 10 minutes. If not, it requires resection.\\n\\n- Concentrate on the loop which is responsible for the obstruction; there is no need to free the whole intestine by dividing all the remaining innocent adhesions. This maneuver may be cosmetically appealing, but adhesions lysed today will reform tomorrow. As aptly stated by Timothy Fabian: “Lysis of all small bowel adhesions is not required because I believe that the bowel is ‘locked in the open position’ by these chronic adhesions.”\\n\\nWe disagree slightly; if we have to perform a bowel resection, we free all the adhesions distal to the anastomosis to prevent a second narrow part causing back pressure on the anastomosis and then perhaps leading to a leak… Ari & Jon\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 456.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'iatrogenic '}]},\n", " {'page': 339,\n", " 'text': ' • Occasionally, multiple points of obstruction appear to be present\\n with no clear area of demarcation between dilated and collapsed\\n bowel. This is more common in patients after multiple operations for\\n SBO or those with early postoperative SBO. In this situation the\\n whole length of the ‘frozen’ gut has to be unraveled — again, very\\n carefully and patiently in order not to damage the bowel. This is\\n tedious surgery indeed!\\n • In this day and age, with so many patients having mesh\\n implanted in their tummies you will occasionaly have to deal\\n with it. An existing mesh, with the viscera adherent to it, could make\\n any abdominal re-entry dreadful, even if it is not the direct cause of\\n obstruction. When opening a ‘meshed abdomen’, try to gain access\\n to the peritoneal cavity above or below the mesh, and work your way\\n from there. Often, you will need to cut the mesh at its center. When\\n separating the intestine from the mesh remember that it is\\n preferable to leave a tiny bit of mesh adherent to the bowel than\\n to leave a piece of bowel on the mesh. Remove the segment of\\n mesh which caused the obstruction but there is no need for a ‘total\\n meshectomy’ — any incorporated mesh away from the problem\\n zone should be left undisturbed. When closing the abdomen you can\\n include the mesh in the suture line.\\n • What to do with a ventral hernia associated with the SBO will be\\n discussed in the next chapter. Remember, your main aim is to\\n relieve the SBO — don’t be obsessed with fancy hernia repairs at\\n this stage.\\n\\n How to manage an iatrogenic intestinal injury during\\n adhesiolysis\\n\\n Transmural enterotomies should be repaired transversely. We\\nrecommend a running, one-layered, absorbable monofilament technique.\\n\\n Some use two layers… Ari\\n\\n Interrupted sutures would do as well. Superficial serosal tears should\\nbe left alone. Areas where the mucosa pouts through the defect should',\n", " 'md': '```markdown\\n# Management of Small Bowel Obstruction (SBO)\\n\\n- Occasionally, multiple points of obstruction appear to be present with no clear area of demarcation between dilated and collapsed bowel. This is more common in patients after multiple operations for SBO or those with early postoperative SBO. In this situation, the whole length of the ‘frozen’ gut has to be unraveled — again, very carefully and patiently in order not to damage the bowel. This is tedious surgery indeed!\\n\\n- In this day and age, with so many patients having mesh implanted in their tummies, you will occasionally have to deal with it. An existing mesh, with the viscera adherent to it, could make any abdominal re-entry dreadful, even if it is not the direct cause of obstruction. When opening a ‘meshed abdomen’, try to gain access to the peritoneal cavity above or below the mesh, and work your way from there. Often, you will need to cut the mesh at its center. When separating the intestine from the mesh, remember that it is preferable to leave a tiny bit of mesh adherent to the bowel than to leave a piece of bowel on the mesh. Remove the segment of mesh which caused the obstruction, but there is no need for a ‘total meshectomy’ — any incorporated mesh away from the problem zone should be left undisturbed. When closing the abdomen, you can include the mesh in the suture line.\\n\\n- What to do with a ventral hernia associated with the SBO will be discussed in the next chapter. Remember, your main aim is to relieve the SBO — don’t be obsessed with fancy hernia repairs at this stage.\\n\\n## How to manage an iatrogenic intestinal injury during adhesiolysis\\n\\n- Transmural enterotomies should be repaired transversely. We recommend a running, one-layered, absorbable monofilament technique.\\n\\n- Some use two layers… Ari\\n\\n- Interrupted sutures would do as well. Superficial serosal tears should be left alone. Areas where the mucosa pouts through the defect should be addressed accordingly.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management of Small Bowel Obstruction (SBO)',\n", " 'md': '# Management of Small Bowel Obstruction (SBO)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Occasionally, multiple points of obstruction appear to be present with no clear area of demarcation between dilated and collapsed bowel. This is more common in patients after multiple operations for SBO or those with early postoperative SBO. In this situation, the whole length of the ‘frozen’ gut has to be unraveled — again, very carefully and patiently in order not to damage the bowel. This is tedious surgery indeed!\\n\\n- In this day and age, with so many patients having mesh implanted in their tummies, you will occasionally have to deal with it. An existing mesh, with the viscera adherent to it, could make any abdominal re-entry dreadful, even if it is not the direct cause of obstruction. When opening a ‘meshed abdomen’, try to gain access to the peritoneal cavity above or below the mesh, and work your way from there. Often, you will need to cut the mesh at its center. When separating the intestine from the mesh, remember that it is preferable to leave a tiny bit of mesh adherent to the bowel than to leave a piece of bowel on the mesh. Remove the segment of mesh which caused the obstruction, but there is no need for a ‘total meshectomy’ — any incorporated mesh away from the problem zone should be left undisturbed. When closing the abdomen, you can include the mesh in the suture line.\\n\\n- What to do with a ventral hernia associated with the SBO will be discussed in the next chapter. Remember, your main aim is to relieve the SBO — don’t be obsessed with fancy hernia repairs at this stage.',\n", " 'md': '- Occasionally, multiple points of obstruction appear to be present with no clear area of demarcation between dilated and collapsed bowel. This is more common in patients after multiple operations for SBO or those with early postoperative SBO. In this situation, the whole length of the ‘frozen’ gut has to be unraveled — again, very carefully and patiently in order not to damage the bowel. This is tedious surgery indeed!\\n\\n- In this day and age, with so many patients having mesh implanted in their tummies, you will occasionally have to deal with it. An existing mesh, with the viscera adherent to it, could make any abdominal re-entry dreadful, even if it is not the direct cause of obstruction. When opening a ‘meshed abdomen’, try to gain access to the peritoneal cavity above or below the mesh, and work your way from there. Often, you will need to cut the mesh at its center. When separating the intestine from the mesh, remember that it is preferable to leave a tiny bit of mesh adherent to the bowel than to leave a piece of bowel on the mesh. Remove the segment of mesh which caused the obstruction, but there is no need for a ‘total meshectomy’ — any incorporated mesh away from the problem zone should be left undisturbed. When closing the abdomen, you can include the mesh in the suture line.\\n\\n- What to do with a ventral hernia associated with the SBO will be discussed in the next chapter. Remember, your main aim is to relieve the SBO — don’t be obsessed with fancy hernia repairs at this stage.',\n", " 'bBox': {'x': 100, 'y': 85, 'w': 437.17, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'How to manage an iatrogenic intestinal injury during adhesiolysis',\n", " 'md': '## How to manage an iatrogenic intestinal injury during adhesiolysis',\n", " 'bBox': {'x': 86, 'y': 534, 'w': 452.48, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Transmural enterotomies should be repaired transversely. We recommend a running, one-layered, absorbable monofilament technique.\\n\\n- Some use two layers… Ari\\n\\n- Interrupted sutures would do as well. Superficial serosal tears should be left alone. Areas where the mucosa pouts through the defect should be addressed accordingly.\\n```',\n", " 'md': '- Transmural enterotomies should be repaired transversely. We recommend a running, one-layered, absorbable monofilament technique.\\n\\n- Some use two layers… Ari\\n\\n- Interrupted sutures would do as well. Superficial serosal tears should be left alone. Areas where the mucosa pouts through the defect should be addressed accordingly.\\n```',\n", " 'bBox': {'x': 72, 'y': 606, 'w': 463.79, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 340,\n", " 'text': 'be repaired.\\n\\n Decompress or not?\\n\\n Ah yes, the proverbial double-edged sword. On the one hand,\\nexcessive bowel distension impedes abdominal closure and\\ncontributes to postoperative intra-abdominal hypertension with its\\nwell-known deleterious physiological consequences. On the other\\nhand, bowel decompression may contribute to postoperative ileus and\\neven cause peritoneal contamination. We, like most others, would\\ndecompress the distended bowel if abdominal closure seems to need\\nexcessive tension. Gently milk the intestinal content towards the\\nstomach, from where it is sucked through the NG tube by the unhappy\\nanesthetist. Milk the bowel very gently by successively squeezing the\\nloops between your fingers in a sequential manner, as the obstructed\\nbowel is thin-walled and very easily injured. Do not pull too hard on the\\nmesentery — it may tear (remember that injury to the peritoneal surfaces\\npromotes formation of adhesions). Palpate the stomach from time to time\\n— if full, gently squeeze and shake it to restore patency of the NG tube.\\nFor a distal SBO, you may also milk the small bowel contents towards the\\ncollapsed colon. Open decompression through an enterotomy is\\nunwise (nay, it is stupid), given the risk of gross bacterial\\ncontamination. Needle decompression is not effective with the thick\\nbowel contents. Obviously, open decompression should be performed if\\nbowel is being resected — insert a Poole sucker or a large sump drain\\nconnected to the suction through the proximal line of bowel transection\\nand gently ‘accordion’ the bowel onto your suction device. Watch with\\nsatisfaction how the suction bottle is being filled with fluidy s**t — one\\nsenses a great accomplishment.\\n\\n Before closing, run the bowel again for missed enterotomies. Check for\\nhemostasis, as extensive adhesiolysis leaves large oozing raw areas;\\nintraperitoneal blood promotes ileus, infection and more adhesion\\nformation. Close the abdomen safely. SBO is a set-up for wound\\ndehiscence and a ticket to the M & M conference.\\n\\n A word about patience',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nBe repaired.\\n\\nDecompress or not?\\n\\nAh yes, the proverbial double-edged sword. On the one hand, excessive bowel distension impedes abdominal closure and contributes to postoperative intra-abdominal hypertension with its well-known deleterious physiological consequences. On the other hand, bowel decompression may contribute to postoperative ileus and even cause peritoneal contamination. We, like most others, would decompress the distended bowel if abdominal closure seems to need excessive tension. Gently milk the intestinal content towards the stomach, from where it is sucked through the NG tube by the unhappy anesthetist. Milk the bowel very gently by successively squeezing the loops between your fingers in a sequential manner, as the obstructed bowel is thin-walled and very easily injured. Do not pull too hard on the mesentery — it may tear (remember that injury to the peritoneal surfaces promotes formation of adhesions). Palpate the stomach from time to time — if full, gently squeeze and shake it to restore patency of the NG tube. For a distal SBO, you may also milk the small bowel contents towards the collapsed colon. Open decompression through an enterotomy is unwise (nay, it is stupid), given the risk of gross bacterial contamination. Needle decompression is not effective with the thick bowel contents. Obviously, open decompression should be performed if bowel is being resected — insert a Poole sucker or a large sump drain connected to the suction through the proximal line of bowel transection and gently ‘accordion’ the bowel onto your suction device. Watch with satisfaction how the suction bottle is being filled with fluidy s**t — one senses a great accomplishment.\\n\\nBefore closing, run the bowel again for missed enterotomies. Check for hemostasis, as extensive adhesiolysis leaves large oozing raw areas; intraperitoneal blood promotes ileus, infection and more adhesion formation. Close the abdomen safely. SBO is a set-up for wound dehiscence and a ticket to the M & M conference.\\n\\nA word about patience.\\n```\\n\\n## Image Identification and Description\\n\\n- **No images, graphs, or tables were identified on this page.**',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Be repaired.\\n\\nDecompress or not?\\n\\nAh yes, the proverbial double-edged sword. On the one hand, excessive bowel distension impedes abdominal closure and contributes to postoperative intra-abdominal hypertension with its well-known deleterious physiological consequences. On the other hand, bowel decompression may contribute to postoperative ileus and even cause peritoneal contamination. We, like most others, would decompress the distended bowel if abdominal closure seems to need excessive tension. Gently milk the intestinal content towards the stomach, from where it is sucked through the NG tube by the unhappy anesthetist. Milk the bowel very gently by successively squeezing the loops between your fingers in a sequential manner, as the obstructed bowel is thin-walled and very easily injured. Do not pull too hard on the mesentery — it may tear (remember that injury to the peritoneal surfaces promotes formation of adhesions). Palpate the stomach from time to time — if full, gently squeeze and shake it to restore patency of the NG tube. For a distal SBO, you may also milk the small bowel contents towards the collapsed colon. Open decompression through an enterotomy is unwise (nay, it is stupid), given the risk of gross bacterial contamination. Needle decompression is not effective with the thick bowel contents. Obviously, open decompression should be performed if bowel is being resected — insert a Poole sucker or a large sump drain connected to the suction through the proximal line of bowel transection and gently ‘accordion’ the bowel onto your suction device. Watch with satisfaction how the suction bottle is being filled with fluidy s**t — one senses a great accomplishment.\\n\\nBefore closing, run the bowel again for missed enterotomies. Check for hemostasis, as extensive adhesiolysis leaves large oozing raw areas; intraperitoneal blood promotes ileus, infection and more adhesion formation. Close the abdomen safely. SBO is a set-up for wound dehiscence and a ticket to the M & M conference.\\n\\nA word about patience.\\n```',\n", " 'md': 'Be repaired.\\n\\nDecompress or not?\\n\\nAh yes, the proverbial double-edged sword. On the one hand, excessive bowel distension impedes abdominal closure and contributes to postoperative intra-abdominal hypertension with its well-known deleterious physiological consequences. On the other hand, bowel decompression may contribute to postoperative ileus and even cause peritoneal contamination. We, like most others, would decompress the distended bowel if abdominal closure seems to need excessive tension. Gently milk the intestinal content towards the stomach, from where it is sucked through the NG tube by the unhappy anesthetist. Milk the bowel very gently by successively squeezing the loops between your fingers in a sequential manner, as the obstructed bowel is thin-walled and very easily injured. Do not pull too hard on the mesentery — it may tear (remember that injury to the peritoneal surfaces promotes formation of adhesions). Palpate the stomach from time to time — if full, gently squeeze and shake it to restore patency of the NG tube. For a distal SBO, you may also milk the small bowel contents towards the collapsed colon. Open decompression through an enterotomy is unwise (nay, it is stupid), given the risk of gross bacterial contamination. Needle decompression is not effective with the thick bowel contents. Obviously, open decompression should be performed if bowel is being resected — insert a Poole sucker or a large sump drain connected to the suction through the proximal line of bowel transection and gently ‘accordion’ the bowel onto your suction device. Watch with satisfaction how the suction bottle is being filled with fluidy s**t — one senses a great accomplishment.\\n\\nBefore closing, run the bowel again for missed enterotomies. Check for hemostasis, as extensive adhesiolysis leaves large oozing raw areas; intraperitoneal blood promotes ileus, infection and more adhesion formation. Close the abdomen safely. SBO is a set-up for wound dehiscence and a ticket to the M & M conference.\\n\\nA word about patience.\\n```',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.96, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **No images, graphs, or tables were identified on this page.**',\n", " 'md': '- **No images, graphs, or tables were identified on this page.**',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 341,\n", " 'text': ' You will understand by now that in some circumstances a laparotomy\\nfor SBO will be a long and difficult operation due to multiple adhesions or\\nradiation enteritis for example. If you begin an operation expecting a\\nquick and easy procedure and are then confronted by a nightmare\\nabdomen the first thing you must do is reset your mental clock. Failure to\\ndo this may mean that you will attempt to rush the procedure and this\\ninevitably leads to disaster with multiple inadvertent enterotomies,\\nperitoneal contamination and ultimately an even longer and more\\ndangerous procedure. When you enter such a disastrous abdomen\\nunexpectedly, tell everyone immediately that the procedure is now\\ngoing to take a few hours while you unravel all the loops necessary\\nto get at the problem and fix it. And then take your time and fix it\\ncarefully and slowly.\\n\\n Laparoscopic approach ( Figure 21.2) 2\\n\\n Laparoscopic management of small bowel obstruction is a very\\nattractive option for several reasons:\\n\\n • The actual maneuver needed in many cases is one snip of the\\n scissors, and subjecting the patient to a major laparotomy to\\n release a single adhesive band is a pity!\\n • Much of the post-laparotomy recovery is related to ileus created by\\n handling the already distended loops of bowel. Saving this\\n manipulation results, in my experience, in very swift recovery —\\n almost as if the obstruction was relieved spontaneously. You can\\n actually see the bowel contents propagate after you release the\\n obstruction, and peristalsis resumes under your laparoscopic vision.\\n NG output quickly reduces, allowing early removal, early diet\\n resumption, and early discharge — as early as postoperative day 1\\n in some satisfying cases.\\n\\n • As every laparotomy induces new adhesions and adds to the risk of\\n future obstructions, it makes sense to try and avoid such added\\n insult. Laparoscopy induces very little adhesions, although it still\\n needs to be proven whether laparoscopic adhesiolysis indeed\\n reduces the incidence of future obstruction episodes.',\n", " 'md': '```markdown\\nYou will understand by now that in some circumstances a laparotomy for SBO will be a long and difficult operation due to multiple adhesions or radiation enteritis for example. If you begin an operation expecting a quick and easy procedure and are then confronted by a nightmare abdomen the first thing you must do is reset your mental clock. Failure to do this may mean that you will attempt to rush the procedure and this inevitably leads to disaster with multiple inadvertent enterotomies, peritoneal contamination and ultimately an even longer and more dangerous procedure. When you enter such a disastrous abdomen unexpectedly, tell everyone immediately that the procedure is now going to take a few hours while you unravel all the loops necessary to get at the problem and fix it. And then take your time and fix it carefully and slowly.\\n\\n### Laparoscopic Approach (Figure 21.2)\\n\\nLaparoscopic management of small bowel obstruction is a very attractive option for several reasons:\\n\\n- The actual maneuver needed in many cases is one snip of the scissors, and subjecting the patient to a major laparotomy to release a single adhesive band is a pity!\\n- Much of the post-laparotomy recovery is related to ileus created by handling the already distended loops of bowel. Saving this manipulation results, in my experience, in very swift recovery — almost as if the obstruction was relieved spontaneously. You can actually see the bowel contents propagate after you release the obstruction, and peristalsis resumes under your laparoscopic vision. NG output quickly reduces, allowing early removal, early diet resumption, and early discharge — as early as postoperative day 1 in some satisfying cases.\\n- As every laparotomy induces new adhesions and adds to the risk of future obstructions, it makes sense to try and avoid such added insult. Laparoscopy induces very little adhesions, although it still needs to be proven whether laparoscopic adhesiolysis indeed reduces the incidence of future obstruction episodes.\\n```\\n\\n### Image Description\\n- **Figure 21.2**: This figure likely illustrates the laparoscopic approach to managing small bowel obstruction. The image may depict the surgical setup, instruments used, or a visual representation of the procedure. However, the specific content of the image is not provided in the text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nYou will understand by now that in some circumstances a laparotomy for SBO will be a long and difficult operation due to multiple adhesions or radiation enteritis for example. If you begin an operation expecting a quick and easy procedure and are then confronted by a nightmare abdomen the first thing you must do is reset your mental clock. Failure to do this may mean that you will attempt to rush the procedure and this inevitably leads to disaster with multiple inadvertent enterotomies, peritoneal contamination and ultimately an even longer and more dangerous procedure. When you enter such a disastrous abdomen unexpectedly, tell everyone immediately that the procedure is now going to take a few hours while you unravel all the loops necessary to get at the problem and fix it. And then take your time and fix it carefully and slowly.',\n", " 'md': '```markdown\\nYou will understand by now that in some circumstances a laparotomy for SBO will be a long and difficult operation due to multiple adhesions or radiation enteritis for example. If you begin an operation expecting a quick and easy procedure and are then confronted by a nightmare abdomen the first thing you must do is reset your mental clock. Failure to do this may mean that you will attempt to rush the procedure and this inevitably leads to disaster with multiple inadvertent enterotomies, peritoneal contamination and ultimately an even longer and more dangerous procedure. When you enter such a disastrous abdomen unexpectedly, tell everyone immediately that the procedure is now going to take a few hours while you unravel all the loops necessary to get at the problem and fix it. And then take your time and fix it carefully and slowly.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Laparoscopic Approach (Figure 21.2)',\n", " 'md': '### Laparoscopic Approach (Figure 21.2)',\n", " 'bBox': {'x': 86, 'y': 328, 'w': 196.8, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Laparoscopic management of small bowel obstruction is a very attractive option for several reasons:\\n\\n- The actual maneuver needed in many cases is one snip of the scissors, and subjecting the patient to a major laparotomy to release a single adhesive band is a pity!\\n- Much of the post-laparotomy recovery is related to ileus created by handling the already distended loops of bowel. Saving this manipulation results, in my experience, in very swift recovery — almost as if the obstruction was relieved spontaneously. You can actually see the bowel contents propagate after you release the obstruction, and peristalsis resumes under your laparoscopic vision. NG output quickly reduces, allowing early removal, early diet resumption, and early discharge — as early as postoperative day 1 in some satisfying cases.\\n- As every laparotomy induces new adhesions and adds to the risk of future obstructions, it makes sense to try and avoid such added insult. Laparoscopy induces very little adhesions, although it still needs to be proven whether laparoscopic adhesiolysis indeed reduces the incidence of future obstruction episodes.\\n```',\n", " 'md': 'Laparoscopic management of small bowel obstruction is a very attractive option for several reasons:\\n\\n- The actual maneuver needed in many cases is one snip of the scissors, and subjecting the patient to a major laparotomy to release a single adhesive band is a pity!\\n- Much of the post-laparotomy recovery is related to ileus created by handling the already distended loops of bowel. Saving this manipulation results, in my experience, in very swift recovery — almost as if the obstruction was relieved spontaneously. You can actually see the bowel contents propagate after you release the obstruction, and peristalsis resumes under your laparoscopic vision. NG output quickly reduces, allowing early removal, early diet resumption, and early discharge — as early as postoperative day 1 in some satisfying cases.\\n- As every laparotomy induces new adhesions and adds to the risk of future obstructions, it makes sense to try and avoid such added insult. Laparoscopy induces very little adhesions, although it still needs to be proven whether laparoscopic adhesiolysis indeed reduces the incidence of future obstruction episodes.\\n```',\n", " 'bBox': {'x': 72, 'y': 381, 'w': 437.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 21.2**: This figure likely illustrates the laparoscopic approach to managing small bowel obstruction. The image may depict the surgical setup, instruments used, or a visual representation of the procedure. However, the specific content of the image is not provided in the text.',\n", " 'md': '- **Figure 21.2**: This figure likely illustrates the laparoscopic approach to managing small bowel obstruction. The image may depict the surgical setup, instruments used, or a visual representation of the procedure. However, the specific content of the image is not provided in the text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 342,\n", " 'text': ' The above mentioned advantages should be carefully weighed\\nagainst the potential risks. This procedure requires advanced\\nlaparoscopic skills! The risk for bowel injury, and uncontrolled spillage\\nof bowel contents from the obstructed bowel, can result in severe, and\\neven lethal sepsis.\\n 2\\n PeRyAQo14\\n Figure 21.2. Assistant: “Sir, permission to try laparoscopically? Where should I insert the\\n first trocar?” Chief: “Idiot! This is a classical case for SILS!”\\n\\n Should you wish to attempt a laparoscopic approach do it selectively\\non the easier cases:\\n\\n • First episode of SBO.\\n • Abdomen not excessively distended (e.g. more proximal SBO).\\n • Patient stable and able to endure a prolonged pneumoperitoneum\\n — superimposed on an already distended abdomen.\\n\\n A few technical tips:',\n", " 'md': '```markdown\\nThe above mentioned advantages should be carefully weighed against the potential risks. This procedure requires advanced laparoscopic skills! The risk for bowel injury, and uncontrolled spillage of bowel contents from the obstructed bowel, can result in severe, and even lethal sepsis.\\n\\nFigure 21.2:\\nAssistant: “Sir, permission to try laparoscopically? Where should I insert the first trocar?”\\nChief: “Idiot! This is a classical case for SILS!”\\n\\nShould you wish to attempt a laparoscopic approach do it selectively on the easier cases:\\n\\n- First episode of SBO.\\n- Abdomen not excessively distended (e.g. more proximal SBO).\\n- Patient stable and able to endure a prolonged pneumoperitoneum — superimposed on an already distended abdomen.\\n\\nA few technical tips:\\n```',\n", " 'images': [{'name': 'img_p341_1.png',\n", " 'height': 581,\n", " 'width': 811,\n", " 'x': 105.84000000000015,\n", " 'y': 165.60000000000002,\n", " 'original_width': 1392,\n", " 'original_height': 997}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nThe above mentioned advantages should be carefully weighed against the potential risks. This procedure requires advanced laparoscopic skills! The risk for bowel injury, and uncontrolled spillage of bowel contents from the obstructed bowel, can result in severe, and even lethal sepsis.\\n\\nFigure 21.2:\\nAssistant: “Sir, permission to try laparoscopically? Where should I insert the first trocar?”\\nChief: “Idiot! This is a classical case for SILS!”\\n\\nShould you wish to attempt a laparoscopic approach do it selectively on the easier cases:\\n\\n- First episode of SBO.\\n- Abdomen not excessively distended (e.g. more proximal SBO).\\n- Patient stable and able to endure a prolonged pneumoperitoneum — superimposed on an already distended abdomen.\\n\\nA few technical tips:\\n```',\n", " 'md': '```markdown\\nThe above mentioned advantages should be carefully weighed against the potential risks. This procedure requires advanced laparoscopic skills! The risk for bowel injury, and uncontrolled spillage of bowel contents from the obstructed bowel, can result in severe, and even lethal sepsis.\\n\\nFigure 21.2:\\nAssistant: “Sir, permission to try laparoscopically? Where should I insert the first trocar?”\\nChief: “Idiot! This is a classical case for SILS!”\\n\\nShould you wish to attempt a laparoscopic approach do it selectively on the easier cases:\\n\\n- First episode of SBO.\\n- Abdomen not excessively distended (e.g. more proximal SBO).\\n- Patient stable and able to endure a prolonged pneumoperitoneum — superimposed on an already distended abdomen.\\n\\nA few technical tips:\\n```',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.47, 'h': 26.7}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 343,\n", " 'text': ' • The first port should be placed through an open approach and away\\n from the old incision.\\n • Try to work on the collapsed distal bowel, and find your way\\n ‘backwards’, until you identify the obstruction site.\\n • Try to handle the mesentery and not the bowel wall itself; a little\\n mesenteric laceration is better than unintended perforation.\\n • Move slowly, and use table tilting and gravity to help you with bowel\\n mobilization and retraction — especially of the heavy, fluid-filled\\n obstructed loops.\\n\\n Most importantly — do not be obstinate; know when to abort —\\nbefore you create too many holes.\\n\\n A comment about dealing with interloop adhesions laparoscopically. I hate trying to divide them\\n and have had missed enterotomies. So if required I just convert. Maybe I am not as good a\\n laparoscopist as others. Jon\\n\\n Special circumstances\\n\\n The virgin abdomen\\n\\n Patients presenting with SBO, but without a previous history of\\nabdominal surgery need special attention: it is here that you have to\\nsuspect non-adhesive causes of SBO, including rare ‘zebra-like’\\nconditions, for example, the one and only obstructing obturator hernia\\nyou are likely to diagnose and treat during your entire glorious surgical\\ncareer.\\n\\n So the patient presents with clinical and radiological features of\\nSBO but with no abdominal wall scar of previous surgery. What to\\ndo?\\n\\n First, ask again about all past procedures including that laparoscopic ovarian\\n cystectomy and a tiny scar hidden in the umbilicus; and while you’re at it, why don’t you',\n", " 'md': '```markdown\\n## Surgical Considerations for Small Bowel Obstruction (SBO)\\n\\n- The first port should be placed through an open approach and away from the old incision.\\n- Try to work on the collapsed distal bowel, and find your way ‘backwards’, until you identify the obstruction site.\\n- Try to handle the mesentery and not the bowel wall itself; a little mesenteric laceration is better than unintended perforation.\\n- Move slowly, and use table tilting and gravity to help you with bowel mobilization and retraction — especially of the heavy, fluid-filled obstructed loops.\\n\\nMost importantly — do not be obstinate; know when to abort — before you create too many holes.\\n\\nA comment about dealing with interloop adhesions laparoscopically. I hate trying to divide them and have had missed enterotomies. So if required I just convert. Maybe I am not as good a laparoscopist as others. Jon\\n\\n### Special Circumstances\\n\\n#### The Virgin Abdomen\\n\\nPatients presenting with SBO, but without a previous history of abdominal surgery need special attention: it is here that you have to suspect non-adhesive causes of SBO, including rare ‘zebra-like’ conditions, for example, the one and only obstructing obturator hernia you are likely to diagnose and treat during your entire glorious surgical career.\\n\\nSo the patient presents with clinical and radiological features of SBO but with no abdominal wall scar of previous surgery. What to do?\\n\\nFirst, ask again about all past procedures including that laparoscopic ovarian cystectomy and a tiny scar hidden in the umbilicus; and while you’re at it, why don’t you...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Considerations for Small Bowel Obstruction (SBO)',\n", " 'md': '## Surgical Considerations for Small Bowel Obstruction (SBO)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The first port should be placed through an open approach and away from the old incision.\\n- Try to work on the collapsed distal bowel, and find your way ‘backwards’, until you identify the obstruction site.\\n- Try to handle the mesentery and not the bowel wall itself; a little mesenteric laceration is better than unintended perforation.\\n- Move slowly, and use table tilting and gravity to help you with bowel mobilization and retraction — especially of the heavy, fluid-filled obstructed loops.\\n\\nMost importantly — do not be obstinate; know when to abort — before you create too many holes.\\n\\nA comment about dealing with interloop adhesions laparoscopically. I hate trying to divide them and have had missed enterotomies. So if required I just convert. Maybe I am not as good a laparoscopist as others. Jon',\n", " 'md': '- The first port should be placed through an open approach and away from the old incision.\\n- Try to work on the collapsed distal bowel, and find your way ‘backwards’, until you identify the obstruction site.\\n- Try to handle the mesentery and not the bowel wall itself; a little mesenteric laceration is better than unintended perforation.\\n- Move slowly, and use table tilting and gravity to help you with bowel mobilization and retraction — especially of the heavy, fluid-filled obstructed loops.\\n\\nMost importantly — do not be obstinate; know when to abort — before you create too many holes.\\n\\nA comment about dealing with interloop adhesions laparoscopically. I hate trying to divide them and have had missed enterotomies. So if required I just convert. Maybe I am not as good a laparoscopist as others. Jon',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 465.02, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Special Circumstances',\n", " 'md': '### Special Circumstances',\n", " 'bBox': {'x': 86, 'y': 412, 'w': 178.43, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'The Virgin Abdomen',\n", " 'md': '#### The Virgin Abdomen',\n", " 'bBox': {'x': 86, 'y': 456, 'w': 157.23, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Patients presenting with SBO, but without a previous history of abdominal surgery need special attention: it is here that you have to suspect non-adhesive causes of SBO, including rare ‘zebra-like’ conditions, for example, the one and only obstructing obturator hernia you are likely to diagnose and treat during your entire glorious surgical career.\\n\\nSo the patient presents with clinical and radiological features of SBO but with no abdominal wall scar of previous surgery. What to do?\\n\\nFirst, ask again about all past procedures including that laparoscopic ovarian cystectomy and a tiny scar hidden in the umbilicus; and while you’re at it, why don’t you...\\n```',\n", " 'md': 'Patients presenting with SBO, but without a previous history of abdominal surgery need special attention: it is here that you have to suspect non-adhesive causes of SBO, including rare ‘zebra-like’ conditions, for example, the one and only obstructing obturator hernia you are likely to diagnose and treat during your entire glorious surgical career.\\n\\nSo the patient presents with clinical and radiological features of SBO but with no abdominal wall scar of previous surgery. What to do?\\n\\nFirst, ask again about all past procedures including that laparoscopic ovarian cystectomy and a tiny scar hidden in the umbilicus; and while you’re at it, why don’t you...\\n```',\n", " 'bBox': {'x': 72, 'y': 574, 'w': 453.37, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured according to the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and structured according to the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 344,\n", " 'text': ' re-examine the groin for incarcerated hernias!\\n\\n In the old days a complete SBO in a scarless abdomen was always an\\nindication for a laparotomy. But nowdays, a CT (use Gastrografin®!) is the\\nway to go — mainly to rule out situations when an operation can be\\navoided; for example, SBO due to previously undiagnosed but suspected\\nCrohn’s disease ( Chapter 26) or bolus obstructions (see below).\\n\\n There is an endless list of potential causes of non-adhesive\\nmechnical SBO, which includes abdominal wall hernias (the ones you\\nhave missed on examination), malignancies (e.g. cecal tumors),\\ninflammatory masses (e.g. ‘lost’ gallstones), internal hernias (e.g.\\nforamen of Winslow hernia), bolus obstruction (e.g. gallstone ileus) and\\nso forth. There is no point pondering too much; just get the CT and\\nproceed with laparotomy/laparoscopy if indicated. In such cases there\\nis no place for a trial of non-operative management.\\n\\n Intussusception\\n\\n Although common in pediatric patients ( Chapter 36), intussusception\\nis a very rare cause of SBO in adults. In adults, the ‘leading point’ is\\nusually organic (e.g. neoplasm, inflammatory lesions), and seldom\\nidiopathic as in children. Patients with small bowel or ileocolic\\nintussusception present with non-specific features of SBO (in a virgin\\nabdomen) necessitating operative treatment. A specific pre-operative\\ndiagnosis can be obtained with ultrasound or CT, showing the multiple\\nconcentric ring sign (bowel within bowel), but won’t change what you\\nneed to do — operate and resect the involved segment of bowel.\\nAlthough controversial, some would attempt reduction of intussusception\\nwhen there are no external signs of ischemia or malignancy and if after\\nreduction no leading point is found (i.e. idiopathic intussusception), one\\ncould leave the bowel alone. Also, ‘partial’ reduction, if the\\nintussusception is long, may limit the extent of resection to the bowel in\\nthe vicinity of the leading point, saving some length of healthy bowel.\\n\\n One more thing: you should differentiate between intussusception as a cause for obstruction',\n", " 'md': '```markdown\\n## Current Page Content\\n\\n### Text\\nRe-examine the groin for incarcerated hernias!\\n\\nIn the old days, a complete SBO in a scarless abdomen was always an indication for a laparotomy. But nowadays, a CT (use Gastrografin®!) is the way to go — mainly to rule out situations when an operation can be avoided; for example, SBO due to previously undiagnosed but suspected Crohn’s disease (Chapter 26) or bolus obstructions (see below).\\n\\nThere is an endless list of potential causes of non-adhesive mechanical SBO, which includes abdominal wall hernias (the ones you have missed on examination), malignancies (e.g. cecal tumors), inflammatory masses (e.g. ‘lost’ gallstones), internal hernias (e.g. foramen of Winslow hernia), bolus obstruction (e.g. gallstone ileus) and so forth. There is no point pondering too much; just get the CT and proceed with laparotomy/laparoscopy if indicated. In such cases, there is no place for a trial of non-operative management.\\n\\n### Intussusception\\nAlthough common in pediatric patients (Chapter 36), intussusception is a very rare cause of SBO in adults. In adults, the ‘leading point’ is usually organic (e.g. neoplasm, inflammatory lesions), and seldom idiopathic as in children. Patients with small bowel or ileocolic intussusception present with non-specific features of SBO (in a virgin abdomen) necessitating operative treatment. A specific pre-operative diagnosis can be obtained with ultrasound or CT, showing the multiple concentric ring sign (bowel within bowel), but won’t change what you need to do — operate and resect the involved segment of bowel. Although controversial, some would attempt reduction of intussusception when there are no external signs of ischemia or malignancy and if after reduction no leading point is found (i.e. idiopathic intussusception), one could leave the bowel alone. Also, ‘partial’ reduction, if the intussusception is long, may limit the extent of resection to the bowel in the vicinity of the leading point, saving some length of healthy bowel.\\n\\nOne more thing: you should differentiate between intussusception as a cause for obstruction.\\n\\n### Figures and Images\\n- **Figure 1**: \\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Re-examine the groin for incarcerated hernias!\\n\\nIn the old days, a complete SBO in a scarless abdomen was always an indication for a laparotomy. But nowadays, a CT (use Gastrografin®!) is the way to go — mainly to rule out situations when an operation can be avoided; for example, SBO due to previously undiagnosed but suspected Crohn’s disease (Chapter 26) or bolus obstructions (see below).\\n\\nThere is an endless list of potential causes of non-adhesive mechanical SBO, which includes abdominal wall hernias (the ones you have missed on examination), malignancies (e.g. cecal tumors), inflammatory masses (e.g. ‘lost’ gallstones), internal hernias (e.g. foramen of Winslow hernia), bolus obstruction (e.g. gallstone ileus) and so forth. There is no point pondering too much; just get the CT and proceed with laparotomy/laparoscopy if indicated. In such cases, there is no place for a trial of non-operative management.',\n", " 'md': 'Re-examine the groin for incarcerated hernias!\\n\\nIn the old days, a complete SBO in a scarless abdomen was always an indication for a laparotomy. But nowadays, a CT (use Gastrografin®!) is the way to go — mainly to rule out situations when an operation can be avoided; for example, SBO due to previously undiagnosed but suspected Crohn’s disease (Chapter 26) or bolus obstructions (see below).\\n\\nThere is an endless list of potential causes of non-adhesive mechanical SBO, which includes abdominal wall hernias (the ones you have missed on examination), malignancies (e.g. cecal tumors), inflammatory masses (e.g. ‘lost’ gallstones), internal hernias (e.g. foramen of Winslow hernia), bolus obstruction (e.g. gallstone ileus) and so forth. There is no point pondering too much; just get the CT and proceed with laparotomy/laparoscopy if indicated. In such cases, there is no place for a trial of non-operative management.',\n", " 'bBox': {'x': 72, 'y': 87, 'w': 467.49, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Intussusception',\n", " 'md': '### Intussusception',\n", " 'bBox': {'x': 86, 'y': 394, 'w': 126.9, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Although common in pediatric patients (Chapter 36), intussusception is a very rare cause of SBO in adults. In adults, the ‘leading point’ is usually organic (e.g. neoplasm, inflammatory lesions), and seldom idiopathic as in children. Patients with small bowel or ileocolic intussusception present with non-specific features of SBO (in a virgin abdomen) necessitating operative treatment. A specific pre-operative diagnosis can be obtained with ultrasound or CT, showing the multiple concentric ring sign (bowel within bowel), but won’t change what you need to do — operate and resect the involved segment of bowel. Although controversial, some would attempt reduction of intussusception when there are no external signs of ischemia or malignancy and if after reduction no leading point is found (i.e. idiopathic intussusception), one could leave the bowel alone. Also, ‘partial’ reduction, if the intussusception is long, may limit the extent of resection to the bowel in the vicinity of the leading point, saving some length of healthy bowel.\\n\\nOne more thing: you should differentiate between intussusception as a cause for obstruction.',\n", " 'md': 'Although common in pediatric patients (Chapter 36), intussusception is a very rare cause of SBO in adults. In adults, the ‘leading point’ is usually organic (e.g. neoplasm, inflammatory lesions), and seldom idiopathic as in children. Patients with small bowel or ileocolic intussusception present with non-specific features of SBO (in a virgin abdomen) necessitating operative treatment. A specific pre-operative diagnosis can be obtained with ultrasound or CT, showing the multiple concentric ring sign (bowel within bowel), but won’t change what you need to do — operate and resect the involved segment of bowel. Although controversial, some would attempt reduction of intussusception when there are no external signs of ischemia or malignancy and if after reduction no leading point is found (i.e. idiopathic intussusception), one could leave the bowel alone. Also, ‘partial’ reduction, if the intussusception is long, may limit the extent of resection to the bowel in the vicinity of the leading point, saving some length of healthy bowel.\\n\\nOne more thing: you should differentiate between intussusception as a cause for obstruction.',\n", " 'bBox': {'x': 72, 'y': 394, 'w': 467.85, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures and Images',\n", " 'md': '### Figures and Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: \\n```',\n", " 'md': '- **Figure 1**: \\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'is a very rare cause of SBO in adults. In adults, the ‘leading point’ is'}]},\n", " {'page': 345,\n", " 'text': ' and that which is an incidental finding on a CT scan. The latter is harmless, intermittent,\\n physiological, and does not require intervention — despite the pressure to ‘fix it’. Just make\\n sure there is no leading point seen by a good quality ‘enterography’ CT. If you succumb to that\\n pressure (“laparoscopy is harmless, just have a look to make sure…”) you may find yourself\\n searching in vain, and then open (“just to make sure by palpation…”), and even resect an\\n innocent segment. Danny\\n\\n The known cancer patient\\n\\n A patient is admitted with SBO a year or two following an operation for\\ngastric or colonic or ovarian cancer. You should first attempt to obtain\\ninformation about the findings at the previous laparotomy. The more\\nadvanced the cancer, the higher the probability that the current\\nobstruction is malignant. Clinically, cachexia, ascites or an abdominal\\nmass suggest diffuse carcinomatosis. These cases present a medical\\nand ethical dilemma. On the one hand, one wishes to relieve the\\nobstruction and offer the patient a further spell of quality life. On the other\\nhand, one tries to spare a terminal patient an unnecessary operation.\\nEach case should be assessed on merit. In the absence of stigmata of\\nadvanced disease, surgery for complete obstruction is justifiable. In many\\ninstances adhesions may be found; in others, a bowel segment\\nobstructed by local spread or metastases can be bypassed. When\\ndiffuse carcinomatosis is suspected clinically or on CT scan, a\\nreasonable option would be to insert a palliative, venting\\npercutaneous gastrostomy, allowing the patient to drink, and to die\\npeacefully at home or in a hospice environment.\\n\\n A sincere, ongoing discussion with the patient, his family, and his\\noncologist is crucial to finding the optimal balance between ‘cure’,\\npalliation and futile care.\\n\\n In doubtful cases, it may be better to operate and find end-stage carcinomatosis than to\\n miss an obstruction that can be readily fixed.',\n", " 'md': '```markdown\\n## Current Page Content\\n\\nA patient is admitted with SBO a year or two following an operation for gastric, colonic, or ovarian cancer. You should first attempt to obtain information about the findings at the previous laparotomy. The more advanced the cancer, the higher the probability that the current obstruction is malignant. Clinically, cachexia, ascites, or an abdominal mass suggest diffuse carcinomatosis. These cases present a medical and ethical dilemma. On the one hand, one wishes to relieve the obstruction and offer the patient a further spell of quality life. On the other hand, one tries to spare a terminal patient an unnecessary operation. Each case should be assessed on merit. In the absence of stigmata of advanced disease, surgery for complete obstruction is justifiable. In many instances, adhesions may be found; in others, a bowel segment obstructed by local spread or metastases can be bypassed. When diffuse carcinomatosis is suspected clinically or on CT scan, a reasonable option would be to insert a palliative, venting percutaneous gastrostomy, allowing the patient to drink, and to die peacefully at home or in a hospice environment.\\n\\nA sincere, ongoing discussion with the patient, his family, and his oncologist is crucial to finding the optimal balance between ‘cure’, palliation, and futile care.\\n\\nIn doubtful cases, it may be better to operate and find end-stage carcinomatosis than to miss an obstruction that can be readily fixed.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted while excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A patient is admitted with SBO a year or two following an operation for gastric, colonic, or ovarian cancer. You should first attempt to obtain information about the findings at the previous laparotomy. The more advanced the cancer, the higher the probability that the current obstruction is malignant. Clinically, cachexia, ascites, or an abdominal mass suggest diffuse carcinomatosis. These cases present a medical and ethical dilemma. On the one hand, one wishes to relieve the obstruction and offer the patient a further spell of quality life. On the other hand, one tries to spare a terminal patient an unnecessary operation. Each case should be assessed on merit. In the absence of stigmata of advanced disease, surgery for complete obstruction is justifiable. In many instances, adhesions may be found; in others, a bowel segment obstructed by local spread or metastases can be bypassed. When diffuse carcinomatosis is suspected clinically or on CT scan, a reasonable option would be to insert a palliative, venting percutaneous gastrostomy, allowing the patient to drink, and to die peacefully at home or in a hospice environment.\\n\\nA sincere, ongoing discussion with the patient, his family, and his oncologist is crucial to finding the optimal balance between ‘cure’, palliation, and futile care.\\n\\nIn doubtful cases, it may be better to operate and find end-stage carcinomatosis than to miss an obstruction that can be readily fixed.\\n```',\n", " 'md': 'A patient is admitted with SBO a year or two following an operation for gastric, colonic, or ovarian cancer. You should first attempt to obtain information about the findings at the previous laparotomy. The more advanced the cancer, the higher the probability that the current obstruction is malignant. Clinically, cachexia, ascites, or an abdominal mass suggest diffuse carcinomatosis. These cases present a medical and ethical dilemma. On the one hand, one wishes to relieve the obstruction and offer the patient a further spell of quality life. On the other hand, one tries to spare a terminal patient an unnecessary operation. Each case should be assessed on merit. In the absence of stigmata of advanced disease, surgery for complete obstruction is justifiable. In many instances, adhesions may be found; in others, a bowel segment obstructed by local spread or metastases can be bypassed. When diffuse carcinomatosis is suspected clinically or on CT scan, a reasonable option would be to insert a palliative, venting percutaneous gastrostomy, allowing the patient to drink, and to die peacefully at home or in a hospice environment.\\n\\nA sincere, ongoing discussion with the patient, his family, and his oncologist is crucial to finding the optimal balance between ‘cure’, palliation, and futile care.\\n\\nIn doubtful cases, it may be better to operate and find end-stage carcinomatosis than to miss an obstruction that can be readily fixed.\\n```',\n", " 'bBox': {'x': 72, 'y': 270, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted while excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted while excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 306, 'y': 502, 'w': 17.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 346,\n", " 'text': ' Radiation enteritis\\n\\n SBO following radiation treatment of abdominal or pelvic\\nmalignancy usually develops months or even years after irradiation.\\nA relentless course of multiple episodes of partial SBO, initially\\nresponding to conservative treatment but eventually culminating in a\\ncomplete obstruction, is characteristic. There is also the uncertainty\\nabout the obstruction being malignant or adhesive in nature. One always\\nhopes that it is adhesive, because SBO due to radiation injury is ‘bad\\nnews’ indeed.\\n\\n When forced to operate for complete obstruction, one finds\\nirradiated loops of bowel glued or welded together and onto\\nadjacent structures. The paper-thin bowel tears easily. Accidental\\nenterotomies are frequent, difficult to repair, and commonly result in\\npostoperative fistulas. Short involved segments of bowel are best\\nresected, but when longer segments are encountered, usually stuck in\\nthe pelvis, it is safest to bail out with an entero-enteric or enterocolic\\nbypass, using non-irradiated bowel for this purpose. Postoperative short-\\nbowel syndrome is common whatever the procedure. Long-term\\nprognosis is poor — radiation enteritis is almost as bad as the\\nmalignancy the radiation had attempted to control.\\n\\n Recurrent multiple episodes of SBO\\n\\n The patient is typically readmitted every second month for SBO\\nand has undergone, in the past, multiple operations for this\\ncondition. How should he be managed?\\n\\n We would treat him as any other patient presenting with adhesive\\nSBO. Fortunately, most such episodes are ‘partial’, and responsive to\\nconservative treatment. When complete obstruction develops, operative\\nmanagement is obviously necessary. Attempts at preventing subsequent\\nepisodes with plication of bowel or mesentery or long tube stenting are\\nrecommended by some. The evidence in favor of such maneuvers is\\nanecdotal at best. We do not practice them. Occasionally a patient\\ndevelops obstruction early in the aftermath of an operation for adhesive',\n", " 'md': \"# Radiation Enteritis\\n\\nRadiation enteritis is a condition that can lead to small bowel obstruction (SBO) following radiation treatment for abdominal or pelvic malignancies. This condition typically develops months or even years after irradiation.\\n\\nA relentless course of multiple episodes of partial SBO is characteristic, initially responding to conservative treatment but eventually culminating in a complete obstruction. There is uncertainty regarding whether the obstruction is malignant or adhesive in nature. It is preferable for the obstruction to be adhesive, as SBO due to radiation injury is considered 'bad news' indeed.\\n\\nWhen surgery is necessary due to complete obstruction, the surgeon often finds irradiated loops of bowel glued or welded together and attached to adjacent structures. The bowel, which becomes paper-thin, tears easily, leading to frequent accidental enterotomies that are difficult to repair and commonly result in postoperative fistulas. Short segments of involved bowel are best resected; however, when longer segments are encountered, typically stuck in the pelvis, it is safer to perform an entero-enteric or enterocolic bypass using non-irradiated bowel. Postoperative short-bowel syndrome is common regardless of the procedure, and the long-term prognosis is poor—radiation enteritis is almost as detrimental as the malignancy that the radiation was intended to control.\\n\\n## Recurrent Multiple Episodes of SBO\\n\\nThe patient is typically readmitted every second month for SBO and has undergone multiple operations for this condition in the past. The management approach for such patients is similar to that for any other patient presenting with adhesive SBO. Fortunately, most episodes are 'partial' and respond well to conservative treatment. When complete obstruction occurs, operative management becomes necessary.\\n\\nSome recommend attempts to prevent subsequent episodes through plication of bowel or mesentery or long tube stenting; however, the evidence supporting these maneuvers is anecdotal at best, and they are not commonly practiced. Occasionally, a patient may develop obstruction early in the aftermath of an operation for adhesive SBO.\",\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Radiation Enteritis',\n", " 'md': '# Radiation Enteritis',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 144.35, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': \"Radiation enteritis is a condition that can lead to small bowel obstruction (SBO) following radiation treatment for abdominal or pelvic malignancies. This condition typically develops months or even years after irradiation.\\n\\nA relentless course of multiple episodes of partial SBO is characteristic, initially responding to conservative treatment but eventually culminating in a complete obstruction. There is uncertainty regarding whether the obstruction is malignant or adhesive in nature. It is preferable for the obstruction to be adhesive, as SBO due to radiation injury is considered 'bad news' indeed.\\n\\nWhen surgery is necessary due to complete obstruction, the surgeon often finds irradiated loops of bowel glued or welded together and attached to adjacent structures. The bowel, which becomes paper-thin, tears easily, leading to frequent accidental enterotomies that are difficult to repair and commonly result in postoperative fistulas. Short segments of involved bowel are best resected; however, when longer segments are encountered, typically stuck in the pelvis, it is safer to perform an entero-enteric or enterocolic bypass using non-irradiated bowel. Postoperative short-bowel syndrome is common regardless of the procedure, and the long-term prognosis is poor—radiation enteritis is almost as detrimental as the malignancy that the radiation was intended to control.\",\n", " 'md': \"Radiation enteritis is a condition that can lead to small bowel obstruction (SBO) following radiation treatment for abdominal or pelvic malignancies. This condition typically develops months or even years after irradiation.\\n\\nA relentless course of multiple episodes of partial SBO is characteristic, initially responding to conservative treatment but eventually culminating in a complete obstruction. There is uncertainty regarding whether the obstruction is malignant or adhesive in nature. It is preferable for the obstruction to be adhesive, as SBO due to radiation injury is considered 'bad news' indeed.\\n\\nWhen surgery is necessary due to complete obstruction, the surgeon often finds irradiated loops of bowel glued or welded together and attached to adjacent structures. The bowel, which becomes paper-thin, tears easily, leading to frequent accidental enterotomies that are difficult to repair and commonly result in postoperative fistulas. Short segments of involved bowel are best resected; however, when longer segments are encountered, typically stuck in the pelvis, it is safer to perform an entero-enteric or enterocolic bypass using non-irradiated bowel. Postoperative short-bowel syndrome is common regardless of the procedure, and the long-term prognosis is poor—radiation enteritis is almost as detrimental as the malignancy that the radiation was intended to control.\",\n", " 'bBox': {'x': 86, 'y': 88, 'w': 144.35, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Recurrent Multiple Episodes of SBO',\n", " 'md': '## Recurrent Multiple Episodes of SBO',\n", " 'bBox': {'x': 86, 'y': 484, 'w': 283.21, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': \"The patient is typically readmitted every second month for SBO and has undergone multiple operations for this condition in the past. The management approach for such patients is similar to that for any other patient presenting with adhesive SBO. Fortunately, most episodes are 'partial' and respond well to conservative treatment. When complete obstruction occurs, operative management becomes necessary.\\n\\nSome recommend attempts to prevent subsequent episodes through plication of bowel or mesentery or long tube stenting; however, the evidence supporting these maneuvers is anecdotal at best, and they are not commonly practiced. Occasionally, a patient may develop obstruction early in the aftermath of an operation for adhesive SBO.\",\n", " 'md': \"The patient is typically readmitted every second month for SBO and has undergone multiple operations for this condition in the past. The management approach for such patients is similar to that for any other patient presenting with adhesive SBO. Fortunately, most episodes are 'partial' and respond well to conservative treatment. When complete obstruction occurs, operative management becomes necessary.\\n\\nSome recommend attempts to prevent subsequent episodes through plication of bowel or mesentery or long tube stenting; however, the evidence supporting these maneuvers is anecdotal at best, and they are not commonly practiced. Occasionally, a patient may develop obstruction early in the aftermath of an operation for adhesive SBO.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 347,\n", " 'text': 'SBO: this is a case par excellence for prolonged non-operative\\nmanagement, with the patient maintained on TPN until adhesions mature\\nand the obstruction resolves (see Chapter 45).\\n\\n In our experience, most such ‘frequent SBO travelers’ know how\\nto treat their episodes of obstruction better than the resident (or\\nsurgeon) on call. Listen to what they have to say. They know that\\nnot every episode requires a CT!\\n\\n Commonly, one is asked by patients or their physicians to perform an\\nelective adhesiolysis in order to prevent further episodes of adhesive\\nSBO. This sounds tempting of course. But anyone who has tried doing so\\nknows that even after a complete and most satisfying adhesiolysis these\\npatients can return with the same problem. Our advice: operate only for\\nnon-resolving SBO — prophylactic surgery does not work.\\n\\n Gallstone ileus\\n\\n Gallstone ileus develops typically in elderly patients with longstanding\\ncholelithiasis. It is caused by a large gallstone eroding into an adjacent\\nsegment of bowel — usually the duodenum — and then migrating distally\\nuntil stuck in the narrow ileum. Presentation is usually vague as\\ninitially the stone may disimpact spontaneously — causing\\nintermittent episodes of partial obstruction.\\n\\n You will never miss the diagnosis once you habitually and\\nobsessively search for air in the bile ducts on any plain abdominal\\nX-ray you order (or on the CT). The air enters the bile duct via the\\nenterocholecystic fistula created by the eroding gallstone (still remember\\nthe differential diagnosis of pneumobilia? If not go back to Chapter 5).\\n\\n Treatment is operative and should be tailored to the condition of\\nthe patient. In frail and sick patients deal only with the SBO: place an\\nenterotomy proximal to the stone and remove it and search for additional\\nstones in the bowel above — you do not want to have to reoperate! In\\npatients who are younger and reasonably fit and well, you may want to\\nalso deal with the cause of the problem — the gallbladder. Perform a',\n", " 'md': '```markdown\\n# Prolonged Non-Operative Management of SBO\\n\\nSBO: This is a case par excellence for prolonged non-operative management, with the patient maintained on TPN until adhesions mature and the obstruction resolves (see Chapter 45).\\n\\nIn our experience, most such ‘frequent SBO travelers’ know how to treat their episodes of obstruction better than the resident (or surgeon) on call. Listen to what they have to say. They know that not every episode requires a CT!\\n\\nCommonly, one is asked by patients or their physicians to perform an elective adhesiolysis in order to prevent further episodes of adhesive SBO. This sounds tempting of course. But anyone who has tried doing so knows that even after a complete and most satisfying adhesiolysis these patients can return with the same problem. Our advice: operate only for non-resolving SBO — prophylactic surgery does not work.\\n\\n## Gallstone Ileus\\n\\nGallstone ileus develops typically in elderly patients with longstanding cholelithiasis. It is caused by a large gallstone eroding into an adjacent segment of bowel — usually the duodenum — and then migrating distally until stuck in the narrow ileum. Presentation is usually vague as initially the stone may disimpact spontaneously — causing intermittent episodes of partial obstruction.\\n\\nYou will never miss the diagnosis once you habitually and obsessively search for air in the bile ducts on any plain abdominal X-ray you order (or on the CT). The air enters the bile duct via the enterocholecystic fistula created by the eroding gallstone (still remember the differential diagnosis of pneumobilia? If not go back to Chapter 5).\\n\\nTreatment is operative and should be tailored to the condition of the patient. In frail and sick patients deal only with the SBO: place an enterotomy proximal to the stone and remove it and search for additional stones in the bowel above — you do not want to have to reoperate! In patients who are younger and reasonably fit and well, you may want to also deal with the cause of the problem — the gallbladder. Perform a...\\n```\\n\\n### Notes:\\n- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been structured and formatted according to the markdown guidelines.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Prolonged Non-Operative Management of SBO',\n", " 'md': '# Prolonged Non-Operative Management of SBO',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'SBO: This is a case par excellence for prolonged non-operative management, with the patient maintained on TPN until adhesions mature and the obstruction resolves (see Chapter 45).\\n\\nIn our experience, most such ‘frequent SBO travelers’ know how to treat their episodes of obstruction better than the resident (or surgeon) on call. Listen to what they have to say. They know that not every episode requires a CT!\\n\\nCommonly, one is asked by patients or their physicians to perform an elective adhesiolysis in order to prevent further episodes of adhesive SBO. This sounds tempting of course. But anyone who has tried doing so knows that even after a complete and most satisfying adhesiolysis these patients can return with the same problem. Our advice: operate only for non-resolving SBO — prophylactic surgery does not work.',\n", " 'md': 'SBO: This is a case par excellence for prolonged non-operative management, with the patient maintained on TPN until adhesions mature and the obstruction resolves (see Chapter 45).\\n\\nIn our experience, most such ‘frequent SBO travelers’ know how to treat their episodes of obstruction better than the resident (or surgeon) on call. Listen to what they have to say. They know that not every episode requires a CT!\\n\\nCommonly, one is asked by patients or their physicians to perform an elective adhesiolysis in order to prevent further episodes of adhesive SBO. This sounds tempting of course. But anyone who has tried doing so knows that even after a complete and most satisfying adhesiolysis these patients can return with the same problem. Our advice: operate only for non-resolving SBO — prophylactic surgery does not work.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.72, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Gallstone Ileus',\n", " 'md': '## Gallstone Ileus',\n", " 'bBox': {'x': 86, 'y': 365, 'w': 117.69, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Gallstone ileus develops typically in elderly patients with longstanding cholelithiasis. It is caused by a large gallstone eroding into an adjacent segment of bowel — usually the duodenum — and then migrating distally until stuck in the narrow ileum. Presentation is usually vague as initially the stone may disimpact spontaneously — causing intermittent episodes of partial obstruction.\\n\\nYou will never miss the diagnosis once you habitually and obsessively search for air in the bile ducts on any plain abdominal X-ray you order (or on the CT). The air enters the bile duct via the enterocholecystic fistula created by the eroding gallstone (still remember the differential diagnosis of pneumobilia? If not go back to Chapter 5).\\n\\nTreatment is operative and should be tailored to the condition of the patient. In frail and sick patients deal only with the SBO: place an enterotomy proximal to the stone and remove it and search for additional stones in the bowel above — you do not want to have to reoperate! In patients who are younger and reasonably fit and well, you may want to also deal with the cause of the problem — the gallbladder. Perform a...\\n```',\n", " 'md': 'Gallstone ileus develops typically in elderly patients with longstanding cholelithiasis. It is caused by a large gallstone eroding into an adjacent segment of bowel — usually the duodenum — and then migrating distally until stuck in the narrow ileum. Presentation is usually vague as initially the stone may disimpact spontaneously — causing intermittent episodes of partial obstruction.\\n\\nYou will never miss the diagnosis once you habitually and obsessively search for air in the bile ducts on any plain abdominal X-ray you order (or on the CT). The air enters the bile duct via the enterocholecystic fistula created by the eroding gallstone (still remember the differential diagnosis of pneumobilia? If not go back to Chapter 5).\\n\\nTreatment is operative and should be tailored to the condition of the patient. In frail and sick patients deal only with the SBO: place an enterotomy proximal to the stone and remove it and search for additional stones in the bowel above — you do not want to have to reoperate! In patients who are younger and reasonably fit and well, you may want to also deal with the cause of the problem — the gallbladder. Perform a...\\n```',\n", " 'bBox': {'x': 72, 'y': 365, 'w': 467.76, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been structured and formatted according to the markdown guidelines.',\n", " 'md': '- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been structured and formatted according to the markdown guidelines.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 348,\n", " 'text': 'cholecystectomy and close the duodenal defect: place your suture line\\ntransversely to avoid narrowing of the duodenum. But again: not\\nremoving the gallbladder after dealing with the obstructing\\ngallstone is a perfectly reasonable option.\\n\\n And some of us think that this is by far the better option. Any large gallstones still in the\\n gallbladder can usually be removed easily by cholecystotomy and then simply close the\\n gallbladder again — much easier and safer than cholecystectomy in this situation. Paul\\n You can also look at the situation as nature’s solution to the gallbladder disease. After\\n spontaneously draining itself into the bowel it is less likely to cause further problems. Danny\\n\\n Bezoars\\n\\n Bezoars are tightly packed collections, or ‘balls’, of partially digested or\\nundigested material forming in the stomach and then migrating distally,\\nwhere they may obstruct the terminal ileum. You may encounter one of\\nthe following types of bezoars:\\n\\n • Phytobezoars: partially digested agglomerations of vegetables or\\n fruits forming in patients with altered gastric physiology (e.g.\\n following gastric resection, vagotomy or bariatric operation and even\\n in patients with diabetic gastroparesis) or health food aficionados,\\n and elderly ‘forget-to-chewers’. Many sorts of fruits and vegetables\\n are implicated, particularly when consumed in large quantity (Moshe\\n once suffered partial SBO after consuming, within an hour, a whole\\n bag of baby carrots; large quantities of popcorn can do the same),\\n but consumption of persimmons is especially notorious in this regard\\n — with patients developing multiple episodes of SBO.\\n • Trichobezoars: most commonly occurring in younger patients with\\n psychiatric disturbances who chew and swallow their own hair.\\n Trichobezoars form in the stomach and often reach a huge size;\\n they break into smaller pieces and migrate into the small bowel\\n where they can obstruct at several points.\\n • Parasitic bezoars: consisting of conglomerates of parasites such as\\n Ascaris lumbricoides which may obstruct the distal ileum. This is',\n", " 'md': '```markdown\\n## Cholecystectomy and Bezoars\\n\\nCholecystectomy and closing the duodenal defect: place your suture line transversely to avoid narrowing of the duodenum. However, not removing the gallbladder after dealing with the obstructing gallstone is a perfectly reasonable option. Some believe that this is by far the better option. Any large gallstones still in the gallbladder can usually be removed easily by cholecystotomy, and then simply close the gallbladder again — much easier and safer than cholecystectomy in this situation.\\n\\nYou can also look at the situation as nature’s solution to gallbladder disease. After spontaneously draining itself into the bowel, it is less likely to cause further problems.\\n\\n### Bezoars\\n\\nBezoars are tightly packed collections, or ‘balls’, of partially digested or undigested material forming in the stomach and then migrating distally, where they may obstruct the terminal ileum. You may encounter one of the following types of bezoars:\\n\\n- **Phytobezoars**: Partially digested agglomerations of vegetables or fruits forming in patients with altered gastric physiology (e.g., following gastric resection, vagotomy, or bariatric operation, and even in patients with diabetic gastroparesis) or health food aficionados, and elderly ‘forget-to-chewers’. Many sorts of fruits and vegetables are implicated, particularly when consumed in large quantities (e.g., Moshe once suffered partial SBO after consuming, within an hour, a whole bag of baby carrots; large quantities of popcorn can do the same), but consumption of persimmons is especially notorious in this regard — with patients developing multiple episodes of SBO.\\n\\n- **Trichobezoars**: Most commonly occurring in younger patients with psychiatric disturbances who chew and swallow their own hair. Trichobezoars form in the stomach and often reach a huge size; they break into smaller pieces and migrate into the small bowel where they can obstruct at several points.\\n\\n- **Parasitic bezoars**: Consisting of conglomerates of parasites such as *Ascaris lumbricoides* which may obstruct the distal ileum.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Cholecystectomy and Bezoars',\n", " 'md': '## Cholecystectomy and Bezoars',\n", " 'bBox': {'x': 86, 'y': 317, 'w': 64.4, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Cholecystectomy and closing the duodenal defect: place your suture line transversely to avoid narrowing of the duodenum. However, not removing the gallbladder after dealing with the obstructing gallstone is a perfectly reasonable option. Some believe that this is by far the better option. Any large gallstones still in the gallbladder can usually be removed easily by cholecystotomy, and then simply close the gallbladder again — much easier and safer than cholecystectomy in this situation.\\n\\nYou can also look at the situation as nature’s solution to gallbladder disease. After spontaneously draining itself into the bowel, it is less likely to cause further problems.',\n", " 'md': 'Cholecystectomy and closing the duodenal defect: place your suture line transversely to avoid narrowing of the duodenum. However, not removing the gallbladder after dealing with the obstructing gallstone is a perfectly reasonable option. Some believe that this is by far the better option. Any large gallstones still in the gallbladder can usually be removed easily by cholecystotomy, and then simply close the gallbladder again — much easier and safer than cholecystectomy in this situation.\\n\\nYou can also look at the situation as nature’s solution to gallbladder disease. After spontaneously draining itself into the bowel, it is less likely to cause further problems.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 286, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Bezoars',\n", " 'md': '### Bezoars',\n", " 'bBox': {'x': 86, 'y': 317, 'w': 64.4, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Bezoars are tightly packed collections, or ‘balls’, of partially digested or undigested material forming in the stomach and then migrating distally, where they may obstruct the terminal ileum. You may encounter one of the following types of bezoars:\\n\\n- **Phytobezoars**: Partially digested agglomerations of vegetables or fruits forming in patients with altered gastric physiology (e.g., following gastric resection, vagotomy, or bariatric operation, and even in patients with diabetic gastroparesis) or health food aficionados, and elderly ‘forget-to-chewers’. Many sorts of fruits and vegetables are implicated, particularly when consumed in large quantities (e.g., Moshe once suffered partial SBO after consuming, within an hour, a whole bag of baby carrots; large quantities of popcorn can do the same), but consumption of persimmons is especially notorious in this regard — with patients developing multiple episodes of SBO.\\n\\n- **Trichobezoars**: Most commonly occurring in younger patients with psychiatric disturbances who chew and swallow their own hair. Trichobezoars form in the stomach and often reach a huge size; they break into smaller pieces and migrate into the small bowel where they can obstruct at several points.\\n\\n- **Parasitic bezoars**: Consisting of conglomerates of parasites such as *Ascaris lumbricoides* which may obstruct the distal ileum.\\n```',\n", " 'md': 'Bezoars are tightly packed collections, or ‘balls’, of partially digested or undigested material forming in the stomach and then migrating distally, where they may obstruct the terminal ileum. You may encounter one of the following types of bezoars:\\n\\n- **Phytobezoars**: Partially digested agglomerations of vegetables or fruits forming in patients with altered gastric physiology (e.g., following gastric resection, vagotomy, or bariatric operation, and even in patients with diabetic gastroparesis) or health food aficionados, and elderly ‘forget-to-chewers’. Many sorts of fruits and vegetables are implicated, particularly when consumed in large quantities (e.g., Moshe once suffered partial SBO after consuming, within an hour, a whole bag of baby carrots; large quantities of popcorn can do the same), but consumption of persimmons is especially notorious in this regard — with patients developing multiple episodes of SBO.\\n\\n- **Trichobezoars**: Most commonly occurring in younger patients with psychiatric disturbances who chew and swallow their own hair. Trichobezoars form in the stomach and often reach a huge size; they break into smaller pieces and migrate into the small bowel where they can obstruct at several points.\\n\\n- **Parasitic bezoars**: Consisting of conglomerates of parasites such as *Ascaris lumbricoides* which may obstruct the distal ileum.\\n```',\n", " 'bBox': {'x': 72, 'y': 317, 'w': 467.03, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 349,\n", " 'text': ' obviously common in endemic areas.\\n\\n Patients present usually with features of partial or ‘smoldering’\\nSBO and a virgin abdomen. ħistory is suggestive, and CT images —\\nshowing the actual intraluminal bezoars — are diagnostic. As mentioned\\nabove, a Gastrografin® challenge can dislodge the obstructing parasites,\\nor other types of bezoars, pushing them into the cecum. But when the\\nobstruction is complete, you have to operate and deal with the\\nobstructing bezoar like you do with the gallstone (see above). However,\\nsome bezoars can sometimes be fragmented, and milked on,\\nwithout the need for enterotomy. It is crucial to palpate the entire small\\nbowel, including the duodenum (and also the stomach) for additional\\nbezoars, and remove all of them. Indeed, intra-operative gastroscopy\\nis recommended to remove the ‘mother bezoar’ before new\\nfragments are passed on. Pre-operative CT may be helpful in mapping\\nsuch additional bezoars for you. You don’t want the patient to develop\\nearly postoperative SBO — caused by a missed bezoar — needing\\nanother laparotomy for removal, do you?\\n\\n For bezoars after gastrectomy, we consider the use of meat tenderizers prior to surgery — to\\n break it up. Jon\\n\\n SBO after gastrectomy\\n\\n With the disappearance of gastrectomy performed for benign disease,\\nand the declining rate of gastric cancer, there are not too many post-\\ngastrectomy patients to present with SBO, although some do. However,\\nwith the mushrooming of bariatric gastric surgery, this entity has\\nbecome relevant again.\\n\\n According to our friends Professor David Dent (Cape Town, South\\nAfrica) and Dr. ħernan Diaz (Santiago, Chile) — both of them ‘old\\ngastrectomists’ — the reasons for SBO in these patients are:\\n\\n • Simple adhesive obstruction — what’s common is common! (See\\n above.)',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nPatients present usually with features of partial or ‘smoldering’ SBO and a virgin abdomen. History is suggestive, and CT images — showing the actual intraluminal bezoars — are diagnostic. As mentioned above, a Gastrografin® challenge can dislodge the obstructing parasites, or other types of bezoars, pushing them into the cecum. But when the obstruction is complete, you have to operate and deal with the obstructing bezoar like you do with the gallstone (see above). However, some bezoars can sometimes be fragmented, and milked on, without the need for enterotomy. It is crucial to palpate the entire small bowel, including the duodenum (and also the stomach) for additional bezoars, and remove all of them. Indeed, intra-operative gastroscopy is recommended to remove the ‘mother bezoar’ before new fragments are passed on. Pre-operative CT may be helpful in mapping such additional bezoars for you. You don’t want the patient to develop early postoperative SBO — caused by a missed bezoar — needing another laparotomy for removal, do you?\\n\\nFor bezoars after gastrectomy, we consider the use of meat tenderizers prior to surgery — to break it up.\\n\\n### SBO after gastrectomy\\n\\nWith the disappearance of gastrectomy performed for benign disease, and the declining rate of gastric cancer, there are not too many post-gastrectomy patients to present with SBO, although some do. However, with the mushrooming of bariatric gastric surgery, this entity has become relevant again.\\n\\nAccording to our friends Professor David Dent (Cape Town, South Africa) and Dr. Hernan Diaz (Santiago, Chile) — both of them ‘old gastrectomists’ — the reasons for SBO in these patients are:\\n\\n- Simple adhesive obstruction — what’s common is common! (See above.)\\n```\\n\\n## Image Identification and Description\\n\\nNo images or graphs were identified on this page.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Patients present usually with features of partial or ‘smoldering’ SBO and a virgin abdomen. History is suggestive, and CT images — showing the actual intraluminal bezoars — are diagnostic. As mentioned above, a Gastrografin® challenge can dislodge the obstructing parasites, or other types of bezoars, pushing them into the cecum. But when the obstruction is complete, you have to operate and deal with the obstructing bezoar like you do with the gallstone (see above). However, some bezoars can sometimes be fragmented, and milked on, without the need for enterotomy. It is crucial to palpate the entire small bowel, including the duodenum (and also the stomach) for additional bezoars, and remove all of them. Indeed, intra-operative gastroscopy is recommended to remove the ‘mother bezoar’ before new fragments are passed on. Pre-operative CT may be helpful in mapping such additional bezoars for you. You don’t want the patient to develop early postoperative SBO — caused by a missed bezoar — needing another laparotomy for removal, do you?\\n\\nFor bezoars after gastrectomy, we consider the use of meat tenderizers prior to surgery — to break it up.',\n", " 'md': 'Patients present usually with features of partial or ‘smoldering’ SBO and a virgin abdomen. History is suggestive, and CT images — showing the actual intraluminal bezoars — are diagnostic. As mentioned above, a Gastrografin® challenge can dislodge the obstructing parasites, or other types of bezoars, pushing them into the cecum. But when the obstruction is complete, you have to operate and deal with the obstructing bezoar like you do with the gallstone (see above). However, some bezoars can sometimes be fragmented, and milked on, without the need for enterotomy. It is crucial to palpate the entire small bowel, including the duodenum (and also the stomach) for additional bezoars, and remove all of them. Indeed, intra-operative gastroscopy is recommended to remove the ‘mother bezoar’ before new fragments are passed on. Pre-operative CT may be helpful in mapping such additional bezoars for you. You don’t want the patient to develop early postoperative SBO — caused by a missed bezoar — needing another laparotomy for removal, do you?\\n\\nFor bezoars after gastrectomy, we consider the use of meat tenderizers prior to surgery — to break it up.',\n", " 'bBox': {'x': 72, 'y': 156, 'w': 467.7, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'SBO after gastrectomy',\n", " 'md': '### SBO after gastrectomy',\n", " 'bBox': {'x': 86, 'y': 485, 'w': 179.33, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'With the disappearance of gastrectomy performed for benign disease, and the declining rate of gastric cancer, there are not too many post-gastrectomy patients to present with SBO, although some do. However, with the mushrooming of bariatric gastric surgery, this entity has become relevant again.\\n\\nAccording to our friends Professor David Dent (Cape Town, South Africa) and Dr. Hernan Diaz (Santiago, Chile) — both of them ‘old gastrectomists’ — the reasons for SBO in these patients are:\\n\\n- Simple adhesive obstruction — what’s common is common! (See above.)\\n```',\n", " 'md': 'With the disappearance of gastrectomy performed for benign disease, and the declining rate of gastric cancer, there are not too many post-gastrectomy patients to present with SBO, although some do. However, with the mushrooming of bariatric gastric surgery, this entity has become relevant again.\\n\\nAccording to our friends Professor David Dent (Cape Town, South Africa) and Dr. Hernan Diaz (Santiago, Chile) — both of them ‘old gastrectomists’ — the reasons for SBO in these patients are:\\n\\n- Simple adhesive obstruction — what’s common is common! (See above.)\\n```',\n", " 'bBox': {'x': 72, 'y': 521, 'w': 467.23, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'No images or graphs were identified on this page.',\n", " 'md': 'No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 350,\n", " 'text': ' • Recurrent gastric carcinoma, with loops of bowel ‘frozen’ by\\n peritoneal carcinomatosis (see above).\\n • Bolus obstruction by bezoars (see above).\\n • Internal herniation of small bowel through defects of the\\n mesocolon or behind the jejunal loop forming the Billroth II (or Roux-\\n en-Y) gastroenterostomy — be it antecolic or retrocolic.\\n • Twisting or volvulus of redundant afferent or efferent jejunal loops.\\n • Another specific type of obstruction is the jejunogastric\\n intussusception. Both the afferent or efferent loops can invaginate\\n into the gastric remnant but the retrograde efferent loop\\n intussusception is more common. This can occur from a few days up\\n to many years after the gastrectomy. Sudden onset of epigastric\\n pain, vomiting and hematemesis, and a palpable epigastric mass in\\n a patient with previous gastric surgery are the classic triad.\\n • Obstruction of the afferent loop after Billroth II or Roux-en-Y\\n reconstruction — by whichever of the above mentioned mechanisms\\n — produces a closed loop obstruction (between the obstructing\\n point and the duodenal stump). ħigh intraluminal pressures are\\n commonly associated with elevation of serum pancreatic enzymes\\n (amylase) and, if the obstruction is not relieved, with necrosis of the\\n involved loop and the attached duodenum. The clinical picture of\\n epigastric pain, upper abdominal mass and hyperamylasemia\\n may confuse you into thinking that you are dealing with acute\\n pancreatitis.\\n\\n Obviously, the more complex the original post-gastrectomy\\nreconstruction, the more potential peritoneal defects created, and the\\n‘looser’ the various intestinal loops — the higher the risk for bowel to kink,\\nrotate, herniate and obstruct. (Now you understand why we prefer Billroth\\nI reconstruction after gastrectomy!)\\n\\n The proximal location of the obstruction is suggested by the\\nfrequent vomiting, lack of abdominal distension and paucity of\\ndilated small bowel on plain abdominal X-ray. CT with oral contrast is\\na superb diagnostic aid, showing the exact anatomy of obstruction, and\\nthe ‘ring sign’ of small bowel within the stomach in the case of',\n", " 'md': '```markdown\\n## Page Content\\n\\n- Recurrent gastric carcinoma, with loops of bowel ‘frozen’ by peritoneal carcinomatosis (see above).\\n- Bolus obstruction by bezoars (see above).\\n- Internal herniation of small bowel through defects of the mesocolon or behind the jejunal loop forming the Billroth II (or Roux-en-Y) gastroenterostomy — be it antecolic or retrocolic.\\n- Twisting or volvulus of redundant afferent or efferent jejunal loops.\\n- Another specific type of obstruction is the jejunogastric intussusception. Both the afferent or efferent loops can invaginate into the gastric remnant but the retrograde efferent loop intussusception is more common. This can occur from a few days up to many years after the gastrectomy. Sudden onset of epigastric pain, vomiting and hematemesis, and a palpable epigastric mass in a patient with previous gastric surgery are the classic triad.\\n- Obstruction of the afferent loop after Billroth II or Roux-en-Y reconstruction — by whichever of the above mentioned mechanisms — produces a closed loop obstruction (between the obstructing point and the duodenal stump). High intraluminal pressures are commonly associated with elevation of serum pancreatic enzymes (amylase) and, if the obstruction is not relieved, with necrosis of the involved loop and the attached duodenum. The clinical picture of epigastric pain, upper abdominal mass and hyperamylasemia may confuse you into thinking that you are dealing with acute pancreatitis.\\n\\nObviously, the more complex the original post-gastrectomy reconstruction, the more potential peritoneal defects created, and the ‘looser’ the various intestinal loops — the higher the risk for bowel to kink, rotate, herniate and obstruct. (Now you understand why we prefer Billroth I reconstruction after gastrectomy!)\\n\\nThe proximal location of the obstruction is suggested by the frequent vomiting, lack of abdominal distension and paucity of dilated small bowel on plain abdominal X-ray. CT with oral contrast is a superb diagnostic aid, showing the exact anatomy of obstruction, and the ‘ring sign’ of small bowel within the stomach in the case of .\\n```\\n\\n### Notes\\n- No images or figures were identified on this page.\\n- All text has been extracted and formatted as per the requirements.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Recurrent gastric carcinoma, with loops of bowel ‘frozen’ by peritoneal carcinomatosis (see above).\\n- Bolus obstruction by bezoars (see above).\\n- Internal herniation of small bowel through defects of the mesocolon or behind the jejunal loop forming the Billroth II (or Roux-en-Y) gastroenterostomy — be it antecolic or retrocolic.\\n- Twisting or volvulus of redundant afferent or efferent jejunal loops.\\n- Another specific type of obstruction is the jejunogastric intussusception. Both the afferent or efferent loops can invaginate into the gastric remnant but the retrograde efferent loop intussusception is more common. This can occur from a few days up to many years after the gastrectomy. Sudden onset of epigastric pain, vomiting and hematemesis, and a palpable epigastric mass in a patient with previous gastric surgery are the classic triad.\\n- Obstruction of the afferent loop after Billroth II or Roux-en-Y reconstruction — by whichever of the above mentioned mechanisms — produces a closed loop obstruction (between the obstructing point and the duodenal stump). High intraluminal pressures are commonly associated with elevation of serum pancreatic enzymes (amylase) and, if the obstruction is not relieved, with necrosis of the involved loop and the attached duodenum. The clinical picture of epigastric pain, upper abdominal mass and hyperamylasemia may confuse you into thinking that you are dealing with acute pancreatitis.\\n\\nObviously, the more complex the original post-gastrectomy reconstruction, the more potential peritoneal defects created, and the ‘looser’ the various intestinal loops — the higher the risk for bowel to kink, rotate, herniate and obstruct. (Now you understand why we prefer Billroth I reconstruction after gastrectomy!)\\n\\nThe proximal location of the obstruction is suggested by the frequent vomiting, lack of abdominal distension and paucity of dilated small bowel on plain abdominal X-ray. CT with oral contrast is a superb diagnostic aid, showing the exact anatomy of obstruction, and the ‘ring sign’ of small bowel within the stomach in the case of .\\n```',\n", " 'md': '- Recurrent gastric carcinoma, with loops of bowel ‘frozen’ by peritoneal carcinomatosis (see above).\\n- Bolus obstruction by bezoars (see above).\\n- Internal herniation of small bowel through defects of the mesocolon or behind the jejunal loop forming the Billroth II (or Roux-en-Y) gastroenterostomy — be it antecolic or retrocolic.\\n- Twisting or volvulus of redundant afferent or efferent jejunal loops.\\n- Another specific type of obstruction is the jejunogastric intussusception. Both the afferent or efferent loops can invaginate into the gastric remnant but the retrograde efferent loop intussusception is more common. This can occur from a few days up to many years after the gastrectomy. Sudden onset of epigastric pain, vomiting and hematemesis, and a palpable epigastric mass in a patient with previous gastric surgery are the classic triad.\\n- Obstruction of the afferent loop after Billroth II or Roux-en-Y reconstruction — by whichever of the above mentioned mechanisms — produces a closed loop obstruction (between the obstructing point and the duodenal stump). High intraluminal pressures are commonly associated with elevation of serum pancreatic enzymes (amylase) and, if the obstruction is not relieved, with necrosis of the involved loop and the attached duodenum. The clinical picture of epigastric pain, upper abdominal mass and hyperamylasemia may confuse you into thinking that you are dealing with acute pancreatitis.\\n\\nObviously, the more complex the original post-gastrectomy reconstruction, the more potential peritoneal defects created, and the ‘looser’ the various intestinal loops — the higher the risk for bowel to kink, rotate, herniate and obstruct. (Now you understand why we prefer Billroth I reconstruction after gastrectomy!)\\n\\nThe proximal location of the obstruction is suggested by the frequent vomiting, lack of abdominal distension and paucity of dilated small bowel on plain abdominal X-ray. CT with oral contrast is a superb diagnostic aid, showing the exact anatomy of obstruction, and the ‘ring sign’ of small bowel within the stomach in the case of .\\n```',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.74, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.\\n- All text has been extracted and formatted as per the requirements.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images or figures were identified on this page.\\n- All text has been extracted and formatted as per the requirements.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 100, 'y': 231, 'w': 309.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 351,\n", " 'text': 'jejunogastric intussusception. Occasionally, endoscopy is needed to\\nclarify the picture. Do understand that acute afferent loop obstruction\\nis a dire emergency — you have to operate before the closed loop\\nobstruction results in complete necrosis of the duodenum!\\n\\n At operation the anatomy has to be restored and this entails resection\\nof non-viable loops of bowel and reconstruction of the upper\\ngastrointestinal tract, as you would do after partial or total gastrectomy.\\n\\n Small bowel volvulus\\n\\n This is also called ‘midgut volvulus’ — distinguishing it from ‘foregut\\nvolvulus’ ( Chapter 16) and ‘hindgut volvulus’ ( Chapter 27).\\n\\n Volvulus — the twisting strangulation of an intestinal segment around\\nan axis formed by a band or an adhesion is a common occurrence in\\nadhesive SBO. A narrow-based loop of small bowel suspended by a\\nMeckel diverticulum can also undergo torsion. But what about\\n‘spontaneous’ volvulus — one that involves the entire, or almost entire,\\nsmall intestine?\\n\\n Spontaneous volvulus of the small bowel, while very rare in the\\ndeveloped world is not uncommon in rural areas of the Indian\\nsubcontinent, central Asia and Africa. It seems more common in healthy\\nfarmers returning home for a large evening meal or, in Muslim countries,\\nduring the fast of Ramadan — when large meals are consumed at night\\nafter the day of fasting. The common pathway appears to be a huge load\\nof high-fiber, indigestible food, arriving suddenly in an empty small bowel.\\nThe sudden distension creates rotational-kinking forces.\\n\\n At operation, typically the twisted bowel is loaded with liters of\\nclay-like undigested food and is often suspended on an unusually\\nlong mesentery. Occasionally, small bowel volvulus occurs in\\ncombination with that of the sigmoid colon, forming the so-called\\nileosigmoid knot where the ileum and the sigmoid entangle each other\\nto form a knot and become gangrenous. An arrangement of the small\\nbowel and sigmoid colon on long, narrow mesenteries would appear to',\n", " 'md': \"```markdown\\n## Jejunogastric Intussusception\\n\\nJejunogastric intussusception is a condition that may require endoscopy to clarify the clinical picture. It is crucial to understand that acute afferent loop obstruction is a dire emergency; surgical intervention is necessary before the closed loop obstruction leads to complete necrosis of the duodenum.\\n\\n### Surgical Intervention\\n\\nDuring surgery, the anatomy must be restored, which involves the resection of non-viable loops of bowel and reconstruction of the upper gastrointestinal tract, similar to procedures performed after partial or total gastrectomy.\\n\\n## Small Bowel Volvulus\\n\\nSmall bowel volvulus, also known as 'midgut volvulus', is distinguished from 'foregut volvulus' (refer to Chapter 16) and 'hindgut volvulus' (refer to Chapter 27).\\n\\n### Definition and Causes\\n\\nVolvulus refers to the twisting and strangulation of an intestinal segment around an axis formed by a band or adhesion, which is a common occurrence in adhesive small bowel obstruction (SBO). A narrow-based loop of small bowel suspended by a Meckel diverticulum can also undergo torsion.\\n\\n#### Spontaneous Volvulus\\n\\nSpontaneous volvulus of the small bowel, while rare in developed countries, is not uncommon in rural areas of the Indian subcontinent, central Asia, and Africa. It appears to be more prevalent among healthy farmers returning home for a large evening meal or during Ramadan when large meals are consumed at night after a day of fasting. The common factor seems to be a sudden intake of a large load of high-fiber, indigestible food, which leads to sudden distension and creates rotational-kinking forces.\\n\\n### Surgical Findings\\n\\nDuring surgery, the twisted bowel is often found to be filled with liters of clay-like undigested food and is frequently suspended on an unusually long mesentery. In some cases, small bowel volvulus may occur alongside sigmoid colon volvulus, resulting in an ileosigmoid knot where the ileum and sigmoid entangle each other, potentially leading to gangrene.\\n\\nAn arrangement of the small bowel and sigmoid colon on long, narrow mesenteries is noted.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Jejunogastric Intussusception',\n", " 'md': '## Jejunogastric Intussusception',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Jejunogastric intussusception is a condition that may require endoscopy to clarify the clinical picture. It is crucial to understand that acute afferent loop obstruction is a dire emergency; surgical intervention is necessary before the closed loop obstruction leads to complete necrosis of the duodenum.',\n", " 'md': 'Jejunogastric intussusception is a condition that may require endoscopy to clarify the clinical picture. It is crucial to understand that acute afferent loop obstruction is a dire emergency; surgical intervention is necessary before the closed loop obstruction leads to complete necrosis of the duodenum.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Surgical Intervention',\n", " 'md': '### Surgical Intervention',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'During surgery, the anatomy must be restored, which involves the resection of non-viable loops of bowel and reconstruction of the upper gastrointestinal tract, similar to procedures performed after partial or total gastrectomy.',\n", " 'md': 'During surgery, the anatomy must be restored, which involves the resection of non-viable loops of bowel and reconstruction of the upper gastrointestinal tract, similar to procedures performed after partial or total gastrectomy.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Small Bowel Volvulus',\n", " 'md': '## Small Bowel Volvulus',\n", " 'bBox': {'x': 86, 'y': 247, 'w': 167.34, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': \"Small bowel volvulus, also known as 'midgut volvulus', is distinguished from 'foregut volvulus' (refer to Chapter 16) and 'hindgut volvulus' (refer to Chapter 27).\",\n", " 'md': \"Small bowel volvulus, also known as 'midgut volvulus', is distinguished from 'foregut volvulus' (refer to Chapter 16) and 'hindgut volvulus' (refer to Chapter 27).\",\n", " 'bBox': {'x': 86, 'y': 247, 'w': 167.34, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Definition and Causes',\n", " 'md': '### Definition and Causes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Volvulus refers to the twisting and strangulation of an intestinal segment around an axis formed by a band or adhesion, which is a common occurrence in adhesive small bowel obstruction (SBO). A narrow-based loop of small bowel suspended by a Meckel diverticulum can also undergo torsion.',\n", " 'md': 'Volvulus refers to the twisting and strangulation of an intestinal segment around an axis formed by a band or adhesion, which is a common occurrence in adhesive small bowel obstruction (SBO). A narrow-based loop of small bowel suspended by a Meckel diverticulum can also undergo torsion.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Spontaneous Volvulus',\n", " 'md': '#### Spontaneous Volvulus',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Spontaneous volvulus of the small bowel, while rare in developed countries, is not uncommon in rural areas of the Indian subcontinent, central Asia, and Africa. It appears to be more prevalent among healthy farmers returning home for a large evening meal or during Ramadan when large meals are consumed at night after a day of fasting. The common factor seems to be a sudden intake of a large load of high-fiber, indigestible food, which leads to sudden distension and creates rotational-kinking forces.',\n", " 'md': 'Spontaneous volvulus of the small bowel, while rare in developed countries, is not uncommon in rural areas of the Indian subcontinent, central Asia, and Africa. It appears to be more prevalent among healthy farmers returning home for a large evening meal or during Ramadan when large meals are consumed at night after a day of fasting. The common factor seems to be a sudden intake of a large load of high-fiber, indigestible food, which leads to sudden distension and creates rotational-kinking forces.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Surgical Findings',\n", " 'md': '### Surgical Findings',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'During surgery, the twisted bowel is often found to be filled with liters of clay-like undigested food and is frequently suspended on an unusually long mesentery. In some cases, small bowel volvulus may occur alongside sigmoid colon volvulus, resulting in an ileosigmoid knot where the ileum and sigmoid entangle each other, potentially leading to gangrene.\\n\\nAn arrangement of the small bowel and sigmoid colon on long, narrow mesenteries is noted.\\n```',\n", " 'md': 'During surgery, the twisted bowel is often found to be filled with liters of clay-like undigested food and is frequently suspended on an unusually long mesentery. In some cases, small bowel volvulus may occur alongside sigmoid colon volvulus, resulting in an ileosigmoid knot where the ileum and sigmoid entangle each other, potentially leading to gangrene.\\n\\nAn arrangement of the small bowel and sigmoid colon on long, narrow mesenteries is noted.\\n```',\n", " 'bBox': {'x': 86, 'y': 247, 'w': 167.34, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 352,\n", " 'text': 'be a prerequisite.\\n\\n As in any other condition resulting in acute vascular compromise of the\\nbowel, patients present with severe central abdominal pain that is\\nout of proportion to the abdominal findings; additionally, systemic\\nsigns of hypovolemia and toxemia are dramatic and dominant. An urgent\\noperation is indicated during which the ischemic intestine is managed as\\ndiscussed above.\\n\\n Intestinal malrotation\\n\\n Most cases of midgut malrotation present within the first weeks or\\nmonths of life. The rest can present sporadically throughout childhood\\nand even in adults. The anatomy of malrotation is depicted in Figure\\n21.3: note how close the D-J flexure (point X) is to the cecum (point Y)\\nand how narrow the base of the mesentery is, and thus prone to torsion.\\n\\n Strangulating midgut volvulus in these patients can present acutely, but\\nmore commonly, especially in older children and adults, volvulus is\\npreceded by recurring attacks of upper and central abdominal colicky\\npain, intermittent vomiting of bile and is often relieved by diarrhea. Once\\nagain, patients presenting with acute midgut volvulus are in great pain\\nand appear ill but have minimal abdominal findings on examination!\\n\\n Classically, the diagnosis was achieved by contrast studies: upper\\ngastrointestinal barium examination showing loss of the ‘duodenal C’\\n(corkscrew duodenum) and the D-J flexure to the right of the midline.\\nBarium enema would show the cecum riding high under the liver. CT\\nhowever has become the optimal diagnostic modality showing the\\nsmall bowel located entirely within the right hemi-abdomen and the\\ncolon situated on the left. Features of the twisted mesentery and\\nintestinal wall ischemia are also seen. Midgut volvulus can also be\\ndiagnosed on Doppler ultrasound by demonstrating the ‘whirlpool sign’ —\\nwrapping of the superior mesenteric vein and the mesentery around the\\nsuperior mesenteric artery.\\n\\n Emergency laparotomy is mandated. Remember that these patients',\n", " 'md': '```markdown\\n## Intestinal Malrotation\\n\\nMost cases of midgut malrotation present within the first weeks or months of life. The rest can present sporadically throughout childhood and even in adults. The anatomy of malrotation is depicted in **Figure 21.3**: note how close the D-J flexure (point X) is to the cecum (point Y) and how narrow the base of the mesentery is, and thus prone to torsion.\\n\\nStrangulating midgut volvulus in these patients can present acutely, but more commonly, especially in older children and adults, volvulus is preceded by recurring attacks of upper and central abdominal colicky pain, intermittent vomiting of bile, and is often relieved by diarrhea. Once again, patients presenting with acute midgut volvulus are in great pain and appear ill but have minimal abdominal findings on examination!\\n\\nClassically, the diagnosis was achieved by contrast studies: upper gastrointestinal barium examination showing loss of the ‘duodenal C’ (corkscrew duodenum) and the D-J flexure to the right of the midline. Barium enema would show the cecum riding high under the liver. CT, however, has become the optimal diagnostic modality showing the small bowel located entirely within the right hemi-abdomen and the colon situated on the left. Features of the twisted mesentery and intestinal wall ischemia are also seen. Midgut volvulus can also be diagnosed on Doppler ultrasound by demonstrating the ‘whirlpool sign’ — wrapping of the superior mesenteric vein and the mesentery around the superior mesenteric artery.\\n\\nEmergency laparotomy is mandated. Remember that these patients...\\n```\\n\\n### Image Description\\n- **Figure 21.3**: This figure illustrates the anatomy of midgut malrotation, highlighting the proximity of the D-J flexure (point X) to the cecum (point Y) and the narrow base of the mesentery, which is prone to torsion. The figure is crucial for understanding the anatomical implications of malrotation in clinical scenarios.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Intestinal Malrotation',\n", " 'md': '## Intestinal Malrotation',\n", " 'bBox': {'x': 86, 'y': 247, 'w': 167.33, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Most cases of midgut malrotation present within the first weeks or months of life. The rest can present sporadically throughout childhood and even in adults. The anatomy of malrotation is depicted in **Figure 21.3**: note how close the D-J flexure (point X) is to the cecum (point Y) and how narrow the base of the mesentery is, and thus prone to torsion.\\n\\nStrangulating midgut volvulus in these patients can present acutely, but more commonly, especially in older children and adults, volvulus is preceded by recurring attacks of upper and central abdominal colicky pain, intermittent vomiting of bile, and is often relieved by diarrhea. Once again, patients presenting with acute midgut volvulus are in great pain and appear ill but have minimal abdominal findings on examination!\\n\\nClassically, the diagnosis was achieved by contrast studies: upper gastrointestinal barium examination showing loss of the ‘duodenal C’ (corkscrew duodenum) and the D-J flexure to the right of the midline. Barium enema would show the cecum riding high under the liver. CT, however, has become the optimal diagnostic modality showing the small bowel located entirely within the right hemi-abdomen and the colon situated on the left. Features of the twisted mesentery and intestinal wall ischemia are also seen. Midgut volvulus can also be diagnosed on Doppler ultrasound by demonstrating the ‘whirlpool sign’ — wrapping of the superior mesenteric vein and the mesentery around the superior mesenteric artery.\\n\\nEmergency laparotomy is mandated. Remember that these patients...\\n```',\n", " 'md': 'Most cases of midgut malrotation present within the first weeks or months of life. The rest can present sporadically throughout childhood and even in adults. The anatomy of malrotation is depicted in **Figure 21.3**: note how close the D-J flexure (point X) is to the cecum (point Y) and how narrow the base of the mesentery is, and thus prone to torsion.\\n\\nStrangulating midgut volvulus in these patients can present acutely, but more commonly, especially in older children and adults, volvulus is preceded by recurring attacks of upper and central abdominal colicky pain, intermittent vomiting of bile, and is often relieved by diarrhea. Once again, patients presenting with acute midgut volvulus are in great pain and appear ill but have minimal abdominal findings on examination!\\n\\nClassically, the diagnosis was achieved by contrast studies: upper gastrointestinal barium examination showing loss of the ‘duodenal C’ (corkscrew duodenum) and the D-J flexure to the right of the midline. Barium enema would show the cecum riding high under the liver. CT, however, has become the optimal diagnostic modality showing the small bowel located entirely within the right hemi-abdomen and the colon situated on the left. Features of the twisted mesentery and intestinal wall ischemia are also seen. Midgut volvulus can also be diagnosed on Doppler ultrasound by demonstrating the ‘whirlpool sign’ — wrapping of the superior mesenteric vein and the mesentery around the superior mesenteric artery.\\n\\nEmergency laparotomy is mandated. Remember that these patients...\\n```',\n", " 'bBox': {'x': 72, 'y': 349, 'w': 467.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 21.3**: This figure illustrates the anatomy of midgut malrotation, highlighting the proximity of the D-J flexure (point X) to the cecum (point Y) and the narrow base of the mesentery, which is prone to torsion. The figure is crucial for understanding the anatomical implications of malrotation in clinical scenarios.',\n", " 'md': '- **Figure 21.3**: This figure illustrates the anatomy of midgut malrotation, highlighting the proximity of the D-J flexure (point X) to the cecum (point Y) and the narrow base of the mesentery, which is prone to torsion. The figure is crucial for understanding the anatomical implications of malrotation in clinical scenarios.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'and even in adults. The anatomy of malrotation is depicted in Figure 21.3: note how close the D-J flexure (point X) is to the cecum (point Y) and how narrow the base of the mesentery is, and thus prone to torsion.'}]},\n", " {'page': 353,\n", " 'text': \"are grossly hypovolemic and need aggressive fluid resuscitation. At\\noperation detort the twisted bowel working in a counterclockwise rotation.\\nIschemic dead bowel needs resection — usually massive resection. For a\\ndiscussion on whether to anastomose or not and whether a second-look\\noperation is necessary — look at Chapter 24.\\n Stomach\\n Duodenum,\\n Cecum\\n Ladd's\\n bands\\n Small\\n intestine\\n Intestinal Midgut\\n malrotation volvulus\\n Figure 21.3. a-c) Small bowel malrotation and volvulus; ci) normal; cii) malrotation; and\\n ciii) following Ladd’s procedure. X = D-J junction; Y = cecum. Modified from: Youngson GG.\\n Common Pediatric Disorders. Royal College of Surgeons of Edinburgh, 1998.\\n\\n After resecting the dead bowel, or convincing yourself that it is viable,\\nyou need to address the anatomical pathology of malrotation by doing\\nwhat has been described by William E. Ladd.\\n\\n 1. Divide the peritoneal folds (Ladd’s bands) that cross from the cecum to the liver,\",\n", " 'md': \"```markdown\\n## Text Extraction\\n\\n- Patients are grossly hypovolemic and need aggressive fluid resuscitation.\\n- At operation, detort the twisted bowel working in a counterclockwise rotation.\\n- Ischemic dead bowel needs resection — usually massive resection.\\n- For a discussion on whether to anastomose or not and whether a second-look operation is necessary — look at Chapter 24.\\n\\n### Anatomical Description\\n- Stomach\\n- Duodenum\\n- Cecum\\n- Ladd's bands\\n- Small intestine\\n- Intestinal malrotation\\n- Midgut volvulus\\n\\n## Figure 21.3 Description\\n**Figure 21.3**: a-c) Small bowel malrotation and volvulus;\\n- ci) normal;\\n- cii) malrotation;\\n- ciii) following Ladd’s procedure.\\n- X = D-J junction;\\n- Y = cecum.\\n- Modified from: Youngson GG. Common Pediatric Disorders. Royal College of Surgeons of Edinburgh, 1998.\\n\\n### Summary of Figure 21.3\\nThis figure illustrates the condition of small bowel malrotation and volvulus, showing three stages: the normal anatomy, the malrotated state, and the anatomy post Ladd’s procedure. The figure highlights the anatomical landmarks such as the D-J junction and the cecum.\\n\\n## Additional Text Extraction\\n- After resecting the dead bowel, or convincing yourself that it is viable, you need to address the anatomical pathology of malrotation by doing what has been described by William E. Ladd.\\n- 1. Divide the peritoneal folds (Ladd’s bands) that cross from the cecum to the liver.\\n```\",\n", " 'images': [{'name': 'img_p352_1.png',\n", " 'height': 374,\n", " 'width': 483,\n", " 'x': 186.47999999999956,\n", " 'y': 165.6,\n", " 'original_width': 1111,\n", " 'original_height': 861},\n", " {'name': 'img_p352_2.png',\n", " 'height': 315,\n", " 'width': 483,\n", " 'x': 186.47999999999956,\n", " 'y': 372.24,\n", " 'original_width': 1108,\n", " 'original_height': 721}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Patients are grossly hypovolemic and need aggressive fluid resuscitation.\\n- At operation, detort the twisted bowel working in a counterclockwise rotation.\\n- Ischemic dead bowel needs resection — usually massive resection.\\n- For a discussion on whether to anastomose or not and whether a second-look operation is necessary — look at Chapter 24.',\n", " 'md': '- Patients are grossly hypovolemic and need aggressive fluid resuscitation.\\n- At operation, detort the twisted bowel working in a counterclockwise rotation.\\n- Ischemic dead bowel needs resection — usually massive resection.\\n- For a discussion on whether to anastomose or not and whether a second-look operation is necessary — look at Chapter 24.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.55, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Anatomical Description',\n", " 'md': '### Anatomical Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- Stomach\\n- Duodenum\\n- Cecum\\n- Ladd's bands\\n- Small intestine\\n- Intestinal malrotation\\n- Midgut volvulus\",\n", " 'md': \"- Stomach\\n- Duodenum\\n- Cecum\\n- Ladd's bands\\n- Small intestine\\n- Intestinal malrotation\\n- Midgut volvulus\",\n", " 'bBox': {'x': 191.92, 'y': 193.8, 'w': 61.37, 'h': 11.87}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 21.3 Description',\n", " 'md': '## Figure 21.3 Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 21.3**: a-c) Small bowel malrotation and volvulus;\\n- ci) normal;\\n- cii) malrotation;\\n- ciii) following Ladd’s procedure.\\n- X = D-J junction;\\n- Y = cecum.\\n- Modified from: Youngson GG. Common Pediatric Disorders. Royal College of Surgeons of Edinburgh, 1998.',\n", " 'md': '**Figure 21.3**: a-c) Small bowel malrotation and volvulus;\\n- ci) normal;\\n- cii) malrotation;\\n- ciii) following Ladd’s procedure.\\n- X = D-J junction;\\n- Y = cecum.\\n- Modified from: Youngson GG. Common Pediatric Disorders. Royal College of Surgeons of Edinburgh, 1998.',\n", " 'bBox': {'x': 75, 'y': 228.43, 'w': 369.26, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary of Figure 21.3',\n", " 'md': '### Summary of Figure 21.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This figure illustrates the condition of small bowel malrotation and volvulus, showing three stages: the normal anatomy, the malrotated state, and the anatomy post Ladd’s procedure. The figure highlights the anatomical landmarks such as the D-J junction and the cecum.',\n", " 'md': 'This figure illustrates the condition of small bowel malrotation and volvulus, showing three stages: the normal anatomy, the malrotated state, and the anatomy post Ladd’s procedure. The figure highlights the anatomical landmarks such as the D-J junction and the cecum.',\n", " 'bBox': {'x': 195.88, 'y': 228.43, 'w': 48.5, 'h': 7.92}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Additional Text Extraction',\n", " 'md': '## Additional Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- After resecting the dead bowel, or convincing yourself that it is viable, you need to address the anatomical pathology of malrotation by doing what has been described by William E. Ladd.\\n- 1. Divide the peritoneal folds (Ladd’s bands) that cross from the cecum to the liver.\\n```',\n", " 'md': '- After resecting the dead bowel, or convincing yourself that it is viable, you need to address the anatomical pathology of malrotation by doing what has been described by William E. Ladd.\\n- 1. Divide the peritoneal folds (Ladd’s bands) that cross from the cecum to the liver.\\n```',\n", " 'bBox': {'x': 72, 'y': 228.43, 'w': 467.51, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 354,\n", " 'text': ' compressing the duodenum.\\n 2. Mobilize the right colon.\\n 3. Mobilize the D-J flexure, freeing the ligament of Treitz — straightening the\\n duodenal loop.\\n 4. Divide any thick peritoneal folds compressing the SMA.\\n 5. Place the bowel in a new pattern as depicted in Figure 21.3ciii — note that\\n now point X is far from point Y.\\n 6. Remove the appendix to prevent ‘atypically situated’ appendicitis.\\n\\n Obviously, after having to resect most of the small bowel you do not\\nneed to worry about recurrence of the volvulus and there is no impetus to\\ncorrect the anatomy, except at points 1, 4, 6.\\n\\n Prognosis\\n\\n Overall, about half of patients presenting with an adhesive SBO can be\\nmanaged without an operation. About a third of patients operated on\\nonce for adhesive SBO will have recurrent problems within 30 years. For\\npatients admitted several times for adhesive SBO, the relative risk of\\nrecurrence increases with the increasing number of prior obstructive\\nepisodes — more than two-thirds of patients with four or more SBO\\nadmissions will reobstruct. The risk of recurrence is a bit lower in patients\\nin whom the previous obstructive episode was treated surgically but this\\ndoes not mean that those patients who were treated conservatively will\\nhave an increased need for operation during their future admissions for\\nSBO. The aim is therefore to operate only when necessary, but not\\nto delay a necessary operation.\\n\\n In our minds, anyone who discovers a viable solution to prevent\\nadhesive SBO would deserve a Nobel Prize. The guys from Uppsala may\\nthink otherwise.\\n\\n “The only thing predictable about small bowel\\n obstruction is its unpredictability.”',\n", " 'md': '```markdown\\n## Surgical Steps for Managing Adhesive Small Bowel Obstruction\\n\\n1. Compressing the duodenum.\\n2. Mobilize the right colon.\\n3. Mobilize the D-J flexure, freeing the ligament of Treitz — straightening the duodenal loop.\\n4. Divide any thick peritoneal folds compressing the SMA.\\n5. Place the bowel in a new pattern as depicted in Figure 21.3ciii — note that now point X is far from point Y.\\n6. Remove the appendix to prevent ‘atypically situated’ appendicitis.\\n\\nObviously, after having to resect most of the small bowel you do not need to worry about recurrence of the volvulus and there is no impetus to correct the anatomy, except at points 1, 4, 6.\\n\\n## Prognosis\\n\\nOverall, about half of patients presenting with an adhesive SBO can be managed without an operation. About a third of patients operated on once for adhesive SBO will have recurrent problems within 30 years. For patients admitted several times for adhesive SBO, the relative risk of recurrence increases with the increasing number of prior obstructive episodes — more than two-thirds of patients with four or more SBO admissions will reobstruct. The risk of recurrence is a bit lower in patients in whom the previous obstructive episode was treated surgically but this does not mean that those patients who were treated conservatively will have an increased need for operation during their future admissions for SBO. The aim is therefore to operate only when necessary, but not to delay a necessary operation.\\n\\nIn our minds, anyone who discovers a viable solution to prevent adhesive SBO would deserve a Nobel Prize. The guys from Uppsala may think otherwise.\\n\\n> “The only thing predictable about small bowel obstruction is its unpredictability.”\\n```\\n\\n### Figure Description\\n- **Figure 21.3ciii**: This figure illustrates the new pattern of the bowel placement after surgical intervention for adhesive small bowel obstruction. The diagram highlights the spatial relationship between points X and Y, indicating that point X is now far from point Y, which is a significant change in the anatomy post-surgery.\\n\\n(Note: The actual image for Figure 21.3ciii is not provided in the text, so it cannot be included here.)',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Steps for Managing Adhesive Small Bowel Obstruction',\n", " 'md': '## Surgical Steps for Managing Adhesive Small Bowel Obstruction',\n", " 'bBox': {'x': 423, 'y': 688, 'w': 46.9, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '1. Compressing the duodenum.\\n2. Mobilize the right colon.\\n3. Mobilize the D-J flexure, freeing the ligament of Treitz — straightening the duodenal loop.\\n4. Divide any thick peritoneal folds compressing the SMA.\\n5. Place the bowel in a new pattern as depicted in Figure 21.3ciii — note that now point X is far from point Y.\\n6. Remove the appendix to prevent ‘atypically situated’ appendicitis.\\n\\nObviously, after having to resect most of the small bowel you do not need to worry about recurrence of the volvulus and there is no impetus to correct the anatomy, except at points 1, 4, 6.',\n", " 'md': '1. Compressing the duodenum.\\n2. Mobilize the right colon.\\n3. Mobilize the D-J flexure, freeing the ligament of Treitz — straightening the duodenal loop.\\n4. Divide any thick peritoneal folds compressing the SMA.\\n5. Place the bowel in a new pattern as depicted in Figure 21.3ciii — note that now point X is far from point Y.\\n6. Remove the appendix to prevent ‘atypically situated’ appendicitis.\\n\\nObviously, after having to resect most of the small bowel you do not need to worry about recurrence of the volvulus and there is no impetus to correct the anatomy, except at points 1, 4, 6.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.52, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Prognosis',\n", " 'md': '## Prognosis',\n", " 'bBox': {'x': 86, 'y': 354, 'w': 80.93, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Overall, about half of patients presenting with an adhesive SBO can be managed without an operation. About a third of patients operated on once for adhesive SBO will have recurrent problems within 30 years. For patients admitted several times for adhesive SBO, the relative risk of recurrence increases with the increasing number of prior obstructive episodes — more than two-thirds of patients with four or more SBO admissions will reobstruct. The risk of recurrence is a bit lower in patients in whom the previous obstructive episode was treated surgically but this does not mean that those patients who were treated conservatively will have an increased need for operation during their future admissions for SBO. The aim is therefore to operate only when necessary, but not to delay a necessary operation.\\n\\nIn our minds, anyone who discovers a viable solution to prevent adhesive SBO would deserve a Nobel Prize. The guys from Uppsala may think otherwise.\\n\\n> “The only thing predictable about small bowel obstruction is its unpredictability.”\\n```',\n", " 'md': 'Overall, about half of patients presenting with an adhesive SBO can be managed without an operation. About a third of patients operated on once for adhesive SBO will have recurrent problems within 30 years. For patients admitted several times for adhesive SBO, the relative risk of recurrence increases with the increasing number of prior obstructive episodes — more than two-thirds of patients with four or more SBO admissions will reobstruct. The risk of recurrence is a bit lower in patients in whom the previous obstructive episode was treated surgically but this does not mean that those patients who were treated conservatively will have an increased need for operation during their future admissions for SBO. The aim is therefore to operate only when necessary, but not to delay a necessary operation.\\n\\nIn our minds, anyone who discovers a viable solution to prevent adhesive SBO would deserve a Nobel Prize. The guys from Uppsala may think otherwise.\\n\\n> “The only thing predictable about small bowel obstruction is its unpredictability.”\\n```',\n", " 'bBox': {'x': 72, 'y': 390, 'w': 467.81, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Description',\n", " 'md': '### Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 21.3ciii**: This figure illustrates the new pattern of the bowel placement after surgical intervention for adhesive small bowel obstruction. The diagram highlights the spatial relationship between points X and Y, indicating that point X is now far from point Y, which is a significant change in the anatomy post-surgery.\\n\\n(Note: The actual image for Figure 21.3ciii is not provided in the text, so it cannot be included here.)',\n", " 'md': '- **Figure 21.3ciii**: This figure illustrates the new pattern of the bowel placement after surgical intervention for adhesive small bowel obstruction. The diagram highlights the spatial relationship between points X and Y, indicating that point X is now far from point Y, which is a significant change in the anatomy post-surgery.\\n\\n(Note: The actual image for Figure 21.3ciii is not provided in the text, so it cannot be included here.)',\n", " 'bBox': {'x': 423, 'y': 688, 'w': 46.9, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 355,\n", " 'text': '1 Schein’s Common Sense Prevention and Management of Surgical Complications.\\n Shrewsbury, UK: tfm publishing, 2013: Chapter 23.\\n2 This section is by Danny.',\n", " 'md': '```markdown\\n# Schein’s Common Sense Prevention and Management of Surgical Complications\\n\\n**Reference:** Shrewsbury, UK: tfm publishing, 2013: Chapter 23.\\n\\n**Author:** Danny\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Schein’s Common Sense Prevention and Management of Surgical Complications',\n", " 'md': '# Schein’s Common Sense Prevention and Management of Surgical Complications',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Reference:** Shrewsbury, UK: tfm publishing, 2013: Chapter 23.\\n\\n**Author:** Danny\\n```',\n", " 'md': '**Reference:** Shrewsbury, UK: tfm publishing, 2013: Chapter 23.\\n\\n**Author:** Danny\\n```',\n", " 'bBox': {'x': 73, 'y': 97, 'w': 241.96, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}, {'text': ''}, {'text': '2'}]},\n", " {'page': 356,\n", " 'text': 'Chapter 22\\nAcute abdominal wall hernias\\nPaul N. Rogers\\n\\n Always explore in cases of persistent vomiting if a lump,\\n however small, is found occupying one of the abdominal\\n rings and its nature is uncertain.\\n Augustus Charles Bernays\\n\\n Acute groin hernia\\n\\n In all parts of the world most groin hernias are now repaired electively.\\nIn spite of this, surgeons are still frequently confronted by acute groin\\nhernias and it is important that you know how to deal with them.\\n\\n Some words about terminology: groin hernias, inguinal or femoral,\\nmay be described as reducible, irreducible, incarcerated, strangulated, or\\nobstructed. This terminology can be confusing and these words, which\\nhave come to mean different things to different people, are much less\\nimportant than the concepts that underlie the recognition and\\nmanagement of acute hernia problems. The important concept to be\\ngrasped is that any hernia that becomes painful, inflamed or tender\\n— and is not readily reducible — should be regarded as a surgical\\nemergency.\\n\\n Presentation',\n", " 'md': '```markdown\\n# Chapter 22: Acute Abdominal Wall Hernias\\n**Author:** Paul N. Rogers\\n\\n> \"Always explore in cases of persistent vomiting if a lump, however small, is found occupying one of the abdominal rings and its nature is uncertain.\"\\n> — Augustus Charles Bernays\\n\\n## Acute Groin Hernia\\n\\nIn all parts of the world, most groin hernias are now repaired electively. In spite of this, surgeons are still frequently confronted by acute groin hernias, and it is important that you know how to deal with them.\\n\\nSome words about terminology: groin hernias, inguinal or femoral, may be described as reducible, irreducible, incarcerated, strangulated, or obstructed. This terminology can be confusing, and these words, which have come to mean different things to different people, are much less important than the concepts that underlie the recognition and management of acute hernia problems. The important concept to be grasped is that any hernia that becomes painful, inflamed, or tender — and is not readily reducible — should be regarded as a surgical emergency.\\n\\n## Presentation\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 22: Acute Abdominal Wall Hernias',\n", " 'md': '# Chapter 22: Acute Abdominal Wall Hernias',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 262.07, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Paul N. Rogers\\n\\n> \"Always explore in cases of persistent vomiting if a lump, however small, is found occupying one of the abdominal rings and its nature is uncertain.\"\\n> — Augustus Charles Bernays',\n", " 'md': '**Author:** Paul N. Rogers\\n\\n> \"Always explore in cases of persistent vomiting if a lump, however small, is found occupying one of the abdominal rings and its nature is uncertain.\"\\n> — Augustus Charles Bernays',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 203.89, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Acute Groin Hernia',\n", " 'md': '## Acute Groin Hernia',\n", " 'bBox': {'x': 86, 'y': 409, 'w': 146.2, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In all parts of the world, most groin hernias are now repaired electively. In spite of this, surgeons are still frequently confronted by acute groin hernias, and it is important that you know how to deal with them.\\n\\nSome words about terminology: groin hernias, inguinal or femoral, may be described as reducible, irreducible, incarcerated, strangulated, or obstructed. This terminology can be confusing, and these words, which have come to mean different things to different people, are much less important than the concepts that underlie the recognition and management of acute hernia problems. The important concept to be grasped is that any hernia that becomes painful, inflamed, or tender — and is not readily reducible — should be regarded as a surgical emergency.',\n", " 'md': 'In all parts of the world, most groin hernias are now repaired electively. In spite of this, surgeons are still frequently confronted by acute groin hernias, and it is important that you know how to deal with them.\\n\\nSome words about terminology: groin hernias, inguinal or femoral, may be described as reducible, irreducible, incarcerated, strangulated, or obstructed. This terminology can be confusing, and these words, which have come to mean different things to different people, are much less important than the concepts that underlie the recognition and management of acute hernia problems. The important concept to be grasped is that any hernia that becomes painful, inflamed, or tender — and is not readily reducible — should be regarded as a surgical emergency.',\n", " 'bBox': {'x': 72, 'y': 409, 'w': 467.46, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Presentation',\n", " 'md': '## Presentation',\n", " 'bBox': {'x': 86, 'y': 690, 'w': 100.24, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 357,\n", " 'text': ' Patients may present acutely in one of two ways:\\n\\n • Symptoms and signs related directly to the hernia itself.\\n • Abdominal symptoms and signs, which at first may not seem to be\\n related to a hernia.\\n\\n The first mode of presentation usually means pain and tenderness in\\na tense, irreducible hernia. A previously reducible hernia may suddenly\\nbecome irreducible. This problem is usually obvious ( Figure 22.1).\\n\\n The second mode of presentation may be much more insidious.\\nBeware the vomiting old lady! Treated at home for several days by the\\nprimary care physician as a case of gastroenteritis, she eventually comes\\nunder the care of the surgeons due to intractable emesis. By this stage\\nshe is dehydrated and in need of much resuscitation. It is surprisingly\\neasy in these circumstances to miss the small femoral hernia barely\\npalpable in the groin, trapping just enough small intestine to\\nproduce obstruction. No abdominal symptoms or signs are present and\\nthe plain abdominal radiographs are non-diagnostic. None of these\\ndifficulties saves you from the embarrassment of the following morning’s\\nround when the hernia is discovered.',\n", " 'md': '```markdown\\n## Presentation of Hernias\\n\\nPatients may present acutely in one of two ways:\\n\\n- Symptoms and signs related directly to the hernia itself.\\n- Abdominal symptoms and signs, which at first may not seem to be related to a hernia.\\n\\nThe first mode of presentation usually means pain and tenderness in a tense, irreducible hernia. A previously reducible hernia may suddenly become irreducible. This problem is usually obvious (Figure 22.1).\\n\\nThe second mode of presentation may be much more insidious. Beware the vomiting old lady! Treated at home for several days by the primary care physician as a case of gastroenteritis, she eventually comes under the care of the surgeons due to intractable emesis. By this stage, she is dehydrated and in need of much resuscitation. It is surprisingly easy in these circumstances to miss the small femoral hernia barely palpable in the groin, trapping just enough small intestine to produce obstruction. No abdominal symptoms or signs are present and the plain abdominal radiographs are non-diagnostic. None of these difficulties saves you from the embarrassment of the following morning’s round when the hernia is discovered.\\n```\\n\\n### Image Description\\n- **Figure 22.1**: This figure likely illustrates a tense, irreducible hernia, highlighting the physical characteristics that differentiate it from a reducible hernia. The image may include annotations or labels to indicate specific areas of concern, but the exact content is not identifiable from the text provided.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Presentation of Hernias',\n", " 'md': '## Presentation of Hernias',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Patients may present acutely in one of two ways:\\n\\n- Symptoms and signs related directly to the hernia itself.\\n- Abdominal symptoms and signs, which at first may not seem to be related to a hernia.\\n\\nThe first mode of presentation usually means pain and tenderness in a tense, irreducible hernia. A previously reducible hernia may suddenly become irreducible. This problem is usually obvious (Figure 22.1).\\n\\nThe second mode of presentation may be much more insidious. Beware the vomiting old lady! Treated at home for several days by the primary care physician as a case of gastroenteritis, she eventually comes under the care of the surgeons due to intractable emesis. By this stage, she is dehydrated and in need of much resuscitation. It is surprisingly easy in these circumstances to miss the small femoral hernia barely palpable in the groin, trapping just enough small intestine to produce obstruction. No abdominal symptoms or signs are present and the plain abdominal radiographs are non-diagnostic. None of these difficulties saves you from the embarrassment of the following morning’s round when the hernia is discovered.\\n```',\n", " 'md': 'Patients may present acutely in one of two ways:\\n\\n- Symptoms and signs related directly to the hernia itself.\\n- Abdominal symptoms and signs, which at first may not seem to be related to a hernia.\\n\\nThe first mode of presentation usually means pain and tenderness in a tense, irreducible hernia. A previously reducible hernia may suddenly become irreducible. This problem is usually obvious (Figure 22.1).\\n\\nThe second mode of presentation may be much more insidious. Beware the vomiting old lady! Treated at home for several days by the primary care physician as a case of gastroenteritis, she eventually comes under the care of the surgeons due to intractable emesis. By this stage, she is dehydrated and in need of much resuscitation. It is surprisingly easy in these circumstances to miss the small femoral hernia barely palpable in the groin, trapping just enough small intestine to produce obstruction. No abdominal symptoms or signs are present and the plain abdominal radiographs are non-diagnostic. None of these difficulties saves you from the embarrassment of the following morning’s round when the hernia is discovered.\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 22.1**: This figure likely illustrates a tense, irreducible hernia, highlighting the physical characteristics that differentiate it from a reducible hernia. The image may include annotations or labels to indicate specific areas of concern, but the exact content is not identifiable from the text provided.',\n", " 'md': '- **Figure 22.1**: This figure likely illustrates a tense, irreducible hernia, highlighting the physical characteristics that differentiate it from a reducible hernia. The image may include annotations or labels to indicate specific areas of concern, but the exact content is not identifiable from the text provided.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 358,\n", " 'text': ' FERKA4\\n Figure 22.1. “This must be strangulated, eh?”\\n\\n These days it is commonly discovered by the mandatory CT scan. Danny\\n\\n Hernias are still one of the commonest causes of small bowel\\nobstruction ( Chapter 21). You must look carefully for them in all\\ncases of actual or suspected intestinal obstruction. This may mean\\nmeticulous, prolonged and disagreeable palpation of groins that have not\\nseen the light of day, let alone soap and water, for a long time. In most\\ncases, however, the diagnosis is obvious with a classical bowel\\nobstruction and a hernia stuck in the scrotum.\\n\\n Beware the Richter’s hernia — typical of femoral hernias, where only\\na portion of the circumference of the bowel is strangulated. Because the\\nintestinal lumen is not completely blocked, bowel obstruction may not\\noccur and presentation is consequently delayed and non-specific.\\n\\n Preparation',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\nFigure 22.1. “This must be strangulated, eh?”\\n\\nThese days it is commonly discovered by the mandatory CT scan. Hernias are still one of the commonest causes of small bowel obstruction (Chapter 21). You must look carefully for them in all cases of actual or suspected intestinal obstruction. This may mean meticulous, prolonged and disagreeable palpation of groins that have not seen the light of day, let alone soap and water, for a long time. In most cases, however, the diagnosis is obvious with a classical bowel obstruction and a hernia stuck in the scrotum.\\n\\nBeware the Richter’s hernia — typical of femoral hernias, where only a portion of the circumference of the bowel is strangulated. Because the intestinal lumen is not completely blocked, bowel obstruction may not occur and presentation is consequently delayed and non-specific.\\n\\n## Image Identification and Description\\n**Figure 22**: The image likely depicts a medical illustration related to hernias, possibly showing the anatomy involved in strangulated hernias. The caption suggests a humorous or informal commentary on the seriousness of the condition.\\n\\n### Summary\\nThe image serves to visually represent the concept of strangulated hernias, which are a significant cause of small bowel obstruction. It emphasizes the importance of careful examination in diagnosing such conditions.\\n\\n## Preparation\\n```',\n", " 'images': [{'name': 'img_p357_1.png',\n", " 'height': 560,\n", " 'width': 800,\n", " 'x': 108,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1374,\n", " 'original_height': 961}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 22.1. “This must be strangulated, eh?”\\n\\nThese days it is commonly discovered by the mandatory CT scan. Hernias are still one of the commonest causes of small bowel obstruction (Chapter 21). You must look carefully for them in all cases of actual or suspected intestinal obstruction. This may mean meticulous, prolonged and disagreeable palpation of groins that have not seen the light of day, let alone soap and water, for a long time. In most cases, however, the diagnosis is obvious with a classical bowel obstruction and a hernia stuck in the scrotum.\\n\\nBeware the Richter’s hernia — typical of femoral hernias, where only a portion of the circumference of the bowel is strangulated. Because the intestinal lumen is not completely blocked, bowel obstruction may not occur and presentation is consequently delayed and non-specific.',\n", " 'md': 'Figure 22.1. “This must be strangulated, eh?”\\n\\nThese days it is commonly discovered by the mandatory CT scan. Hernias are still one of the commonest causes of small bowel obstruction (Chapter 21). You must look carefully for them in all cases of actual or suspected intestinal obstruction. This may mean meticulous, prolonged and disagreeable palpation of groins that have not seen the light of day, let alone soap and water, for a long time. In most cases, however, the diagnosis is obvious with a classical bowel obstruction and a hernia stuck in the scrotum.\\n\\nBeware the Richter’s hernia — typical of femoral hernias, where only a portion of the circumference of the bowel is strangulated. Because the intestinal lumen is not completely blocked, bowel obstruction may not occur and presentation is consequently delayed and non-specific.',\n", " 'bBox': {'x': 72, 'y': 380, 'w': 467.47, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 22**: The image likely depicts a medical illustration related to hernias, possibly showing the anatomy involved in strangulated hernias. The caption suggests a humorous or informal commentary on the seriousness of the condition.',\n", " 'md': '**Figure 22**: The image likely depicts a medical illustration related to hernias, possibly showing the anatomy involved in strangulated hernias. The caption suggests a humorous or informal commentary on the seriousness of the condition.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The image serves to visually represent the concept of strangulated hernias, which are a significant cause of small bowel obstruction. It emphasizes the importance of careful examination in diagnosing such conditions.',\n", " 'md': 'The image serves to visually represent the concept of strangulated hernias, which are a significant cause of small bowel obstruction. It emphasizes the importance of careful examination in diagnosing such conditions.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Preparation',\n", " 'md': '## Preparation',\n", " 'bBox': {'x': 86, 'y': 684, 'w': 91.96, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'cases of actual or suspected intestinal obstruction. This may mean'}]},\n", " {'page': 359,\n", " 'text': ' Surgery for acute groin hernia problems should be carried out without\\nundue delay, but these patients must not be rushed to surgery without\\ncareful assessment and preparation. As we suggested earlier, some\\npatients may be in need of quite a bit of resuscitation on admission to\\nhospital. Quite often these patients still have a hernia because they\\nhave been deemed ‘unfit’ for elective repair; comorbidity in this\\ngroup of patients may be a significant problem.\\n\\n Analgesia is an important part of the management of these patients.\\nOpiate analgesia and bed rest with the foot of the bed slightly elevated\\nmay successfully manage a painful obstructed hernia of short duration.\\nGentle attempts at reduction of such a hernia are justified once the\\nanalgesics have taken effect. A successful reduction of the hernia\\nmeans that emergency surgery at unsociable hours may be traded for a\\nsemi-elective procedure on the next available routine list — a benefit for\\nboth patient and surgeon. Note that manual reduction of the\\nincarcerated hernia should be attempted only in the absence of\\nsigns of intestinal strangulation; it should be gently performed, to\\navoid reduction en masse — when the herniated bowel and the\\nconstricting ring are reduced together, providing a false sense of\\nachievement and a delay of necessary surgery.\\n\\n The operation\\n\\n Inguinal hernia\\n The choice of anesthesia — whether local, spinal or general — is up to\\nyou, the habitus of the patient and your institutional dogmas. But we\\nprefer doing these cases under local anesthesia (and i.v. sedation by the\\nanesthetist) which is also our practice in the elective situation. An\\ninguinal incision is a satisfactory approach. Even if a bowel\\nresection is required it is possible to deliver sufficient length of\\nintestine through the limited incision.\\n\\n The main difference in dissection in an emergency hernia operation\\ncompared to an elective procedure is the moment at which the hernial\\nsac is opened. In the emergency situation the hernia will often reduce\\nspontaneously as soon as the constricting ring is divided. The site of',\n", " 'md': '```markdown\\n# Surgery for Acute Groin Hernia Problems\\n\\nSurgery for acute groin hernia problems should be carried out without undue delay, but these patients must not be rushed to surgery without careful assessment and preparation. As we suggested earlier, some patients may be in need of quite a bit of resuscitation on admission to hospital. Quite often these patients still have a hernia because they have been deemed ‘unfit’ for elective repair; comorbidity in this group of patients may be a significant problem.\\n\\nAnalgesia is an important part of the management of these patients. Opiate analgesia and bed rest with the foot of the bed slightly elevated may successfully manage a painful obstructed hernia of short duration. Gentle attempts at reduction of such a hernia are justified once the analgesics have taken effect. A successful reduction of the hernia means that emergency surgery at unsociable hours may be traded for a semi-elective procedure on the next available routine list — a benefit for both patient and surgeon. Note that manual reduction of the incarcerated hernia should be attempted only in the absence of signs of intestinal strangulation; it should be gently performed, to avoid reduction en masse — when the herniated bowel and the constricting ring are reduced together, providing a false sense of achievement and a delay of necessary surgery.\\n\\n## The Operation\\n\\n### Inguinal Hernia\\n\\nThe choice of anesthesia — whether local, spinal or general — is up to you, the habitus of the patient and your institutional dogmas. But we prefer doing these cases under local anesthesia (and i.v. sedation by the anesthetist) which is also our practice in the elective situation. An inguinal incision is a satisfactory approach. Even if a bowel resection is required it is possible to deliver sufficient length of intestine through the limited incision.\\n\\nThe main difference in dissection in an emergency hernia operation compared to an elective procedure is the moment at which the hernial sac is opened. In the emergency situation, the hernia will often reduce spontaneously as soon as the constricting ring is divided.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Surgery for Acute Groin Hernia Problems',\n", " 'md': '# Surgery for Acute Groin Hernia Problems',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Surgery for acute groin hernia problems should be carried out without undue delay, but these patients must not be rushed to surgery without careful assessment and preparation. As we suggested earlier, some patients may be in need of quite a bit of resuscitation on admission to hospital. Quite often these patients still have a hernia because they have been deemed ‘unfit’ for elective repair; comorbidity in this group of patients may be a significant problem.\\n\\nAnalgesia is an important part of the management of these patients. Opiate analgesia and bed rest with the foot of the bed slightly elevated may successfully manage a painful obstructed hernia of short duration. Gentle attempts at reduction of such a hernia are justified once the analgesics have taken effect. A successful reduction of the hernia means that emergency surgery at unsociable hours may be traded for a semi-elective procedure on the next available routine list — a benefit for both patient and surgeon. Note that manual reduction of the incarcerated hernia should be attempted only in the absence of signs of intestinal strangulation; it should be gently performed, to avoid reduction en masse — when the herniated bowel and the constricting ring are reduced together, providing a false sense of achievement and a delay of necessary surgery.',\n", " 'md': 'Surgery for acute groin hernia problems should be carried out without undue delay, but these patients must not be rushed to surgery without careful assessment and preparation. As we suggested earlier, some patients may be in need of quite a bit of resuscitation on admission to hospital. Quite often these patients still have a hernia because they have been deemed ‘unfit’ for elective repair; comorbidity in this group of patients may be a significant problem.\\n\\nAnalgesia is an important part of the management of these patients. Opiate analgesia and bed rest with the foot of the bed slightly elevated may successfully manage a painful obstructed hernia of short duration. Gentle attempts at reduction of such a hernia are justified once the analgesics have taken effect. A successful reduction of the hernia means that emergency surgery at unsociable hours may be traded for a semi-elective procedure on the next available routine list — a benefit for both patient and surgeon. Note that manual reduction of the incarcerated hernia should be attempted only in the absence of signs of intestinal strangulation; it should be gently performed, to avoid reduction en masse — when the herniated bowel and the constricting ring are reduced together, providing a false sense of achievement and a delay of necessary surgery.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Operation',\n", " 'md': '## The Operation',\n", " 'bBox': {'x': 86, 'y': 462, 'w': 109.42, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Inguinal Hernia',\n", " 'md': '### Inguinal Hernia',\n", " 'bBox': {'x': 86, 'y': 502, 'w': 102.29, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The choice of anesthesia — whether local, spinal or general — is up to you, the habitus of the patient and your institutional dogmas. But we prefer doing these cases under local anesthesia (and i.v. sedation by the anesthetist) which is also our practice in the elective situation. An inguinal incision is a satisfactory approach. Even if a bowel resection is required it is possible to deliver sufficient length of intestine through the limited incision.\\n\\nThe main difference in dissection in an emergency hernia operation compared to an elective procedure is the moment at which the hernial sac is opened. In the emergency situation, the hernia will often reduce spontaneously as soon as the constricting ring is divided.\\n```',\n", " 'md': 'The choice of anesthesia — whether local, spinal or general — is up to you, the habitus of the patient and your institutional dogmas. But we prefer doing these cases under local anesthesia (and i.v. sedation by the anesthetist) which is also our practice in the elective situation. An inguinal incision is a satisfactory approach. Even if a bowel resection is required it is possible to deliver sufficient length of intestine through the limited incision.\\n\\nThe main difference in dissection in an emergency hernia operation compared to an elective procedure is the moment at which the hernial sac is opened. In the emergency situation, the hernia will often reduce spontaneously as soon as the constricting ring is divided.\\n```',\n", " 'bBox': {'x': 72, 'y': 522, 'w': 467.59, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 360,\n", " 'text': 'constriction may be the superficial inguinal ring, in which case the hernia\\nreduces when external oblique is opened. It is recommended,\\ntherefore, that the sac be opened and the contents grasped for later\\ninspection before the constricting tissues are released. If the hernia\\nreduces before the sac contents are inspected, it is important that they\\nare subsequently identified and retrieved so that a loop of non-viable gut\\nis not inadvertently left in the abdomen. Retrieval of reduced sac contents\\ncan be an awkward business via the internal ring and occasionally a\\nformal laparotomy may be required to inspect matters properly. It is for\\nthese reasons that great care should be taken to secure the sac contents\\nfor inspection as soon as possible during the procedure. In this modern\\nera of laparoscopy, it may be possible to inspect the reduced sac\\ncontents by insertion of the scope via the hernia sac if this should be\\nnecessary.\\n\\n When the hernia sac contains only omentum, any tissue that is\\nnecrotic, or of doubtful viability, is excised, ensuring meticulous\\nhemostasis in the process — even a tiny bleeder from the stump of the\\nresected omentum may bring you back to the OR! If, on the other hand,\\nbowel is involved, then any areas of questionable viability should be\\nwrapped in a warm moist gauze pack and left for a few minutes to\\nrecover. Irreversibly ischemic gut should be resected. If there is a small\\npatch of necrosis that does not involve the whole circumference of the\\nbowel then this can sometimes be dealt with by invagination rather than\\nby resorting to resection. In this situation the injured bowel wall is\\ninvaginated by a seromuscular suture, taking bites on the viable bowel on\\neither side of the defective area of gut.\\n\\n Occasionally, particularly if bowel resection has been necessary,\\nedema of the herniated gut makes its replacement in the abdomen\\ndifficult. Maneuvers such as putting the patient into a marked\\nTrendelenburg position and gently compressing the eviscerated gut,\\ncovered by a large moist gauze swab, will almost invariably allow the\\nbowel to be replaced in the abdomen. It is possible to minimize the\\nchances of this difficulty arising if care is taken during any bowel\\nresection not to have any more gut outside the abdomen than is\\nabsolutely necessary. Very rarely, the herniated viscera won’t return to\\nthe abdomen without pulling on it from within; in such instances La',\n", " 'md': '```markdown\\n## Surgical Considerations for Hernia Repair\\n\\nConstricting tissues may be the superficial inguinal ring, in which case the hernia reduces when the external oblique is opened. It is recommended, therefore, that the sac be opened and the contents grasped for later inspection before the constricting tissues are released. If the hernia reduces before the sac contents are inspected, it is important that they are subsequently identified and retrieved so that a loop of non-viable gut is not inadvertently left in the abdomen. Retrieval of reduced sac contents can be an awkward business via the internal ring, and occasionally a formal laparotomy may be required to inspect matters properly. It is for these reasons that great care should be taken to secure the sac contents for inspection as soon as possible during the procedure. In this modern era of laparoscopy, it may be possible to inspect the reduced sac contents by insertion of the scope via the hernia sac if this should be necessary.\\n\\nWhen the hernia sac contains only omentum, any tissue that is necrotic, or of doubtful viability, is excised, ensuring meticulous hemostasis in the process — even a tiny bleeder from the stump of the resected omentum may bring you back to the OR! If, on the other hand, bowel is involved, then any areas of questionable viability should be wrapped in a warm moist gauze pack and left for a few minutes to recover. Irreversibly ischemic gut should be resected. If there is a small patch of necrosis that does not involve the whole circumference of the bowel, then this can sometimes be dealt with by invagination rather than by resorting to resection. In this situation, the injured bowel wall is invaginated by a seromuscular suture, taking bites on the viable bowel on either side of the defective area of gut.\\n\\nOccasionally, particularly if bowel resection has been necessary, edema of the herniated gut makes its replacement in the abdomen difficult. Maneuvers such as putting the patient into a marked Trendelenburg position and gently compressing the eviscerated gut, covered by a large moist gauze swab, will almost invariably allow the bowel to be replaced in the abdomen. It is possible to minimize the chances of this difficulty arising if care is taken during any bowel resection not to have any more gut outside the abdomen than is absolutely necessary. Very rarely, the herniated viscera won’t return to the abdomen without pulling on it from within; in such instances, La\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Considerations for Hernia Repair',\n", " 'md': '## Surgical Considerations for Hernia Repair',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Constricting tissues may be the superficial inguinal ring, in which case the hernia reduces when the external oblique is opened. It is recommended, therefore, that the sac be opened and the contents grasped for later inspection before the constricting tissues are released. If the hernia reduces before the sac contents are inspected, it is important that they are subsequently identified and retrieved so that a loop of non-viable gut is not inadvertently left in the abdomen. Retrieval of reduced sac contents can be an awkward business via the internal ring, and occasionally a formal laparotomy may be required to inspect matters properly. It is for these reasons that great care should be taken to secure the sac contents for inspection as soon as possible during the procedure. In this modern era of laparoscopy, it may be possible to inspect the reduced sac contents by insertion of the scope via the hernia sac if this should be necessary.\\n\\nWhen the hernia sac contains only omentum, any tissue that is necrotic, or of doubtful viability, is excised, ensuring meticulous hemostasis in the process — even a tiny bleeder from the stump of the resected omentum may bring you back to the OR! If, on the other hand, bowel is involved, then any areas of questionable viability should be wrapped in a warm moist gauze pack and left for a few minutes to recover. Irreversibly ischemic gut should be resected. If there is a small patch of necrosis that does not involve the whole circumference of the bowel, then this can sometimes be dealt with by invagination rather than by resorting to resection. In this situation, the injured bowel wall is invaginated by a seromuscular suture, taking bites on the viable bowel on either side of the defective area of gut.\\n\\nOccasionally, particularly if bowel resection has been necessary, edema of the herniated gut makes its replacement in the abdomen difficult. Maneuvers such as putting the patient into a marked Trendelenburg position and gently compressing the eviscerated gut, covered by a large moist gauze swab, will almost invariably allow the bowel to be replaced in the abdomen. It is possible to minimize the chances of this difficulty arising if care is taken during any bowel resection not to have any more gut outside the abdomen than is absolutely necessary. Very rarely, the herniated viscera won’t return to the abdomen without pulling on it from within; in such instances, La\\n```',\n", " 'md': 'Constricting tissues may be the superficial inguinal ring, in which case the hernia reduces when the external oblique is opened. It is recommended, therefore, that the sac be opened and the contents grasped for later inspection before the constricting tissues are released. If the hernia reduces before the sac contents are inspected, it is important that they are subsequently identified and retrieved so that a loop of non-viable gut is not inadvertently left in the abdomen. Retrieval of reduced sac contents can be an awkward business via the internal ring, and occasionally a formal laparotomy may be required to inspect matters properly. It is for these reasons that great care should be taken to secure the sac contents for inspection as soon as possible during the procedure. In this modern era of laparoscopy, it may be possible to inspect the reduced sac contents by insertion of the scope via the hernia sac if this should be necessary.\\n\\nWhen the hernia sac contains only omentum, any tissue that is necrotic, or of doubtful viability, is excised, ensuring meticulous hemostasis in the process — even a tiny bleeder from the stump of the resected omentum may bring you back to the OR! If, on the other hand, bowel is involved, then any areas of questionable viability should be wrapped in a warm moist gauze pack and left for a few minutes to recover. Irreversibly ischemic gut should be resected. If there is a small patch of necrosis that does not involve the whole circumference of the bowel, then this can sometimes be dealt with by invagination rather than by resorting to resection. In this situation, the injured bowel wall is invaginated by a seromuscular suture, taking bites on the viable bowel on either side of the defective area of gut.\\n\\nOccasionally, particularly if bowel resection has been necessary, edema of the herniated gut makes its replacement in the abdomen difficult. Maneuvers such as putting the patient into a marked Trendelenburg position and gently compressing the eviscerated gut, covered by a large moist gauze swab, will almost invariably allow the bowel to be replaced in the abdomen. It is possible to minimize the chances of this difficulty arising if care is taken during any bowel resection not to have any more gut outside the abdomen than is absolutely necessary. Very rarely, the herniated viscera won’t return to the abdomen without pulling on it from within; in such instances, La\\n```',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.8, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 361,\n", " 'text': 'Rocque’s maneuver may be useful: extend the skin incision up and\\nlaterally; then extend the split of the external oblique aponeurosis and\\nfollow this with a muscle-splitting incision of internal oblique and\\ntransverse muscles above the internal ring. Through this incision you\\nenter the peritoneal cavity and reduce the herniated viscera from within\\n(like at laparoscopy).\\n\\n The question of the type of hernia repair to be employed is a\\nmatter for the individual surgeon, with one proviso — in these days\\nof tension-free hernia repair, it seems imprudent to place large amounts\\nof mesh in the groin if necrotic gut has had to be resected. In this\\nsituation some other type of repair seems advisable to obviate the\\nprolonged misery of infected mesh.\\n\\n Femoral hernia\\n You can approach the acute femoral hernia from below the\\ninguinal canal, from above, or through it.\\n\\n With the low approach, you place the incision below the inguinal\\nligament, directly over the bulge. You find the hernial sac and open it,\\nmaking sure to grasp its contents for proper inspection. Strangulated\\nomentum may be excised and viable bowel is reduced back into the\\nperitoneal cavity through the femoral ring. When the ring is tight, and\\nusually it is, you can stretch it with your small finger, inserted medially to\\nthe femoral vein; occasionally, you’ll have to cut the lower fibers of the\\noverlying inguinal ligament to let your finger enter the femoral canal. You\\ncan resect non-viable small bowel through this approach and even\\nanastomose its ends, but pushing the sutured or stapled anastomosis\\nback into the abdomen is like trying to squeeze a tomato into a cocktail\\nglass. Therefore, when bowel has to be resected, it is advisable to\\ndo it through a small right (or left) lower quadrant muscle-splitting\\nlaparotomy (as for appendectomy).\\n\\n Some authorities favor an approach via the inguinal canal but we see\\nlittle merit in this approach, which must disrupt the anatomy of the canal\\nand presumably risks a subsequent inguinal hernia.\\n\\n Yet another approach is McEvedy’s. This involves access to the',\n", " 'md': '```markdown\\n## Surgical Approaches to Hernia Repair\\n\\nRocque’s maneuver may be useful: extend the skin incision up and laterally; then extend the split of the external oblique aponeurosis and follow this with a muscle-splitting incision of internal oblique and transverse muscles above the internal ring. Through this incision, you enter the peritoneal cavity and reduce the herniated viscera from within (like at laparoscopy).\\n\\nThe question of the type of hernia repair to be employed is a matter for the individual surgeon, with one proviso — in these days of tension-free hernia repair, it seems imprudent to place large amounts of mesh in the groin if necrotic gut has had to be resected. In this situation, some other type of repair seems advisable to obviate the prolonged misery of infected mesh.\\n\\n### Femoral Hernia\\n\\nYou can approach the acute femoral hernia from below the inguinal canal, from above, or through it.\\n\\nWith the low approach, you place the incision below the inguinal ligament, directly over the bulge. You find the hernial sac and open it, making sure to grasp its contents for proper inspection. Strangulated omentum may be excised and viable bowel is reduced back into the peritoneal cavity through the femoral ring. When the ring is tight, and usually it is, you can stretch it with your small finger, inserted medially to the femoral vein; occasionally, you’ll have to cut the lower fibers of the overlying inguinal ligament to let your finger enter the femoral canal. You can resect non-viable small bowel through this approach and even anastomose its ends, but pushing the sutured or stapled anastomosis back into the abdomen is like trying to squeeze a tomato into a cocktail glass. Therefore, when bowel has to be resected, it is advisable to do it through a small right (or left) lower quadrant muscle-splitting laparotomy (as for appendectomy).\\n\\nSome authorities favor an approach via the inguinal canal but we see little merit in this approach, which must disrupt the anatomy of the canal and presumably risks a subsequent inguinal hernia.\\n\\nYet another approach is McEvedy’s. This involves access to the...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Approaches to Hernia Repair',\n", " 'md': '## Surgical Approaches to Hernia Repair',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Rocque’s maneuver may be useful: extend the skin incision up and laterally; then extend the split of the external oblique aponeurosis and follow this with a muscle-splitting incision of internal oblique and transverse muscles above the internal ring. Through this incision, you enter the peritoneal cavity and reduce the herniated viscera from within (like at laparoscopy).\\n\\nThe question of the type of hernia repair to be employed is a matter for the individual surgeon, with one proviso — in these days of tension-free hernia repair, it seems imprudent to place large amounts of mesh in the groin if necrotic gut has had to be resected. In this situation, some other type of repair seems advisable to obviate the prolonged misery of infected mesh.',\n", " 'md': 'Rocque’s maneuver may be useful: extend the skin incision up and laterally; then extend the split of the external oblique aponeurosis and follow this with a muscle-splitting incision of internal oblique and transverse muscles above the internal ring. Through this incision, you enter the peritoneal cavity and reduce the herniated viscera from within (like at laparoscopy).\\n\\nThe question of the type of hernia repair to be employed is a matter for the individual surgeon, with one proviso — in these days of tension-free hernia repair, it seems imprudent to place large amounts of mesh in the groin if necrotic gut has had to be resected. In this situation, some other type of repair seems advisable to obviate the prolonged misery of infected mesh.',\n", " 'bBox': {'x': 72, 'y': 168, 'w': 467.89, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Femoral Hernia',\n", " 'md': '### Femoral Hernia',\n", " 'bBox': {'x': 86, 'y': 325, 'w': 103.14, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'You can approach the acute femoral hernia from below the inguinal canal, from above, or through it.\\n\\nWith the low approach, you place the incision below the inguinal ligament, directly over the bulge. You find the hernial sac and open it, making sure to grasp its contents for proper inspection. Strangulated omentum may be excised and viable bowel is reduced back into the peritoneal cavity through the femoral ring. When the ring is tight, and usually it is, you can stretch it with your small finger, inserted medially to the femoral vein; occasionally, you’ll have to cut the lower fibers of the overlying inguinal ligament to let your finger enter the femoral canal. You can resect non-viable small bowel through this approach and even anastomose its ends, but pushing the sutured or stapled anastomosis back into the abdomen is like trying to squeeze a tomato into a cocktail glass. Therefore, when bowel has to be resected, it is advisable to do it through a small right (or left) lower quadrant muscle-splitting laparotomy (as for appendectomy).\\n\\nSome authorities favor an approach via the inguinal canal but we see little merit in this approach, which must disrupt the anatomy of the canal and presumably risks a subsequent inguinal hernia.\\n\\nYet another approach is McEvedy’s. This involves access to the...\\n```',\n", " 'md': 'You can approach the acute femoral hernia from below the inguinal canal, from above, or through it.\\n\\nWith the low approach, you place the incision below the inguinal ligament, directly over the bulge. You find the hernial sac and open it, making sure to grasp its contents for proper inspection. Strangulated omentum may be excised and viable bowel is reduced back into the peritoneal cavity through the femoral ring. When the ring is tight, and usually it is, you can stretch it with your small finger, inserted medially to the femoral vein; occasionally, you’ll have to cut the lower fibers of the overlying inguinal ligament to let your finger enter the femoral canal. You can resect non-viable small bowel through this approach and even anastomose its ends, but pushing the sutured or stapled anastomosis back into the abdomen is like trying to squeeze a tomato into a cocktail glass. Therefore, when bowel has to be resected, it is advisable to do it through a small right (or left) lower quadrant muscle-splitting laparotomy (as for appendectomy).\\n\\nSome authorities favor an approach via the inguinal canal but we see little merit in this approach, which must disrupt the anatomy of the canal and presumably risks a subsequent inguinal hernia.\\n\\nYet another approach is McEvedy’s. This involves access to the...\\n```',\n", " 'bBox': {'x': 72, 'y': 325, 'w': 467.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 362,\n", " 'text': 'extraperitoneal space along the lateral border of the lower part of rectus\\nabdominis. The skin incision may be vertical, in line with the border of\\nrectus, or oblique/horizontal. A vertical skin incision has the merit of\\nallowing extension to a point below the inguinal ligament and this may be\\nhelpful in reducing stubborn hernias, allowing traction from above and\\ncompression from below. Once the space behind the rectus muscle has\\nbeen accessed, the hernia can usually be freed from behind the inguinal\\nligament. The peritoneum can be opened as widely as necessary to\\npermit inspection of the contents of the hernia sac and to carry out\\nintestinal resection if that is required.\\n\\n All of the above approaches are reasonable provided the contents of\\nthe hernia sac are examined and dealt with appropriately. As with\\ninguinal hernias, the implantation of large amounts of mesh should be\\navoided in patients who have contamination of the operative field with\\nintestinal contents. With this caveat the choice of repair is not different\\nfrom what you would do in the elective situation. Our choice: in the\\nabsence of gross contamination, the femoral canal is obliterated\\nwith a mesh plug. When gross contamination is present, we would\\n‘close’ the femoral canal by suturing the inguinal ligament, above, to the\\npectineal fascia, below.\\n\\n Incisional/ventral hernias\\n\\n Incisional hernias are common but most are asymptomatic except for\\nthe unsightly bulge and discomfort they sometimes produce. It is the\\nsmall incisional hernias (or the small septate compartments within a\\nlarge hernia) with the tight neck that become acutely symptomatic\\n— incarcerating omentum or intestine.\\n\\n The presentation is well known to you: an old ‘silent’ hernia or\\nabdominal scar, which has now become painful. When bowel has\\nbeen incarcerated there may be associated symptoms of small bowel (or,\\nrarely, colon) obstruction. The hernia itself is tense, tender and non-\\nreducible.\\n\\n It is important to decide whether the intestinal obstruction is',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nThe extraperitoneal space along the lateral border of the lower part of rectus abdominis. The skin incision may be vertical, in line with the border of rectus, or oblique/horizontal. A vertical skin incision has the merit of allowing extension to a point below the inguinal ligament and this may be helpful in reducing stubborn hernias, allowing traction from above and compression from below. Once the space behind the rectus muscle has been accessed, the hernia can usually be freed from behind the inguinal ligament. The peritoneum can be opened as widely as necessary to permit inspection of the contents of the hernia sac and to carry out intestinal resection if that is required.\\n\\nAll of the above approaches are reasonable provided the contents of the hernia sac are examined and dealt with appropriately. As with inguinal hernias, the implantation of large amounts of mesh should be avoided in patients who have contamination of the operative field with intestinal contents. With this caveat the choice of repair is not different from what you would do in the elective situation. Our choice: in the absence of gross contamination, the femoral canal is obliterated with a mesh plug. When gross contamination is present, we would ‘close’ the femoral canal by suturing the inguinal ligament, above, to the pectineal fascia, below.\\n\\n### Incisional/Ventral Hernias\\n\\nIncisional hernias are common but most are asymptomatic except for the unsightly bulge and discomfort they sometimes produce. It is the small incisional hernias (or the small septate compartments within a large hernia) with the tight neck that become acutely symptomatic — incarcerating omentum or intestine.\\n\\nThe presentation is well known to you: an old ‘silent’ hernia or abdominal scar, which has now become painful. When bowel has been incarcerated there may be associated symptoms of small bowel (or, rarely, colon) obstruction. The hernia itself is tense, tender and non-reducible.\\n\\nIt is important to decide whether the intestinal obstruction is...\\n\\n## Image Identification and Description\\n\\n*No images or figures were identified on this page.*\\n\\n## Formulas\\n\\n*No formulas were identified on this page.*\\n\\n## Tables\\n\\n*No tables were identified on this page.*\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The extraperitoneal space along the lateral border of the lower part of rectus abdominis. The skin incision may be vertical, in line with the border of rectus, or oblique/horizontal. A vertical skin incision has the merit of allowing extension to a point below the inguinal ligament and this may be helpful in reducing stubborn hernias, allowing traction from above and compression from below. Once the space behind the rectus muscle has been accessed, the hernia can usually be freed from behind the inguinal ligament. The peritoneum can be opened as widely as necessary to permit inspection of the contents of the hernia sac and to carry out intestinal resection if that is required.\\n\\nAll of the above approaches are reasonable provided the contents of the hernia sac are examined and dealt with appropriately. As with inguinal hernias, the implantation of large amounts of mesh should be avoided in patients who have contamination of the operative field with intestinal contents. With this caveat the choice of repair is not different from what you would do in the elective situation. Our choice: in the absence of gross contamination, the femoral canal is obliterated with a mesh plug. When gross contamination is present, we would ‘close’ the femoral canal by suturing the inguinal ligament, above, to the pectineal fascia, below.',\n", " 'md': 'The extraperitoneal space along the lateral border of the lower part of rectus abdominis. The skin incision may be vertical, in line with the border of rectus, or oblique/horizontal. A vertical skin incision has the merit of allowing extension to a point below the inguinal ligament and this may be helpful in reducing stubborn hernias, allowing traction from above and compression from below. Once the space behind the rectus muscle has been accessed, the hernia can usually be freed from behind the inguinal ligament. The peritoneum can be opened as widely as necessary to permit inspection of the contents of the hernia sac and to carry out intestinal resection if that is required.\\n\\nAll of the above approaches are reasonable provided the contents of the hernia sac are examined and dealt with appropriately. As with inguinal hernias, the implantation of large amounts of mesh should be avoided in patients who have contamination of the operative field with intestinal contents. With this caveat the choice of repair is not different from what you would do in the elective situation. Our choice: in the absence of gross contamination, the femoral canal is obliterated with a mesh plug. When gross contamination is present, we would ‘close’ the femoral canal by suturing the inguinal ligament, above, to the pectineal fascia, below.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Incisional/Ventral Hernias',\n", " 'md': '### Incisional/Ventral Hernias',\n", " 'bBox': {'x': 86, 'y': 462, 'w': 198.61, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Incisional hernias are common but most are asymptomatic except for the unsightly bulge and discomfort they sometimes produce. It is the small incisional hernias (or the small septate compartments within a large hernia) with the tight neck that become acutely symptomatic — incarcerating omentum or intestine.\\n\\nThe presentation is well known to you: an old ‘silent’ hernia or abdominal scar, which has now become painful. When bowel has been incarcerated there may be associated symptoms of small bowel (or, rarely, colon) obstruction. The hernia itself is tense, tender and non-reducible.\\n\\nIt is important to decide whether the intestinal obstruction is...',\n", " 'md': 'Incisional hernias are common but most are asymptomatic except for the unsightly bulge and discomfort they sometimes produce. It is the small incisional hernias (or the small septate compartments within a large hernia) with the tight neck that become acutely symptomatic — incarcerating omentum or intestine.\\n\\nThe presentation is well known to you: an old ‘silent’ hernia or abdominal scar, which has now become painful. When bowel has been incarcerated there may be associated symptoms of small bowel (or, rarely, colon) obstruction. The hernia itself is tense, tender and non-reducible.\\n\\nIt is important to decide whether the intestinal obstruction is...',\n", " 'bBox': {'x': 72, 'y': 531, 'w': 467.56, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*',\n", " 'md': '*No images or figures were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formulas',\n", " 'md': '## Formulas',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No formulas were identified on this page.*',\n", " 'md': '*No formulas were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No tables were identified on this page.*\\n```',\n", " 'md': '*No tables were identified on this page.*\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 363,\n", " 'text': 'caused by the incisional hernia or simply associated with it ( Figure\\n22.2). The latter situation, which is not uncommon, implies that the\\npatient suffers small bowel obstruction, due to adhesions for example,\\nand the obstructed and distended loops of bowel invade the longstanding\\nincisional hernia as a secondary phenomenon. On examination, the\\nbowel-filled tender hernia may mimic incarceration. It is for this reason\\nthat the contents of any hernia associated with obstruction must be\\nexamined carefully at operation to ensure that the hernia truly is the\\ncause of the obstruction (This applies to all kinds of hernias. We recall\\na case of obstruction that was addressed by reducing and repairing a\\ntense femoral hernia, only for the obturator hernia, which was the true\\ncause of the obstruction, to be discovered at laparotomy many days later\\nwhen the patient failed to recover from the first operation.)\\n\\n Obviously, with liberal use of pre-operative CT imaging, the site of obstruction and the\\n nature of the contents of the hernia can be accurately delineated, providing a road map\\n for surgery.',\n", " 'md': \"```markdown\\n### Text Extraction\\n\\nThe text discusses complications associated with incisional hernias, particularly in relation to small bowel obstruction. It highlights that the obstruction may be due to adhesions, leading to the invasion of the hernia by distended loops of bowel. The examination of a bowel-filled tender hernia may resemble incarceration, necessitating careful evaluation during surgery to confirm the hernia's role in the obstruction. The text also references a case where a femoral hernia was initially repaired, but the true cause of obstruction, an obturator hernia, was only identified later during laparotomy.\\n\\nThe importance of pre-operative CT imaging is emphasized, as it can accurately identify the site of obstruction and the contents of the hernia, aiding in surgical planning.\\n\\n### Figure Identification\\n\\n- **Figure 22.2**: The text references this figure, which likely illustrates the relationship between incisional hernias and small bowel obstruction. However, the content of the figure is not provided in the text.\\n\\n### Summary\\n\\nThe passage outlines the complexities of diagnosing and treating hernias associated with bowel obstruction, stressing the need for thorough examination and the utility of imaging techniques in surgical planning.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text Extraction',\n", " 'md': '### Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"The text discusses complications associated with incisional hernias, particularly in relation to small bowel obstruction. It highlights that the obstruction may be due to adhesions, leading to the invasion of the hernia by distended loops of bowel. The examination of a bowel-filled tender hernia may resemble incarceration, necessitating careful evaluation during surgery to confirm the hernia's role in the obstruction. The text also references a case where a femoral hernia was initially repaired, but the true cause of obstruction, an obturator hernia, was only identified later during laparotomy.\\n\\nThe importance of pre-operative CT imaging is emphasized, as it can accurately identify the site of obstruction and the contents of the hernia, aiding in surgical planning.\",\n", " 'md': \"The text discusses complications associated with incisional hernias, particularly in relation to small bowel obstruction. It highlights that the obstruction may be due to adhesions, leading to the invasion of the hernia by distended loops of bowel. The examination of a bowel-filled tender hernia may resemble incarceration, necessitating careful evaluation during surgery to confirm the hernia's role in the obstruction. The text also references a case where a femoral hernia was initially repaired, but the true cause of obstruction, an obturator hernia, was only identified later during laparotomy.\\n\\nThe importance of pre-operative CT imaging is emphasized, as it can accurately identify the site of obstruction and the contents of the hernia, aiding in surgical planning.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Identification',\n", " 'md': '### Figure Identification',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 22.2**: The text references this figure, which likely illustrates the relationship between incisional hernias and small bowel obstruction. However, the content of the figure is not provided in the text.',\n", " 'md': '- **Figure 22.2**: The text references this figure, which likely illustrates the relationship between incisional hernias and small bowel obstruction. However, the content of the figure is not provided in the text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The passage outlines the complexities of diagnosing and treating hernias associated with bowel obstruction, stressing the need for thorough examination and the utility of imaging techniques in surgical planning.\\n```',\n", " 'md': 'The passage outlines the complexities of diagnosing and treating hernias associated with bowel obstruction, stressing the need for thorough examination and the utility of imaging techniques in surgical planning.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'caused by the incisional hernia or simply associated with it ( Figure 22.2). The latter situation, which is not uncommon, implies that the patient suffers '}]},\n", " {'page': 364,\n", " 'text': ' KumoR\\n Per 14\\n Figure 22.2. Professor of surgery to assistant: “Just reduce the hernia and repair with\\n light mesh…” A medical student: “Excuse me Sir, but did you see the pre-op CT?”\\n\\n Any ‘acute’ incisional hernia is a surgical emergency. This is also\\ntrue with other types of abdominal wall hernias, such as paraumbilical or\\nepigastric ones. It should be noted, however, that epigastric hernias\\nrarely, if ever, cause trouble. They contain only extraperitoneal fat from\\nthe falciform ligament, and for this reason need not be repaired routinely\\nin the absence of symptoms. Also, the acutely incarcerated umbilical\\nhernia is unlikely to involve intestine.\\n\\n At operation, the hernia sac has to be entered to evaluate the\\nincarcerated contents that are to be reduced or resected depending on\\nthe findings. And the surgical findings should explain the clinical\\npresentation. For example, if you do not find strangulated omentum or\\nbowel in the sac, you have to retrieve the whole length of the intestine in\\nsearch for distal small bowel obstruction. If you find pus within the sac\\nyou have to look for the source. We have seen patients operated upon\\nfor a ‘strangulated incisional hernia’ when the underlying diagnosis was\\nperforated appendicitis. We have operated for ‘strangulated femoral',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Figure 22.2\\n**Caption:** Professor of surgery to assistant: “Just reduce the hernia and repair with light mesh…” A medical student: “Excuse me Sir, but did you see the pre-op CT?”\\n\\nAny ‘acute’ incisional hernia is a surgical emergency. This is also true with other types of abdominal wall hernias, such as paraumbilical or epigastric ones. It should be noted, however, that epigastric hernias rarely, if ever, cause trouble. They contain only extraperitoneal fat from the falciform ligament, and for this reason need not be repaired routinely in the absence of symptoms. Also, the acutely incarcerated umbilical hernia is unlikely to involve intestine.\\n\\nAt operation, the hernia sac has to be entered to evaluate the incarcerated contents that are to be reduced or resected depending on the findings. The surgical findings should explain the clinical presentation. For example, if you do not find strangulated omentum or bowel in the sac, you have to retrieve the whole length of the intestine in search for distal small bowel obstruction. If you find pus within the sac you have to look for the source. We have seen patients operated upon for a ‘strangulated incisional hernia’ when the underlying diagnosis was perforated appendicitis. We have operated for ‘strangulated femoral...\\n\\n```\\n### Image Description\\n- **Figure 22.2**: The image depicts a scene in a surgical setting where a professor is instructing an assistant about hernia repair while a medical student raises a question regarding the pre-operative CT scan. The image captures the dynamics of a surgical team and highlights the importance of pre-operative assessments in surgical procedures.\\n\\n### Summary\\nThis page discusses the urgency of addressing acute incisional hernias and provides insights into the surgical approach and considerations during operations. It emphasizes the need for thorough evaluation of the hernia sac and the potential for misdiagnosis in surgical emergencies.',\n", " 'images': [{'name': 'img_p363_1.png',\n", " 'height': 572,\n", " 'width': 803,\n", " 'x': 107.27999999999975,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1380,\n", " 'original_height': 982}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 22.2',\n", " 'md': '## Figure 22.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** Professor of surgery to assistant: “Just reduce the hernia and repair with light mesh…” A medical student: “Excuse me Sir, but did you see the pre-op CT?”\\n\\nAny ‘acute’ incisional hernia is a surgical emergency. This is also true with other types of abdominal wall hernias, such as paraumbilical or epigastric ones. It should be noted, however, that epigastric hernias rarely, if ever, cause trouble. They contain only extraperitoneal fat from the falciform ligament, and for this reason need not be repaired routinely in the absence of symptoms. Also, the acutely incarcerated umbilical hernia is unlikely to involve intestine.\\n\\nAt operation, the hernia sac has to be entered to evaluate the incarcerated contents that are to be reduced or resected depending on the findings. The surgical findings should explain the clinical presentation. For example, if you do not find strangulated omentum or bowel in the sac, you have to retrieve the whole length of the intestine in search for distal small bowel obstruction. If you find pus within the sac you have to look for the source. We have seen patients operated upon for a ‘strangulated incisional hernia’ when the underlying diagnosis was perforated appendicitis. We have operated for ‘strangulated femoral...\\n\\n```',\n", " 'md': '**Caption:** Professor of surgery to assistant: “Just reduce the hernia and repair with light mesh…” A medical student: “Excuse me Sir, but did you see the pre-op CT?”\\n\\nAny ‘acute’ incisional hernia is a surgical emergency. This is also true with other types of abdominal wall hernias, such as paraumbilical or epigastric ones. It should be noted, however, that epigastric hernias rarely, if ever, cause trouble. They contain only extraperitoneal fat from the falciform ligament, and for this reason need not be repaired routinely in the absence of symptoms. Also, the acutely incarcerated umbilical hernia is unlikely to involve intestine.\\n\\nAt operation, the hernia sac has to be entered to evaluate the incarcerated contents that are to be reduced or resected depending on the findings. The surgical findings should explain the clinical presentation. For example, if you do not find strangulated omentum or bowel in the sac, you have to retrieve the whole length of the intestine in search for distal small bowel obstruction. If you find pus within the sac you have to look for the source. We have seen patients operated upon for a ‘strangulated incisional hernia’ when the underlying diagnosis was perforated appendicitis. We have operated for ‘strangulated femoral...\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 398, 'w': 467.59, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 22.2**: The image depicts a scene in a surgical setting where a professor is instructing an assistant about hernia repair while a medical student raises a question regarding the pre-operative CT scan. The image captures the dynamics of a surgical team and highlights the importance of pre-operative assessments in surgical procedures.',\n", " 'md': '- **Figure 22.2**: The image depicts a scene in a surgical setting where a professor is instructing an assistant about hernia repair while a medical student raises a question regarding the pre-operative CT scan. The image captures the dynamics of a surgical team and highlights the importance of pre-operative assessments in surgical procedures.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the urgency of addressing acute incisional hernias and provides insights into the surgical approach and considerations during operations. It emphasizes the need for thorough evaluation of the hernia sac and the potential for misdiagnosis in surgical emergencies.',\n", " 'md': 'This page discusses the urgency of addressing acute incisional hernias and provides insights into the surgical approach and considerations during operations. It emphasizes the need for thorough evaluation of the hernia sac and the potential for misdiagnosis in surgical emergencies.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 365,\n", " 'text': 'hernia’ to find the hernia sac full of pus originating from a tubo-ovarian\\nabscess. (Again, this hints at the usefulness of a pre-operative CT scan!)\\n\\n After the contents of the hernia have been dealt with, identify the\\nfascial margins of the defect. Use your conventional ‘best’ repair but do\\nnot forget that placing a mesh in a contaminated field is potentially\\nproblematic. Not everybody agrees with such dogma and there are those\\nwho do report ‘reasonable’ results with implantation of non-absorbable\\nmesh in acute situations and even in grossly contaminated fields — after\\nresection of bowel.\\n\\n A few caveats should you plan to use synthetic mesh:\\n\\n • In contaminated fields use polypropylene (e.g. Marlex®) which is\\n relatively resistant to infection rather than polytetrafluoroethylene\\n (PTFE — Gore-Tex®) which is not. Infected Marlex® grafts are often\\n salvageable while infected Gore-Tex® patches always have to be\\n removed. The ‘lighter’ and more porous the mesh — the less\\n susceptible it is to infection!\\n • Bear in mind also that leaving non-absorbable mesh in contact\\n with the gut leads to difficulties and disasters later. Mesh repair\\n of an incisional hernia should always aim to place the prosthetic\\n material outside the peritoneum, ideally in the pre-peritoneal\\n retromuscular position. At the very least omentum should be placed\\n between any unavoidable intraperitoneal mesh and the viscera.\\n Experience with subsequent laparotomies in patients with\\n intraperitoneal mesh shows that adhesions are much denser than\\n with extraperitoneal mesh and as a result small bowel resection is\\n often required simply to access the abdominal cavity. And although\\n uncommon we have all seen spontaneous intestinal fistulas\\n developing at the contact point with the mesh. The manufacturers of\\n the ‘dual’-type mesh (smooth or coated on the inside, porous on the\\n outside) claim that their products are safe for intraperitoneal use;\\n however, injury to bowel has also been observed with such types of\\n mesh.\\n • A relatively newly available product to repair abdominal wall hernias\\n in contaminated fields are one of the biomaterials which although',\n", " 'md': \"```markdown\\n## Hernia Repair Considerations\\n\\nIn the context of hernia repair, particularly when dealing with a hernia sac full of pus originating from a tubo-ovarian abscess, the importance of a pre-operative CT scan is highlighted.\\n\\nAfter addressing the contents of the hernia, it is crucial to identify the fascial margins of the defect. The conventional 'best' repair should be utilized, but caution is advised when placing a mesh in a contaminated field, as this can be problematic. While there are differing opinions on this matter, some report 'reasonable' outcomes with the implantation of non-absorbable mesh in acute situations, even in grossly contaminated fields, following bowel resection.\\n\\n### Caveats for Using Synthetic Mesh\\n\\n- In contaminated fields, it is recommended to use polypropylene (e.g., Marlex®), which is relatively resistant to infection, rather than polytetrafluoroethylene (PTFE — Gore-Tex®), which is not. Infected Marlex® grafts are often salvageable, while infected Gore-Tex® patches typically require removal. The lighter and more porous the mesh, the less susceptible it is to infection.\\n\\n- It is also important to consider that leaving non-absorbable mesh in contact with the gut can lead to complications later. Mesh repair of an incisional hernia should aim to place the prosthetic material outside the peritoneum, ideally in the pre-peritoneal retromuscular position. At a minimum, omentum should be placed between any unavoidable intraperitoneal mesh and the viscera. Experience with subsequent laparotomies in patients with intraperitoneal mesh indicates that adhesions are denser than with extraperitoneal mesh, often necessitating small bowel resection to access the abdominal cavity. Although uncommon, spontaneous intestinal fistulas have been observed at the contact point with the mesh.\\n\\n- Manufacturers of 'dual'-type mesh (smooth or coated on the inside, porous on the outside) claim their products are safe for intraperitoneal use; however, bowel injury has also been reported with such types of mesh.\\n\\n- A relatively new product for repairing abdominal wall hernias in contaminated fields is one of the biomaterials, which although...\\n```\\n\\n*Note: The text was extracted without any identifiable images, graphs, or tables. If there were any images or figures, they would be described and numbered accordingly.*\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Hernia Repair Considerations',\n", " 'md': '## Hernia Repair Considerations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"In the context of hernia repair, particularly when dealing with a hernia sac full of pus originating from a tubo-ovarian abscess, the importance of a pre-operative CT scan is highlighted.\\n\\nAfter addressing the contents of the hernia, it is crucial to identify the fascial margins of the defect. The conventional 'best' repair should be utilized, but caution is advised when placing a mesh in a contaminated field, as this can be problematic. While there are differing opinions on this matter, some report 'reasonable' outcomes with the implantation of non-absorbable mesh in acute situations, even in grossly contaminated fields, following bowel resection.\",\n", " 'md': \"In the context of hernia repair, particularly when dealing with a hernia sac full of pus originating from a tubo-ovarian abscess, the importance of a pre-operative CT scan is highlighted.\\n\\nAfter addressing the contents of the hernia, it is crucial to identify the fascial margins of the defect. The conventional 'best' repair should be utilized, but caution is advised when placing a mesh in a contaminated field, as this can be problematic. While there are differing opinions on this matter, some report 'reasonable' outcomes with the implantation of non-absorbable mesh in acute situations, even in grossly contaminated fields, following bowel resection.\",\n", " 'bBox': {'x': 188, 'y': 516, 'w': 29.59, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Caveats for Using Synthetic Mesh',\n", " 'md': '### Caveats for Using Synthetic Mesh',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- In contaminated fields, it is recommended to use polypropylene (e.g., Marlex®), which is relatively resistant to infection, rather than polytetrafluoroethylene (PTFE — Gore-Tex®), which is not. Infected Marlex® grafts are often salvageable, while infected Gore-Tex® patches typically require removal. The lighter and more porous the mesh, the less susceptible it is to infection.\\n\\n- It is also important to consider that leaving non-absorbable mesh in contact with the gut can lead to complications later. Mesh repair of an incisional hernia should aim to place the prosthetic material outside the peritoneum, ideally in the pre-peritoneal retromuscular position. At a minimum, omentum should be placed between any unavoidable intraperitoneal mesh and the viscera. Experience with subsequent laparotomies in patients with intraperitoneal mesh indicates that adhesions are denser than with extraperitoneal mesh, often necessitating small bowel resection to access the abdominal cavity. Although uncommon, spontaneous intestinal fistulas have been observed at the contact point with the mesh.\\n\\n- Manufacturers of 'dual'-type mesh (smooth or coated on the inside, porous on the outside) claim their products are safe for intraperitoneal use; however, bowel injury has also been reported with such types of mesh.\\n\\n- A relatively new product for repairing abdominal wall hernias in contaminated fields is one of the biomaterials, which although...\\n```\\n\\n*Note: The text was extracted without any identifiable images, graphs, or tables. If there were any images or figures, they would be described and numbered accordingly.*\",\n", " 'md': \"- In contaminated fields, it is recommended to use polypropylene (e.g., Marlex®), which is relatively resistant to infection, rather than polytetrafluoroethylene (PTFE — Gore-Tex®), which is not. Infected Marlex® grafts are often salvageable, while infected Gore-Tex® patches typically require removal. The lighter and more porous the mesh, the less susceptible it is to infection.\\n\\n- It is also important to consider that leaving non-absorbable mesh in contact with the gut can lead to complications later. Mesh repair of an incisional hernia should aim to place the prosthetic material outside the peritoneum, ideally in the pre-peritoneal retromuscular position. At a minimum, omentum should be placed between any unavoidable intraperitoneal mesh and the viscera. Experience with subsequent laparotomies in patients with intraperitoneal mesh indicates that adhesions are denser than with extraperitoneal mesh, often necessitating small bowel resection to access the abdominal cavity. Although uncommon, spontaneous intestinal fistulas have been observed at the contact point with the mesh.\\n\\n- Manufacturers of 'dual'-type mesh (smooth or coated on the inside, porous on the outside) claim their products are safe for intraperitoneal use; however, bowel injury has also been reported with such types of mesh.\\n\\n- A relatively new product for repairing abdominal wall hernias in contaminated fields is one of the biomaterials, which although...\\n```\\n\\n*Note: The text was extracted without any identifiable images, graphs, or tables. If there were any images or figures, they would be described and numbered accordingly.*\",\n", " 'bBox': {'x': 100, 'y': 516, 'w': 86.36, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 366,\n", " 'text': ' resistant to infection are prone to late formation of ‘weaknesses’ and\\n ‘bulges’ of the abdominal wall.\\n\\n Parastomal hernias are a particular type of incisional hernia with extra\\nproblems. The principles of management here are the same as for other\\nventral hernias. If a ‘clean’ operation is possible — no necrosis, no bowel\\nresection — then a definitive hernia repair might be attempted. The\\nSugarbaker method seems the most favored: an intraperitoneal mesh\\nis placed to widely cover the stoma opening, and the bowel, on its way to\\nthe stoma, is ‘parietalized’ — it is placed between the mesh and the\\nabdominal wall. Combination of this repair, together with a slit-mesh\\nplaced around the bowel (called together ‘the sandwich technique’),\\nyields the highest success rate.\\n\\n For a long and detailed assessment of the evidence in emergency\\nhernia repair, see the World Society of Emergency Surgery guidelines\\nhere: www.wses.org.uk/pdf/compl%20her%20gl.pdf. It is notable that the\\nrecommendations are mostly level ‘C’, i.e. based on weak (or no)\\nevidence!\\n\\n In a critically ill patient, when the repair is deemed complex or is\\njudged to increase the intra-abdominal pressure significantly, we\\nwould simply close the skin — leaving the patient with a large\\nincisional hernia. We have seen patients dying from respiratory failure\\nprompted by the abdominal compartment syndrome after herniated\\ncontents were stuffed back into the abdomen! Remember — patients do\\nnot die from the hernia but from its intestinal complications or a\\nclosure that is too tight.\\n\\n The place of laparoscopy in acute hernia surgery is expanding as\\nexperience with laparoscopy in the surgical community develops.\\nLaparoscopy is simply a different method of achieving the same results\\nas in open surgery. The same principles apply. Two factors are important:\\nthe skill and experience of the laparoscopist and the condition of the\\npatient. This is not surgery to be attempted by a beginner in laparoscopy.\\nNeither is it suitable for a patient with extensive comorbidities and who\\nmight not be able to withstand a prolonged procedure or the additional\\ninsult of a pneumoperitoneum. Choose carefully. At least in our place',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nResistant to infection are prone to late formation of ‘weaknesses’ and ‘bulges’ of the abdominal wall.\\n\\nParastomal hernias are a particular type of incisional hernia with extra problems. The principles of management here are the same as for other ventral hernias. If a ‘clean’ operation is possible — no necrosis, no bowel resection — then a definitive hernia repair might be attempted. The Sugarbaker method seems the most favored: an intraperitoneal mesh is placed to widely cover the stoma opening, and the bowel, on its way to the stoma, is ‘parietalized’ — it is placed between the mesh and the abdominal wall. Combination of this repair, together with a slit-mesh placed around the bowel (called together ‘the sandwich technique’), yields the highest success rate.\\n\\nFor a long and detailed assessment of the evidence in emergency hernia repair, see the World Society of Emergency Surgery guidelines here: [www.wses.org.uk/pdf/compl%20her%20gl.pdf](http://www.wses.org.uk/pdf/compl%20her%20gl.pdf). It is notable that the recommendations are mostly level ‘C’, i.e. based on weak (or no) evidence!\\n\\nIn a critically ill patient, when the repair is deemed complex or is judged to increase the intra-abdominal pressure significantly, we would simply close the skin — leaving the patient with a large incisional hernia. We have seen patients dying from respiratory failure prompted by the abdominal compartment syndrome after herniated contents were stuffed back into the abdomen! Remember — patients do not die from the hernia but from its intestinal complications or a closure that is too tight.\\n\\nThe place of laparoscopy in acute hernia surgery is expanding as experience with laparoscopy in the surgical community develops. Laparoscopy is simply a different method of achieving the same results as in open surgery. The same principles apply. Two factors are important: the skill and experience of the laparoscopist and the condition of the patient. This is not surgery to be attempted by a beginner in laparoscopy. Neither is it suitable for a patient with extensive comorbidities and who might not be able to withstand a prolonged procedure or the additional insult of a pneumoperitoneum. Choose carefully. At least in our place.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the requirements.\\n- The hyperlink has been extracted and presented correctly.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Resistant to infection are prone to late formation of ‘weaknesses’ and ‘bulges’ of the abdominal wall.\\n\\nParastomal hernias are a particular type of incisional hernia with extra problems. The principles of management here are the same as for other ventral hernias. If a ‘clean’ operation is possible — no necrosis, no bowel resection — then a definitive hernia repair might be attempted. The Sugarbaker method seems the most favored: an intraperitoneal mesh is placed to widely cover the stoma opening, and the bowel, on its way to the stoma, is ‘parietalized’ — it is placed between the mesh and the abdominal wall. Combination of this repair, together with a slit-mesh placed around the bowel (called together ‘the sandwich technique’), yields the highest success rate.\\n\\nFor a long and detailed assessment of the evidence in emergency hernia repair, see the World Society of Emergency Surgery guidelines here: [www.wses.org.uk/pdf/compl%20her%20gl.pdf](http://www.wses.org.uk/pdf/compl%20her%20gl.pdf). It is notable that the recommendations are mostly level ‘C’, i.e. based on weak (or no) evidence!\\n\\nIn a critically ill patient, when the repair is deemed complex or is judged to increase the intra-abdominal pressure significantly, we would simply close the skin — leaving the patient with a large incisional hernia. We have seen patients dying from respiratory failure prompted by the abdominal compartment syndrome after herniated contents were stuffed back into the abdomen! Remember — patients do not die from the hernia but from its intestinal complications or a closure that is too tight.\\n\\nThe place of laparoscopy in acute hernia surgery is expanding as experience with laparoscopy in the surgical community develops. Laparoscopy is simply a different method of achieving the same results as in open surgery. The same principles apply. Two factors are important: the skill and experience of the laparoscopist and the condition of the patient. This is not surgery to be attempted by a beginner in laparoscopy. Neither is it suitable for a patient with extensive comorbidities and who might not be able to withstand a prolonged procedure or the additional insult of a pneumoperitoneum. Choose carefully. At least in our place.\\n```',\n", " 'md': 'Resistant to infection are prone to late formation of ‘weaknesses’ and ‘bulges’ of the abdominal wall.\\n\\nParastomal hernias are a particular type of incisional hernia with extra problems. The principles of management here are the same as for other ventral hernias. If a ‘clean’ operation is possible — no necrosis, no bowel resection — then a definitive hernia repair might be attempted. The Sugarbaker method seems the most favored: an intraperitoneal mesh is placed to widely cover the stoma opening, and the bowel, on its way to the stoma, is ‘parietalized’ — it is placed between the mesh and the abdominal wall. Combination of this repair, together with a slit-mesh placed around the bowel (called together ‘the sandwich technique’), yields the highest success rate.\\n\\nFor a long and detailed assessment of the evidence in emergency hernia repair, see the World Society of Emergency Surgery guidelines here: [www.wses.org.uk/pdf/compl%20her%20gl.pdf](http://www.wses.org.uk/pdf/compl%20her%20gl.pdf). It is notable that the recommendations are mostly level ‘C’, i.e. based on weak (or no) evidence!\\n\\nIn a critically ill patient, when the repair is deemed complex or is judged to increase the intra-abdominal pressure significantly, we would simply close the skin — leaving the patient with a large incisional hernia. We have seen patients dying from respiratory failure prompted by the abdominal compartment syndrome after herniated contents were stuffed back into the abdomen! Remember — patients do not die from the hernia but from its intestinal complications or a closure that is too tight.\\n\\nThe place of laparoscopy in acute hernia surgery is expanding as experience with laparoscopy in the surgical community develops. Laparoscopy is simply a different method of achieving the same results as in open surgery. The same principles apply. Two factors are important: the skill and experience of the laparoscopist and the condition of the patient. This is not surgery to be attempted by a beginner in laparoscopy. Neither is it suitable for a patient with extensive comorbidities and who might not be able to withstand a prolonged procedure or the additional insult of a pneumoperitoneum. Choose carefully. At least in our place.\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.81, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the requirements.\\n- The hyperlink has been extracted and presented correctly.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the requirements.\\n- The hyperlink has been extracted and presented correctly.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'url': 'http://www.wses.org.uk/pdf/compl%20her%20gl.pdf',\n", " 'text': 'recommendations are mostly level ‘C’, i.e. based on weak (or no)'}]},\n", " {'page': 367,\n", " 'text': 'laparoscopy is not widely used in emergency surgery for hernias even if\\nwe do a lot of elective laparoscopic hernia surgery.\\n\\n “Always explore in cases of persistent vomiting if a lump,\\n however small, is found occupying one of the abdominal\\n rings and its nature is uncertain.”\\n Augustus Charles Bernays',\n", " 'md': '```markdown\\n## Page Content\\n\\nLaparoscopy is not widely used in emergency surgery for hernias even if we do a lot of elective laparoscopic hernia surgery.\\n\\n“Always explore in cases of persistent vomiting if a lump, however small, is found occupying one of the abdominal rings and its nature is uncertain.”\\n— Augustus Charles Bernays\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Laparoscopy is not widely used in emergency surgery for hernias even if we do a lot of elective laparoscopic hernia surgery.\\n\\n“Always explore in cases of persistent vomiting if a lump, however small, is found occupying one of the abdominal rings and its nature is uncertain.”\\n— Augustus Charles Bernays\\n```',\n", " 'md': 'Laparoscopy is not widely used in emergency surgery for hernias even if we do a lot of elective laparoscopic hernia surgery.\\n\\n“Always explore in cases of persistent vomiting if a lump, however small, is found occupying one of the abdominal rings and its nature is uncertain.”\\n— Augustus Charles Bernays\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.31, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 368,\n", " 'text': 'Chapter 23\\nAcute appendicitis\\nRoland E. Andersson 1\\n\\n This chapter has been subdivided into the following two\\n sections:\\n\\n 1. Acute appendicitis.\\n 2. Laparoscopic appendectomy.\\n\\n Acute appendicitis\\n1 Roland E. Andersson\\n I cannot see what harm has been done if the appendix has\\n been removed. The perfect man is the man without an\\n appendix.\\n R. H. Harte\\n\\n We all know: “Whatever the clinical presentation, whatever the\\nabdominal findings, always keep acute appendicitis at the back of your\\nmind.”\\n\\n Acute appendicitis (AA) is among the first diagnoses that a surgeon\\nhas to master. ħe may soon find his way through the complex maze of',\n", " 'md': '# Chapter 23: Acute Appendicitis\\n\\n## Sections\\n1. Acute appendicitis\\n2. Laparoscopic appendectomy\\n\\n### Acute Appendicitis\\n> \"I cannot see what harm has been done if the appendix has been removed. The perfect man is the man without an appendix.\"\\n> — R. H. Harte\\n\\nWe all know: “Whatever the clinical presentation, whatever the abdominal findings, always keep acute appendicitis at the back of your mind.”\\n\\nAcute appendicitis (AA) is among the first diagnoses that a surgeon has to master. He may soon find his way through the complex maze of...\\n\\n----\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the current page.*',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 23: Acute Appendicitis',\n", " 'md': '# Chapter 23: Acute Appendicitis',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 163.53, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Sections',\n", " 'md': '## Sections',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. Acute appendicitis\\n2. Laparoscopic appendectomy',\n", " 'md': '1. Acute appendicitis\\n2. Laparoscopic appendectomy',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 163.53, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Acute Appendicitis',\n", " 'md': '### Acute Appendicitis',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 163.53, 'h': 20.16}},\n", " {'type': 'text',\n", " 'value': '> \"I cannot see what harm has been done if the appendix has been removed. The perfect man is the man without an appendix.\"\\n> — R. H. Harte\\n\\nWe all know: “Whatever the clinical presentation, whatever the abdominal findings, always keep acute appendicitis at the back of your mind.”\\n\\nAcute appendicitis (AA) is among the first diagnoses that a surgeon has to master. He may soon find his way through the complex maze of...\\n\\n----\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the current page.*',\n", " 'md': '> \"I cannot see what harm has been done if the appendix has been removed. The perfect man is the man without an appendix.\"\\n> — R. H. Harte\\n\\nWe all know: “Whatever the clinical presentation, whatever the abdominal findings, always keep acute appendicitis at the back of your mind.”\\n\\nAcute appendicitis (AA) is among the first diagnoses that a surgeon has to master. He may soon find his way through the complex maze of...\\n\\n----\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the current page.*',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 381.35, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Roland E. Andersson 1'}]},\n", " {'page': 369,\n", " 'text': 'history, clinical and laboratory evaluation, and diagnostic imaging to get\\nhis personal way of handling these patients. Most surgeons soon become\\n‘experts’ on AA or so they think — often with strong opinions based on\\npersonal experience. As a consequence, there are wide variations in\\nhow this group of patients is managed, not only over the world but\\nalso between individual surgeons — different cultural and economic\\nsituations also play a role. All this impedes the establishment of\\ngenerally accepted guidelines on how to manage patients with suspected\\nAA.\\n\\n Why the treatment of obstruction, strangulation, or\\n perforation of the part of the intestine known as the\\n vermiform appendix should have given rise to such a\\n confusion of creeds, such a pandemonium of assertions,\\n doubts, and arguments is not altogether easy to\\n understand.\\n Charles A. Balance\\n\\n So what can we tell you that you do not already know? Perhaps\\nnothing. But let us emphasize a few points — trying to wipe out a\\nfew dogmas from your head:\\n\\n • Untreated appendicitis does not necessarily progress to\\n perforation. Many cases of mild, simple AA can resolve without\\n treatment. This, often forgotten, natural history of appendicitis has\\n important implications on how we think about and should treat AA.\\n • Appendicitis cannot be confirmed or excluded by any single\\n symptom, sign or laboratory finding. The opposite is true: the\\n whole clinical picture and the various laboratory parameters of the\\n inflammatory response have to be considered together.\\n • The synthesis of clinical and laboratory findings can be made\\n more objective with the help of a diagnostic score. The Alvarado\\n Score is the best known but has been outperformed by the\\n Appendicitis Inflammatory Response (AIR) — this is the score\\n that we use ( Table 23.1). Remember: the score can support a\\n decision but clinical judgment is still needed in every case!\\n • Patients with a suspicion of appendicitis are heterogeneous.\\n We cannot use a single approach for all, but need to vary the',\n", " 'md': '```markdown\\n## Key Points on Appendicitis Management\\n\\n- **Untreated appendicitis does not necessarily progress to perforation.** Many cases of mild, simple appendicitis can resolve without treatment. This often forgotten natural history of appendicitis has important implications on how we think about and should treat appendicitis.\\n\\n- **Appendicitis cannot be confirmed or excluded by any single symptom, sign, or laboratory finding.** The opposite is true: the whole clinical picture and the various laboratory parameters of the inflammatory response have to be considered together.\\n\\n- **The synthesis of clinical and laboratory findings can be made more objective with the help of a diagnostic score.** The Alvarado Score is the best known but has been outperformed by the Appendicitis Inflammatory Response (AIR) — this is the score that we use (Table 23.1). Remember: the score can support a decision but clinical judgment is still needed in every case!\\n\\n- **Patients with a suspicion of appendicitis are heterogeneous.** We cannot use a single approach for all, but need to vary the management based on individual patient characteristics.\\n\\n### Quote\\n> \"So what can we tell you that you do not already know? Perhaps nothing. But let us emphasize a few points — trying to wipe out a few dogmas from your head.\"\\n> — Charles A. Balance\\n```\\n\\n### Table\\n- **Table 23.1**: Appendicitis Inflammatory Response (AIR) Score\\n- (Note: The content of the table is not provided in the current text. Please refer to the original document for details.)\\n\\n### Image Identification and Description\\n- **No images or graphs were identified on this page.**\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Key Points on Appendicitis Management',\n", " 'md': '## Key Points on Appendicitis Management',\n", " 'bBox': {'x': 292, 'y': 315, 'w': 14.4, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Untreated appendicitis does not necessarily progress to perforation.** Many cases of mild, simple appendicitis can resolve without treatment. This often forgotten natural history of appendicitis has important implications on how we think about and should treat appendicitis.\\n\\n- **Appendicitis cannot be confirmed or excluded by any single symptom, sign, or laboratory finding.** The opposite is true: the whole clinical picture and the various laboratory parameters of the inflammatory response have to be considered together.\\n\\n- **The synthesis of clinical and laboratory findings can be made more objective with the help of a diagnostic score.** The Alvarado Score is the best known but has been outperformed by the Appendicitis Inflammatory Response (AIR) — this is the score that we use (Table 23.1). Remember: the score can support a decision but clinical judgment is still needed in every case!\\n\\n- **Patients with a suspicion of appendicitis are heterogeneous.** We cannot use a single approach for all, but need to vary the management based on individual patient characteristics.',\n", " 'md': '- **Untreated appendicitis does not necessarily progress to perforation.** Many cases of mild, simple appendicitis can resolve without treatment. This often forgotten natural history of appendicitis has important implications on how we think about and should treat appendicitis.\\n\\n- **Appendicitis cannot be confirmed or excluded by any single symptom, sign, or laboratory finding.** The opposite is true: the whole clinical picture and the various laboratory parameters of the inflammatory response have to be considered together.\\n\\n- **The synthesis of clinical and laboratory findings can be made more objective with the help of a diagnostic score.** The Alvarado Score is the best known but has been outperformed by the Appendicitis Inflammatory Response (AIR) — this is the score that we use (Table 23.1). Remember: the score can support a decision but clinical judgment is still needed in every case!\\n\\n- **Patients with a suspicion of appendicitis are heterogeneous.** We cannot use a single approach for all, but need to vary the management based on individual patient characteristics.',\n", " 'bBox': {'x': 100, 'y': 315, 'w': 404.43, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Quote',\n", " 'md': '### Quote',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '> \"So what can we tell you that you do not already know? Perhaps nothing. But let us emphasize a few points — trying to wipe out a few dogmas from your head.\"\\n> — Charles A. Balance\\n```',\n", " 'md': '> \"So what can we tell you that you do not already know? Perhaps nothing. But let us emphasize a few points — trying to wipe out a few dogmas from your head.\"\\n> — Charles A. Balance\\n```',\n", " 'bBox': {'x': 317, 'y': 315, 'w': 130.33, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table',\n", " 'md': '### Table',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Table 23.1**: Appendicitis Inflammatory Response (AIR) Score\\n- (Note: The content of the table is not provided in the current text. Please refer to the original document for details.)',\n", " 'md': '- **Table 23.1**: Appendicitis Inflammatory Response (AIR) Score\\n- (Note: The content of the table is not provided in the current text. Please refer to the original document for details.)',\n", " 'bBox': {'x': 292, 'y': 315, 'w': 23.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 170, 'y': 315, 'w': 28, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **No images or graphs were identified on this page.**\\n```',\n", " 'md': '- **No images or graphs were identified on this page.**\\n```',\n", " 'bBox': {'x': 292, 'y': 315, 'w': 14.4, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'decision but clinical judgment is still needed in every case!'}]},\n", " {'page': 370,\n", " 'text': ' management depending on the clinical presentation and the\\n perceived probability of perforation.\\n• Appendicitis is associated with a dynamic inflammatory\\n response. Therefore, if the diagnosis is unclear at presentation it is\\n worthwhile reassessing the patient after a few hours of\\n observation.\\n• Imaging is important in selected cases, not only for diagnostic\\n accuracy but also to rule out other conditions like ureteral stone,\\n acute sigmoid or cecal diverticulitis, ovarian torsion, Crohn’s disease\\n or pelvic inflammatory disease.\\n\\n Resolving appendicitis? Simple AA progressing to perforation?',\n", " 'md': '```markdown\\n## Page Content\\n\\n- Management depending on the clinical presentation and the perceived probability of perforation.\\n- Appendicitis is associated with a dynamic inflammatory response. Therefore, if the diagnosis is unclear at presentation, it is worthwhile reassessing the patient after a few hours of observation.\\n- Imaging is important in selected cases, not only for diagnostic accuracy but also to rule out other conditions like ureteral stone, acute sigmoid or cecal diverticulitis, ovarian torsion, Crohn’s disease, or pelvic inflammatory disease.\\n\\n### Summary\\nThis page discusses the management of appendicitis, emphasizing the importance of clinical presentation and the need for reassessment if the diagnosis is uncertain. It also highlights the role of imaging in diagnosing appendicitis and ruling out other potential conditions.\\n\\n### Note\\nThere are no figures, tables, or images present on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Management depending on the clinical presentation and the perceived probability of perforation.\\n- Appendicitis is associated with a dynamic inflammatory response. Therefore, if the diagnosis is unclear at presentation, it is worthwhile reassessing the patient after a few hours of observation.\\n- Imaging is important in selected cases, not only for diagnostic accuracy but also to rule out other conditions like ureteral stone, acute sigmoid or cecal diverticulitis, ovarian torsion, Crohn’s disease, or pelvic inflammatory disease.',\n", " 'md': '- Management depending on the clinical presentation and the perceived probability of perforation.\\n- Appendicitis is associated with a dynamic inflammatory response. Therefore, if the diagnosis is unclear at presentation, it is worthwhile reassessing the patient after a few hours of observation.\\n- Imaging is important in selected cases, not only for diagnostic accuracy but also to rule out other conditions like ureteral stone, acute sigmoid or cecal diverticulitis, ovarian torsion, Crohn’s disease, or pelvic inflammatory disease.',\n", " 'bBox': {'x': 100, 'y': 102, 'w': 436.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the management of appendicitis, emphasizing the importance of clinical presentation and the need for reassessment if the diagnosis is uncertain. It also highlights the role of imaging in diagnosing appendicitis and ruling out other potential conditions.',\n", " 'md': 'This page discusses the management of appendicitis, emphasizing the importance of clinical presentation and the need for reassessment if the diagnosis is uncertain. It also highlights the role of imaging in diagnosing appendicitis and ruling out other potential conditions.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Note',\n", " 'md': '### Note',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'There are no figures, tables, or images present on this page.\\n```',\n", " 'md': 'There are no figures, tables, or images present on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 371,\n", " 'text': ' Table 23.1. Appendicitis Inflammatory Response (AIR) score.\\n Andersson M; Andersson RE. The Appendicitis Inflammatory Response Score: a tool for the diagnosis\\n of acute appendicitis that outperforms the Alvarado score. World Surg 2008; 32(8): 1843-9.\\n Variable Level Score\\n Pain/tenderness RIF +1\\n Vomiting\\n (the strongest)\\n Defence or rebound\\n Strong\\n Slight\\n Moderate \"\\n WBC 10-14.9 x 109/L +2\\n 215.0\\n Proportion neutrophils 70-84% t2\\n 285\\n CRP 10-49mg/L +2\\n 250\\n Temperature 238.5*C +1\\n Sum points:\\n 0-4 Low probability of appendicitis\\n 5-8 Indeterminate\\n 9-12 High probability of appendicitis\\n We all fear perforation, with its increased morbidity and mortality. We\\nhave been taught that delay is dangerous and that perforations can be\\nprevented by early diagnosis and operation, even at the expense of a\\nhigh proportion of unnecessary operations (up to 30% ‘white’\\nappendectomies in some series). This is also what families and\\nlawyers tend to believe. But in a population study, when we',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Table 23.1. Appendicitis Inflammatory Response (AIR) Score\\n\\n**Reference:** Andersson M; Andersson RE. The Appendicitis Inflammatory Response Score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. *World Surg* 2008; 32(8): 1843-9.\\n\\n| Variable | Level | Score |\\n|-----------------------------------|------------------------|-------|\\n| Pain/tenderness RIF | | +1 |\\n| Vomiting | (the strongest) | |\\n| Defence or rebound | Strong | |\\n| | Slight | |\\n| | Moderate | \" |\\n| WBC | 10-14.9 x 10^9/L | +2 |\\n| | 215.0 | |\\n| Proportion neutrophils | 70-84% | t2 |\\n| | 285 | |\\n| CRP | 10-49 mg/L | +2 |\\n| | 250 | |\\n| Temperature | 38.5°C | +1 |\\n\\n**Sum points:**\\n- 0-4: Low probability of appendicitis\\n- 5-8: Indeterminate\\n- 9-12: High probability of appendicitis\\n\\n----\\n\\nWe all fear perforation, with its increased morbidity and mortality. We have been taught that delay is dangerous and that perforations can be prevented by early diagnosis and operation, even at the expense of a high proportion of unnecessary operations (up to 30% ‘white’ appendectomies in some series). This is also what families and lawyers tend to believe. But in a population study, when we...\\n```',\n", " 'images': [{'name': 'img_p370_1.png',\n", " 'height': 1046,\n", " 'width': 824,\n", " 'x': 102.24000000000001,\n", " 'y': 72,\n", " 'original_width': 1416,\n", " 'original_height': 1800}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 23.1. Appendicitis Inflammatory Response (AIR) Score',\n", " 'md': '## Table 23.1. Appendicitis Inflammatory Response (AIR) Score',\n", " 'bBox': {'x': 111.14, 'y': 80.91, 'w': 73.2, 'h': 14.85}},\n", " {'type': 'text',\n", " 'value': '**Reference:** Andersson M; Andersson RE. The Appendicitis Inflammatory Response Score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. *World Surg* 2008; 32(8): 1843-9.',\n", " 'md': '**Reference:** Andersson M; Andersson RE. The Appendicitis Inflammatory Response Score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. *World Surg* 2008; 32(8): 1843-9.',\n", " 'bBox': {'x': 111.14, 'y': 99.22, 'w': 395.65, 'h': 14.4}},\n", " {'type': 'table',\n", " 'rows': [['Variable', 'Level', 'Score'],\n", " ['Pain/tenderness RIF', '', '+1'],\n", " ['Vomiting', '(the strongest)', ''],\n", " ['Defence or rebound', 'Strong', ''],\n", " ['', 'Slight', ''],\n", " ['', 'Moderate', '\"'],\n", " ['WBC', '10-14.9 x 10^9/L', '+2'],\n", " ['', '215.0', ''],\n", " ['Proportion neutrophils', '70-84%', 't2'],\n", " ['', '285', ''],\n", " ['CRP', '10-49 mg/L', '+2'],\n", " ['', '250', ''],\n", " ['Temperature', '38.5°C', '+1']],\n", " 'md': '| Variable | Level | Score |\\n|-----------------------------------|------------------------|-------|\\n| Pain/tenderness RIF | | +1 |\\n| Vomiting | (the strongest) | |\\n| Defence or rebound | Strong | |\\n| | Slight | |\\n| | Moderate | \" |\\n| WBC | 10-14.9 x 10^9/L | +2 |\\n| | 215.0 | |\\n| Proportion neutrophils | 70-84% | t2 |\\n| | 285 | |\\n| CRP | 10-49 mg/L | +2 |\\n| | 250 | |\\n| Temperature | 38.5°C | +1 |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Variable\",\"Level\",\"Score\"\\n\"Pain/tenderness RIF\",\"\",\"+1\"\\n\"Vomiting\",\"(the strongest)\",\"\"\\n\"Defence or rebound\",\"Strong\",\"\"\\n\"\",\"Slight\",\"\"\\n\"\",\"Moderate\",\"\"\"\"\\n\"WBC\",\"10-14.9 x 10^9/L\",\"+2\"\\n\"\",\"215.0\",\"\"\\n\"Proportion neutrophils\",\"70-84%\",\"t2\"\\n\"\",\"285\",\"\"\\n\"CRP\",\"10-49 mg/L\",\"+2\"\\n\"\",\"250\",\"\"\\n\"Temperature\",\"38.5°C\",\"+1\"',\n", " 'bBox': {'x': 110.15, 'y': 137.33, 'w': 107.81, 'h': 48.5}},\n", " {'type': 'text',\n", " 'value': '**Sum points:**\\n- 0-4: Low probability of appendicitis\\n- 5-8: Indeterminate\\n- 9-12: High probability of appendicitis\\n\\n----\\n\\nWe all fear perforation, with its increased morbidity and mortality. We have been taught that delay is dangerous and that perforations can be prevented by early diagnosis and operation, even at the expense of a high proportion of unnecessary operations (up to 30% ‘white’ appendectomies in some series). This is also what families and lawyers tend to believe. But in a population study, when we...\\n```',\n", " 'md': '**Sum points:**\\n- 0-4: Low probability of appendicitis\\n- 5-8: Indeterminate\\n- 9-12: High probability of appendicitis\\n\\n----\\n\\nWe all fear perforation, with its increased morbidity and mortality. We have been taught that delay is dangerous and that perforations can be prevented by early diagnosis and operation, even at the expense of a high proportion of unnecessary operations (up to 30% ‘white’ appendectomies in some series). This is also what families and lawyers tend to believe. But in a population study, when we...\\n```',\n", " 'bBox': {'x': 72, 'y': 496.64, 'w': 179.6, 'h': 15.34}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 372,\n", " 'text': 'compared the number of perforations per 100,000 inhabitants in\\ndifferent geographical areas, we found out that this is almost\\nidentical at centers that apply liberal or restrictive policies to\\nappendectomy2. Centers that apply a liberal policy have of course more\\nnegative explorations but we also found that they operated on more\\ncases with true appendicitis than centers with a restrictive attitude to\\nappendectomy. This teaches us that a restrained attitude allows\\npatients with mild appendicitis to resolve, undetected, without\\ntreatment and without causing more cases to perforate. ħowever, as\\nfewer cases of mild appendicitis are detected, the denominator will be\\nsmaller giving a higher proportion of perforation. A high proportion of\\nperforations therefore represents a satisfactory situation as it is the\\nconsequence of allowing cases of mild appendicitis to resolve\\nwithout operation. Capisce?\\n\\n Charles McBurney recognized this more than 100 years ago:\\n\\n But, lest I give a wrong impression, I must distinctly state\\n here, that there are many cases of appendicitis of a mild\\n character which rapidly convalesce under no other\\n treatment than that just referred to, and that not a few\\n severe cases eventually recover without other active aid.\\n\\n We know, and hope you do too, that perforation is a different\\ndisease, one that is essentially unpreventable. Most perforations\\ndevelop early, before the patient arrives at hospital — they do not\\nperforate while we investigate or observe them. Sure, sometimes a\\n‘masked’ perforation is diagnosed after a delay and a perforation may\\nrarely occur in obstructed appendicitis that arrives early at hospital, but\\nthat’s another, uncommon, story.\\n\\n Diagnosis\\n\\n Classification\\n\\n AA starts as an inflammation which can progress to infection. The\\ninflammation may be caused by an obstruction of the outlet of the',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nCompared the number of perforations per 100,000 inhabitants in different geographical areas, we found out that this is almost identical at centers that apply liberal or restrictive policies to appendectomy. Centers that apply a liberal policy have of course more negative explorations but we also found that they operated on more cases with true appendicitis than centers with a restrictive attitude to appendectomy. This teaches us that a restrained attitude allows patients with mild appendicitis to resolve, undetected, without treatment and without causing more cases to perforate. However, as fewer cases of mild appendicitis are detected, the denominator will be smaller giving a higher proportion of perforation. A high proportion of perforations therefore represents a satisfactory situation as it is the consequence of allowing cases of mild appendicitis to resolve without operation. Capisce?\\n\\nCharles McBurney recognized this more than 100 years ago:\\n\\n> But, lest I give a wrong impression, I must distinctly state here, that there are many cases of appendicitis of a mild character which rapidly convalesce under no other treatment than that just referred to, and that not a few severe cases eventually recover without other active aid.\\n\\nWe know, and hope you do too, that perforation is a different disease, one that is essentially unpreventable. Most perforations develop early, before the patient arrives at hospital — they do not perforate while we investigate or observe them. Sure, sometimes a ‘masked’ perforation is diagnosed after a delay and a perforation may rarely occur in obstructed appendicitis that arrives early at hospital, but that’s another, uncommon, story.\\n\\n### Diagnosis\\n\\n### Classification\\n\\nAA starts as an inflammation which can progress to infection. The inflammation may be caused by an obstruction of the outlet of the...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and formatted according to the requirements.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Compared the number of perforations per 100,000 inhabitants in different geographical areas, we found out that this is almost identical at centers that apply liberal or restrictive policies to appendectomy. Centers that apply a liberal policy have of course more negative explorations but we also found that they operated on more cases with true appendicitis than centers with a restrictive attitude to appendectomy. This teaches us that a restrained attitude allows patients with mild appendicitis to resolve, undetected, without treatment and without causing more cases to perforate. However, as fewer cases of mild appendicitis are detected, the denominator will be smaller giving a higher proportion of perforation. A high proportion of perforations therefore represents a satisfactory situation as it is the consequence of allowing cases of mild appendicitis to resolve without operation. Capisce?\\n\\nCharles McBurney recognized this more than 100 years ago:\\n\\n> But, lest I give a wrong impression, I must distinctly state here, that there are many cases of appendicitis of a mild character which rapidly convalesce under no other treatment than that just referred to, and that not a few severe cases eventually recover without other active aid.\\n\\nWe know, and hope you do too, that perforation is a different disease, one that is essentially unpreventable. Most perforations develop early, before the patient arrives at hospital — they do not perforate while we investigate or observe them. Sure, sometimes a ‘masked’ perforation is diagnosed after a delay and a perforation may rarely occur in obstructed appendicitis that arrives early at hospital, but that’s another, uncommon, story.',\n", " 'md': 'Compared the number of perforations per 100,000 inhabitants in different geographical areas, we found out that this is almost identical at centers that apply liberal or restrictive policies to appendectomy. Centers that apply a liberal policy have of course more negative explorations but we also found that they operated on more cases with true appendicitis than centers with a restrictive attitude to appendectomy. This teaches us that a restrained attitude allows patients with mild appendicitis to resolve, undetected, without treatment and without causing more cases to perforate. However, as fewer cases of mild appendicitis are detected, the denominator will be smaller giving a higher proportion of perforation. A high proportion of perforations therefore represents a satisfactory situation as it is the consequence of allowing cases of mild appendicitis to resolve without operation. Capisce?\\n\\nCharles McBurney recognized this more than 100 years ago:\\n\\n> But, lest I give a wrong impression, I must distinctly state here, that there are many cases of appendicitis of a mild character which rapidly convalesce under no other treatment than that just referred to, and that not a few severe cases eventually recover without other active aid.\\n\\nWe know, and hope you do too, that perforation is a different disease, one that is essentially unpreventable. Most perforations develop early, before the patient arrives at hospital — they do not perforate while we investigate or observe them. Sure, sometimes a ‘masked’ perforation is diagnosed after a delay and a perforation may rarely occur in obstructed appendicitis that arrives early at hospital, but that’s another, uncommon, story.',\n", " 'bBox': {'x': 72, 'y': 270, 'w': 467.86, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diagnosis',\n", " 'md': '### Diagnosis',\n", " 'bBox': {'x': 86, 'y': 613, 'w': 79.09, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Classification',\n", " 'md': '### Classification',\n", " 'bBox': {'x': 86, 'y': 657, 'w': 107.59, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'AA starts as an inflammation which can progress to infection. The inflammation may be caused by an obstruction of the outlet of the...\\n```',\n", " 'md': 'AA starts as an inflammation which can progress to infection. The inflammation may be caused by an obstruction of the outlet of the...\\n```',\n", " 'bBox': {'x': 86, 'y': 693, 'w': 452.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and formatted according to the requirements.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and formatted according to the requirements.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ' 2'}]},\n", " {'page': 373,\n", " 'text': 'appendix (by an appendicolith for example) and this can progress rapidly\\nto necrosis, perforation and life-threatening free peritonitis. ħowever, mild\\nattacks of spontaneously resolving phlegmonous appendicitis that do\\nnot need any treatment are common — if you rush to diagnose it by CT,\\nand then operate upon such early mild cases, you will never realize how\\ncommon such self-limited attacks are. You will continue to believe that\\nyou are preventing perforations! (Isn’t that what you tell the family after\\nthe operation: “we were lucky to catch it in time!”?)\\n\\n Let us bring here a simple classification of AA to facilitate the\\ndiscussion of diagnosis and management. In essence, AA is either\\nsimple or complicated:\\n\\n • ‘Simple’ AA implies inflammation of the appendix in the absence of\\n appendiceal gangrene, perforation or any associated pus formation.\\n • ‘Complicated’ AA exists whenever any of the aforementioned\\n features are present.\\n\\n Some pathologists may report small inflammatory changes as\\n“endoappendicitis”, “early appendicitis”, “catarrhal appendicitis” or\\n“chronic appendicitis”. Such inflammatory changes are commonly seen in\\nasymptomatic patients who have had appendectomy en passant. (Some\\npathologists, as you know, would go out of their way to report something\\n‘positive’ on any pristine appendix placed on their desk…). These\\nentities have no clinical significance. It is not the beginning of a\\nprogressive disease that will end with perforation and should not be\\ncalled appendicitis.\\n\\n Another entity you should be familiar with — because it requires a\\ndifferent approach — is the appendiceal mass, developing late in the\\nnatural history of AA. The ‘mass’ is an inflammatory phlegmon made\\nof omentum and/or adjacent viscera, walling off a complicated\\nappendicitis. A mass containing a variable amount of pus is an\\nappendiceal abscess.\\n\\n “What about ‘chronic appendicitis’?” some of you may ask. You find a\\npatient with chronic tenderness in the right iliac fossa. If you operate he\\nwill probably be thankful for your understanding attitude of taking his',\n", " 'md': '```markdown\\n## Appendix Classification and Management\\n\\nAppendicitis can progress rapidly to necrosis, perforation, and life-threatening free peritonitis. However, mild attacks of spontaneously resolving phlegmonous appendicitis that do not require treatment are common. If one rushes to diagnose it by CT and operates on such early mild cases, the prevalence of self-limited attacks may go unrecognized. This leads to a belief that perforations are being prevented, often communicated to families post-operation with statements like, “we were lucky to catch it in time!”\\n\\n### Classification of Appendicitis\\n\\nTo facilitate the discussion of diagnosis and management, a simple classification of appendicitis (AA) is presented:\\n\\n- **Simple AA**: Involves inflammation of the appendix without appendiceal gangrene, perforation, or associated pus formation.\\n- **Complicated AA**: Exists whenever any of the aforementioned features are present.\\n\\nSome pathologists may report small inflammatory changes as “endoappendicitis,” “early appendicitis,” “catarrhal appendicitis,” or “chronic appendicitis.” These inflammatory changes are commonly seen in asymptomatic patients who have had appendectomy en passant. Such entities have no clinical significance and should not be considered the beginning of a progressive disease that will end with perforation.\\n\\n### Appendiceal Mass\\n\\nAnother entity to be familiar with is the appendiceal mass, which develops late in the natural history of appendicitis. The ‘mass’ is an inflammatory phlegmon made of omentum and/or adjacent viscera, walling off a complicated appendicitis. A mass containing a variable amount of pus is referred to as an appendiceal abscess.\\n\\n### Chronic Appendicitis\\n\\n“What about ‘chronic appendicitis’?” some may ask. A patient with chronic tenderness in the right iliac fossa may benefit from surgical intervention, and he will likely appreciate the understanding approach taken in addressing his condition.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Appendix Classification and Management',\n", " 'md': '## Appendix Classification and Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Appendicitis can progress rapidly to necrosis, perforation, and life-threatening free peritonitis. However, mild attacks of spontaneously resolving phlegmonous appendicitis that do not require treatment are common. If one rushes to diagnose it by CT and operates on such early mild cases, the prevalence of self-limited attacks may go unrecognized. This leads to a belief that perforations are being prevented, often communicated to families post-operation with statements like, “we were lucky to catch it in time!”',\n", " 'md': 'Appendicitis can progress rapidly to necrosis, perforation, and life-threatening free peritonitis. However, mild attacks of spontaneously resolving phlegmonous appendicitis that do not require treatment are common. If one rushes to diagnose it by CT and operates on such early mild cases, the prevalence of self-limited attacks may go unrecognized. This leads to a belief that perforations are being prevented, often communicated to families post-operation with statements like, “we were lucky to catch it in time!”',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Classification of Appendicitis',\n", " 'md': '### Classification of Appendicitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'To facilitate the discussion of diagnosis and management, a simple classification of appendicitis (AA) is presented:\\n\\n- **Simple AA**: Involves inflammation of the appendix without appendiceal gangrene, perforation, or associated pus formation.\\n- **Complicated AA**: Exists whenever any of the aforementioned features are present.\\n\\nSome pathologists may report small inflammatory changes as “endoappendicitis,” “early appendicitis,” “catarrhal appendicitis,” or “chronic appendicitis.” These inflammatory changes are commonly seen in asymptomatic patients who have had appendectomy en passant. Such entities have no clinical significance and should not be considered the beginning of a progressive disease that will end with perforation.',\n", " 'md': 'To facilitate the discussion of diagnosis and management, a simple classification of appendicitis (AA) is presented:\\n\\n- **Simple AA**: Involves inflammation of the appendix without appendiceal gangrene, perforation, or associated pus formation.\\n- **Complicated AA**: Exists whenever any of the aforementioned features are present.\\n\\nSome pathologists may report small inflammatory changes as “endoappendicitis,” “early appendicitis,” “catarrhal appendicitis,” or “chronic appendicitis.” These inflammatory changes are commonly seen in asymptomatic patients who have had appendectomy en passant. Such entities have no clinical significance and should not be considered the beginning of a progressive disease that will end with perforation.',\n", " 'bBox': {'x': 100, 'y': 358, 'w': 132.74, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Appendiceal Mass',\n", " 'md': '### Appendiceal Mass',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Another entity to be familiar with is the appendiceal mass, which develops late in the natural history of appendicitis. The ‘mass’ is an inflammatory phlegmon made of omentum and/or adjacent viscera, walling off a complicated appendicitis. A mass containing a variable amount of pus is referred to as an appendiceal abscess.',\n", " 'md': 'Another entity to be familiar with is the appendiceal mass, which develops late in the natural history of appendicitis. The ‘mass’ is an inflammatory phlegmon made of omentum and/or adjacent viscera, walling off a complicated appendicitis. A mass containing a variable amount of pus is referred to as an appendiceal abscess.',\n", " 'bBox': {'x': 72, 'y': 646, 'w': 147, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Chronic Appendicitis',\n", " 'md': '### Chronic Appendicitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '“What about ‘chronic appendicitis’?” some may ask. A patient with chronic tenderness in the right iliac fossa may benefit from surgical intervention, and he will likely appreciate the understanding approach taken in addressing his condition.\\n```',\n", " 'md': '“What about ‘chronic appendicitis’?” some may ask. A patient with chronic tenderness in the right iliac fossa may benefit from surgical intervention, and he will likely appreciate the understanding approach taken in addressing his condition.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 374,\n", " 'text': 'problem seriously, but he will very likely come back after 6 months with\\nthe same (or other) problems. The placebo effect is strong but short-\\nlived.\\n\\n Clinical features\\n\\n The classic signs and symptoms of AA are well known; even your\\ndentist can diagnose classic AA ( Figure 23.1): a history of ‘gastric\\nupset’ with vomiting or nausea, associated with mid-abdominal ‘visceral’\\ndiscomfort which gradually migrates to the right lower quadrant (RLQ)\\nand becomes ‘somatic’. Add to this the physical findings of localized\\nperitoneal irritation and, most important, clinical and/or laboratory\\nevidence of systemic inflammation. But as you know, a number of\\nother conditions can have a similar presentation and not all cases\\nof AA follow this classic path.\\n 000\\n PerY474\\n Figure 23.1. “Even dentists can diagnose it!”\\n\\n In fact, the clinical presentation of AA varies considerably depending',\n", " 'md': '```markdown\\n## Clinical Features\\n\\nThe classic signs and symptoms of Acute Appendicitis (AA) are well known; even your dentist can diagnose classic AA (Figure 23.1): a history of ‘gastric upset’ with vomiting or nausea, associated with mid-abdominal ‘visceral’ discomfort which gradually migrates to the right lower quadrant (RLQ) and becomes ‘somatic’. Add to this the physical findings of localized peritoneal irritation and, most important, clinical and/or laboratory evidence of systemic inflammation. But as you know, a number of other conditions can have a similar presentation and not all cases of AA follow this classic path.\\n\\n### Figure 23.1\\n**Caption:** “Even dentists can diagnose it!”\\n**Description:** This figure likely illustrates the classic signs of Acute Appendicitis, possibly including visual representations of symptoms or diagnostic criteria. The content may include diagrams or images relevant to the diagnosis of AA, but specific details are not provided in the text.\\n\\n```',\n", " 'images': [{'name': 'img_p373_1.png',\n", " 'height': 598,\n", " 'width': 789,\n", " 'x': 110.88000000000011,\n", " 'y': 344.1599999999999,\n", " 'original_width': 1356,\n", " 'original_height': 1028}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Features',\n", " 'md': '## Clinical Features',\n", " 'bBox': {'x': 86, 'y': 162, 'w': 127.82, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The classic signs and symptoms of Acute Appendicitis (AA) are well known; even your dentist can diagnose classic AA (Figure 23.1): a history of ‘gastric upset’ with vomiting or nausea, associated with mid-abdominal ‘visceral’ discomfort which gradually migrates to the right lower quadrant (RLQ) and becomes ‘somatic’. Add to this the physical findings of localized peritoneal irritation and, most important, clinical and/or laboratory evidence of systemic inflammation. But as you know, a number of other conditions can have a similar presentation and not all cases of AA follow this classic path.',\n", " 'md': 'The classic signs and symptoms of Acute Appendicitis (AA) are well known; even your dentist can diagnose classic AA (Figure 23.1): a history of ‘gastric upset’ with vomiting or nausea, associated with mid-abdominal ‘visceral’ discomfort which gradually migrates to the right lower quadrant (RLQ) and becomes ‘somatic’. Add to this the physical findings of localized peritoneal irritation and, most important, clinical and/or laboratory evidence of systemic inflammation. But as you know, a number of other conditions can have a similar presentation and not all cases of AA follow this classic path.',\n", " 'bBox': {'x': 72, 'y': 231, 'w': 467.63, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 23.1',\n", " 'md': '### Figure 23.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** “Even dentists can diagnose it!”\\n**Description:** This figure likely illustrates the classic signs of Acute Appendicitis, possibly including visual representations of symptoms or diagnostic criteria. The content may include diagrams or images relevant to the diagnosis of AA, but specific details are not provided in the text.\\n\\n```',\n", " 'md': '**Caption:** “Even dentists can diagnose it!”\\n**Description:** This figure likely illustrates the classic signs of Acute Appendicitis, possibly including visual representations of symptoms or diagnostic criteria. The content may include diagrams or images relevant to the diagnosis of AA, but specific details are not provided in the text.\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'upset’ with vomiting or nausea, associated with mid-abdominal ‘visceral’'}]},\n", " {'page': 375,\n", " 'text': 'on the duration of symptoms, the stage of inflammation, the anatomical\\nposition of the appendix (e.g. retrocecal, pelvic) and the patient’s\\nphysiognomy. For some patients the diagnosis is evident and for others it\\nis very vague. Thus, not all patients with suspected AA can be\\napproached the same way. We need a structured management based\\non the degree of suspicion.\\n\\n An algorithm for a structured approach\\n Appendicitis?\\n Estimate the AIR score after clinical lab examination\\n Patients with atypical presentation (long duration, the elderly)lower threshold for imaging\\n High suspicion Equivocal Low suspicion\\n AIR score >8 AIR score 5-8 AIR score <5\\n Unaltered generalcondition\\n Appendectomy Active observation Observation at home\\n Re-evaluation nextday\\n Repeat examination\\n Rescoring after 4-8 hours\\n High suspicion Still equivocal Low suspicion\\n AIR score >8 or signs of resolution AIR score <5\\n Appendectomy Continued active observationImaging or laparoscopy Discharge\\n Figure 23.2. An algorithm for a structured approach to suspected AA.',\n", " 'md': '```markdown\\n## Structured Management of Suspected Appendicitis\\n\\nOn the duration of symptoms, the stage of inflammation, the anatomical position of the appendix (e.g., retrocecal, pelvic), and the patient’s physiognomy. For some patients, the diagnosis is evident, and for others, it is very vague. Thus, not all patients with suspected appendicitis (AA) can be approached the same way. We need a structured management based on the degree of suspicion.\\n\\n### Algorithm for a Structured Approach\\n\\n1. **Appendicitis?**\\n- Estimate the AIR score after clinical lab examination.\\n- Patients with atypical presentation (long duration, the elderly) have a lower threshold for imaging.\\n\\n2. **Suspicion Levels:**\\n- **High suspicion:** AIR score > 8\\n- **Action:** Appendectomy\\n- **Equivocal:** AIR score 5-8\\n- **Action:** Active observation\\n- Unaltered general condition\\n- Re-evaluation next day\\n- Repeat examination\\n- Rescoring after 4-8 hours\\n- **Low suspicion:** AIR score < 5\\n- **Action:** Observation at home\\n\\n3. **Follow-up for High Suspicion:**\\n- **High suspicion:** AIR score > 8\\n- **Action:** Appendectomy\\n- **Equivocal:** AIR score or signs of resolution\\n- **Action:** Continued active observation, imaging, or laparoscopy\\n- **Low suspicion:** AIR score < 5\\n- **Action:** Discharge\\n\\n### Figure 23.2\\n**Description:** An algorithm for a structured approach to suspected appendicitis (AA). The flowchart outlines the decision-making process based on the AIR score, detailing actions for high suspicion, equivocal cases, and low suspicion scenarios.\\n```',\n", " 'images': [{'name': 'img_p374_1.png',\n", " 'height': 896,\n", " 'width': 806,\n", " 'x': 106.55999999999995,\n", " 'y': 226.08000000000004,\n", " 'original_width': 1386,\n", " 'original_height': 1541}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Structured Management of Suspected Appendicitis',\n", " 'md': '## Structured Management of Suspected Appendicitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'On the duration of symptoms, the stage of inflammation, the anatomical position of the appendix (e.g., retrocecal, pelvic), and the patient’s physiognomy. For some patients, the diagnosis is evident, and for others, it is very vague. Thus, not all patients with suspected appendicitis (AA) can be approached the same way. We need a structured management based on the degree of suspicion.',\n", " 'md': 'On the duration of symptoms, the stage of inflammation, the anatomical position of the appendix (e.g., retrocecal, pelvic), and the patient’s physiognomy. For some patients, the diagnosis is evident, and for others, it is very vague. Thus, not all patients with suspected appendicitis (AA) can be approached the same way. We need a structured management based on the degree of suspicion.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.38, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Algorithm for a Structured Approach',\n", " 'md': '### Algorithm for a Structured Approach',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. **Appendicitis?**\\n- Estimate the AIR score after clinical lab examination.\\n- Patients with atypical presentation (long duration, the elderly) have a lower threshold for imaging.\\n\\n2. **Suspicion Levels:**\\n- **High suspicion:** AIR score > 8\\n- **Action:** Appendectomy\\n- **Equivocal:** AIR score 5-8\\n- **Action:** Active observation\\n- Unaltered general condition\\n- Re-evaluation next day\\n- Repeat examination\\n- Rescoring after 4-8 hours\\n- **Low suspicion:** AIR score < 5\\n- **Action:** Observation at home\\n\\n3. **Follow-up for High Suspicion:**\\n- **High suspicion:** AIR score > 8\\n- **Action:** Appendectomy\\n- **Equivocal:** AIR score or signs of resolution\\n- **Action:** Continued active observation, imaging, or laparoscopy\\n- **Low suspicion:** AIR score < 5\\n- **Action:** Discharge',\n", " 'md': '1. **Appendicitis?**\\n- Estimate the AIR score after clinical lab examination.\\n- Patients with atypical presentation (long duration, the elderly) have a lower threshold for imaging.\\n\\n2. **Suspicion Levels:**\\n- **High suspicion:** AIR score > 8\\n- **Action:** Appendectomy\\n- **Equivocal:** AIR score 5-8\\n- **Action:** Active observation\\n- Unaltered general condition\\n- Re-evaluation next day\\n- Repeat examination\\n- Rescoring after 4-8 hours\\n- **Low suspicion:** AIR score < 5\\n- **Action:** Observation at home\\n\\n3. **Follow-up for High Suspicion:**\\n- **High suspicion:** AIR score > 8\\n- **Action:** Appendectomy\\n- **Equivocal:** AIR score or signs of resolution\\n- **Action:** Continued active observation, imaging, or laparoscopy\\n- **Low suspicion:** AIR score < 5\\n- **Action:** Discharge',\n", " 'bBox': {'x': 118.44, 'y': 238.95, 'w': 305.84, 'h': 17.82}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 23.2',\n", " 'md': '### Figure 23.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** An algorithm for a structured approach to suspected appendicitis (AA). The flowchart outlines the decision-making process based on the AIR score, detailing actions for high suspicion, equivocal cases, and low suspicion scenarios.\\n```',\n", " 'md': '**Description:** An algorithm for a structured approach to suspected appendicitis (AA). The flowchart outlines the decision-making process based on the AIR score, detailing actions for high suspicion, equivocal cases, and low suspicion scenarios.\\n```',\n", " 'bBox': {'x': 86, 'y': 211, 'w': 308.02, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 376,\n", " 'text': ' Figure 23.2 depicts an algorithm of how we manage these patients. It\\nis based on the AIR score (see Table 23.1), which is a simple tool that\\ncan help to determine the probability of appendicitis. There is nothing\\nmagic with it but based on objective findings it can help to put things into\\nperspective with regard to your patient. It is based on the variables that\\nare most important for making the diagnosis, and it assigns a proper\\nweight to each of these variables. The cut-off points are chosen based on\\nthe outcome of many hundreds of similar patients. Validation studies on\\nthousands of patients from different hospitals, in different\\ncountries, have shown that the results are valid and can be\\nreplicated. This means that the score has a built in experience of more\\npatients than any surgeon will ever see in his career. It can therefore be\\nespecially useful for the less experienced surgeon at the beginning of his\\ncareer, let alone for the physician or ER doc who sees these patients\\ninitially.\\n\\n The score divides the patients into three groups according to the\\nprobability of their suffering from AA — high, low and intermediate:\\n\\n • Patients with a high probability of AA. Such patients, I believe,\\n don’t need any further work-up. A negative imaging study would\\n not rule out AA in a young man with a classic presentation, the\\n presence of rebound or guarding tenderness and a strong\\n inflammatory response (i.e. AIR score >8). Before sending such a\\n patient for imaging you may ask yourself what your action would be\\n if it turned out negative. You would probably need to do at least a\\n diagnostic laparoscopy anyway so the imaging will not change your\\n management.\\n • Patients with a low probability of AA. Take for example a young\\n patient with abdominal pain but no signs of peritonism and no\\n inflammatory response (i.e. AIR score <5) and no other alarm\\n symptoms — here the probability of complicated AA in need of\\n prompt appendectomy is extremely low! An imaging study may\\n only lead to a false-positive examination or you may detect a mild\\n appendicitis that may resolve without treatment within a few hours\\n — I hear from my American friends, who almost routinely obtain\\n CTs, about the entity of so-called ‘CT appendicitis’ (see below).\\n Most of these patients can be safely observed at home and',\n", " 'md': '```markdown\\n# Page Content\\n\\nFigure 23.2 depicts an algorithm of how we manage these patients. It is based on the AIR score (see Table 23.1), which is a simple tool that can help to determine the probability of appendicitis. There is nothing magic with it but based on objective findings it can help to put things into perspective with regard to your patient. It is based on the variables that are most important for making the diagnosis, and it assigns a proper weight to each of these variables. The cut-off points are chosen based on the outcome of many hundreds of similar patients. Validation studies on thousands of patients from different hospitals, in different countries, have shown that the results are valid and can be replicated. This means that the score has a built-in experience of more patients than any surgeon will ever see in his career. It can therefore be especially useful for the less experienced surgeon at the beginning of his career, let alone for the physician or ER doc who sees these patients initially.\\n\\nThe score divides the patients into three groups according to the probability of their suffering from AA — high, low, and intermediate:\\n\\n- **Patients with a high probability of AA**. Such patients, I believe, don’t need any further work-up. A negative imaging study would not rule out AA in a young man with a classic presentation, the presence of rebound or guarding tenderness, and a strong inflammatory response (i.e., AIR score > 8). Before sending such a patient for imaging you may ask yourself what your action would be if it turned out negative. You would probably need to do at least a diagnostic laparoscopy anyway so the imaging will not change your management.\\n\\n- **Patients with a low probability of AA**. Take for example a young patient with abdominal pain but no signs of peritonism and no inflammatory response (i.e., AIR score < 5) and no other alarm symptoms — here the probability of complicated AA in need of prompt appendectomy is extremely low! An imaging study may only lead to a false-positive examination or you may detect a mild appendicitis that may resolve without treatment within a few hours — I hear from my American friends, who almost routinely obtain CTs, about the entity of so-called ‘CT appendicitis’ (see below). Most of these patients can be safely observed at home.\\n\\n# Figures and Tables\\n\\n## Figure 23.2\\n- **Description**: This figure illustrates an algorithm for managing patients suspected of having appendicitis based on the AIR score. The algorithm categorizes patients into three groups based on their probability of having acute appendicitis (AA): high, low, and intermediate.\\n- **Summary**: The algorithm serves as a decision-making tool for clinicians, particularly useful for less experienced surgeons and emergency room physicians.\\n\\n## Table 23.1\\n- **Description**: This table presents the AIR score, which includes various clinical variables and their assigned weights to help determine the probability of appendicitis.\\n- **Summary**: The table is a critical component of the algorithm, providing the necessary data for calculating the AIR score.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 23.2 depicts an algorithm of how we manage these patients. It is based on the AIR score (see Table 23.1), which is a simple tool that can help to determine the probability of appendicitis. There is nothing magic with it but based on objective findings it can help to put things into perspective with regard to your patient. It is based on the variables that are most important for making the diagnosis, and it assigns a proper weight to each of these variables. The cut-off points are chosen based on the outcome of many hundreds of similar patients. Validation studies on thousands of patients from different hospitals, in different countries, have shown that the results are valid and can be replicated. This means that the score has a built-in experience of more patients than any surgeon will ever see in his career. It can therefore be especially useful for the less experienced surgeon at the beginning of his career, let alone for the physician or ER doc who sees these patients initially.\\n\\nThe score divides the patients into three groups according to the probability of their suffering from AA — high, low, and intermediate:\\n\\n- **Patients with a high probability of AA**. Such patients, I believe, don’t need any further work-up. A negative imaging study would not rule out AA in a young man with a classic presentation, the presence of rebound or guarding tenderness, and a strong inflammatory response (i.e., AIR score > 8). Before sending such a patient for imaging you may ask yourself what your action would be if it turned out negative. You would probably need to do at least a diagnostic laparoscopy anyway so the imaging will not change your management.\\n\\n- **Patients with a low probability of AA**. Take for example a young patient with abdominal pain but no signs of peritonism and no inflammatory response (i.e., AIR score < 5) and no other alarm symptoms — here the probability of complicated AA in need of prompt appendectomy is extremely low! An imaging study may only lead to a false-positive examination or you may detect a mild appendicitis that may resolve without treatment within a few hours — I hear from my American friends, who almost routinely obtain CTs, about the entity of so-called ‘CT appendicitis’ (see below). Most of these patients can be safely observed at home.',\n", " 'md': 'Figure 23.2 depicts an algorithm of how we manage these patients. It is based on the AIR score (see Table 23.1), which is a simple tool that can help to determine the probability of appendicitis. There is nothing magic with it but based on objective findings it can help to put things into perspective with regard to your patient. It is based on the variables that are most important for making the diagnosis, and it assigns a proper weight to each of these variables. The cut-off points are chosen based on the outcome of many hundreds of similar patients. Validation studies on thousands of patients from different hospitals, in different countries, have shown that the results are valid and can be replicated. This means that the score has a built-in experience of more patients than any surgeon will ever see in his career. It can therefore be especially useful for the less experienced surgeon at the beginning of his career, let alone for the physician or ER doc who sees these patients initially.\\n\\nThe score divides the patients into three groups according to the probability of their suffering from AA — high, low, and intermediate:\\n\\n- **Patients with a high probability of AA**. Such patients, I believe, don’t need any further work-up. A negative imaging study would not rule out AA in a young man with a classic presentation, the presence of rebound or guarding tenderness, and a strong inflammatory response (i.e., AIR score > 8). Before sending such a patient for imaging you may ask yourself what your action would be if it turned out negative. You would probably need to do at least a diagnostic laparoscopy anyway so the imaging will not change your management.\\n\\n- **Patients with a low probability of AA**. Take for example a young patient with abdominal pain but no signs of peritonism and no inflammatory response (i.e., AIR score < 5) and no other alarm symptoms — here the probability of complicated AA in need of prompt appendectomy is extremely low! An imaging study may only lead to a false-positive examination or you may detect a mild appendicitis that may resolve without treatment within a few hours — I hear from my American friends, who almost routinely obtain CTs, about the entity of so-called ‘CT appendicitis’ (see below). Most of these patients can be safely observed at home.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.92, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Figures and Tables',\n", " 'md': '# Figures and Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 23.2',\n", " 'md': '## Figure 23.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure illustrates an algorithm for managing patients suspected of having appendicitis based on the AIR score. The algorithm categorizes patients into three groups based on their probability of having acute appendicitis (AA): high, low, and intermediate.\\n- **Summary**: The algorithm serves as a decision-making tool for clinicians, particularly useful for less experienced surgeons and emergency room physicians.',\n", " 'md': '- **Description**: This figure illustrates an algorithm for managing patients suspected of having appendicitis based on the AIR score. The algorithm categorizes patients into three groups based on their probability of having acute appendicitis (AA): high, low, and intermediate.\\n- **Summary**: The algorithm serves as a decision-making tool for clinicians, particularly useful for less experienced surgeons and emergency room physicians.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 23.1',\n", " 'md': '## Table 23.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This table presents the AIR score, which includes various clinical variables and their assigned weights to help determine the probability of appendicitis.\\n- **Summary**: The table is a critical component of the algorithm, providing the necessary data for calculating the AIR score.\\n```',\n", " 'md': '- **Description**: This table presents the AIR score, which includes various clinical variables and their assigned weights to help determine the probability of appendicitis.\\n- **Summary**: The table is a critical component of the algorithm, providing the necessary data for calculating the AIR score.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'is based on the AIR score (see '},\n", " {'text': 'can help to determine the probability of appendicitis. There is nothing'}]},\n", " {'page': 377,\n", " 'text': ' return for re-examination after some hours if not improved.\\n • Patients with an intermediate probability of AA. Periodic re-\\n evaluation is a time-honored and proven diagnostic modality in\\n the doubtful case. Unfortunately, the art of active observation and\\n the virtue of patience are disappearing from the scene of modern\\n practice. Instead, the current emphasis is on obsessive activity,\\n where in order to prove oneself one must always ‘do something’.\\n However, in the absence of clear peritonitis and strong\\n inflammatory response, very rarely are attacks of AA a true\\n emergency requiring an immediate operation. So if the clinical\\n presentation is indeterminate (AIR score 5-8), admit the patient for\\n active observation, which means planned complete re-examination,\\n including laboratory work-up and rescoring after 6-8 hours. In most\\n instances, AA will declare itself and in non-specific abdominal\\n pain the ‘attack’ will wane. (If the diagnosis still remains unclear at\\n the reassessment you may order imaging or diagnostic\\n laparoscopy.) A significant decrease in the inflammatory response at\\n the re-evaluation (especially the white blood cell [WBC] count and\\n proportion of neutrophils, whereas the C-reactive protein [CRP]\\n levels can increase as explained below) may indicate a resolving\\n appendicitis. If you give such a patient a second round of\\n observation you may often find that he is ready to be discharged\\n home. Remember: such patients do not perforate under\\n surgical observation!\\n\\n Indicators of inflammation\\n\\n The Editors asked me for an explanation of my views on this topic —\\nhere it is: The most important diagnostic information in AA comes from\\nthe inflammatory variables — temperature, WBC, proportion of\\nneutrophils and CRP. I contend that some of these variables are in\\nfact stronger predictors than signs of peritoneal irritation. That is\\nwhy you should make use of them!\\n\\n But remember that the inflammatory response is dynamic — it\\ntakes some time to start up (please do not use the term ‘kick-off’)\\nand it also decelerates with a delay. This is especially true for',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nPatients with an intermediate probability of appendicitis (AA). Periodic re-evaluation is a time-honored and proven diagnostic modality in the doubtful case. Unfortunately, the art of active observation and the virtue of patience are disappearing from the scene of modern practice. Instead, the current emphasis is on obsessive activity, where in order to prove oneself one must always ‘do something’. However, in the absence of clear peritonitis and strong inflammatory response, very rarely are attacks of AA a true emergency requiring an immediate operation. So if the clinical presentation is indeterminate (AIR score 5-8), admit the patient for active observation, which means planned complete re-examination, including laboratory work-up and rescoring after 6-8 hours. In most instances, AA will declare itself and in non-specific abdominal pain the ‘attack’ will wane. (If the diagnosis still remains unclear at the reassessment you may order imaging or diagnostic laparoscopy.) A significant decrease in the inflammatory response at the re-evaluation (especially the white blood cell [WBC] count and proportion of neutrophils, whereas the C-reactive protein [CRP] levels can increase as explained below) may indicate a resolving appendicitis. If you give such a patient a second round of observation you may often find that he is ready to be discharged home. Remember: such patients do not perforate under surgical observation!\\n\\nIndicators of inflammation\\n\\nThe Editors asked me for an explanation of my views on this topic — here it is: The most important diagnostic information in AA comes from the inflammatory variables — temperature, WBC, proportion of neutrophils and CRP. I contend that some of these variables are in fact stronger predictors than signs of peritoneal irritation. That is why you should make use of them!\\n\\nBut remember that the inflammatory response is dynamic — it takes some time to start up (please do not use the term ‘kick-off’) and it also decelerates with a delay. This is especially true for...\\n\\n## Formula Extraction\\n\\n- White Blood Cell Count: \\\\( \\\\text{WBC} \\\\)\\n- C-reactive Protein: \\\\( \\\\text{CRP} \\\\)\\n\\n## Image Identification and Description\\n\\n- **Figure 1**: No images or graphs were identified on this page.\\n\\n## Summary\\n\\nThis page discusses the management of patients with an intermediate probability of appendicitis, emphasizing the importance of active observation and periodic re-evaluation. It highlights the significance of inflammatory variables in diagnosing appendicitis and cautions against rushing to surgery in ambiguous cases. The text also notes the dynamic nature of the inflammatory response.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Patients with an intermediate probability of appendicitis (AA). Periodic re-evaluation is a time-honored and proven diagnostic modality in the doubtful case. Unfortunately, the art of active observation and the virtue of patience are disappearing from the scene of modern practice. Instead, the current emphasis is on obsessive activity, where in order to prove oneself one must always ‘do something’. However, in the absence of clear peritonitis and strong inflammatory response, very rarely are attacks of AA a true emergency requiring an immediate operation. So if the clinical presentation is indeterminate (AIR score 5-8), admit the patient for active observation, which means planned complete re-examination, including laboratory work-up and rescoring after 6-8 hours. In most instances, AA will declare itself and in non-specific abdominal pain the ‘attack’ will wane. (If the diagnosis still remains unclear at the reassessment you may order imaging or diagnostic laparoscopy.) A significant decrease in the inflammatory response at the re-evaluation (especially the white blood cell [WBC] count and proportion of neutrophils, whereas the C-reactive protein [CRP] levels can increase as explained below) may indicate a resolving appendicitis. If you give such a patient a second round of observation you may often find that he is ready to be discharged home. Remember: such patients do not perforate under surgical observation!\\n\\nIndicators of inflammation\\n\\nThe Editors asked me for an explanation of my views on this topic — here it is: The most important diagnostic information in AA comes from the inflammatory variables — temperature, WBC, proportion of neutrophils and CRP. I contend that some of these variables are in fact stronger predictors than signs of peritoneal irritation. That is why you should make use of them!\\n\\nBut remember that the inflammatory response is dynamic — it takes some time to start up (please do not use the term ‘kick-off’) and it also decelerates with a delay. This is especially true for...',\n", " 'md': 'Patients with an intermediate probability of appendicitis (AA). Periodic re-evaluation is a time-honored and proven diagnostic modality in the doubtful case. Unfortunately, the art of active observation and the virtue of patience are disappearing from the scene of modern practice. Instead, the current emphasis is on obsessive activity, where in order to prove oneself one must always ‘do something’. However, in the absence of clear peritonitis and strong inflammatory response, very rarely are attacks of AA a true emergency requiring an immediate operation. So if the clinical presentation is indeterminate (AIR score 5-8), admit the patient for active observation, which means planned complete re-examination, including laboratory work-up and rescoring after 6-8 hours. In most instances, AA will declare itself and in non-specific abdominal pain the ‘attack’ will wane. (If the diagnosis still remains unclear at the reassessment you may order imaging or diagnostic laparoscopy.) A significant decrease in the inflammatory response at the re-evaluation (especially the white blood cell [WBC] count and proportion of neutrophils, whereas the C-reactive protein [CRP] levels can increase as explained below) may indicate a resolving appendicitis. If you give such a patient a second round of observation you may often find that he is ready to be discharged home. Remember: such patients do not perforate under surgical observation!\\n\\nIndicators of inflammation\\n\\nThe Editors asked me for an explanation of my views on this topic — here it is: The most important diagnostic information in AA comes from the inflammatory variables — temperature, WBC, proportion of neutrophils and CRP. I contend that some of these variables are in fact stronger predictors than signs of peritoneal irritation. That is why you should make use of them!\\n\\nBut remember that the inflammatory response is dynamic — it takes some time to start up (please do not use the term ‘kick-off’) and it also decelerates with a delay. This is especially true for...',\n", " 'bBox': {'x': 72, 'y': 121, 'w': 467.12, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formula Extraction',\n", " 'md': '## Formula Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- White Blood Cell Count: \\\\( \\\\text{WBC} \\\\)\\n- C-reactive Protein: \\\\( \\\\text{CRP} \\\\)',\n", " 'md': '- White Blood Cell Count: \\\\( \\\\text{WBC} \\\\)\\n- C-reactive Protein: \\\\( \\\\text{CRP} \\\\)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: No images or graphs were identified on this page.',\n", " 'md': '- **Figure 1**: No images or graphs were identified on this page.',\n", " 'bBox': {'x': 443, 'y': 337, 'w': 16.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the management of patients with an intermediate probability of appendicitis, emphasizing the importance of active observation and periodic re-evaluation. It highlights the significance of inflammatory variables in diagnosing appendicitis and cautions against rushing to surgery in ambiguous cases. The text also notes the dynamic nature of the inflammatory response.\\n```',\n", " 'md': 'This page discusses the management of patients with an intermediate probability of appendicitis, emphasizing the importance of active observation and periodic re-evaluation. It highlights the significance of inflammatory variables in diagnosing appendicitis and cautions against rushing to surgery in ambiguous cases. The text also notes the dynamic nature of the inflammatory response.\\n```',\n", " 'bBox': {'x': 100, 'y': 337, 'w': 23.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 378,\n", " 'text': 'temperature and CRP which reacts with at least a 12-hour delay while\\nthe WBC count and proportion of neutrophils can change rapidly, within\\nhours. In an AA patient with only a few hours’ duration of symptoms, you\\nmay therefore have (almost) normal laboratory results. That is why the\\ndiagnostic information of the inflammatory variables increases if\\nyou repeat them after a few hours of observation.\\n\\n Just as an increase in the inflammatory response can suggest the\\npresence of AA, a marked decrease can suggest spontaneous resolution.\\nħere the decrease comes in reverse order. You will first notice it in a\\ndecrease in the WBC count and proportion of neutrophils, whereas the\\nslow reacting CRP can still be on the increase. It may take another 24\\nhours for the CRP to start the decline.\\n\\n What about antibiotics during ‘observation’?\\n\\n If you decide to observe the patient, do not administer antibiotics as\\nthey may mask the findings or ‘partially treat’ which may just delay the\\ndiagnosis and time until surgery. Reports and experience that\\nappendicitis may be cured by antibiotics is no proof that the antibiotics\\nwere efficient. The inflammation may have resolved all by itself. Of\\ncourse, if you diagnose AA and decide to treat it with antibiotics\\nthen this is a different story (see below).\\n\\n The atypical patient is the one where imaging is indicated\\n\\n Patients with atypical presentation (>3 days’ duration of symptoms,\\nrecurrent episodes of abdominal pain, a palpable mass, the elderly or\\npatients where the intensity of pain is out of proportion to the weak\\nclinical or laboratory findings; or when there is a discrepancy between the\\nclinical and laboratory findings) need special consideration. Imaging may\\nbe indicated to detect/exclude an appendiceal phlegmon or abscess,\\nCrohn’s disease, diverticulitis, tumor, strangulated intestinal obstruction,\\ntorsion of the ovary, appendicitis epiploicae, torsion of the omentum,\\nureteral calculi or other differential diagnoses.',\n", " 'md': '```markdown\\n## Page Content\\n\\nTemperature and CRP which reacts with at least a 12-hour delay while the WBC count and proportion of neutrophils can change rapidly, within hours. In an AA patient with only a few hours’ duration of symptoms, you may therefore have (almost) normal laboratory results. That is why the diagnostic information of the inflammatory variables increases if you repeat them after a few hours of observation.\\n\\nJust as an increase in the inflammatory response can suggest the presence of AA, a marked decrease can suggest spontaneous resolution. Here the decrease comes in reverse order. You will first notice it in a decrease in the WBC count and proportion of neutrophils, whereas the slow reacting CRP can still be on the increase. It may take another 24 hours for the CRP to start the decline.\\n\\nWhat about antibiotics during ‘observation’?\\n\\nIf you decide to observe the patient, do not administer antibiotics as they may mask the findings or ‘partially treat’ which may just delay the diagnosis and time until surgery. Reports and experience that appendicitis may be cured by antibiotics is no proof that the antibiotics were efficient. The inflammation may have resolved all by itself. Of course, if you diagnose AA and decide to treat it with antibiotics then this is a different story (see below).\\n\\nThe atypical patient is the one where imaging is indicated.\\n\\nPatients with atypical presentation (>3 days’ duration of symptoms, recurrent episodes of abdominal pain, a palpable mass, the elderly or patients where the intensity of pain is out of proportion to the weak clinical or laboratory findings; or when there is a discrepancy between the clinical and laboratory findings) need special consideration. Imaging may be indicated to detect/exclude an appendiceal phlegmon or abscess, Crohn’s disease, diverticulitis, tumor, strangulated intestinal obstruction, torsion of the ovary, appendicitis epiploicae, torsion of the omentum, ureteral calculi or other differential diagnoses.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Temperature and CRP which reacts with at least a 12-hour delay while the WBC count and proportion of neutrophils can change rapidly, within hours. In an AA patient with only a few hours’ duration of symptoms, you may therefore have (almost) normal laboratory results. That is why the diagnostic information of the inflammatory variables increases if you repeat them after a few hours of observation.\\n\\nJust as an increase in the inflammatory response can suggest the presence of AA, a marked decrease can suggest spontaneous resolution. Here the decrease comes in reverse order. You will first notice it in a decrease in the WBC count and proportion of neutrophils, whereas the slow reacting CRP can still be on the increase. It may take another 24 hours for the CRP to start the decline.\\n\\nWhat about antibiotics during ‘observation’?\\n\\nIf you decide to observe the patient, do not administer antibiotics as they may mask the findings or ‘partially treat’ which may just delay the diagnosis and time until surgery. Reports and experience that appendicitis may be cured by antibiotics is no proof that the antibiotics were efficient. The inflammation may have resolved all by itself. Of course, if you diagnose AA and decide to treat it with antibiotics then this is a different story (see below).\\n\\nThe atypical patient is the one where imaging is indicated.\\n\\nPatients with atypical presentation (>3 days’ duration of symptoms, recurrent episodes of abdominal pain, a palpable mass, the elderly or patients where the intensity of pain is out of proportion to the weak clinical or laboratory findings; or when there is a discrepancy between the clinical and laboratory findings) need special consideration. Imaging may be indicated to detect/exclude an appendiceal phlegmon or abscess, Crohn’s disease, diverticulitis, tumor, strangulated intestinal obstruction, torsion of the ovary, appendicitis epiploicae, torsion of the omentum, ureteral calculi or other differential diagnoses.\\n```',\n", " 'md': 'Temperature and CRP which reacts with at least a 12-hour delay while the WBC count and proportion of neutrophils can change rapidly, within hours. In an AA patient with only a few hours’ duration of symptoms, you may therefore have (almost) normal laboratory results. That is why the diagnostic information of the inflammatory variables increases if you repeat them after a few hours of observation.\\n\\nJust as an increase in the inflammatory response can suggest the presence of AA, a marked decrease can suggest spontaneous resolution. Here the decrease comes in reverse order. You will first notice it in a decrease in the WBC count and proportion of neutrophils, whereas the slow reacting CRP can still be on the increase. It may take another 24 hours for the CRP to start the decline.\\n\\nWhat about antibiotics during ‘observation’?\\n\\nIf you decide to observe the patient, do not administer antibiotics as they may mask the findings or ‘partially treat’ which may just delay the diagnosis and time until surgery. Reports and experience that appendicitis may be cured by antibiotics is no proof that the antibiotics were efficient. The inflammation may have resolved all by itself. Of course, if you diagnose AA and decide to treat it with antibiotics then this is a different story (see below).\\n\\nThe atypical patient is the one where imaging is indicated.\\n\\nPatients with atypical presentation (>3 days’ duration of symptoms, recurrent episodes of abdominal pain, a palpable mass, the elderly or patients where the intensity of pain is out of proportion to the weak clinical or laboratory findings; or when there is a discrepancy between the clinical and laboratory findings) need special consideration. Imaging may be indicated to detect/exclude an appendiceal phlegmon or abscess, Crohn’s disease, diverticulitis, tumor, strangulated intestinal obstruction, torsion of the ovary, appendicitis epiploicae, torsion of the omentum, ureteral calculi or other differential diagnoses.\\n```',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.93, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 379,\n", " 'text': ' Abdominal imaging in acute appendicitis\\n\\n I believe that imaging has a role, especially in selected patients like the\\nelderly or in those whose presentation is atypical as mentioned above,\\nbut its efficiency as a universal tool to detect or exclude appendicitis has\\nbeen overemphasized. A CT scanner is also not readily available\\neverywhere. CT and ultrasound are two wonderful techniques but “a fool\\nwith a tool is still a fool”. Indiscriminate and non-selective use of modern\\ndiagnostic technology is not going to help. What is needed is common\\nsense and rational deployment of available investigations. Ultrasound in\\ngood hands has been reported to be accurate in the diagnosis of AA and\\nis useful in excluding other diagnoses, which may require a different\\ntherapy (e.g. hydronephrosis), or incision (e.g. acute cholecystitis), or\\nindeed no therapy at all (e.g. ovarian cyst — in women endovaginal US\\nis a great tool to exclude/diagnose pelvic pathology!). ħowever, most\\nof us do not work in an institution where we can be so confident of the\\nradiologist’s diagnosis of appendicitis on the basis of ultrasound. In most\\nsettings CT examination is more reliable than ultrasound. The value\\nof CT in diagnosing conditions which mimic AA but may not need\\noperative treatment (e.g. cecal diverticulitis) is emphasized in Chapter\\n5.\\n\\n So we order imaging selectively. Unfortunately in many places the\\ndiagnostic algorithm is increasingly driven by dogmatic emergency\\nroom personnel who perform CT scans in lieu of clinical evaluation.\\nSuch indiscriminate use of CT scanning leads to a new syndrome of ‘CT\\nappendicitis’: you admit for observation a patient with right lower\\nquadrant pain and ambiguous clinical findings. Meanwhile the emergency\\nroom doctor orders a CT, which is reported by the radiologist the\\nfollowing morning. At this stage, the patient feels much better, his\\nabdomen is benign, and he wants to go home but the radiologist claims\\nthat the appendix is inflamed (“cannot exclude AA…” or “suggestive of\\nAA...”). But should we treat the CT image or the patient? You know the\\nanswer.\\n\\n Diagnostic laparoscopy',\n", " 'md': \"# Abdominal Imaging in Acute Appendicitis\\n\\nI believe that imaging has a role, especially in selected patients like the elderly or in those whose presentation is atypical as mentioned above, but its efficiency as a universal tool to detect or exclude appendicitis has been overemphasized. A CT scanner is also not readily available everywhere. CT and ultrasound are two wonderful techniques but “a fool with a tool is still a fool”. Indiscriminate and non-selective use of modern diagnostic technology is not going to help. What is needed is common sense and rational deployment of available investigations.\\n\\nUltrasound in good hands has been reported to be accurate in the diagnosis of acute appendicitis (AA) and is useful in excluding other diagnoses, which may require a different therapy (e.g., hydronephrosis), or incision (e.g., acute cholecystitis), or indeed no therapy at all (e.g., ovarian cyst — in women endovaginal ultrasound is a great tool to exclude/diagnose pelvic pathology!). However, most of us do not work in an institution where we can be so confident of the radiologist’s diagnosis of appendicitis on the basis of ultrasound. In most settings, CT examination is more reliable than ultrasound. The value of CT in diagnosing conditions which mimic AA but may not need operative treatment (e.g., cecal diverticulitis) is emphasized in Chapter 5.\\n\\nSo we order imaging selectively. Unfortunately, in many places, the diagnostic algorithm is increasingly driven by dogmatic emergency room personnel who perform CT scans in lieu of clinical evaluation. Such indiscriminate use of CT scanning leads to a new syndrome of ‘CT appendicitis’: you admit for observation a patient with right lower quadrant pain and ambiguous clinical findings. Meanwhile, the emergency room doctor orders a CT, which is reported by the radiologist the following morning. At this stage, the patient feels much better, his abdomen is benign, and he wants to go home but the radiologist claims that the appendix is inflamed (“cannot exclude AA…” or “suggestive of AA...”). But should we treat the CT image or the patient? You know the answer.\\n\\n## Diagnostic Laparoscopy\\n\\n----\\n\\n### Summary\\nThis section discusses the role of imaging in diagnosing acute appendicitis, emphasizing the selective use of CT and ultrasound. It critiques the over-reliance on imaging technology in clinical settings and highlights the importance of clinical evaluation. The text also introduces the concept of 'CT appendicitis', where imaging results may lead to unnecessary treatment despite clinical improvement.\",\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Abdominal Imaging in Acute Appendicitis',\n", " 'md': '# Abdominal Imaging in Acute Appendicitis',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 321.8, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'I believe that imaging has a role, especially in selected patients like the elderly or in those whose presentation is atypical as mentioned above, but its efficiency as a universal tool to detect or exclude appendicitis has been overemphasized. A CT scanner is also not readily available everywhere. CT and ultrasound are two wonderful techniques but “a fool with a tool is still a fool”. Indiscriminate and non-selective use of modern diagnostic technology is not going to help. What is needed is common sense and rational deployment of available investigations.\\n\\nUltrasound in good hands has been reported to be accurate in the diagnosis of acute appendicitis (AA) and is useful in excluding other diagnoses, which may require a different therapy (e.g., hydronephrosis), or incision (e.g., acute cholecystitis), or indeed no therapy at all (e.g., ovarian cyst — in women endovaginal ultrasound is a great tool to exclude/diagnose pelvic pathology!). However, most of us do not work in an institution where we can be so confident of the radiologist’s diagnosis of appendicitis on the basis of ultrasound. In most settings, CT examination is more reliable than ultrasound. The value of CT in diagnosing conditions which mimic AA but may not need operative treatment (e.g., cecal diverticulitis) is emphasized in Chapter 5.\\n\\nSo we order imaging selectively. Unfortunately, in many places, the diagnostic algorithm is increasingly driven by dogmatic emergency room personnel who perform CT scans in lieu of clinical evaluation. Such indiscriminate use of CT scanning leads to a new syndrome of ‘CT appendicitis’: you admit for observation a patient with right lower quadrant pain and ambiguous clinical findings. Meanwhile, the emergency room doctor orders a CT, which is reported by the radiologist the following morning. At this stage, the patient feels much better, his abdomen is benign, and he wants to go home but the radiologist claims that the appendix is inflamed (“cannot exclude AA…” or “suggestive of AA...”). But should we treat the CT image or the patient? You know the answer.',\n", " 'md': 'I believe that imaging has a role, especially in selected patients like the elderly or in those whose presentation is atypical as mentioned above, but its efficiency as a universal tool to detect or exclude appendicitis has been overemphasized. A CT scanner is also not readily available everywhere. CT and ultrasound are two wonderful techniques but “a fool with a tool is still a fool”. Indiscriminate and non-selective use of modern diagnostic technology is not going to help. What is needed is common sense and rational deployment of available investigations.\\n\\nUltrasound in good hands has been reported to be accurate in the diagnosis of acute appendicitis (AA) and is useful in excluding other diagnoses, which may require a different therapy (e.g., hydronephrosis), or incision (e.g., acute cholecystitis), or indeed no therapy at all (e.g., ovarian cyst — in women endovaginal ultrasound is a great tool to exclude/diagnose pelvic pathology!). However, most of us do not work in an institution where we can be so confident of the radiologist’s diagnosis of appendicitis on the basis of ultrasound. In most settings, CT examination is more reliable than ultrasound. The value of CT in diagnosing conditions which mimic AA but may not need operative treatment (e.g., cecal diverticulitis) is emphasized in Chapter 5.\\n\\nSo we order imaging selectively. Unfortunately, in many places, the diagnostic algorithm is increasingly driven by dogmatic emergency room personnel who perform CT scans in lieu of clinical evaluation. Such indiscriminate use of CT scanning leads to a new syndrome of ‘CT appendicitis’: you admit for observation a patient with right lower quadrant pain and ambiguous clinical findings. Meanwhile, the emergency room doctor orders a CT, which is reported by the radiologist the following morning. At this stage, the patient feels much better, his abdomen is benign, and he wants to go home but the radiologist claims that the appendix is inflamed (“cannot exclude AA…” or “suggestive of AA...”). But should we treat the CT image or the patient? You know the answer.',\n", " 'bBox': {'x': 72, 'y': 124, 'w': 467.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnostic Laparoscopy',\n", " 'md': '## Diagnostic Laparoscopy',\n", " 'bBox': {'x': 86, 'y': 682, 'w': 186.69, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '----',\n", " 'md': '----',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"This section discusses the role of imaging in diagnosing acute appendicitis, emphasizing the selective use of CT and ultrasound. It critiques the over-reliance on imaging technology in clinical settings and highlights the importance of clinical evaluation. The text also introduces the concept of 'CT appendicitis', where imaging results may lead to unnecessary treatment despite clinical improvement.\",\n", " 'md': \"This section discusses the role of imaging in diagnosing acute appendicitis, emphasizing the selective use of CT and ultrasound. It critiques the over-reliance on imaging technology in clinical settings and highlights the importance of clinical evaluation. The text also introduces the concept of 'CT appendicitis', where imaging results may lead to unnecessary treatment despite clinical improvement.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'operative treatment (e.g. cecal diverticulitis) is emphasized in Chapter 5.'}]},\n", " {'page': 380,\n", " 'text': ' Diagnostic laparoscopy is a wonderful technique, but it is\\ninvasive and should not replace conventional clinical diagnosis and\\nimaging. It has been recommended that a macroscopically non-inflamed\\nappendix be left in situ, thus reducing the ‘negative appendectomy rate’\\nbut this is just a white wash. It is still an unproductive abdominal\\nexploration which is associated with unnecessary pain, risk of\\ncomplications and increased costs. Anyway, most surgeons I know are\\nreluctant not to remove the appendix in such circumstances — what\\nabout you? If your non-therapeutic laparoscopic exploration rate is\\nhigher than 15% you are misusing the procedure.\\n\\n Diagnostic laparoscopy is useful for the patient with an equivocal\\ndiagnosis of appendicitis that has not improved after observation,\\nwhen imaging has not clarified the situation and the patient’s\\npresentation is such that he cannot be discharged.\\n\\n In my practice I have never had such a patient — I find no need for diagnostic laparoscopy\\n when using CT! Moshe\\n\\n So here is how I do it in Sweden.\\n\\n First I gather all the data needed to calculate the AIR score. It\\nhelps me put the patient into a wider perspective. I never make any\\ndecision until I have all this information. For premenopausal women a\\ngynecological examination including a transvaginal ultrasound is also\\ndone, as this can detect ovarian pathology ( Chapter 35).\\n\\n • Patients with a low probability of AA — no peritoneal irritation,\\n all inflammatory variables normal (score <5). This group\\n represents the majority of all patients with suspected AA. They can\\n safely be observed at home if there are no other symptoms that\\n motivate observation at hospital. Plan a reassessment after 6-12\\n hours (i.e. the next morning). Imaging is not indicated unless you\\n think the patient may have another disease.\\n • Patients with a typical presentation — presence of peritoneal\\n irritation and strong inflammatory response (score >8). These\\n patients need an operation! A few hours’ delay is acceptable, but',\n", " 'md': '```markdown\\n# Diagnostic Laparoscopy\\n\\nDiagnostic laparoscopy is a wonderful technique, but it is invasive and should not replace conventional clinical diagnosis and imaging. It has been recommended that a macroscopically non-inflamed appendix be left in situ, thus reducing the ‘negative appendectomy rate’ but this is just a white wash. It is still an unproductive abdominal exploration which is associated with unnecessary pain, risk of complications, and increased costs. Anyway, most surgeons I know are reluctant not to remove the appendix in such circumstances — what about you? If your non-therapeutic laparoscopic exploration rate is higher than 15% you are misusing the procedure.\\n\\nDiagnostic laparoscopy is useful for the patient with an equivocal diagnosis of appendicitis that has not improved after observation, when imaging has not clarified the situation and the patient’s presentation is such that he cannot be discharged.\\n\\nIn my practice, I have never had such a patient — I find no need for diagnostic laparoscopy when using CT! Moshe\\n\\nSo here is how I do it in Sweden.\\n\\nFirst, I gather all the data needed to calculate the AIR score. It helps me put the patient into a wider perspective. I never make any decision until I have all this information. For premenopausal women, a gynecological examination including a transvaginal ultrasound is also done, as this can detect ovarian pathology (Chapter 35).\\n\\n- Patients with a low probability of AA — no peritoneal irritation, all inflammatory variables normal (score <5). This group represents the majority of all patients with suspected AA. They can safely be observed at home if there are no other symptoms that motivate observation at hospital. Plan a reassessment after 6-12 hours (i.e. the next morning). Imaging is not indicated unless you think the patient may have another disease.\\n- Patients with a typical presentation — presence of peritoneal irritation and strong inflammatory response (score >8). These patients need an operation! A few hours’ delay is acceptable, but...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Diagnostic Laparoscopy',\n", " 'md': '# Diagnostic Laparoscopy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Diagnostic laparoscopy is a wonderful technique, but it is invasive and should not replace conventional clinical diagnosis and imaging. It has been recommended that a macroscopically non-inflamed appendix be left in situ, thus reducing the ‘negative appendectomy rate’ but this is just a white wash. It is still an unproductive abdominal exploration which is associated with unnecessary pain, risk of complications, and increased costs. Anyway, most surgeons I know are reluctant not to remove the appendix in such circumstances — what about you? If your non-therapeutic laparoscopic exploration rate is higher than 15% you are misusing the procedure.\\n\\nDiagnostic laparoscopy is useful for the patient with an equivocal diagnosis of appendicitis that has not improved after observation, when imaging has not clarified the situation and the patient’s presentation is such that he cannot be discharged.\\n\\nIn my practice, I have never had such a patient — I find no need for diagnostic laparoscopy when using CT! Moshe\\n\\nSo here is how I do it in Sweden.\\n\\nFirst, I gather all the data needed to calculate the AIR score. It helps me put the patient into a wider perspective. I never make any decision until I have all this information. For premenopausal women, a gynecological examination including a transvaginal ultrasound is also done, as this can detect ovarian pathology (Chapter 35).\\n\\n- Patients with a low probability of AA — no peritoneal irritation, all inflammatory variables normal (score <5). This group represents the majority of all patients with suspected AA. They can safely be observed at home if there are no other symptoms that motivate observation at hospital. Plan a reassessment after 6-12 hours (i.e. the next morning). Imaging is not indicated unless you think the patient may have another disease.\\n- Patients with a typical presentation — presence of peritoneal irritation and strong inflammatory response (score >8). These patients need an operation! A few hours’ delay is acceptable, but...\\n```',\n", " 'md': 'Diagnostic laparoscopy is a wonderful technique, but it is invasive and should not replace conventional clinical diagnosis and imaging. It has been recommended that a macroscopically non-inflamed appendix be left in situ, thus reducing the ‘negative appendectomy rate’ but this is just a white wash. It is still an unproductive abdominal exploration which is associated with unnecessary pain, risk of complications, and increased costs. Anyway, most surgeons I know are reluctant not to remove the appendix in such circumstances — what about you? If your non-therapeutic laparoscopic exploration rate is higher than 15% you are misusing the procedure.\\n\\nDiagnostic laparoscopy is useful for the patient with an equivocal diagnosis of appendicitis that has not improved after observation, when imaging has not clarified the situation and the patient’s presentation is such that he cannot be discharged.\\n\\nIn my practice, I have never had such a patient — I find no need for diagnostic laparoscopy when using CT! Moshe\\n\\nSo here is how I do it in Sweden.\\n\\nFirst, I gather all the data needed to calculate the AIR score. It helps me put the patient into a wider perspective. I never make any decision until I have all this information. For premenopausal women, a gynecological examination including a transvaginal ultrasound is also done, as this can detect ovarian pathology (Chapter 35).\\n\\n- Patients with a low probability of AA — no peritoneal irritation, all inflammatory variables normal (score <5). This group represents the majority of all patients with suspected AA. They can safely be observed at home if there are no other symptoms that motivate observation at hospital. Plan a reassessment after 6-12 hours (i.e. the next morning). Imaging is not indicated unless you think the patient may have another disease.\\n- Patients with a typical presentation — presence of peritoneal irritation and strong inflammatory response (score >8). These patients need an operation! A few hours’ delay is acceptable, but...\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.94, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 381,\n", " 'text': ' in this group of patients there are many with perforation so I would\\n start antibiotic treatment and arrange for an operation without undue\\n delay, especially if the patient is septic (rapid respiration or pulse, or\\n leukopenia). Imaging is not indicated, as a negative examination will\\n probably not change this decision. If I am in doubt about the\\n diagnosis I start the operation laparoscopically — for many of\\n you this is probably a routine anyway.\\n• Patients with an indeterminate presentation (score 5-8) are\\n admitted to hospital and re-examined after 6-8 hours. The\\n clinical picture of the AA patient will by then unfold with a significant\\n increase in clinical symptoms and inflammation. If still atypical you\\n may order a CT or proceed with laparoscopy. If there is a marked\\n decrease in inflammation at re-examination (especially fever, WBC\\n count, proportion of neutrophils), but the suspicion of AA remains, I\\n plan another re-examination after 6-8 hours. As I will not operate\\n during that time I allow the patient to have a meal and then to fast\\n again. I often find further improvement after a second observation\\n period and sometimes the patient can be sent home. I have seen\\n this many times, even in patients with CT-verified appendicitis.\\n• Small children, the fragile elderly — yes, beware the old\\n patients in whom presentation of perforated appendicitis is\\n often atypical and delays can be lethal — and patients with an\\n atypical presentation (>3 days’ duration of symptoms, recurrent\\n episodes of abdominal pain, a palpable mass or if the intensity of\\n pain is disproportionate to weak clinical or laboratory findings) need\\n special consideration as described above. In this situation I have a\\n low threshold for imaging.\\n\\nDr. Andersson of Sweden — whom we consider to be the ultimate international guru on AA —\\npreaches a selective use of abdominal imaging. However, in the USA, where I\\npractice, the decision whom and when to scan is no longer in our\\nsurgical hands. The fact of the matter is that most patients have already undergone a CT\\nscan, before we, surgeons, are called to assess them. Typically, these scans are ordered by\\nemergency room physicians, or family docs, before consulting the surgeon. In most hospitals in\\nthe USA, even the tiny rural ones, high-tech CT images are much easier to obtain than a\\ngourmet meal or even a cup of good coffee. And radiologists are always readily available to',\n", " 'md': '```markdown\\n## Clinical Management of Appendicitis\\n\\nIn this group of patients, there are many with perforation, so I would start antibiotic treatment and arrange for an operation without undue delay, especially if the patient is septic (rapid respiration or pulse, or leukopenia). Imaging is not indicated, as a negative examination will probably not change this decision. If I am in doubt about the diagnosis, I start the operation laparoscopically — for many of you, this is probably a routine anyway.\\n\\n- Patients with an indeterminate presentation (score 5-8) are admitted to hospital and re-examined after 6-8 hours. The clinical picture of the AA patient will by then unfold with a significant increase in clinical symptoms and inflammation. If still atypical, you may order a CT or proceed with laparoscopy. If there is a marked decrease in inflammation at re-examination (especially fever, WBC count, proportion of neutrophils), but the suspicion of AA remains, I plan another re-examination after 6-8 hours. As I will not operate during that time, I allow the patient to have a meal and then to fast again. I often find further improvement after a second observation period, and sometimes the patient can be sent home. I have seen this many times, even in patients with CT-verified appendicitis.\\n\\n- Small children, the fragile elderly — yes, beware the old patients in whom the presentation of perforated appendicitis is often atypical and delays can be lethal — and patients with an atypical presentation (>3 days’ duration of symptoms, recurrent episodes of abdominal pain, a palpable mass, or if the intensity of pain is disproportionate to weak clinical or laboratory findings) need special consideration as described above. In this situation, I have a low threshold for imaging.\\n\\nDr. Andersson of Sweden — whom we consider to be the ultimate international guru on AA — preaches a selective use of abdominal imaging. However, in the USA, where I practice, the decision of whom and when to scan is no longer in our surgical hands. The fact of the matter is that most patients have already undergone a CT scan before we, surgeons, are called to assess them. Typically, these scans are ordered by emergency room physicians or family docs before consulting the surgeon. In most hospitals in the USA, even the tiny rural ones, high-tech CT images are much easier to obtain than a gourmet meal or even a cup of good coffee. And radiologists are always readily available to...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Management of Appendicitis',\n", " 'md': '## Clinical Management of Appendicitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In this group of patients, there are many with perforation, so I would start antibiotic treatment and arrange for an operation without undue delay, especially if the patient is septic (rapid respiration or pulse, or leukopenia). Imaging is not indicated, as a negative examination will probably not change this decision. If I am in doubt about the diagnosis, I start the operation laparoscopically — for many of you, this is probably a routine anyway.\\n\\n- Patients with an indeterminate presentation (score 5-8) are admitted to hospital and re-examined after 6-8 hours. The clinical picture of the AA patient will by then unfold with a significant increase in clinical symptoms and inflammation. If still atypical, you may order a CT or proceed with laparoscopy. If there is a marked decrease in inflammation at re-examination (especially fever, WBC count, proportion of neutrophils), but the suspicion of AA remains, I plan another re-examination after 6-8 hours. As I will not operate during that time, I allow the patient to have a meal and then to fast again. I often find further improvement after a second observation period, and sometimes the patient can be sent home. I have seen this many times, even in patients with CT-verified appendicitis.\\n\\n- Small children, the fragile elderly — yes, beware the old patients in whom the presentation of perforated appendicitis is often atypical and delays can be lethal — and patients with an atypical presentation (>3 days’ duration of symptoms, recurrent episodes of abdominal pain, a palpable mass, or if the intensity of pain is disproportionate to weak clinical or laboratory findings) need special consideration as described above. In this situation, I have a low threshold for imaging.\\n\\nDr. Andersson of Sweden — whom we consider to be the ultimate international guru on AA — preaches a selective use of abdominal imaging. However, in the USA, where I practice, the decision of whom and when to scan is no longer in our surgical hands. The fact of the matter is that most patients have already undergone a CT scan before we, surgeons, are called to assess them. Typically, these scans are ordered by emergency room physicians or family docs before consulting the surgeon. In most hospitals in the USA, even the tiny rural ones, high-tech CT images are much easier to obtain than a gourmet meal or even a cup of good coffee. And radiologists are always readily available to...\\n```',\n", " 'md': 'In this group of patients, there are many with perforation, so I would start antibiotic treatment and arrange for an operation without undue delay, especially if the patient is septic (rapid respiration or pulse, or leukopenia). Imaging is not indicated, as a negative examination will probably not change this decision. If I am in doubt about the diagnosis, I start the operation laparoscopically — for many of you, this is probably a routine anyway.\\n\\n- Patients with an indeterminate presentation (score 5-8) are admitted to hospital and re-examined after 6-8 hours. The clinical picture of the AA patient will by then unfold with a significant increase in clinical symptoms and inflammation. If still atypical, you may order a CT or proceed with laparoscopy. If there is a marked decrease in inflammation at re-examination (especially fever, WBC count, proportion of neutrophils), but the suspicion of AA remains, I plan another re-examination after 6-8 hours. As I will not operate during that time, I allow the patient to have a meal and then to fast again. I often find further improvement after a second observation period, and sometimes the patient can be sent home. I have seen this many times, even in patients with CT-verified appendicitis.\\n\\n- Small children, the fragile elderly — yes, beware the old patients in whom the presentation of perforated appendicitis is often atypical and delays can be lethal — and patients with an atypical presentation (>3 days’ duration of symptoms, recurrent episodes of abdominal pain, a palpable mass, or if the intensity of pain is disproportionate to weak clinical or laboratory findings) need special consideration as described above. In this situation, I have a low threshold for imaging.\\n\\nDr. Andersson of Sweden — whom we consider to be the ultimate international guru on AA — preaches a selective use of abdominal imaging. However, in the USA, where I practice, the decision of whom and when to scan is no longer in our surgical hands. The fact of the matter is that most patients have already undergone a CT scan before we, surgeons, are called to assess them. Typically, these scans are ordered by emergency room physicians or family docs before consulting the surgeon. In most hospitals in the USA, even the tiny rural ones, high-tech CT images are much easier to obtain than a gourmet meal or even a cup of good coffee. And radiologists are always readily available to...\\n```',\n", " 'bBox': {'x': 77, 'y': 102, 'w': 459.95, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 382,\n", " 'text': 'interpret the images online. It’s no wonder then that physicians confronted\\nwith a potentially acute abdomen feel compelled to get a CT when\\nit is as easily procured as junk food.\\n\\nIs such a practice of (almost) routine CT scanning, imposed on us\\nby others, ‘good’ or ‘bad’ for our patients? It is very difficult, if not unfeasible,\\nto prove scientifically that the increased use of CT scanning is beneficial overall. But what about\\nthe individual patient?\\n\\nThe advantages of ‘liberal scanning’ are familiar to those of us who use it ( Chapter 5) and\\ninclude:\\n\\n A large number of patients with ‘non-specific abdominal\\n pain’ can be discharged safely after a normal CT scan;\\n hospital admission for clinical observation is thus rendered\\n obsolete.\\n Greater accuracy in the diagnosis — gone are the days\\n when a 15-20% rate of ‘lily-white’ appendices was considered an\\n acceptable price to pay for not delaying an operation in a case of\\n genuine appendicitis.\\n Other diagnoses are readily diagnosed and treated\\n correctly. Dr. Andersson claims that patients with a ‘typical\\n presentation’ (score >8) do not need imaging. ħowever, patients\\n with acute diverticulitis of the cecum or sigmoid may present with\\n typical features of AA. ħere, age and sex matters: a 17-year-old\\n male with typical features is much more likely to suffer from AA\\n than a fertile woman or an elderly patient — the type of patients\\n who tend to benefit from imaging.\\n Avoidance of unnecessary operations — CT is safer and\\n more cost effective in excluding AA in a lady with a ruptured\\n ovarian cyst than diagnostic laparoscopy.',\n", " 'md': '```markdown\\n## Advantages of Liberal CT Scanning\\n\\nThe practice of routine CT scanning in cases of potentially acute abdomen raises questions about its overall benefit to patients. While it is challenging to prove scientifically that increased CT use is beneficial, the advantages for individual patients are notable:\\n\\n1. **Safe Discharge**: A large number of patients with ‘non-specific abdominal pain’ can be discharged safely after a normal CT scan, making hospital admission for clinical observation unnecessary.\\n\\n2. **Increased Diagnostic Accuracy**: The accuracy in diagnosis has improved significantly. Previously, a 15-20% rate of ‘lily-white’ appendices was deemed acceptable to avoid delaying surgery for genuine appendicitis.\\n\\n3. **Correct Diagnosis and Treatment**: Other conditions can be diagnosed and treated more effectively. Dr. Andersson suggests that patients with a ‘typical presentation’ (score >8) may not require imaging. However, patients with acute diverticulitis of the cecum or sigmoid may present with typical features of appendicitis (AA). Age and sex are critical factors; for instance, a 17-year-old male with typical features is more likely to have AA compared to a fertile woman or an elderly patient, who are the demographics that tend to benefit from imaging.\\n\\n4. **Avoidance of Unnecessary Operations**: CT scanning is safer and more cost-effective for excluding AA in cases such as a ruptured ovarian cyst compared to diagnostic laparoscopy.\\n```',\n", " 'images': [{'name': 'img_p381_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 443.5199999999995,\n", " 'y': 236.16},\n", " {'name': 'img_p381_2.png',\n", " 'height': 10,\n", " 'width': 10,\n", " 'x': 89.27999999999975,\n", " 'y': 290.16},\n", " {'name': 'img_p381_2.png',\n", " 'height': 10,\n", " 'width': 10,\n", " 'x': 89.27999999999975,\n", " 'y': 381.6},\n", " {'name': 'img_p381_2.png',\n", " 'height': 10,\n", " 'width': 10,\n", " 'x': 89.27999999999975,\n", " 'y': 472.32},\n", " {'name': 'img_p381_2.png',\n", " 'height': 10,\n", " 'width': 10,\n", " 'x': 89.27999999999975,\n", " 'y': 649.4399999999999}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Advantages of Liberal CT Scanning',\n", " 'md': '## Advantages of Liberal CT Scanning',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The practice of routine CT scanning in cases of potentially acute abdomen raises questions about its overall benefit to patients. While it is challenging to prove scientifically that increased CT use is beneficial, the advantages for individual patients are notable:\\n\\n1. **Safe Discharge**: A large number of patients with ‘non-specific abdominal pain’ can be discharged safely after a normal CT scan, making hospital admission for clinical observation unnecessary.\\n\\n2. **Increased Diagnostic Accuracy**: The accuracy in diagnosis has improved significantly. Previously, a 15-20% rate of ‘lily-white’ appendices was deemed acceptable to avoid delaying surgery for genuine appendicitis.\\n\\n3. **Correct Diagnosis and Treatment**: Other conditions can be diagnosed and treated more effectively. Dr. Andersson suggests that patients with a ‘typical presentation’ (score >8) may not require imaging. However, patients with acute diverticulitis of the cecum or sigmoid may present with typical features of appendicitis (AA). Age and sex are critical factors; for instance, a 17-year-old male with typical features is more likely to have AA compared to a fertile woman or an elderly patient, who are the demographics that tend to benefit from imaging.\\n\\n4. **Avoidance of Unnecessary Operations**: CT scanning is safer and more cost-effective for excluding AA in cases such as a ruptured ovarian cyst compared to diagnostic laparoscopy.\\n```',\n", " 'md': 'The practice of routine CT scanning in cases of potentially acute abdomen raises questions about its overall benefit to patients. While it is challenging to prove scientifically that increased CT use is beneficial, the advantages for individual patients are notable:\\n\\n1. **Safe Discharge**: A large number of patients with ‘non-specific abdominal pain’ can be discharged safely after a normal CT scan, making hospital admission for clinical observation unnecessary.\\n\\n2. **Increased Diagnostic Accuracy**: The accuracy in diagnosis has improved significantly. Previously, a 15-20% rate of ‘lily-white’ appendices was deemed acceptable to avoid delaying surgery for genuine appendicitis.\\n\\n3. **Correct Diagnosis and Treatment**: Other conditions can be diagnosed and treated more effectively. Dr. Andersson suggests that patients with a ‘typical presentation’ (score >8) may not require imaging. However, patients with acute diverticulitis of the cecum or sigmoid may present with typical features of appendicitis (AA). Age and sex are critical factors; for instance, a 17-year-old male with typical features is more likely to have AA compared to a fertile woman or an elderly patient, who are the demographics that tend to benefit from imaging.\\n\\n4. **Avoidance of Unnecessary Operations**: CT scanning is safer and more cost-effective for excluding AA in cases such as a ruptured ovarian cyst compared to diagnostic laparoscopy.\\n```',\n", " 'bBox': {'x': 113, 'y': 464, 'w': 419.77, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 383,\n", " 'text': ' Many small hospitals do not have an experienced\\n general surgeon readily available to evaluate each and\\n every patient ‘à la Dr. Andersson’. A negative CT allows the rural\\n surgeon to sleep better at night and avoids unnecessary ‘shipping\\n out’ (transfer of patients to another institution).\\n Legal considerations: juries in the USA have been awarding\\n almost a million dollars for a “failure to obtain imaging” and thus,\\n allegedly, causing a delay in diagnosis of AA — with resulting\\n morbidity. While not advocating ‘defensive medicine’ it is\\n impossible to ignore such harsh realities.\\n\\n No, we do not support routine CT scanning. But its liberal use undoubtedly makes for better\\n clinical management. And anyway, the train has already left the station — we have a useful\\n diagnostic tool, which will improve (become faster and emit smaller doses of radiation) — and\\n there is no way back. And BTW: in pregnant women — consider MRI.\\n\\n Finally, for those of you who like to use ‘scores’: I repeat what Dr.\\n Andersson said, that scores are only an adjunct to clinical judgment. While statistically solid\\n they can ‘misfire’ in the individual patient. Just recently I reviewed a case of an elderly patient\\n presenting with lower abdominal pain and an elevated WBC count and CRP level. His AIR\\n score would have been 5. He was admitted for observation. Perforated AA was found\\n at laparotomy the next day; he died from overwhelming sepsis. A CT on admission\\n may have saved him! Such a patient falls into the uncertain category described by Dr.\\n Andersson. Moshe\\n\\n Treatment\\n\\n Antibiotics\\n\\n Judicious administration of antibiotics, to cover Gram-negative and\\nanaerobic bacteria, will minimize the incidence of postoperative wound',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nMany small hospitals do not have an experienced general surgeon readily available to evaluate each and every patient ‘à la Dr. Andersson’. A negative CT allows the rural surgeon to sleep better at night and avoids unnecessary ‘shipping out’ (transfer of patients to another institution). Legal considerations: juries in the USA have been awarding almost a million dollars for a “failure to obtain imaging” and thus, allegedly, causing a delay in diagnosis of AA — with resulting morbidity. While not advocating ‘defensive medicine’ it is impossible to ignore such harsh realities.\\n\\nNo, we do not support routine CT scanning. But its liberal use undoubtedly makes for better clinical management. And anyway, the train has already left the station — we have a useful diagnostic tool, which will improve (become faster and emit smaller doses of radiation) — and there is no way back. And BTW: in pregnant women — consider MRI.\\n\\nFinally, for those of you who like to use ‘scores’: I repeat what Dr. Andersson said, that scores are only an adjunct to clinical judgment. While statistically solid they can ‘misfire’ in the individual patient. Just recently I reviewed a case of an elderly patient presenting with lower abdominal pain and an elevated WBC count and CRP level. His AIR score would have been 5. He was admitted for observation. Perforated AA was found at laparotomy the next day; he died from overwhelming sepsis. A CT on admission may have saved him! Such a patient falls into the uncertain category described by Dr. Andersson. Moshe\\n\\n### Treatment\\n\\n#### Antibiotics\\n\\nJudicious administration of antibiotics, to cover Gram-negative and anaerobic bacteria, will minimize the incidence of postoperative wound.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and structured as per the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Many small hospitals do not have an experienced general surgeon readily available to evaluate each and every patient ‘à la Dr. Andersson’. A negative CT allows the rural surgeon to sleep better at night and avoids unnecessary ‘shipping out’ (transfer of patients to another institution). Legal considerations: juries in the USA have been awarding almost a million dollars for a “failure to obtain imaging” and thus, allegedly, causing a delay in diagnosis of AA — with resulting morbidity. While not advocating ‘defensive medicine’ it is impossible to ignore such harsh realities.\\n\\nNo, we do not support routine CT scanning. But its liberal use undoubtedly makes for better clinical management. And anyway, the train has already left the station — we have a useful diagnostic tool, which will improve (become faster and emit smaller doses of radiation) — and there is no way back. And BTW: in pregnant women — consider MRI.\\n\\nFinally, for those of you who like to use ‘scores’: I repeat what Dr. Andersson said, that scores are only an adjunct to clinical judgment. While statistically solid they can ‘misfire’ in the individual patient. Just recently I reviewed a case of an elderly patient presenting with lower abdominal pain and an elevated WBC count and CRP level. His AIR score would have been 5. He was admitted for observation. Perforated AA was found at laparotomy the next day; he died from overwhelming sepsis. A CT on admission may have saved him! Such a patient falls into the uncertain category described by Dr. Andersson. Moshe',\n", " 'md': 'Many small hospitals do not have an experienced general surgeon readily available to evaluate each and every patient ‘à la Dr. Andersson’. A negative CT allows the rural surgeon to sleep better at night and avoids unnecessary ‘shipping out’ (transfer of patients to another institution). Legal considerations: juries in the USA have been awarding almost a million dollars for a “failure to obtain imaging” and thus, allegedly, causing a delay in diagnosis of AA — with resulting morbidity. While not advocating ‘defensive medicine’ it is impossible to ignore such harsh realities.\\n\\nNo, we do not support routine CT scanning. But its liberal use undoubtedly makes for better clinical management. And anyway, the train has already left the station — we have a useful diagnostic tool, which will improve (become faster and emit smaller doses of radiation) — and there is no way back. And BTW: in pregnant women — consider MRI.\\n\\nFinally, for those of you who like to use ‘scores’: I repeat what Dr. Andersson said, that scores are only an adjunct to clinical judgment. While statistically solid they can ‘misfire’ in the individual patient. Just recently I reviewed a case of an elderly patient presenting with lower abdominal pain and an elevated WBC count and CRP level. His AIR score would have been 5. He was admitted for observation. Perforated AA was found at laparotomy the next day; he died from overwhelming sepsis. A CT on admission may have saved him! Such a patient falls into the uncertain category described by Dr. Andersson. Moshe',\n", " 'bBox': {'x': 77, 'y': 132, 'w': 457.58, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Treatment',\n", " 'md': '### Treatment',\n", " 'bBox': {'x': 86, 'y': 607, 'w': 79.1, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Antibiotics',\n", " 'md': '#### Antibiotics',\n", " 'bBox': {'x': 86, 'y': 651, 'w': 85.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Judicious administration of antibiotics, to cover Gram-negative and anaerobic bacteria, will minimize the incidence of postoperative wound.\\n```',\n", " 'md': 'Judicious administration of antibiotics, to cover Gram-negative and anaerobic bacteria, will minimize the incidence of postoperative wound.\\n```',\n", " 'bBox': {'x': 86, 'y': 266, 'w': 445.39, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and structured as per the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted and structured as per the requirements.',\n", " 'bBox': {'x': 521, 'y': 266, 'w': 10.39, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 384,\n", " 'text': '(common) and intra-abdominal (rare) infective complications ( Chapter\\n13). In simple AA the antibiotics are considered prophylactic, while in\\ncomplicated AA they are therapeutic ( Chapter 7). We encourage you\\nto administer the first dose of antibiotics just before you scrub. If the\\npatient appears ‘septic’ with significant peritonitis and you suspect\\nperforated appendicitis, you should start antibiotics immediately\\nwhen you decide on an operation.\\n\\n If at surgery the AA proves to be simple and there is no visible pus, no\\npostoperative administration is necessary. Should you, on the other\\nhand, discover complicated AA, additional postoperative doses are\\nindicated. We suggest that you tailor the duration of administration\\nto the operative findings. Gangrenous AA, without any pus formation, is\\na ‘resectable infection’, which does not require prolonged postoperative\\nantibiotics. When pus is found or the appendix is perforated, you should\\nprobably give at least 5 days of treatment ( Chapters 7, 13 and 44).\\nPlease note however that iatrogenic perforation of the appendix may\\noccur during laparoscopic appendectomy. This may result in significant\\ncontamination of the peritoneal cavity. Add to this, unwarranted peritoneal\\nlavage — which is not completely evacuated (see the laparoscopic\\nsection below) — and you get the ideal recipe for postoperative infected\\nascites! In these circumstances consider prolonging the postop\\ncourse of antibiotics.\\n\\n Non-operative management of acute appendicitis\\n\\n As already said, simple AA can frequently resolve without treatment.\\nNo wonder that reports have shown that ‘assumed’ or image-proven\\nsimple AA can respond to non-operative management with\\nintravenous broad-spectrum antibiotics. However, I believe that in\\nthe majority of patients the symptoms resolve spontaneously and\\nnot because of the antibiotics. This parallels recent findings that\\npatients with uncomplicated acute diverticulitis have identical healing\\nrates whether they receive antibiotics or not.\\n\\n I think there are problems with giving antibiotics to a patient with\\nassumed AA. One is that if the patient gets better you do not know if he\\nhad AA in the first place and you do not know if the improvement was',\n", " 'md': '```markdown\\n## Non-operative Management of Acute Appendicitis\\n\\nIn simple acute appendicitis (AA), antibiotics are considered prophylactic, while in complicated AA, they are therapeutic. It is encouraged to administer the first dose of antibiotics just before scrubbing for surgery. If the patient appears ‘septic’ with significant peritonitis and there is a suspicion of perforated appendicitis, antibiotics should be started immediately upon deciding on an operation.\\n\\nIf during surgery the AA is found to be simple and there is no visible pus, no postoperative administration of antibiotics is necessary. Conversely, if complicated AA is discovered, additional postoperative doses are indicated. The duration of antibiotic administration should be tailored to the operative findings. Gangrenous AA, without any pus formation, is considered a ‘resectable infection’ that does not require prolonged postoperative antibiotics. However, if pus is found or the appendix is perforated, at least 5 days of treatment is recommended.\\n\\nIt is important to note that iatrogenic perforation of the appendix may occur during laparoscopic appendectomy, potentially leading to significant contamination of the peritoneal cavity. This, combined with unwarranted peritoneal lavage that is not completely evacuated, creates an ideal scenario for postoperative infected ascites. In such cases, consider prolonging the postoperative course of antibiotics.\\n\\n### Non-operative Management Insights\\n\\nSimple AA can frequently resolve without treatment. Reports indicate that ‘assumed’ or image-proven simple AA can respond to non-operative management with intravenous broad-spectrum antibiotics. However, it is believed that in the majority of patients, symptoms resolve spontaneously rather than due to antibiotics. This is supported by recent findings that patients with uncomplicated acute diverticulitis have identical healing rates whether they receive antibiotics or not.\\n\\nThere are concerns regarding the administration of antibiotics to a patient with assumed AA. One issue is that if the patient improves, it remains unclear whether they had AA initially and whether the improvement was due to the antibiotics.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Non-operative Management of Acute Appendicitis',\n", " 'md': '## Non-operative Management of Acute Appendicitis',\n", " 'bBox': {'x': 86, 'y': 495, 'w': 387.14, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In simple acute appendicitis (AA), antibiotics are considered prophylactic, while in complicated AA, they are therapeutic. It is encouraged to administer the first dose of antibiotics just before scrubbing for surgery. If the patient appears ‘septic’ with significant peritonitis and there is a suspicion of perforated appendicitis, antibiotics should be started immediately upon deciding on an operation.\\n\\nIf during surgery the AA is found to be simple and there is no visible pus, no postoperative administration of antibiotics is necessary. Conversely, if complicated AA is discovered, additional postoperative doses are indicated. The duration of antibiotic administration should be tailored to the operative findings. Gangrenous AA, without any pus formation, is considered a ‘resectable infection’ that does not require prolonged postoperative antibiotics. However, if pus is found or the appendix is perforated, at least 5 days of treatment is recommended.\\n\\nIt is important to note that iatrogenic perforation of the appendix may occur during laparoscopic appendectomy, potentially leading to significant contamination of the peritoneal cavity. This, combined with unwarranted peritoneal lavage that is not completely evacuated, creates an ideal scenario for postoperative infected ascites. In such cases, consider prolonging the postoperative course of antibiotics.',\n", " 'md': 'In simple acute appendicitis (AA), antibiotics are considered prophylactic, while in complicated AA, they are therapeutic. It is encouraged to administer the first dose of antibiotics just before scrubbing for surgery. If the patient appears ‘septic’ with significant peritonitis and there is a suspicion of perforated appendicitis, antibiotics should be started immediately upon deciding on an operation.\\n\\nIf during surgery the AA is found to be simple and there is no visible pus, no postoperative administration of antibiotics is necessary. Conversely, if complicated AA is discovered, additional postoperative doses are indicated. The duration of antibiotic administration should be tailored to the operative findings. Gangrenous AA, without any pus formation, is considered a ‘resectable infection’ that does not require prolonged postoperative antibiotics. However, if pus is found or the appendix is perforated, at least 5 days of treatment is recommended.\\n\\nIt is important to note that iatrogenic perforation of the appendix may occur during laparoscopic appendectomy, potentially leading to significant contamination of the peritoneal cavity. This, combined with unwarranted peritoneal lavage that is not completely evacuated, creates an ideal scenario for postoperative infected ascites. In such cases, consider prolonging the postoperative course of antibiotics.',\n", " 'bBox': {'x': 72, 'y': 286, 'w': 467.63, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Non-operative Management Insights',\n", " 'md': '### Non-operative Management Insights',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Simple AA can frequently resolve without treatment. Reports indicate that ‘assumed’ or image-proven simple AA can respond to non-operative management with intravenous broad-spectrum antibiotics. However, it is believed that in the majority of patients, symptoms resolve spontaneously rather than due to antibiotics. This is supported by recent findings that patients with uncomplicated acute diverticulitis have identical healing rates whether they receive antibiotics or not.\\n\\nThere are concerns regarding the administration of antibiotics to a patient with assumed AA. One issue is that if the patient improves, it remains unclear whether they had AA initially and whether the improvement was due to the antibiotics.\\n```',\n", " 'md': 'Simple AA can frequently resolve without treatment. Reports indicate that ‘assumed’ or image-proven simple AA can respond to non-operative management with intravenous broad-spectrum antibiotics. However, it is believed that in the majority of patients, symptoms resolve spontaneously rather than due to antibiotics. This is supported by recent findings that patients with uncomplicated acute diverticulitis have identical healing rates whether they receive antibiotics or not.\\n\\nThere are concerns regarding the administration of antibiotics to a patient with assumed AA. One issue is that if the patient improves, it remains unclear whether they had AA initially and whether the improvement was due to the antibiotics.\\n```',\n", " 'bBox': {'x': 72, 'y': 647, 'w': 281.45, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '(common) and intra-abdominal (rare) infective complications ( Chapter 13). In simple AA the antibiotics are considered prophylactic , while in complicated AA they are '},\n", " {'text': 'to administer the first dose of antibiotics just before you scrub. '},\n", " {'text': 'iatrogenic perforation'},\n", " {'text': ' of the appendix may'},\n", " {'text': ' of the appendix may'}]},\n", " {'page': 385,\n", " 'text': 'spontaneous or due to the antibiotics. So you are forced to ‘complete’ the\\ntreatment, which may prolong the hospital stay. A second is that if the\\npatient has complicated AA you may see only a partial response, which\\nwill also prolong the suffering. This is why I do not support non-surgical\\nmanagement with antibiotics for ‘everyone’.\\n\\n However, non-operative management of AA can be reasonable in\\nthe following categories of patients:\\n\\n • Patients with a prohibitive surgical-anesthetic risk (e.g. post-\\n myocardial infarction).\\n • Patients who refuse an operation.\\n • Patients in the middle of the Pacific Ocean or on a nuclear\\n submarine, or in rural locations where no surgeon is available.\\n Or on a space ship to Mars.\\n • Morbidly obese patients.\\n • Pregnant women (1st trimester) with mild AA, where any operation\\n may induce abortion. (ħowever, this may be controversial as some,\\n including myself, think that this is a myth.)\\n • Obviously, patients with an appendiceal mass or phlegmon should\\n be managed non-operatively. This is accepted by most surgeons\\n and is no longer controversial (see below)!\\n\\n Careful clinical assessment, augmented by scoring systems\\nand/or imaging, should distinguish between the mild cases, which\\nare best amenable to non-operative treatment and the gangrenous\\nor perforated ones which are not likely to resolve and probably\\nmandate an operation.\\n\\n Communicating with surgeons all over the world (on SURGINET —\\n http://www3.sympatico.ca/tgilas/SURGINET.FAQ.htm) we realize that although non-surgical\\n treatment is acceptable in some settings, the vast majority of surgeons are strongly addicted to\\n the policy of “always an appendectomy — the sooner the better”. The reasons for this attitude\\n are numerous and include: deeply entrenched dogmas and teaching; (unfounded) fear of\\n progression of mild appendicitis to perforation; fear of litigation, perceiving that non-operative',\n", " 'md': '```markdown\\n## Non-Operative Management of Appendicitis\\n\\nSpontaneous or due to the antibiotics. So you are forced to ‘complete’ the treatment, which may prolong the hospital stay. A second is that if the patient has complicated appendicitis (AA) you may see only a partial response, which will also prolong the suffering. This is why I do not support non-surgical management with antibiotics for ‘everyone’.\\n\\nHowever, non-operative management of AA can be reasonable in the following categories of patients:\\n\\n- Patients with a prohibitive surgical-anesthetic risk (e.g. post-myocardial infarction).\\n- Patients who refuse an operation.\\n- Patients in the middle of the Pacific Ocean or on a nuclear submarine, or in rural locations where no surgeon is available. Or on a space ship to Mars.\\n- Morbidly obese patients.\\n- Pregnant women (1st trimester) with mild AA, where any operation may induce abortion. (However, this may be controversial as some, including myself, think that this is a myth.)\\n- Obviously, patients with an appendiceal mass or phlegmon should be managed non-operatively. This is accepted by most surgeons and is no longer controversial (see below)!\\n\\nCareful clinical assessment, augmented by scoring systems and/or imaging, should distinguish between the mild cases, which are best amenable to non-operative treatment and the gangrenous or perforated ones which are not likely to resolve and probably mandate an operation.\\n\\nCommunicating with surgeons all over the world (on SURGINET — [SURGINET FAQ](http://www3.sympatico.ca/tgilas/SURGINET.FAQ.htm)) we realize that although non-surgical treatment is acceptable in some settings, the vast majority of surgeons are strongly addicted to the policy of “always an appendectomy — the sooner the better”. The reasons for this attitude are numerous and include: deeply entrenched dogmas and teaching; (unfounded) fear of progression of mild appendicitis to perforation; fear of litigation, perceiving that non-operative treatment may lead to complications.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Non-Operative Management of Appendicitis',\n", " 'md': '## Non-Operative Management of Appendicitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Spontaneous or due to the antibiotics. So you are forced to ‘complete’ the treatment, which may prolong the hospital stay. A second is that if the patient has complicated appendicitis (AA) you may see only a partial response, which will also prolong the suffering. This is why I do not support non-surgical management with antibiotics for ‘everyone’.\\n\\nHowever, non-operative management of AA can be reasonable in the following categories of patients:\\n\\n- Patients with a prohibitive surgical-anesthetic risk (e.g. post-myocardial infarction).\\n- Patients who refuse an operation.\\n- Patients in the middle of the Pacific Ocean or on a nuclear submarine, or in rural locations where no surgeon is available. Or on a space ship to Mars.\\n- Morbidly obese patients.\\n- Pregnant women (1st trimester) with mild AA, where any operation may induce abortion. (However, this may be controversial as some, including myself, think that this is a myth.)\\n- Obviously, patients with an appendiceal mass or phlegmon should be managed non-operatively. This is accepted by most surgeons and is no longer controversial (see below)!\\n\\nCareful clinical assessment, augmented by scoring systems and/or imaging, should distinguish between the mild cases, which are best amenable to non-operative treatment and the gangrenous or perforated ones which are not likely to resolve and probably mandate an operation.\\n\\nCommunicating with surgeons all over the world (on SURGINET — [SURGINET FAQ](http://www3.sympatico.ca/tgilas/SURGINET.FAQ.htm)) we realize that although non-surgical treatment is acceptable in some settings, the vast majority of surgeons are strongly addicted to the policy of “always an appendectomy — the sooner the better”. The reasons for this attitude are numerous and include: deeply entrenched dogmas and teaching; (unfounded) fear of progression of mild appendicitis to perforation; fear of litigation, perceiving that non-operative treatment may lead to complications.\\n```',\n", " 'md': 'Spontaneous or due to the antibiotics. So you are forced to ‘complete’ the treatment, which may prolong the hospital stay. A second is that if the patient has complicated appendicitis (AA) you may see only a partial response, which will also prolong the suffering. This is why I do not support non-surgical management with antibiotics for ‘everyone’.\\n\\nHowever, non-operative management of AA can be reasonable in the following categories of patients:\\n\\n- Patients with a prohibitive surgical-anesthetic risk (e.g. post-myocardial infarction).\\n- Patients who refuse an operation.\\n- Patients in the middle of the Pacific Ocean or on a nuclear submarine, or in rural locations where no surgeon is available. Or on a space ship to Mars.\\n- Morbidly obese patients.\\n- Pregnant women (1st trimester) with mild AA, where any operation may induce abortion. (However, this may be controversial as some, including myself, think that this is a myth.)\\n- Obviously, patients with an appendiceal mass or phlegmon should be managed non-operatively. This is accepted by most surgeons and is no longer controversial (see below)!\\n\\nCareful clinical assessment, augmented by scoring systems and/or imaging, should distinguish between the mild cases, which are best amenable to non-operative treatment and the gangrenous or perforated ones which are not likely to resolve and probably mandate an operation.\\n\\nCommunicating with surgeons all over the world (on SURGINET — [SURGINET FAQ](http://www3.sympatico.ca/tgilas/SURGINET.FAQ.htm)) we realize that although non-surgical treatment is acceptable in some settings, the vast majority of surgeons are strongly addicted to the policy of “always an appendectomy — the sooner the better”. The reasons for this attitude are numerous and include: deeply entrenched dogmas and teaching; (unfounded) fear of progression of mild appendicitis to perforation; fear of litigation, perceiving that non-operative treatment may lead to complications.\\n```',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.96, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'url': 'http://www3.sympatico.ca/tgilas/SURGINET.FAQ.htm',\n", " 'text': 'http://www3.sympatico.ca/tgilas/SURGINET.FAQ.htm) we realize that although non-surgical'}]},\n", " {'page': 386,\n", " 'text': 'management is not the accepted standard of care in their communities; the perception that\\nappendectomy (particularly laparoscopic) offers an instant remedy with minimal morbidity;\\nreluctance to subject patients to a prolonged hospitalization and antibiotic treatment, whereas\\nfollowing an uneventful appendectomy for mild AA they usually go home within 24 hours.\\nMoreover, many surgeons find it difficult, if not impossible, to\\nconvince patients and their physicians that not all forms of AA\\nneed an appendectomy and that avoiding an operation won’t\\nendanger their patients’ lives. And, as always, there are the financial aspects to\\nconsider in countries where surgeons work on a ‘fee for service’ basis: when the surgeon is paid\\nfor appendectomy ten times the amount he receives for non-operative management there will\\nbe always the conscious or subconscious drive to operate rather than not. Even strictly salaried\\nsurgeons often suffer from the syndrome of funktionslust: isn’t operating more fun than\\nobserving or prescribing antibiotics?\\n\\nIt should be clear that we believe that AA is not a single disease that needs one treatment, but\\nhas a spectrum of presentations and pathologies that can be treated in different ways —\\nincluding without an operation. We wish we knew how to modulate the\\nprevailing educational, cultural, economic and legal components\\nwhich still influence most surgeons to believe that any diseased\\nappendix belongs in the formalin jar. Moshe\\n\\n The operation\\n The point of greatest tenderness is, in the average adult,\\n almost exactly 2 inches from the anterior iliac spine, on a\\n line drawn from this process through the umbilicus.\\n Charles McBurney\\n\\n The appendix is generally attached to the cecum.\\n Mark M. Ravitch\\n\\n When to operate?',\n", " 'md': '```markdown\\n## Management of Acute Appendicitis\\n\\nManagement is not the accepted standard of care in their communities; the perception that appendectomy (particularly laparoscopic) offers an instant remedy with minimal morbidity; reluctance to subject patients to a prolonged hospitalization and antibiotic treatment, whereas following an uneventful appendectomy for mild acute appendicitis (AA) they usually go home within 24 hours.\\n\\nMoreover, many surgeons find it difficult, if not impossible, to convince patients and their physicians that not all forms of AA need an appendectomy and that avoiding an operation won’t endanger their patients’ lives. And, as always, there are the financial aspects to consider in countries where surgeons work on a ‘fee for service’ basis: when the surgeon is paid for appendectomy ten times the amount he receives for non-operative management, there will always be the conscious or subconscious drive to operate rather than not. Even strictly salaried surgeons often suffer from the syndrome of funktionslust: isn’t operating more fun than observing or prescribing antibiotics?\\n\\nIt should be clear that we believe that AA is not a single disease that needs one treatment, but has a spectrum of presentations and pathologies that can be treated in different ways — including without an operation. We wish we knew how to modulate the prevailing educational, cultural, economic, and legal components which still influence most surgeons to believe that any diseased appendix belongs in the formalin jar.\\n\\n### The Operation\\n\\nThe point of greatest tenderness is, in the average adult, almost exactly 2 inches from the anterior iliac spine, on a line drawn from this process through the umbilicus. — Charles McBurney\\n\\nThe appendix is generally attached to the cecum. — Mark M. Ravitch\\n\\n### When to Operate?\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Acute Appendicitis',\n", " 'md': '## Management of Acute Appendicitis',\n", " 'bBox': {'x': 119, 'y': 204, 'w': 16.8, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Management is not the accepted standard of care in their communities; the perception that appendectomy (particularly laparoscopic) offers an instant remedy with minimal morbidity; reluctance to subject patients to a prolonged hospitalization and antibiotic treatment, whereas following an uneventful appendectomy for mild acute appendicitis (AA) they usually go home within 24 hours.\\n\\nMoreover, many surgeons find it difficult, if not impossible, to convince patients and their physicians that not all forms of AA need an appendectomy and that avoiding an operation won’t endanger their patients’ lives. And, as always, there are the financial aspects to consider in countries where surgeons work on a ‘fee for service’ basis: when the surgeon is paid for appendectomy ten times the amount he receives for non-operative management, there will always be the conscious or subconscious drive to operate rather than not. Even strictly salaried surgeons often suffer from the syndrome of funktionslust: isn’t operating more fun than observing or prescribing antibiotics?\\n\\nIt should be clear that we believe that AA is not a single disease that needs one treatment, but has a spectrum of presentations and pathologies that can be treated in different ways — including without an operation. We wish we knew how to modulate the prevailing educational, cultural, economic, and legal components which still influence most surgeons to believe that any diseased appendix belongs in the formalin jar.',\n", " 'md': 'Management is not the accepted standard of care in their communities; the perception that appendectomy (particularly laparoscopic) offers an instant remedy with minimal morbidity; reluctance to subject patients to a prolonged hospitalization and antibiotic treatment, whereas following an uneventful appendectomy for mild acute appendicitis (AA) they usually go home within 24 hours.\\n\\nMoreover, many surgeons find it difficult, if not impossible, to convince patients and their physicians that not all forms of AA need an appendectomy and that avoiding an operation won’t endanger their patients’ lives. And, as always, there are the financial aspects to consider in countries where surgeons work on a ‘fee for service’ basis: when the surgeon is paid for appendectomy ten times the amount he receives for non-operative management, there will always be the conscious or subconscious drive to operate rather than not. Even strictly salaried surgeons often suffer from the syndrome of funktionslust: isn’t operating more fun than observing or prescribing antibiotics?\\n\\nIt should be clear that we believe that AA is not a single disease that needs one treatment, but has a spectrum of presentations and pathologies that can be treated in different ways — including without an operation. We wish we knew how to modulate the prevailing educational, cultural, economic, and legal components which still influence most surgeons to believe that any diseased appendix belongs in the formalin jar.',\n", " 'bBox': {'x': 77, 'y': 165, 'w': 457.89, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Operation',\n", " 'md': '### The Operation',\n", " 'bBox': {'x': 86, 'y': 204, 'w': 400.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The point of greatest tenderness is, in the average adult, almost exactly 2 inches from the anterior iliac spine, on a line drawn from this process through the umbilicus. — Charles McBurney\\n\\nThe appendix is generally attached to the cecum. — Mark M. Ravitch',\n", " 'md': 'The point of greatest tenderness is, in the average adult, almost exactly 2 inches from the anterior iliac spine, on a line drawn from this process through the umbilicus. — Charles McBurney\\n\\nThe appendix is generally attached to the cecum. — Mark M. Ravitch',\n", " 'bBox': {'x': 108, 'y': 204, 'w': 323.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'When to Operate?',\n", " 'md': '### When to Operate?',\n", " 'bBox': {'x': 86, 'y': 685, 'w': 139.76, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 387,\n", " 'text': ' You don’t have to rush to the operating room as soon as possible\\nwith each patient diagnosed with AA. Obviously, if your patient is\\nseptic with rapid respiration and tachycardia or has impressive abdominal\\nfindings (suggesting a perforation), then the patient should receive\\noptimal resuscitation while you start antibiotic treatment, and then you\\nshould operate without delay. Otherwise, you can safely defer an\\noperation to daytime — I do not recall having removed a non-perforated\\nappendix after midnight; except in young children of course. You do not\\nrush to the operating room with acute diverticulitis ( Chapter 28), so\\nwhat’s the difference?\\n\\n This is yet another example of the ‘working environment bias’ that so much affects the approach\\n to AA (and other surgical conditions) in different, ‘real world’ situations. When our chief resident\\n has to deal with 3-5 cases of AA per night, most of the activity, even for non-perforated\\n appendicitis, will take place after midnight — but before 8am when the elective list starts.\\n Danny\\n\\n Open versus laparoscopic approach\\n\\n As pointed out above, the liberal use of diagnostic laparoscopy for\\nsuspected AA leads to a high incidence of unnecessary, invasive and\\nnon-therapeutic abdominal exploration — procedures that are not free of\\ncomplications — which commonly end with an appendectomy even if the\\nappendix is ‘normal’. But what about laparoscopic appendectomy\\n(LA) if the diagnosis has been established? The voluminous\\nliterature on this controversy can be summarized like this:\\ncompared to the open procedure, LA is associated with better\\ncosmesis, some reduction in postoperative pain, marginally earlier\\ndischarge and a lower incidence of wound infection. ħowever, LA is\\nassociated with a higher risk of postoperative intra-abdominal\\ncollections/abscesses and other rare, but serious, complications like\\nintestinal and vascular injuries. Concerning costs, the money saved by an\\nearlier discharge after LA is spent on a more expensive and longer\\nprocedure. We cannot therefore declare a winner between these\\nmethods, so the choice depends on the preferences of the surgeon and\\nthe patient and the local situation. LA may, however, have a clear',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nYou don’t have to rush to the operating room as soon as possible with each patient diagnosed with AA. Obviously, if your patient is septic with rapid respiration and tachycardia or has impressive abdominal findings (suggesting a perforation), then the patient should receive optimal resuscitation while you start antibiotic treatment, and then you should operate without delay. Otherwise, you can safely defer an operation to daytime — I do not recall having removed a non-perforated appendix after midnight; except in young children of course. You do not rush to the operating room with acute diverticulitis (Chapter 28), so what’s the difference?\\n\\nThis is yet another example of the ‘working environment bias’ that so much affects the approach to AA (and other surgical conditions) in different, ‘real world’ situations. When our chief resident has to deal with 3-5 cases of AA per night, most of the activity, even for non-perforated appendicitis, will take place after midnight — but before 8am when the elective list starts. Danny\\n\\n### Open versus laparoscopic approach\\n\\nAs pointed out above, the liberal use of diagnostic laparoscopy for suspected AA leads to a high incidence of unnecessary, invasive and non-therapeutic abdominal exploration — procedures that are not free of complications — which commonly end with an appendectomy even if the appendix is ‘normal’. But what about laparoscopic appendectomy (LA) if the diagnosis has been established? The voluminous literature on this controversy can be summarized like this: compared to the open procedure, LA is associated with better cosmesis, some reduction in postoperative pain, marginally earlier discharge and a lower incidence of wound infection. However, LA is associated with a higher risk of postoperative intra-abdominal collections/abscesses and other rare, but serious, complications like intestinal and vascular injuries. Concerning costs, the money saved by an earlier discharge after LA is spent on a more expensive and longer procedure. We cannot therefore declare a winner between these methods, so the choice depends on the preferences of the surgeon and the patient and the local situation. LA may, however, have a clear...\\n\\n## Image Identification and Description\\n\\n*No images or graphs were identified on this page.*\\n\\n## Summary\\n\\nThe text discusses the management of patients diagnosed with acute appendicitis (AA), emphasizing the importance of not rushing to surgery unless there are severe symptoms. It also contrasts open and laparoscopic appendectomy, highlighting the pros and cons of each approach, including recovery times, complications, and costs.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'You don’t have to rush to the operating room as soon as possible with each patient diagnosed with AA. Obviously, if your patient is septic with rapid respiration and tachycardia or has impressive abdominal findings (suggesting a perforation), then the patient should receive optimal resuscitation while you start antibiotic treatment, and then you should operate without delay. Otherwise, you can safely defer an operation to daytime — I do not recall having removed a non-perforated appendix after midnight; except in young children of course. You do not rush to the operating room with acute diverticulitis (Chapter 28), so what’s the difference?\\n\\nThis is yet another example of the ‘working environment bias’ that so much affects the approach to AA (and other surgical conditions) in different, ‘real world’ situations. When our chief resident has to deal with 3-5 cases of AA per night, most of the activity, even for non-perforated appendicitis, will take place after midnight — but before 8am when the elective list starts. Danny',\n", " 'md': 'You don’t have to rush to the operating room as soon as possible with each patient diagnosed with AA. Obviously, if your patient is septic with rapid respiration and tachycardia or has impressive abdominal findings (suggesting a perforation), then the patient should receive optimal resuscitation while you start antibiotic treatment, and then you should operate without delay. Otherwise, you can safely defer an operation to daytime — I do not recall having removed a non-perforated appendix after midnight; except in young children of course. You do not rush to the operating room with acute diverticulitis (Chapter 28), so what’s the difference?\\n\\nThis is yet another example of the ‘working environment bias’ that so much affects the approach to AA (and other surgical conditions) in different, ‘real world’ situations. When our chief resident has to deal with 3-5 cases of AA per night, most of the activity, even for non-perforated appendicitis, will take place after midnight — but before 8am when the elective list starts. Danny',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Open versus laparoscopic approach',\n", " 'md': '### Open versus laparoscopic approach',\n", " 'bBox': {'x': 86, 'y': 404, 'w': 286.01, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As pointed out above, the liberal use of diagnostic laparoscopy for suspected AA leads to a high incidence of unnecessary, invasive and non-therapeutic abdominal exploration — procedures that are not free of complications — which commonly end with an appendectomy even if the appendix is ‘normal’. But what about laparoscopic appendectomy (LA) if the diagnosis has been established? The voluminous literature on this controversy can be summarized like this: compared to the open procedure, LA is associated with better cosmesis, some reduction in postoperative pain, marginally earlier discharge and a lower incidence of wound infection. However, LA is associated with a higher risk of postoperative intra-abdominal collections/abscesses and other rare, but serious, complications like intestinal and vascular injuries. Concerning costs, the money saved by an earlier discharge after LA is spent on a more expensive and longer procedure. We cannot therefore declare a winner between these methods, so the choice depends on the preferences of the surgeon and the patient and the local situation. LA may, however, have a clear...',\n", " 'md': 'As pointed out above, the liberal use of diagnostic laparoscopy for suspected AA leads to a high incidence of unnecessary, invasive and non-therapeutic abdominal exploration — procedures that are not free of complications — which commonly end with an appendectomy even if the appendix is ‘normal’. But what about laparoscopic appendectomy (LA) if the diagnosis has been established? The voluminous literature on this controversy can be summarized like this: compared to the open procedure, LA is associated with better cosmesis, some reduction in postoperative pain, marginally earlier discharge and a lower incidence of wound infection. However, LA is associated with a higher risk of postoperative intra-abdominal collections/abscesses and other rare, but serious, complications like intestinal and vascular injuries. Concerning costs, the money saved by an earlier discharge after LA is spent on a more expensive and longer procedure. We cannot therefore declare a winner between these methods, so the choice depends on the preferences of the surgeon and the patient and the local situation. LA may, however, have a clear...',\n", " 'bBox': {'x': 72, 'y': 473, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or graphs were identified on this page.*',\n", " 'md': '*No images or graphs were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the management of patients diagnosed with acute appendicitis (AA), emphasizing the importance of not rushing to surgery unless there are severe symptoms. It also contrasts open and laparoscopic appendectomy, highlighting the pros and cons of each approach, including recovery times, complications, and costs.\\n```',\n", " 'md': 'The text discusses the management of patients diagnosed with acute appendicitis (AA), emphasizing the importance of not rushing to surgery unless there are severe symptoms. It also contrasts open and laparoscopic appendectomy, highlighting the pros and cons of each approach, including recovery times, complications, and costs.\\n```',\n", " 'bBox': {'x': 155, 'y': 605, 'w': 29.59, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 388,\n", " 'text': 'advantage in the very obese patient, by avoiding a large incision. For\\ndetails about LA and another perspective see the section at the end of\\nthis chapter.\\n\\n Technical points for open appendectomy\\n\\n Did anybody ever teach you how to do an open ‘appy’? Even if you\\nare a ‘lap-appy’ afficionado do not deprive yourself of the skills (and\\npleasures) of being able to remove a diseased appendix through a small\\nright lower quadrant incision. Such skills may be useful when\\n‘converting’ a difficult LA — and no, a midline incision is usually not\\nnecessary in that situation!\\n\\n It is possible that you have done your share of open appendectomies\\nalready as an intern. ħowever, having seen many surgeons transform a\\nroutine appendectomy to an elaborate operation resembling a Whipple’s\\nprocedure, we remind you of the KISS principle — keep it simple, stupid!\\nħere are a few tips:\\n\\n • Incision: you do not need the long unsightly oblique incision —\\n except in the muscular young man whose possible retrocecal\\n appendix may be unreachable through a transverse hole. Use a\\n transverse one! A common error is to place it too medially over the\\n rectus sheath. If you center the incision slightly lateral to the point of\\n McBurney you will in most cases get it right. Incise the fascia, split\\n the muscles and open the peritoneum. Start with a small incision\\n about 4-5cm long; it can be always extended to each side by\\n cutting the lateral edge of the rectus fascia and/or muscle.\\n • Appendectomy: you can remove the appendix in an antegrade or\\n retrograde fashion but there is no need to invert the stump unless\\n you are hooked on useless rituals. Just ligate or suture-transfix the\\n appendix at its base and chop off the rest. When the tissue is friable,\\n overrun the divided meso-appendix with a running suture. The\\n common fetishes of painting the stump with Betadine® or burning it\\n with diathermy are ridiculous. If the appendix has perforated just\\n at its base you have to include some healthy cecal wall to\\n secure the stump safely — just place a linear stapler across the',\n", " 'md': '```markdown\\n## Technical Points for Open Appendectomy\\n\\nDid anybody ever teach you how to do an open ‘appy’? Even if you are a ‘lap-appy’ aficionado, do not deprive yourself of the skills (and pleasures) of being able to remove a diseased appendix through a small right lower quadrant incision. Such skills may be useful when ‘converting’ a difficult LA — and no, a midline incision is usually not necessary in that situation!\\n\\nIt is possible that you have done your share of open appendectomies already as an intern. However, having seen many surgeons transform a routine appendectomy into an elaborate operation resembling a Whipple’s procedure, we remind you of the KISS principle — keep it simple, stupid! Here are a few tips:\\n\\n- **Incision**: You do not need the long unsightly oblique incision — except in the muscular young man whose possible retrocecal appendix may be unreachable through a transverse hole. Use a transverse one! A common error is to place it too medially over the rectus sheath. If you center the incision slightly lateral to the point of McBurney, you will in most cases get it right. Incise the fascia, split the muscles, and open the peritoneum. Start with a small incision about 4-5 cm long; it can always be extended to each side by cutting the lateral edge of the rectus fascia and/or muscle.\\n\\n- **Appendectomy**: You can remove the appendix in an antegrade or retrograde fashion, but there is no need to invert the stump unless you are hooked on useless rituals. Just ligate or suture-transfix the appendix at its base and chop off the rest. When the tissue is friable, overrun the divided meso-appendix with a running suture. The common fetishes of painting the stump with Betadine® or burning it with diathermy are ridiculous. If the appendix has perforated just at its base, you have to include some healthy cecal wall to secure the stump safely — just place a linear stapler across the...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Technical Points for Open Appendectomy',\n", " 'md': '## Technical Points for Open Appendectomy',\n", " 'bBox': {'x': 86, 'y': 162, 'w': 321.53, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Did anybody ever teach you how to do an open ‘appy’? Even if you are a ‘lap-appy’ aficionado, do not deprive yourself of the skills (and pleasures) of being able to remove a diseased appendix through a small right lower quadrant incision. Such skills may be useful when ‘converting’ a difficult LA — and no, a midline incision is usually not necessary in that situation!\\n\\nIt is possible that you have done your share of open appendectomies already as an intern. However, having seen many surgeons transform a routine appendectomy into an elaborate operation resembling a Whipple’s procedure, we remind you of the KISS principle — keep it simple, stupid! Here are a few tips:\\n\\n- **Incision**: You do not need the long unsightly oblique incision — except in the muscular young man whose possible retrocecal appendix may be unreachable through a transverse hole. Use a transverse one! A common error is to place it too medially over the rectus sheath. If you center the incision slightly lateral to the point of McBurney, you will in most cases get it right. Incise the fascia, split the muscles, and open the peritoneum. Start with a small incision about 4-5 cm long; it can always be extended to each side by cutting the lateral edge of the rectus fascia and/or muscle.\\n\\n- **Appendectomy**: You can remove the appendix in an antegrade or retrograde fashion, but there is no need to invert the stump unless you are hooked on useless rituals. Just ligate or suture-transfix the appendix at its base and chop off the rest. When the tissue is friable, overrun the divided meso-appendix with a running suture. The common fetishes of painting the stump with Betadine® or burning it with diathermy are ridiculous. If the appendix has perforated just at its base, you have to include some healthy cecal wall to secure the stump safely — just place a linear stapler across the...\\n```',\n", " 'md': 'Did anybody ever teach you how to do an open ‘appy’? Even if you are a ‘lap-appy’ aficionado, do not deprive yourself of the skills (and pleasures) of being able to remove a diseased appendix through a small right lower quadrant incision. Such skills may be useful when ‘converting’ a difficult LA — and no, a midline incision is usually not necessary in that situation!\\n\\nIt is possible that you have done your share of open appendectomies already as an intern. However, having seen many surgeons transform a routine appendectomy into an elaborate operation resembling a Whipple’s procedure, we remind you of the KISS principle — keep it simple, stupid! Here are a few tips:\\n\\n- **Incision**: You do not need the long unsightly oblique incision — except in the muscular young man whose possible retrocecal appendix may be unreachable through a transverse hole. Use a transverse one! A common error is to place it too medially over the rectus sheath. If you center the incision slightly lateral to the point of McBurney, you will in most cases get it right. Incise the fascia, split the muscles, and open the peritoneum. Start with a small incision about 4-5 cm long; it can always be extended to each side by cutting the lateral edge of the rectus fascia and/or muscle.\\n\\n- **Appendectomy**: You can remove the appendix in an antegrade or retrograde fashion, but there is no need to invert the stump unless you are hooked on useless rituals. Just ligate or suture-transfix the appendix at its base and chop off the rest. When the tissue is friable, overrun the divided meso-appendix with a running suture. The common fetishes of painting the stump with Betadine® or burning it with diathermy are ridiculous. If the appendix has perforated just at its base, you have to include some healthy cecal wall to secure the stump safely — just place a linear stapler across the...\\n```',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.83, 'h': 17.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 389,\n", " 'text': ' cecum proximal to the perforation and fire. If you do not have a\\n stapler then do it by hand — close the cecal defect with your best\\n anastomotic technique!\\n• Peritoneal toilet: just aspirate and mop the fluid (do not forget the\\n pelvis). Peritoneal lavage is useless or even harmful — responsible\\n for those fluid collections that you see on post-op imaging.\\n• Hemostasis: be meticulous! The partial evisceration of the cecum\\n places the blood supply under tension and may interrupt the blood\\n flow, thus concealing bleeding. When the cecum is repositioned, its\\n circulation recovers and bleeding from the divided artery or the\\n meso-appendix may declare itself. Thus, always check the stump\\n of the meso-appendix after returning the cecum to its natural\\n position. Place some gauze into the depths of the wound: if it\\n comes out pink, you have to recheck the hemostasis.\\n• Microbiological culture: taking it in this case is unnecessary and\\n wasteful unless the operation is after failed antibiotic treatment (\\n Chapter 13).\\n• Drains: are very (very!) seldom necessary after appendectomy\\n (no, I am not kidding) and have also been shown to be harmful (\\n Chapter 39).\\n• Closure: theoretically, closing the peritoneum is unnecessary\\n because it adds no strength to the repair, and we know that the\\n peritoneum repairs itself within 48 hours. ħowever, this step ‘covers’\\n the bulging viscera, facilitating careful closure of the abdominal wall\\n layers and may thus help prevent interstitial hernias. Next the\\n muscles are approximated loosely with a few sutures to obliterate\\n dead space; the fascia is closed with a running suture. The\\n subcutaneous layer, if thick, may be approximated with a few fine\\n sutures. Close the skin in continuous subcuticular fashion, even in\\n complicated cases. Use absorbable sutures and avoid including too\\n much tissue, as this may cause necrosis and infection. Some still\\n advocate secondary wound closure in complicated appendicitis.\\n This may prevent a few wound infections at the cost of prolonged\\n suffering from changes of dressings and further manipulations and\\n an ugly scar for all patients. This is not worth the cost as explained\\n in Chapters 40 and 50.\\n\\n The surgeon who can describe the extent of an appendiceal',\n", " 'md': '```markdown\\n## Surgical Considerations for Appendectomy\\n\\n- **Cecal Closure**: If you do not have a stapler, then do it by hand — close the cecal defect with your best anastomotic technique!\\n\\n- **Peritoneal Toilet**: Just aspirate and mop the fluid (do not forget the pelvis). Peritoneal lavage is useless or even harmful — responsible for those fluid collections that you see on post-op imaging.\\n\\n- **Hemostasis**: Be meticulous! The partial evisceration of the cecum places the blood supply under tension and may interrupt the blood flow, thus concealing bleeding. When the cecum is repositioned, its circulation recovers and bleeding from the divided artery or the meso-appendix may declare itself. Thus, always check the stump of the meso-appendix after returning the cecum to its natural position. Place some gauze into the depths of the wound: if it comes out pink, you have to recheck the hemostasis.\\n\\n- **Microbiological Culture**: Taking it in this case is unnecessary and wasteful unless the operation is after failed antibiotic treatment (Chapter 13).\\n\\n- **Drains**: Are very (very!) seldom necessary after appendectomy (no, I am not kidding) and have also been shown to be harmful (Chapter 39).\\n\\n- **Closure**: Theoretically, closing the peritoneum is unnecessary because it adds no strength to the repair, and we know that the peritoneum repairs itself within 48 hours. However, this step ‘covers’ the bulging viscera, facilitating careful closure of the abdominal wall layers and may thus help prevent interstitial hernias. Next, the muscles are approximated loosely with a few sutures to obliterate dead space; the fascia is closed with a running suture. The subcutaneous layer, if thick, may be approximated with a few fine sutures. Close the skin in continuous subcuticular fashion, even in complicated cases. Use absorbable sutures and avoid including too much tissue, as this may cause necrosis and infection. Some still advocate secondary wound closure in complicated appendicitis. This may prevent a few wound infections at the cost of prolonged suffering from changes of dressings and further manipulations and an ugly scar for all patients. This is not worth the cost as explained in Chapters 40 and 50.\\n\\nThe surgeon who can describe the extent of an appendiceal...\\n```\\n\\n*Note: There are no figures, images, or tables present in the extracted text.*',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Considerations for Appendectomy',\n", " 'md': '## Surgical Considerations for Appendectomy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Cecal Closure**: If you do not have a stapler, then do it by hand — close the cecal defect with your best anastomotic technique!\\n\\n- **Peritoneal Toilet**: Just aspirate and mop the fluid (do not forget the pelvis). Peritoneal lavage is useless or even harmful — responsible for those fluid collections that you see on post-op imaging.\\n\\n- **Hemostasis**: Be meticulous! The partial evisceration of the cecum places the blood supply under tension and may interrupt the blood flow, thus concealing bleeding. When the cecum is repositioned, its circulation recovers and bleeding from the divided artery or the meso-appendix may declare itself. Thus, always check the stump of the meso-appendix after returning the cecum to its natural position. Place some gauze into the depths of the wound: if it comes out pink, you have to recheck the hemostasis.\\n\\n- **Microbiological Culture**: Taking it in this case is unnecessary and wasteful unless the operation is after failed antibiotic treatment (Chapter 13).\\n\\n- **Drains**: Are very (very!) seldom necessary after appendectomy (no, I am not kidding) and have also been shown to be harmful (Chapter 39).\\n\\n- **Closure**: Theoretically, closing the peritoneum is unnecessary because it adds no strength to the repair, and we know that the peritoneum repairs itself within 48 hours. However, this step ‘covers’ the bulging viscera, facilitating careful closure of the abdominal wall layers and may thus help prevent interstitial hernias. Next, the muscles are approximated loosely with a few sutures to obliterate dead space; the fascia is closed with a running suture. The subcutaneous layer, if thick, may be approximated with a few fine sutures. Close the skin in continuous subcuticular fashion, even in complicated cases. Use absorbable sutures and avoid including too much tissue, as this may cause necrosis and infection. Some still advocate secondary wound closure in complicated appendicitis. This may prevent a few wound infections at the cost of prolonged suffering from changes of dressings and further manipulations and an ugly scar for all patients. This is not worth the cost as explained in Chapters 40 and 50.\\n\\nThe surgeon who can describe the extent of an appendiceal...\\n```\\n\\n*Note: There are no figures, images, or tables present in the extracted text.*',\n", " 'md': '- **Cecal Closure**: If you do not have a stapler, then do it by hand — close the cecal defect with your best anastomotic technique!\\n\\n- **Peritoneal Toilet**: Just aspirate and mop the fluid (do not forget the pelvis). Peritoneal lavage is useless or even harmful — responsible for those fluid collections that you see on post-op imaging.\\n\\n- **Hemostasis**: Be meticulous! The partial evisceration of the cecum places the blood supply under tension and may interrupt the blood flow, thus concealing bleeding. When the cecum is repositioned, its circulation recovers and bleeding from the divided artery or the meso-appendix may declare itself. Thus, always check the stump of the meso-appendix after returning the cecum to its natural position. Place some gauze into the depths of the wound: if it comes out pink, you have to recheck the hemostasis.\\n\\n- **Microbiological Culture**: Taking it in this case is unnecessary and wasteful unless the operation is after failed antibiotic treatment (Chapter 13).\\n\\n- **Drains**: Are very (very!) seldom necessary after appendectomy (no, I am not kidding) and have also been shown to be harmful (Chapter 39).\\n\\n- **Closure**: Theoretically, closing the peritoneum is unnecessary because it adds no strength to the repair, and we know that the peritoneum repairs itself within 48 hours. However, this step ‘covers’ the bulging viscera, facilitating careful closure of the abdominal wall layers and may thus help prevent interstitial hernias. Next, the muscles are approximated loosely with a few sutures to obliterate dead space; the fascia is closed with a running suture. The subcutaneous layer, if thick, may be approximated with a few fine sutures. Close the skin in continuous subcuticular fashion, even in complicated cases. Use absorbable sutures and avoid including too much tissue, as this may cause necrosis and infection. Some still advocate secondary wound closure in complicated appendicitis. This may prevent a few wound infections at the cost of prolonged suffering from changes of dressings and further manipulations and an ugly scar for all patients. This is not worth the cost as explained in Chapters 40 and 50.\\n\\nThe surgeon who can describe the extent of an appendiceal...\\n```\\n\\n*Note: There are no figures, images, or tables present in the extracted text.*',\n", " 'bBox': {'x': 100, 'y': 119, 'w': 436.97, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}, {'text': ''}, {'text': ''}]},\n", " {'page': 390,\n", " 'text': ' peritonitis has convicted himself of performing an improper\\n operation.\\n Mark M. Ravitch\\n\\n (If you do not understand this aphorism please feel free to email the\\nEditors.)\\n\\n Special considerations\\n\\n The ‘white’ appendix\\n What should you do when the appendix proves to be pristine?\\nWell, you can rub it allowing the pathologist to diagnose mild acute\\ninflammation (just kidding). The classic dictum is that whenever an\\nabdominal appendectomy incision exists the appendix should be\\nremoved in order not to confuse matters in the future. What about a\\nnormal appendix visualized at laparoscopy? Should it also be\\nremoved? The emerging consensus is to leave it alone, informing the\\npatient or the parents that the appendix has been left in situ. As we\\nmentioned above, the problem is that most surgeons are reluctant to\\nfollow such an (alleged) consensus. What about you?\\n\\n Obviously, when the appendix appears normal (very unlikely if you\\nhave followed our diagnostic approach or obtained a CT scan) you\\nshould search for alternative diagnoses such as Meckel’s diverticulitis (\\nChapter 36), adnexal pathology ( Chapter 35), perforated cecal\\ndiverticulitis ( Chapter 28), or mesenteric lymphadenitis (whatever that\\nis). In most instances, however, you’ll find nothing. What should you do if\\nfoul-smelling, murky, or bile-stained peritoneal fluid is encountered,\\nsuggesting a serious alternative pathology elsewhere? If the source of\\nthe pathology is not evident you could do a diagnostic laparoscopy\\nthrough the partly closed gridiron incision. If it is evident then close the\\nincision and place a new one where the action is. Do not try to do a colon\\nresection through an extended transverse incision. Bile should guide you\\ninto the upper abdomen. Feces or its odor direct you towards the\\nsigmoid. Think of perforated duodenal ulcer and intestinal perforation.',\n", " 'md': '```markdown\\n# Special Considerations\\n\\n## The ‘White’ Appendix\\n\\nWhat should you do when the appendix proves to be pristine? Well, you can rub it allowing the pathologist to diagnose mild acute inflammation (just kidding). The classic dictum is that whenever an abdominal appendectomy incision exists, the appendix should be removed in order not to confuse matters in the future.\\n\\nWhat about a normal appendix visualized at laparoscopy? Should it also be removed? The emerging consensus is to leave it alone, informing the patient or the parents that the appendix has been left in situ. As we mentioned above, the problem is that most surgeons are reluctant to follow such an (alleged) consensus. What about you?\\n\\nObviously, when the appendix appears normal (very unlikely if you have followed our diagnostic approach or obtained a CT scan), you should search for alternative diagnoses such as Meckel’s diverticulitis (Chapter 36), adnexal pathology (Chapter 35), perforated cecal diverticulitis (Chapter 28), or mesenteric lymphadenitis (whatever that is). In most instances, however, you’ll find nothing.\\n\\nWhat should you do if foul-smelling, murky, or bile-stained peritoneal fluid is encountered, suggesting a serious alternative pathology elsewhere? If the source of the pathology is not evident, you could do a diagnostic laparoscopy through the partly closed gridiron incision. If it is evident, then close the incision and place a new one where the action is. Do not try to do a colon resection through an extended transverse incision. Bile should guide you into the upper abdomen. Feces or its odor direct you towards the sigmoid. Think of perforated duodenal ulcer and intestinal perforation.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Special Considerations',\n", " 'md': '# Special Considerations',\n", " 'bBox': {'x': 86, 'y': 221, 'w': 180.24, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The ‘White’ Appendix',\n", " 'md': '## The ‘White’ Appendix',\n", " 'bBox': {'x': 86, 'y': 260, 'w': 140.93, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'What should you do when the appendix proves to be pristine? Well, you can rub it allowing the pathologist to diagnose mild acute inflammation (just kidding). The classic dictum is that whenever an abdominal appendectomy incision exists, the appendix should be removed in order not to confuse matters in the future.\\n\\nWhat about a normal appendix visualized at laparoscopy? Should it also be removed? The emerging consensus is to leave it alone, informing the patient or the parents that the appendix has been left in situ. As we mentioned above, the problem is that most surgeons are reluctant to follow such an (alleged) consensus. What about you?\\n\\nObviously, when the appendix appears normal (very unlikely if you have followed our diagnostic approach or obtained a CT scan), you should search for alternative diagnoses such as Meckel’s diverticulitis (Chapter 36), adnexal pathology (Chapter 35), perforated cecal diverticulitis (Chapter 28), or mesenteric lymphadenitis (whatever that is). In most instances, however, you’ll find nothing.\\n\\nWhat should you do if foul-smelling, murky, or bile-stained peritoneal fluid is encountered, suggesting a serious alternative pathology elsewhere? If the source of the pathology is not evident, you could do a diagnostic laparoscopy through the partly closed gridiron incision. If it is evident, then close the incision and place a new one where the action is. Do not try to do a colon resection through an extended transverse incision. Bile should guide you into the upper abdomen. Feces or its odor direct you towards the sigmoid. Think of perforated duodenal ulcer and intestinal perforation.\\n```',\n", " 'md': 'What should you do when the appendix proves to be pristine? Well, you can rub it allowing the pathologist to diagnose mild acute inflammation (just kidding). The classic dictum is that whenever an abdominal appendectomy incision exists, the appendix should be removed in order not to confuse matters in the future.\\n\\nWhat about a normal appendix visualized at laparoscopy? Should it also be removed? The emerging consensus is to leave it alone, informing the patient or the parents that the appendix has been left in situ. As we mentioned above, the problem is that most surgeons are reluctant to follow such an (alleged) consensus. What about you?\\n\\nObviously, when the appendix appears normal (very unlikely if you have followed our diagnostic approach or obtained a CT scan), you should search for alternative diagnoses such as Meckel’s diverticulitis (Chapter 36), adnexal pathology (Chapter 35), perforated cecal diverticulitis (Chapter 28), or mesenteric lymphadenitis (whatever that is). In most instances, however, you’ll find nothing.\\n\\nWhat should you do if foul-smelling, murky, or bile-stained peritoneal fluid is encountered, suggesting a serious alternative pathology elsewhere? If the source of the pathology is not evident, you could do a diagnostic laparoscopy through the partly closed gridiron incision. If it is evident, then close the incision and place a new one where the action is. Do not try to do a colon resection through an extended transverse incision. Bile should guide you into the upper abdomen. Feces or its odor direct you towards the sigmoid. Think of perforated duodenal ulcer and intestinal perforation.\\n```',\n", " 'bBox': {'x': 72, 'y': 430, 'w': 467.96, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 36), adnexal pathology ( diverticulitis ('},\n", " {'text': ' Chapter 28), or mesenteric lymphadenitis (whatever that'},\n", " {'text': 'is). In most instances, however, you’ll find nothing. What should you do if'}]},\n", " {'page': 391,\n", " 'text': ' I did a few cecal resections for perforated cecal diverticulitis and sigmoid resections for sigmoid\\n diverticulitis through an extended RLQ incision. But again, in this day and age, a pre-\\n operative CT (or laparoscopy) would have saved you all those old-fashioned headaches.\\n Moshe\\n\\n Postoperative appendiceal stump phlegmon/abscess and stump\\n appendicitis\\n Your patient had an uneventful appendectomy for acute appendicitis\\nfollowing which he happily went home. Seven days later he presents with\\nright lower quadrant pain, a temperature and a high white cell count. The\\nwound looks OK. This may be a postoperative abdominal abscess or an\\nappendix stump phlegmon. Nowadays the diagnosis is simple — a CT\\nwill demonstrate an abscess or a phlegmon which involves the cecum.\\nBoth are cured by a few days of antibiotic therapy but an abscess\\nmay need percutaneous drainage, especially if larger than 5cm.\\n\\n With stump appendicitis be aware that patients can develop classic\\nacute appendicitis at any time after appendectomy. ħistorically this\\nfollowed appendectomy for complicated appendicitis, often by a relatively\\ninexperienced family doctor/surgeon. It is now becoming more common\\nin the era of laparoscopic appendectomy, where during the procedure\\nsurgeons may misidentify the cecal base of the appendix and\\nconsequently leave a long appendiceal stump — prone to stump\\nappendicitis and requiring a re-appendectomy. Few ER or family\\npractice docs realize that post-appendectomy patients can (rarely)\\nsuffer from acute appendicitis — do explain it to them!\\n\\n Appendiceal mass (phlegmon)\\n Typically, patients with an appendiceal mass present late in the course\\nof the disease, and this should be suspected when symptoms have\\npersisted for more than 3 days. Occasionally, they report a spontaneous\\nimprovement in their symptoms, reflecting localization of the inflammatory\\nprocess. On clinical examination you will find a right iliac fossa\\nmass. Overlying tenderness or obesity may obscure the presence of the\\nmass. Therefore, suspect an appendiceal mass in the ‘late presenters’ or\\nthose with an atypical smoldering picture. When palpation is not',\n", " 'md': '```markdown\\n# Postoperative Complications in Appendectomy\\n\\n## Text\\n\\nI did a few cecal resections for perforated cecal diverticulitis and sigmoid resections for sigmoid diverticulitis through an extended RLQ incision. But again, in this day and age, a pre-operative CT (or laparoscopy) would have saved you all those old-fashioned headaches. Moshe\\n\\n### Postoperative appendiceal stump phlegmon/abscess and stump appendicitis\\n\\nYour patient had an uneventful appendectomy for acute appendicitis following which he happily went home. Seven days later he presents with right lower quadrant pain, a temperature and a high white cell count. The wound looks OK. This may be a postoperative abdominal abscess or an appendix stump phlegmon. Nowadays the diagnosis is simple — a CT will demonstrate an abscess or a phlegmon which involves the cecum. Both are cured by a few days of antibiotic therapy but an abscess may need percutaneous drainage, especially if larger than 5cm.\\n\\nWith stump appendicitis be aware that patients can develop classic acute appendicitis at any time after appendectomy. Historically this followed appendectomy for complicated appendicitis, often by a relatively inexperienced family doctor/surgeon. It is now becoming more common in the era of laparoscopic appendectomy, where during the procedure surgeons may misidentify the cecal base of the appendix and consequently leave a long appendiceal stump — prone to stump appendicitis and requiring a re-appendectomy. Few ER or family practice docs realize that post-appendectomy patients can (rarely) suffer from acute appendicitis — do explain it to them!\\n\\n### Appendiceal mass (phlegmon)\\n\\nTypically, patients with an appendiceal mass present late in the course of the disease, and this should be suspected when symptoms have persisted for more than 3 days. Occasionally, they report a spontaneous improvement in their symptoms, reflecting localization of the inflammatory process. On clinical examination you will find a right iliac fossa mass. Overlying tenderness or obesity may obscure the presence of the mass. Therefore, suspect an appendiceal mass in the ‘late presenters’ or those with an atypical smoldering picture. When palpation is not...\\n\\n## Images\\n\\n*No images were identified on this page.*\\n\\n## Formulas\\n\\n*No formulas were identified on this page.*\\n\\n## Tables\\n\\n*No tables were identified on this page.*\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Postoperative Complications in Appendectomy',\n", " 'md': '# Postoperative Complications in Appendectomy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'I did a few cecal resections for perforated cecal diverticulitis and sigmoid resections for sigmoid diverticulitis through an extended RLQ incision. But again, in this day and age, a pre-operative CT (or laparoscopy) would have saved you all those old-fashioned headaches. Moshe',\n", " 'md': 'I did a few cecal resections for perforated cecal diverticulitis and sigmoid resections for sigmoid diverticulitis through an extended RLQ incision. But again, in this day and age, a pre-operative CT (or laparoscopy) would have saved you all those old-fashioned headaches. Moshe',\n", " 'bBox': {'x': 77, 'y': 91, 'w': 457.46, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Postoperative appendiceal stump phlegmon/abscess and stump appendicitis',\n", " 'md': '### Postoperative appendiceal stump phlegmon/abscess and stump appendicitis',\n", " 'bBox': {'x': 86, 'y': 214, 'w': 83.92, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Your patient had an uneventful appendectomy for acute appendicitis following which he happily went home. Seven days later he presents with right lower quadrant pain, a temperature and a high white cell count. The wound looks OK. This may be a postoperative abdominal abscess or an appendix stump phlegmon. Nowadays the diagnosis is simple — a CT will demonstrate an abscess or a phlegmon which involves the cecum. Both are cured by a few days of antibiotic therapy but an abscess may need percutaneous drainage, especially if larger than 5cm.\\n\\nWith stump appendicitis be aware that patients can develop classic acute appendicitis at any time after appendectomy. Historically this followed appendectomy for complicated appendicitis, often by a relatively inexperienced family doctor/surgeon. It is now becoming more common in the era of laparoscopic appendectomy, where during the procedure surgeons may misidentify the cecal base of the appendix and consequently leave a long appendiceal stump — prone to stump appendicitis and requiring a re-appendectomy. Few ER or family practice docs realize that post-appendectomy patients can (rarely) suffer from acute appendicitis — do explain it to them!',\n", " 'md': 'Your patient had an uneventful appendectomy for acute appendicitis following which he happily went home. Seven days later he presents with right lower quadrant pain, a temperature and a high white cell count. The wound looks OK. This may be a postoperative abdominal abscess or an appendix stump phlegmon. Nowadays the diagnosis is simple — a CT will demonstrate an abscess or a phlegmon which involves the cecum. Both are cured by a few days of antibiotic therapy but an abscess may need percutaneous drainage, especially if larger than 5cm.\\n\\nWith stump appendicitis be aware that patients can develop classic acute appendicitis at any time after appendectomy. Historically this followed appendectomy for complicated appendicitis, often by a relatively inexperienced family doctor/surgeon. It is now becoming more common in the era of laparoscopic appendectomy, where during the procedure surgeons may misidentify the cecal base of the appendix and consequently leave a long appendiceal stump — prone to stump appendicitis and requiring a re-appendectomy. Few ER or family practice docs realize that post-appendectomy patients can (rarely) suffer from acute appendicitis — do explain it to them!',\n", " 'bBox': {'x': 72, 'y': 214, 'w': 467.9, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Appendiceal mass (phlegmon)',\n", " 'md': '### Appendiceal mass (phlegmon)',\n", " 'bBox': {'x': 86, 'y': 574, 'w': 208.62, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Typically, patients with an appendiceal mass present late in the course of the disease, and this should be suspected when symptoms have persisted for more than 3 days. Occasionally, they report a spontaneous improvement in their symptoms, reflecting localization of the inflammatory process. On clinical examination you will find a right iliac fossa mass. Overlying tenderness or obesity may obscure the presence of the mass. Therefore, suspect an appendiceal mass in the ‘late presenters’ or those with an atypical smoldering picture. When palpation is not...',\n", " 'md': 'Typically, patients with an appendiceal mass present late in the course of the disease, and this should be suspected when symptoms have persisted for more than 3 days. Occasionally, they report a spontaneous improvement in their symptoms, reflecting localization of the inflammatory process. On clinical examination you will find a right iliac fossa mass. Overlying tenderness or obesity may obscure the presence of the mass. Therefore, suspect an appendiceal mass in the ‘late presenters’ or those with an atypical smoldering picture. When palpation is not...',\n", " 'bBox': {'x': 72, 'y': 594, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images were identified on this page.*',\n", " 'md': '*No images were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formulas',\n", " 'md': '## Formulas',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No formulas were identified on this page.*',\n", " 'md': '*No formulas were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No tables were identified on this page.*\\n```',\n", " 'md': '*No tables were identified on this page.*\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 392,\n", " 'text': 'rewarding, obtain a CT scan, which is the best way to document an\\nappendiceal mass. Another indication for CT is associated evidence of\\nundrained pus such as a spiking fever and toxicity, signifying an\\nappendiceal abscess.\\n\\n Why should you distinguish between AA and appendiceal mass or\\nabscess? Because the appendiceal mass (and abscess) can (and\\nshould) be managed non-operatively. You could operate on both, as\\nyou operate on AA, but removal of the appendix involved in an\\ninflammatory mass may be more hazardous than usual, occasionally\\nnecessitating a right hemicolectomy. On the other hand, conservative\\ntreatment with antibiotics leads to resolution of the mass in the vast\\nmajority of cases. Failure of the mass to respond to antibiotics signifies\\nan abscess (rare). CT or ultrasound-guided percutaneous drainage is the\\nmost rational approach ( Chapter 46).\\n\\n I would like to point out that a recent randomized study from our institution in Helsinki,\\n comparing immediate laparoscopic appendectomy to conservative\\n management in patients with appendiceal abscess (Mentula P, et al. Ann\\n Surg 2015), demonstrated immediate surgery to be a safe option — associated with fewer\\n readmissions and additional interventions, and not prolonging hospital stay. The rate of\\n uneventful recovery was 90% following early laparoscopy and 50%\\n after conservative treatment, respectively. Since then we have\\n adopted a new policy: patients with an appendiceal mass (phlegmon or abscess)\\n undergo early ‘day-time’ laparoscopic surgery. The abscess is located with blunt dissection\\n using the suction tip, and is emptied. Any residual appendix that can be found is removed and\\n the stump secured with an endoloop, suture or stapler. So, if you are a great laparoscopist —\\n insert the scope and deal with it! Otherwise do what the others do. Everything in life is\\n controversial. Ari\\n\\n Interval appendectomy\\n As no more than one out of ten patients treated conservatively for\\nappendiceal mass will suffer a recurrence of AA (usually within 1 year\\nand not a complicated attack), the dogma of routine interval\\nappendectomy has become obsolete. In patients over the age of 40',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nRewarding, obtain a CT scan, which is the best way to document an appendiceal mass. Another indication for CT is associated evidence of undrained pus such as a spiking fever and toxicity, signifying an appendiceal abscess.\\n\\nWhy should you distinguish between AA and appendiceal mass or abscess? Because the appendiceal mass (and abscess) can (and should) be managed non-operatively. You could operate on both, as you operate on AA, but removal of the appendix involved in an inflammatory mass may be more hazardous than usual, occasionally necessitating a right hemicolectomy. On the other hand, conservative treatment with antibiotics leads to resolution of the mass in the vast majority of cases. Failure of the mass to respond to antibiotics signifies an abscess (rare). CT or ultrasound-guided percutaneous drainage is the most rational approach (Chapter 46).\\n\\nI would like to point out that a recent randomized study from our institution in Helsinki, comparing immediate laparoscopic appendectomy to conservative management in patients with appendiceal abscess (Mentula P, et al. Ann Surg 2015), demonstrated immediate surgery to be a safe option — associated with fewer readmissions and additional interventions, and not prolonging hospital stay. The rate of uneventful recovery was 90% following early laparoscopy and 50% after conservative treatment, respectively. Since then we have adopted a new policy: patients with an appendiceal mass (phlegmon or abscess) undergo early ‘day-time’ laparoscopic surgery. The abscess is located with blunt dissection using the suction tip, and is emptied. Any residual appendix that can be found is removed and the stump secured with an endoloop, suture or stapler. So, if you are a great laparoscopist — insert the scope and deal with it! Otherwise do what the others do. Everything in life is controversial. Ari\\n\\n### Interval Appendectomy\\n\\nAs no more than one out of ten patients treated conservatively for appendiceal mass will suffer a recurrence of AA (usually within 1 year and not a complicated attack), the dogma of routine interval appendectomy has become obsolete. In patients over the age of 40...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Rewarding, obtain a CT scan, which is the best way to document an appendiceal mass. Another indication for CT is associated evidence of undrained pus such as a spiking fever and toxicity, signifying an appendiceal abscess.\\n\\nWhy should you distinguish between AA and appendiceal mass or abscess? Because the appendiceal mass (and abscess) can (and should) be managed non-operatively. You could operate on both, as you operate on AA, but removal of the appendix involved in an inflammatory mass may be more hazardous than usual, occasionally necessitating a right hemicolectomy. On the other hand, conservative treatment with antibiotics leads to resolution of the mass in the vast majority of cases. Failure of the mass to respond to antibiotics signifies an abscess (rare). CT or ultrasound-guided percutaneous drainage is the most rational approach (Chapter 46).\\n\\nI would like to point out that a recent randomized study from our institution in Helsinki, comparing immediate laparoscopic appendectomy to conservative management in patients with appendiceal abscess (Mentula P, et al. Ann Surg 2015), demonstrated immediate surgery to be a safe option — associated with fewer readmissions and additional interventions, and not prolonging hospital stay. The rate of uneventful recovery was 90% following early laparoscopy and 50% after conservative treatment, respectively. Since then we have adopted a new policy: patients with an appendiceal mass (phlegmon or abscess) undergo early ‘day-time’ laparoscopic surgery. The abscess is located with blunt dissection using the suction tip, and is emptied. Any residual appendix that can be found is removed and the stump secured with an endoloop, suture or stapler. So, if you are a great laparoscopist — insert the scope and deal with it! Otherwise do what the others do. Everything in life is controversial. Ari',\n", " 'md': 'Rewarding, obtain a CT scan, which is the best way to document an appendiceal mass. Another indication for CT is associated evidence of undrained pus such as a spiking fever and toxicity, signifying an appendiceal abscess.\\n\\nWhy should you distinguish between AA and appendiceal mass or abscess? Because the appendiceal mass (and abscess) can (and should) be managed non-operatively. You could operate on both, as you operate on AA, but removal of the appendix involved in an inflammatory mass may be more hazardous than usual, occasionally necessitating a right hemicolectomy. On the other hand, conservative treatment with antibiotics leads to resolution of the mass in the vast majority of cases. Failure of the mass to respond to antibiotics signifies an abscess (rare). CT or ultrasound-guided percutaneous drainage is the most rational approach (Chapter 46).\\n\\nI would like to point out that a recent randomized study from our institution in Helsinki, comparing immediate laparoscopic appendectomy to conservative management in patients with appendiceal abscess (Mentula P, et al. Ann Surg 2015), demonstrated immediate surgery to be a safe option — associated with fewer readmissions and additional interventions, and not prolonging hospital stay. The rate of uneventful recovery was 90% following early laparoscopy and 50% after conservative treatment, respectively. Since then we have adopted a new policy: patients with an appendiceal mass (phlegmon or abscess) undergo early ‘day-time’ laparoscopic surgery. The abscess is located with blunt dissection using the suction tip, and is emptied. Any residual appendix that can be found is removed and the stump secured with an endoloop, suture or stapler. So, if you are a great laparoscopist — insert the scope and deal with it! Otherwise do what the others do. Everything in life is controversial. Ari',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Interval Appendectomy',\n", " 'md': '### Interval Appendectomy',\n", " 'bBox': {'x': 86, 'y': 643, 'w': 156.69, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'As no more than one out of ten patients treated conservatively for appendiceal mass will suffer a recurrence of AA (usually within 1 year and not a complicated attack), the dogma of routine interval appendectomy has become obsolete. In patients over the age of 40...\\n```',\n", " 'md': 'As no more than one out of ten patients treated conservatively for appendiceal mass will suffer a recurrence of AA (usually within 1 year and not a complicated attack), the dogma of routine interval appendectomy has become obsolete. In patients over the age of 40...\\n```',\n", " 'bBox': {'x': 86, 'y': 643, 'w': 156.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured according to the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured according to the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 393,\n", " 'text': 'years, we suggest elective colonoscopy/colonic imaging after 1 month to\\nexclude the rare situation in which carcinoma of the appendix or cecum\\nwas the cause of the mass. Cancer or inflammatory bowel disease will be\\ndetected only in 2 out of 100 such patients. So apply the “if it were me\\n(IIWM)” test and do not recommend interval appendectomies to\\nyour patients!\\n\\n Appendicitis epiploica (appendagitis)\\n We mention this condition here because of its name. You have\\nprobably not heard much about it but it is not so rare and often imitates\\nAA. Appendicitis epiploica (some call it ‘epiploic appendagitis’) follows\\nspontaneous torsion of an appendix epiploica — the peritoneum-covered\\ntabs of fat attached along the tenia coli. It is more common in obese\\nindividuals and in the cecum and sigmoid. Since the sigmoid colon often\\ncrosses the midline, the most common manifestation is localized\\ntenderness and peritoneal signs in the right iliac fossa. Typically, patients\\ndo not lose their appetite and do not feel or appear sick despite these\\nfindings. Thus, ‘AA on examination’ in an afebrile and healthy looking\\npatient should raise your suspicions. The natural history is\\nspontaneous remission as the appendix epiploica sloughs off,\\ntransforming into that loose calcified peritoneal body that you\\noccasionally find during unrelated abdominal procedures. A CT scan\\nusually identifies the localized area of pericolonic inflammation, excludes\\nAA and thus helps you to avoid unnecessary surgery or diagnostic\\nlaparoscopy ( Chapter 5). If you are misled into an operation just\\nremove the necrotic piece of fat. Then look in the mirror and say: “ħow\\nstupid I was to operate!”\\n\\n Laparoscopic appendectomy 3\\n2 Danny Rosin\\n Up to the decision to operate, there should be no difference in the\\ndecision process between surgeons who prefer laparoscopic\\nappendectomy and the ‘open’ enthusiasts. They all aim to diagnose\\ncorrectly, as explained above, and proceed with the treatment. But, as\\nmentioned briefly in Chapter 4, some perceive laparoscopy to be an',\n", " 'md': '```markdown\\n## Text Extraction\\n\\n- We suggest elective colonoscopy/colonic imaging after 1 month to exclude the rare situation in which carcinoma of the appendix or cecum was the cause of the mass. Cancer or inflammatory bowel disease will be detected only in 2 out of 100 such patients. So apply the “if it were me (IIWM)” test and do not recommend interval appendectomies to your patients!\\n\\n### Appendicitis Epiploica (Appendagitis)\\n\\n- We mention this condition here because of its name. You have probably not heard much about it but it is not so rare and often imitates AA. Appendicitis epiploica (some call it ‘epiploic appendagitis’) follows spontaneous torsion of an appendix epiploica — the peritoneum-covered tabs of fat attached along the tenia coli. It is more common in obese individuals and in the cecum and sigmoid. Since the sigmoid colon often crosses the midline, the most common manifestation is localized tenderness and peritoneal signs in the right iliac fossa. Typically, patients do not lose their appetite and do not feel or appear sick despite these findings. Thus, ‘AA on examination’ in an afebrile and healthy looking patient should raise your suspicions. The natural history is spontaneous remission as the appendix epiploica sloughs off, transforming into that loose calcified peritoneal body that you occasionally find during unrelated abdominal procedures. A CT scan usually identifies the localized area of pericolonic inflammation, excludes AA and thus helps you to avoid unnecessary surgery or diagnostic laparoscopy (Chapter 5). If you are misled into an operation just remove the necrotic piece of fat. Then look in the mirror and say: “ħow stupid I was to operate!”\\n\\n### Laparoscopic Appendectomy\\n\\n- Up to the decision to operate, there should be no difference in the decision process between surgeons who prefer laparoscopic appendectomy and the ‘open’ enthusiasts. They all aim to diagnose correctly, as explained above, and proceed with the treatment. But, as mentioned briefly in Chapter 4, some perceive laparoscopy to be an...\\n\\n## Image Identification and Description\\n\\n- **Figure 1**: \\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- We suggest elective colonoscopy/colonic imaging after 1 month to exclude the rare situation in which carcinoma of the appendix or cecum was the cause of the mass. Cancer or inflammatory bowel disease will be detected only in 2 out of 100 such patients. So apply the “if it were me (IIWM)” test and do not recommend interval appendectomies to your patients!',\n", " 'md': '- We suggest elective colonoscopy/colonic imaging after 1 month to exclude the rare situation in which carcinoma of the appendix or cecum was the cause of the mass. Cancer or inflammatory bowel disease will be detected only in 2 out of 100 such patients. So apply the “if it were me (IIWM)” test and do not recommend interval appendectomies to your patients!',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.7, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Appendicitis Epiploica (Appendagitis)',\n", " 'md': '### Appendicitis Epiploica (Appendagitis)',\n", " 'bBox': {'x': 86, 'y': 207, 'w': 254.93, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- We mention this condition here because of its name. You have probably not heard much about it but it is not so rare and often imitates AA. Appendicitis epiploica (some call it ‘epiploic appendagitis’) follows spontaneous torsion of an appendix epiploica — the peritoneum-covered tabs of fat attached along the tenia coli. It is more common in obese individuals and in the cecum and sigmoid. Since the sigmoid colon often crosses the midline, the most common manifestation is localized tenderness and peritoneal signs in the right iliac fossa. Typically, patients do not lose their appetite and do not feel or appear sick despite these findings. Thus, ‘AA on examination’ in an afebrile and healthy looking patient should raise your suspicions. The natural history is spontaneous remission as the appendix epiploica sloughs off, transforming into that loose calcified peritoneal body that you occasionally find during unrelated abdominal procedures. A CT scan usually identifies the localized area of pericolonic inflammation, excludes AA and thus helps you to avoid unnecessary surgery or diagnostic laparoscopy (Chapter 5). If you are misled into an operation just remove the necrotic piece of fat. Then look in the mirror and say: “ħow stupid I was to operate!”',\n", " 'md': '- We mention this condition here because of its name. You have probably not heard much about it but it is not so rare and often imitates AA. Appendicitis epiploica (some call it ‘epiploic appendagitis’) follows spontaneous torsion of an appendix epiploica — the peritoneum-covered tabs of fat attached along the tenia coli. It is more common in obese individuals and in the cecum and sigmoid. Since the sigmoid colon often crosses the midline, the most common manifestation is localized tenderness and peritoneal signs in the right iliac fossa. Typically, patients do not lose their appetite and do not feel or appear sick despite these findings. Thus, ‘AA on examination’ in an afebrile and healthy looking patient should raise your suspicions. The natural history is spontaneous remission as the appendix epiploica sloughs off, transforming into that loose calcified peritoneal body that you occasionally find during unrelated abdominal procedures. A CT scan usually identifies the localized area of pericolonic inflammation, excludes AA and thus helps you to avoid unnecessary surgery or diagnostic laparoscopy (Chapter 5). If you are misled into an operation just remove the necrotic piece of fat. Then look in the mirror and say: “ħow stupid I was to operate!”',\n", " 'bBox': {'x': 72, 'y': 245, 'w': 467.84, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Laparoscopic Appendectomy',\n", " 'md': '### Laparoscopic Appendectomy',\n", " 'bBox': {'x': 458, 'y': 651, 'w': 80.78, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- Up to the decision to operate, there should be no difference in the decision process between surgeons who prefer laparoscopic appendectomy and the ‘open’ enthusiasts. They all aim to diagnose correctly, as explained above, and proceed with the treatment. But, as mentioned briefly in Chapter 4, some perceive laparoscopy to be an...',\n", " 'md': '- Up to the decision to operate, there should be no difference in the decision process between surgeons who prefer laparoscopic appendectomy and the ‘open’ enthusiasts. They all aim to diagnose correctly, as explained above, and proceed with the treatment. But, as mentioned briefly in Chapter 4, some perceive laparoscopy to be an...',\n", " 'bBox': {'x': 72, 'y': 410, 'w': 196.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: \\n```',\n", " 'md': '- **Figure 1**: \\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'remove the necrotic piece of fat'},\n", " {'text': 'Laparoscopic appendectomy 3'},\n", " {'text': ''}]},\n", " {'page': 394,\n", " 'text': 'extension of the diagnostic effort: “We are not sure if the appendix is\\ninflamed or not, let’s avoid the CT radiation, let’s avoid the annoying\\nobservation, let’s stick the scope in and know for sure!” And while this\\napproach may make sense, we tend to forget its downsides, the\\ninvasiveness and its risks, the anesthesia and its risk (minimal,\\nadmittedly, but existent), and the tendency ‘to do something’, even\\nremove a normal appendix, just a souvenir from a nice trip to the\\nabdomen.\\n\\n So, while we cannot claim that diagnostic laparoscopy for suspected\\nappendicitis is a gross mistake, or God forbid a crime, we try to minimize\\nits use.\\n\\n Why laparoscopy?\\n\\n My first instinctive reply would be: it’s a good procedure, I do it well, I\\nfeel comfortable with it and the patients are happy. After years of almost\\nexclusive appendectomy by laparoscopy I feel it’s a good and honest\\nanswer, and many young surgeons who trained with lap appendectomy\\nas the routine procedure feel the same, and mainly feel it’s easier and\\n‘cleaner’ than to struggle through a mini incision. But I realize that some\\nolder surgeons will read the above sincere text and say “bulls**t!”, and I\\nacknowledge the fact that a serious book like this deserves some more\\nscientific text. And it’s not as if we don’t have good arguments:\\n\\n • Differential diagnosis. Despite all modern diagnostic modalities,\\n we have not completely eliminated surgical surprises, and a normal\\n appendix may still wait for us inside, along with some other\\n unexpected pathology. Laparoscopy is a much better diagnostic and\\n therapeutic tool in these cases than a limited RLQ incision. And\\n while ‘young fertile women’ are nearly in the consensus for lap\\n appendectomy, even Valentino had an unexpected pathology 4.\\n • Wound infection. Dealing with an infective process, it’s no wonder\\n laparoscopy is associated with fewer incisional problems. Even if a\\n wound infection occurs (surely it’s less frequent) — the result is a\\n small annoying wound infection and not an open large one, destined\\n for a long secondary healing and an ugly scar. Although hernia in a',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nThe extension of the diagnostic effort: “We are not sure if the appendix is inflamed or not, let’s avoid the CT radiation, let’s avoid the annoying observation, let’s stick the scope in and know for sure!” And while this approach may make sense, we tend to forget its downsides, the invasiveness and its risks, the anesthesia and its risk (minimal, admittedly, but existent), and the tendency ‘to do something’, even remove a normal appendix, just a souvenir from a nice trip to the abdomen.\\n\\nSo, while we cannot claim that diagnostic laparoscopy for suspected appendicitis is a gross mistake, or God forbid a crime, we try to minimize its use.\\n\\nWhy laparoscopy?\\n\\nMy first instinctive reply would be: it’s a good procedure, I do it well, I feel comfortable with it and the patients are happy. After years of almost exclusive appendectomy by laparoscopy I feel it’s a good and honest answer, and many young surgeons who trained with lap appendectomy as the routine procedure feel the same, and mainly feel it’s easier and ‘cleaner’ than to struggle through a mini incision. But I realize that some older surgeons will read the above sincere text and say “bulls**t!”, and I acknowledge the fact that a serious book like this deserves some more scientific text. And it’s not as if we don’t have good arguments:\\n\\n- Differential diagnosis. Despite all modern diagnostic modalities, we have not completely eliminated surgical surprises, and a normal appendix may still wait for us inside, along with some other unexpected pathology. Laparoscopy is a much better diagnostic and therapeutic tool in these cases than a limited RLQ incision. And while ‘young fertile women’ are nearly in the consensus for lap appendectomy, even Valentino had an unexpected pathology.\\n- Wound infection. Dealing with an infective process, it’s no wonder laparoscopy is associated with fewer incisional problems. Even if a wound infection occurs (surely it’s less frequent) — the result is a small annoying wound infection and not an open large one, destined for a long secondary healing and an ugly scar. Although hernia in a\\n\\n## Image Identification and Description\\n\\n*No images or graphs were identified on this page.*\\n\\n## Summary\\n\\nThis page discusses the considerations surrounding the use of diagnostic laparoscopy for suspected appendicitis. It highlights the benefits of the procedure, such as improved diagnostic capabilities and reduced risk of wound infection, while also acknowledging the potential downsides and the need for careful consideration in its application.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The extension of the diagnostic effort: “We are not sure if the appendix is inflamed or not, let’s avoid the CT radiation, let’s avoid the annoying observation, let’s stick the scope in and know for sure!” And while this approach may make sense, we tend to forget its downsides, the invasiveness and its risks, the anesthesia and its risk (minimal, admittedly, but existent), and the tendency ‘to do something’, even remove a normal appendix, just a souvenir from a nice trip to the abdomen.\\n\\nSo, while we cannot claim that diagnostic laparoscopy for suspected appendicitis is a gross mistake, or God forbid a crime, we try to minimize its use.\\n\\nWhy laparoscopy?\\n\\nMy first instinctive reply would be: it’s a good procedure, I do it well, I feel comfortable with it and the patients are happy. After years of almost exclusive appendectomy by laparoscopy I feel it’s a good and honest answer, and many young surgeons who trained with lap appendectomy as the routine procedure feel the same, and mainly feel it’s easier and ‘cleaner’ than to struggle through a mini incision. But I realize that some older surgeons will read the above sincere text and say “bulls**t!”, and I acknowledge the fact that a serious book like this deserves some more scientific text. And it’s not as if we don’t have good arguments:\\n\\n- Differential diagnosis. Despite all modern diagnostic modalities, we have not completely eliminated surgical surprises, and a normal appendix may still wait for us inside, along with some other unexpected pathology. Laparoscopy is a much better diagnostic and therapeutic tool in these cases than a limited RLQ incision. And while ‘young fertile women’ are nearly in the consensus for lap appendectomy, even Valentino had an unexpected pathology.\\n- Wound infection. Dealing with an infective process, it’s no wonder laparoscopy is associated with fewer incisional problems. Even if a wound infection occurs (surely it’s less frequent) — the result is a small annoying wound infection and not an open large one, destined for a long secondary healing and an ugly scar. Although hernia in a',\n", " 'md': 'The extension of the diagnostic effort: “We are not sure if the appendix is inflamed or not, let’s avoid the CT radiation, let’s avoid the annoying observation, let’s stick the scope in and know for sure!” And while this approach may make sense, we tend to forget its downsides, the invasiveness and its risks, the anesthesia and its risk (minimal, admittedly, but existent), and the tendency ‘to do something’, even remove a normal appendix, just a souvenir from a nice trip to the abdomen.\\n\\nSo, while we cannot claim that diagnostic laparoscopy for suspected appendicitis is a gross mistake, or God forbid a crime, we try to minimize its use.\\n\\nWhy laparoscopy?\\n\\nMy first instinctive reply would be: it’s a good procedure, I do it well, I feel comfortable with it and the patients are happy. After years of almost exclusive appendectomy by laparoscopy I feel it’s a good and honest answer, and many young surgeons who trained with lap appendectomy as the routine procedure feel the same, and mainly feel it’s easier and ‘cleaner’ than to struggle through a mini incision. But I realize that some older surgeons will read the above sincere text and say “bulls**t!”, and I acknowledge the fact that a serious book like this deserves some more scientific text. And it’s not as if we don’t have good arguments:\\n\\n- Differential diagnosis. Despite all modern diagnostic modalities, we have not completely eliminated surgical surprises, and a normal appendix may still wait for us inside, along with some other unexpected pathology. Laparoscopy is a much better diagnostic and therapeutic tool in these cases than a limited RLQ incision. And while ‘young fertile women’ are nearly in the consensus for lap appendectomy, even Valentino had an unexpected pathology.\\n- Wound infection. Dealing with an infective process, it’s no wonder laparoscopy is associated with fewer incisional problems. Even if a wound infection occurs (surely it’s less frequent) — the result is a small annoying wound infection and not an open large one, destined for a long secondary healing and an ugly scar. Although hernia in a',\n", " 'bBox': {'x': 72, 'y': 201, 'w': 467.9, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or graphs were identified on this page.*',\n", " 'md': '*No images or graphs were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the considerations surrounding the use of diagnostic laparoscopy for suspected appendicitis. It highlights the benefits of the procedure, such as improved diagnostic capabilities and reduced risk of wound infection, while also acknowledging the potential downsides and the need for careful consideration in its application.\\n```',\n", " 'md': 'This page discusses the considerations surrounding the use of diagnostic laparoscopy for suspected appendicitis. It highlights the benefits of the procedure, such as improved diagnostic capabilities and reduced risk of wound infection, while also acknowledging the potential downsides and the need for careful consideration in its application.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'appendectomy, even Valentino had an unexpected pathology 4'}]},\n", " {'page': 395,\n", " 'text': ' McBurney scar is rare, we have seen it following wound infection\\n and impaired wound healing.\\n• Pain and recovery. The problem with ‘small’ operations, like\\n appendectomy, is that the advantages of laparoscopy are more\\n subtle and more difficult to prove. This does not mean that the\\n advantages are not there, and we (and the patients) witness it on a\\n daily basis. McBurney aficionados will wave papers about “no\\n statistical difference” in QOL scores measured by scales we don’t\\n really understand, but we know our patients do well and, and\\n recover swiftly.\\n• Cosmesis. Yes, this is a minor issue. And yet...\\n\\n Why not laparoscopy?\\n\\n• You don’t know how to do it. This may be the most important\\n contraindication for lap appendectomy. Never attempt a procedure\\n you don’t master, just because it’s fashionable. No one here claims\\n that open appendectomy is bad, only that maybe, under optimal\\n conditions, lap appendectomy may have some advantages. Lack of\\n experience, and lack of proper equipment, are very good reasons to\\n stick with the safe and proven open approach. A little more pain is\\n preferable to some horrendous complications we sometimes see\\n after misguided attempts to keep this simple procedure ‘minimally\\n invasive’. (You have to read Chapter 17 in Schein’s Common Sense\\n Prevention and Management of Surgical Complications, tfm\\n publishing, 2013.)\\n• Intra-abdominal collections. I’m not sure this issue is solved yet.\\n There have been claims for a higher incidence of post-\\n appendectomy pelvic collections after laparoscopy. While we do see\\n this occasionally, many studies claim that the rate is not really\\n different compared to the open procedure. It may be that excessive\\n irrigation by laparoscopy contributes to spreading the localized\\n infection. We are not sure it’s true — but we don’t irrigate, just\\n aspirate the pus, and it seems to work just fine. The other\\n Editors agree with me about this — just suck the muck out!\\n• Relative contraindications. In situations like pregnancy, or',\n", " 'md': '```markdown\\n# Laparoscopic Appendectomy Considerations\\n\\n## McBurney Scar\\nMcBurney scar is rare; we have seen it following wound infection and impaired wound healing.\\n\\n## Pain and Recovery\\nThe problem with ‘small’ operations, like appendectomy, is that the advantages of laparoscopy are more subtle and more difficult to prove. This does not mean that the advantages are not there, and we (and the patients) witness it on a daily basis. McBurney aficionados will wave papers about “no statistical difference” in QOL scores measured by scales we don’t really understand, but we know our patients do well and recover swiftly.\\n\\n## Cosmesis\\nYes, this is a minor issue. And yet...\\n\\n## Why Not Laparoscopy?\\n- **You don’t know how to do it.** This may be the most important contraindication for lap appendectomy. Never attempt a procedure you don’t master, just because it’s fashionable. No one here claims that open appendectomy is bad, only that maybe, under optimal conditions, lap appendectomy may have some advantages. Lack of experience, and lack of proper equipment, are very good reasons to stick with the safe and proven open approach. A little more pain is preferable to some horrendous complications we sometimes see after misguided attempts to keep this simple procedure ‘minimally invasive’. (You have to read Chapter 17 in Schein’s *Common Sense Prevention and Management of Surgical Complications*, tfm publishing, 2013.)\\n\\n- **Intra-abdominal collections.** I’m not sure this issue is solved yet. There have been claims for a higher incidence of post-appendectomy pelvic collections after laparoscopy. While we do see this occasionally, many studies claim that the rate is not really different compared to the open procedure. It may be that excessive irrigation by laparoscopy contributes to spreading the localized infection. We are not sure it’s true — but we don’t irrigate, just aspirate the pus, and it seems to work just fine. The other Editors agree with me about this — just suck the muck out!\\n\\n- **Relative contraindications.** In situations like pregnancy, or...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Laparoscopic Appendectomy Considerations',\n", " 'md': '# Laparoscopic Appendectomy Considerations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'McBurney Scar',\n", " 'md': '## McBurney Scar',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'McBurney scar is rare; we have seen it following wound infection and impaired wound healing.',\n", " 'md': 'McBurney scar is rare; we have seen it following wound infection and impaired wound healing.',\n", " 'bBox': {'x': 100, 'y': 102, 'w': 183.92, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Pain and Recovery',\n", " 'md': '## Pain and Recovery',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The problem with ‘small’ operations, like appendectomy, is that the advantages of laparoscopy are more subtle and more difficult to prove. This does not mean that the advantages are not there, and we (and the patients) witness it on a daily basis. McBurney aficionados will wave papers about “no statistical difference” in QOL scores measured by scales we don’t really understand, but we know our patients do well and recover swiftly.',\n", " 'md': 'The problem with ‘small’ operations, like appendectomy, is that the advantages of laparoscopy are more subtle and more difficult to prove. This does not mean that the advantages are not there, and we (and the patients) witness it on a daily basis. McBurney aficionados will wave papers about “no statistical difference” in QOL scores measured by scales we don’t really understand, but we know our patients do well and recover swiftly.',\n", " 'bBox': {'x': 100, 'y': 171, 'w': 436.89, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Cosmesis',\n", " 'md': '## Cosmesis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Yes, this is a minor issue. And yet...',\n", " 'md': 'Yes, this is a minor issue. And yet...',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Why Not Laparoscopy?',\n", " 'md': '## Why Not Laparoscopy?',\n", " 'bBox': {'x': 86, 'y': 311, 'w': 177.47, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- **You don’t know how to do it.** This may be the most important contraindication for lap appendectomy. Never attempt a procedure you don’t master, just because it’s fashionable. No one here claims that open appendectomy is bad, only that maybe, under optimal conditions, lap appendectomy may have some advantages. Lack of experience, and lack of proper equipment, are very good reasons to stick with the safe and proven open approach. A little more pain is preferable to some horrendous complications we sometimes see after misguided attempts to keep this simple procedure ‘minimally invasive’. (You have to read Chapter 17 in Schein’s *Common Sense Prevention and Management of Surgical Complications*, tfm publishing, 2013.)\\n\\n- **Intra-abdominal collections.** I’m not sure this issue is solved yet. There have been claims for a higher incidence of post-appendectomy pelvic collections after laparoscopy. While we do see this occasionally, many studies claim that the rate is not really different compared to the open procedure. It may be that excessive irrigation by laparoscopy contributes to spreading the localized infection. We are not sure it’s true — but we don’t irrigate, just aspirate the pus, and it seems to work just fine. The other Editors agree with me about this — just suck the muck out!\\n\\n- **Relative contraindications.** In situations like pregnancy, or...\\n```',\n", " 'md': '- **You don’t know how to do it.** This may be the most important contraindication for lap appendectomy. Never attempt a procedure you don’t master, just because it’s fashionable. No one here claims that open appendectomy is bad, only that maybe, under optimal conditions, lap appendectomy may have some advantages. Lack of experience, and lack of proper equipment, are very good reasons to stick with the safe and proven open approach. A little more pain is preferable to some horrendous complications we sometimes see after misguided attempts to keep this simple procedure ‘minimally invasive’. (You have to read Chapter 17 in Schein’s *Common Sense Prevention and Management of Surgical Complications*, tfm publishing, 2013.)\\n\\n- **Intra-abdominal collections.** I’m not sure this issue is solved yet. There have been claims for a higher incidence of post-appendectomy pelvic collections after laparoscopy. While we do see this occasionally, many studies claim that the rate is not really different compared to the open procedure. It may be that excessive irrigation by laparoscopy contributes to spreading the localized infection. We are not sure it’s true — but we don’t irrigate, just aspirate the pus, and it seems to work just fine. The other Editors agree with me about this — just suck the muck out!\\n\\n- **Relative contraindications.** In situations like pregnancy, or...\\n```',\n", " 'bBox': {'x': 100, 'y': 381, 'w': 436.85, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Management '}]},\n", " {'page': 396,\n", " 'text': ' perforated appendicitis with generalized peritonitis, one may argue\\n that laparoscopy is less advisable, or more risky. The level of\\n surgical experience may play a role here, as well as a large dose of\\n common sense. Remember that obese patients may actually\\n benefit from laparoscopy, despite the fact that a more difficult\\n operation is expected.\\n • Cost. No, we will not go into this. Cost is such a complicated topic!\\n It’s enough to say that if you do have basic laparoscopic equipment,\\n you can remove the appendix quite cheaply, with reusable\\n instruments, a cheap energy source, a few ties and a homemade\\n bag. Leave the Harmonic Scalpel® and the staples to others, use\\n your excellent manual skills, and be thankful you have fewer obese\\n patients to operate on than those poor guys in the USA.\\n\\n How to do it?\\n 0 10 0 5 010\\n 10 10\\n Figure 23.3. Options for trocar placement in laparoscopic appendectomy.\\n\\n You may have learned your technique from your chief resident, and\\nbeen convinced that this is the ‘correct’ way to do it. Please remember\\nthat surgical variability is good; I will avoid the horrible ‘cat skinning’\\naphorism but just tell you that after almost 20 years of lap appendectomy\\nI still modify the technique from time to time, if only for the fun of it. See\\nFigure 23.3 for some of the trocar placement options that are favored\\nby different surgeons. Note that I skipped the single port and the robotic\\nconfigurations. I advise you to skip them too… But with all the variability,\\nthere are several key points you should remember, to make the\\nprocedure run smoothly and safely. ħere they are:',\n", " 'md': '```markdown\\n## Laparoscopic Appendectomy Considerations\\n\\nPerforated appendicitis with generalized peritonitis may lead to the argument that laparoscopy is less advisable or more risky. The level of surgical experience may play a role here, as well as a large dose of common sense. Remember that obese patients may actually benefit from laparoscopy, despite the fact that a more difficult operation is expected.\\n\\n- **Cost**: Cost is a complicated topic! It’s enough to say that if you do have basic laparoscopic equipment, you can remove the appendix quite cheaply, with reusable instruments, a cheap energy source, a few ties, and a homemade bag. Leave the Harmonic Scalpel® and the staples to others, use your excellent manual skills, and be thankful you have fewer obese patients to operate on than those poor guys in the USA.\\n\\n### How to do it?\\n\\n#### Figure 23.3\\nOptions for trocar placement in laparoscopic appendectomy.\\n\\nYou may have learned your technique from your chief resident and been convinced that this is the ‘correct’ way to do it. Please remember that surgical variability is good; I will avoid the horrible ‘cat skinning’ aphorism but just tell you that after almost 20 years of laparoscopic appendectomy, I still modify the technique from time to time, if only for the fun of it. See Figure 23.3 for some of the trocar placement options that are favored by different surgeons. Note that I skipped the single port and the robotic configurations. I advise you to skip them too… But with all the variability, there are several key points you should remember to make the procedure run smoothly and safely. Here they are:\\n```\\n\\n### Image Description\\n- **Figure 23.3**: This figure illustrates various options for trocar placement in laparoscopic appendectomy. The diagram likely includes different configurations and angles for trocar insertion, which are essential for performing the procedure effectively. The visual representation aids in understanding the spatial arrangement and technique variations that can be employed by surgeons.',\n", " 'images': [{'name': 'img_p395_1.png',\n", " 'height': 297,\n", " 'width': 750,\n", " 'x': 120.95999999999913,\n", " 'y': 349.2,\n", " 'original_width': 1287,\n", " 'original_height': 511}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Laparoscopic Appendectomy Considerations',\n", " 'md': '## Laparoscopic Appendectomy Considerations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Perforated appendicitis with generalized peritonitis may lead to the argument that laparoscopy is less advisable or more risky. The level of surgical experience may play a role here, as well as a large dose of common sense. Remember that obese patients may actually benefit from laparoscopy, despite the fact that a more difficult operation is expected.\\n\\n- **Cost**: Cost is a complicated topic! It’s enough to say that if you do have basic laparoscopic equipment, you can remove the appendix quite cheaply, with reusable instruments, a cheap energy source, a few ties, and a homemade bag. Leave the Harmonic Scalpel® and the staples to others, use your excellent manual skills, and be thankful you have fewer obese patients to operate on than those poor guys in the USA.',\n", " 'md': 'Perforated appendicitis with generalized peritonitis may lead to the argument that laparoscopy is less advisable or more risky. The level of surgical experience may play a role here, as well as a large dose of common sense. Remember that obese patients may actually benefit from laparoscopy, despite the fact that a more difficult operation is expected.\\n\\n- **Cost**: Cost is a complicated topic! It’s enough to say that if you do have basic laparoscopic equipment, you can remove the appendix quite cheaply, with reusable instruments, a cheap energy source, a few ties, and a homemade bag. Leave the Harmonic Scalpel® and the staples to others, use your excellent manual skills, and be thankful you have fewer obese patients to operate on than those poor guys in the USA.',\n", " 'bBox': {'x': 100, 'y': 119, 'w': 437.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'How to do it?',\n", " 'md': '### How to do it?',\n", " 'bBox': {'x': 86, 'y': 335, 'w': 104.79, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Figure 23.3',\n", " 'md': '#### Figure 23.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Options for trocar placement in laparoscopic appendectomy.\\n\\nYou may have learned your technique from your chief resident and been convinced that this is the ‘correct’ way to do it. Please remember that surgical variability is good; I will avoid the horrible ‘cat skinning’ aphorism but just tell you that after almost 20 years of laparoscopic appendectomy, I still modify the technique from time to time, if only for the fun of it. See Figure 23.3 for some of the trocar placement options that are favored by different surgeons. Note that I skipped the single port and the robotic configurations. I advise you to skip them too… But with all the variability, there are several key points you should remember to make the procedure run smoothly and safely. Here they are:\\n```',\n", " 'md': 'Options for trocar placement in laparoscopic appendectomy.\\n\\nYou may have learned your technique from your chief resident and been convinced that this is the ‘correct’ way to do it. Please remember that surgical variability is good; I will avoid the horrible ‘cat skinning’ aphorism but just tell you that after almost 20 years of laparoscopic appendectomy, I still modify the technique from time to time, if only for the fun of it. See Figure 23.3 for some of the trocar placement options that are favored by different surgeons. Note that I skipped the single port and the robotic configurations. I advise you to skip them too… But with all the variability, there are several key points you should remember to make the procedure run smoothly and safely. Here they are:\\n```',\n", " 'bBox': {'x': 72, 'y': 629, 'w': 467.73, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 23.3**: This figure illustrates various options for trocar placement in laparoscopic appendectomy. The diagram likely includes different configurations and angles for trocar insertion, which are essential for performing the procedure effectively. The visual representation aids in understanding the spatial arrangement and technique variations that can be employed by surgeons.',\n", " 'md': '- **Figure 23.3**: This figure illustrates various options for trocar placement in laparoscopic appendectomy. The diagram likely includes different configurations and angles for trocar insertion, which are essential for performing the procedure effectively. The visual representation aids in understanding the spatial arrangement and technique variations that can be employed by surgeons.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Figure 23.3 for some of the by different surgeons. Note that I skipped the single port and the robotic'}]},\n", " {'page': 397,\n", " 'text': '• Urine. Let the patient empty the bladder before surgery. I know\\n that many surgeons prefer a Foley catheter for every lower\\n abdominal laparoscopy, but why give those who oppose\\n laparoscopy another good argument against it? And why give your\\n patient an increased risk for UTI? An empty bladder will keep the\\n pelvic space free for you, and allow you safely to insert the lower\\n trocar. And no, you don’t need urinary monitoring for such a short\\n operation, unless it takes you more than 2 hours… but then you\\n shouldn’t do it…\\n• Position. Make the operation convenient for you. Tuck the arms\\n along the body so you’ll be able to stand comfortably, with the\\n assistant standing near you. Secure the patient to the table so the\\n anesthetist will have no excuse against a steep Trendelenburg and\\n left tilt. You don’t need the small bowel obstructing your surgical\\n field of interest.\\n• Equipment. Use the best equipment you can have. Make your\\n laparoscopic conditions optimal; the less you struggle the better is\\n your operation\\n optics and light source should prevent you from working in\\n the dark. If you have a good 5mm scope (that will allow you to\\n move between the trocars as needed) — fine. If not — use the\\n 10;\\n energy sources, depending on availability, can make life\\n easier. The Harmonic Scalpel®, LigaSure® and other variants\\n from different companies, can all save you time and save the\\n patient his erythrocytes. But remember that a good\\n laparoscopic surgeon can achieve the same with simple\\n monopolar or bipolar energy, and some pre-tied loops or\\n even simple surgical ties. We encourage you to master these\\n skills even if you live in Utopia and staplers are free.\\n• Mobilization. Not every appendix will wait for you in full erection\\n (oy vey). The high, low, retrocecal, subhepatic or “WTF — where is\\n it for heaven’s sake” appendix may play hide and seek with your\\n nerves and ego. But here comes the real advantage of\\n laparoscopy: you are not limited to the confines of a strange\\n incision in the corner of the abdomen. Look around, explore, follow\\n the tenia, follow the terminal ileum, mobilize the cecum, mobilize',\n", " 'md': '```markdown\\n# Surgical Guidelines for Laparoscopy\\n\\n## Urine\\n- Let the patient empty the bladder before surgery. Many surgeons prefer a Foley catheter for every lower abdominal laparoscopy, but why give those who oppose laparoscopy another good argument against it? And why give your patient an increased risk for UTI? An empty bladder will keep the pelvic space free for you and allow you safely to insert the lower trocar.\\n- You don’t need urinary monitoring for such a short operation, unless it takes you more than 2 hours… but then you shouldn’t do it…\\n\\n## Position\\n- Make the operation convenient for you. Tuck the arms along the body so you’ll be able to stand comfortably, with the assistant standing near you. Secure the patient to the table so the anesthetist will have no excuse against a steep Trendelenburg and left tilt. You don’t need the small bowel obstructing your surgical field of interest.\\n\\n## Equipment\\n- Use the best equipment you can have. Make your laparoscopic conditions optimal; the less you struggle the better your operation.\\n- Optics and light source should prevent you from working in the dark. If you have a good 5mm scope (that will allow you to move between the trocars as needed) — fine. If not — use the 10.\\n- Energy sources, depending on availability, can make life easier. The Harmonic Scalpel®, LigaSure® and other variants from different companies can all save you time and save the patient his erythrocytes.\\n- But remember that a good laparoscopic surgeon can achieve the same with simple monopolar or bipolar energy, and some pre-tied loops or even simple surgical ties. We encourage you to master these skills even if you live in Utopia and staplers are free.\\n\\n## Mobilization\\n- Not every appendix will wait for you in full erection (oy vey). The high, low, retrocecal, subhepatic or “WTF — where is it for heaven’s sake” appendix may play hide and seek with your nerves and ego.\\n- But here comes the real advantage of laparoscopy: you are not limited to the confines of a strange incision in the corner of the abdomen. Look around, explore, follow the tenia, follow the terminal ileum, mobilize the cecum.\\n```',\n", " 'images': [{'name': 'img_p396_1.png',\n", " 'height': 8,\n", " 'width': 8,\n", " 'x': 110.15999999999985,\n", " 'y': 382.32},\n", " {'name': 'img_p396_1.png',\n", " 'height': 8,\n", " 'width': 8,\n", " 'x': 110.15999999999985,\n", " 'y': 451.44}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Surgical Guidelines for Laparoscopy',\n", " 'md': '# Surgical Guidelines for Laparoscopy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Urine',\n", " 'md': '## Urine',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Let the patient empty the bladder before surgery. Many surgeons prefer a Foley catheter for every lower abdominal laparoscopy, but why give those who oppose laparoscopy another good argument against it? And why give your patient an increased risk for UTI? An empty bladder will keep the pelvic space free for you and allow you safely to insert the lower trocar.\\n- You don’t need urinary monitoring for such a short operation, unless it takes you more than 2 hours… but then you shouldn’t do it…',\n", " 'md': '- Let the patient empty the bladder before surgery. Many surgeons prefer a Foley catheter for every lower abdominal laparoscopy, but why give those who oppose laparoscopy another good argument against it? And why give your patient an increased risk for UTI? An empty bladder will keep the pelvic space free for you and allow you safely to insert the lower trocar.\\n- You don’t need urinary monitoring for such a short operation, unless it takes you more than 2 hours… but then you shouldn’t do it…',\n", " 'bBox': {'x': 108, 'y': 121, 'w': 429.42, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Position',\n", " 'md': '## Position',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Make the operation convenient for you. Tuck the arms along the body so you’ll be able to stand comfortably, with the assistant standing near you. Secure the patient to the table so the anesthetist will have no excuse against a steep Trendelenburg and left tilt. You don’t need the small bowel obstructing your surgical field of interest.',\n", " 'md': '- Make the operation convenient for you. Tuck the arms along the body so you’ll be able to stand comfortably, with the assistant standing near you. Secure the patient to the table so the anesthetist will have no excuse against a steep Trendelenburg and left tilt. You don’t need the small bowel obstructing your surgical field of interest.',\n", " 'bBox': {'x': 108, 'y': 273, 'w': 429.71, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Equipment',\n", " 'md': '## Equipment',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Use the best equipment you can have. Make your laparoscopic conditions optimal; the less you struggle the better your operation.\\n- Optics and light source should prevent you from working in the dark. If you have a good 5mm scope (that will allow you to move between the trocars as needed) — fine. If not — use the 10.\\n- Energy sources, depending on availability, can make life easier. The Harmonic Scalpel®, LigaSure® and other variants from different companies can all save you time and save the patient his erythrocytes.\\n- But remember that a good laparoscopic surgeon can achieve the same with simple monopolar or bipolar energy, and some pre-tied loops or even simple surgical ties. We encourage you to master these skills even if you live in Utopia and staplers are free.',\n", " 'md': '- Use the best equipment you can have. Make your laparoscopic conditions optimal; the less you struggle the better your operation.\\n- Optics and light source should prevent you from working in the dark. If you have a good 5mm scope (that will allow you to move between the trocars as needed) — fine. If not — use the 10.\\n- Energy sources, depending on availability, can make life easier. The Harmonic Scalpel®, LigaSure® and other variants from different companies can all save you time and save the patient his erythrocytes.\\n- But remember that a good laparoscopic surgeon can achieve the same with simple monopolar or bipolar energy, and some pre-tied loops or even simple surgical ties. We encourage you to master these skills even if you live in Utopia and staplers are free.',\n", " 'bBox': {'x': 108, 'y': 121, 'w': 404.51, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Mobilization',\n", " 'md': '## Mobilization',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Not every appendix will wait for you in full erection (oy vey). The high, low, retrocecal, subhepatic or “WTF — where is it for heaven’s sake” appendix may play hide and seek with your nerves and ego.\\n- But here comes the real advantage of laparoscopy: you are not limited to the confines of a strange incision in the corner of the abdomen. Look around, explore, follow the tenia, follow the terminal ileum, mobilize the cecum.\\n```',\n", " 'md': '- Not every appendix will wait for you in full erection (oy vey). The high, low, retrocecal, subhepatic or “WTF — where is it for heaven’s sake” appendix may play hide and seek with your nerves and ego.\\n- But here comes the real advantage of laparoscopy: you are not limited to the confines of a strange incision in the corner of the abdomen. Look around, explore, follow the tenia, follow the terminal ileum, mobilize the cecum.\\n```',\n", " 'bBox': {'x': 108, 'y': 121, 'w': 429.65, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 398,\n", " 'text': ' the whole right colon — do whatever it takes to find the bastard;\\n you can do it and you have the technology!\\n• Mesenteric transection. Once you have localized the appendix\\n you have to start working on it. You may need to separate some\\n more adhesions around it, peel the omentum that is already\\n attached to it, or even adherent bowel. You must do this in order to\\n elevate the appendix and expose the mesentery. “Can I grab it?!”\\n you ask, sheepishly, and the president’s answer would be,\\n surprisingly, “Yes you can!” But that is only because you are a\\n common sense surgeon, you know how to manipulate it gently,\\n or grab the mesentery just underneath, and avoid crushing,\\n perforating, ripping and spreading the infection. The\\n mesenteric transection can be accomplished by any means you\\n prefer (and afford) — ties, clips, bipolar, any modern energy source\\n or even a vascular stapler, but please remember — this is not\\n cancer surgery: you don’t have to cut too proximal if the\\n mesentery is thickened and inflamed. It is perfectly safe to transect\\n close to or on the appendix itself, decreasing the risk of bleeding\\n and the bulkiness of the specimen to be removed.\\n• Appendiceal transection. Although, at times, you start with\\n transecting the base (retrograde appendectomy, when the tip is\\n buried somewhere), this is usually the phase when success can be\\n declared, the anesthetist can be woken up, and the nurse can be\\n promised that coffee is really soon. Do you know how to tie,\\n intracorporeally or extracorporeally, and impress the intern? Do you\\n want to use the friendly Endoloop®? Do you expect a ‘conference’\\n sponsored by one of the stapler companies? All methods are\\n legitimate as long as the base is secured. And if it is all swollen or\\n necrotic down to the base — get a piece of the cecum with a\\n stapler — exactly like you would in an open case.\\n• Extraction. Please don’t ruin your beautiful operation with non-\\n elegant extraction of the specimen; this will not only make you look\\n bad in the eyes of the nurses but will also increase the chance of\\n infective complications. Use an extraction bag (unless you remove\\n a slender, white appendix…). Enlarge the incision a bit if the\\n appendix is too bulky. Make it look easy and effortless, and don’t\\n worry about four more millimeters to the incision length. It is\\n better than an infected short incision.',\n", " 'md': '```markdown\\n## Surgical Procedure Overview\\n\\n- **Mesenteric Transection**:\\nOnce you have localized the appendix, you need to start working on it. You may need to separate some more adhesions around it, peel the omentum that is already attached to it, or even adherent bowel. You must do this in order to elevate the appendix and expose the mesentery. “Can I grab it?!” you ask, sheepishly, and the president’s answer would be, surprisingly, “Yes you can!” But that is only because you are a common sense surgeon; you know how to manipulate it gently, or grab the mesentery just underneath, and avoid crushing, perforating, ripping, and spreading the infection. The mesenteric transection can be accomplished by any means you prefer (and afford) — ties, clips, bipolar, any modern energy source, or even a vascular stapler. Please remember — this is not cancer surgery: you don’t have to cut too proximal if the mesentery is thickened and inflamed. It is perfectly safe to transect close to or on the appendix itself, decreasing the risk of bleeding and the bulkiness of the specimen to be removed.\\n\\n- **Appendiceal Transection**:\\nAlthough, at times, you start with transecting the base (retrograde appendectomy, when the tip is buried somewhere), this is usually the phase when success can be declared, the anesthetist can be woken up, and the nurse can be promised that coffee is really soon. Do you know how to tie, intracorporeally or extracorporeally, and impress the intern? Do you want to use the friendly Endoloop®? Do you expect a ‘conference’ sponsored by one of the stapler companies? All methods are legitimate as long as the base is secured. And if it is all swollen or necrotic down to the base — get a piece of the cecum with a stapler — exactly like you would in an open case.\\n\\n- **Extraction**:\\nPlease don’t ruin your beautiful operation with non-elegant extraction of the specimen; this will not only make you look bad in the eyes of the nurses but will also increase the chance of infective complications. Use an extraction bag (unless you remove a slender, white appendix…). Enlarge the incision a bit if the appendix is too bulky. Make it look easy and effortless, and don’t worry about four more millimeters to the incision length. It is better than an infected short incision.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Procedure Overview',\n", " 'md': '## Surgical Procedure Overview',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Mesenteric Transection**:\\nOnce you have localized the appendix, you need to start working on it. You may need to separate some more adhesions around it, peel the omentum that is already attached to it, or even adherent bowel. You must do this in order to elevate the appendix and expose the mesentery. “Can I grab it?!” you ask, sheepishly, and the president’s answer would be, surprisingly, “Yes you can!” But that is only because you are a common sense surgeon; you know how to manipulate it gently, or grab the mesentery just underneath, and avoid crushing, perforating, ripping, and spreading the infection. The mesenteric transection can be accomplished by any means you prefer (and afford) — ties, clips, bipolar, any modern energy source, or even a vascular stapler. Please remember — this is not cancer surgery: you don’t have to cut too proximal if the mesentery is thickened and inflamed. It is perfectly safe to transect close to or on the appendix itself, decreasing the risk of bleeding and the bulkiness of the specimen to be removed.\\n\\n- **Appendiceal Transection**:\\nAlthough, at times, you start with transecting the base (retrograde appendectomy, when the tip is buried somewhere), this is usually the phase when success can be declared, the anesthetist can be woken up, and the nurse can be promised that coffee is really soon. Do you know how to tie, intracorporeally or extracorporeally, and impress the intern? Do you want to use the friendly Endoloop®? Do you expect a ‘conference’ sponsored by one of the stapler companies? All methods are legitimate as long as the base is secured. And if it is all swollen or necrotic down to the base — get a piece of the cecum with a stapler — exactly like you would in an open case.\\n\\n- **Extraction**:\\nPlease don’t ruin your beautiful operation with non-elegant extraction of the specimen; this will not only make you look bad in the eyes of the nurses but will also increase the chance of infective complications. Use an extraction bag (unless you remove a slender, white appendix…). Enlarge the incision a bit if the appendix is too bulky. Make it look easy and effortless, and don’t worry about four more millimeters to the incision length. It is better than an infected short incision.\\n```',\n", " 'md': '- **Mesenteric Transection**:\\nOnce you have localized the appendix, you need to start working on it. You may need to separate some more adhesions around it, peel the omentum that is already attached to it, or even adherent bowel. You must do this in order to elevate the appendix and expose the mesentery. “Can I grab it?!” you ask, sheepishly, and the president’s answer would be, surprisingly, “Yes you can!” But that is only because you are a common sense surgeon; you know how to manipulate it gently, or grab the mesentery just underneath, and avoid crushing, perforating, ripping, and spreading the infection. The mesenteric transection can be accomplished by any means you prefer (and afford) — ties, clips, bipolar, any modern energy source, or even a vascular stapler. Please remember — this is not cancer surgery: you don’t have to cut too proximal if the mesentery is thickened and inflamed. It is perfectly safe to transect close to or on the appendix itself, decreasing the risk of bleeding and the bulkiness of the specimen to be removed.\\n\\n- **Appendiceal Transection**:\\nAlthough, at times, you start with transecting the base (retrograde appendectomy, when the tip is buried somewhere), this is usually the phase when success can be declared, the anesthetist can be woken up, and the nurse can be promised that coffee is really soon. Do you know how to tie, intracorporeally or extracorporeally, and impress the intern? Do you want to use the friendly Endoloop®? Do you expect a ‘conference’ sponsored by one of the stapler companies? All methods are legitimate as long as the base is secured. And if it is all swollen or necrotic down to the base — get a piece of the cecum with a stapler — exactly like you would in an open case.\\n\\n- **Extraction**:\\nPlease don’t ruin your beautiful operation with non-elegant extraction of the specimen; this will not only make you look bad in the eyes of the nurses but will also increase the chance of infective complications. Use an extraction bag (unless you remove a slender, white appendix…). Enlarge the incision a bit if the appendix is too bulky. Make it look easy and effortless, and don’t worry about four more millimeters to the incision length. It is better than an infected short incision.\\n```',\n", " 'bBox': {'x': 108, 'y': 171, 'w': 429.79, 'h': 19.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 399,\n", " 'text': ' To conclude, laparoscopic appendectomy is a very good option.\\nIt’s your responsibility to play it safely, and prove that I am right!\\n\\n Gosh, I almost forgot, take care to remove the whole appendix, not\\nonly part of it — not a rare occurrence in laparoscopic hands which are\\nnot as skilled as yours… (see Figure 23.4).\\n APPENbix\\n Fezzy\\n Figure 23.4. Patient: “But Doc, how could it be possible? I had my appendix removed\\n laparoscopically last year at the Mayonnaise Clinic! Could I have two appendixes?”\\n\\n Acute appendicitis, like any other surgical condition, has a spectrum. To reach the diagnosis,\\n consider historical, physical and laboratory findings together. No isolated variable can confirm or\\n exclude AA, but the more of the classic abnormalities that are present, the higher the chance\\n that you are dealing with AA. Whether you operate immediately or tomorrow, whether you\\n observe or obtain additional tests, is determined selectively based on your individual patient.\\n\\n It has been said that “The good thing about standards of care is that there are so many to\\n choose from.” And this is true of course concering the choice between open and laparoscopic\\n appendectomy. If you are as good a laparoscopist as Danny and his disciples then the\\n laparoscopic approach is almost always preferable. So strive for laparoscopic excellence but be',\n", " 'md': \"```markdown\\nTo conclude, laparoscopic appendectomy is a very good option. It’s your responsibility to play it safely, and prove that I am right!\\n\\nGosh, I almost forgot, take care to remove the whole appendix, not only part of it — not a rare occurrence in laparoscopic hands which are not as skilled as yours… (see Figure 23.4).\\n\\n**Figure 23.4**: Patient: “But Doc, how could it be possible? I had my appendix removed laparoscopically last year at the Mayonnaise Clinic! Could I have two appendixes?”\\n\\nAcute appendicitis, like any other surgical condition, has a spectrum. To reach the diagnosis, consider historical, physical and laboratory findings together. No isolated variable can confirm or exclude AA, but the more of the classic abnormalities that are present, the higher the chance that you are dealing with AA. Whether you operate immediately or tomorrow, whether you observe or obtain additional tests, is determined selectively based on your individual patient.\\n\\nIt has been said that “The good thing about standards of care is that there are so many to choose from.” And this is true of course concerning the choice between open and laparoscopic appendectomy. If you are as good a laparoscopist as Danny and his disciples then the laparoscopic approach is almost always preferable. So strive for laparoscopic excellence but be...\\n```\\n\\n### Image Description\\n- **Figure 23.4**: The image depicts a humorous dialogue between a patient and a doctor regarding the possibility of having two appendixes after a laparoscopic appendectomy. The caption highlights the patient's confusion about the surgical procedure. The image likely illustrates a cartoon or comic style representation, emphasizing the light-hearted nature of the conversation.\\n\\n### Summary\\nThe text discusses the importance of complete removal of the appendix during laparoscopic surgery and the considerations involved in diagnosing acute appendicitis. It emphasizes the need for skilled surgical techniques and the variability in standards of care between open and laparoscopic approaches.\",\n", " 'images': [{'name': 'img_p398_1.png',\n", " 'height': 578,\n", " 'width': 796,\n", " 'x': 109.43999999999869,\n", " 'y': 184.32,\n", " 'original_width': 1368,\n", " 'original_height': 992}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nTo conclude, laparoscopic appendectomy is a very good option. It’s your responsibility to play it safely, and prove that I am right!\\n\\nGosh, I almost forgot, take care to remove the whole appendix, not only part of it — not a rare occurrence in laparoscopic hands which are not as skilled as yours… (see Figure 23.4).\\n\\n**Figure 23.4**: Patient: “But Doc, how could it be possible? I had my appendix removed laparoscopically last year at the Mayonnaise Clinic! Could I have two appendixes?”\\n\\nAcute appendicitis, like any other surgical condition, has a spectrum. To reach the diagnosis, consider historical, physical and laboratory findings together. No isolated variable can confirm or exclude AA, but the more of the classic abnormalities that are present, the higher the chance that you are dealing with AA. Whether you operate immediately or tomorrow, whether you observe or obtain additional tests, is determined selectively based on your individual patient.\\n\\nIt has been said that “The good thing about standards of care is that there are so many to choose from.” And this is true of course concerning the choice between open and laparoscopic appendectomy. If you are as good a laparoscopist as Danny and his disciples then the laparoscopic approach is almost always preferable. So strive for laparoscopic excellence but be...\\n```',\n", " 'md': '```markdown\\nTo conclude, laparoscopic appendectomy is a very good option. It’s your responsibility to play it safely, and prove that I am right!\\n\\nGosh, I almost forgot, take care to remove the whole appendix, not only part of it — not a rare occurrence in laparoscopic hands which are not as skilled as yours… (see Figure 23.4).\\n\\n**Figure 23.4**: Patient: “But Doc, how could it be possible? I had my appendix removed laparoscopically last year at the Mayonnaise Clinic! Could I have two appendixes?”\\n\\nAcute appendicitis, like any other surgical condition, has a spectrum. To reach the diagnosis, consider historical, physical and laboratory findings together. No isolated variable can confirm or exclude AA, but the more of the classic abnormalities that are present, the higher the chance that you are dealing with AA. Whether you operate immediately or tomorrow, whether you observe or obtain additional tests, is determined selectively based on your individual patient.\\n\\nIt has been said that “The good thing about standards of care is that there are so many to choose from.” And this is true of course concerning the choice between open and laparoscopic appendectomy. If you are as good a laparoscopist as Danny and his disciples then the laparoscopic approach is almost always preferable. So strive for laparoscopic excellence but be...\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.46, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- **Figure 23.4**: The image depicts a humorous dialogue between a patient and a doctor regarding the possibility of having two appendixes after a laparoscopic appendectomy. The caption highlights the patient's confusion about the surgical procedure. The image likely illustrates a cartoon or comic style representation, emphasizing the light-hearted nature of the conversation.\",\n", " 'md': \"- **Figure 23.4**: The image depicts a humorous dialogue between a patient and a doctor regarding the possibility of having two appendixes after a laparoscopic appendectomy. The caption highlights the patient's confusion about the surgical procedure. The image likely illustrates a cartoon or comic style representation, emphasizing the light-hearted nature of the conversation.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the importance of complete removal of the appendix during laparoscopic surgery and the considerations involved in diagnosing acute appendicitis. It emphasizes the need for skilled surgical techniques and the variability in standards of care between open and laparoscopic approaches.',\n", " 'md': 'The text discusses the importance of complete removal of the appendix during laparoscopic surgery and the considerations involved in diagnosing acute appendicitis. It emphasizes the need for skilled surgical techniques and the variability in standards of care between open and laparoscopic approaches.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 400,\n", " 'text': ' careful. Looking around us — beyond what is published in the literature — we see an epidemic\\n of complications developing after laparoscopic appendectomy which we have (almost) never\\n seen before: intraperitoneal abscesses, intestinal obstruction, cecal fistula, recurrent\\n appendicitis, bowel injury, bladder injury, vascular injury 5. And yes, hernias can develop at the\\n trocar site. So decide for yourself and play it safe!\\n\\n Never become blasé about AA; it can kill even today, and may\\n humble even the most experienced surgeon. Moshe\\n\\n You may ask yourself: why such an extra long chapter, dedicated to\\nsuch a tiny worm-like organ?\\n\\n “There are two things in life that we will never\\n understand: women and acute appendicitis.”\\n\\n1 The laparoscopic appendectomy section has been written by Danny Rosin.\\n2 Andersson RE. The natural history and traditional management of appendicitis revisited:\\n spontaneous resolution and predominance of prehospital perforations imply that a correct\\n diagnosis is more important than an early diagnosis. World J Surg 2007; 31: 86-92.\\n3 Prof. Ahmad Assalia contributed to this section in the third edition of this book.\\n4 Remember the case of the famous movie actor and womanizer Rudolph Valentino who\\n underwent an appendectomy for suspected acute appendicitis in New York (1926). He\\n became gravely ill after the operation and died; autopsy revealed a perforated peptic ulcer...\\n5 For a more detailed discussion of the complications of appendectomy and how to prevent\\n them read Chapter 17 in Schein’s Common Sense Prevention and Management of Surgical\\n Complications. Shrewsbury, UK: tfm publishing, 2013.',\n", " 'md': '```markdown\\n## Text\\n\\nCareful. Looking around us — beyond what is published in the literature — we see an epidemic of complications developing after laparoscopic appendectomy which we have (almost) never seen before: intraperitoneal abscesses, intestinal obstruction, cecal fistula, recurrent appendicitis, bowel injury, bladder injury, vascular injury. And yes, hernias can develop at the trocar site. So decide for yourself and play it safe!\\n\\nNever become blasé about AA; it can kill even today, and may humble even the most experienced surgeon. Moshe\\n\\nYou may ask yourself: why such an extra long chapter, dedicated to such a tiny worm-like organ?\\n\\n“There are two things in life that we will never understand: women and acute appendicitis.”\\n\\n1. The laparoscopic appendectomy section has been written by Danny Rosin.\\n2. Andersson RE. The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J Surg 2007; 31: 86-92.\\n3. Prof. Ahmad Assalia contributed to this section in the third edition of this book.\\n4. Remember the case of the famous movie actor and womanizer Rudolph Valentino who underwent an appendectomy for suspected acute appendicitis in New York (1926). He became gravely ill after the operation and died; autopsy revealed a perforated peptic ulcer...\\n5. For a more detailed discussion of the complications of appendectomy and how to prevent them read Chapter 17 in Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013. [Read more](https://www.tfm-publishing.com)\\n\\n## Images\\n\\n*No images or graphs were identified on this page.*\\n\\n## Summary\\n\\nThis page discusses the complications associated with laparoscopic appendectomy, emphasizing the seriousness of the procedure and the potential for various complications. It includes anecdotes and references to literature on the subject, highlighting the importance of accurate diagnosis and management of appendicitis.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Careful. Looking around us — beyond what is published in the literature — we see an epidemic of complications developing after laparoscopic appendectomy which we have (almost) never seen before: intraperitoneal abscesses, intestinal obstruction, cecal fistula, recurrent appendicitis, bowel injury, bladder injury, vascular injury. And yes, hernias can develop at the trocar site. So decide for yourself and play it safe!\\n\\nNever become blasé about AA; it can kill even today, and may humble even the most experienced surgeon. Moshe\\n\\nYou may ask yourself: why such an extra long chapter, dedicated to such a tiny worm-like organ?\\n\\n“There are two things in life that we will never understand: women and acute appendicitis.”\\n\\n1. The laparoscopic appendectomy section has been written by Danny Rosin.\\n2. Andersson RE. The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J Surg 2007; 31: 86-92.\\n3. Prof. Ahmad Assalia contributed to this section in the third edition of this book.\\n4. Remember the case of the famous movie actor and womanizer Rudolph Valentino who underwent an appendectomy for suspected acute appendicitis in New York (1926). He became gravely ill after the operation and died; autopsy revealed a perforated peptic ulcer...\\n5. For a more detailed discussion of the complications of appendectomy and how to prevent them read Chapter 17 in Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013. [Read more](https://www.tfm-publishing.com)',\n", " 'md': 'Careful. Looking around us — beyond what is published in the literature — we see an epidemic of complications developing after laparoscopic appendectomy which we have (almost) never seen before: intraperitoneal abscesses, intestinal obstruction, cecal fistula, recurrent appendicitis, bowel injury, bladder injury, vascular injury. And yes, hernias can develop at the trocar site. So decide for yourself and play it safe!\\n\\nNever become blasé about AA; it can kill even today, and may humble even the most experienced surgeon. Moshe\\n\\nYou may ask yourself: why such an extra long chapter, dedicated to such a tiny worm-like organ?\\n\\n“There are two things in life that we will never understand: women and acute appendicitis.”\\n\\n1. The laparoscopic appendectomy section has been written by Danny Rosin.\\n2. Andersson RE. The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J Surg 2007; 31: 86-92.\\n3. Prof. Ahmad Assalia contributed to this section in the third edition of this book.\\n4. Remember the case of the famous movie actor and womanizer Rudolph Valentino who underwent an appendectomy for suspected acute appendicitis in New York (1926). He became gravely ill after the operation and died; autopsy revealed a perforated peptic ulcer...\\n5. For a more detailed discussion of the complications of appendectomy and how to prevent them read Chapter 17 in Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013. [Read more](https://www.tfm-publishing.com)',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 462.85, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or graphs were identified on this page.*',\n", " 'md': '*No images or graphs were identified on this page.*',\n", " 'bBox': {'x': 409, 'y': 321, 'w': 22.08, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the complications associated with laparoscopic appendectomy, emphasizing the seriousness of the procedure and the potential for various complications. It includes anecdotes and references to literature on the subject, highlighting the importance of accurate diagnosis and management of appendicitis.\\n```',\n", " 'md': 'This page discusses the complications associated with laparoscopic appendectomy, emphasizing the seriousness of the procedure and the potential for various complications. It includes anecdotes and references to literature on the subject, highlighting the importance of accurate diagnosis and management of appendicitis.\\n```',\n", " 'bBox': {'x': 295, 'y': 321, 'w': 14.71, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': '1'},\n", " {'text': '2'},\n", " {'text': '3'},\n", " {'text': '4'},\n", " {'text': '5'},\n", " {'text': 'Complications'}]},\n", " {'page': 401,\n", " 'text': 'Chapter 24\\nAcute mesenteric ischemia\\nMoshe Schein and Paul N. Rogers\\n\\n Vascular surgery is peculiar because, above all, it is mainly\\n surgery of ruins.\\n Cid dos Santos\\n\\n Occlusion of the mesenteric vessels is regarded as one of\\n those conditions of which the diagnosis is impossible, the\\n prognosis hopeless, and the treatment almost useless.\\n A. Cokkins\\n\\n Which of you hasn’t been called by the internists or ER docs, to the ER\\nor medical floor, or the intensive care unit, to “rule out mesenteric\\nischemia” in some elderly patient? As a rule, on such occasions you will\\nfind a groaning patient with non-specific abdominal complaints and a\\nhospital chart that outweighs you. “Rule out mesenteric ischemia”—\\neasier said than done!\\n\\n Acute mesenteric ischemia usually involves the region supplied by the\\nsuperior mesenteric artery (SMA). Thus, the small intestine is\\npredominantly affected but the right colon, which is also supplied by the\\nSMA, can be involved as well. Isolated ischemia of the colon, which is\\nmuch less common, will be discussed separately under the heading of\\nIschemic colitis in Chapter 26.',\n", " 'md': '```markdown\\n# Chapter 24: Acute Mesenteric Ischemia\\n**Authors:** Moshe Schein and Paul N. Rogers\\n\\n> \"Vascular surgery is peculiar because, above all, it is mainly surgery of ruins.\"\\n> — Cid dos Santos\\n\\n> \"Occlusion of the mesenteric vessels is regarded as one of those conditions of which the diagnosis is impossible, the prognosis hopeless, and the treatment almost useless.\"\\n> — A. Cokkins\\n\\n## Overview\\nWhich of you hasn’t been called by the internists or ER docs, to the ER or medical floor, or the intensive care unit, to “rule out mesenteric ischemia” in some elderly patient? As a rule, on such occasions you will find a groaning patient with non-specific abdominal complaints and a hospital chart that outweighs you. “Rule out mesenteric ischemia”—easier said than done!\\n\\nAcute mesenteric ischemia usually involves the region supplied by the superior mesenteric artery (SMA). Thus, the small intestine is predominantly affected but the right colon, which is also supplied by the SMA, can be involved as well. Isolated ischemia of the colon, which is much less common, will be discussed separately under the heading of Ischemic colitis in Chapter 26.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 24: Acute Mesenteric Ischemia',\n", " 'md': '# Chapter 24: Acute Mesenteric Ischemia',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 240.77, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Moshe Schein and Paul N. Rogers\\n\\n> \"Vascular surgery is peculiar because, above all, it is mainly surgery of ruins.\"\\n> — Cid dos Santos\\n\\n> \"Occlusion of the mesenteric vessels is regarded as one of those conditions of which the diagnosis is impossible, the prognosis hopeless, and the treatment almost useless.\"\\n> — A. Cokkins',\n", " 'md': '**Authors:** Moshe Schein and Paul N. Rogers\\n\\n> \"Vascular surgery is peculiar because, above all, it is mainly surgery of ruins.\"\\n> — Cid dos Santos\\n\\n> \"Occlusion of the mesenteric vessels is regarded as one of those conditions of which the diagnosis is impossible, the prognosis hopeless, and the treatment almost useless.\"\\n> — A. Cokkins',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 381.6, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Overview',\n", " 'md': '## Overview',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Which of you hasn’t been called by the internists or ER docs, to the ER or medical floor, or the intensive care unit, to “rule out mesenteric ischemia” in some elderly patient? As a rule, on such occasions you will find a groaning patient with non-specific abdominal complaints and a hospital chart that outweighs you. “Rule out mesenteric ischemia”—easier said than done!\\n\\nAcute mesenteric ischemia usually involves the region supplied by the superior mesenteric artery (SMA). Thus, the small intestine is predominantly affected but the right colon, which is also supplied by the SMA, can be involved as well. Isolated ischemia of the colon, which is much less common, will be discussed separately under the heading of Ischemic colitis in Chapter 26.\\n```',\n", " 'md': 'Which of you hasn’t been called by the internists or ER docs, to the ER or medical floor, or the intensive care unit, to “rule out mesenteric ischemia” in some elderly patient? As a rule, on such occasions you will find a groaning patient with non-specific abdominal complaints and a hospital chart that outweighs you. “Rule out mesenteric ischemia”—easier said than done!\\n\\nAcute mesenteric ischemia usually involves the region supplied by the superior mesenteric artery (SMA). Thus, the small intestine is predominantly affected but the right colon, which is also supplied by the SMA, can be involved as well. Isolated ischemia of the colon, which is much less common, will be discussed separately under the heading of Ischemic colitis in Chapter 26.\\n```',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.59, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 402,\n", " 'text': ' The problem\\n\\n The problem is a sudden reduction in arterial perfusion of the small\\nbowel, which quickly leads to central abdominal pain. If left untreated, the\\nprocess progressively involves the muscular layer of the intestines and it\\nis only after some hours, when the serosa is affected, that peritoneal\\nsigns appear. In an attempt to simplify matters, let us divide acute arterial\\nmesenteric ischemia (AMI) into three types.\\n\\n Thrombotic: due to an acute arterial thrombosis (of a chronically diseased\\n artery), which usually occludes the orifice of the SMA, resulting in massive\\n ischemia of the entire small bowel plus the right colon —\\n the area supplied by the SMA.\\n Embolic: due to a shower of embolic material originating proximally — from the\\n heart (atrial fibrillation, post-myocardial infarction, diseased valve) or an\\n aneurysmal or atherosclerotic aorta. Emboli usually lodge in the proximal SMA, but\\n beyond the exit of the middle colic artery; therefore, as a rule, the most proximal\\n segment of proximal small bowel is spared, along with the transverse and\\n (probably) the right colon. Emboli tend to fragment and re-\\n embolize distally, producing a patchy type of small bowel\\n ischemia. Note that embolism can occur against a background of chronic\\n mesenteric arterial disease.\\n Non-occlusive mesenteric ischemia (NOMI): due to a ‘low-flow\\n state’, in the absence of documented arterial thrombosis or embolus. Note,\\n however, that underlying mesenteric atherosclerosis may be a\\n precipitating/contributory factor. The low-flow state is a product of low cardiac\\n output (e.g. cardiogenic shock), reduced mesenteric flow (e.g. intra-abdominal\\n hypertension) or mesenteric vasoconstriction (e.g. administration of vasopressors)\\n — usually, however, it is due to a combination of these\\n factors, developing in the setting of a pre-existing critical\\n illness.\\n\\n Mesenteric venous thrombosis can also produce small bowel',\n", " 'md': '```markdown\\n# The Problem\\n\\nThe problem is a sudden reduction in arterial perfusion of the small bowel, which quickly leads to central abdominal pain. If left untreated, the process progressively involves the muscular layer of the intestines and it is only after some hours, when the serosa is affected, that peritoneal signs appear. In an attempt to simplify matters, let us divide acute arterial mesenteric ischemia (AMI) into three types.\\n\\n1. **Thrombotic**: due to an acute arterial thrombosis (of a chronically diseased artery), which usually occludes the orifice of the SMA, resulting in massive ischemia of the entire small bowel plus the right colon — the area supplied by the SMA.\\n\\n2. **Embolic**: due to a shower of embolic material originating proximally — from the heart (atrial fibrillation, post-myocardial infarction, diseased valve) or an aneurysmal or atherosclerotic aorta. Emboli usually lodge in the proximal SMA, but beyond the exit of the middle colic artery; therefore, as a rule, the most proximal segment of proximal small bowel is spared, along with the transverse and (probably) the right colon. Emboli tend to fragment and re-embolize distally, producing a patchy type of small bowel ischemia. Note that embolism can occur against a background of chronic mesenteric arterial disease.\\n\\n3. **Non-occlusive mesenteric ischemia (NOMI)**: due to a ‘low-flow state’, in the absence of documented arterial thrombosis or embolus. Note, however, that underlying mesenteric atherosclerosis may be a precipitating/contributory factor. The low-flow state is a product of low cardiac output (e.g. cardiogenic shock), reduced mesenteric flow (e.g. intra-abdominal hypertension) or mesenteric vasoconstriction (e.g. administration of vasopressors) — usually, however, it is due to a combination of these factors, developing in the setting of a pre-existing critical illness.\\n\\nMesenteric venous thrombosis can also produce small bowel ischemia.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 524, 'y': 551, 'w': 6, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'The Problem',\n", " 'md': '# The Problem',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 99.31, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The problem is a sudden reduction in arterial perfusion of the small bowel, which quickly leads to central abdominal pain. If left untreated, the process progressively involves the muscular layer of the intestines and it is only after some hours, when the serosa is affected, that peritoneal signs appear. In an attempt to simplify matters, let us divide acute arterial mesenteric ischemia (AMI) into three types.\\n\\n1. **Thrombotic**: due to an acute arterial thrombosis (of a chronically diseased artery), which usually occludes the orifice of the SMA, resulting in massive ischemia of the entire small bowel plus the right colon — the area supplied by the SMA.\\n\\n2. **Embolic**: due to a shower of embolic material originating proximally — from the heart (atrial fibrillation, post-myocardial infarction, diseased valve) or an aneurysmal or atherosclerotic aorta. Emboli usually lodge in the proximal SMA, but beyond the exit of the middle colic artery; therefore, as a rule, the most proximal segment of proximal small bowel is spared, along with the transverse and (probably) the right colon. Emboli tend to fragment and re-embolize distally, producing a patchy type of small bowel ischemia. Note that embolism can occur against a background of chronic mesenteric arterial disease.\\n\\n3. **Non-occlusive mesenteric ischemia (NOMI)**: due to a ‘low-flow state’, in the absence of documented arterial thrombosis or embolus. Note, however, that underlying mesenteric atherosclerosis may be a precipitating/contributory factor. The low-flow state is a product of low cardiac output (e.g. cardiogenic shock), reduced mesenteric flow (e.g. intra-abdominal hypertension) or mesenteric vasoconstriction (e.g. administration of vasopressors) — usually, however, it is due to a combination of these factors, developing in the setting of a pre-existing critical illness.\\n\\nMesenteric venous thrombosis can also produce small bowel ischemia.\\n```',\n", " 'md': 'The problem is a sudden reduction in arterial perfusion of the small bowel, which quickly leads to central abdominal pain. If left untreated, the process progressively involves the muscular layer of the intestines and it is only after some hours, when the serosa is affected, that peritoneal signs appear. In an attempt to simplify matters, let us divide acute arterial mesenteric ischemia (AMI) into three types.\\n\\n1. **Thrombotic**: due to an acute arterial thrombosis (of a chronically diseased artery), which usually occludes the orifice of the SMA, resulting in massive ischemia of the entire small bowel plus the right colon — the area supplied by the SMA.\\n\\n2. **Embolic**: due to a shower of embolic material originating proximally — from the heart (atrial fibrillation, post-myocardial infarction, diseased valve) or an aneurysmal or atherosclerotic aorta. Emboli usually lodge in the proximal SMA, but beyond the exit of the middle colic artery; therefore, as a rule, the most proximal segment of proximal small bowel is spared, along with the transverse and (probably) the right colon. Emboli tend to fragment and re-embolize distally, producing a patchy type of small bowel ischemia. Note that embolism can occur against a background of chronic mesenteric arterial disease.\\n\\n3. **Non-occlusive mesenteric ischemia (NOMI)**: due to a ‘low-flow state’, in the absence of documented arterial thrombosis or embolus. Note, however, that underlying mesenteric atherosclerosis may be a precipitating/contributory factor. The low-flow state is a product of low cardiac output (e.g. cardiogenic shock), reduced mesenteric flow (e.g. intra-abdominal hypertension) or mesenteric vasoconstriction (e.g. administration of vasopressors) — usually, however, it is due to a combination of these factors, developing in the setting of a pre-existing critical illness.\\n\\nMesenteric venous thrombosis can also produce small bowel ischemia.\\n```',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.78, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 403,\n", " 'text': 'ischemia. The features and management of this entity differ drastically\\nfrom the other three. It will be discussed separately below.\\n\\n The problem is that in clinical practice, outside the textbook,\\nmesenteric ischemia is usually recognized when it has already led\\nto intestinal gangrene. At that stage the Pandora’s box of SIRS has\\nbeen opened and even removal of the entire gangrenous intestine will not\\nalways stop the progression to organ failure and death. Even if such\\nphysiological consequences can be overcome, the patient commonly\\nbecomes an ‘intestinal cripple’, suffering from the short bowel syndrome.\\n\\n ħave we depressed you enough yet?\\n\\n Assessing the problem\\n\\n Typically, the early clinical picture is non-specific — the patient\\ncomplains of severe abdominal pain — if he is able to complain at\\nall — and the doctor finds little on physical examination.\\n\\n Textbooks will tell you that, early on, the abdominal pain is out of\\nproportion to the clinical findings — the patient shouts and groans but\\nhis abdomen is innocent! ħowever, we have seen patients with almost a\\npainless presentation — the (fully alert) patient presenting with what\\nappears as ‘ileus’, doesn’t complain about pain, but at laparotomy a\\nsegment of his small bowel is already necrotic. So the key is always to\\nhave the suspicion of AMI in your mind! Remember: occasionally\\nwhat the ER doc or internist admits as a “gastroenteritis”, or\\n“partial small bowel obstruction” or “ileus” would prove (often too\\nlate) to be AMI. Thus, you must resist the natural temptation to ascribe\\npatients’ non-specific symptoms to some other benign condition unless\\nthe clinical features, including imaging, for the alternative explanation are\\nfully present. And by the way — in the elderly — the diagnosis of\\nacute gastroenteritis is rarely the final diagnosis; unless it was the\\nwrong diagnosis!\\n\\n There may have been preceding symptoms of a similar sort of pain\\ndeveloping with meals and accompanied by weight loss, suggesting pre-',\n", " 'md': '```markdown\\n## Page Content\\n\\nThe features and management of this entity differ drastically from the other three. It will be discussed separately below.\\n\\nThe problem is that in clinical practice, outside the textbook, mesenteric ischemia is usually recognized when it has already led to intestinal gangrene. At that stage the Pandora’s box of SIRS has been opened and even removal of the entire gangrenous intestine will not always stop the progression to organ failure and death. Even if such physiological consequences can be overcome, the patient commonly becomes an ‘intestinal cripple’, suffering from the short bowel syndrome.\\n\\nHave we depressed you enough yet?\\n\\n### Assessing the Problem\\n\\nTypically, the early clinical picture is non-specific — the patient complains of severe abdominal pain — if he is able to complain at all — and the doctor finds little on physical examination.\\n\\nTextbooks will tell you that, early on, the abdominal pain is out of proportion to the clinical findings — the patient shouts and groans but his abdomen is innocent! However, we have seen patients with almost a painless presentation — the (fully alert) patient presenting with what appears as ‘ileus’, doesn’t complain about pain, but at laparotomy a segment of his small bowel is already necrotic. So the key is always to have the suspicion of AMI in your mind! Remember: occasionally what the ER doc or internist admits as a “gastroenteritis”, or “partial small bowel obstruction” or “ileus” would prove (often too late) to be AMI. Thus, you must resist the natural temptation to ascribe patients’ non-specific symptoms to some other benign condition unless the clinical features, including imaging, for the alternative explanation are fully present. And by the way — in the elderly — the diagnosis of acute gastroenteritis is rarely the final diagnosis; unless it was the wrong diagnosis!\\n\\nThere may have been preceding symptoms of a similar sort of pain developing with meals and accompanied by weight loss, suggesting pre-\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The features and management of this entity differ drastically from the other three. It will be discussed separately below.\\n\\nThe problem is that in clinical practice, outside the textbook, mesenteric ischemia is usually recognized when it has already led to intestinal gangrene. At that stage the Pandora’s box of SIRS has been opened and even removal of the entire gangrenous intestine will not always stop the progression to organ failure and death. Even if such physiological consequences can be overcome, the patient commonly becomes an ‘intestinal cripple’, suffering from the short bowel syndrome.\\n\\nHave we depressed you enough yet?',\n", " 'md': 'The features and management of this entity differ drastically from the other three. It will be discussed separately below.\\n\\nThe problem is that in clinical practice, outside the textbook, mesenteric ischemia is usually recognized when it has already led to intestinal gangrene. At that stage the Pandora’s box of SIRS has been opened and even removal of the entire gangrenous intestine will not always stop the progression to organ failure and death. Even if such physiological consequences can be overcome, the patient commonly becomes an ‘intestinal cripple’, suffering from the short bowel syndrome.\\n\\nHave we depressed you enough yet?',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Assessing the Problem',\n", " 'md': '### Assessing the Problem',\n", " 'bBox': {'x': 86, 'y': 315, 'w': 182.09, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Typically, the early clinical picture is non-specific — the patient complains of severe abdominal pain — if he is able to complain at all — and the doctor finds little on physical examination.\\n\\nTextbooks will tell you that, early on, the abdominal pain is out of proportion to the clinical findings — the patient shouts and groans but his abdomen is innocent! However, we have seen patients with almost a painless presentation — the (fully alert) patient presenting with what appears as ‘ileus’, doesn’t complain about pain, but at laparotomy a segment of his small bowel is already necrotic. So the key is always to have the suspicion of AMI in your mind! Remember: occasionally what the ER doc or internist admits as a “gastroenteritis”, or “partial small bowel obstruction” or “ileus” would prove (often too late) to be AMI. Thus, you must resist the natural temptation to ascribe patients’ non-specific symptoms to some other benign condition unless the clinical features, including imaging, for the alternative explanation are fully present. And by the way — in the elderly — the diagnosis of acute gastroenteritis is rarely the final diagnosis; unless it was the wrong diagnosis!\\n\\nThere may have been preceding symptoms of a similar sort of pain developing with meals and accompanied by weight loss, suggesting pre-\\n```',\n", " 'md': 'Typically, the early clinical picture is non-specific — the patient complains of severe abdominal pain — if he is able to complain at all — and the doctor finds little on physical examination.\\n\\nTextbooks will tell you that, early on, the abdominal pain is out of proportion to the clinical findings — the patient shouts and groans but his abdomen is innocent! However, we have seen patients with almost a painless presentation — the (fully alert) patient presenting with what appears as ‘ileus’, doesn’t complain about pain, but at laparotomy a segment of his small bowel is already necrotic. So the key is always to have the suspicion of AMI in your mind! Remember: occasionally what the ER doc or internist admits as a “gastroenteritis”, or “partial small bowel obstruction” or “ileus” would prove (often too late) to be AMI. Thus, you must resist the natural temptation to ascribe patients’ non-specific symptoms to some other benign condition unless the clinical features, including imaging, for the alternative explanation are fully present. And by the way — in the elderly — the diagnosis of acute gastroenteritis is rarely the final diagnosis; unless it was the wrong diagnosis!\\n\\nThere may have been preceding symptoms of a similar sort of pain developing with meals and accompanied by weight loss, suggesting pre-\\n```',\n", " 'bBox': {'x': 72, 'y': 384, 'w': 467.8, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 404,\n", " 'text': 'existing mesenteric angina. A history or evidence of systemic\\natherosclerotic vascular disease is almost the rule in patients with\\nmesenteric thrombosis, while a source for emboli, such as atrial\\nfibrillation, is usually present in patients with mesenteric embolism. Low-\\nflow state patients are commonly moribund due to underlying critical\\ndisease and are not infrequently found in the cardiac surgery ICU.\\n\\n Nausea, vomiting, diarrhea (caused by ‘reflex bowel emptying’) and\\nhematochezia may come late, if ever, and are, again, non-specific.\\nPhysical examination in the early stages of the process is treacherously\\nbenign; peritoneal irritation appears too late, when the bowel is already\\ndead.\\n\\n Laboratory tests are not much help here either. Evidence of\\ncompromised bowel such as elevated serum lactic acid, C-reactive\\nprotein (CRP), amylase or a negative base excess are suggestive but\\nnon-specific. ħowever, extreme leukocytosis is not uncommon even\\nbefore the intestine dies.\\n\\n Plain abdominal X-rays early in the course of the illness are normal.\\nLater, there may be a pattern of adynamic ileus, with visible loops of\\nsmall bowel and fluid levels, but with gas and feces seen within the\\nnormal colon and rectum.\\n\\n The bottom line is that initially in acute mesenteric ischemia the\\nphysical examination and all commonly available X-rays and blood\\ntests may be normal.\\n\\n At this stage, entertaining the diagnosis of mesenteric ischemia, you\\nhave two options: the first is to enter in the chart “abdominal examination\\nnormal; mesenteric ischemia cannot be ruled out; will reassess later”.\\nThis, you will do only if you are a lazy moron, which, we trust, you are\\nnot. The second option — the right one — is to order a CT scan with\\nintravenous contrast, which has replaced mesenteric angiography as\\nthe initial, screening imaging modality in AMI. Although angiography is\\nmore specific and accurate, surgeons have been reluctant to offer such\\nan invasive procedure in patients with a non-specific clinical picture.\\nUnfortunately, the first option is still common in some places — leading to',\n", " 'md': '```markdown\\n## Page Content\\n\\nExisting mesenteric angina. A history or evidence of systemic atherosclerotic vascular disease is almost the rule in patients with mesenteric thrombosis, while a source for emboli, such as atrial fibrillation, is usually present in patients with mesenteric embolism. Low-flow state patients are commonly moribund due to underlying critical disease and are not infrequently found in the cardiac surgery ICU.\\n\\nNausea, vomiting, diarrhea (caused by ‘reflex bowel emptying’) and hematochezia may come late, if ever, and are, again, non-specific. Physical examination in the early stages of the process is treacherously benign; peritoneal irritation appears too late, when the bowel is already dead.\\n\\nLaboratory tests are not much help here either. Evidence of compromised bowel such as elevated serum lactic acid, C-reactive protein (CRP), amylase or a negative base excess are suggestive but non-specific. However, extreme leukocytosis is not uncommon even before the intestine dies.\\n\\nPlain abdominal X-rays early in the course of the illness are normal. Later, there may be a pattern of adynamic ileus, with visible loops of small bowel and fluid levels, but with gas and feces seen within the normal colon and rectum.\\n\\nThe bottom line is that initially in acute mesenteric ischemia the physical examination and all commonly available X-rays and blood tests may be normal.\\n\\nAt this stage, entertaining the diagnosis of mesenteric ischemia, you have two options: the first is to enter in the chart “abdominal examination normal; mesenteric ischemia cannot be ruled out; will reassess later”. This, you will do only if you are a lazy moron, which, we trust, you are not. The second option — the right one — is to order a CT scan with intravenous contrast, which has replaced mesenteric angiography as the initial, screening imaging modality in AMI. Although angiography is more specific and accurate, surgeons have been reluctant to offer such an invasive procedure in patients with a non-specific clinical picture. Unfortunately, the first option is still common in some places — leading to...\\n\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Existing mesenteric angina. A history or evidence of systemic atherosclerotic vascular disease is almost the rule in patients with mesenteric thrombosis, while a source for emboli, such as atrial fibrillation, is usually present in patients with mesenteric embolism. Low-flow state patients are commonly moribund due to underlying critical disease and are not infrequently found in the cardiac surgery ICU.\\n\\nNausea, vomiting, diarrhea (caused by ‘reflex bowel emptying’) and hematochezia may come late, if ever, and are, again, non-specific. Physical examination in the early stages of the process is treacherously benign; peritoneal irritation appears too late, when the bowel is already dead.\\n\\nLaboratory tests are not much help here either. Evidence of compromised bowel such as elevated serum lactic acid, C-reactive protein (CRP), amylase or a negative base excess are suggestive but non-specific. However, extreme leukocytosis is not uncommon even before the intestine dies.\\n\\nPlain abdominal X-rays early in the course of the illness are normal. Later, there may be a pattern of adynamic ileus, with visible loops of small bowel and fluid levels, but with gas and feces seen within the normal colon and rectum.\\n\\nThe bottom line is that initially in acute mesenteric ischemia the physical examination and all commonly available X-rays and blood tests may be normal.\\n\\nAt this stage, entertaining the diagnosis of mesenteric ischemia, you have two options: the first is to enter in the chart “abdominal examination normal; mesenteric ischemia cannot be ruled out; will reassess later”. This, you will do only if you are a lazy moron, which, we trust, you are not. The second option — the right one — is to order a CT scan with intravenous contrast, which has replaced mesenteric angiography as the initial, screening imaging modality in AMI. Although angiography is more specific and accurate, surgeons have been reluctant to offer such an invasive procedure in patients with a non-specific clinical picture. Unfortunately, the first option is still common in some places — leading to...\\n\\n```',\n", " 'md': 'Existing mesenteric angina. A history or evidence of systemic atherosclerotic vascular disease is almost the rule in patients with mesenteric thrombosis, while a source for emboli, such as atrial fibrillation, is usually present in patients with mesenteric embolism. Low-flow state patients are commonly moribund due to underlying critical disease and are not infrequently found in the cardiac surgery ICU.\\n\\nNausea, vomiting, diarrhea (caused by ‘reflex bowel emptying’) and hematochezia may come late, if ever, and are, again, non-specific. Physical examination in the early stages of the process is treacherously benign; peritoneal irritation appears too late, when the bowel is already dead.\\n\\nLaboratory tests are not much help here either. Evidence of compromised bowel such as elevated serum lactic acid, C-reactive protein (CRP), amylase or a negative base excess are suggestive but non-specific. However, extreme leukocytosis is not uncommon even before the intestine dies.\\n\\nPlain abdominal X-rays early in the course of the illness are normal. Later, there may be a pattern of adynamic ileus, with visible loops of small bowel and fluid levels, but with gas and feces seen within the normal colon and rectum.\\n\\nThe bottom line is that initially in acute mesenteric ischemia the physical examination and all commonly available X-rays and blood tests may be normal.\\n\\nAt this stage, entertaining the diagnosis of mesenteric ischemia, you have two options: the first is to enter in the chart “abdominal examination normal; mesenteric ischemia cannot be ruled out; will reassess later”. This, you will do only if you are a lazy moron, which, we trust, you are not. The second option — the right one — is to order a CT scan with intravenous contrast, which has replaced mesenteric angiography as the initial, screening imaging modality in AMI. Although angiography is more specific and accurate, surgeons have been reluctant to offer such an invasive procedure in patients with a non-specific clinical picture. Unfortunately, the first option is still common in some places — leading to...\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 405,\n", " 'text': 'procrastination, late diagnosis and treatment, and a very high mortality\\nrate.\\n\\n Computed tomography\\n\\n To be diagnostic, the examination should include appropiately\\ntimed intravenous contrast (‘CT angio’), with the focus on two\\nareas: the bowel wall and mesenteric vessels. The commonest finding\\nis bowel wall thickening, which is, however, non-specific. The bowel wall\\nmay appear low in attenuation due to edema or, when submucosal\\nhemorrhage is present, it may appear of high attenuation due to the\\nblood products. Visualization of the dynamic enhancement pattern of the\\naffected bowel loops may improve diagnosis. Affected bowel loops may\\ndemonstrate absence of enhancement, delay in enhancement, or\\npersistent enhancement when compared to unaffected loops.\\nPneumatosis and portal vein gas are uncommon but specific, albeit late,\\nsigns — due to intraluminal gas dissecting into the friable bowel wall and\\nthen into the portal venous tributaries. CT angio can also visualize\\nacute changes such as emboli within the SMA or thrombosis at its\\norigin; it can also demonstrate chronic changes, such as stenosis\\nor occlusion of the chief collateral sources of mesenteric blood\\nsupply — the celiac and/or inferior mesenteric artery. Often,\\nhowever, even the CT findings in this condition are subtle and easy to\\nmiss.\\n\\n Magnetic resonance angiography (MRA) could be superb in imaging\\nmesenteric vessels (with reduced risk of contrast nephrotoxicity) but, like\\nCT angio, is far inferior to conventional angiography in visualizing distal\\nbranches. In addition, in how many hospitals would MRA be available in\\nthe middle of the night?\\n\\n Mesenteric angiography\\n\\n To be beneficial the angiogram should be performed before the\\nbowel has become gangrenous. The clock is ticking; every passing\\nminute reduces the chances of the bowel and the patient surviving. Note\\nthat an acute abdomen with peritoneal signs is a contraindication to',\n", " 'md': '```markdown\\n# Page Content\\n\\nProcrastination, late diagnosis and treatment, and a very high mortality rate.\\n\\n## Computed Tomography\\n\\nTo be diagnostic, the examination should include appropriately timed intravenous contrast (‘CT angio’), with the focus on two areas: the bowel wall and mesenteric vessels. The commonest finding is bowel wall thickening, which is, however, non-specific. The bowel wall may appear low in attenuation due to edema or, when submucosal hemorrhage is present, it may appear of high attenuation due to the blood products. Visualization of the dynamic enhancement pattern of the affected bowel loops may improve diagnosis. Affected bowel loops may demonstrate absence of enhancement, delay in enhancement, or persistent enhancement when compared to unaffected loops. Pneumatosis and portal vein gas are uncommon but specific, albeit late, signs — due to intraluminal gas dissecting into the friable bowel wall and then into the portal venous tributaries. CT angio can also visualize acute changes such as emboli within the SMA or thrombosis at its origin; it can also demonstrate chronic changes, such as stenosis or occlusion of the chief collateral sources of mesenteric blood supply — the celiac and/or inferior mesenteric artery. Often, however, even the CT findings in this condition are subtle and easy to miss.\\n\\n## Magnetic Resonance Angiography (MRA)\\n\\nMRA could be superb in imaging mesenteric vessels (with reduced risk of contrast nephrotoxicity) but, like CT angio, is far inferior to conventional angiography in visualizing distal branches. In addition, in how many hospitals would MRA be available in the middle of the night?\\n\\n## Mesenteric Angiography\\n\\nTo be beneficial, the angiogram should be performed before the bowel has become gangrenous. The clock is ticking; every passing minute reduces the chances of the bowel and the patient surviving. Note that an acute abdomen with peritoneal signs is a contraindication to...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted appropriately.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Procrastination, late diagnosis and treatment, and a very high mortality rate.',\n", " 'md': 'Procrastination, late diagnosis and treatment, and a very high mortality rate.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 28.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Computed Tomography',\n", " 'md': '## Computed Tomography',\n", " 'bBox': {'x': 86, 'y': 145, 'w': 182.07, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'To be diagnostic, the examination should include appropriately timed intravenous contrast (‘CT angio’), with the focus on two areas: the bowel wall and mesenteric vessels. The commonest finding is bowel wall thickening, which is, however, non-specific. The bowel wall may appear low in attenuation due to edema or, when submucosal hemorrhage is present, it may appear of high attenuation due to the blood products. Visualization of the dynamic enhancement pattern of the affected bowel loops may improve diagnosis. Affected bowel loops may demonstrate absence of enhancement, delay in enhancement, or persistent enhancement when compared to unaffected loops. Pneumatosis and portal vein gas are uncommon but specific, albeit late, signs — due to intraluminal gas dissecting into the friable bowel wall and then into the portal venous tributaries. CT angio can also visualize acute changes such as emboli within the SMA or thrombosis at its origin; it can also demonstrate chronic changes, such as stenosis or occlusion of the chief collateral sources of mesenteric blood supply — the celiac and/or inferior mesenteric artery. Often, however, even the CT findings in this condition are subtle and easy to miss.',\n", " 'md': 'To be diagnostic, the examination should include appropriately timed intravenous contrast (‘CT angio’), with the focus on two areas: the bowel wall and mesenteric vessels. The commonest finding is bowel wall thickening, which is, however, non-specific. The bowel wall may appear low in attenuation due to edema or, when submucosal hemorrhage is present, it may appear of high attenuation due to the blood products. Visualization of the dynamic enhancement pattern of the affected bowel loops may improve diagnosis. Affected bowel loops may demonstrate absence of enhancement, delay in enhancement, or persistent enhancement when compared to unaffected loops. Pneumatosis and portal vein gas are uncommon but specific, albeit late, signs — due to intraluminal gas dissecting into the friable bowel wall and then into the portal venous tributaries. CT angio can also visualize acute changes such as emboli within the SMA or thrombosis at its origin; it can also demonstrate chronic changes, such as stenosis or occlusion of the chief collateral sources of mesenteric blood supply — the celiac and/or inferior mesenteric artery. Often, however, even the CT findings in this condition are subtle and easy to miss.',\n", " 'bBox': {'x': 72, 'y': 214, 'w': 467.84, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Magnetic Resonance Angiography (MRA)',\n", " 'md': '## Magnetic Resonance Angiography (MRA)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'MRA could be superb in imaging mesenteric vessels (with reduced risk of contrast nephrotoxicity) but, like CT angio, is far inferior to conventional angiography in visualizing distal branches. In addition, in how many hospitals would MRA be available in the middle of the night?',\n", " 'md': 'MRA could be superb in imaging mesenteric vessels (with reduced risk of contrast nephrotoxicity) but, like CT angio, is far inferior to conventional angiography in visualizing distal branches. In addition, in how many hospitals would MRA be available in the middle of the night?',\n", " 'bBox': {'x': 72, 'y': 330, 'w': 467.84, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Mesenteric Angiography',\n", " 'md': '## Mesenteric Angiography',\n", " 'bBox': {'x': 86, 'y': 624, 'w': 190.37, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'To be beneficial, the angiogram should be performed before the bowel has become gangrenous. The clock is ticking; every passing minute reduces the chances of the bowel and the patient surviving. Note that an acute abdomen with peritoneal signs is a contraindication to...\\n```',\n", " 'md': 'To be beneficial, the angiogram should be performed before the bowel has become gangrenous. The clock is ticking; every passing minute reduces the chances of the bowel and the patient surviving. Note that an acute abdomen with peritoneal signs is a contraindication to...\\n```',\n", " 'bBox': {'x': 72, 'y': 330, 'w': 467.29, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted appropriately.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted appropriately.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 388, 'y': 330, 'w': 16, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 406,\n", " 'text': 'angiography, for such patients belong in the operating room. So\\nthese days angiography is obtained usually after the ‘CT-angio’ to\\nestablish which revascularization option, if any, is advisable. The\\nradiologist should start with biplanar angiography (i.e. including a lateral\\nview to show the origins of the SMA and the celiac axis). An occluded\\nostium of the SMA denotes thrombosis and calls for an immediate\\nrevascularization procedure (radiological or surgical) — unless there is\\nevidence of a good collateral inflow — the angiography providing the\\nroad map for vascular reconstruction. When the ostium is patent the\\nradiologist advances the catheter into the SMA. Emboli lodge distal to the\\ntake-off of the middle colic artery, produce a smooth filling defect on the\\nbackground of a normal SMA, and can be multiple.\\n\\n Non-operative treatment\\n\\n In the absence of peritoneal signs, attempts at non-operative treatment\\nare justified — tailored to the clinical/CT/angiographic findings. Selective\\ndiagnostic angiography can now become therapeutic — infusing a\\nthrombolytic agent to lyse the thrombus or embolus with or without\\nadding papaverine to relieve the associated mesenteric vasospasm. At\\nthe same time stents can be inserted to alleviate significant stenosis of\\nthe SMA and, if necessary, the celiac artery. Cessation of abdominal\\nsymptoms together with angiographic resolution means that the\\nemergency is over.\\n\\n In the event of non-occlusive mesenteric ischemia, the approach\\ninvolves attempts at restoring compromised hemodynamics. To\\nrelieve associated arteriospasm, a selective intra-arterial infusion of a\\nvasodilator, such as papaverine, has been advocated. The few\\nchampions of this method have reported “favorable responses” although\\nthat 20-year-old retrospective study from New York was never confirmed\\nby firm data, so we may be dealing with a myth. When emboli are the\\ncause, after successful transcatheter therapy, long-term anticoagulation\\nis indicated. A final point — while rushing to the arteriography suite,\\nremember to ensure adequate hydration of your patient to oppose the\\nnephrotoxic effect of the contrast media.',\n", " 'md': '```markdown\\n## Angiography and Non-Operative Treatment\\n\\nAngiography for such patients belongs in the operating room. Nowadays, angiography is usually obtained after the ‘CT-angio’ to establish which revascularization option, if any, is advisable. The radiologist should start with biplanar angiography (i.e., including a lateral view to show the origins of the SMA and the celiac axis). An occluded ostium of the SMA denotes thrombosis and calls for an immediate revascularization procedure (radiological or surgical) — unless there is evidence of a good collateral inflow — the angiography providing the roadmap for vascular reconstruction. When the ostium is patent, the radiologist advances the catheter into the SMA. Emboli lodge distal to the take-off of the middle colic artery, producing a smooth filling defect on the background of a normal SMA, and can be multiple.\\n\\n### Non-Operative Treatment\\n\\nIn the absence of peritoneal signs, attempts at non-operative treatment are justified — tailored to the clinical/CT/angiographic findings. Selective diagnostic angiography can now become therapeutic — infusing a thrombolytic agent to lyse the thrombus or embolus with or without adding papaverine to relieve the associated mesenteric vasospasm. At the same time, stents can be inserted to alleviate significant stenosis of the SMA and, if necessary, the celiac artery. Cessation of abdominal symptoms together with angiographic resolution means that the emergency is over.\\n\\nIn the event of non-occlusive mesenteric ischemia, the approach involves attempts at restoring compromised hemodynamics. To relieve associated arteriospasm, a selective intra-arterial infusion of a vasodilator, such as papaverine, has been advocated. The few champions of this method have reported “favorable responses” although that 20-year-old retrospective study from New York was never confirmed by firm data, so we may be dealing with a myth. When emboli are the cause, after successful transcatheter therapy, long-term anticoagulation is indicated. A final point — while rushing to the arteriography suite, remember to ensure adequate hydration of your patient to oppose the nephrotoxic effect of the contrast media.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Angiography and Non-Operative Treatment',\n", " 'md': '## Angiography and Non-Operative Treatment',\n", " 'bBox': {'x': 86, 'y': 311, 'w': 191.27, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Angiography for such patients belongs in the operating room. Nowadays, angiography is usually obtained after the ‘CT-angio’ to establish which revascularization option, if any, is advisable. The radiologist should start with biplanar angiography (i.e., including a lateral view to show the origins of the SMA and the celiac axis). An occluded ostium of the SMA denotes thrombosis and calls for an immediate revascularization procedure (radiological or surgical) — unless there is evidence of a good collateral inflow — the angiography providing the roadmap for vascular reconstruction. When the ostium is patent, the radiologist advances the catheter into the SMA. Emboli lodge distal to the take-off of the middle colic artery, producing a smooth filling defect on the background of a normal SMA, and can be multiple.',\n", " 'md': 'Angiography for such patients belongs in the operating room. Nowadays, angiography is usually obtained after the ‘CT-angio’ to establish which revascularization option, if any, is advisable. The radiologist should start with biplanar angiography (i.e., including a lateral view to show the origins of the SMA and the celiac axis). An occluded ostium of the SMA denotes thrombosis and calls for an immediate revascularization procedure (radiological or surgical) — unless there is evidence of a good collateral inflow — the angiography providing the roadmap for vascular reconstruction. When the ostium is patent, the radiologist advances the catheter into the SMA. Emboli lodge distal to the take-off of the middle colic artery, producing a smooth filling defect on the background of a normal SMA, and can be multiple.',\n", " 'bBox': {'x': 72, 'y': 235, 'w': 467.46, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Non-Operative Treatment',\n", " 'md': '### Non-Operative Treatment',\n", " 'bBox': {'x': 86, 'y': 311, 'w': 191.27, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In the absence of peritoneal signs, attempts at non-operative treatment are justified — tailored to the clinical/CT/angiographic findings. Selective diagnostic angiography can now become therapeutic — infusing a thrombolytic agent to lyse the thrombus or embolus with or without adding papaverine to relieve the associated mesenteric vasospasm. At the same time, stents can be inserted to alleviate significant stenosis of the SMA and, if necessary, the celiac artery. Cessation of abdominal symptoms together with angiographic resolution means that the emergency is over.\\n\\nIn the event of non-occlusive mesenteric ischemia, the approach involves attempts at restoring compromised hemodynamics. To relieve associated arteriospasm, a selective intra-arterial infusion of a vasodilator, such as papaverine, has been advocated. The few champions of this method have reported “favorable responses” although that 20-year-old retrospective study from New York was never confirmed by firm data, so we may be dealing with a myth. When emboli are the cause, after successful transcatheter therapy, long-term anticoagulation is indicated. A final point — while rushing to the arteriography suite, remember to ensure adequate hydration of your patient to oppose the nephrotoxic effect of the contrast media.\\n```',\n", " 'md': 'In the absence of peritoneal signs, attempts at non-operative treatment are justified — tailored to the clinical/CT/angiographic findings. Selective diagnostic angiography can now become therapeutic — infusing a thrombolytic agent to lyse the thrombus or embolus with or without adding papaverine to relieve the associated mesenteric vasospasm. At the same time, stents can be inserted to alleviate significant stenosis of the SMA and, if necessary, the celiac artery. Cessation of abdominal symptoms together with angiographic resolution means that the emergency is over.\\n\\nIn the event of non-occlusive mesenteric ischemia, the approach involves attempts at restoring compromised hemodynamics. To relieve associated arteriospasm, a selective intra-arterial infusion of a vasodilator, such as papaverine, has been advocated. The few champions of this method have reported “favorable responses” although that 20-year-old retrospective study from New York was never confirmed by firm data, so we may be dealing with a myth. When emboli are the cause, after successful transcatheter therapy, long-term anticoagulation is indicated. A final point — while rushing to the arteriography suite, remember to ensure adequate hydration of your patient to oppose the nephrotoxic effect of the contrast media.\\n```',\n", " 'bBox': {'x': 72, 'y': 311, 'w': 467.96, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 407,\n", " 'text': ' Operative treatment\\n\\n As we have already told you — peritoneal signs, considered together\\nwith a suggestive clinical (and CT) picture, are an indication not to do\\narteriography but to operate; the same applies to failure of the non-\\noperative regimen discussed above.\\n PERIA 2o1y\\nFigure 24.1. “How much should I resect?”\\n\\n Through a midline incision assess the viability of the intestine. In\\ngeneral there are two main possible scenarios: one is that the bowel\\nis frankly gangrenous (dead); the second is when the bowel appears\\nischemic (dusky) and of questionable viability:\\n\\n • Frank gangrene of the entire small bowel is usually combined\\n with the same problem in the right colon and signifies SMA\\n thrombosis. Theoretically, a sporadic patient could survive\\n resection of the entire small bowel and right colon. ħe may even\\n tolerate a duodenocolic anastomosis while being nutritionally\\n supported at home with total parenteral nutrition (TPN). But the',\n", " 'md': '```markdown\\n# Operative Treatment\\n\\nAs we have already told you — peritoneal signs, considered together with a suggestive clinical (and CT) picture, are an indication not to do arteriography but to operate; the same applies to failure of the non-operative regimen discussed above.\\n\\n**Figure 24.1.** “How much should I resect?”\\n\\nThrough a midline incision assess the viability of the intestine. In general, there are two main possible scenarios: one is that the bowel is frankly gangrenous (dead); the second is when the bowel appears ischemic (dusky) and of questionable viability:\\n\\n- Frank gangrene of the entire small bowel is usually combined with the same problem in the right colon and signifies SMA thrombosis. Theoretically, a sporadic patient could survive resection of the entire small bowel and right colon. He may even tolerate a duodenocolic anastomosis while being nutritionally supported at home with total parenteral nutrition (TPN). But the\\n```',\n", " 'images': [{'name': 'img_p406_1.png',\n", " 'height': 594,\n", " 'width': 690,\n", " 'x': 135.35999999999967,\n", " 'y': 187.2,\n", " 'original_width': 1184,\n", " 'original_height': 1020}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Operative Treatment',\n", " 'md': '# Operative Treatment',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 156.33, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As we have already told you — peritoneal signs, considered together with a suggestive clinical (and CT) picture, are an indication not to do arteriography but to operate; the same applies to failure of the non-operative regimen discussed above.\\n\\n**Figure 24.1.** “How much should I resect?”\\n\\nThrough a midline incision assess the viability of the intestine. In general, there are two main possible scenarios: one is that the bowel is frankly gangrenous (dead); the second is when the bowel appears ischemic (dusky) and of questionable viability:\\n\\n- Frank gangrene of the entire small bowel is usually combined with the same problem in the right colon and signifies SMA thrombosis. Theoretically, a sporadic patient could survive resection of the entire small bowel and right colon. He may even tolerate a duodenocolic anastomosis while being nutritionally supported at home with total parenteral nutrition (TPN). But the\\n```',\n", " 'md': 'As we have already told you — peritoneal signs, considered together with a suggestive clinical (and CT) picture, are an indication not to do arteriography but to operate; the same applies to failure of the non-operative regimen discussed above.\\n\\n**Figure 24.1.** “How much should I resect?”\\n\\nThrough a midline incision assess the viability of the intestine. In general, there are two main possible scenarios: one is that the bowel is frankly gangrenous (dead); the second is when the bowel appears ischemic (dusky) and of questionable viability:\\n\\n- Frank gangrene of the entire small bowel is usually combined with the same problem in the right colon and signifies SMA thrombosis. Theoretically, a sporadic patient could survive resection of the entire small bowel and right colon. He may even tolerate a duodenocolic anastomosis while being nutritionally supported at home with total parenteral nutrition (TPN). But the\\n```',\n", " 'bBox': {'x': 72, 'y': 173, 'w': 467.1, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 408,\n", " 'text': ' eventual mortality of such an exercise in the average elderly\\n vasculopath approaches 100% and the cost is immense. Our\\n recommendation to you when involved in a similar situation is to\\n walk out to talk to the family, and explain that anything done will only\\n increase the suffering of their beloved. If the family wishes so then\\n return to close the abdomen over the dead bowel. Provide a lot of\\n morphine and comfort. As with everything in life — there are\\n exceptions: in a relatively young and active patient, and when local\\n circumstances are favorable (we doubt that there are facilities for\\n home TPN in rural Afghanistan or even Eastern Ukraine), you and\\n the family may want to strive for long-term survival.\\n• Frank gangrene of a shorter segment, or multiple segments of\\n small bowel, usually denotes embolism. After excising all dead\\n segments carefully examine the remaining bowel. Measure it: how\\n long is it? Only about half of patients left with less than 1 meter\\n (3 feet) of small bowel will live without TPN (saving the\\n ileocecal valve improves the prognosis). Now, observe the\\n remaining bowel. Is it truly non-compromised? Are the mesenteric\\n arcades pulsating well? Feel the SMA at its root — is it vigorously\\n pulsating?\\n• Dusky bowel. When you are not happy with the remaining\\n bowel, or when the bowel is not dead but appears ischemic and\\n of questionable viability from the start, proceed as follows.\\n First, if possible, revascularize using the techniques described in the\\n next section. Then wrap the bowel in warm, saline-moistened\\n sponges and wait 15 minutes. Unscrub and have a coffee; surgeons\\n cannot stare at an inactive field for that long without starting to\\n fiddle. Failure of the bowel to pink-up mandates its resection. When\\n the length of remaining normal-looking bowel reduces towards 1.5\\n meters (5 feet) it may be advisable to leave the doubtful bowel in\\n situ, to be re-examined during a relook operation (see below).\\n Salvaging even a short segment of small bowel may improve the\\n chances of preserving a life worth living. Some authors recommend\\n the use of hand-held Doppler to examine the perfusion of the anti-\\n mesenteric side of the bowel; others use intra-operative fluorescein\\n angiography. More practical appears to be a pulse oximeter —\\n sterile probes are now available. You may choose to use such\\n modalities if available to you but your clinical judgment should be',\n", " 'md': '```markdown\\n# Page Content\\n\\nThe eventual mortality of such an exercise in the average elderly vasculopath approaches 100% and the cost is immense. Our recommendation to you when involved in a similar situation is to walk out to talk to the family, and explain that anything done will only increase the suffering of their beloved. If the family wishes so then return to close the abdomen over the dead bowel. Provide a lot of morphine and comfort. As with everything in life — there are exceptions: in a relatively young and active patient, and when local circumstances are favorable (we doubt that there are facilities for home TPN in rural Afghanistan or even Eastern Ukraine), you and the family may want to strive for long-term survival.\\n\\n- Frank gangrene of a shorter segment, or multiple segments of small bowel, usually denotes embolism. After excising all dead segments carefully examine the remaining bowel. Measure it: how long is it? Only about half of patients left with less than 1 meter (3 feet) of small bowel will live without TPN (saving the ileocecal valve improves the prognosis). Now, observe the remaining bowel. Is it truly non-compromised? Are the mesenteric arcades pulsating well? Feel the SMA at its root — is it vigorously pulsating?\\n\\n- Dusky bowel. When you are not happy with the remaining bowel, or when the bowel is not dead but appears ischemic and of questionable viability from the start, proceed as follows. First, if possible, revascularize using the techniques described in the next section. Then wrap the bowel in warm, saline-moistened sponges and wait 15 minutes. Unscrub and have a coffee; surgeons cannot stare at an inactive field for that long without starting to fiddle. Failure of the bowel to pink-up mandates its resection. When the length of remaining normal-looking bowel reduces towards 1.5 meters (5 feet) it may be advisable to leave the doubtful bowel in situ, to be re-examined during a relook operation (see below). Salvaging even a short segment of small bowel may improve the chances of preserving a life worth living. Some authors recommend the use of hand-held Doppler to examine the perfusion of the anti-mesenteric side of the bowel; others use intra-operative fluorescein angiography. More practical appears to be a pulse oximeter — sterile probes are now available. You may choose to use such modalities if available to you but your clinical judgment should be.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The eventual mortality of such an exercise in the average elderly vasculopath approaches 100% and the cost is immense. Our recommendation to you when involved in a similar situation is to walk out to talk to the family, and explain that anything done will only increase the suffering of their beloved. If the family wishes so then return to close the abdomen over the dead bowel. Provide a lot of morphine and comfort. As with everything in life — there are exceptions: in a relatively young and active patient, and when local circumstances are favorable (we doubt that there are facilities for home TPN in rural Afghanistan or even Eastern Ukraine), you and the family may want to strive for long-term survival.\\n\\n- Frank gangrene of a shorter segment, or multiple segments of small bowel, usually denotes embolism. After excising all dead segments carefully examine the remaining bowel. Measure it: how long is it? Only about half of patients left with less than 1 meter (3 feet) of small bowel will live without TPN (saving the ileocecal valve improves the prognosis). Now, observe the remaining bowel. Is it truly non-compromised? Are the mesenteric arcades pulsating well? Feel the SMA at its root — is it vigorously pulsating?\\n\\n- Dusky bowel. When you are not happy with the remaining bowel, or when the bowel is not dead but appears ischemic and of questionable viability from the start, proceed as follows. First, if possible, revascularize using the techniques described in the next section. Then wrap the bowel in warm, saline-moistened sponges and wait 15 minutes. Unscrub and have a coffee; surgeons cannot stare at an inactive field for that long without starting to fiddle. Failure of the bowel to pink-up mandates its resection. When the length of remaining normal-looking bowel reduces towards 1.5 meters (5 feet) it may be advisable to leave the doubtful bowel in situ, to be re-examined during a relook operation (see below). Salvaging even a short segment of small bowel may improve the chances of preserving a life worth living. Some authors recommend the use of hand-held Doppler to examine the perfusion of the anti-mesenteric side of the bowel; others use intra-operative fluorescein angiography. More practical appears to be a pulse oximeter — sterile probes are now available. You may choose to use such modalities if available to you but your clinical judgment should be.\\n\\n```',\n", " 'md': 'The eventual mortality of such an exercise in the average elderly vasculopath approaches 100% and the cost is immense. Our recommendation to you when involved in a similar situation is to walk out to talk to the family, and explain that anything done will only increase the suffering of their beloved. If the family wishes so then return to close the abdomen over the dead bowel. Provide a lot of morphine and comfort. As with everything in life — there are exceptions: in a relatively young and active patient, and when local circumstances are favorable (we doubt that there are facilities for home TPN in rural Afghanistan or even Eastern Ukraine), you and the family may want to strive for long-term survival.\\n\\n- Frank gangrene of a shorter segment, or multiple segments of small bowel, usually denotes embolism. After excising all dead segments carefully examine the remaining bowel. Measure it: how long is it? Only about half of patients left with less than 1 meter (3 feet) of small bowel will live without TPN (saving the ileocecal valve improves the prognosis). Now, observe the remaining bowel. Is it truly non-compromised? Are the mesenteric arcades pulsating well? Feel the SMA at its root — is it vigorously pulsating?\\n\\n- Dusky bowel. When you are not happy with the remaining bowel, or when the bowel is not dead but appears ischemic and of questionable viability from the start, proceed as follows. First, if possible, revascularize using the techniques described in the next section. Then wrap the bowel in warm, saline-moistened sponges and wait 15 minutes. Unscrub and have a coffee; surgeons cannot stare at an inactive field for that long without starting to fiddle. Failure of the bowel to pink-up mandates its resection. When the length of remaining normal-looking bowel reduces towards 1.5 meters (5 feet) it may be advisable to leave the doubtful bowel in situ, to be re-examined during a relook operation (see below). Salvaging even a short segment of small bowel may improve the chances of preserving a life worth living. Some authors recommend the use of hand-held Doppler to examine the perfusion of the anti-mesenteric side of the bowel; others use intra-operative fluorescein angiography. More practical appears to be a pulse oximeter — sterile probes are now available. You may choose to use such modalities if available to you but your clinical judgment should be.\\n\\n```',\n", " 'bBox': {'x': 100, 'y': 135, 'w': 436.95, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 409,\n", " 'text': ' just as good as any gimmick ( Figure 24.1).\\n\\n Adjunctive vascular procedures\\n\\n The ideal setting for surgical improvement of the perfusion of ischemic\\nsmall bowel is when the operation follows emergency arteriography (plus\\nfailed angiographic therapy) and the bowel is viable or doubtful.\\nObviously, when the bowel is dead it cannot be revived! Arteriography\\nserves as a road map; when the SMA is thrombosed at its origin, a vein\\nor other graft bypass, antegrade or retrograde, is indicated to reperfuse\\nthe SMA. The two main options here are autogenous vein bypass or\\nexternally supported polytetrafluoroethylene (PTFE) inserted in a ‘lazy\\nloop’ fashion. The origin of these bypass grafts is often determined by the\\npattern of disease affecting the other intra-abdominal vessels. Usually the\\niliac vessels are the best source of pulsatile flow but care must be taken\\nwhen vein is used, to see that it does not kink when the gut is returned to\\nits normal position.\\n\\n The above scenario is, however, rare; more commonly you’ll\\nencounter a picture of SMA embolism. Feel for the SMA just at the\\nbase of the mesocolon; if non-pulsatile you’ll find it, after incising the\\nperitoneum, to the right (as you look at it from below) of the large, blue\\nsuperior mesenteric vein. After obtaining control, open the artery\\ntransversely and pass up and down a small Fogarty embolectomy\\nballoon catheter. You may conclude the procedure with a shot of\\nurokinase injected distally to lyse the clots in the distal branches, which\\nare inaccessible to your embolectomy balloon catheter. ħeparinize the\\nvessels before repairing the arteriotomy.\\n\\n If you work at an ‘ivory tower’ the option of endovascular therapies\\nmay be available as well. Early lysis and stenting of an ‘acute on chronic’\\nocclusion of the SMA may obviate the need for laparotomy altogether.\\nEven if bowel resection is needed, the patient can be transfered\\ndirecty from the OR to the radiology suite for stenting of the SMA\\n(and/or celiac artery) to improve the blood supply to the remaining,\\nmarginally perfused intestine.',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Adjunctive Vascular Procedures\\n\\nThe ideal setting for surgical improvement of the perfusion of ischemic small bowel is when the operation follows emergency arteriography (plus failed angiographic therapy) and the bowel is viable or doubtful. Obviously, when the bowel is dead it cannot be revived! Arteriography serves as a road map; when the SMA is thrombosed at its origin, a vein or other graft bypass, antegrade or retrograde, is indicated to reperfuse the SMA. The two main options here are autogenous vein bypass or externally supported polytetrafluoroethylene (PTFE) inserted in a ‘lazy loop’ fashion. The origin of these bypass grafts is often determined by the pattern of disease affecting the other intra-abdominal vessels. Usually, the iliac vessels are the best source of pulsatile flow but care must be taken when vein is used, to see that it does not kink when the gut is returned to its normal position.\\n\\nThe above scenario is, however, rare; more commonly you’ll encounter a picture of SMA embolism. Feel for the SMA just at the base of the mesocolon; if non-pulsatile you’ll find it, after incising the peritoneum, to the right (as you look at it from below) of the large, blue superior mesenteric vein. After obtaining control, open the artery transversely and pass up and down a small Fogarty embolectomy balloon catheter. You may conclude the procedure with a shot of urokinase injected distally to lyse the clots in the distal branches, which are inaccessible to your embolectomy balloon catheter. Heparinize the vessels before repairing the arteriotomy.\\n\\nIf you work at an ‘ivory tower’ the option of endovascular therapies may be available as well. Early lysis and stenting of an ‘acute on chronic’ occlusion of the SMA may obviate the need for laparotomy altogether. Even if bowel resection is needed, the patient can be transferred directly from the OR to the radiology suite for stenting of the SMA (and/or celiac artery) to improve the blood supply to the remaining, marginally perfused intestine.\\n\\n### Figures\\n\\n- **Figure 24.1**: The text references a figure related to the discussion but does not provide a description or content of the figure itself.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Adjunctive Vascular Procedures',\n", " 'md': '### Adjunctive Vascular Procedures',\n", " 'bBox': {'x': 86, 'y': 131, 'w': 251.07, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The ideal setting for surgical improvement of the perfusion of ischemic small bowel is when the operation follows emergency arteriography (plus failed angiographic therapy) and the bowel is viable or doubtful. Obviously, when the bowel is dead it cannot be revived! Arteriography serves as a road map; when the SMA is thrombosed at its origin, a vein or other graft bypass, antegrade or retrograde, is indicated to reperfuse the SMA. The two main options here are autogenous vein bypass or externally supported polytetrafluoroethylene (PTFE) inserted in a ‘lazy loop’ fashion. The origin of these bypass grafts is often determined by the pattern of disease affecting the other intra-abdominal vessels. Usually, the iliac vessels are the best source of pulsatile flow but care must be taken when vein is used, to see that it does not kink when the gut is returned to its normal position.\\n\\nThe above scenario is, however, rare; more commonly you’ll encounter a picture of SMA embolism. Feel for the SMA just at the base of the mesocolon; if non-pulsatile you’ll find it, after incising the peritoneum, to the right (as you look at it from below) of the large, blue superior mesenteric vein. After obtaining control, open the artery transversely and pass up and down a small Fogarty embolectomy balloon catheter. You may conclude the procedure with a shot of urokinase injected distally to lyse the clots in the distal branches, which are inaccessible to your embolectomy balloon catheter. Heparinize the vessels before repairing the arteriotomy.\\n\\nIf you work at an ‘ivory tower’ the option of endovascular therapies may be available as well. Early lysis and stenting of an ‘acute on chronic’ occlusion of the SMA may obviate the need for laparotomy altogether. Even if bowel resection is needed, the patient can be transferred directly from the OR to the radiology suite for stenting of the SMA (and/or celiac artery) to improve the blood supply to the remaining, marginally perfused intestine.',\n", " 'md': 'The ideal setting for surgical improvement of the perfusion of ischemic small bowel is when the operation follows emergency arteriography (plus failed angiographic therapy) and the bowel is viable or doubtful. Obviously, when the bowel is dead it cannot be revived! Arteriography serves as a road map; when the SMA is thrombosed at its origin, a vein or other graft bypass, antegrade or retrograde, is indicated to reperfuse the SMA. The two main options here are autogenous vein bypass or externally supported polytetrafluoroethylene (PTFE) inserted in a ‘lazy loop’ fashion. The origin of these bypass grafts is often determined by the pattern of disease affecting the other intra-abdominal vessels. Usually, the iliac vessels are the best source of pulsatile flow but care must be taken when vein is used, to see that it does not kink when the gut is returned to its normal position.\\n\\nThe above scenario is, however, rare; more commonly you’ll encounter a picture of SMA embolism. Feel for the SMA just at the base of the mesocolon; if non-pulsatile you’ll find it, after incising the peritoneum, to the right (as you look at it from below) of the large, blue superior mesenteric vein. After obtaining control, open the artery transversely and pass up and down a small Fogarty embolectomy balloon catheter. You may conclude the procedure with a shot of urokinase injected distally to lyse the clots in the distal branches, which are inaccessible to your embolectomy balloon catheter. Heparinize the vessels before repairing the arteriotomy.\\n\\nIf you work at an ‘ivory tower’ the option of endovascular therapies may be available as well. Early lysis and stenting of an ‘acute on chronic’ occlusion of the SMA may obviate the need for laparotomy altogether. Even if bowel resection is needed, the patient can be transferred directly from the OR to the radiology suite for stenting of the SMA (and/or celiac artery) to improve the blood supply to the remaining, marginally perfused intestine.',\n", " 'bBox': {'x': 72, 'y': 167, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 24.1**: The text references a figure related to the discussion but does not provide a description or content of the figure itself.\\n\\n```',\n", " 'md': '- **Figure 24.1**: The text references a figure related to the discussion but does not provide a description or content of the figure itself.\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 410,\n", " 'text': ' To anastomose or not?\\n\\n You should be very selective in attempting an anastomosis\\nfollowing any resection of devitalized intestine. The patient has to be\\nhemodynamically stable and his nutritional status at least fair. To be\\nhooked-up, the remaining bowel has to be unquestionably viable and the\\nperitoneal cavity free of established infection. Most crucially, the cause\\nof ischemia has to be definitively solved.\\n\\n Another factor strongly bearing on your decision is the length of\\nthe remaining bowel and its predicted postoperative function. When\\nmore than half of the small bowel is resected, the resection is\\nconsidered ‘massive’. Restoring intestinal continuity in such cases\\nwould lead to poorly tolerated and intractable diarrhea. And finally, the\\nchief reason not to anastomose the bowel is the possibility that further\\nischemia may develop. In addition, a stoma provides an external window,\\nalbeit not a perfect one, allowing you to assess viability of the remaining\\nbowel.\\n\\n We recommend, therefore, that whenever the above-mentioned\\nfavorable factors are absent, or when resection is massive, the two ends\\nof the resected bowel should be exteriorized as an end-enterostomy and\\nmucous fistula — if possible via one abdominal wall site as a ‘double-\\nbarrel stoma’. This will allow a subsequent elective reanastomosis —\\nafter the patient has reached optimal nutritional status, and the bowel\\nremnant achieved its maximal adaptation — without a major laparotomy.\\nThe postoperative appearance of the stomas will, in most cases, reflect\\nthe status of the remaining bowel — but not always: in patients with\\npatchy intestinal injury — usually caused by a shower of microemboli —\\na perfect looking stoma may coexisist with a patch of gangrene in\\nthe bowel above or below it!\\n\\n Second-look operations?\\n\\n A routine planned ‘second-look’ reoperation allows direct\\nreassessment of intestinal viability at an early stage, before\\nadditional mediators of SIRS have been released, and in a way that',\n", " 'md': '```markdown\\n## To anastomose or not?\\n\\nYou should be very selective in attempting an anastomosis following any resection of devitalized intestine. The patient has to be hemodynamically stable and his nutritional status at least fair. To be hooked-up, the remaining bowel has to be unquestionably viable and the peritoneal cavity free of established infection. Most crucially, the cause of ischemia has to be definitively solved.\\n\\nAnother factor strongly bearing on your decision is the length of the remaining bowel and its predicted postoperative function. When more than half of the small bowel is resected, the resection is considered ‘massive’. Restoring intestinal continuity in such cases would lead to poorly tolerated and intractable diarrhea. And finally, the chief reason not to anastomose the bowel is the possibility that further ischemia may develop. In addition, a stoma provides an external window, albeit not a perfect one, allowing you to assess viability of the remaining bowel.\\n\\nWe recommend, therefore, that whenever the above-mentioned favorable factors are absent, or when resection is massive, the two ends of the resected bowel should be exteriorized as an end-enterostomy and mucous fistula — if possible via one abdominal wall site as a ‘double-barrel stoma’. This will allow a subsequent elective reanastomosis — after the patient has reached optimal nutritional status, and the bowel remnant achieved its maximal adaptation — without a major laparotomy. The postoperative appearance of the stomas will, in most cases, reflect the status of the remaining bowel — but not always: in patients with patchy intestinal injury — usually caused by a shower of microemboli — a perfect looking stoma may coexist with a patch of gangrene in the bowel above or below it!\\n\\n## Second-look operations?\\n\\nA routine planned ‘second-look’ reoperation allows direct reassessment of intestinal viability at an early stage, before additional mediators of SIRS have been released, and in a way that...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the requirements.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'To anastomose or not?',\n", " 'md': '## To anastomose or not?',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 181.76, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'You should be very selective in attempting an anastomosis following any resection of devitalized intestine. The patient has to be hemodynamically stable and his nutritional status at least fair. To be hooked-up, the remaining bowel has to be unquestionably viable and the peritoneal cavity free of established infection. Most crucially, the cause of ischemia has to be definitively solved.\\n\\nAnother factor strongly bearing on your decision is the length of the remaining bowel and its predicted postoperative function. When more than half of the small bowel is resected, the resection is considered ‘massive’. Restoring intestinal continuity in such cases would lead to poorly tolerated and intractable diarrhea. And finally, the chief reason not to anastomose the bowel is the possibility that further ischemia may develop. In addition, a stoma provides an external window, albeit not a perfect one, allowing you to assess viability of the remaining bowel.\\n\\nWe recommend, therefore, that whenever the above-mentioned favorable factors are absent, or when resection is massive, the two ends of the resected bowel should be exteriorized as an end-enterostomy and mucous fistula — if possible via one abdominal wall site as a ‘double-barrel stoma’. This will allow a subsequent elective reanastomosis — after the patient has reached optimal nutritional status, and the bowel remnant achieved its maximal adaptation — without a major laparotomy. The postoperative appearance of the stomas will, in most cases, reflect the status of the remaining bowel — but not always: in patients with patchy intestinal injury — usually caused by a shower of microemboli — a perfect looking stoma may coexist with a patch of gangrene in the bowel above or below it!',\n", " 'md': 'You should be very selective in attempting an anastomosis following any resection of devitalized intestine. The patient has to be hemodynamically stable and his nutritional status at least fair. To be hooked-up, the remaining bowel has to be unquestionably viable and the peritoneal cavity free of established infection. Most crucially, the cause of ischemia has to be definitively solved.\\n\\nAnother factor strongly bearing on your decision is the length of the remaining bowel and its predicted postoperative function. When more than half of the small bowel is resected, the resection is considered ‘massive’. Restoring intestinal continuity in such cases would lead to poorly tolerated and intractable diarrhea. And finally, the chief reason not to anastomose the bowel is the possibility that further ischemia may develop. In addition, a stoma provides an external window, albeit not a perfect one, allowing you to assess viability of the remaining bowel.\\n\\nWe recommend, therefore, that whenever the above-mentioned favorable factors are absent, or when resection is massive, the two ends of the resected bowel should be exteriorized as an end-enterostomy and mucous fistula — if possible via one abdominal wall site as a ‘double-barrel stoma’. This will allow a subsequent elective reanastomosis — after the patient has reached optimal nutritional status, and the bowel remnant achieved its maximal adaptation — without a major laparotomy. The postoperative appearance of the stomas will, in most cases, reflect the status of the remaining bowel — but not always: in patients with patchy intestinal injury — usually caused by a shower of microemboli — a perfect looking stoma may coexist with a patch of gangrene in the bowel above or below it!',\n", " 'bBox': {'x': 72, 'y': 140, 'w': 467.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Second-look operations?',\n", " 'md': '## Second-look operations?',\n", " 'bBox': {'x': 86, 'y': 635, 'w': 198.62, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A routine planned ‘second-look’ reoperation allows direct reassessment of intestinal viability at an early stage, before additional mediators of SIRS have been released, and in a way that...\\n```',\n", " 'md': 'A routine planned ‘second-look’ reoperation allows direct reassessment of intestinal viability at an early stage, before additional mediators of SIRS have been released, and in a way that...\\n```',\n", " 'bBox': {'x': 72, 'y': 704, 'w': 467.92, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the requirements.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the requirements.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 411,\n", " 'text': 'aims to preserve the greatest possible length of viable intestine.\\nThis concept, which in theory at least is attractive, motivates many\\nsurgeons to re-explore their patients routinely after 24 to 48 hours. This is\\nan ideal situation for an ‘abbreviated laparotomy’ at the initial surgery.\\nThe sections of bowel that are definitely dead are excised after stapling\\nand dividing the bowel. The stapled ends are simply dropped back into\\nthe peritoneal cavity.\\n\\n A 24-hour interval allows the patient’s deranged physiology to recover\\nbefore a second look. The finding of completely normal bowel at\\nreoperation is of course reassuring and allows an anastomosis to be\\nfashioned with confidence (but the anastomosis may still leak 5 days\\nlater). If you plan a second-look operation there is no need to close\\nthe abdomen at the end of the first procedure; instead, treat the\\nabdomen as a laparostomy until re-exploration, relieving any intra-\\nabdominal hypertension to improve mesenteric blood flow further.\\n\\n An alternative would be to close the abdomen, and perform a second-\\nlook laparoscopy (if you have heard about leaving laparoscopic ports at\\nthe first operation to be used the next day — just forget about this\\nunnecessary gimmick).\\n\\n To sum up — it appears that in most patients a second-look\\nprocedure is indicated, even in those who have a stoma but with\\nwhom you are not totally happy. Those with viable stomas, who are\\notherwise well, can be observed. ħowever, we would not sell them any\\nlife insurance policy at this stage. In patients whose ischemia was due to\\nembolism, a postoperative search for sources of emboli seems prudent.\\n\\n Mesenteric venous thrombosis\\n\\n In this rarer condition, the so-called ‘DVT of the abdomen’, the\\nvenous outflow of the bowel is occluded. The clinical presentation is\\nless striking and non-specific. Abdominal pain and varying\\ngastrointestinal symptoms may last a few days until eventually the\\nintestines are compromised and peritoneal signs develop.',\n", " 'md': \"```markdown\\n## Text Extraction\\n\\nThe text discusses surgical practices aimed at preserving viable intestine length during operations. It emphasizes the importance of re-exploring patients within 24 to 48 hours post-surgery to assess bowel viability. Key points include:\\n\\n- The concept of an 'abbreviated laparotomy' during initial surgery.\\n- Excising dead bowel sections after stapling and dividing.\\n- The benefits of a 24-hour interval for patient recovery before reoperation.\\n- The reassurance of finding normal bowel during reoperation, although anastomosis may still leak later.\\n- Recommendations for managing the abdomen during the second-look operation, including treating it as a laparostomy.\\n- The suggestion to avoid unnecessary laparoscopic ports for second-look laparoscopy.\\n- The indication for a second-look procedure in most patients, especially those with stomas.\\n- Caution against selling life insurance to patients at this stage.\\n- The importance of searching for emboli sources in patients with ischemia.\\n\\n### Mesenteric Venous Thrombosis\\n\\nThis section describes a rarer condition known as 'DVT of the abdomen', where the venous outflow of the bowel is occluded. The clinical presentation is less striking and non-specific, with symptoms including:\\n\\n- Abdominal pain.\\n- Varying gastrointestinal symptoms lasting a few days until intestinal compromise and peritoneal signs develop.\\n\\n## Image Identification and Description\\n\\nNo images, graphs, or tables were identified on this page.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"The text discusses surgical practices aimed at preserving viable intestine length during operations. It emphasizes the importance of re-exploring patients within 24 to 48 hours post-surgery to assess bowel viability. Key points include:\\n\\n- The concept of an 'abbreviated laparotomy' during initial surgery.\\n- Excising dead bowel sections after stapling and dividing.\\n- The benefits of a 24-hour interval for patient recovery before reoperation.\\n- The reassurance of finding normal bowel during reoperation, although anastomosis may still leak later.\\n- Recommendations for managing the abdomen during the second-look operation, including treating it as a laparostomy.\\n- The suggestion to avoid unnecessary laparoscopic ports for second-look laparoscopy.\\n- The indication for a second-look procedure in most patients, especially those with stomas.\\n- Caution against selling life insurance to patients at this stage.\\n- The importance of searching for emboli sources in patients with ischemia.\",\n", " 'md': \"The text discusses surgical practices aimed at preserving viable intestine length during operations. It emphasizes the importance of re-exploring patients within 24 to 48 hours post-surgery to assess bowel viability. Key points include:\\n\\n- The concept of an 'abbreviated laparotomy' during initial surgery.\\n- Excising dead bowel sections after stapling and dividing.\\n- The benefits of a 24-hour interval for patient recovery before reoperation.\\n- The reassurance of finding normal bowel during reoperation, although anastomosis may still leak later.\\n- Recommendations for managing the abdomen during the second-look operation, including treating it as a laparostomy.\\n- The suggestion to avoid unnecessary laparoscopic ports for second-look laparoscopy.\\n- The indication for a second-look procedure in most patients, especially those with stomas.\\n- Caution against selling life insurance to patients at this stage.\\n- The importance of searching for emboli sources in patients with ischemia.\",\n", " 'bBox': {'x': 179, 'y': 651, 'w': 28, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Mesenteric Venous Thrombosis',\n", " 'md': '### Mesenteric Venous Thrombosis',\n", " 'bBox': {'x': 86, 'y': 582, 'w': 243.7, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': \"This section describes a rarer condition known as 'DVT of the abdomen', where the venous outflow of the bowel is occluded. The clinical presentation is less striking and non-specific, with symptoms including:\\n\\n- Abdominal pain.\\n- Varying gastrointestinal symptoms lasting a few days until intestinal compromise and peritoneal signs develop.\",\n", " 'md': \"This section describes a rarer condition known as 'DVT of the abdomen', where the venous outflow of the bowel is occluded. The clinical presentation is less striking and non-specific, with symptoms including:\\n\\n- Abdominal pain.\\n- Varying gastrointestinal symptoms lasting a few days until intestinal compromise and peritoneal signs develop.\",\n", " 'bBox': {'x': 72, 'y': 635, 'w': 467.25, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 179, 'y': 651, 'w': 28, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'No images, graphs, or tables were identified on this page.\\n```',\n", " 'md': 'No images, graphs, or tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 412,\n", " 'text': ' Mesenteric venous thrombosis may be idiopathic (i.e. the doctor is an\\nidiot — ignorant of the underlying reason), but commonly an underlying\\nhypercoagulable state (such as polycythemia rubra vera) or sluggish\\nportal flow due to hepatic cirrhosis, is present. It has also been described\\nin the postoperative phase after upper abdominal procedures such as\\nsplenectomy. It can be iatrogenic as well, due to operative injury and\\nligation of the SMV.\\n\\n Typically, many of these patients are admitted to the medical floor with\\na surgeon consulted much later — to operate for non-viable bowel.\\nHowever, an early trip to a contrast-enhanced CT scan may achieve\\nan earlier diagnosis, helping to avoid an operation altogether and\\nimproving survival.\\n\\n Characteristic findings on CT consist of a triad:\\n\\n A hypodensity in the trunk of the superior mesenteric vein.\\n Associated intraperitoneal fluid.\\n Thickened segment of small bowel.\\n\\n Thus, anytime we review a CT in a patient with a non-specific\\nabdominal picture (e.g. alleged ileus), we make the point to look at the\\nSMV, and force the radiologist to look at it. Remember: radiologists read\\nnumeorus images a day; if you do not ask them questions they can miss\\nsignificant findings…\\n\\n With the above findings, and in the absence of peritoneal signs,\\nfull systemic anticoagulation with heparin may result in a\\nspontaneous resolution of the process. The role of systemic or\\nselective angiographic thrombolysis is not clear. Failure to improve or\\nthe development of peritoneal signs mandates an operation.\\n\\n At surgery, you’ll find some free serosanguinous peritoneal fluid; the\\nsmall bowel will be thick, edematous, dark blue but not frankly dead, with\\nthe involved intestinal segment poorly demarcated. Arterial pulsations\\nwill be present and thrombosed veins seen. You’ll need to resect',\n", " 'md': '```markdown\\n# Mesenteric Venous Thrombosis\\n\\nMesenteric venous thrombosis may be idiopathic (i.e. the doctor is an idiot — ignorant of the underlying reason), but commonly an underlying hypercoagulable state (such as polycythemia rubra vera) or sluggish portal flow due to hepatic cirrhosis is present. It has also been described in the postoperative phase after upper abdominal procedures such as splenectomy. It can be iatrogenic as well, due to operative injury and ligation of the SMV.\\n\\nTypically, many of these patients are admitted to the medical floor with a surgeon consulted much later — to operate for non-viable bowel. However, an early trip to a contrast-enhanced CT scan may achieve an earlier diagnosis, helping to avoid an operation altogether and improving survival.\\n\\nCharacteristic findings on CT consist of a triad:\\n\\n1. A hypodensity in the trunk of the superior mesenteric vein.\\n2. Associated intraperitoneal fluid.\\n3. Thickened segment of small bowel.\\n\\nThus, anytime we review a CT in a patient with a non-specific abdominal picture (e.g. alleged ileus), we make the point to look at the SMV, and force the radiologist to look at it. Remember: radiologists read numerous images a day; if you do not ask them questions they can miss significant findings…\\n\\nWith the above findings, and in the absence of peritoneal signs, full systemic anticoagulation with heparin may result in a spontaneous resolution of the process. The role of systemic or selective angiographic thrombolysis is not clear. Failure to improve or the development of peritoneal signs mandates an operation.\\n\\nAt surgery, you’ll find some free serosanguinous peritoneal fluid; the small bowel will be thick, edematous, dark blue but not frankly dead, with the involved intestinal segment poorly demarcated. Arterial pulsations will be present and thrombosed veins seen. You’ll need to resect.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Mesenteric Venous Thrombosis',\n", " 'md': '# Mesenteric Venous Thrombosis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Mesenteric venous thrombosis may be idiopathic (i.e. the doctor is an idiot — ignorant of the underlying reason), but commonly an underlying hypercoagulable state (such as polycythemia rubra vera) or sluggish portal flow due to hepatic cirrhosis is present. It has also been described in the postoperative phase after upper abdominal procedures such as splenectomy. It can be iatrogenic as well, due to operative injury and ligation of the SMV.\\n\\nTypically, many of these patients are admitted to the medical floor with a surgeon consulted much later — to operate for non-viable bowel. However, an early trip to a contrast-enhanced CT scan may achieve an earlier diagnosis, helping to avoid an operation altogether and improving survival.\\n\\nCharacteristic findings on CT consist of a triad:\\n\\n1. A hypodensity in the trunk of the superior mesenteric vein.\\n2. Associated intraperitoneal fluid.\\n3. Thickened segment of small bowel.\\n\\nThus, anytime we review a CT in a patient with a non-specific abdominal picture (e.g. alleged ileus), we make the point to look at the SMV, and force the radiologist to look at it. Remember: radiologists read numerous images a day; if you do not ask them questions they can miss significant findings…\\n\\nWith the above findings, and in the absence of peritoneal signs, full systemic anticoagulation with heparin may result in a spontaneous resolution of the process. The role of systemic or selective angiographic thrombolysis is not clear. Failure to improve or the development of peritoneal signs mandates an operation.\\n\\nAt surgery, you’ll find some free serosanguinous peritoneal fluid; the small bowel will be thick, edematous, dark blue but not frankly dead, with the involved intestinal segment poorly demarcated. Arterial pulsations will be present and thrombosed veins seen. You’ll need to resect.\\n```',\n", " 'md': 'Mesenteric venous thrombosis may be idiopathic (i.e. the doctor is an idiot — ignorant of the underlying reason), but commonly an underlying hypercoagulable state (such as polycythemia rubra vera) or sluggish portal flow due to hepatic cirrhosis is present. It has also been described in the postoperative phase after upper abdominal procedures such as splenectomy. It can be iatrogenic as well, due to operative injury and ligation of the SMV.\\n\\nTypically, many of these patients are admitted to the medical floor with a surgeon consulted much later — to operate for non-viable bowel. However, an early trip to a contrast-enhanced CT scan may achieve an earlier diagnosis, helping to avoid an operation altogether and improving survival.\\n\\nCharacteristic findings on CT consist of a triad:\\n\\n1. A hypodensity in the trunk of the superior mesenteric vein.\\n2. Associated intraperitoneal fluid.\\n3. Thickened segment of small bowel.\\n\\nThus, anytime we review a CT in a patient with a non-specific abdominal picture (e.g. alleged ileus), we make the point to look at the SMV, and force the radiologist to look at it. Remember: radiologists read numerous images a day; if you do not ask them questions they can miss significant findings…\\n\\nWith the above findings, and in the absence of peritoneal signs, full systemic anticoagulation with heparin may result in a spontaneous resolution of the process. The role of systemic or selective angiographic thrombolysis is not clear. Failure to improve or the development of peritoneal signs mandates an operation.\\n\\nAt surgery, you’ll find some free serosanguinous peritoneal fluid; the small bowel will be thick, edematous, dark blue but not frankly dead, with the involved intestinal segment poorly demarcated. Arterial pulsations will be present and thrombosed veins seen. You’ll need to resect.\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 413,\n", " 'text': 'irretrievably ischemic bowel; gut of questionable viability may be left for a\\n‘second look’. As to whether or not to anastomose and the need for a\\nsecond look — apply the same judgment as discussed above for arterial\\ninsufficiency. Postoperative anticoagulation is mandatory to prevent\\nprogression of the thrombotic process. Adding a venous thrombectomy is\\nadvocated by some, so is intra-operative thrombolysis; the real benefits\\nof these controversial approaches are unknown.\\n\\n To sum up…\\n\\n In most places the mortality rate of acute mesenteric ischemia is\\n still prohibitive. Why? Because surgeons fail to do the following:\\n\\n Suspect ischemia before intestinal gangrene develops.\\n Proceed with diagnostic/therapeutic angiography.\\n Improve intestinal perfusion during laparotomy.\\n Exteriorize the bowel or execute a second-look operation.\\n\\n So here is the ‘catch 22’: if you wish to see survivors of this horrendous\\ncondition you will have to be aggressive. On the other hand, the\\npresentation of these patients is so non-specific and, frequently, the CT\\nfindings so subtle that if an aggressive approach is taken, many patients\\nwith self-limiting minor abdominal complaints will have unnecessary\\ninvestigations and operations, and yet cases will still be missed.\\nFurthermore, these patients rarely have simple pathology. They\\ncommonly suffer from multisystem disease and even in receipt of optimal\\ncare they will have a high mortality. Regrettably, in the majority of patients\\nthis condition seems likely to remain an agonal complaint. As our\\nmentors taught us: “you can’t save ‘em all!”\\n\\n “The man is as old as his arteries.”\\n Thomas Sydenham',\n", " 'md': '```markdown\\n## Summary of Acute Mesenteric Ischemia Management\\n\\n### Key Points\\n- **Irretrievably ischemic bowel**: The gut of questionable viability may be left for a ‘second look’.\\n- **Anastomosis Decision**: The decision to anastomose and the need for a second look should follow the same judgment as for arterial insufficiency.\\n- **Postoperative Care**: Anticoagulation is mandatory to prevent progression of the thrombotic process. Some advocate for adding a venous thrombectomy or intra-operative thrombolysis, though the real benefits of these approaches are unknown.\\n\\n### Conclusion\\n- The mortality rate of acute mesenteric ischemia remains high due to several factors:\\n- Failure to suspect ischemia before intestinal gangrene develops.\\n- Lack of diagnostic/therapeutic angiography.\\n- Inadequate improvement of intestinal perfusion during laparotomy.\\n- Not exteriorizing the bowel or executing a second-look operation.\\n\\n### The Dilemma\\n- There is a ‘catch 22’: to see survivors of this condition, an aggressive approach is necessary. However, the non-specific presentation and subtle CT findings can lead to unnecessary investigations and operations for patients with minor complaints, while still missing critical cases.\\n- Patients often have multisystem disease, and even with optimal care, the mortality rate remains high. This condition is likely to remain an agonal complaint for many patients.\\n\\n### Quote\\n> “The man is as old as his arteries.”\\n> — Thomas Sydenham\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary of Acute Mesenteric Ischemia Management',\n", " 'md': '## Summary of Acute Mesenteric Ischemia Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key Points',\n", " 'md': '### Key Points',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Irretrievably ischemic bowel**: The gut of questionable viability may be left for a ‘second look’.\\n- **Anastomosis Decision**: The decision to anastomose and the need for a second look should follow the same judgment as for arterial insufficiency.\\n- **Postoperative Care**: Anticoagulation is mandatory to prevent progression of the thrombotic process. Some advocate for adding a venous thrombectomy or intra-operative thrombolysis, though the real benefits of these approaches are unknown.',\n", " 'md': '- **Irretrievably ischemic bowel**: The gut of questionable viability may be left for a ‘second look’.\\n- **Anastomosis Decision**: The decision to anastomose and the need for a second look should follow the same judgment as for arterial insufficiency.\\n- **Postoperative Care**: Anticoagulation is mandatory to prevent progression of the thrombotic process. Some advocate for adding a venous thrombectomy or intra-operative thrombolysis, though the real benefits of these approaches are unknown.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Conclusion',\n", " 'md': '### Conclusion',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The mortality rate of acute mesenteric ischemia remains high due to several factors:\\n- Failure to suspect ischemia before intestinal gangrene develops.\\n- Lack of diagnostic/therapeutic angiography.\\n- Inadequate improvement of intestinal perfusion during laparotomy.\\n- Not exteriorizing the bowel or executing a second-look operation.',\n", " 'md': '- The mortality rate of acute mesenteric ischemia remains high due to several factors:\\n- Failure to suspect ischemia before intestinal gangrene develops.\\n- Lack of diagnostic/therapeutic angiography.\\n- Inadequate improvement of intestinal perfusion during laparotomy.\\n- Not exteriorizing the bowel or executing a second-look operation.',\n", " 'bBox': {'x': 127, 'y': 328, 'w': 261.38, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Dilemma',\n", " 'md': '### The Dilemma',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- There is a ‘catch 22’: to see survivors of this condition, an aggressive approach is necessary. However, the non-specific presentation and subtle CT findings can lead to unnecessary investigations and operations for patients with minor complaints, while still missing critical cases.\\n- Patients often have multisystem disease, and even with optimal care, the mortality rate remains high. This condition is likely to remain an agonal complaint for many patients.',\n", " 'md': '- There is a ‘catch 22’: to see survivors of this condition, an aggressive approach is necessary. However, the non-specific presentation and subtle CT findings can lead to unnecessary investigations and operations for patients with minor complaints, while still missing critical cases.\\n- Patients often have multisystem disease, and even with optimal care, the mortality rate remains high. This condition is likely to remain an agonal complaint for many patients.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Quote',\n", " 'md': '### Quote',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '> “The man is as old as his arteries.”\\n> — Thomas Sydenham\\n```',\n", " 'md': '> “The man is as old as his arteries.”\\n> — Thomas Sydenham\\n```',\n", " 'bBox': {'x': 79, 'y': 653, 'w': 275.85, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 414,\n", " 'text': 'Chapter 25\\nHepatic emergencies\\nErik Schadde\\n\\n The liver confounds the surgeon’s dependence on anatomy.\\n J. Foster\\n\\n When I was an intern I overheard a mid-level resident saying to the\\nchief resident that there is a ‘liver patient’ in the emergency room. My\\nchief resident appeared gloomy and concerned. I didn’t understand what\\n‘liver patient’ referred to in this context. Every patient in the emergency\\nroom has a liver — a liver trauma? A liver tumor? Soon I learned: ‘liver\\npatient’ refers to those with chronic liver disease: cirrhosis and portal\\nhypertension or after a liver transplant. In short, any patient who belongs\\nto the hepatology service or is on the liver transplant service.\\n\\n In this chapter I will address first the acute problems arising in the\\nchronic liver patient. Hepatic trauma will be addressed next. Finally,\\nI will look at some miscellaneous conditions of the liver that may\\npresent as an emergency.\\n\\n The ‘liver patient’ — chronically diseased hepatic\\n parenchyma\\n\\n In the emergency room\\n\\n The patients with chronic liver disease you are called to see in the',\n", " 'md': '```markdown\\n# Chapter 25: Hepatic Emergencies\\n**Author:** Erik Schadde\\n\\n> \"The liver confounds the surgeon’s dependence on anatomy.\" - J. Foster\\n\\nWhen I was an intern, I overheard a mid-level resident saying to the chief resident that there is a ‘liver patient’ in the emergency room. My chief resident appeared gloomy and concerned. I didn’t understand what ‘liver patient’ referred to in this context. Every patient in the emergency room has a liver — a liver trauma? A liver tumor? Soon I learned: ‘liver patient’ refers to those with chronic liver disease: cirrhosis and portal hypertension or after a liver transplant. In short, any patient who belongs to the hepatology service or is on the liver transplant service.\\n\\nIn this chapter, I will address first the acute problems arising in the chronic liver patient. Hepatic trauma will be addressed next. Finally, I will look at some miscellaneous conditions of the liver that may present as an emergency.\\n\\n## The ‘Liver Patient’ — Chronically Diseased Hepatic Parenchyma\\n\\n### In the Emergency Room\\n\\nThe patients with chronic liver disease you are called to see in the...\\n```\\n\\n*Note: The text extraction is complete, but the page appears to be cut off. If there are any images, graphs, or tables on this page, please provide that information for further extraction and description.*',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 25: Hepatic Emergencies',\n", " 'md': '# Chapter 25: Hepatic Emergencies',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 189.27, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Erik Schadde\\n\\n> \"The liver confounds the surgeon’s dependence on anatomy.\" - J. Foster\\n\\nWhen I was an intern, I overheard a mid-level resident saying to the chief resident that there is a ‘liver patient’ in the emergency room. My chief resident appeared gloomy and concerned. I didn’t understand what ‘liver patient’ referred to in this context. Every patient in the emergency room has a liver — a liver trauma? A liver tumor? Soon I learned: ‘liver patient’ refers to those with chronic liver disease: cirrhosis and portal hypertension or after a liver transplant. In short, any patient who belongs to the hepatology service or is on the liver transplant service.\\n\\nIn this chapter, I will address first the acute problems arising in the chronic liver patient. Hepatic trauma will be addressed next. Finally, I will look at some miscellaneous conditions of the liver that may present as an emergency.',\n", " 'md': '**Author:** Erik Schadde\\n\\n> \"The liver confounds the surgeon’s dependence on anatomy.\" - J. Foster\\n\\nWhen I was an intern, I overheard a mid-level resident saying to the chief resident that there is a ‘liver patient’ in the emergency room. My chief resident appeared gloomy and concerned. I didn’t understand what ‘liver patient’ referred to in this context. Every patient in the emergency room has a liver — a liver trauma? A liver tumor? Soon I learned: ‘liver patient’ refers to those with chronic liver disease: cirrhosis and portal hypertension or after a liver transplant. In short, any patient who belongs to the hepatology service or is on the liver transplant service.\\n\\nIn this chapter, I will address first the acute problems arising in the chronic liver patient. Hepatic trauma will be addressed next. Finally, I will look at some miscellaneous conditions of the liver that may present as an emergency.',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 467.8, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The ‘Liver Patient’ — Chronically Diseased Hepatic Parenchyma',\n", " 'md': '## The ‘Liver Patient’ — Chronically Diseased Hepatic Parenchyma',\n", " 'bBox': {'x': 86, 'y': 612, 'w': 97.51, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'In the Emergency Room',\n", " 'md': '### In the Emergency Room',\n", " 'bBox': {'x': 86, 'y': 612, 'w': 182.08, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The patients with chronic liver disease you are called to see in the...\\n```\\n\\n*Note: The text extraction is complete, but the page appears to be cut off. If there are any images, graphs, or tables on this page, please provide that information for further extraction and description.*',\n", " 'md': 'The patients with chronic liver disease you are called to see in the...\\n```\\n\\n*Note: The text extraction is complete, but the page appears to be cut off. If there are any images, graphs, or tables on this page, please provide that information for further extraction and description.*',\n", " 'bBox': {'x': 86, 'y': 612, 'w': 29.43, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 415,\n", " 'text': 'emergency room usually have one of two issues: either they have a\\nproblem that the internists cannot manage any more or they are in some\\nway or other involved with liver transplantation — the surgical treatment\\nof end-stage liver disease since the 1980s. It is important that the latter\\ngroup of patients are seen by their respective transplant physicians:\\ndecompensated patients on the liver transplant list might need to be\\n‘deactivated’ (i.e. removed from that holy list) and their MELD score 1\\nupgraded. Decompensated liver patients are generally managed by\\ninternists or even better — hepatologists.\\n\\n Variceal bleeding\\n\\n Esophageal varices are the source of upper gastrointestinal (GI)\\nbleeding in about 90% of patients with cirrhosis and portal\\nhypertension. The emergency room usually calls the interventional\\ngastroenterologist, who performs endoscopic variceal rubber band\\nligation and (rarely) sclerotherapy. If they can’t visualize the bleeding and\\ncontrol it, you, the surgeon, may be called and asked whether you can\\noffer a surgical solution — an emergency surgical shunt for example.\\nYour answer, however, should always be “no”!\\n\\n The space that surgical shunt procedures still occupy in traditional\\nsurgical textbooks is inversely correlated with their use in real life. While\\nyou know that surgery in this situation is out of the question because you\\nwill not find the source of bleeding by performing a laparotomy but almost\\ncertainly bring the patient to the verge of death, your surgical advice is\\nstill needed: remember that there is still a minority of patients in\\nwhom the upper GI bleeding is caused by peptic ulcers, Mallory-\\nWeiss tears or Dieulafoy lesions and not variceal disease — despite\\ntheir cirrhosis and portal hypertension.\\n\\n Your advice should be to perform another round of gastric irrigation\\nand another endoscopy. You may improve conditions with two simple\\ninterventions before the second endoscopy: i.v. administration of\\nsomatostatin (or equivalent terlipressin) and forced gastric emptying\\nusing erythromycin and wait 30 minutes. If this fails again — move to the\\nangiography suite to perform an emergency TIPS (transjugular',\n", " 'md': '```markdown\\n# Emergency Room Management of Liver Patients\\n\\nEmergency room patients usually have one of two issues: either they have a problem that the internists cannot manage any more or they are involved with liver transplantation — the surgical treatment of end-stage liver disease since the 1980s. It is important that the latter group of patients is seen by their respective transplant physicians: decompensated patients on the liver transplant list might need to be ‘deactivated’ (i.e., removed from that holy list) and their MELD score upgraded. Decompensated liver patients are generally managed by internists or, even better, hepatologists.\\n\\n## Variceal Bleeding\\n\\nEsophageal varices are the source of upper gastrointestinal (GI) bleeding in about 90% of patients with cirrhosis and portal hypertension. The emergency room usually calls the interventional gastroenterologist, who performs endoscopic variceal rubber band ligation and (rarely) sclerotherapy. If they can’t visualize the bleeding and control it, you, the surgeon, may be called and asked whether you can offer a surgical solution — an emergency surgical shunt, for example. Your answer, however, should always be “no”!\\n\\nThe space that surgical shunt procedures still occupy in traditional surgical textbooks is inversely correlated with their use in real life. While you know that surgery in this situation is out of the question because you will not find the source of bleeding by performing a laparotomy but almost certainly bring the patient to the verge of death, your surgical advice is still needed: remember that there is still a minority of patients in whom the upper GI bleeding is caused by peptic ulcers, Mallory-Weiss tears, or Dieulafoy lesions and not variceal disease — despite their cirrhosis and portal hypertension.\\n\\nYour advice should be to perform another round of gastric irrigation and another endoscopy. You may improve conditions with two simple interventions before the second endoscopy: i.v. administration of somatostatin (or equivalent terlipressin) and forced gastric emptying using erythromycin and wait 30 minutes. If this fails again — move to the angiography suite to perform an emergency TIPS (transjugular intrahepatic portosystemic shunt).\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Emergency Room Management of Liver Patients',\n", " 'md': '# Emergency Room Management of Liver Patients',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Emergency room patients usually have one of two issues: either they have a problem that the internists cannot manage any more or they are involved with liver transplantation — the surgical treatment of end-stage liver disease since the 1980s. It is important that the latter group of patients is seen by their respective transplant physicians: decompensated patients on the liver transplant list might need to be ‘deactivated’ (i.e., removed from that holy list) and their MELD score upgraded. Decompensated liver patients are generally managed by internists or, even better, hepatologists.',\n", " 'md': 'Emergency room patients usually have one of two issues: either they have a problem that the internists cannot manage any more or they are involved with liver transplantation — the surgical treatment of end-stage liver disease since the 1980s. It is important that the latter group of patients is seen by their respective transplant physicians: decompensated patients on the liver transplant list might need to be ‘deactivated’ (i.e., removed from that holy list) and their MELD score upgraded. Decompensated liver patients are generally managed by internists or, even better, hepatologists.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.5, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Variceal Bleeding',\n", " 'md': '## Variceal Bleeding',\n", " 'bBox': {'x': 86, 'y': 263, 'w': 135.18, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Esophageal varices are the source of upper gastrointestinal (GI) bleeding in about 90% of patients with cirrhosis and portal hypertension. The emergency room usually calls the interventional gastroenterologist, who performs endoscopic variceal rubber band ligation and (rarely) sclerotherapy. If they can’t visualize the bleeding and control it, you, the surgeon, may be called and asked whether you can offer a surgical solution — an emergency surgical shunt, for example. Your answer, however, should always be “no”!\\n\\nThe space that surgical shunt procedures still occupy in traditional surgical textbooks is inversely correlated with their use in real life. While you know that surgery in this situation is out of the question because you will not find the source of bleeding by performing a laparotomy but almost certainly bring the patient to the verge of death, your surgical advice is still needed: remember that there is still a minority of patients in whom the upper GI bleeding is caused by peptic ulcers, Mallory-Weiss tears, or Dieulafoy lesions and not variceal disease — despite their cirrhosis and portal hypertension.\\n\\nYour advice should be to perform another round of gastric irrigation and another endoscopy. You may improve conditions with two simple interventions before the second endoscopy: i.v. administration of somatostatin (or equivalent terlipressin) and forced gastric emptying using erythromycin and wait 30 minutes. If this fails again — move to the angiography suite to perform an emergency TIPS (transjugular intrahepatic portosystemic shunt).\\n```',\n", " 'md': 'Esophageal varices are the source of upper gastrointestinal (GI) bleeding in about 90% of patients with cirrhosis and portal hypertension. The emergency room usually calls the interventional gastroenterologist, who performs endoscopic variceal rubber band ligation and (rarely) sclerotherapy. If they can’t visualize the bleeding and control it, you, the surgeon, may be called and asked whether you can offer a surgical solution — an emergency surgical shunt, for example. Your answer, however, should always be “no”!\\n\\nThe space that surgical shunt procedures still occupy in traditional surgical textbooks is inversely correlated with their use in real life. While you know that surgery in this situation is out of the question because you will not find the source of bleeding by performing a laparotomy but almost certainly bring the patient to the verge of death, your surgical advice is still needed: remember that there is still a minority of patients in whom the upper GI bleeding is caused by peptic ulcers, Mallory-Weiss tears, or Dieulafoy lesions and not variceal disease — despite their cirrhosis and portal hypertension.\\n\\nYour advice should be to perform another round of gastric irrigation and another endoscopy. You may improve conditions with two simple interventions before the second endoscopy: i.v. administration of somatostatin (or equivalent terlipressin) and forced gastric emptying using erythromycin and wait 30 minutes. If this fails again — move to the angiography suite to perform an emergency TIPS (transjugular intrahepatic portosystemic shunt).\\n```',\n", " 'bBox': {'x': 72, 'y': 366, 'w': 467.94, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 416,\n", " 'text': 'intrahepatic portosystemic shunt) procedure. The TIPS creates a\\nconnection between the hepatic vein and the portal vein to provide\\ncentral decompression of the hypertensive portal venous system. It may\\nincrease pre-existing encephalopathy or lead to new-onset\\nencephalopathy and therefore the indication has to be carefully\\nconsidered. In Child-Pugh C cirrhosis (see Table 25.1) patients with\\nelevated bilirubin >10mg/dL (171μmol/L) undergoing TIPS, there is a real\\nrisk that the liver will decompensate. But when sclerotherapy and\\nvariceal banding fail twice, it is the logical next step in an\\nemergency despite this risk.\\n\\n ħowever, you might become a little bit more involved if your\\ninterventional radiologist does not routinely do TIPS or (even better…\\nand more common) there is nobody around who has ever heard about\\nTIPS. Your hemorrhaging patient will have to be transferred to a different\\ncenter (only God can help the patient if such a center does not exist in\\nyour country) and a balloon tamponade will be necessary to\\ntemporize the situation — and it is possible that your gastroenterologist\\nwill need your assistance for that. It is rare nowadays to find any board\\ncertified surgeon who has placed more than a few, if any, balloon tubes\\n(Sengstaken-Blakemore or Linton-Nachlas) in his life, so here below are\\na few words about the technique.\\n\\n Advice on the technique of esophageal balloon catheter\\nplacement:\\n\\n • Make sure you insert balloon tubes only after the patient has\\n been intubated and the airway is protected. (BTW, patients with\\n massive upper GI hemorrhage should have already been intubated\\n for the endoscopy.)\\n • Find out what type of balloon tube you have available, take the time\\n to understand the different access channels and the different balloon\\n tubes, and test the integrity of the balloons in a small bucket of\\n water. It is useful to keep the balloons in the freezer, as it makes\\n them rigid and easier to insert.\\n • Insert the tube with the help of a laryngoscope and a Magill’s\\n forceps, or — even better — side-by-side with endoscopic\\n assistance, because your endoscopist is already there. Test the',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nThe intrahepatic portosystemic shunt (TIPS) procedure creates a connection between the hepatic vein and the portal vein to provide central decompression of the hypertensive portal venous system. It may increase pre-existing encephalopathy or lead to new-onset encephalopathy and therefore the indication has to be carefully considered. In Child-Pugh C cirrhosis (see Table 25.1) patients with elevated bilirubin >10mg/dL (171μmol/L) undergoing TIPS, there is a real risk that the liver will decompensate. But when sclerotherapy and variceal banding fail twice, it is the logical next step in an emergency despite this risk.\\n\\nHowever, you might become a little bit more involved if your interventional radiologist does not routinely do TIPS or (even better… and more common) there is nobody around who has ever heard about TIPS. Your hemorrhaging patient will have to be transferred to a different center (only God can help the patient if such a center does not exist in your country) and a balloon tamponade will be necessary to temporize the situation — and it is possible that your gastroenterologist will need your assistance for that. It is rare nowadays to find any board-certified surgeon who has placed more than a few, if any, balloon tubes (Sengstaken-Blakemore or Linton-Nachlas) in his life, so here below are a few words about the technique.\\n\\n### Advice on the Technique of Esophageal Balloon Catheter Placement:\\n\\n- Make sure you insert balloon tubes only after the patient has been intubated and the airway is protected. (BTW, patients with massive upper GI hemorrhage should have already been intubated for the endoscopy.)\\n- Find out what type of balloon tube you have available, take the time to understand the different access channels and the different balloon tubes, and test the integrity of the balloons in a small bucket of water. It is useful to keep the balloons in the freezer, as it makes them rigid and easier to insert.\\n- Insert the tube with the help of a laryngoscope and a Magill’s forceps, or — even better — side-by-side with endoscopic assistance, because your endoscopist is already there. Test the...\\n\\n## Table Extraction\\n\\n| Table Number | Description |\\n|--------------|-------------|\\n| 25.1 | Child-Pugh classification for liver disease |\\n\\n## Image Identification and Description\\n\\n- **Figure 1**: \\n```',\n", " 'images': [{'name': 'img_p415_1.png',\n", " 'height': 12,\n", " 'width': 12,\n", " 'x': 361.44000000000005,\n", " 'y': 159.12}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The intrahepatic portosystemic shunt (TIPS) procedure creates a connection between the hepatic vein and the portal vein to provide central decompression of the hypertensive portal venous system. It may increase pre-existing encephalopathy or lead to new-onset encephalopathy and therefore the indication has to be carefully considered. In Child-Pugh C cirrhosis (see Table 25.1) patients with elevated bilirubin >10mg/dL (171μmol/L) undergoing TIPS, there is a real risk that the liver will decompensate. But when sclerotherapy and variceal banding fail twice, it is the logical next step in an emergency despite this risk.\\n\\nHowever, you might become a little bit more involved if your interventional radiologist does not routinely do TIPS or (even better… and more common) there is nobody around who has ever heard about TIPS. Your hemorrhaging patient will have to be transferred to a different center (only God can help the patient if such a center does not exist in your country) and a balloon tamponade will be necessary to temporize the situation — and it is possible that your gastroenterologist will need your assistance for that. It is rare nowadays to find any board-certified surgeon who has placed more than a few, if any, balloon tubes (Sengstaken-Blakemore or Linton-Nachlas) in his life, so here below are a few words about the technique.',\n", " 'md': 'The intrahepatic portosystemic shunt (TIPS) procedure creates a connection between the hepatic vein and the portal vein to provide central decompression of the hypertensive portal venous system. It may increase pre-existing encephalopathy or lead to new-onset encephalopathy and therefore the indication has to be carefully considered. In Child-Pugh C cirrhosis (see Table 25.1) patients with elevated bilirubin >10mg/dL (171μmol/L) undergoing TIPS, there is a real risk that the liver will decompensate. But when sclerotherapy and variceal banding fail twice, it is the logical next step in an emergency despite this risk.\\n\\nHowever, you might become a little bit more involved if your interventional radiologist does not routinely do TIPS or (even better… and more common) there is nobody around who has ever heard about TIPS. Your hemorrhaging patient will have to be transferred to a different center (only God can help the patient if such a center does not exist in your country) and a balloon tamponade will be necessary to temporize the situation — and it is possible that your gastroenterologist will need your assistance for that. It is rare nowadays to find any board-certified surgeon who has placed more than a few, if any, balloon tubes (Sengstaken-Blakemore or Linton-Nachlas) in his life, so here below are a few words about the technique.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.81, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Advice on the Technique of Esophageal Balloon Catheter Placement:',\n", " 'md': '### Advice on the Technique of Esophageal Balloon Catheter Placement:',\n", " 'bBox': {'x': 72, 'y': 487, 'w': 75, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- Make sure you insert balloon tubes only after the patient has been intubated and the airway is protected. (BTW, patients with massive upper GI hemorrhage should have already been intubated for the endoscopy.)\\n- Find out what type of balloon tube you have available, take the time to understand the different access channels and the different balloon tubes, and test the integrity of the balloons in a small bucket of water. It is useful to keep the balloons in the freezer, as it makes them rigid and easier to insert.\\n- Insert the tube with the help of a laryngoscope and a Magill’s forceps, or — even better — side-by-side with endoscopic assistance, because your endoscopist is already there. Test the...',\n", " 'md': '- Make sure you insert balloon tubes only after the patient has been intubated and the airway is protected. (BTW, patients with massive upper GI hemorrhage should have already been intubated for the endoscopy.)\\n- Find out what type of balloon tube you have available, take the time to understand the different access channels and the different balloon tubes, and test the integrity of the balloons in a small bucket of water. It is useful to keep the balloons in the freezer, as it makes them rigid and easier to insert.\\n- Insert the tube with the help of a laryngoscope and a Magill’s forceps, or — even better — side-by-side with endoscopic assistance, because your endoscopist is already there. Test the...',\n", " 'bBox': {'x': 100, 'y': 135, 'w': 437.22, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table Extraction',\n", " 'md': '## Table Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Table Number', 'Description'],\n", " ['25.1', 'Child-Pugh classification for liver disease']],\n", " 'md': '| Table Number | Description |\\n|--------------|-------------|\\n| 25.1 | Child-Pugh classification for liver disease |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Table Number\",\"Description\"\\n\"25.1\",\"Child-Pugh classification for liver disease\"',\n", " 'bBox': {'x': 361, 'y': 135, 'w': 16.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: \\n```',\n", " 'md': '- **Figure 1**: \\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'elevated bilirubin >10mg/dL (171μmol/L) undergoing TIPS, there is a real'}]},\n", " {'page': 417,\n", " 'text': ' position of the gastric lumen with a stethoscope, as with an NG tube.\\n If in doubt about the position get an X-ray.\\n• Insufflate the gastric balloon stepwise to a 200-250cc final volume; if\\n necessary stop and readjust if there is resistance. (I recently\\n admitted an unstable cirrhotic patient with a balloon tube from an\\n outside hospital. ħe had a torn gastroesophageal junction and died\\n after salvage surgery.) Adjust the tension to the gastroesophageal\\n junction by fixing the tube to the patient (not to the bed), with the\\n split tennis-ball technique — using a ‘bite block’ to provide counter\\n resistance.\\n• If the patient stabilizes, don’t inflate the esophageal balloon if you\\n have a Senkstaken-Blakemore tube (the Linton-Nachlas doesn’t\\n have an esophageal balloon, which is why I prefer it — Figure\\n 25.1), but leave it alone. In the vast majority of cases there is no\\n need to inflate the esophageal balloon. But if you get the impression\\n that the esophageal bleeding hasn’t stopped, connect the\\n esophageal balloon (with a three-way stopcock) to a manometer and\\n do not inflate above 35mmHg.\\n• If the patient does not stabilize, deflate the balloon, perform another\\n endoscopy and if visualization is still bad, perform a CT arteriogram\\n or regular arteriogram, because you might be dealing with a\\n bleeding peptic ulcer or a Dieulafoy gastric lesion.',\n", " 'md': \"```markdown\\n## Medical Procedure Guidelines\\n\\n- Position the gastric lumen with a stethoscope, as with an NG tube. If in doubt about the position, get an X-ray.\\n- Insufflate the gastric balloon stepwise to a final volume of 200-250cc; if necessary, stop and readjust if there is resistance. (I recently admitted an unstable cirrhotic patient with a balloon tube from an outside hospital. He had a torn gastroesophageal junction and died after salvage surgery.) Adjust the tension to the gastroesophageal junction by fixing the tube to the patient (not to the bed), using the split tennis-ball technique — using a ‘bite block’ to provide counter resistance.\\n- If the patient stabilizes, don’t inflate the esophageal balloon if you have a Sengstaken-Blakemore tube (the Linton-Nachlas doesn’t have an esophageal balloon, which is why I prefer it — **Figure 25.1**), but leave it alone. In the vast majority of cases, there is no need to inflate the esophageal balloon. But if you get the impression that the esophageal bleeding hasn’t stopped, connect the esophageal balloon (with a three-way stopcock) to a manometer and do not inflate above 35 mmHg.\\n- If the patient does not stabilize, deflate the balloon, perform another endoscopy, and if visualization is still bad, perform a CT arteriogram or regular arteriogram, because you might be dealing with a bleeding peptic ulcer or a Dieulafoy gastric lesion.\\n```\\n\\n### Figure Description\\n- **Figure 25.1**: This figure likely illustrates the Sengstaken-Blakemore tube, which is used in medical procedures related to esophageal bleeding. The image may include details about the tube's structure and its application in stabilizing patients with gastrointestinal bleeding. The exact content of the figure is not provided in the text, but it is referenced in the context of the procedure.\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Medical Procedure Guidelines',\n", " 'md': '## Medical Procedure Guidelines',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Position the gastric lumen with a stethoscope, as with an NG tube. If in doubt about the position, get an X-ray.\\n- Insufflate the gastric balloon stepwise to a final volume of 200-250cc; if necessary, stop and readjust if there is resistance. (I recently admitted an unstable cirrhotic patient with a balloon tube from an outside hospital. He had a torn gastroesophageal junction and died after salvage surgery.) Adjust the tension to the gastroesophageal junction by fixing the tube to the patient (not to the bed), using the split tennis-ball technique — using a ‘bite block’ to provide counter resistance.\\n- If the patient stabilizes, don’t inflate the esophageal balloon if you have a Sengstaken-Blakemore tube (the Linton-Nachlas doesn’t have an esophageal balloon, which is why I prefer it — **Figure 25.1**), but leave it alone. In the vast majority of cases, there is no need to inflate the esophageal balloon. But if you get the impression that the esophageal bleeding hasn’t stopped, connect the esophageal balloon (with a three-way stopcock) to a manometer and do not inflate above 35 mmHg.\\n- If the patient does not stabilize, deflate the balloon, perform another endoscopy, and if visualization is still bad, perform a CT arteriogram or regular arteriogram, because you might be dealing with a bleeding peptic ulcer or a Dieulafoy gastric lesion.\\n```',\n", " 'md': '- Position the gastric lumen with a stethoscope, as with an NG tube. If in doubt about the position, get an X-ray.\\n- Insufflate the gastric balloon stepwise to a final volume of 200-250cc; if necessary, stop and readjust if there is resistance. (I recently admitted an unstable cirrhotic patient with a balloon tube from an outside hospital. He had a torn gastroesophageal junction and died after salvage surgery.) Adjust the tension to the gastroesophageal junction by fixing the tube to the patient (not to the bed), using the split tennis-ball technique — using a ‘bite block’ to provide counter resistance.\\n- If the patient stabilizes, don’t inflate the esophageal balloon if you have a Sengstaken-Blakemore tube (the Linton-Nachlas doesn’t have an esophageal balloon, which is why I prefer it — **Figure 25.1**), but leave it alone. In the vast majority of cases, there is no need to inflate the esophageal balloon. But if you get the impression that the esophageal bleeding hasn’t stopped, connect the esophageal balloon (with a three-way stopcock) to a manometer and do not inflate above 35 mmHg.\\n- If the patient does not stabilize, deflate the balloon, perform another endoscopy, and if visualization is still bad, perform a CT arteriogram or regular arteriogram, because you might be dealing with a bleeding peptic ulcer or a Dieulafoy gastric lesion.\\n```',\n", " 'bBox': {'x': 100, 'y': 237, 'w': 436.89, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Description',\n", " 'md': '### Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- **Figure 25.1**: This figure likely illustrates the Sengstaken-Blakemore tube, which is used in medical procedures related to esophageal bleeding. The image may include details about the tube's structure and its application in stabilizing patients with gastrointestinal bleeding. The exact content of the figure is not provided in the text, but it is referenced in the context of the procedure.\",\n", " 'md': \"- **Figure 25.1**: This figure likely illustrates the Sengstaken-Blakemore tube, which is used in medical procedures related to esophageal bleeding. The image may include details about the tube's structure and its application in stabilizing patients with gastrointestinal bleeding. The exact content of the figure is not provided in the text, but it is referenced in the context of the procedure.\",\n", " 'bBox': {'x': 139, 'y': 340, 'w': 78.39, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ' Figure need to inflate the esophageal balloon. But if you get the impression'}]},\n", " {'page': 418,\n", " 'text': ' Gastric Gastric\\n balloon balloon\\n Gastric Gastric\\n lumen lumen\\n Esophageal Esophageal\\n balloon lumen\\n Sengstaken-Blakemore tube Linton-Nachlas tube\\nFigure 25.1. Sengstaken-Blakemore vs. Linton-Nachlas tubes.\\n\\n The esophageal ‘hemostatic’ stent\\n Patients do not always survive the ordeal. And there remain difficult\\ndecisions further down the road from this emergency. For example, a\\nmassive hemorrhage from an ulcer developing at the banded variceal\\nsite. In this situation we have advocated a newly available variceal stent.\\nOriginally designed for blind insertion in the ambulance, it was, however,\\nnever used in that setting. But in the emergency room after intubation it\\nmay be a promising option to stop esophageal bleeding from ulcers or\\nvarices in severe reflux esophagitis, where rubber bands are not\\napplicable. The device comes with a temporary Linton balloon to define\\nthe esophagogastric junction. The device is introduced over an\\nendoscopically-placed guidewire. ħaving inflated the gastric balloon,\\nunder gentle traction, the large (30 x 135mm) covered self-expanding\\nmetal stent is released ( Figure 25.2). The stent can be left in place for 1\\nweek. In most cases this time interval is enough to come up with a better\\ntreatment plan…',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Figure 25.1\\n**Description:** This figure compares two types of tubes used in medical procedures: the Sengstaken-Blakemore tube and the Linton-Nachlas tube. The image likely illustrates the anatomical placement of these tubes in relation to the gastric and esophageal structures.\\n\\n**Summary:** The figure visually represents the differences between the Sengstaken-Blakemore tube and the Linton-Nachlas tube, highlighting their respective positions in the gastric and esophageal regions.\\n\\n----\\n\\n## Text\\nThe esophageal ‘hemostatic’ stent\\nPatients do not always survive the ordeal. And there remain difficult decisions further down the road from this emergency. For example, a massive hemorrhage from an ulcer developing at the banded variceal site. In this situation, we have advocated a newly available variceal stent. Originally designed for blind insertion in the ambulance, it was, however, never used in that setting. But in the emergency room after intubation, it may be a promising option to stop esophageal bleeding from ulcers or varices in severe reflux esophagitis, where rubber bands are not applicable. The device comes with a temporary Linton balloon to define the esophagogastric junction. The device is introduced over an endoscopically-placed guidewire. Having inflated the gastric balloon, under gentle traction, the large (30 x 135 mm) covered self-expanding metal stent is released (Figure 25.2). The stent can be left in place for 1 week. In most cases, this time interval is enough to come up with a better treatment plan…\\n\\n## Figure 25.2\\n**Description:** This figure depicts the process of releasing a covered self-expanding metal stent after inflating the gastric balloon. The stent is designed for use in emergency situations to manage esophageal bleeding.\\n\\n**Summary:** The figure illustrates the procedure involving the gastric balloon and the release of the stent, emphasizing its application in treating severe esophageal bleeding.\\n\\n```',\n", " 'images': [{'name': 'img_p417_1.png',\n", " 'height': 614,\n", " 'width': 699,\n", " 'x': 133.19999999999982,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1200,\n", " 'original_height': 1056}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 25.1',\n", " 'md': '## Figure 25.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure compares two types of tubes used in medical procedures: the Sengstaken-Blakemore tube and the Linton-Nachlas tube. The image likely illustrates the anatomical placement of these tubes in relation to the gastric and esophageal structures.\\n\\n**Summary:** The figure visually represents the differences between the Sengstaken-Blakemore tube and the Linton-Nachlas tube, highlighting their respective positions in the gastric and esophageal regions.\\n\\n----',\n", " 'md': '**Description:** This figure compares two types of tubes used in medical procedures: the Sengstaken-Blakemore tube and the Linton-Nachlas tube. The image likely illustrates the anatomical placement of these tubes in relation to the gastric and esophageal structures.\\n\\n**Summary:** The figure visually represents the differences between the Sengstaken-Blakemore tube and the Linton-Nachlas tube, highlighting their respective positions in the gastric and esophageal regions.\\n\\n----',\n", " 'bBox': {'x': 137.65, 'y': 148.62, 'w': 219.52, 'h': 11.88}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The esophageal ‘hemostatic’ stent\\nPatients do not always survive the ordeal. And there remain difficult decisions further down the road from this emergency. For example, a massive hemorrhage from an ulcer developing at the banded variceal site. In this situation, we have advocated a newly available variceal stent. Originally designed for blind insertion in the ambulance, it was, however, never used in that setting. But in the emergency room after intubation, it may be a promising option to stop esophageal bleeding from ulcers or varices in severe reflux esophagitis, where rubber bands are not applicable. The device comes with a temporary Linton balloon to define the esophagogastric junction. The device is introduced over an endoscopically-placed guidewire. Having inflated the gastric balloon, under gentle traction, the large (30 x 135 mm) covered self-expanding metal stent is released (Figure 25.2). The stent can be left in place for 1 week. In most cases, this time interval is enough to come up with a better treatment plan…',\n", " 'md': 'The esophageal ‘hemostatic’ stent\\nPatients do not always survive the ordeal. And there remain difficult decisions further down the road from this emergency. For example, a massive hemorrhage from an ulcer developing at the banded variceal site. In this situation, we have advocated a newly available variceal stent. Originally designed for blind insertion in the ambulance, it was, however, never used in that setting. But in the emergency room after intubation, it may be a promising option to stop esophageal bleeding from ulcers or varices in severe reflux esophagitis, where rubber bands are not applicable. The device comes with a temporary Linton balloon to define the esophagogastric junction. The device is introduced over an endoscopically-placed guidewire. Having inflated the gastric balloon, under gentle traction, the large (30 x 135 mm) covered self-expanding metal stent is released (Figure 25.2). The stent can be left in place for 1 week. In most cases, this time interval is enough to come up with a better treatment plan…',\n", " 'bBox': {'x': 72, 'y': 148.62, 'w': 467.67, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 25.2',\n", " 'md': '## Figure 25.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure depicts the process of releasing a covered self-expanding metal stent after inflating the gastric balloon. The stent is designed for use in emergency situations to manage esophageal bleeding.\\n\\n**Summary:** The figure illustrates the procedure involving the gastric balloon and the release of the stent, emphasizing its application in treating severe esophageal bleeding.\\n\\n```',\n", " 'md': '**Description:** This figure depicts the process of releasing a covered self-expanding metal stent after inflating the gastric balloon. The stent is designed for use in emergency situations to manage esophageal bleeding.\\n\\n**Summary:** The figure illustrates the procedure involving the gastric balloon and the release of the stent, emphasizing its application in treating severe esophageal bleeding.\\n\\n```',\n", " 'bBox': {'x': 137.65, 'y': 148.62, 'w': 219.52, 'h': 11.88}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'week. In most cases this time interval is enough to come up with a better'}]},\n", " {'page': 419,\n", " 'text': ' Introduction of the delivery system over b stomach: of the delivery\\n Fixation system the\\n the guidewire. This step follows previousguidewire through\\n insertion the the\\n working channel of the endoscope:\\n loCK\\n HANDlE\\n The protecting plate touches the mouthpiece_ Remove the blue lock. Push the balloon out of the\\n sheath until the white lock touches the sheath handle\\n Fixation of the delivery system in the d Stent deployment:\\n stomach.\\n 50 mi2x WhMe\\n locK\\n Ist step: Inflation the balloon. Znd step: Ist step Remove the white lock: Znd step: Pull the\\n Fixation of the ballooon in the cardia by pulling it sheath handle until it reaches the Y-connector:\\n back: 3rd step: Move the protecting plate to the\\n mouthpiece and lock it:\\n Delivery system removal: Delivery system removal.\\n Unscrew the ballooon valve and remove it: The Remove the delivery system_ Finally, remove the\\n balloon gets empty. (cca 30 sec). guidewire\\nFigure 25.2. The esophageal hemostatic stent. Promoted and introduced to me by Christoph\\nGubler, MD, at the University Hospital of Zurich.\\n\\n The patient with cirrhosis and portal hypertension who',\n", " 'md': \"```markdown\\n# Page Content\\n\\n## Text\\n- Introduction of the delivery system over the stomach: Fixation of the delivery system the guidewire. This step follows previous guidewire insertion through the working channel of the endoscope.\\n- The protecting plate touches the mouthpiece. Remove the blue lock. Push the balloon out of the sheath until the white lock touches the sheath handle.\\n- Fixation of the delivery system in the stomach.\\n- 1st step: Inflation of the balloon. 2nd step: Remove the white lock. 3rd step: Pull the sheath handle until it reaches the Y-connector.\\n- Delivery system removal: Unscrew the balloon valve and remove it. The balloon gets empty (cca 30 sec). Finally, remove the guidewire.\\n\\n## Figure\\n**Figure 25.2**: The esophageal hemostatic stent. Promoted and introduced to me by Christoph Gubler, MD, at the University Hospital of Zurich. The patient with cirrhosis and portal hypertension who .\\n\\n### Summary of Figure 25.2\\nThis figure illustrates the esophageal hemostatic stent, which is a medical device used in patients with conditions such as cirrhosis and portal hypertension. The stent is designed to assist in managing esophageal bleeding and is introduced through an endoscopic procedure. The figure likely includes details about the stent's design and application, although specific wording is not identifiable.\\n```\",\n", " 'images': [{'name': 'img_p418_1.png',\n", " 'height': 371,\n", " 'width': 670,\n", " 'x': 140.4000000000001,\n", " 'y': 72,\n", " 'original_width': 1200,\n", " 'original_height': 666},\n", " {'name': 'img_p418_2.png',\n", " 'height': 373,\n", " 'width': 670,\n", " 'x': 140.4000000000001,\n", " 'y': 266.4,\n", " 'original_width': 1200,\n", " 'original_height': 669},\n", " {'name': 'img_p418_3.png',\n", " 'height': 306,\n", " 'width': 670,\n", " 'x': 140.4000000000001,\n", " 'y': 472.32,\n", " 'original_width': 1200,\n", " 'original_height': 549}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Introduction of the delivery system over the stomach: Fixation of the delivery system the guidewire. This step follows previous guidewire insertion through the working channel of the endoscope.\\n- The protecting plate touches the mouthpiece. Remove the blue lock. Push the balloon out of the sheath until the white lock touches the sheath handle.\\n- Fixation of the delivery system in the stomach.\\n- 1st step: Inflation of the balloon. 2nd step: Remove the white lock. 3rd step: Pull the sheath handle until it reaches the Y-connector.\\n- Delivery system removal: Unscrew the balloon valve and remove it. The balloon gets empty (cca 30 sec). Finally, remove the guidewire.',\n", " 'md': '- Introduction of the delivery system over the stomach: Fixation of the delivery system the guidewire. This step follows previous guidewire insertion through the working channel of the endoscope.\\n- The protecting plate touches the mouthpiece. Remove the blue lock. Push the balloon out of the sheath until the white lock touches the sheath handle.\\n- Fixation of the delivery system in the stomach.\\n- 1st step: Inflation of the balloon. 2nd step: Remove the white lock. 3rd step: Pull the sheath handle until it reaches the Y-connector.\\n- Delivery system removal: Unscrew the balloon valve and remove it. The balloon gets empty (cca 30 sec). Finally, remove the guidewire.',\n", " 'bBox': {'x': 166.6, 'y': 76.45, 'w': 160.16, 'h': 10.89}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure',\n", " 'md': '## Figure',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 25.2**: The esophageal hemostatic stent. Promoted and introduced to me by Christoph Gubler, MD, at the University Hospital of Zurich. The patient with cirrhosis and portal hypertension who .',\n", " 'md': '**Figure 25.2**: The esophageal hemostatic stent. Promoted and introduced to me by Christoph Gubler, MD, at the University Hospital of Zurich. The patient with cirrhosis and portal hypertension who .',\n", " 'bBox': {'x': 75, 'y': 76.45, 'w': 452.78, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary of Figure 25.2',\n", " 'md': '### Summary of Figure 25.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"This figure illustrates the esophageal hemostatic stent, which is a medical device used in patients with conditions such as cirrhosis and portal hypertension. The stent is designed to assist in managing esophageal bleeding and is introduced through an endoscopic procedure. The figure likely includes details about the stent's design and application, although specific wording is not identifiable.\\n```\",\n", " 'md': \"This figure illustrates the esophageal hemostatic stent, which is a medical device used in patients with conditions such as cirrhosis and portal hypertension. The stent is designed to assist in managing esophageal bleeding and is introduced through an endoscopic procedure. The figure likely includes details about the stent's design and application, although specific wording is not identifiable.\\n```\",\n", " 'bBox': {'x': 210.1, 'y': 76.45, 'w': 109.74, 'h': 10.89}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 420,\n", " 'text': ' needs emergency general surgery\\n\\n The liver patient does not make an attractive surgical candidate — for\\nany surgery except for one operation; that in which you exchange the\\ndiseased liver with a new, transplanted one. Therefore, all surgery\\nshould be avoided if possible; even a dental procedure may end up\\nwith a blood transfusion due to coagulopathy. ħowever, liver patients\\nnot infrequently present with general surgery emergencies and those\\nneed to be addressed.\\n\\n A time-honored and well-validated tool to assess the risk of liver\\npatients is the Child-Pugh Score ( Table 25.1). Although initially\\ndeveloped in the context of surgery for portal hypertension, the score has\\nbeen useful to generations of surgeons to assess the mortality risk of\\nchronic liver patients undergoing anything from a hernia repair to a\\nWhipple procedure.\\n\\n The score categorizes patients in Child A as those with an\\nacceptable risk for any general surgery procedure; Child B as those\\nwhere the indications have to be very selective due to an increased risk\\nof decompensation; and Child C as those who should not undergo any\\nprocedure due to very high mortality. The score is useful, even though\\nsome of the parameters assessed depend on the clinician’s subjective\\njudgment. Some authors prefer the MELD score — consisting of three\\nlaboratory values (International Normalized Ratio [INR], bilirubin and\\ncreatinine) and which reflects 3-month mortality on the liver transplant\\nwaiting list. Many papers have been written on which score is better but\\nthey don’t pay attention to the fact that the value of the score derives\\nfrom the way it is used. The MELD score ( Figure 25.3) was introduced\\nto rationalize organ utilization among centers who ‘cheated’ by\\ntransplanting patients who were less sick than others. Such a score\\nindeed requires minimal subjective judgment. To judge the severity of\\nliver disease for everyday use and put your patient into one of these\\nthree categories, the Child score is perfect and doesn’t need any\\nimprovement. There are some tools that can hardly be improved\\nupon, such as hammers — the Child score is such a tool.',\n", " 'md': '```markdown\\n# Emergency General Surgery in Liver Patients\\n\\nLiver patients do not make attractive surgical candidates for any surgery except for one operation: the transplantation of a diseased liver with a new one. Therefore, all surgery should be avoided if possible; even a dental procedure may end up with a blood transfusion due to coagulopathy. However, liver patients not infrequently present with general surgery emergencies that need to be addressed.\\n\\nA time-honored and well-validated tool to assess the risk of liver patients is the **Child-Pugh Score** (Table 25.1). Although initially developed in the context of surgery for portal hypertension, the score has been useful to generations of surgeons to assess the mortality risk of chronic liver patients undergoing anything from a hernia repair to a Whipple procedure.\\n\\nThe score categorizes patients as follows:\\n- **Child A**: Those with an acceptable risk for any general surgery procedure.\\n- **Child B**: Those where the indications have to be very selective due to an increased risk of decompensation.\\n- **Child C**: Those who should not undergo any procedure due to very high mortality.\\n\\nThe score is useful, even though some of the parameters assessed depend on the clinician’s subjective judgment. Some authors prefer the **MELD score**, which consists of three laboratory values (International Normalized Ratio [INR], bilirubin, and creatinine) and reflects 3-month mortality on the liver transplant waiting list. Many papers have been written on which score is better, but they don’t pay attention to the fact that the value of the score derives from the way it is used.\\n\\nThe MELD score (Figure 25.3) was introduced to rationalize organ utilization among centers that ‘cheated’ by transplanting patients who were less sick than others. Such a score indeed requires minimal subjective judgment. To judge the severity of liver disease for everyday use and categorize your patient into one of these three categories, the Child score is perfect and doesn’t need any improvement. There are some tools that can hardly be improved upon, such as hammers — the Child score is such a tool.\\n\\n## Figures\\n\\n### Figure 25.3\\n- **Description**: The MELD score is depicted in this figure, illustrating its components and significance in assessing liver disease severity and mortality risk.\\n- **Summary**: The MELD score is a critical tool for evaluating liver patients, requiring minimal subjective judgment and aiding in organ allocation decisions.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Emergency General Surgery in Liver Patients',\n", " 'md': '# Emergency General Surgery in Liver Patients',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Liver patients do not make attractive surgical candidates for any surgery except for one operation: the transplantation of a diseased liver with a new one. Therefore, all surgery should be avoided if possible; even a dental procedure may end up with a blood transfusion due to coagulopathy. However, liver patients not infrequently present with general surgery emergencies that need to be addressed.\\n\\nA time-honored and well-validated tool to assess the risk of liver patients is the **Child-Pugh Score** (Table 25.1). Although initially developed in the context of surgery for portal hypertension, the score has been useful to generations of surgeons to assess the mortality risk of chronic liver patients undergoing anything from a hernia repair to a Whipple procedure.\\n\\nThe score categorizes patients as follows:\\n- **Child A**: Those with an acceptable risk for any general surgery procedure.\\n- **Child B**: Those where the indications have to be very selective due to an increased risk of decompensation.\\n- **Child C**: Those who should not undergo any procedure due to very high mortality.\\n\\nThe score is useful, even though some of the parameters assessed depend on the clinician’s subjective judgment. Some authors prefer the **MELD score**, which consists of three laboratory values (International Normalized Ratio [INR], bilirubin, and creatinine) and reflects 3-month mortality on the liver transplant waiting list. Many papers have been written on which score is better, but they don’t pay attention to the fact that the value of the score derives from the way it is used.\\n\\nThe MELD score (Figure 25.3) was introduced to rationalize organ utilization among centers that ‘cheated’ by transplanting patients who were less sick than others. Such a score indeed requires minimal subjective judgment. To judge the severity of liver disease for everyday use and categorize your patient into one of these three categories, the Child score is perfect and doesn’t need any improvement. There are some tools that can hardly be improved upon, such as hammers — the Child score is such a tool.',\n", " 'md': 'Liver patients do not make attractive surgical candidates for any surgery except for one operation: the transplantation of a diseased liver with a new one. Therefore, all surgery should be avoided if possible; even a dental procedure may end up with a blood transfusion due to coagulopathy. However, liver patients not infrequently present with general surgery emergencies that need to be addressed.\\n\\nA time-honored and well-validated tool to assess the risk of liver patients is the **Child-Pugh Score** (Table 25.1). Although initially developed in the context of surgery for portal hypertension, the score has been useful to generations of surgeons to assess the mortality risk of chronic liver patients undergoing anything from a hernia repair to a Whipple procedure.\\n\\nThe score categorizes patients as follows:\\n- **Child A**: Those with an acceptable risk for any general surgery procedure.\\n- **Child B**: Those where the indications have to be very selective due to an increased risk of decompensation.\\n- **Child C**: Those who should not undergo any procedure due to very high mortality.\\n\\nThe score is useful, even though some of the parameters assessed depend on the clinician’s subjective judgment. Some authors prefer the **MELD score**, which consists of three laboratory values (International Normalized Ratio [INR], bilirubin, and creatinine) and reflects 3-month mortality on the liver transplant waiting list. Many papers have been written on which score is better, but they don’t pay attention to the fact that the value of the score derives from the way it is used.\\n\\nThe MELD score (Figure 25.3) was introduced to rationalize organ utilization among centers that ‘cheated’ by transplanting patients who were less sick than others. Such a score indeed requires minimal subjective judgment. To judge the severity of liver disease for everyday use and categorize your patient into one of these three categories, the Child score is perfect and doesn’t need any improvement. There are some tools that can hardly be improved upon, such as hammers — the Child score is such a tool.',\n", " 'bBox': {'x': 72, 'y': 173, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures',\n", " 'md': '## Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 25.3',\n", " 'md': '### Figure 25.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: The MELD score is depicted in this figure, illustrating its components and significance in assessing liver disease severity and mortality risk.\\n- **Summary**: The MELD score is a critical tool for evaluating liver patients, requiring minimal subjective judgment and aiding in organ allocation decisions.\\n```',\n", " 'md': '- **Description**: The MELD score is depicted in this figure, illustrating its components and significance in assessing liver disease severity and mortality risk.\\n- **Summary**: The MELD score is a critical tool for evaluating liver patients, requiring minimal subjective judgment and aiding in organ allocation decisions.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'developed in the context of surgery for portal hypertension, the score has'},\n", " {'text': 'centers '}]},\n", " {'page': 421,\n", " 'text': ' I33poie]\\n Meld2\\n Sco\\n FeRyA2o14\\nFigure 25.3. “Sir, you have 33 points on the MELD score. We need… to find a new liver for\\nyou. Perhaps from China?” Patient: “Actually, I would like another piece of chicken. And\\nget me some better wine. This one sucks!”',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\nFigure 25.3. “Sir, you have 33 points on the MELD score. We need… to find a new liver for you. Perhaps from China?” Patient: “Actually, I would like another piece of chicken. And get me some better wine. This one sucks!”\\n\\n## Image Identification and Description\\n**Figure 25**: This image likely depicts a humorous cartoon or illustration related to the MELD score, which is a scoring system used to prioritize patients for liver transplants. The dialogue between the doctor and the patient adds a comedic twist, highlighting the patient\\'s unexpected request for food and drink instead of focusing on the serious medical situation.\\n\\n### Summary\\nThe image presents a light-hearted take on a serious medical topic, contrasting the gravity of needing a liver transplant with the patient\\'s humorous and trivial concerns. The figure number is noted as \"Figure 25\".\\n```',\n", " 'images': [{'name': 'img_p420_1.png',\n", " 'height': 641,\n", " 'width': 808,\n", " 'x': 106.55999999999995,\n", " 'y': 82.79999999999995,\n", " 'original_width': 1388,\n", " 'original_height': 1100}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 25.3. “Sir, you have 33 points on the MELD score. We need… to find a new liver for you. Perhaps from China?” Patient: “Actually, I would like another piece of chicken. And get me some better wine. This one sucks!”',\n", " 'md': 'Figure 25.3. “Sir, you have 33 points on the MELD score. We need… to find a new liver for you. Perhaps from China?” Patient: “Actually, I would like another piece of chicken. And get me some better wine. This one sucks!”',\n", " 'bBox': {'x': 75, 'y': 201.41, 'w': 460.42, 'h': 11.86}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"**Figure 25**: This image likely depicts a humorous cartoon or illustration related to the MELD score, which is a scoring system used to prioritize patients for liver transplants. The dialogue between the doctor and the patient adds a comedic twist, highlighting the patient's unexpected request for food and drink instead of focusing on the serious medical situation.\",\n", " 'md': \"**Figure 25**: This image likely depicts a humorous cartoon or illustration related to the MELD score, which is a scoring system used to prioritize patients for liver transplants. The dialogue between the doctor and the patient adds a comedic twist, highlighting the patient's unexpected request for food and drink instead of focusing on the serious medical situation.\",\n", " 'bBox': {'x': 308.83, 'y': 201.41, 'w': 31.16, 'h': 11.86}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The image presents a light-hearted take on a serious medical topic, contrasting the gravity of needing a liver transplant with the patient\\'s humorous and trivial concerns. The figure number is noted as \"Figure 25\".\\n```',\n", " 'md': 'The image presents a light-hearted take on a serious medical topic, contrasting the gravity of needing a liver transplant with the patient\\'s humorous and trivial concerns. The figure number is noted as \"Figure 25\".\\n```',\n", " 'bBox': {'x': 326.14, 'y': 206.36, 'w': 11.87, 'h': 11.86}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 422,\n", " 'text': ' Table 25.1. The Child-Pugh classification* _\\n Score**\\n Bilirubin (mg%) <2 2-3 >3\\n Albumin (g%) >3.5 2.8-3.5 <2.8\\n INR <1.7 1.7-2.3 >2.3\\n Encephalopathy None Mild Marked\\n Ascites None Mild Marked\\n Charles Gardner Child IIl (1908-1991) was Professor of Surgery at the University of\\n Michigan RN.H. Pugh published his classification in 1973 (Pugh et al. Transection of the\\n esophagus for bleeding esophageal varices. Br Surg 1973; 60: 649-90).\\n The individual scores are summed and then grouped as:\\n <7 = Child A\\n 7-9 =Child B\\n >9 = Child C\\n Child C classification forecasts a survival of less than 12 months)\\n Typically, you are called because a Child B patient has an incarcerated\\ninguinal hernia and his internist wants it fixed. Make sure you explain\\nthat the hernia repair might easily kill him, get an experienced\\nanesthetist involved and, if you can, perform the repair under local\\nanesthesia. Correcting coagulopathy with fresh frozen plasma (FFP) is\\ndifficult and frequently does not help; vitamin K should be obligatory but\\nfrequently doesn’t help either in improving coagulopathy in cirrhotic\\npatients.\\n\\n By the way, what you learn when you do liver transplants is that a\\nliver patient with an INR of 2.5 is not necessarily coagulopathic like\\na patient who takes coumadin and has an INR of 2.5. While correcting',\n", " 'md': '```markdown\\n# Table 25.1. The Child-Pugh Classification\\n\\n| Score** | Bilirubin (mg%) | Albumin (g%) | INR | Encephalopathy | Ascites |\\n|-----------------------------|------------------|---------------|-------------|----------------|---------------|\\n| | <2 | >3.5 | <1.7 | None | None |\\n| | 2-3 | 2.8-3.5 | 1.7-2.3 | Mild | Mild |\\n| | >3 | <2.8 | >2.3 | Marked | Marked |\\n\\nThe individual scores are summed and then grouped as:\\n- <7 = Child A\\n- 7-9 = Child B\\n- >9 = Child C\\n\\nChild C classification forecasts a survival of less than 12 months.\\n\\nTypically, you are called because a Child B patient has an incarcerated inguinal hernia and his internist wants it fixed. Make sure you explain that the hernia repair might easily kill him, get an experienced anesthetist involved and, if you can, perform the repair under local anesthesia. Correcting coagulopathy with fresh frozen plasma (FFP) is difficult and frequently does not help; vitamin K should be obligatory but frequently doesn’t help either in improving coagulopathy in cirrhotic patients.\\n\\nBy the way, what you learn when you do liver transplants is that a liver patient with an INR of 2.5 is not necessarily coagulopathic like a patient who takes coumadin and has an INR of 2.5.\\n```',\n", " 'images': [{'name': 'img_p421_1.png',\n", " 'height': 843,\n", " 'width': 819,\n", " 'x': 103.67999999999984,\n", " 'y': 72,\n", " 'original_width': 1407,\n", " 'original_height': 1447}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Table 25.1. The Child-Pugh Classification',\n", " 'md': '# Table 25.1. The Child-Pugh Classification',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Score**',\n", " 'Bilirubin (mg%)',\n", " 'Albumin (g%)',\n", " 'INR',\n", " 'Encephalopathy',\n", " 'Ascites'],\n", " ['', '<2', '>3.5', '<1.7', 'None', 'None'],\n", " ['', '2-3', '2.8-3.5', '1.7-2.3', 'Mild', 'Mild'],\n", " ['', '>3', '<2.8', '>2.3', 'Marked', 'Marked']],\n", " 'md': '| Score** | Bilirubin (mg%) | Albumin (g%) | INR | Encephalopathy | Ascites |\\n|-----------------------------|------------------|---------------|-------------|----------------|---------------|\\n| | <2 | >3.5 | <1.7 | None | None |\\n| | 2-3 | 2.8-3.5 | 1.7-2.3 | Mild | Mild |\\n| | >3 | <2.8 | >2.3 | Marked | Marked |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Score**\",\"Bilirubin (mg%)\",\"Albumin (g%)\",\"INR\",\"Encephalopathy\",\"Ascites\"\\n\"\",\"<2\",\">3.5\",\"<1.7\",\"None\",\"None\"\\n\"\",\"2-3\",\"2.8-3.5\",\"1.7-2.3\",\"Mild\",\"Mild\"\\n\"\",\">3\",\"<2.8\",\">2.3\",\"Marked\",\"Marked\"',\n", " 'bBox': {'x': 109.12, 'y': 115.52, 'w': 265.79, 'h': 14.84}},\n", " {'type': 'text',\n", " 'value': 'The individual scores are summed and then grouped as:\\n- <7 = Child A\\n- 7-9 = Child B\\n- >9 = Child C\\n\\nChild C classification forecasts a survival of less than 12 months.\\n\\nTypically, you are called because a Child B patient has an incarcerated inguinal hernia and his internist wants it fixed. Make sure you explain that the hernia repair might easily kill him, get an experienced anesthetist involved and, if you can, perform the repair under local anesthesia. Correcting coagulopathy with fresh frozen plasma (FFP) is difficult and frequently does not help; vitamin K should be obligatory but frequently doesn’t help either in improving coagulopathy in cirrhotic patients.\\n\\nBy the way, what you learn when you do liver transplants is that a liver patient with an INR of 2.5 is not necessarily coagulopathic like a patient who takes coumadin and has an INR of 2.5.\\n```',\n", " 'md': 'The individual scores are summed and then grouped as:\\n- <7 = Child A\\n- 7-9 = Child B\\n- >9 = Child C\\n\\nChild C classification forecasts a survival of less than 12 months.\\n\\nTypically, you are called because a Child B patient has an incarcerated inguinal hernia and his internist wants it fixed. Make sure you explain that the hernia repair might easily kill him, get an experienced anesthetist involved and, if you can, perform the repair under local anesthesia. Correcting coagulopathy with fresh frozen plasma (FFP) is difficult and frequently does not help; vitamin K should be obligatory but frequently doesn’t help either in improving coagulopathy in cirrhotic patients.\\n\\nBy the way, what you learn when you do liver transplants is that a liver patient with an INR of 2.5 is not necessarily coagulopathic like a patient who takes coumadin and has an INR of 2.5.\\n```',\n", " 'bBox': {'x': 72, 'y': 218.87, 'w': 467.83, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 423,\n", " 'text': 'the INR with FFP in anticoagulated patients is indicated and effective,\\nmost surgeons dealing with cirrhotic patients do not attempt this before\\nthe operation. Giving people 6 units of FFP upfront will volume-overload\\nthem, cause ascites and more bleeding from venous congestion. I never\\ndo it — except occasionally to control postoperative bleeding. Now you\\nwill ask me about the evidence… (“Definition of a modern surgeon: one\\nwhose ignorance is due to lack of experience, but evidence-based.”)…,\\nbut it is an area where it is difficult to perform a clinical trial as we try to\\navoid operating on these patients anyway.\\n\\n Obsessive hemostasis and meticulous respect for peritoneal\\nintegrity to avoid postoperative leak of ascites (leading to its\\ninfection) are the mainstays of successful surgical management.\\nThese patients have a tendency to develop postoperative hematomas,\\ninfectious complications, ascites and renal failure. Fluid management\\nshould be restrictive; low doses of peri-operative diuretics are helpful to\\ncorrect the volume retention physiology of chronic liver disease. Make\\nsure your residents are well instructed to avoid volume overloading at\\nnight when called by the nurses about oliguria. Unlike in the routine\\npostop surgical patient, oliguria here usually means ‘Lasix®’ rather\\nthan ‘lactated Ringer’s’…\\n\\n Child C patients have a short life expectancy (unless\\ntransplanted…) and they should only be operated on if there is no\\nother option and should be clearly informed about their high\\nmortality risk.\\n\\n Typically, due to the large-volume ascites, they have umbilical\\nhernia emergencies, that require emergency surgery. I have spent\\nmany hours at the bedside of patients high on the transplant list slowly\\nreducing a few loops of bowel that had incarcerated, but were not\\nstrangulated, to spare them the umbilical hernia repair that could easily\\nbring them to the ICU with a 20 MELD point gain within 24 hours. At the\\nsame time I have seen courageous (reckless? inexperienced?) young\\ntransplant surgeons taking Child C patients to the OR arguing that in the\\nevent of decompensation “they are already listed for transplantation”. It is\\nimportant to note here that the outcome for patients who are transplanted\\nafter decompensation is dramatically worse.',\n", " 'md': '```markdown\\n## Surgical Management of Anticoagulated Patients with Cirrhosis\\n\\nThe INR with FFP in anticoagulated patients is indicated and effective; however, most surgeons dealing with cirrhotic patients do not attempt this before the operation. Administering 6 units of FFP upfront can lead to volume overload, causing ascites and increased bleeding from venous congestion. I rarely do it—except occasionally to control postoperative bleeding. You may ask about the evidence… (“Definition of a modern surgeon: one whose ignorance is due to lack of experience, but evidence-based.”)… but it is challenging to conduct a clinical trial in this area as we generally avoid operating on these patients.\\n\\nObsessive hemostasis and meticulous respect for peritoneal integrity are crucial to prevent postoperative leaks of ascites (which can lead to infection). These patients are prone to developing postoperative hematomas, infectious complications, ascites, and renal failure. Fluid management should be restrictive; low doses of peri-operative diuretics can help correct the volume retention associated with chronic liver disease. Ensure that your residents are well instructed to avoid volume overload at night when nurses report oliguria. Unlike routine postoperative surgical patients, oliguria in these cases usually indicates the need for ‘Lasix®’ rather than ‘lactated Ringer’s’.\\n\\nChild C patients have a short life expectancy (unless transplanted) and should only be operated on if there are no other options. They must be clearly informed about their high mortality risk.\\n\\nTypically, due to large-volume ascites, these patients experience umbilical hernia emergencies that necessitate emergency surgery. I have spent many hours at the bedside of patients high on the transplant list, slowly reducing a few loops of bowel that had incarcerated but were not strangulated, to spare them the umbilical hernia repair that could easily lead them to the ICU with a 20 MELD point gain within 24 hours. Simultaneously, I have witnessed young transplant surgeons, who may be courageous (or reckless? inexperienced?), taking Child C patients to the OR, arguing that in the event of decompensation, “they are already listed for transplantation.” It is important to note that the outcome for patients who are transplanted after decompensation is significantly worse.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Management of Anticoagulated Patients with Cirrhosis',\n", " 'md': '## Surgical Management of Anticoagulated Patients with Cirrhosis',\n", " 'bBox': {'x': 165, 'y': 456, 'w': 59.15, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The INR with FFP in anticoagulated patients is indicated and effective; however, most surgeons dealing with cirrhotic patients do not attempt this before the operation. Administering 6 units of FFP upfront can lead to volume overload, causing ascites and increased bleeding from venous congestion. I rarely do it—except occasionally to control postoperative bleeding. You may ask about the evidence… (“Definition of a modern surgeon: one whose ignorance is due to lack of experience, but evidence-based.”)… but it is challenging to conduct a clinical trial in this area as we generally avoid operating on these patients.\\n\\nObsessive hemostasis and meticulous respect for peritoneal integrity are crucial to prevent postoperative leaks of ascites (which can lead to infection). These patients are prone to developing postoperative hematomas, infectious complications, ascites, and renal failure. Fluid management should be restrictive; low doses of peri-operative diuretics can help correct the volume retention associated with chronic liver disease. Ensure that your residents are well instructed to avoid volume overload at night when nurses report oliguria. Unlike routine postoperative surgical patients, oliguria in these cases usually indicates the need for ‘Lasix®’ rather than ‘lactated Ringer’s’.\\n\\nChild C patients have a short life expectancy (unless transplanted) and should only be operated on if there are no other options. They must be clearly informed about their high mortality risk.\\n\\nTypically, due to large-volume ascites, these patients experience umbilical hernia emergencies that necessitate emergency surgery. I have spent many hours at the bedside of patients high on the transplant list, slowly reducing a few loops of bowel that had incarcerated but were not strangulated, to spare them the umbilical hernia repair that could easily lead them to the ICU with a 20 MELD point gain within 24 hours. Simultaneously, I have witnessed young transplant surgeons, who may be courageous (or reckless? inexperienced?), taking Child C patients to the OR, arguing that in the event of decompensation, “they are already listed for transplantation.” It is important to note that the outcome for patients who are transplanted after decompensation is significantly worse.\\n```',\n", " 'md': 'The INR with FFP in anticoagulated patients is indicated and effective; however, most surgeons dealing with cirrhotic patients do not attempt this before the operation. Administering 6 units of FFP upfront can lead to volume overload, causing ascites and increased bleeding from venous congestion. I rarely do it—except occasionally to control postoperative bleeding. You may ask about the evidence… (“Definition of a modern surgeon: one whose ignorance is due to lack of experience, but evidence-based.”)… but it is challenging to conduct a clinical trial in this area as we generally avoid operating on these patients.\\n\\nObsessive hemostasis and meticulous respect for peritoneal integrity are crucial to prevent postoperative leaks of ascites (which can lead to infection). These patients are prone to developing postoperative hematomas, infectious complications, ascites, and renal failure. Fluid management should be restrictive; low doses of peri-operative diuretics can help correct the volume retention associated with chronic liver disease. Ensure that your residents are well instructed to avoid volume overload at night when nurses report oliguria. Unlike routine postoperative surgical patients, oliguria in these cases usually indicates the need for ‘Lasix®’ rather than ‘lactated Ringer’s’.\\n\\nChild C patients have a short life expectancy (unless transplanted) and should only be operated on if there are no other options. They must be clearly informed about their high mortality risk.\\n\\nTypically, due to large-volume ascites, these patients experience umbilical hernia emergencies that necessitate emergency surgery. I have spent many hours at the bedside of patients high on the transplant list, slowly reducing a few loops of bowel that had incarcerated but were not strangulated, to spare them the umbilical hernia repair that could easily lead them to the ICU with a 20 MELD point gain within 24 hours. Simultaneously, I have witnessed young transplant surgeons, who may be courageous (or reckless? inexperienced?), taking Child C patients to the OR, arguing that in the event of decompensation, “they are already listed for transplantation.” It is important to note that the outcome for patients who are transplanted after decompensation is significantly worse.\\n```',\n", " 'bBox': {'x': 72, 'y': 456, 'w': 96, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 424,\n", " 'text': ' Another typical emergency for a jaundiced Child C patient with\\nmassive ascites is a sprinkling little fountain of ascites at a thinned-\\nout skin ulceration at the base of a large umbilical hernia filled with\\nascites. I strongly recommend that you do not perform a conventional\\numbilical hernia repair here, but just cover the defect with normal\\nsurrounding skin under local anesthesia. Whether you excise the\\nulcerated skin and suture over the clean margins, or only approximate\\nthe edges of the ulcer with big ‘bites’, or even just ‘fold over’ the\\nsurrounding skin, depends on the condition of the tissues. Then put the\\npatient on antibiotics to prevent bacterial peritonitis. The dermis has a lot\\nof mechanical stability and ultimately these lesions may heal.\\n\\n On occasion, however, you will have no choice but to bite the bullet as\\nin a recent case of colonoscopy perforation during the work-up for a liver\\ntransplant. When you take these patients to the operating room, dissect\\nvery carefully and be aware of the venous collaterals of the abdominal\\nwall and the retroperitoneum. Among the many energy device gadgets\\nyou get offered in a modern hospital, the LigaSure® is really helpful in this\\nsituation.\\n\\n During colon surgery in liver patients with ascites, the question of\\nprimary intestinal anastomosis versus stoma formation comes up.\\nWhile I would do an elective colonic anastomosis in the presence of\\nascites, the emergency situation calls for diversion or exteriorization\\n— especially if the patient is hypoalbuminemic. Make sure, however,\\nthat the ascites is meticulously controlled with drains when you leave a\\npatient with ascites with an ostomy — to allow healing of the ostomy and\\navoid bacterial peritonitis. Keep the drains in situ until the stoma is\\nwell healed. The protein losses of prolonged drainage in patients with\\nascites are prohibitive and I would not drain a standard colon\\nanastomosis otherwise, but rather intermittently and regularly tap the\\nascites (every day or every 2 days) to prevent leakage through the\\nincision and allow early recognition of anastomotic leaks via infected\\nascites. This holds true for many other operations, including partial\\nhepatectomies, in liver patients with ascites.\\n\\n At any rate, if your Child C patient survives the first few weeks after\\nsurgery, you and they have been very lucky. You should present these',\n", " 'md': '```markdown\\n## Page Content\\n\\nAnother typical emergency for a jaundiced Child C patient with massive ascites is a sprinkling little fountain of ascites at a thinned-out skin ulceration at the base of a large umbilical hernia filled with ascites. I strongly recommend that you do not perform a conventional umbilical hernia repair here, but just cover the defect with normal surrounding skin under local anesthesia. Whether you excise the ulcerated skin and suture over the clean margins, or only approximate the edges of the ulcer with big ‘bites’, or even just ‘fold over’ the surrounding skin, depends on the condition of the tissues. Then put the patient on antibiotics to prevent bacterial peritonitis. The dermis has a lot of mechanical stability and ultimately these lesions may heal.\\n\\nOn occasion, however, you will have no choice but to bite the bullet as in a recent case of colonoscopy perforation during the work-up for a liver transplant. When you take these patients to the operating room, dissect very carefully and be aware of the venous collaterals of the abdominal wall and the retroperitoneum. Among the many energy device gadgets you get offered in a modern hospital, the LigaSure® is really helpful in this situation.\\n\\nDuring colon surgery in liver patients with ascites, the question of primary intestinal anastomosis versus stoma formation comes up. While I would do an elective colonic anastomosis in the presence of ascites, the emergency situation calls for diversion or exteriorization — especially if the patient is hypoalbuminemic. Make sure, however, that the ascites is meticulously controlled with drains when you leave a patient with ascites with an ostomy — to allow healing of the ostomy and avoid bacterial peritonitis. Keep the drains in situ until the stoma is well healed. The protein losses of prolonged drainage in patients with ascites are prohibitive and I would not drain a standard colon anastomosis otherwise, but rather intermittently and regularly tap the ascites (every day or every 2 days) to prevent leakage through the incision and allow early recognition of anastomotic leaks via infected ascites. This holds true for many other operations, including partial hepatectomies, in liver patients with ascites.\\n\\nAt any rate, if your Child C patient survives the first few weeks after surgery, you and they have been very lucky. You should present these...\\n\\n## Figures and Images\\n\\n- **Figure 1**: \\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Another typical emergency for a jaundiced Child C patient with massive ascites is a sprinkling little fountain of ascites at a thinned-out skin ulceration at the base of a large umbilical hernia filled with ascites. I strongly recommend that you do not perform a conventional umbilical hernia repair here, but just cover the defect with normal surrounding skin under local anesthesia. Whether you excise the ulcerated skin and suture over the clean margins, or only approximate the edges of the ulcer with big ‘bites’, or even just ‘fold over’ the surrounding skin, depends on the condition of the tissues. Then put the patient on antibiotics to prevent bacterial peritonitis. The dermis has a lot of mechanical stability and ultimately these lesions may heal.\\n\\nOn occasion, however, you will have no choice but to bite the bullet as in a recent case of colonoscopy perforation during the work-up for a liver transplant. When you take these patients to the operating room, dissect very carefully and be aware of the venous collaterals of the abdominal wall and the retroperitoneum. Among the many energy device gadgets you get offered in a modern hospital, the LigaSure® is really helpful in this situation.\\n\\nDuring colon surgery in liver patients with ascites, the question of primary intestinal anastomosis versus stoma formation comes up. While I would do an elective colonic anastomosis in the presence of ascites, the emergency situation calls for diversion or exteriorization — especially if the patient is hypoalbuminemic. Make sure, however, that the ascites is meticulously controlled with drains when you leave a patient with ascites with an ostomy — to allow healing of the ostomy and avoid bacterial peritonitis. Keep the drains in situ until the stoma is well healed. The protein losses of prolonged drainage in patients with ascites are prohibitive and I would not drain a standard colon anastomosis otherwise, but rather intermittently and regularly tap the ascites (every day or every 2 days) to prevent leakage through the incision and allow early recognition of anastomotic leaks via infected ascites. This holds true for many other operations, including partial hepatectomies, in liver patients with ascites.\\n\\nAt any rate, if your Child C patient survives the first few weeks after surgery, you and they have been very lucky. You should present these...',\n", " 'md': 'Another typical emergency for a jaundiced Child C patient with massive ascites is a sprinkling little fountain of ascites at a thinned-out skin ulceration at the base of a large umbilical hernia filled with ascites. I strongly recommend that you do not perform a conventional umbilical hernia repair here, but just cover the defect with normal surrounding skin under local anesthesia. Whether you excise the ulcerated skin and suture over the clean margins, or only approximate the edges of the ulcer with big ‘bites’, or even just ‘fold over’ the surrounding skin, depends on the condition of the tissues. Then put the patient on antibiotics to prevent bacterial peritonitis. The dermis has a lot of mechanical stability and ultimately these lesions may heal.\\n\\nOn occasion, however, you will have no choice but to bite the bullet as in a recent case of colonoscopy perforation during the work-up for a liver transplant. When you take these patients to the operating room, dissect very carefully and be aware of the venous collaterals of the abdominal wall and the retroperitoneum. Among the many energy device gadgets you get offered in a modern hospital, the LigaSure® is really helpful in this situation.\\n\\nDuring colon surgery in liver patients with ascites, the question of primary intestinal anastomosis versus stoma formation comes up. While I would do an elective colonic anastomosis in the presence of ascites, the emergency situation calls for diversion or exteriorization — especially if the patient is hypoalbuminemic. Make sure, however, that the ascites is meticulously controlled with drains when you leave a patient with ascites with an ostomy — to allow healing of the ostomy and avoid bacterial peritonitis. Keep the drains in situ until the stoma is well healed. The protein losses of prolonged drainage in patients with ascites are prohibitive and I would not drain a standard colon anastomosis otherwise, but rather intermittently and regularly tap the ascites (every day or every 2 days) to prevent leakage through the incision and allow early recognition of anastomotic leaks via infected ascites. This holds true for many other operations, including partial hepatectomies, in liver patients with ascites.\\n\\nAt any rate, if your Child C patient survives the first few weeks after surgery, you and they have been very lucky. You should present these...',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.98, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures and Images',\n", " 'md': '## Figures and Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: \\n```',\n", " 'md': '- **Figure 1**: \\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 425,\n", " 'text': 'patients on your weekly M & M as S & S (‘Survival and Success’…).\\n\\n The decompensated patient with cirrhosis and portal\\n hypertension who needs to be transferred to a transplant\\n center\\n\\n There are quite a few patients who present to emergency rooms\\nacross the world with elevated liver function tests and unexplained\\njaundice. Who should be sent to a hepatologist for a further work-up next\\nweek and who should be quickly referred to a transplant center? ħere are\\nthe criteria which have been proposed for an immediate referral to a\\ntransplant centers 2:\\n\\n • Extreme hyperbilirubinemia (>10mg/ml). Exclude, however,\\n obstructive jaundice.\\n • Metabolic acidosis (pħ <7.3). This should be very rare after\\n adequate resuscitation.\\n • Drug use or overdose of toxic substances (e.g. mushrooms\\n ingested) which could have damaged the liver.\\n • Marked decreased synthetic liver function (INR >3, or any\\n progressive increase after admission).\\n • Encephalopathy.\\n • Compromised renal function (new onset, progressive — despite\\n adequate hydration).\\n\\n Chronic liver patients with any of the above should be evaluated\\nin a transplant center as soon as possible. Let them worry about\\nwhen and if to transplant — just make sure that you give the\\npatients that chance.\\n\\n The liver patient emergency on the ward\\n\\n Usually liver patients are admitted to internal medicine wards with a\\ngazillion of consultations: to hepatology to give recommendations\\nconcerning the work-up and need for transplantation; to nephrology to',\n", " 'md': '```markdown\\n# Page Content\\n\\nPatients on your weekly M & M as S & S (‘Survival and Success’…).\\n\\nThe decompensated patient with cirrhosis and portal hypertension who needs to be transferred to a transplant center.\\n\\nThere are quite a few patients who present to emergency rooms across the world with elevated liver function tests and unexplained jaundice. Who should be sent to a hepatologist for a further work-up next week and who should be quickly referred to a transplant center? Here are the criteria which have been proposed for an immediate referral to a transplant center:\\n\\n- Extreme hyperbilirubinemia (>10 mg/ml). Exclude, however, obstructive jaundice.\\n- Metabolic acidosis (pH < 7.3). This should be very rare after adequate resuscitation.\\n- Drug use or overdose of toxic substances (e.g. mushrooms ingested) which could have damaged the liver.\\n- Marked decreased synthetic liver function (INR > 3, or any progressive increase after admission).\\n- Encephalopathy.\\n- Compromised renal function (new onset, progressive — despite adequate hydration).\\n\\nChronic liver patients with any of the above should be evaluated in a transplant center as soon as possible. Let them worry about when and if to transplant — just make sure that you give the patients that chance.\\n\\nThe liver patient emergency on the ward.\\n\\nUsually, liver patients are admitted to internal medicine wards with a gazillion of consultations: to hepatology to give recommendations concerning the work-up and need for transplantation; to nephrology to...\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted while excluding any diagonal text, headers, and footers.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Patients on your weekly M & M as S & S (‘Survival and Success’…).\\n\\nThe decompensated patient with cirrhosis and portal hypertension who needs to be transferred to a transplant center.\\n\\nThere are quite a few patients who present to emergency rooms across the world with elevated liver function tests and unexplained jaundice. Who should be sent to a hepatologist for a further work-up next week and who should be quickly referred to a transplant center? Here are the criteria which have been proposed for an immediate referral to a transplant center:\\n\\n- Extreme hyperbilirubinemia (>10 mg/ml). Exclude, however, obstructive jaundice.\\n- Metabolic acidosis (pH < 7.3). This should be very rare after adequate resuscitation.\\n- Drug use or overdose of toxic substances (e.g. mushrooms ingested) which could have damaged the liver.\\n- Marked decreased synthetic liver function (INR > 3, or any progressive increase after admission).\\n- Encephalopathy.\\n- Compromised renal function (new onset, progressive — despite adequate hydration).\\n\\nChronic liver patients with any of the above should be evaluated in a transplant center as soon as possible. Let them worry about when and if to transplant — just make sure that you give the patients that chance.\\n\\nThe liver patient emergency on the ward.\\n\\nUsually, liver patients are admitted to internal medicine wards with a gazillion of consultations: to hepatology to give recommendations concerning the work-up and need for transplantation; to nephrology to...\\n```',\n", " 'md': 'Patients on your weekly M & M as S & S (‘Survival and Success’…).\\n\\nThe decompensated patient with cirrhosis and portal hypertension who needs to be transferred to a transplant center.\\n\\nThere are quite a few patients who present to emergency rooms across the world with elevated liver function tests and unexplained jaundice. Who should be sent to a hepatologist for a further work-up next week and who should be quickly referred to a transplant center? Here are the criteria which have been proposed for an immediate referral to a transplant center:\\n\\n- Extreme hyperbilirubinemia (>10 mg/ml). Exclude, however, obstructive jaundice.\\n- Metabolic acidosis (pH < 7.3). This should be very rare after adequate resuscitation.\\n- Drug use or overdose of toxic substances (e.g. mushrooms ingested) which could have damaged the liver.\\n- Marked decreased synthetic liver function (INR > 3, or any progressive increase after admission).\\n- Encephalopathy.\\n- Compromised renal function (new onset, progressive — despite adequate hydration).\\n\\nChronic liver patients with any of the above should be evaluated in a transplant center as soon as possible. Let them worry about when and if to transplant — just make sure that you give the patients that chance.\\n\\nThe liver patient emergency on the ward.\\n\\nUsually, liver patients are admitted to internal medicine wards with a gazillion of consultations: to hepatology to give recommendations concerning the work-up and need for transplantation; to nephrology to...\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 468, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted while excluding any diagonal text, headers, and footers.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted while excluding any diagonal text, headers, and footers.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'transplant centers '}]},\n", " {'page': 426,\n", " 'text': 'deal with compromised renal function; to infectious disease to give a\\ndifferential diagnosis for the unexplained fever; to nutrition to address the\\nlow albumin; to dermatology to explain their rash and scratch marks; to\\ngastroenterology when patients develop GI bleeding; to psychiatry for\\ndelirium; and of course — everybody writes a bill.\\n\\n Surgeons may be called too, for a very specific emergency — GI\\nbleeding in patients with cirrhosis and an ileostomy or colostomy.\\nSince I have seen a few patients almost die from this, I think it is worth\\ntalking about. The situation is oulined in the case box opposite.\\n\\n A patient had to undergo a colon resection in the presence of liver disease and portal\\n hypertension. While it is known that the patient has varices, there has never been a problem\\n with GI bleeding up to now. However, the day prior to consultation there suddenly were several\\n liters of blood in the stoma bag. At upper endoscopy a source of bleeding was not identified.\\n Next you hear that the patient became unstable with another few liters of blood loss but the\\n source remains mysterious. ‘Bleeding scans’ are being performed, trans-stoma enteroscopies\\n scheduled and a capsule endoscopy is planned — which is exactly the time point at which you\\n decide to just go up there and see the patient yourself.\\n\\n To make the diagnosis, you have to do the unprecedented and\\n really examine the patient and take off the stoma bag — which is a\\n huge effort and you may dirty your hands! You will find a\\n peristomal varicosity that is directly dripping blood into the\\n ostomy bag. Now you ask the nurse for a needle holder and a Vicryl® suture and you\\n overrun, with deep locking bites, the bleeding area. Such varicosities may be familiar to the\\n stoma nurses, but they are not around when patients bleed. And — as we all know — regular\\n ward nurses are not generally changing stoma bags any more. The surgical consult resident\\n long ago lost the habit to thoroughly examine the stoma and the resident who takes over the\\n next shift never actually saw the patient and is only able to tell you that there is a capsule\\n endoscopy scheduled for the next day. The shift mentality — hallelujah!\\n\\n The liver patient emergency in the operating room',\n", " 'md': \"```markdown\\n## Text Extraction\\n\\nThe text discusses the management of patients with compromised renal function, infectious diseases, nutritional issues, dermatological concerns, gastrointestinal (GI) bleeding, and psychiatric conditions. It emphasizes the importance of a differential diagnosis for unexplained fever and the role of various specialists in patient care.\\n\\nSurgeons may be called for specific emergencies, particularly GI bleeding in patients with cirrhosis and an ileostomy or colostomy. The text outlines a case where a patient with liver disease and portal hypertension underwent a colon resection. Despite having known varices, the patient experienced sudden GI bleeding, leading to significant blood loss.\\n\\nThe narrative describes the challenges faced in diagnosing the source of bleeding, including the use of various diagnostic procedures such as bleeding scans and endoscopies. Ultimately, the clinician decides to examine the patient directly, discovering a peristomal varicosity that was bleeding into the ostomy bag. The text highlights the importance of thorough examination and the potential for overlooked complications in patients with stomas.\\n\\n## Image Identification and Description\\n\\n**Figure 1**: The case box mentioned in the text is likely a graphical element that summarizes the patient's situation. However, the content of this box is not provided in the text, and thus it is flagged as .\\n\\n## Summary\\n\\nThe page discusses the complexities of managing patients with liver disease and the critical role of thorough clinical examination in identifying complications such as GI bleeding from varicosities. It underscores the need for collaboration among various specialties and the importance of direct patient assessment in emergency situations.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 524, 'y': 489, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 524, 'y': 489, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the management of patients with compromised renal function, infectious diseases, nutritional issues, dermatological concerns, gastrointestinal (GI) bleeding, and psychiatric conditions. It emphasizes the importance of a differential diagnosis for unexplained fever and the role of various specialists in patient care.\\n\\nSurgeons may be called for specific emergencies, particularly GI bleeding in patients with cirrhosis and an ileostomy or colostomy. The text outlines a case where a patient with liver disease and portal hypertension underwent a colon resection. Despite having known varices, the patient experienced sudden GI bleeding, leading to significant blood loss.\\n\\nThe narrative describes the challenges faced in diagnosing the source of bleeding, including the use of various diagnostic procedures such as bleeding scans and endoscopies. Ultimately, the clinician decides to examine the patient directly, discovering a peristomal varicosity that was bleeding into the ostomy bag. The text highlights the importance of thorough examination and the potential for overlooked complications in patients with stomas.',\n", " 'md': 'The text discusses the management of patients with compromised renal function, infectious diseases, nutritional issues, dermatological concerns, gastrointestinal (GI) bleeding, and psychiatric conditions. It emphasizes the importance of a differential diagnosis for unexplained fever and the role of various specialists in patient care.\\n\\nSurgeons may be called for specific emergencies, particularly GI bleeding in patients with cirrhosis and an ileostomy or colostomy. The text outlines a case where a patient with liver disease and portal hypertension underwent a colon resection. Despite having known varices, the patient experienced sudden GI bleeding, leading to significant blood loss.\\n\\nThe narrative describes the challenges faced in diagnosing the source of bleeding, including the use of various diagnostic procedures such as bleeding scans and endoscopies. Ultimately, the clinician decides to examine the patient directly, discovering a peristomal varicosity that was bleeding into the ostomy bag. The text highlights the importance of thorough examination and the potential for overlooked complications in patients with stomas.',\n", " 'bBox': {'x': 79, 'y': 489, 'w': 119.81, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 170, 'y': 489, 'w': 25.58, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': \"**Figure 1**: The case box mentioned in the text is likely a graphical element that summarizes the patient's situation. However, the content of this box is not provided in the text, and thus it is flagged as .\",\n", " 'md': \"**Figure 1**: The case box mentioned in the text is likely a graphical element that summarizes the patient's situation. However, the content of this box is not provided in the text, and thus it is flagged as .\",\n", " 'bBox': {'x': 170, 'y': 489, 'w': 26.37, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 524, 'y': 489, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The page discusses the complexities of managing patients with liver disease and the critical role of thorough clinical examination in identifying complications such as GI bleeding from varicosities. It underscores the need for collaboration among various specialties and the importance of direct patient assessment in emergency situations.\\n```',\n", " 'md': 'The page discusses the complexities of managing patients with liver disease and the critical role of thorough clinical examination in identifying complications such as GI bleeding from varicosities. It underscores the need for collaboration among various specialties and the importance of direct patient assessment in emergency situations.\\n```',\n", " 'bBox': {'x': 170, 'y': 489, 'w': 25.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 427,\n", " 'text': ' We sometimes stumble across patients with portal hypertension in the\\noperating room, either because we were unaware of their liver disease\\nand portal hypertension or because we were led awry by an error in\\ndiagnosis or because one of our fellow surgeons calls us unprepared and\\ngives us the honor of consulting the so-called ‘liver expert’ — which I,\\nhumbly, am ; and I must admit that in such situations it is good to be\\nthe liver expert.\\n\\n You should not miss the fact that a patient has cirrhosis with\\nportal hypertension during the pre-operative work-up. There are too\\nmany red lights along the way. If your patient has no stigmata of liver\\ndisease like spider naevi, ascites, encephalopathy, edema, cachexia\\n(when was the last time you have elicited flapping tremor?), he surely\\nmust have undergone some routine laboratory test like a platelet count,\\nINR, or bilirubin or creatinine level — which are abnormal. Remember:\\nwhen the diagnosis of cirrhosis is missed, laboratory abnormalities\\nare generally not overlooked, but misattributed — thrombocytopenia\\nis due to idiopathic thrombocytopenic purpura (ITP); the INR is high due\\nto oral anticoagulation for atrial fibrillation (oh, and the patient mentioned\\nthat he only had to take coumadin once per week); the patient has been\\ntold that the hyperbilirubinemia is due to Gilbert syndrome and there are\\nnumerous reasons to have renal insufficiency. If despite this and other\\nthings — the CT scan with an enlarged spleen, the dysmorphic liver with\\nan irregular surface and the convolutes of varices visible even on a CT\\nscan without contrast — the alarm bell doesn’t ring in your brain, then\\nyou should seriously consider applying for an early recertification exam or\\nbecome a hospitalist.\\n\\n However, the interesting scenario I found myself in several times\\nis the patient known to you as having cirrhosis but you\\nunderestimated the risk (see the case below).\\n\\n You have a Child A patient who needs a wedge resection of a single hepatocelllular carcinoma\\n lesion. According to the Barcelona Clinic Algorithm 3, you diligently check portal wedge\\n pressures and the gradient with the CVP. At 8mmHg the gradient is absolutely normal in your\\n patients (up to 12mmHg); furthermore, it was done by the new interventional radiology\\n attending who was trained at the big center downtown. Upon entering the abdomen you come',\n", " 'md': '```markdown\\n## Page Content\\n\\nWe sometimes stumble across patients with portal hypertension in the operating room, either because we were unaware of their liver disease and portal hypertension or because we were led awry by an error in diagnosis or because one of our fellow surgeons calls us unprepared and gives us the honor of consulting the so-called ‘liver expert’ — which I, humbly, am; and I must admit that in such situations it is good to be the liver expert.\\n\\nYou should not miss the fact that a patient has cirrhosis with portal hypertension during the pre-operative work-up. There are too many red lights along the way. If your patient has no stigmata of liver disease like spider naevi, ascites, encephalopathy, edema, cachexia (when was the last time you have elicited flapping tremor?), he surely must have undergone some routine laboratory test like a platelet count, INR, or bilirubin or creatinine level — which are abnormal. Remember: when the diagnosis of cirrhosis is missed, laboratory abnormalities are generally not overlooked, but misattributed — thrombocytopenia is due to idiopathic thrombocytopenic purpura (ITP); the INR is high due to oral anticoagulation for atrial fibrillation (oh, and the patient mentioned that he only had to take coumadin once per week); the patient has been told that the hyperbilirubinemia is due to Gilbert syndrome and there are numerous reasons to have renal insufficiency. If despite this and other things — the CT scan with an enlarged spleen, the dysmorphic liver with an irregular surface and the convolutes of varices visible even on a CT scan without contrast — the alarm bell doesn’t ring in your brain, then you should seriously consider applying for an early recertification exam or become a hospitalist.\\n\\nHowever, the interesting scenario I found myself in several times is the patient known to you as having cirrhosis but you underestimated the risk (see the case below).\\n\\nYou have a Child A patient who needs a wedge resection of a single hepatocellular carcinoma lesion. According to the Barcelona Clinic Algorithm, you diligently check portal wedge pressures and the gradient with the CVP. At 8mmHg the gradient is absolutely normal in your patients (up to 12mmHg); furthermore, it was done by the new interventional radiology attending who was trained at the big center downtown. Upon entering the abdomen you come...\\n\\n## Figures and Images\\n\\n*No images or figures were identified on this page.*\\n```',\n", " 'images': [{'name': 'img_p426_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 151.92000000000007,\n", " 'y': 157.67999999999998}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'We sometimes stumble across patients with portal hypertension in the operating room, either because we were unaware of their liver disease and portal hypertension or because we were led awry by an error in diagnosis or because one of our fellow surgeons calls us unprepared and gives us the honor of consulting the so-called ‘liver expert’ — which I, humbly, am; and I must admit that in such situations it is good to be the liver expert.\\n\\nYou should not miss the fact that a patient has cirrhosis with portal hypertension during the pre-operative work-up. There are too many red lights along the way. If your patient has no stigmata of liver disease like spider naevi, ascites, encephalopathy, edema, cachexia (when was the last time you have elicited flapping tremor?), he surely must have undergone some routine laboratory test like a platelet count, INR, or bilirubin or creatinine level — which are abnormal. Remember: when the diagnosis of cirrhosis is missed, laboratory abnormalities are generally not overlooked, but misattributed — thrombocytopenia is due to idiopathic thrombocytopenic purpura (ITP); the INR is high due to oral anticoagulation for atrial fibrillation (oh, and the patient mentioned that he only had to take coumadin once per week); the patient has been told that the hyperbilirubinemia is due to Gilbert syndrome and there are numerous reasons to have renal insufficiency. If despite this and other things — the CT scan with an enlarged spleen, the dysmorphic liver with an irregular surface and the convolutes of varices visible even on a CT scan without contrast — the alarm bell doesn’t ring in your brain, then you should seriously consider applying for an early recertification exam or become a hospitalist.\\n\\nHowever, the interesting scenario I found myself in several times is the patient known to you as having cirrhosis but you underestimated the risk (see the case below).\\n\\nYou have a Child A patient who needs a wedge resection of a single hepatocellular carcinoma lesion. According to the Barcelona Clinic Algorithm, you diligently check portal wedge pressures and the gradient with the CVP. At 8mmHg the gradient is absolutely normal in your patients (up to 12mmHg); furthermore, it was done by the new interventional radiology attending who was trained at the big center downtown. Upon entering the abdomen you come...',\n", " 'md': 'We sometimes stumble across patients with portal hypertension in the operating room, either because we were unaware of their liver disease and portal hypertension or because we were led awry by an error in diagnosis or because one of our fellow surgeons calls us unprepared and gives us the honor of consulting the so-called ‘liver expert’ — which I, humbly, am; and I must admit that in such situations it is good to be the liver expert.\\n\\nYou should not miss the fact that a patient has cirrhosis with portal hypertension during the pre-operative work-up. There are too many red lights along the way. If your patient has no stigmata of liver disease like spider naevi, ascites, encephalopathy, edema, cachexia (when was the last time you have elicited flapping tremor?), he surely must have undergone some routine laboratory test like a platelet count, INR, or bilirubin or creatinine level — which are abnormal. Remember: when the diagnosis of cirrhosis is missed, laboratory abnormalities are generally not overlooked, but misattributed — thrombocytopenia is due to idiopathic thrombocytopenic purpura (ITP); the INR is high due to oral anticoagulation for atrial fibrillation (oh, and the patient mentioned that he only had to take coumadin once per week); the patient has been told that the hyperbilirubinemia is due to Gilbert syndrome and there are numerous reasons to have renal insufficiency. If despite this and other things — the CT scan with an enlarged spleen, the dysmorphic liver with an irregular surface and the convolutes of varices visible even on a CT scan without contrast — the alarm bell doesn’t ring in your brain, then you should seriously consider applying for an early recertification exam or become a hospitalist.\\n\\nHowever, the interesting scenario I found myself in several times is the patient known to you as having cirrhosis but you underestimated the risk (see the case below).\\n\\nYou have a Child A patient who needs a wedge resection of a single hepatocellular carcinoma lesion. According to the Barcelona Clinic Algorithm, you diligently check portal wedge pressures and the gradient with the CVP. At 8mmHg the gradient is absolutely normal in your patients (up to 12mmHg); furthermore, it was done by the new interventional radiology attending who was trained at the big center downtown. Upon entering the abdomen you come...',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.81, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures and Images',\n", " 'md': '## Figures and Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*\\n```',\n", " 'md': '*No images or figures were identified on this page.*\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '3'}]},\n", " {'page': 428,\n", " 'text': ' across some slightly enlarged veins which are bleeding slightly more than they should.\\n Surprised, you go back to the CT scan on the computer screen and you see that the spleen is\\n around 12cm. Because the venous phase of the CT scan was not well timed, the varices do\\n not seem quite as impressive as they appear in reality.\\n\\n Comforted by the ‘normal’ value of the pre-operative portocaval gradient, you decide to\\n continue with the exploration. The omental veins are engorged as well and when you detach\\n the omentum from the gallbladder bed (years ago the patient underwent a cholecystectomy)\\n there is some bleeding. Before you even start your hepatic ultrasound to find the lesion you\\n want to resect, you have lost a liter of blood. Despite these red lights you continue heroically.\\n At the end of the procedure, the patient, who could have had radiofrequency ablation or\\n transarterial chemoembolization, has lost 2L of blood, develops ascites and temporary renal\\n failure, and spends a month in the hospital despite the best peri-operative management. He is\\n lucky to survive!\\n\\n Remember: single tests may be wrong. And it is not too late to\\nstop a planned operation after the exploratory laparotomy.\\n\\n Liver trauma (see also Chapter 32)\\n\\n ħappily enough, the majority of acutely injured livers have a normal\\nparenchyma, unless you work in the famous trauma center downtown\\nthat receives the homeless alcoholic run over by a car while your posh\\nneighbor level 1 trauma center receives the Maserati-driving photo model\\nwith concussion.\\n\\n Blunt liver trauma\\n\\n There are three different mechanisms of injury:\\n\\n • Anterior/posterior impact injuries like the typical steering wheel ‘bear\\n claw injuries’.\\n • T-bone impact injuries generally result in lateral serial rib fractures\\n and a transverse rupture of the liver along the division line of the',\n", " 'md': '```markdown\\n## Page Content\\n\\nAcross some slightly enlarged veins which are bleeding slightly more than they should. Surprised, you go back to the CT scan on the computer screen and you see that the spleen is around 12cm. Because the venous phase of the CT scan was not well timed, the varices do not seem quite as impressive as they appear in reality.\\n\\nComforted by the ‘normal’ value of the pre-operative portocaval gradient, you decide to continue with the exploration. The omental veins are engorged as well and when you detach the omentum from the gallbladder bed (years ago the patient underwent a cholecystectomy) there is some bleeding. Before you even start your hepatic ultrasound to find the lesion you want to resect, you have lost a liter of blood. Despite these red lights you continue heroically. At the end of the procedure, the patient, who could have had radiofrequency ablation or transarterial chemoembolization, has lost 2L of blood, develops ascites and temporary renal failure, and spends a month in the hospital despite the best peri-operative management. He is lucky to survive!\\n\\nRemember: single tests may be wrong. And it is not too late to stop a planned operation after the exploratory laparotomy.\\n\\n### Liver Trauma (see also Chapter 32)\\n\\nHappily enough, the majority of acutely injured livers have a normal parenchyma, unless you work in the famous trauma center downtown that receives the homeless alcoholic run over by a car while your posh neighbor level 1 trauma center receives the Maserati-driving photo model with concussion.\\n\\n### Blunt Liver Trauma\\n\\nThere are three different mechanisms of injury:\\n\\n- Anterior/posterior impact injuries like the typical steering wheel ‘bear claw injuries’.\\n- T-bone impact injuries generally result in lateral serial rib fractures and a transverse rupture of the liver along the division line of the...\\n```\\n\\n### Notes:\\n- No images or figures were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- There are no formulas present in the text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Across some slightly enlarged veins which are bleeding slightly more than they should. Surprised, you go back to the CT scan on the computer screen and you see that the spleen is around 12cm. Because the venous phase of the CT scan was not well timed, the varices do not seem quite as impressive as they appear in reality.\\n\\nComforted by the ‘normal’ value of the pre-operative portocaval gradient, you decide to continue with the exploration. The omental veins are engorged as well and when you detach the omentum from the gallbladder bed (years ago the patient underwent a cholecystectomy) there is some bleeding. Before you even start your hepatic ultrasound to find the lesion you want to resect, you have lost a liter of blood. Despite these red lights you continue heroically. At the end of the procedure, the patient, who could have had radiofrequency ablation or transarterial chemoembolization, has lost 2L of blood, develops ascites and temporary renal failure, and spends a month in the hospital despite the best peri-operative management. He is lucky to survive!\\n\\nRemember: single tests may be wrong. And it is not too late to stop a planned operation after the exploratory laparotomy.',\n", " 'md': 'Across some slightly enlarged veins which are bleeding slightly more than they should. Surprised, you go back to the CT scan on the computer screen and you see that the spleen is around 12cm. Because the venous phase of the CT scan was not well timed, the varices do not seem quite as impressive as they appear in reality.\\n\\nComforted by the ‘normal’ value of the pre-operative portocaval gradient, you decide to continue with the exploration. The omental veins are engorged as well and when you detach the omentum from the gallbladder bed (years ago the patient underwent a cholecystectomy) there is some bleeding. Before you even start your hepatic ultrasound to find the lesion you want to resect, you have lost a liter of blood. Despite these red lights you continue heroically. At the end of the procedure, the patient, who could have had radiofrequency ablation or transarterial chemoembolization, has lost 2L of blood, develops ascites and temporary renal failure, and spends a month in the hospital despite the best peri-operative management. He is lucky to survive!\\n\\nRemember: single tests may be wrong. And it is not too late to stop a planned operation after the exploratory laparotomy.',\n", " 'bBox': {'x': 72, 'y': 106, 'w': 460.5, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Liver Trauma (see also Chapter 32)',\n", " 'md': '### Liver Trauma (see also Chapter 32)',\n", " 'bBox': {'x': 86, 'y': 442, 'w': 174.73, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Happily enough, the majority of acutely injured livers have a normal parenchyma, unless you work in the famous trauma center downtown that receives the homeless alcoholic run over by a car while your posh neighbor level 1 trauma center receives the Maserati-driving photo model with concussion.',\n", " 'md': 'Happily enough, the majority of acutely injured livers have a normal parenchyma, unless you work in the famous trauma center downtown that receives the homeless alcoholic run over by a car while your posh neighbor level 1 trauma center receives the Maserati-driving photo model with concussion.',\n", " 'bBox': {'x': 72, 'y': 528, 'w': 467.52, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Blunt Liver Trauma',\n", " 'md': '### Blunt Liver Trauma',\n", " 'bBox': {'x': 86, 'y': 587, 'w': 140.67, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'There are three different mechanisms of injury:\\n\\n- Anterior/posterior impact injuries like the typical steering wheel ‘bear claw injuries’.\\n- T-bone impact injuries generally result in lateral serial rib fractures and a transverse rupture of the liver along the division line of the...\\n```',\n", " 'md': 'There are three different mechanisms of injury:\\n\\n- Anterior/posterior impact injuries like the typical steering wheel ‘bear claw injuries’.\\n- T-bone impact injuries generally result in lateral serial rib fractures and a transverse rupture of the liver along the division line of the...\\n```',\n", " 'bBox': {'x': 86, 'y': 623, 'w': 436.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- There are no formulas present in the text.',\n", " 'md': '- No images or figures were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- There are no formulas present in the text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 429,\n", " 'text': ' superior and inferior segments, and may result in severe injuries of\\n the right lobe.\\n • The most significant injury to the liver results from an extreme\\n deceleration and vascular avulsion from the vena cava which\\n typically results in massive immediate exsanguination.\\n\\n Prior to the advent of CT, many patients with blood in their diagnostic\\nperitoneal lavage underwent laparotomy. Frequently, no more was found\\nthan a laceration of the liver or the spleen which would have stopped\\nbleeding spontaneously — the great majority of these laparotomies\\nended up being non-therapeutic as far as the liver was concerned.\\n\\n Nowadays, liver lacerations are graded by a CT scan. Grade I or II\\ninjuries almost always can be managed conservatively (unless there is an\\nadditional injury that is non-liver-related), while injuries above Grade III\\nmay require surgical intervention in a little more than half of patients.\\nTherefore, you have to know how to distinguish a Grade III or higher\\ninjury from a lesser injury.\\n\\n What is a ≥Grade III liver injury by CT?\\n\\n • Subcapsular hematoma >50% or expanding.\\n • Intraparenchymal hematoma >10cm.\\n • Laceration >3cm in depth.\\n If you encounter a ≥Grade III injury, but the patient is well and there is\\nno other reason to take him to the operating room, you may safely\\nobserve him. However, if the patient with a ≥Grade III liver injury\\n‘turns a hair’, in terms of hemodynamic stability, it is safer to take\\nhim to the operating room. Of course, if the abdomen is distended\\nand there is a lot of blood in the abdomen on CT, you will ignore\\nyour laceration grading and explore the patient. Remember that\\ninjury grading is a guide only and what matters most is the clinical\\ncondition of the patient.',\n", " 'md': '```markdown\\n## Liver Injury Management\\n\\n- Superior and inferior segments may result in severe injuries of the right lobe.\\n- The most significant injury to the liver results from extreme deceleration and vascular avulsion from the vena cava, which typically results in massive immediate exsanguination.\\n\\nPrior to the advent of CT, many patients with blood in their diagnostic peritoneal lavage underwent laparotomy. Frequently, no more was found than a laceration of the liver or the spleen, which would have stopped bleeding spontaneously — the great majority of these laparotomies ended up being non-therapeutic as far as the liver was concerned.\\n\\nNowadays, liver lacerations are graded by a CT scan. Grade I or II injuries almost always can be managed conservatively (unless there is an additional injury that is non-liver-related), while injuries above Grade III may require surgical intervention in a little more than half of patients. Therefore, you have to know how to distinguish a Grade III or higher injury from a lesser injury.\\n\\n### What is a ≥Grade III liver injury by CT?\\n\\n- Subcapsular hematoma >50% or expanding.\\n- Intraparenchymal hematoma >10cm.\\n- Laceration >3cm in depth.\\n\\nIf you encounter a ≥Grade III injury, but the patient is well and there is no other reason to take him to the operating room, you may safely observe him. However, if the patient with a ≥Grade III liver injury ‘turns a hair’ in terms of hemodynamic stability, it is safer to take him to the operating room. Of course, if the abdomen is distended and there is a lot of blood in the abdomen on CT, you will ignore your laceration grading and explore the patient. Remember that injury grading is a guide only and what matters most is the clinical condition of the patient.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Liver Injury Management',\n", " 'md': '## Liver Injury Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Superior and inferior segments may result in severe injuries of the right lobe.\\n- The most significant injury to the liver results from extreme deceleration and vascular avulsion from the vena cava, which typically results in massive immediate exsanguination.\\n\\nPrior to the advent of CT, many patients with blood in their diagnostic peritoneal lavage underwent laparotomy. Frequently, no more was found than a laceration of the liver or the spleen, which would have stopped bleeding spontaneously — the great majority of these laparotomies ended up being non-therapeutic as far as the liver was concerned.\\n\\nNowadays, liver lacerations are graded by a CT scan. Grade I or II injuries almost always can be managed conservatively (unless there is an additional injury that is non-liver-related), while injuries above Grade III may require surgical intervention in a little more than half of patients. Therefore, you have to know how to distinguish a Grade III or higher injury from a lesser injury.',\n", " 'md': '- Superior and inferior segments may result in severe injuries of the right lobe.\\n- The most significant injury to the liver results from extreme deceleration and vascular avulsion from the vena cava, which typically results in massive immediate exsanguination.\\n\\nPrior to the advent of CT, many patients with blood in their diagnostic peritoneal lavage underwent laparotomy. Frequently, no more was found than a laceration of the liver or the spleen, which would have stopped bleeding spontaneously — the great majority of these laparotomies ended up being non-therapeutic as far as the liver was concerned.\\n\\nNowadays, liver lacerations are graded by a CT scan. Grade I or II injuries almost always can be managed conservatively (unless there is an additional injury that is non-liver-related), while injuries above Grade III may require surgical intervention in a little more than half of patients. Therefore, you have to know how to distinguish a Grade III or higher injury from a lesser injury.',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'What is a ≥Grade III liver injury by CT?',\n", " 'md': '### What is a ≥Grade III liver injury by CT?',\n", " 'bBox': {'x': 86, 'y': 412, 'w': 261.94, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- Subcapsular hematoma >50% or expanding.\\n- Intraparenchymal hematoma >10cm.\\n- Laceration >3cm in depth.\\n\\nIf you encounter a ≥Grade III injury, but the patient is well and there is no other reason to take him to the operating room, you may safely observe him. However, if the patient with a ≥Grade III liver injury ‘turns a hair’ in terms of hemodynamic stability, it is safer to take him to the operating room. Of course, if the abdomen is distended and there is a lot of blood in the abdomen on CT, you will ignore your laceration grading and explore the patient. Remember that injury grading is a guide only and what matters most is the clinical condition of the patient.\\n```',\n", " 'md': '- Subcapsular hematoma >50% or expanding.\\n- Intraparenchymal hematoma >10cm.\\n- Laceration >3cm in depth.\\n\\nIf you encounter a ≥Grade III injury, but the patient is well and there is no other reason to take him to the operating room, you may safely observe him. However, if the patient with a ≥Grade III liver injury ‘turns a hair’ in terms of hemodynamic stability, it is safer to take him to the operating room. Of course, if the abdomen is distended and there is a lot of blood in the abdomen on CT, you will ignore your laceration grading and explore the patient. Remember that injury grading is a guide only and what matters most is the clinical condition of the patient.\\n```',\n", " 'bBox': {'x': 72, 'y': 448, 'w': 467.74, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 430,\n", " 'text': ' Now, what are the surgical steps to explore the injured liver?\\n\\n • Packing to obtain hemostasis.\\n • Mobilization of the liver and opening of the lesser sac.\\n • Surgical control of bleeding:\\n if necessary resectional debridement;\\n if necessary control of arterial and portal inflow and selective\\n clamping.\\n • Re-exploration if the viability of liver tissue is questionable.\\n As straightforward as this sounds, a recipe like this can result in a\\ndisastrous outcome in the hands of surgeons inexperienced with the liver.\\nWhat has made people underestimate the value of proper training in liver\\nsurgery in the management of trauma is the myth that any liver trauma\\ncan be fixed by packing alone — see the case below.\\n\\n As a freshly graduated transplant surgeon I worked in Indochina with an American veteran\\n surgeon who had been to many theaters of war and humanitarian disasters, had graduated\\n from several fellowships and might easily have been one of the most experienced surgeons I\\n have ever worked with. I was sure he would never have to summon me for help… but one\\n night he called me in: a 16-year-old girl had been involved in a bus injury and was brought in,\\n in an unstable condition, to our little ‘trauma center’. On exploration she had a 30cm ruptured\\n subcapsular hematoma from a direct impact injury. My partner had packed the liver well by\\n carefully placing laparotomy pads around it; relatives had donated full blood to keep her alive\\n but despite the transfusion of four units she had become unstable in the early morning hours.\\n We re-explored her together; the extensive amount of arterial bleeding from the large capsular\\n defect was obvious to somebody who had just learned how to transplant and resect lots of\\n livers, and a line of running sutures with a large MH needle along the arterial bleeders fixed the\\n ongoing blood loss almost immediately. The girl recovered with one more exploration to\\n remove the packs.',\n", " 'md': '```markdown\\n## Surgical Steps to Explore the Injured Liver\\n\\n1. Packing to obtain hemostasis.\\n2. Mobilization of the liver and opening of the lesser sac.\\n3. Surgical control of bleeding:\\n- If necessary, resectional debridement.\\n- If necessary, control of arterial and portal inflow and selective clamping.\\n4. Re-exploration if the viability of liver tissue is questionable.\\n\\nAs straightforward as this sounds, a recipe like this can result in a disastrous outcome in the hands of surgeons inexperienced with the liver. What has made people underestimate the value of proper training in liver surgery in the management of trauma is the myth that any liver trauma can be fixed by packing alone — see the case below.\\n\\nAs a freshly graduated transplant surgeon, I worked in Indochina with an American veteran surgeon who had been to many theaters of war and humanitarian disasters, had graduated from several fellowships, and might easily have been one of the most experienced surgeons I have ever worked with. I was sure he would never have to summon me for help… but one night he called me in: a 16-year-old girl had been involved in a bus injury and was brought in, in an unstable condition, to our little ‘trauma center’.\\n\\nOn exploration, she had a 30cm ruptured subcapsular hematoma from a direct impact injury. My partner had packed the liver well by carefully placing laparotomy pads around it; relatives had donated full blood to keep her alive but despite the transfusion of four units, she had become unstable in the early morning hours.\\n\\nWe re-explored her together; the extensive amount of arterial bleeding from the large capsular defect was obvious to somebody who had just learned how to transplant and resect lots of livers, and a line of running sutures with a large MH needle along the arterial bleeders fixed the ongoing blood loss almost immediately. The girl recovered with one more exploration to remove the packs.\\n```',\n", " 'images': [{'name': 'img_p429_1.png',\n", " 'height': 8,\n", " 'width': 8,\n", " 'x': 110.15999999999985,\n", " 'y': 193.68},\n", " {'name': 'img_p429_1.png',\n", " 'height': 8,\n", " 'width': 8,\n", " 'x': 110.15999999999985,\n", " 'y': 213.12}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Steps to Explore the Injured Liver',\n", " 'md': '## Surgical Steps to Explore the Injured Liver',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. Packing to obtain hemostasis.\\n2. Mobilization of the liver and opening of the lesser sac.\\n3. Surgical control of bleeding:\\n- If necessary, resectional debridement.\\n- If necessary, control of arterial and portal inflow and selective clamping.\\n4. Re-exploration if the viability of liver tissue is questionable.\\n\\nAs straightforward as this sounds, a recipe like this can result in a disastrous outcome in the hands of surgeons inexperienced with the liver. What has made people underestimate the value of proper training in liver surgery in the management of trauma is the myth that any liver trauma can be fixed by packing alone — see the case below.\\n\\nAs a freshly graduated transplant surgeon, I worked in Indochina with an American veteran surgeon who had been to many theaters of war and humanitarian disasters, had graduated from several fellowships, and might easily have been one of the most experienced surgeons I have ever worked with. I was sure he would never have to summon me for help… but one night he called me in: a 16-year-old girl had been involved in a bus injury and was brought in, in an unstable condition, to our little ‘trauma center’.\\n\\nOn exploration, she had a 30cm ruptured subcapsular hematoma from a direct impact injury. My partner had packed the liver well by carefully placing laparotomy pads around it; relatives had donated full blood to keep her alive but despite the transfusion of four units, she had become unstable in the early morning hours.\\n\\nWe re-explored her together; the extensive amount of arterial bleeding from the large capsular defect was obvious to somebody who had just learned how to transplant and resect lots of livers, and a line of running sutures with a large MH needle along the arterial bleeders fixed the ongoing blood loss almost immediately. The girl recovered with one more exploration to remove the packs.\\n```',\n", " 'md': '1. Packing to obtain hemostasis.\\n2. Mobilization of the liver and opening of the lesser sac.\\n3. Surgical control of bleeding:\\n- If necessary, resectional debridement.\\n- If necessary, control of arterial and portal inflow and selective clamping.\\n4. Re-exploration if the viability of liver tissue is questionable.\\n\\nAs straightforward as this sounds, a recipe like this can result in a disastrous outcome in the hands of surgeons inexperienced with the liver. What has made people underestimate the value of proper training in liver surgery in the management of trauma is the myth that any liver trauma can be fixed by packing alone — see the case below.\\n\\nAs a freshly graduated transplant surgeon, I worked in Indochina with an American veteran surgeon who had been to many theaters of war and humanitarian disasters, had graduated from several fellowships, and might easily have been one of the most experienced surgeons I have ever worked with. I was sure he would never have to summon me for help… but one night he called me in: a 16-year-old girl had been involved in a bus injury and was brought in, in an unstable condition, to our little ‘trauma center’.\\n\\nOn exploration, she had a 30cm ruptured subcapsular hematoma from a direct impact injury. My partner had packed the liver well by carefully placing laparotomy pads around it; relatives had donated full blood to keep her alive but despite the transfusion of four units, she had become unstable in the early morning hours.\\n\\nWe re-explored her together; the extensive amount of arterial bleeding from the large capsular defect was obvious to somebody who had just learned how to transplant and resect lots of livers, and a line of running sutures with a large MH needle along the arterial bleeders fixed the ongoing blood loss almost immediately. The girl recovered with one more exploration to remove the packs.\\n```',\n", " 'bBox': {'x': 72, 'y': 121, 'w': 467.82, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 431,\n", " 'text': ' The lesson here is that arterial bleeding from a liver injury cannot\\neasily be fixed by packing alone.\\n\\n That is true and therefore many centers routinely perform angiography and embolization — as\\n needed — in all patients undergoing perihepatic packing. However, perihepatic packing usually\\n stops bleeding from low pressure venous injuries and is the preferred method especially for\\n surgeons not experienced in liver surgery. And the key is always: pack early! Ari\\n\\n In complex liver injuries, suture ligation of the bleeding source is the\\nkey to achieving a good outcome for patients. Similarly, resectional\\ndebridement minimizes the amount of necrotic liver tissue that might\\nserve as a source of bile leaks and infections. Packing liver injuries\\nfrequently serves as damage control in patients who are\\nhypothermic and coagulopathic. It is not a mistake to then get the\\nsurgeons who have the most experience with liver surgery involved\\nin re-exploration. Or ship out!\\n\\n Bleeding that you cannot stop by packing and suture ligation is rare in\\nliver trauma; however, it does occur. There is a common misconception\\nthat the hepatic artery may be ligated when bleeding does not stop; I\\nhave even heard chief residents teach this to their juniors. ħistorically,\\nocclusion of the common hepatic artery has been described, because\\ncollateral flow is maintained through the gastroduodenal artery, thereby\\nbleeding can be slowed or stopped without completely abolishing arterial\\ninflow. This sounds great in theory but every time I have seen the\\ncommon hepatic artery injured and not reconstructed, the outcome\\nwas dismal.\\n\\n Here are some general rules about the vascular supply of the liver\\nin trauma:\\n\\n • Vascular inflow into the liver cannot be occluded with impunity in\\n trauma, neither on the portal venous, nor on the arterial side.\\n • Complete occlusion of the common hepatic artery may well result in\\n postoperative liver failure, intrahepatic cholangiopathy, cholangitis\\n and abscesses.',\n", " 'md': '```markdown\\n# Vascular Supply of the Liver in Trauma\\n\\nThe lesson here is that arterial bleeding from a liver injury cannot easily be fixed by packing alone.\\n\\nThat is true and therefore many centers routinely perform angiography and embolization — as needed — in all patients undergoing perihepatic packing. However, perihepatic packing usually stops bleeding from low pressure venous injuries and is the preferred method especially for surgeons not experienced in liver surgery. And the key is always: pack early!\\n\\nIn complex liver injuries, suture ligation of the bleeding source is the key to achieving a good outcome for patients. Similarly, resectional debridement minimizes the amount of necrotic liver tissue that might serve as a source of bile leaks and infections. Packing liver injuries frequently serves as damage control in patients who are hypothermic and coagulopathic. It is not a mistake to then get the surgeons who have the most experience with liver surgery involved in re-exploration. Or ship out!\\n\\nBleeding that you cannot stop by packing and suture ligation is rare in liver trauma; however, it does occur. There is a common misconception that the hepatic artery may be ligated when bleeding does not stop; I have even heard chief residents teach this to their juniors. Historically, occlusion of the common hepatic artery has been described, because collateral flow is maintained through the gastroduodenal artery, thereby bleeding can be slowed or stopped without completely abolishing arterial inflow. This sounds great in theory but every time I have seen the common hepatic artery injured and not reconstructed, the outcome was dismal.\\n\\nHere are some general rules about the vascular supply of the liver in trauma:\\n\\n- Vascular inflow into the liver cannot be occluded with impunity in trauma, neither on the portal venous, nor on the arterial side.\\n- Complete occlusion of the common hepatic artery may well result in postoperative liver failure, intrahepatic cholangiopathy, cholangitis and abscesses.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Vascular Supply of the Liver in Trauma',\n", " 'md': '# Vascular Supply of the Liver in Trauma',\n", " 'bBox': {'x': 377, 'y': 311, 'w': 16.78, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The lesson here is that arterial bleeding from a liver injury cannot easily be fixed by packing alone.\\n\\nThat is true and therefore many centers routinely perform angiography and embolization — as needed — in all patients undergoing perihepatic packing. However, perihepatic packing usually stops bleeding from low pressure venous injuries and is the preferred method especially for surgeons not experienced in liver surgery. And the key is always: pack early!\\n\\nIn complex liver injuries, suture ligation of the bleeding source is the key to achieving a good outcome for patients. Similarly, resectional debridement minimizes the amount of necrotic liver tissue that might serve as a source of bile leaks and infections. Packing liver injuries frequently serves as damage control in patients who are hypothermic and coagulopathic. It is not a mistake to then get the surgeons who have the most experience with liver surgery involved in re-exploration. Or ship out!\\n\\nBleeding that you cannot stop by packing and suture ligation is rare in liver trauma; however, it does occur. There is a common misconception that the hepatic artery may be ligated when bleeding does not stop; I have even heard chief residents teach this to their juniors. Historically, occlusion of the common hepatic artery has been described, because collateral flow is maintained through the gastroduodenal artery, thereby bleeding can be slowed or stopped without completely abolishing arterial inflow. This sounds great in theory but every time I have seen the common hepatic artery injured and not reconstructed, the outcome was dismal.\\n\\nHere are some general rules about the vascular supply of the liver in trauma:\\n\\n- Vascular inflow into the liver cannot be occluded with impunity in trauma, neither on the portal venous, nor on the arterial side.\\n- Complete occlusion of the common hepatic artery may well result in postoperative liver failure, intrahepatic cholangiopathy, cholangitis and abscesses.\\n```',\n", " 'md': 'The lesson here is that arterial bleeding from a liver injury cannot easily be fixed by packing alone.\\n\\nThat is true and therefore many centers routinely perform angiography and embolization — as needed — in all patients undergoing perihepatic packing. However, perihepatic packing usually stops bleeding from low pressure venous injuries and is the preferred method especially for surgeons not experienced in liver surgery. And the key is always: pack early!\\n\\nIn complex liver injuries, suture ligation of the bleeding source is the key to achieving a good outcome for patients. Similarly, resectional debridement minimizes the amount of necrotic liver tissue that might serve as a source of bile leaks and infections. Packing liver injuries frequently serves as damage control in patients who are hypothermic and coagulopathic. It is not a mistake to then get the surgeons who have the most experience with liver surgery involved in re-exploration. Or ship out!\\n\\nBleeding that you cannot stop by packing and suture ligation is rare in liver trauma; however, it does occur. There is a common misconception that the hepatic artery may be ligated when bleeding does not stop; I have even heard chief residents teach this to their juniors. Historically, occlusion of the common hepatic artery has been described, because collateral flow is maintained through the gastroduodenal artery, thereby bleeding can be slowed or stopped without completely abolishing arterial inflow. This sounds great in theory but every time I have seen the common hepatic artery injured and not reconstructed, the outcome was dismal.\\n\\nHere are some general rules about the vascular supply of the liver in trauma:\\n\\n- Vascular inflow into the liver cannot be occluded with impunity in trauma, neither on the portal venous, nor on the arterial side.\\n- Complete occlusion of the common hepatic artery may well result in postoperative liver failure, intrahepatic cholangiopathy, cholangitis and abscesses.\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.87, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 432,\n", " 'text': ' • Complete and sudden occlusion of portal venous flow will result in\\n massive liver necrosis with hemodynamic instability and sepsis.\\n\\n In desperate situations, the portal vein can be ligated to stop massive bleeding, but it has about\\n a 50% mortality rate. Ari\\n\\n Penetrating liver trauma\\n\\n Penetrating liver trauma occurs because the liver is the largest\\nparenchymatous organ and is located in the mid-portion of the torso in an\\narea which is frequently targeted. Injuries to the parenchyma are only\\nproblematic when high-velocity missiles are involved due to the large\\namount of energy deposited and the ensuing cavity with a lot of necrosis.\\n\\n Usually packing as immediate damage control, hemodynamic\\nresuscitation and then resectional debridement are the way to go.\\n\\n Resectional debridement is seldom needed — mostly in high-velocity gunshot wounds. Ari\\n\\n Low-velocity gunshot wounds rarely result in problems especially when\\nthey penetrate through and through, except for hematomas. The\\nassociated chest trauma, however, should not be underestimated; while\\nthis has already been picked up by the pneumothorax found on the chest\\nX-ray (and treated), remember that gunshot wounds through the liver\\ntypically traverse the diaphragm as well.\\n\\n There are three major scares even to the experienced trauma\\nsurgeon who also is an occasional liver surgeon:\\n\\n • Hepatic artery and bile duct injuries may cause extensive\\n bleeding and make visualization of not-pre-dissected porta hepatis\\n extremely difficult.\\n • Portal vein injuries may be difficult to visualize and repair,\\n especially if they are behind the pancreatic head. (“I do know that it\\n is harder to control bleeding from the back side of the portal vein',\n", " 'md': '```markdown\\n## Penetrating Liver Trauma\\n\\n- Complete and sudden occlusion of portal venous flow will result in massive liver necrosis with hemodynamic instability and sepsis.\\n\\nIn desperate situations, the portal vein can be ligated to stop massive bleeding, but it has about a 50% mortality rate.\\n\\n### Overview of Penetrating Liver Trauma\\n\\n- Penetrating liver trauma occurs because the liver is the largest parenchymatous organ and is located in the mid-portion of the torso in an area which is frequently targeted. Injuries to the parenchyma are only problematic when high-velocity missiles are involved due to the large amount of energy deposited and the ensuing cavity with a lot of necrosis.\\n\\n- Usually, packing as immediate damage control, hemodynamic resuscitation, and then resectional debridement are the way to go. Resectional debridement is seldom needed — mostly in high-velocity gunshot wounds.\\n\\n- Low-velocity gunshot wounds rarely result in problems especially when they penetrate through and through, except for hematomas. The associated chest trauma, however, should not be underestimated; while this has already been picked up by the pneumothorax found on the chest X-ray (and treated), remember that gunshot wounds through the liver typically traverse the diaphragm as well.\\n\\n### Major Concerns for Trauma Surgeons\\n\\nThere are three major scares even to the experienced trauma surgeon who also is an occasional liver surgeon:\\n\\n1. Hepatic artery and bile duct injuries may cause extensive bleeding and make visualization of not-pre-dissected porta hepatis extremely difficult.\\n2. Portal vein injuries may be difficult to visualize and repair, especially if they are behind the pancreatic head. (“I do know that it is harder to control bleeding from the back side of the portal vein.”)\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Penetrating Liver Trauma',\n", " 'md': '## Penetrating Liver Trauma',\n", " 'bBox': {'x': 86, 'y': 216, 'w': 189.42, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Complete and sudden occlusion of portal venous flow will result in massive liver necrosis with hemodynamic instability and sepsis.\\n\\nIn desperate situations, the portal vein can be ligated to stop massive bleeding, but it has about a 50% mortality rate.',\n", " 'md': '- Complete and sudden occlusion of portal venous flow will result in massive liver necrosis with hemodynamic instability and sepsis.\\n\\nIn desperate situations, the portal vein can be ligated to stop massive bleeding, but it has about a 50% mortality rate.',\n", " 'bBox': {'x': 77, 'y': 102, 'w': 457.34, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Overview of Penetrating Liver Trauma',\n", " 'md': '### Overview of Penetrating Liver Trauma',\n", " 'bBox': {'x': 86, 'y': 216, 'w': 189.42, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Penetrating liver trauma occurs because the liver is the largest parenchymatous organ and is located in the mid-portion of the torso in an area which is frequently targeted. Injuries to the parenchyma are only problematic when high-velocity missiles are involved due to the large amount of energy deposited and the ensuing cavity with a lot of necrosis.\\n\\n- Usually, packing as immediate damage control, hemodynamic resuscitation, and then resectional debridement are the way to go. Resectional debridement is seldom needed — mostly in high-velocity gunshot wounds.\\n\\n- Low-velocity gunshot wounds rarely result in problems especially when they penetrate through and through, except for hematomas. The associated chest trauma, however, should not be underestimated; while this has already been picked up by the pneumothorax found on the chest X-ray (and treated), remember that gunshot wounds through the liver typically traverse the diaphragm as well.',\n", " 'md': '- Penetrating liver trauma occurs because the liver is the largest parenchymatous organ and is located in the mid-portion of the torso in an area which is frequently targeted. Injuries to the parenchyma are only problematic when high-velocity missiles are involved due to the large amount of energy deposited and the ensuing cavity with a lot of necrosis.\\n\\n- Usually, packing as immediate damage control, hemodynamic resuscitation, and then resectional debridement are the way to go. Resectional debridement is seldom needed — mostly in high-velocity gunshot wounds.\\n\\n- Low-velocity gunshot wounds rarely result in problems especially when they penetrate through and through, except for hematomas. The associated chest trauma, however, should not be underestimated; while this has already been picked up by the pneumothorax found on the chest X-ray (and treated), remember that gunshot wounds through the liver typically traverse the diaphragm as well.',\n", " 'bBox': {'x': 72, 'y': 216, 'w': 467.6, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Major Concerns for Trauma Surgeons',\n", " 'md': '### Major Concerns for Trauma Surgeons',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'There are three major scares even to the experienced trauma surgeon who also is an occasional liver surgeon:\\n\\n1. Hepatic artery and bile duct injuries may cause extensive bleeding and make visualization of not-pre-dissected porta hepatis extremely difficult.\\n2. Portal vein injuries may be difficult to visualize and repair, especially if they are behind the pancreatic head. (“I do know that it is harder to control bleeding from the back side of the portal vein.”)\\n```',\n", " 'md': 'There are three major scares even to the experienced trauma surgeon who also is an occasional liver surgeon:\\n\\n1. Hepatic artery and bile duct injuries may cause extensive bleeding and make visualization of not-pre-dissected porta hepatis extremely difficult.\\n2. Portal vein injuries may be difficult to visualize and repair, especially if they are behind the pancreatic head. (“I do know that it is harder to control bleeding from the back side of the portal vein.”)\\n```',\n", " 'bBox': {'x': 72, 'y': 589, 'w': 436.97, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 433,\n", " 'text': ' than it is to land a 737 with an engine on fire.” Richard C. Karl.)\\n • Retrohepatic vena cava injuries may result in massive bleeding if\\n they do not remain contained in the retroperitoneum.\\n\\n For management of these situations you have to have a decent\\namount of experience with three maneuvers. If you don’t — get help early\\nenough. If such help is not available — call the Priest or the Rabbi (or the\\nImam — Editors):\\n\\n • Pringle maneuver: rapid placement of an umbilical tape around the\\n porta hepatis to stop vascular inflow and allow the dissection of\\n portal structures. Limit clamping to 15 minutes if you can and isolate\\n injured structures as soon as you can, to avoid global ischemia.\\n • Cattell-Braasch maneuver: to expose injuries to the portal vein and\\n the pancreatic head you have be able to rapidly perform a complete\\n medial visceral rotation on the right side of the abdomen. The right\\n colon is mobilized and an extended Kocher maneuver performed to\\n mobilize the duodenum. The root of the small bowel mesentery is\\n mobilized up to the superior mesenteric artery and inferior border of\\n the pancreas. Now you may control the portal vein with finger\\n compression and expose the inferior vena cava which is frequently\\n injured as well.\\n • Heaney maneuver: mobilization of the porta hepatis, the right lobe\\n of the liver, the infrahepatic inferior vena cava and the suprahepatic\\n inferior vena cava to perform total vascular exclusion of the liver in\\n extensive vascular injuries of the liver and the vena cava.\\n\\n Retrohepatic vena cava injuries\\n If a hematoma behind the liver is not expanding, don’t mobilize,\\n just pack. If massively bleeding, mobilize the right lobe and then pack. If unsuccessful and\\n you are an experienced liver surgeon, attempt hepatic vascular isolation (Pringle plus clamping\\n suprahepatic/infradiaphragmatic vena cava and infrahepatic/suprarenal vena cava), expose the\\n retrohepatic vena cava and repair. If not, pack and call for help. Atriocaval shunts are\\n cumbersome, take too much time and seldom work, except in\\n publications of which there are more than survivors — usually',\n", " 'md': '```markdown\\n## Management of Retrohepatic Vena Cava Injuries\\n\\nRetrohepatic vena cava injuries may result in massive bleeding if they do not remain contained in the retroperitoneum. For management of these situations, you have to have a decent amount of experience with three maneuvers. If you don’t — get help early enough. If such help is not available — call the Priest or the Rabbi (or the Imam — Editors):\\n\\n1. **Pringle maneuver**: Rapid placement of an umbilical tape around the porta hepatis to stop vascular inflow and allow the dissection of portal structures. Limit clamping to 15 minutes if you can and isolate injured structures as soon as you can, to avoid global ischemia.\\n\\n2. **Cattell-Braasch maneuver**: To expose injuries to the portal vein and the pancreatic head, you have to be able to rapidly perform a complete medial visceral rotation on the right side of the abdomen. The right colon is mobilized and an extended Kocher maneuver performed to mobilize the duodenum. The root of the small bowel mesentery is mobilized up to the superior mesenteric artery and inferior border of the pancreas. Now you may control the portal vein with finger compression and expose the inferior vena cava which is frequently injured as well.\\n\\n3. **Heaney maneuver**: Mobilization of the porta hepatis, the right lobe of the liver, the infrahepatic inferior vena cava, and the suprahepatic inferior vena cava to perform total vascular exclusion of the liver in extensive vascular injuries of the liver and the vena cava.\\n\\n### Retrohepatic Vena Cava Injuries\\n\\nIf a hematoma behind the liver is not expanding, don’t mobilize, just pack. If massively bleeding, mobilize the right lobe and then pack. If unsuccessful and you are an experienced liver surgeon, attempt hepatic vascular isolation (Pringle plus clamping suprahepatic/infradiaphragmatic vena cava and infrahepatic/suprarenal vena cava), expose the retrohepatic vena cava and repair. If not, pack and call for help. Atriocaval shunts are cumbersome, take too much time and seldom work, except in publications of which there are more than survivors — usually.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Retrohepatic Vena Cava Injuries',\n", " 'md': '## Management of Retrohepatic Vena Cava Injuries',\n", " 'bBox': {'x': 77, 'y': 560, 'w': 248.3, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Retrohepatic vena cava injuries may result in massive bleeding if they do not remain contained in the retroperitoneum. For management of these situations, you have to have a decent amount of experience with three maneuvers. If you don’t — get help early enough. If such help is not available — call the Priest or the Rabbi (or the Imam — Editors):\\n\\n1. **Pringle maneuver**: Rapid placement of an umbilical tape around the porta hepatis to stop vascular inflow and allow the dissection of portal structures. Limit clamping to 15 minutes if you can and isolate injured structures as soon as you can, to avoid global ischemia.\\n\\n2. **Cattell-Braasch maneuver**: To expose injuries to the portal vein and the pancreatic head, you have to be able to rapidly perform a complete medial visceral rotation on the right side of the abdomen. The right colon is mobilized and an extended Kocher maneuver performed to mobilize the duodenum. The root of the small bowel mesentery is mobilized up to the superior mesenteric artery and inferior border of the pancreas. Now you may control the portal vein with finger compression and expose the inferior vena cava which is frequently injured as well.\\n\\n3. **Heaney maneuver**: Mobilization of the porta hepatis, the right lobe of the liver, the infrahepatic inferior vena cava, and the suprahepatic inferior vena cava to perform total vascular exclusion of the liver in extensive vascular injuries of the liver and the vena cava.',\n", " 'md': 'Retrohepatic vena cava injuries may result in massive bleeding if they do not remain contained in the retroperitoneum. For management of these situations, you have to have a decent amount of experience with three maneuvers. If you don’t — get help early enough. If such help is not available — call the Priest or the Rabbi (or the Imam — Editors):\\n\\n1. **Pringle maneuver**: Rapid placement of an umbilical tape around the porta hepatis to stop vascular inflow and allow the dissection of portal structures. Limit clamping to 15 minutes if you can and isolate injured structures as soon as you can, to avoid global ischemia.\\n\\n2. **Cattell-Braasch maneuver**: To expose injuries to the portal vein and the pancreatic head, you have to be able to rapidly perform a complete medial visceral rotation on the right side of the abdomen. The right colon is mobilized and an extended Kocher maneuver performed to mobilize the duodenum. The root of the small bowel mesentery is mobilized up to the superior mesenteric artery and inferior border of the pancreas. Now you may control the portal vein with finger compression and expose the inferior vena cava which is frequently injured as well.\\n\\n3. **Heaney maneuver**: Mobilization of the porta hepatis, the right lobe of the liver, the infrahepatic inferior vena cava, and the suprahepatic inferior vena cava to perform total vascular exclusion of the liver in extensive vascular injuries of the liver and the vena cava.',\n", " 'bBox': {'x': 72, 'y': 105, 'w': 467.66, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Retrohepatic Vena Cava Injuries',\n", " 'md': '### Retrohepatic Vena Cava Injuries',\n", " 'bBox': {'x': 77, 'y': 560, 'w': 248.3, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'If a hematoma behind the liver is not expanding, don’t mobilize, just pack. If massively bleeding, mobilize the right lobe and then pack. If unsuccessful and you are an experienced liver surgeon, attempt hepatic vascular isolation (Pringle plus clamping suprahepatic/infradiaphragmatic vena cava and infrahepatic/suprarenal vena cava), expose the retrohepatic vena cava and repair. If not, pack and call for help. Atriocaval shunts are cumbersome, take too much time and seldom work, except in publications of which there are more than survivors — usually.\\n```',\n", " 'md': 'If a hematoma behind the liver is not expanding, don’t mobilize, just pack. If massively bleeding, mobilize the right lobe and then pack. If unsuccessful and you are an experienced liver surgeon, attempt hepatic vascular isolation (Pringle plus clamping suprahepatic/infradiaphragmatic vena cava and infrahepatic/suprarenal vena cava), expose the retrohepatic vena cava and repair. If not, pack and call for help. Atriocaval shunts are cumbersome, take too much time and seldom work, except in publications of which there are more than survivors — usually.\\n```',\n", " 'bBox': {'x': 77, 'y': 589, 'w': 457.92, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 434,\n", " 'text': ' authored by more authors than reported cases. I have treated one patient\\n with an anterior stab wound splitting the liver and the anterior wall of the retrohepatic vena cava,\\n where the cava was already exposed, managed to suture it and completed the (left) lobectomy,\\n and the patient survived (made a nice case report). Ari\\n\\n Patients with penetrating trauma requiring any of these\\nmaneuvers are rare… and so are the survivors!\\n\\n Emergencies arising from hepatic lesions\\n A trained surgeon knows how to do it; an educated surgeon\\n knows why you do it.\\n Rodney Peyton\\n\\n These are exceedingly rare but it is good to know them well.\\n\\n ‘Ruptured’ hepatic cysts\\n\\n This is one of the most common questions by patients who have been\\ndiagnosed with incidental hepatic cysts: Will it rupture? Or rather: What\\nhappens when it ruptures? The truth is, hepatic cysts almost never\\nrupture.\\n\\n So you will hear the question from the patient with a large incidentally\\ndiscovered asymptomatic cyst — whether he/she may continue taking\\nTaekwondo or kick-boxing classes? While some surgeons use scenarios\\nlike these to scare people into performing surgery on simple cysts, I have\\nyet to see a hepatic cyst rupture from the practice of martial arts. I would\\navoid fear-mongering along these lines and tell patients they may\\ncontinue to do everything they have done in the past even after having\\nbeen diagnosed with a hepatic cyst.\\n\\n Despite the above, every 5 years or so, I see a patient with acute\\nabdominal pain who is admitted with a disintegrated hepatic cyst, some\\nfree abdominal fluid and a thin membrane hanging from the liver on the',\n", " 'md': '```markdown\\n## Text Extraction\\n\\n- Authored by more authors than reported cases. I have treated one patient with an anterior stab wound splitting the liver and the anterior wall of the retrohepatic vena cava, where the cava was already exposed, managed to suture it and completed the (left) lobectomy, and the patient survived (made a nice case report). Ari\\n- Patients with penetrating trauma requiring any of these maneuvers are rare… and so are the survivors!\\n\\n### Emergencies arising from hepatic lesions\\n- A trained surgeon knows how to do it; an educated surgeon knows why you do it.\\n- Rodney Peyton\\n- These are exceedingly rare but it is good to know them well.\\n\\n### ‘Ruptured’ hepatic cysts\\n- This is one of the most common questions by patients who have been diagnosed with incidental hepatic cysts: Will it rupture? Or rather: What happens when it ruptures? The truth is, hepatic cysts almost never rupture.\\n- So you will hear the question from the patient with a large incidentally discovered asymptomatic cyst — whether he/she may continue taking Taekwondo or kick-boxing classes? While some surgeons use scenarios like these to scare people into performing surgery on simple cysts, I have yet to see a hepatic cyst rupture from the practice of martial arts. I would avoid fear-mongering along these lines and tell patients they may continue to do everything they have done in the past even after having been diagnosed with a hepatic cyst.\\n- Despite the above, every 5 years or so, I see a patient with acute abdominal pain who is admitted with a disintegrated hepatic cyst, some free abdominal fluid and a thin membrane hanging from the liver on the...\\n\\n## Image Identification and Description\\n\\n- No images or graphs were identified on this page.\\n\\n## Formulas\\n\\n- No formulas were identified on this page.\\n\\n## Tables\\n\\n- No tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Authored by more authors than reported cases. I have treated one patient with an anterior stab wound splitting the liver and the anterior wall of the retrohepatic vena cava, where the cava was already exposed, managed to suture it and completed the (left) lobectomy, and the patient survived (made a nice case report). Ari\\n- Patients with penetrating trauma requiring any of these maneuvers are rare… and so are the survivors!',\n", " 'md': '- Authored by more authors than reported cases. I have treated one patient with an anterior stab wound splitting the liver and the anterior wall of the retrohepatic vena cava, where the cava was already exposed, managed to suture it and completed the (left) lobectomy, and the patient survived (made a nice case report). Ari\\n- Patients with penetrating trauma requiring any of these maneuvers are rare… and so are the survivors!',\n", " 'bBox': {'x': 72, 'y': 87, 'w': 462.39, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Emergencies arising from hepatic lesions',\n", " 'md': '### Emergencies arising from hepatic lesions',\n", " 'bBox': {'x': 86, 'y': 248, 'w': 327.36, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- A trained surgeon knows how to do it; an educated surgeon knows why you do it.\\n- Rodney Peyton\\n- These are exceedingly rare but it is good to know them well.',\n", " 'md': '- A trained surgeon knows how to do it; an educated surgeon knows why you do it.\\n- Rodney Peyton\\n- These are exceedingly rare but it is good to know them well.',\n", " 'bBox': {'x': 86, 'y': 188, 'w': 453.58, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': '‘Ruptured’ hepatic cysts',\n", " 'md': '### ‘Ruptured’ hepatic cysts',\n", " 'bBox': {'x': 86, 'y': 399, 'w': 191.28, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- This is one of the most common questions by patients who have been diagnosed with incidental hepatic cysts: Will it rupture? Or rather: What happens when it ruptures? The truth is, hepatic cysts almost never rupture.\\n- So you will hear the question from the patient with a large incidentally discovered asymptomatic cyst — whether he/she may continue taking Taekwondo or kick-boxing classes? While some surgeons use scenarios like these to scare people into performing surgery on simple cysts, I have yet to see a hepatic cyst rupture from the practice of martial arts. I would avoid fear-mongering along these lines and tell patients they may continue to do everything they have done in the past even after having been diagnosed with a hepatic cyst.\\n- Despite the above, every 5 years or so, I see a patient with acute abdominal pain who is admitted with a disintegrated hepatic cyst, some free abdominal fluid and a thin membrane hanging from the liver on the...',\n", " 'md': '- This is one of the most common questions by patients who have been diagnosed with incidental hepatic cysts: Will it rupture? Or rather: What happens when it ruptures? The truth is, hepatic cysts almost never rupture.\\n- So you will hear the question from the patient with a large incidentally discovered asymptomatic cyst — whether he/she may continue taking Taekwondo or kick-boxing classes? While some surgeons use scenarios like these to scare people into performing surgery on simple cysts, I have yet to see a hepatic cyst rupture from the practice of martial arts. I would avoid fear-mongering along these lines and tell patients they may continue to do everything they have done in the past even after having been diagnosed with a hepatic cyst.\\n- Despite the above, every 5 years or so, I see a patient with acute abdominal pain who is admitted with a disintegrated hepatic cyst, some free abdominal fluid and a thin membrane hanging from the liver on the...',\n", " 'bBox': {'x': 72, 'y': 188, 'w': 467.82, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formulas',\n", " 'md': '## Formulas',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No formulas were identified on this page.',\n", " 'md': '- No formulas were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No tables were identified on this page.\\n```',\n", " 'md': '- No tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 435,\n", " 'text': 'CT scan. My recommendation: check serology for Echinococcus,\\nexplore the liver laparoscopically, wash out the abdomen, culture\\nthe fluid and resect the cyst wall. Because this is an extremely rare\\nevent there are no reliable data on this versus other approaches but it\\nsaves you a lot of headaches. Ruptured echinococcal cysts may present\\nin patients with anaphylactic shock. I saw it once in my life in Switzerland\\nwhere Echinococcus is endemic.\\n\\n Liver abscesses\\n\\n The diagnosis of an hepatic abscess is made by ultrasound or CT in a\\npatient with fevers and abdominal pain. As usual it is worth looking at\\nthe images carefully as your residents may call a hepatic abscess\\nwhat is actually a ‘subphrenic’ or ‘subhepatic’ abscess. Spilled\\nstones after a previous cholecystectomy, cholecystitis, any source of\\nabdominal infection like appendicitis, deep surgical space infections,\\nvisceral perforations due to diverticulitis and inflammatory bowel disease\\nmay cause subphrenic and subhepatic abscesses in the peritoneal\\nspaces above and below the liver that are tightly sealed off by the bulge\\nof liver parenchyma. A thorough work-up of the history of the patient and\\nthe laboratory and imaging data should guide you to the diagnosis.\\n\\n Most true liver abscesses in the western world are pyogenic and\\namoebic abscesses occur mostly in third world countries. While\\namoebic abscesses almost always respond to antibiotic treatment (with\\nmetronidazole), pyogenic abscesses are more tricky. While some may\\nsimply be aspirated with a needle under US guidance, and resolve with\\nantibiotic therapy, very large ones and especially loculated ones\\nusually require transcutaneous interventional drainage.\\n\\n There are two types of mistakes I have observed with liver abscesses:\\none is to drag every patient with a liver abscess into the operating room,\\nbecause of the misguided concept that the world is waiting for professor-\\nsurgeons to solve all problems; the other is not to use surgical common\\nsense early enough — see the case below.\\n\\n Sometimes we receive a consultation about a patient with a non-resolving liver abscess: a little',\n", " 'md': \"```markdown\\n## Liver Abscesses\\n\\nThe diagnosis of a hepatic abscess is made by ultrasound or CT in a patient with fevers and abdominal pain. It is important to carefully examine the images, as residents may misidentify a hepatic abscess as a ‘subphrenic’ or ‘subhepatic’ abscess.\\n\\nSpilled stones after a previous cholecystectomy, cholecystitis, any source of abdominal infection like appendicitis, deep surgical space infections, visceral perforations due to diverticulitis, and inflammatory bowel disease may cause subphrenic and subhepatic abscesses in the peritoneal spaces above and below the liver that are tightly sealed off by the bulge of liver parenchyma. A thorough work-up of the patient's history and the laboratory and imaging data should guide you to the diagnosis.\\n\\nMost true liver abscesses in the western world are pyogenic, while amoebic abscesses occur mostly in third world countries. Amoebic abscesses almost always respond to antibiotic treatment (with metronidazole), whereas pyogenic abscesses are more complex. Some may simply be aspirated with a needle under ultrasound guidance and resolve with antibiotic therapy, but very large and especially loculated abscesses usually require transcutaneous interventional drainage.\\n\\nThere are two types of mistakes I have observed with liver abscesses: one is to drag every patient with a liver abscess into the operating room, due to the misguided belief that the world is waiting for professor-surgeons to solve all problems; the other is not to use surgical common sense early enough.\\n\\nSometimes we receive a consultation about a patient with a non-resolving liver abscess: a little \\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Liver Abscesses',\n", " 'md': '## Liver Abscesses',\n", " 'bBox': {'x': 86, 'y': 228, 'w': 127.87, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': \"The diagnosis of a hepatic abscess is made by ultrasound or CT in a patient with fevers and abdominal pain. It is important to carefully examine the images, as residents may misidentify a hepatic abscess as a ‘subphrenic’ or ‘subhepatic’ abscess.\\n\\nSpilled stones after a previous cholecystectomy, cholecystitis, any source of abdominal infection like appendicitis, deep surgical space infections, visceral perforations due to diverticulitis, and inflammatory bowel disease may cause subphrenic and subhepatic abscesses in the peritoneal spaces above and below the liver that are tightly sealed off by the bulge of liver parenchyma. A thorough work-up of the patient's history and the laboratory and imaging data should guide you to the diagnosis.\\n\\nMost true liver abscesses in the western world are pyogenic, while amoebic abscesses occur mostly in third world countries. Amoebic abscesses almost always respond to antibiotic treatment (with metronidazole), whereas pyogenic abscesses are more complex. Some may simply be aspirated with a needle under ultrasound guidance and resolve with antibiotic therapy, but very large and especially loculated abscesses usually require transcutaneous interventional drainage.\\n\\nThere are two types of mistakes I have observed with liver abscesses: one is to drag every patient with a liver abscess into the operating room, due to the misguided belief that the world is waiting for professor-surgeons to solve all problems; the other is not to use surgical common sense early enough.\\n\\nSometimes we receive a consultation about a patient with a non-resolving liver abscess: a little \\n```\",\n", " 'md': \"The diagnosis of a hepatic abscess is made by ultrasound or CT in a patient with fevers and abdominal pain. It is important to carefully examine the images, as residents may misidentify a hepatic abscess as a ‘subphrenic’ or ‘subhepatic’ abscess.\\n\\nSpilled stones after a previous cholecystectomy, cholecystitis, any source of abdominal infection like appendicitis, deep surgical space infections, visceral perforations due to diverticulitis, and inflammatory bowel disease may cause subphrenic and subhepatic abscesses in the peritoneal spaces above and below the liver that are tightly sealed off by the bulge of liver parenchyma. A thorough work-up of the patient's history and the laboratory and imaging data should guide you to the diagnosis.\\n\\nMost true liver abscesses in the western world are pyogenic, while amoebic abscesses occur mostly in third world countries. Amoebic abscesses almost always respond to antibiotic treatment (with metronidazole), whereas pyogenic abscesses are more complex. Some may simply be aspirated with a needle under ultrasound guidance and resolve with antibiotic therapy, but very large and especially loculated abscesses usually require transcutaneous interventional drainage.\\n\\nThere are two types of mistakes I have observed with liver abscesses: one is to drag every patient with a liver abscess into the operating room, due to the misguided belief that the world is waiting for professor-surgeons to solve all problems; the other is not to use surgical common sense early enough.\\n\\nSometimes we receive a consultation about a patient with a non-resolving liver abscess: a little \\n```\",\n", " 'bBox': {'x': 72, 'y': 228, 'w': 467.76, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 436,\n", " 'text': ' 9Fr catheter has been inserted by a radiologist who never saw the patient afterwards and has\\n since retired. A 9Fr drain is hanging from the patient’s side without being flushed regularly. It is\\n obstructed half of the time and otherwise draining thick pus that has not changed in quality\\n over the last 10 days. Once the surgical service receives a consultation about such a patient, it\\n is good judgment to first recommend upsizing to a 12 or 15Fr catheter, frequent flushing to\\n address the source of the infection and to consider surgery if things don’t improve after the\\n lesion has been well drained.\\n\\n Surgery is not quite indicated unless the patient has really been\\ntreated non-surgically. On the other hand, there are situations where\\nsurgical drainage of non-resolving hepatic and perihepatic abscesses\\nmay solve a problem immediately that, if not addressed — especially in\\nolder patients — may cost the patient’s life. Non-resolving perihepatic\\nabscesses nowadays are best addressed through a laparotomy with\\nadequate antibiotic coverage, careful debridement and drain placement.\\nThe extraperitoneal approaches (plus/minus rib resection) belong to the\\nskill set of a different generation of general surgeons and are not\\npracticed any more.\\n\\n When a hepatic abscess is drained surgically, I recommend\\npoking a straight finger into the usually loculated collection to break\\nit up and refrain from tearing apart the inner walls of the loculated\\ncollections with a curved finger, since this will invariable destroy\\nthe Glissonian structures crossing the abscess and cause bile\\nleaks.\\n\\n Hemobilia\\n\\n ħemobilia is most frequently a complication of interventional radiology\\nprocedures and is treated by interventional radiologists as well. As a\\nsurgeon you simply have to recognize the entity, know how it is\\ndiagnosed and pass it on to the specialty who fixes it. Most frequently,\\npatients present with stigmata of GI bleeding like melena, anemia\\nand sometimes hemodynamic instability and a recent history of\\ninstrumentation of the liver — either by transcutaneous biopsy,\\nendoscopic retrograde cholangiography or even a laparoscopic',\n", " 'md': '```markdown\\n## Page Content\\n\\nA 9Fr catheter has been inserted by a radiologist who never saw the patient afterwards and has since retired. A 9Fr drain is hanging from the patient’s side without being flushed regularly. It is obstructed half of the time and otherwise draining thick pus that has not changed in quality over the last 10 days. Once the surgical service receives a consultation about such a patient, it is good judgment to first recommend upsizing to a 12 or 15Fr catheter, frequent flushing to address the source of the infection, and to consider surgery if things don’t improve after the lesion has been well drained.\\n\\nSurgery is not quite indicated unless the patient has really been treated non-surgically. On the other hand, there are situations where surgical drainage of non-resolving hepatic and perihepatic abscesses may solve a problem immediately that, if not addressed — especially in older patients — may cost the patient’s life. Non-resolving perihepatic abscesses nowadays are best addressed through a laparotomy with adequate antibiotic coverage, careful debridement, and drain placement. The extraperitoneal approaches (plus/minus rib resection) belong to the skill set of a different generation of general surgeons and are not practiced anymore.\\n\\nWhen a hepatic abscess is drained surgically, I recommend poking a straight finger into the usually loculated collection to break it up and refrain from tearing apart the inner walls of the loculated collections with a curved finger, since this will invariably destroy the Glissonian structures crossing the abscess and cause bile leaks.\\n\\n### Hemobilia\\n\\nHemobilia is most frequently a complication of interventional radiology procedures and is treated by interventional radiologists as well. As a surgeon, you simply have to recognize the entity, know how it is diagnosed, and pass it on to the specialty who fixes it. Most frequently, patients present with stigmata of GI bleeding like melena, anemia, and sometimes hemodynamic instability and a recent history of instrumentation of the liver — either by transcutaneous biopsy, endoscopic retrograde cholangiography, or even a laparoscopic.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A 9Fr catheter has been inserted by a radiologist who never saw the patient afterwards and has since retired. A 9Fr drain is hanging from the patient’s side without being flushed regularly. It is obstructed half of the time and otherwise draining thick pus that has not changed in quality over the last 10 days. Once the surgical service receives a consultation about such a patient, it is good judgment to first recommend upsizing to a 12 or 15Fr catheter, frequent flushing to address the source of the infection, and to consider surgery if things don’t improve after the lesion has been well drained.\\n\\nSurgery is not quite indicated unless the patient has really been treated non-surgically. On the other hand, there are situations where surgical drainage of non-resolving hepatic and perihepatic abscesses may solve a problem immediately that, if not addressed — especially in older patients — may cost the patient’s life. Non-resolving perihepatic abscesses nowadays are best addressed through a laparotomy with adequate antibiotic coverage, careful debridement, and drain placement. The extraperitoneal approaches (plus/minus rib resection) belong to the skill set of a different generation of general surgeons and are not practiced anymore.\\n\\nWhen a hepatic abscess is drained surgically, I recommend poking a straight finger into the usually loculated collection to break it up and refrain from tearing apart the inner walls of the loculated collections with a curved finger, since this will invariably destroy the Glissonian structures crossing the abscess and cause bile leaks.',\n", " 'md': 'A 9Fr catheter has been inserted by a radiologist who never saw the patient afterwards and has since retired. A 9Fr drain is hanging from the patient’s side without being flushed regularly. It is obstructed half of the time and otherwise draining thick pus that has not changed in quality over the last 10 days. Once the surgical service receives a consultation about such a patient, it is good judgment to first recommend upsizing to a 12 or 15Fr catheter, frequent flushing to address the source of the infection, and to consider surgery if things don’t improve after the lesion has been well drained.\\n\\nSurgery is not quite indicated unless the patient has really been treated non-surgically. On the other hand, there are situations where surgical drainage of non-resolving hepatic and perihepatic abscesses may solve a problem immediately that, if not addressed — especially in older patients — may cost the patient’s life. Non-resolving perihepatic abscesses nowadays are best addressed through a laparotomy with adequate antibiotic coverage, careful debridement, and drain placement. The extraperitoneal approaches (plus/minus rib resection) belong to the skill set of a different generation of general surgeons and are not practiced anymore.\\n\\nWhen a hepatic abscess is drained surgically, I recommend poking a straight finger into the usually loculated collection to break it up and refrain from tearing apart the inner walls of the loculated collections with a curved finger, since this will invariably destroy the Glissonian structures crossing the abscess and cause bile leaks.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Hemobilia',\n", " 'md': '### Hemobilia',\n", " 'bBox': {'x': 86, 'y': 565, 'w': 79.08, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Hemobilia is most frequently a complication of interventional radiology procedures and is treated by interventional radiologists as well. As a surgeon, you simply have to recognize the entity, know how it is diagnosed, and pass it on to the specialty who fixes it. Most frequently, patients present with stigmata of GI bleeding like melena, anemia, and sometimes hemodynamic instability and a recent history of instrumentation of the liver — either by transcutaneous biopsy, endoscopic retrograde cholangiography, or even a laparoscopic.\\n\\n```',\n", " 'md': 'Hemobilia is most frequently a complication of interventional radiology procedures and is treated by interventional radiologists as well. As a surgeon, you simply have to recognize the entity, know how it is diagnosed, and pass it on to the specialty who fixes it. Most frequently, patients present with stigmata of GI bleeding like melena, anemia, and sometimes hemodynamic instability and a recent history of instrumentation of the liver — either by transcutaneous biopsy, endoscopic retrograde cholangiography, or even a laparoscopic.\\n\\n```',\n", " 'bBox': {'x': 86, 'y': 565, 'w': 79.08, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 437,\n", " 'text': 'cholecystectomy — see the case below.\\n\\n Do you remember the laparoscopic cholecystectomy you did in a diabetic patient a few weeks\\n ago — the one with a baked-in chronically inflamed gallbladder? You got into the wrong plane,\\n there was some bleeding from the gallbladder bed, in the end you asked for the argon beam\\n coagulator. Ultimately it stopped. The patient did fine. A few weeks later he presented with\\n melena, but a negative colonoscopy and a negative upper GI endoscopy. The\\n gastroenterologist did not visualize the papilla, but they might have not seen anything anyway,\\n because hemobilia is intermittent. However, because you are smart, you order a CT\\n arteriogram and there it is: an intrahepatic aneurysm of the right hepatic\\n artery!\\n\\n The pathophysiology is an arteriobiliary shunt causing bleeding into the\\nbiliary system and — therefore — GI bleeding. Embolization of the\\npseudo-aneurysm is the treatment of choice. Only in scenarios of\\ntumors causing arteriobiliary fistulas and the non-availability of an\\ninterventional radiologist, is a surgical resection of one liver lobe or\\nsurgical ligation of either hepatic artery required; this is rare.\\n\\n Hepatic tumors\\n\\n Liver tumors may present as an emergency because of intra-\\nabdominal bleeding. The “bleeding hepatic tumor” announced by the\\nemergency room crew frequently turns out to be a transfer from another\\nhospital, because a liver lesion had been transcutaneously biopsied,\\nalthough imaging with three-phase contrast CTs or MRIs could have\\nestablished the diagnosis. To be fair, there is a risk of spontaneous\\nbleeding in adenomas and hepatocellular carcinomas, but it\\nremains an uncommon presentation.\\n\\n Bleeding of hepatic adenomas is more common specifically in pregnant\\nwomen. Bleeding hepatic tumors are nowadays managed by\\ntranscatheter embolization to stop the bleeding. Convince your\\ninterventional radiologist to embolize the bleeding as selectively as',\n", " 'md': '```markdown\\n## Cholecystectomy Case Study\\n\\nDo you remember the laparoscopic cholecystectomy you did in a diabetic patient a few weeks ago — the one with a baked-in chronically inflamed gallbladder? You got into the wrong plane, there was some bleeding from the gallbladder bed, in the end you asked for the argon beam coagulator. Ultimately it stopped. The patient did fine. A few weeks later he presented with melena, but a negative colonoscopy and a negative upper GI endoscopy. The gastroenterologist did not visualize the papilla, but they might have not seen anything anyway, because hemobilia is intermittent. However, because you are smart, you order a CT arteriogram and there it is: an intrahepatic aneurysm of the right hepatic artery!\\n\\nThe pathophysiology is an arteriobiliary shunt causing bleeding into the biliary system and — therefore — GI bleeding. Embolization of the pseudo-aneurysm is the treatment of choice. Only in scenarios of tumors causing arteriobiliary fistulas and the non-availability of an interventional radiologist, is a surgical resection of one liver lobe or surgical ligation of either hepatic artery required; this is rare.\\n\\n### Hepatic Tumors\\n\\nLiver tumors may present as an emergency because of intra-abdominal bleeding. The “bleeding hepatic tumor” announced by the emergency room crew frequently turns out to be a transfer from another hospital, because a liver lesion had been transcutaneously biopsied, although imaging with three-phase contrast CTs or MRIs could have established the diagnosis. To be fair, there is a risk of spontaneous bleeding in adenomas and hepatocellular carcinomas, but it remains an uncommon presentation.\\n\\nBleeding of hepatic adenomas is more common specifically in pregnant women. Bleeding hepatic tumors are nowadays managed by transcatheter embolization to stop the bleeding. Convince your interventional radiologist to embolize the bleeding as selectively as possible.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Cholecystectomy Case Study',\n", " 'md': '## Cholecystectomy Case Study',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Do you remember the laparoscopic cholecystectomy you did in a diabetic patient a few weeks ago — the one with a baked-in chronically inflamed gallbladder? You got into the wrong plane, there was some bleeding from the gallbladder bed, in the end you asked for the argon beam coagulator. Ultimately it stopped. The patient did fine. A few weeks later he presented with melena, but a negative colonoscopy and a negative upper GI endoscopy. The gastroenterologist did not visualize the papilla, but they might have not seen anything anyway, because hemobilia is intermittent. However, because you are smart, you order a CT arteriogram and there it is: an intrahepatic aneurysm of the right hepatic artery!\\n\\nThe pathophysiology is an arteriobiliary shunt causing bleeding into the biliary system and — therefore — GI bleeding. Embolization of the pseudo-aneurysm is the treatment of choice. Only in scenarios of tumors causing arteriobiliary fistulas and the non-availability of an interventional radiologist, is a surgical resection of one liver lobe or surgical ligation of either hepatic artery required; this is rare.',\n", " 'md': 'Do you remember the laparoscopic cholecystectomy you did in a diabetic patient a few weeks ago — the one with a baked-in chronically inflamed gallbladder? You got into the wrong plane, there was some bleeding from the gallbladder bed, in the end you asked for the argon beam coagulator. Ultimately it stopped. The patient did fine. A few weeks later he presented with melena, but a negative colonoscopy and a negative upper GI endoscopy. The gastroenterologist did not visualize the papilla, but they might have not seen anything anyway, because hemobilia is intermittent. However, because you are smart, you order a CT arteriogram and there it is: an intrahepatic aneurysm of the right hepatic artery!\\n\\nThe pathophysiology is an arteriobiliary shunt causing bleeding into the biliary system and — therefore — GI bleeding. Embolization of the pseudo-aneurysm is the treatment of choice. Only in scenarios of tumors causing arteriobiliary fistulas and the non-availability of an interventional radiologist, is a surgical resection of one liver lobe or surgical ligation of either hepatic artery required; this is rare.',\n", " 'bBox': {'x': 72, 'y': 132, 'w': 460.34, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Hepatic Tumors',\n", " 'md': '### Hepatic Tumors',\n", " 'bBox': {'x': 86, 'y': 466, 'w': 120.47, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Liver tumors may present as an emergency because of intra-abdominal bleeding. The “bleeding hepatic tumor” announced by the emergency room crew frequently turns out to be a transfer from another hospital, because a liver lesion had been transcutaneously biopsied, although imaging with three-phase contrast CTs or MRIs could have established the diagnosis. To be fair, there is a risk of spontaneous bleeding in adenomas and hepatocellular carcinomas, but it remains an uncommon presentation.\\n\\nBleeding of hepatic adenomas is more common specifically in pregnant women. Bleeding hepatic tumors are nowadays managed by transcatheter embolization to stop the bleeding. Convince your interventional radiologist to embolize the bleeding as selectively as possible.\\n```',\n", " 'md': 'Liver tumors may present as an emergency because of intra-abdominal bleeding. The “bleeding hepatic tumor” announced by the emergency room crew frequently turns out to be a transfer from another hospital, because a liver lesion had been transcutaneously biopsied, although imaging with three-phase contrast CTs or MRIs could have established the diagnosis. To be fair, there is a risk of spontaneous bleeding in adenomas and hepatocellular carcinomas, but it remains an uncommon presentation.\\n\\nBleeding of hepatic adenomas is more common specifically in pregnant women. Bleeding hepatic tumors are nowadays managed by transcatheter embolization to stop the bleeding. Convince your interventional radiologist to embolize the bleeding as selectively as possible.\\n```',\n", " 'bBox': {'x': 72, 'y': 466, 'w': 467.97, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 438,\n", " 'text': 'possible and avoid embolizing the entire hemi-liver, because necrosis\\nand intrahepatic cholangiopathy may ensue, which ultimately requires a\\nmore extensive resection than initially necessary to remove the tumor. It\\nshould be rare that tumor bleeding cannot be controlled by an\\nangiographic intervention.\\n\\n Only after embolization, are a thoughtful imaging work-up and\\nstaging indicated to establish a surgical treatment plan. Sometimes\\nan interval of several weeks is required until the hepatic hematoma has\\nresolved to be able to establish a radiologic diagnosis by MRI. Do not\\nplan elective resectional surgery until the hematoma has completely\\nresolved. A large central hematoma can compress hepatic veins causing\\na Budd-Chiari syndrome — operating in such circumstances may prove\\ndisastrous!\\n\\n If no interventional radiologist is available, laparotomy and rapid inflow\\ncontrol of the liver may be necessary. In older, frail patients with\\ncomorbidities and limited reserves and a bleeding exophytic\\nhepatocellular carcinoma, I have used a hand-assisted laparoscopic\\napproach and stapler tumorectomy to rapidly remove the bleeding mass.\\n\\n Should you encounter a bleeding liver tumor causing\\nhemodynamic instability with no local angiographic facilities, no\\nexpertise in liver surgery, and no immediate options of rapid\\ntransferal — do what you would do with liver trauma: open up and\\npack!\\n\\n Another emergency scenario is the incidentally discovered liver\\ntumor, either during an emergency exploratory laparotomy or during\\nan elective laparoscopy or laparotomy. You might ask: should I excise\\nthe lesion or perform a biopsy? If the lesion is small and peripheral, it is\\nno mistake to excise it, but I wouldn’t take any risks, since it is not easy to\\nexclude other lesions in the rest of the liver without cross-sectional\\nimaging by CT or MRI, unless you are a very good ultrasonographer. I\\nwould strongly advise not to perform a direct biopsy into a tumor visible\\non the liver surface, but if you do, then only do it by driving a core needle\\nthrough healthy liver tissue and then carefully ablating the needle tract\\nafterwards. You just don’t want to spill tumor tissue throughout the',\n", " 'md': '```markdown\\n## Page Content\\n\\nIt is possible to avoid embolizing the entire hemi-liver, because necrosis and intrahepatic cholangiopathy may ensue, which ultimately requires a more extensive resection than initially necessary to remove the tumor. It should be rare that tumor bleeding cannot be controlled by an angiographic intervention.\\n\\nOnly after embolization are a thoughtful imaging work-up and staging indicated to establish a surgical treatment plan. Sometimes an interval of several weeks is required until the hepatic hematoma has resolved to be able to establish a radiologic diagnosis by MRI. Do not plan elective resectional surgery until the hematoma has completely resolved. A large central hematoma can compress hepatic veins causing a Budd-Chiari syndrome — operating in such circumstances may prove disastrous!\\n\\nIf no interventional radiologist is available, laparotomy and rapid inflow control of the liver may be necessary. In older, frail patients with comorbidities and limited reserves and a bleeding exophytic hepatocellular carcinoma, I have used a hand-assisted laparoscopic approach and stapler tumorectomy to rapidly remove the bleeding mass.\\n\\nShould you encounter a bleeding liver tumor causing hemodynamic instability with no local angiographic facilities, no expertise in liver surgery, and no immediate options of rapid transferal — do what you would do with liver trauma: open up and pack!\\n\\nAnother emergency scenario is the incidentally discovered liver tumor, either during an emergency exploratory laparotomy or during an elective laparoscopy or laparotomy. You might ask: should I excise the lesion or perform a biopsy? If the lesion is small and peripheral, it is no mistake to excise it, but I wouldn’t take any risks, since it is not easy to exclude other lesions in the rest of the liver without cross-sectional imaging by CT or MRI, unless you are a very good ultrasonographer. I would strongly advise not to perform a direct biopsy into a tumor visible on the liver surface, but if you do, then only do it by driving a core needle through healthy liver tissue and then carefully ablating the needle tract afterwards. You just don’t want to spill tumor tissue throughout the liver.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'It is possible to avoid embolizing the entire hemi-liver, because necrosis and intrahepatic cholangiopathy may ensue, which ultimately requires a more extensive resection than initially necessary to remove the tumor. It should be rare that tumor bleeding cannot be controlled by an angiographic intervention.\\n\\nOnly after embolization are a thoughtful imaging work-up and staging indicated to establish a surgical treatment plan. Sometimes an interval of several weeks is required until the hepatic hematoma has resolved to be able to establish a radiologic diagnosis by MRI. Do not plan elective resectional surgery until the hematoma has completely resolved. A large central hematoma can compress hepatic veins causing a Budd-Chiari syndrome — operating in such circumstances may prove disastrous!\\n\\nIf no interventional radiologist is available, laparotomy and rapid inflow control of the liver may be necessary. In older, frail patients with comorbidities and limited reserves and a bleeding exophytic hepatocellular carcinoma, I have used a hand-assisted laparoscopic approach and stapler tumorectomy to rapidly remove the bleeding mass.\\n\\nShould you encounter a bleeding liver tumor causing hemodynamic instability with no local angiographic facilities, no expertise in liver surgery, and no immediate options of rapid transferal — do what you would do with liver trauma: open up and pack!\\n\\nAnother emergency scenario is the incidentally discovered liver tumor, either during an emergency exploratory laparotomy or during an elective laparoscopy or laparotomy. You might ask: should I excise the lesion or perform a biopsy? If the lesion is small and peripheral, it is no mistake to excise it, but I wouldn’t take any risks, since it is not easy to exclude other lesions in the rest of the liver without cross-sectional imaging by CT or MRI, unless you are a very good ultrasonographer. I would strongly advise not to perform a direct biopsy into a tumor visible on the liver surface, but if you do, then only do it by driving a core needle through healthy liver tissue and then carefully ablating the needle tract afterwards. You just don’t want to spill tumor tissue throughout the liver.\\n\\n```',\n", " 'md': 'It is possible to avoid embolizing the entire hemi-liver, because necrosis and intrahepatic cholangiopathy may ensue, which ultimately requires a more extensive resection than initially necessary to remove the tumor. It should be rare that tumor bleeding cannot be controlled by an angiographic intervention.\\n\\nOnly after embolization are a thoughtful imaging work-up and staging indicated to establish a surgical treatment plan. Sometimes an interval of several weeks is required until the hepatic hematoma has resolved to be able to establish a radiologic diagnosis by MRI. Do not plan elective resectional surgery until the hematoma has completely resolved. A large central hematoma can compress hepatic veins causing a Budd-Chiari syndrome — operating in such circumstances may prove disastrous!\\n\\nIf no interventional radiologist is available, laparotomy and rapid inflow control of the liver may be necessary. In older, frail patients with comorbidities and limited reserves and a bleeding exophytic hepatocellular carcinoma, I have used a hand-assisted laparoscopic approach and stapler tumorectomy to rapidly remove the bleeding mass.\\n\\nShould you encounter a bleeding liver tumor causing hemodynamic instability with no local angiographic facilities, no expertise in liver surgery, and no immediate options of rapid transferal — do what you would do with liver trauma: open up and pack!\\n\\nAnother emergency scenario is the incidentally discovered liver tumor, either during an emergency exploratory laparotomy or during an elective laparoscopy or laparotomy. You might ask: should I excise the lesion or perform a biopsy? If the lesion is small and peripheral, it is no mistake to excise it, but I wouldn’t take any risks, since it is not easy to exclude other lesions in the rest of the liver without cross-sectional imaging by CT or MRI, unless you are a very good ultrasonographer. I would strongly advise not to perform a direct biopsy into a tumor visible on the liver surface, but if you do, then only do it by driving a core needle through healthy liver tissue and then carefully ablating the needle tract afterwards. You just don’t want to spill tumor tissue throughout the liver.\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.91, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 439,\n", " 'text': 'abdomen by performing a biopsy with a needle coming through the\\nabdominal cavity. Nowadays MRI diagnosis of liver tumors both in\\nhealthy and diseased livers is excellent and tissue diagnosis is not\\nalways necessary to decide on further treatment courses: don’t let\\nanybody talk you into a biopsy; the work-up should be performed after\\nthe surgery is over.\\n\\n To sum up…\\n\\n The liver is a quiet organ and doesn’t cause many problems unless\\nchronically ill. Patients with chronic liver disease may present with\\ndramatic emergencies and it is important for surgeons and endoscopists\\nto be well prepared for those. Blunt liver trauma can frequently be treated\\nnon-operatively; this is also true for hepatic stab wounds and low-velocity\\ngunshot wounds — unless associated with severe bleeding or other\\ninjuries. In emergencies arising with hepatic lesions, it is good to know\\nwhen not to operate. But isn’t this true for anything else?\\n\\n “Liver is my number one most hated food. Oh, God, I get\\n sick talking about it!”\\n Guy Fieri\\n\\n1 MELD — Model of Endstage Liver Disease based on the patient’s age, bilirubin, creatinine and INR levels.\\n calculate go to: http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/\\n2 http://www.odt.nhs.uk/pdf/advisory_group_papers/LAG/referral_for_transplantation.pdf.\\n3 http://www.aasld.org/practiceguidelines/documents/bookmarked%20practice%20guidelines/hccupdate2010.p',\n", " 'md': '```markdown\\n## Summary of Liver Diagnosis and Treatment\\n\\nThe liver is a quiet organ and doesn’t cause many problems unless chronically ill. Patients with chronic liver disease may present with dramatic emergencies, and it is important for surgeons and endoscopists to be well prepared for those. Blunt liver trauma can frequently be treated non-operatively; this is also true for hepatic stab wounds and low-velocity gunshot wounds — unless associated with severe bleeding or other injuries. In emergencies arising with hepatic lesions, it is good to know when not to operate.\\n\\n### Quote\\n> “Liver is my number one most hated food. Oh, God, I get sick talking about it!”\\n> — Guy Fieri\\n\\n### Notes\\n1. **MELD** — Model of Endstage Liver Disease based on the patient’s age, bilirubin, creatinine, and INR levels. For calculation, visit [MDCalc](http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/).\\n2. For more information, refer to [NHS Guidelines](http://www.odt.nhs.uk/pdf/advisory_group_papers/LAG/referral_for_transplantation.pdf).\\n3. Additional guidelines can be found at [AASLD Practice Guidelines](http://www.aasld.org/practiceguidelines/documents/bookmarked%20practice%20guidelines/hccupdate2010.p).\\n\\n### Conclusion\\nThe work-up for liver conditions should be performed after surgery is over, and tissue diagnosis is not always necessary to decide on further treatment courses. Don’t let anybody talk you into a biopsy.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary of Liver Diagnosis and Treatment',\n", " 'md': '## Summary of Liver Diagnosis and Treatment',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The liver is a quiet organ and doesn’t cause many problems unless chronically ill. Patients with chronic liver disease may present with dramatic emergencies, and it is important for surgeons and endoscopists to be well prepared for those. Blunt liver trauma can frequently be treated non-operatively; this is also true for hepatic stab wounds and low-velocity gunshot wounds — unless associated with severe bleeding or other injuries. In emergencies arising with hepatic lesions, it is good to know when not to operate.',\n", " 'md': 'The liver is a quiet organ and doesn’t cause many problems unless chronically ill. Patients with chronic liver disease may present with dramatic emergencies, and it is important for surgeons and endoscopists to be well prepared for those. Blunt liver trauma can frequently be treated non-operatively; this is also true for hepatic stab wounds and low-velocity gunshot wounds — unless associated with severe bleeding or other injuries. In emergencies arising with hepatic lesions, it is good to know when not to operate.',\n", " 'bBox': {'x': 72, 'y': 297, 'w': 467.49, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Quote',\n", " 'md': '### Quote',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '> “Liver is my number one most hated food. Oh, God, I get sick talking about it!”\\n> — Guy Fieri',\n", " 'md': '> “Liver is my number one most hated food. Oh, God, I get sick talking about it!”\\n> — Guy Fieri',\n", " 'bBox': {'x': 79, 'y': 411, 'w': 453.59, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. **MELD** — Model of Endstage Liver Disease based on the patient’s age, bilirubin, creatinine, and INR levels. For calculation, visit [MDCalc](http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/).\\n2. For more information, refer to [NHS Guidelines](http://www.odt.nhs.uk/pdf/advisory_group_papers/LAG/referral_for_transplantation.pdf).\\n3. Additional guidelines can be found at [AASLD Practice Guidelines](http://www.aasld.org/practiceguidelines/documents/bookmarked%20practice%20guidelines/hccupdate2010.p).',\n", " 'md': '1. **MELD** — Model of Endstage Liver Disease based on the patient’s age, bilirubin, creatinine, and INR levels. For calculation, visit [MDCalc](http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/).\\n2. For more information, refer to [NHS Guidelines](http://www.odt.nhs.uk/pdf/advisory_group_papers/LAG/referral_for_transplantation.pdf).\\n3. Additional guidelines can be found at [AASLD Practice Guidelines](http://www.aasld.org/practiceguidelines/documents/bookmarked%20practice%20guidelines/hccupdate2010.p).',\n", " 'bBox': {'x': 73, 'y': 526, 'w': 519.78, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Conclusion',\n", " 'md': '### Conclusion',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The work-up for liver conditions should be performed after surgery is over, and tissue diagnosis is not always necessary to decide on further treatment courses. Don’t let anybody talk you into a biopsy.\\n```',\n", " 'md': 'The work-up for liver conditions should be performed after surgery is over, and tissue diagnosis is not always necessary to decide on further treatment courses. Don’t let anybody talk you into a biopsy.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'url': 'http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/',\n", " 'text': ''},\n", " {'text': ''},\n", " {'url': 'http://www.odt.nhs.uk/pdf/advisory_group_papers/LAG/referral_for_transplantation.pdf',\n", " 'text': ''},\n", " {'text': ''},\n", " {'url': 'http://www.aasld.org/practiceguidelines/documents/bookmarked%20practice%20guidelines/hccupdate2010.pdf',\n", " 'text': ''}]},\n", " {'page': 440,\n", " 'text': 'Chapter 26\\nInflammatory bowel disease and other types of\\ncolitis\\nBashar Safar and Jonathan Efron 1\\n\\n Save the patient, not the colon.\\n John C. Goligher\\n\\n Colitis refers to inflammation of the colon. It might affect the\\nentire colon or its segments. Ulcerative colitis starts in the rectum\\nand migrates proximally whereas Crohn’s colitis affects any part of\\nthe colon — as well as the terminal small intestine — but tends to\\npresent with generalized colitis. Some patients present acutely with\\nsevere disease, but more often both disease states progress slowly with\\nintermittent flares leading to the need for eventual surgical treatment.\\n\\n The patient and the gastroenterologists view surgery for\\ninflammatory bowel disease as a failure of medical therapy. Thus,\\nmany of these patients have spent much of their lives attempting to avoid\\nsurgery at all costs. It is for this reason that most patients with\\ninflammatory bowel disease are on multiple immunosuppressive\\nmedications and can be severely debilitated by the time a surgeon\\nis consulted to consider an operation. It is important to remember that:\\n\\n • Crohn’s disease (CD) is a transmural process, is not curable and\\n that surgical therapy is aimed at palliating the patient’s symptoms\\n and controlling active infections and severe disease.\\n Ulcerative colitis on the other hand, affects the mucosa only and is',\n", " 'md': '```markdown\\n# Chapter 26: Inflammatory Bowel Disease and Other Types of Colitis\\n**Authors:** Bashar Safar and Jonathan Efron\\n\\n> \"Save the patient, not the colon.\" - John C. Goligher\\n\\nColitis refers to inflammation of the colon. It might affect the entire colon or its segments. Ulcerative colitis starts in the rectum and migrates proximally, whereas Crohn’s colitis affects any part of the colon — as well as the terminal small intestine — but tends to present with generalized colitis. Some patients present acutely with severe disease, but more often both disease states progress slowly with intermittent flares leading to the need for eventual surgical treatment.\\n\\nThe patient and the gastroenterologists view surgery for inflammatory bowel disease as a failure of medical therapy. Thus, many of these patients have spent much of their lives attempting to avoid surgery at all costs. It is for this reason that most patients with inflammatory bowel disease are on multiple immunosuppressive medications and can be severely debilitated by the time a surgeon is consulted to consider an operation. It is important to remember that:\\n\\n- **Crohn’s disease (CD)** is a transmural process, is not curable, and that surgical therapy is aimed at palliating the patient’s symptoms and controlling active infections and severe disease.\\n- **Ulcerative colitis**, on the other hand, affects the mucosa only and is...\\n```\\n\\n*Note: The text extraction is complete, but the page seems to be cut off at the end. If there are any images, graphs, or tables on this page, please provide them for further extraction and description.*',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 26: Inflammatory Bowel Disease and Other Types of Colitis',\n", " 'md': '# Chapter 26: Inflammatory Bowel Disease and Other Types of Colitis',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 416.58, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Bashar Safar and Jonathan Efron\\n\\n> \"Save the patient, not the colon.\" - John C. Goligher\\n\\nColitis refers to inflammation of the colon. It might affect the entire colon or its segments. Ulcerative colitis starts in the rectum and migrates proximally, whereas Crohn’s colitis affects any part of the colon — as well as the terminal small intestine — but tends to present with generalized colitis. Some patients present acutely with severe disease, but more often both disease states progress slowly with intermittent flares leading to the need for eventual surgical treatment.\\n\\nThe patient and the gastroenterologists view surgery for inflammatory bowel disease as a failure of medical therapy. Thus, many of these patients have spent much of their lives attempting to avoid surgery at all costs. It is for this reason that most patients with inflammatory bowel disease are on multiple immunosuppressive medications and can be severely debilitated by the time a surgeon is consulted to consider an operation. It is important to remember that:\\n\\n- **Crohn’s disease (CD)** is a transmural process, is not curable, and that surgical therapy is aimed at palliating the patient’s symptoms and controlling active infections and severe disease.\\n- **Ulcerative colitis**, on the other hand, affects the mucosa only and is...\\n```\\n\\n*Note: The text extraction is complete, but the page seems to be cut off at the end. If there are any images, graphs, or tables on this page, please provide them for further extraction and description.*',\n", " 'md': '**Authors:** Bashar Safar and Jonathan Efron\\n\\n> \"Save the patient, not the colon.\" - John C. Goligher\\n\\nColitis refers to inflammation of the colon. It might affect the entire colon or its segments. Ulcerative colitis starts in the rectum and migrates proximally, whereas Crohn’s colitis affects any part of the colon — as well as the terminal small intestine — but tends to present with generalized colitis. Some patients present acutely with severe disease, but more often both disease states progress slowly with intermittent flares leading to the need for eventual surgical treatment.\\n\\nThe patient and the gastroenterologists view surgery for inflammatory bowel disease as a failure of medical therapy. Thus, many of these patients have spent much of their lives attempting to avoid surgery at all costs. It is for this reason that most patients with inflammatory bowel disease are on multiple immunosuppressive medications and can be severely debilitated by the time a surgeon is consulted to consider an operation. It is important to remember that:\\n\\n- **Crohn’s disease (CD)** is a transmural process, is not curable, and that surgical therapy is aimed at palliating the patient’s symptoms and controlling active infections and severe disease.\\n- **Ulcerative colitis**, on the other hand, affects the mucosa only and is...\\n```\\n\\n*Note: The text extraction is complete, but the page seems to be cut off at the end. If there are any images, graphs, or tables on this page, please provide them for further extraction and description.*',\n", " 'bBox': {'x': 72, 'y': 222, 'w': 467.63, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Bashar Safar and Jonathan Efron '}]},\n", " {'page': 441,\n", " 'text': ' • confined to the colon and rectum. When the entire colon is inflamed,\\n the surface area is very large and results in generalized sickness.\\n Removal of the large intestine results in cure.\\n\\n A few words on medical therapy\\n\\n As mentioned, gastroenterologists view surgery as failure of medical\\ntherapy and measure their success by the length of time without bowel\\nresection. The best gastroenterologists are those that know when to\\nthrow in the towel and clearly state to the patient “it is time for your\\ncolon to be removed” — the opposite is depicted in Figure 26.1...\\n 00\\n 9ug\\n Rerva1l\\nFigure 26.1. “Pancolitis, eh? Shouldn’t we increase the steroids and add Imuran®?”\\n\\n Over the last two decades a variety of new medications have emerged\\nfor the treatment of inflammatory bowel disease — primarily a cornucopia\\nof anti-tumor necrosis factor (TNF) drugs. Most patients you see will have\\nbeen tried on anti-TNF drugs in combination with a purine inhibitor and\\nhigh doses of steroids. It is well known that taking steroids increases the\\nrisk of wound and septic complications. What is not so well known is the',\n", " 'md': '```markdown\\n## Medical Therapy for Inflammatory Bowel Disease\\n\\nWhen the entire colon is inflamed, the surface area is very large and results in generalized sickness. Removal of the large intestine results in a cure.\\n\\n### A Few Words on Medical Therapy\\n\\nAs mentioned, gastroenterologists view surgery as a failure of medical therapy and measure their success by the length of time without bowel resection. The best gastroenterologists are those that know when to throw in the towel and clearly state to the patient, “it is time for your colon to be removed” — the opposite is depicted in **Figure 26.1**.\\n\\n![Figure 26.1]()\\n**Figure 26.1:** “Pancolitis, eh? Shouldn’t we increase the steroids and add Imuran®?”\\n\\nOver the last two decades, a variety of new medications have emerged for the treatment of inflammatory bowel disease — primarily a cornucopia of anti-tumor necrosis factor (TNF) drugs. Most patients you see will have been tried on anti-TNF drugs in combination with a purine inhibitor and high doses of steroids. It is well known that taking steroids increases the risk of wound and septic complications. What is not so well known is the...\\n```',\n", " 'images': [{'name': 'img_p440_1.png',\n", " 'height': 571,\n", " 'width': 806,\n", " 'x': 106.56,\n", " 'y': 280.0799999999999,\n", " 'original_width': 1384,\n", " 'original_height': 980}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Medical Therapy for Inflammatory Bowel Disease',\n", " 'md': '## Medical Therapy for Inflammatory Bowel Disease',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'When the entire colon is inflamed, the surface area is very large and results in generalized sickness. Removal of the large intestine results in a cure.',\n", " 'md': 'When the entire colon is inflamed, the surface area is very large and results in generalized sickness. Removal of the large intestine results in a cure.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'A Few Words on Medical Therapy',\n", " 'md': '### A Few Words on Medical Therapy',\n", " 'bBox': {'x': 86, 'y': 164, 'w': 252.24, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As mentioned, gastroenterologists view surgery as a failure of medical therapy and measure their success by the length of time without bowel resection. The best gastroenterologists are those that know when to throw in the towel and clearly state to the patient, “it is time for your colon to be removed” — the opposite is depicted in **Figure 26.1**.\\n\\n![Figure 26.1]()\\n**Figure 26.1:** “Pancolitis, eh? Shouldn’t we increase the steroids and add Imuran®?”\\n\\nOver the last two decades, a variety of new medications have emerged for the treatment of inflammatory bowel disease — primarily a cornucopia of anti-tumor necrosis factor (TNF) drugs. Most patients you see will have been tried on anti-TNF drugs in combination with a purine inhibitor and high doses of steroids. It is well known that taking steroids increases the risk of wound and septic complications. What is not so well known is the...\\n```',\n", " 'md': 'As mentioned, gastroenterologists view surgery as a failure of medical therapy and measure their success by the length of time without bowel resection. The best gastroenterologists are those that know when to throw in the towel and clearly state to the patient, “it is time for your colon to be removed” — the opposite is depicted in **Figure 26.1**.\\n\\n![Figure 26.1]()\\n**Figure 26.1:** “Pancolitis, eh? Shouldn’t we increase the steroids and add Imuran®?”\\n\\nOver the last two decades, a variety of new medications have emerged for the treatment of inflammatory bowel disease — primarily a cornucopia of anti-tumor necrosis factor (TNF) drugs. Most patients you see will have been tried on anti-TNF drugs in combination with a purine inhibitor and high doses of steroids. It is well known that taking steroids increases the risk of wound and septic complications. What is not so well known is the...\\n```',\n", " 'bBox': {'x': 72, 'y': 233, 'w': 467.63, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 442,\n", " 'text': 'effect that anti-TNF medications may have on surgical outcomes. Some\\nauthors have reported significant increases in infectious complications\\nand even mortality when operating on patients receiving such medication;\\nothers have refuted this. Be that as it may, there is little doubt that a\\npatient with severe colitis who requires urgent surgery, and who is\\non multiple immunosuppressive medications, has increased\\nmorbidity and mortality as compared to those who are not. It is for\\nthis reason that it is crucial for the gastroenterologist and the surgeon to\\nhave an excellent working relationship and be in constant communication\\nwhen managing patients with acute colitis.\\n\\n Surgeons are consulted to see patients with colitis in two\\ndifferent scenarios: in the office, or in the hospital. In the office,\\npatients are referred due to failure of medical therapy, complications of\\nthe disease or concern for malignancy. In the hospital, patients are\\nusually admitted due to a sudden deterioration and lack of response to\\nmedical therapy. It is always better for the patient to meet the surgeon as\\nan outpatient and have time to ask questions, understand what it means\\nto have surgery and be seen by a stoma nurse if needed.\\n\\n We request that a surgical consultation be obtained when a\\npatient is admitted for colitis even if the patient is not thought to\\nrequire surgery at the time of admission. Patients frequently have\\nmisconceptions regarding surgical outcomes and life with a stoma and\\nmay benefit from a clearer explanation of surgical options so that when\\nsurgery is required they are mentally prepared for the outcome.\\n\\n With escalating immunosuppression for the treatment of\\nulcerative colitis prior to surgical intervention, many patients now\\nsuffer superinfections with Clostridium difficile or Cytomegalovirus\\n(CMV). It is important to exclude these diagnoses in patients admitted\\nwith an exacerbation of ulcerative colitis. Clearly the treatment is very\\ndifferent if one of these infections is identified. Most acute exacerbations\\nof inflammatory bowel disease, whether Crohn’s or ulcerative colitis, are\\ntreated with high-dose steroids and tend to respond well. (Steroids,\\nhowever, should never be considered for maintenance therapy.) In the\\npresence of CMV or Clostridium difficile infection, the\\nimmunosuppression may need to be tailored, which makes taking care of',\n", " 'md': '```markdown\\n# Surgical Management of Colitis\\n\\nThe effect that anti-TNF medications may have on surgical outcomes is a topic of discussion. Some authors have reported significant increases in infectious complications and even mortality when operating on patients receiving such medication; others have refuted this. Be that as it may, there is little doubt that a patient with severe colitis who requires urgent surgery, and who is on multiple immunosuppressive medications, has increased morbidity and mortality compared to those who are not. It is for this reason that it is crucial for the gastroenterologist and the surgeon to have an excellent working relationship and be in constant communication when managing patients with acute colitis.\\n\\nSurgeons are consulted to see patients with colitis in two different scenarios: in the office or in the hospital. In the office, patients are referred due to failure of medical therapy, complications of the disease, or concern for malignancy. In the hospital, patients are usually admitted due to a sudden deterioration and lack of response to medical therapy. It is always better for the patient to meet the surgeon as an outpatient and have time to ask questions, understand what it means to have surgery, and be seen by a stoma nurse if needed.\\n\\nWe request that a surgical consultation be obtained when a patient is admitted for colitis even if the patient is not thought to require surgery at the time of admission. Patients frequently have misconceptions regarding surgical outcomes and life with a stoma and may benefit from a clearer explanation of surgical options so that when surgery is required, they are mentally prepared for the outcome.\\n\\nWith escalating immunosuppression for the treatment of ulcerative colitis prior to surgical intervention, many patients now suffer superinfections with Clostridium difficile or Cytomegalovirus (CMV). It is important to exclude these diagnoses in patients admitted with an exacerbation of ulcerative colitis. Clearly, the treatment is very different if one of these infections is identified. Most acute exacerbations of inflammatory bowel disease, whether Crohn’s or ulcerative colitis, are treated with high-dose steroids and tend to respond well. (Steroids, however, should never be considered for maintenance therapy.) In the presence of CMV or Clostridium difficile infection, the immunosuppression may need to be tailored, which makes taking care of the patient more complex.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Surgical Management of Colitis',\n", " 'md': '# Surgical Management of Colitis',\n", " 'bBox': {'x': 153, 'y': 539, 'w': 385.58, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The effect that anti-TNF medications may have on surgical outcomes is a topic of discussion. Some authors have reported significant increases in infectious complications and even mortality when operating on patients receiving such medication; others have refuted this. Be that as it may, there is little doubt that a patient with severe colitis who requires urgent surgery, and who is on multiple immunosuppressive medications, has increased morbidity and mortality compared to those who are not. It is for this reason that it is crucial for the gastroenterologist and the surgeon to have an excellent working relationship and be in constant communication when managing patients with acute colitis.\\n\\nSurgeons are consulted to see patients with colitis in two different scenarios: in the office or in the hospital. In the office, patients are referred due to failure of medical therapy, complications of the disease, or concern for malignancy. In the hospital, patients are usually admitted due to a sudden deterioration and lack of response to medical therapy. It is always better for the patient to meet the surgeon as an outpatient and have time to ask questions, understand what it means to have surgery, and be seen by a stoma nurse if needed.\\n\\nWe request that a surgical consultation be obtained when a patient is admitted for colitis even if the patient is not thought to require surgery at the time of admission. Patients frequently have misconceptions regarding surgical outcomes and life with a stoma and may benefit from a clearer explanation of surgical options so that when surgery is required, they are mentally prepared for the outcome.\\n\\nWith escalating immunosuppression for the treatment of ulcerative colitis prior to surgical intervention, many patients now suffer superinfections with Clostridium difficile or Cytomegalovirus (CMV). It is important to exclude these diagnoses in patients admitted with an exacerbation of ulcerative colitis. Clearly, the treatment is very different if one of these infections is identified. Most acute exacerbations of inflammatory bowel disease, whether Crohn’s or ulcerative colitis, are treated with high-dose steroids and tend to respond well. (Steroids, however, should never be considered for maintenance therapy.) In the presence of CMV or Clostridium difficile infection, the immunosuppression may need to be tailored, which makes taking care of the patient more complex.\\n```',\n", " 'md': 'The effect that anti-TNF medications may have on surgical outcomes is a topic of discussion. Some authors have reported significant increases in infectious complications and even mortality when operating on patients receiving such medication; others have refuted this. Be that as it may, there is little doubt that a patient with severe colitis who requires urgent surgery, and who is on multiple immunosuppressive medications, has increased morbidity and mortality compared to those who are not. It is for this reason that it is crucial for the gastroenterologist and the surgeon to have an excellent working relationship and be in constant communication when managing patients with acute colitis.\\n\\nSurgeons are consulted to see patients with colitis in two different scenarios: in the office or in the hospital. In the office, patients are referred due to failure of medical therapy, complications of the disease, or concern for malignancy. In the hospital, patients are usually admitted due to a sudden deterioration and lack of response to medical therapy. It is always better for the patient to meet the surgeon as an outpatient and have time to ask questions, understand what it means to have surgery, and be seen by a stoma nurse if needed.\\n\\nWe request that a surgical consultation be obtained when a patient is admitted for colitis even if the patient is not thought to require surgery at the time of admission. Patients frequently have misconceptions regarding surgical outcomes and life with a stoma and may benefit from a clearer explanation of surgical options so that when surgery is required, they are mentally prepared for the outcome.\\n\\nWith escalating immunosuppression for the treatment of ulcerative colitis prior to surgical intervention, many patients now suffer superinfections with Clostridium difficile or Cytomegalovirus (CMV). It is important to exclude these diagnoses in patients admitted with an exacerbation of ulcerative colitis. Clearly, the treatment is very different if one of these infections is identified. Most acute exacerbations of inflammatory bowel disease, whether Crohn’s or ulcerative colitis, are treated with high-dose steroids and tend to respond well. (Steroids, however, should never be considered for maintenance therapy.) In the presence of CMV or Clostridium difficile infection, the immunosuppression may need to be tailored, which makes taking care of the patient more complex.\\n```',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.88, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 443,\n", " 'text': 'these patients very challenging. We find that, even when identified and\\ntreated appropriately, approximately 40% will still require\\ncolectomy.\\n\\n Colitis in the elderly deserves a special mention. Younger patients\\nwho have no other medical comorbidities are able to tolerate a much\\nbigger insult than elderly frail ones. With improved peri-operative care\\nand management of critically ill patients, mortality from colectomy in the\\nurgent setting is low. Elderly patients do not follow this treatment\\nparadigm and may require surgical intervention earlier if a favorable\\noutcome is to be achieved.\\n\\n When to operate? Severe colitis, fulminant colitis, and\\n toxic colitis-megacolon\\n\\n Patients with severe or fulminant colitis often do not appear\\novertly ‘septic’; however, close watching of these patients is\\nessential as they can ‘look well’ for long periods of time (days, even\\nweeks) but can deteriorate suddenly and progress onto toxic colitis.\\n\\n Patients with severe colitis require urgent colectomy, but waiting to\\nperform the operation in daylight hours is acceptable. On the other\\nhand, when patients progress to toxic colitis, surgical intervention\\nbecomes an emergency.\\n\\n When dealing with acute colitis there is really no difference in either the\\nsurgical or medical management of ulcerative colitis, Crohn’s colitis, or\\nindeterminate colitis; but when using the terms ‘severe colitis’ or\\n‘fulminant colitis’, most individuals are speaking about ulcerative colitis.\\n\\n To identify when and who to operate on with colitis, we need first\\nto provide some definitions:\\n\\n • Severe colitis: >5 bloody bowel movements a day, cramps, fever,\\n heart rate >90, anemia, raised ESR (≥30mm/hour).\\n • Fulminant colitis: >9 bloody bowel movements a day, continuous\\n bleeding, pain, signs of toxic symptoms (anorexia, fever,',\n", " 'md': '```markdown\\n## Colitis Management in Elderly Patients\\n\\nThese patients are very challenging. We find that, even when identified and treated appropriately, approximately 40% will still require colectomy.\\n\\nColitis in the elderly deserves a special mention. Younger patients who have no other medical comorbidities are able to tolerate a much bigger insult than elderly frail ones. With improved peri-operative care and management of critically ill patients, mortality from colectomy in the urgent setting is low. Elderly patients do not follow this treatment paradigm and may require surgical intervention earlier if a favorable outcome is to be achieved.\\n\\n### When to Operate?\\n\\nSevere colitis, fulminant colitis, and toxic colitis-megacolon.\\n\\nPatients with severe or fulminant colitis often do not appear overtly ‘septic’; however, close watching of these patients is essential as they can ‘look well’ for long periods of time (days, even weeks) but can deteriorate suddenly and progress onto toxic colitis.\\n\\nPatients with severe colitis require urgent colectomy, but waiting to perform the operation in daylight hours is acceptable. On the other hand, when patients progress to toxic colitis, surgical intervention becomes an emergency.\\n\\nWhen dealing with acute colitis, there is really no difference in either the surgical or medical management of ulcerative colitis, Crohn’s colitis, or indeterminate colitis; but when using the terms ‘severe colitis’ or ‘fulminant colitis’, most individuals are speaking about ulcerative colitis.\\n\\nTo identify when and who to operate on with colitis, we need first to provide some definitions:\\n\\n- **Severe colitis**: >5 bloody bowel movements a day, cramps, fever, heart rate >90, anemia, raised ESR (≥30mm/hour).\\n- **Fulminant colitis**: >9 bloody bowel movements a day, continuous bleeding, pain, signs of toxic symptoms (anorexia, fever, ).\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Colitis Management in Elderly Patients',\n", " 'md': '## Colitis Management in Elderly Patients',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'These patients are very challenging. We find that, even when identified and treated appropriately, approximately 40% will still require colectomy.\\n\\nColitis in the elderly deserves a special mention. Younger patients who have no other medical comorbidities are able to tolerate a much bigger insult than elderly frail ones. With improved peri-operative care and management of critically ill patients, mortality from colectomy in the urgent setting is low. Elderly patients do not follow this treatment paradigm and may require surgical intervention earlier if a favorable outcome is to be achieved.',\n", " 'md': 'These patients are very challenging. We find that, even when identified and treated appropriately, approximately 40% will still require colectomy.\\n\\nColitis in the elderly deserves a special mention. Younger patients who have no other medical comorbidities are able to tolerate a much bigger insult than elderly frail ones. With improved peri-operative care and management of critically ill patients, mortality from colectomy in the urgent setting is low. Elderly patients do not follow this treatment paradigm and may require surgical intervention earlier if a favorable outcome is to be achieved.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.81, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'When to Operate?',\n", " 'md': '### When to Operate?',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Severe colitis, fulminant colitis, and toxic colitis-megacolon.\\n\\nPatients with severe or fulminant colitis often do not appear overtly ‘septic’; however, close watching of these patients is essential as they can ‘look well’ for long periods of time (days, even weeks) but can deteriorate suddenly and progress onto toxic colitis.\\n\\nPatients with severe colitis require urgent colectomy, but waiting to perform the operation in daylight hours is acceptable. On the other hand, when patients progress to toxic colitis, surgical intervention becomes an emergency.\\n\\nWhen dealing with acute colitis, there is really no difference in either the surgical or medical management of ulcerative colitis, Crohn’s colitis, or indeterminate colitis; but when using the terms ‘severe colitis’ or ‘fulminant colitis’, most individuals are speaking about ulcerative colitis.\\n\\nTo identify when and who to operate on with colitis, we need first to provide some definitions:\\n\\n- **Severe colitis**: >5 bloody bowel movements a day, cramps, fever, heart rate >90, anemia, raised ESR (≥30mm/hour).\\n- **Fulminant colitis**: >9 bloody bowel movements a day, continuous bleeding, pain, signs of toxic symptoms (anorexia, fever, ).\\n```',\n", " 'md': 'Severe colitis, fulminant colitis, and toxic colitis-megacolon.\\n\\nPatients with severe or fulminant colitis often do not appear overtly ‘septic’; however, close watching of these patients is essential as they can ‘look well’ for long periods of time (days, even weeks) but can deteriorate suddenly and progress onto toxic colitis.\\n\\nPatients with severe colitis require urgent colectomy, but waiting to perform the operation in daylight hours is acceptable. On the other hand, when patients progress to toxic colitis, surgical intervention becomes an emergency.\\n\\nWhen dealing with acute colitis, there is really no difference in either the surgical or medical management of ulcerative colitis, Crohn’s colitis, or indeterminate colitis; but when using the terms ‘severe colitis’ or ‘fulminant colitis’, most individuals are speaking about ulcerative colitis.\\n\\nTo identify when and who to operate on with colitis, we need first to provide some definitions:\\n\\n- **Severe colitis**: >5 bloody bowel movements a day, cramps, fever, heart rate >90, anemia, raised ESR (≥30mm/hour).\\n- **Fulminant colitis**: >9 bloody bowel movements a day, continuous bleeding, pain, signs of toxic symptoms (anorexia, fever, ).\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.83, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 444,\n", " 'text': ' tachycardia).\\n • Toxic colitis-megacolon: a patient with fulminant colitis and\\n radiographic evidence of distension of the colon; transverse colon\\n >6cm in diameter or cecum >9cm in diameter. Only 1-5% of\\n patients with inflammatory bowel disease ever develop toxic\\n megacolon. (Clostridium difficile colitis on the other hand can result\\n in toxic colitis — manifesting with a massive colonic edema on CT\\n rather than a megacolon — in up to 3% and the incidence is rising.\\n Other causes of toxic megacolon are CMV colitis, Salmonella,\\n Shigella, Campylobacter, Entamoeba, and ischemic colitis. These\\n are all rare.)\\n\\n Truelove and Witts (Br Med J 1955; 2: 1041-8) developed an ulcerative\\ncolitis severity index which classifies the acute episode as mild, moderate\\nor severe (Google it up....). In Table 26.1, we bring our simplified\\nversion which is a helpful way of thinking about these patients.\\n Table 26.1. Grading the severity of ulcerative colitis.\\n Mild/moderate colitis Severe colitis\\n Temperature <38*€ >38*C\\n Pulse <90/min >90/min\\n Diarrhea Five per day or less Six per day or more\\n Blood in stool None or little Large amounts\\n Anemia None or mild Severe\\n Albumin >3g/L <3g/L\\n Abdominal pain None or some Severe\\n There are different algorithms for medically managing severe colitis,\\nbut from our point of view, if someone has severe colitis (moderate\\non the Truelove scale) we think that if they haven’t improved after 5\\ndays of medical management (whichever drugs the\\ngastroenterologists are using), they are not going to improve, and\\ncolectomy is recommended.',\n", " 'md': '```markdown\\n## Ulcerative Colitis Severity Index\\n\\n- **Toxic colitis-megacolon**: A patient with fulminant colitis and radiographic evidence of distension of the colon; transverse colon >6cm in diameter or cecum >9cm in diameter. Only 1-5% of patients with inflammatory bowel disease ever develop toxic megacolon. (Clostridium difficile colitis, on the other hand, can result in toxic colitis — manifesting with a massive colonic edema on CT rather than a megacolon — in up to 3% and the incidence is rising. Other causes of toxic megacolon are CMV colitis, Salmonella, Shigella, Campylobacter, Entamoeba, and ischemic colitis. These are all rare.)\\n\\n- Truelove and Witts (Br Med J 1955; 2: 1041-8) developed an ulcerative colitis severity index which classifies the acute episode as mild, moderate, or severe (Google it up....).\\n\\n### Table 26.1. Grading the Severity of Ulcerative Colitis\\n\\n| Severity Level | Mild/Moderate Colitis | Severe Colitis |\\n|---------------------------|-----------------------------|-----------------------------|\\n| Temperature | <38°C | >38°C |\\n| Pulse | <90/min | >90/min |\\n| Diarrhea | Five per day or less | Six per day or more |\\n| Blood in stool | None or little | Large amounts |\\n| Anemia | None or mild | Severe |\\n| Albumin | >3g/L | <3g/L |\\n| Abdominal pain | None or some | Severe |\\n\\nThere are different algorithms for medically managing severe colitis, but from our point of view, if someone has severe colitis (moderate on the Truelove scale), we think that if they haven’t improved after 5 days of medical management (whichever drugs the gastroenterologists are using), they are not going to improve, and colectomy is recommended.\\n```',\n", " 'images': [{'name': 'img_p443_1.png',\n", " 'height': 434,\n", " 'width': 818,\n", " 'x': 103.67999999999984,\n", " 'y': 354.96,\n", " 'original_width': 1404,\n", " 'original_height': 745}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Ulcerative Colitis Severity Index',\n", " 'md': '## Ulcerative Colitis Severity Index',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Toxic colitis-megacolon**: A patient with fulminant colitis and radiographic evidence of distension of the colon; transverse colon >6cm in diameter or cecum >9cm in diameter. Only 1-5% of patients with inflammatory bowel disease ever develop toxic megacolon. (Clostridium difficile colitis, on the other hand, can result in toxic colitis — manifesting with a massive colonic edema on CT rather than a megacolon — in up to 3% and the incidence is rising. Other causes of toxic megacolon are CMV colitis, Salmonella, Shigella, Campylobacter, Entamoeba, and ischemic colitis. These are all rare.)\\n\\n- Truelove and Witts (Br Med J 1955; 2: 1041-8) developed an ulcerative colitis severity index which classifies the acute episode as mild, moderate, or severe (Google it up....).',\n", " 'md': '- **Toxic colitis-megacolon**: A patient with fulminant colitis and radiographic evidence of distension of the colon; transverse colon >6cm in diameter or cecum >9cm in diameter. Only 1-5% of patients with inflammatory bowel disease ever develop toxic megacolon. (Clostridium difficile colitis, on the other hand, can result in toxic colitis — manifesting with a massive colonic edema on CT rather than a megacolon — in up to 3% and the incidence is rising. Other causes of toxic megacolon are CMV colitis, Salmonella, Shigella, Campylobacter, Entamoeba, and ischemic colitis. These are all rare.)\\n\\n- Truelove and Witts (Br Med J 1955; 2: 1041-8) developed an ulcerative colitis severity index which classifies the acute episode as mild, moderate, or severe (Google it up....).',\n", " 'bBox': {'x': 72, 'y': 204, 'w': 467.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 26.1. Grading the Severity of Ulcerative Colitis',\n", " 'md': '### Table 26.1. Grading the Severity of Ulcerative Colitis',\n", " 'bBox': {'x': 128, 'y': 651, 'w': 21.59, 'h': 14.4}},\n", " {'type': 'table',\n", " 'rows': [['Severity Level', 'Mild/Moderate Colitis', 'Severe Colitis'],\n", " ['Temperature', '<38°C', '>38°C'],\n", " ['Pulse', '<90/min', '>90/min'],\n", " ['Diarrhea', 'Five per day or less', 'Six per day or more'],\n", " ['Blood in stool', 'None or little', 'Large amounts'],\n", " ['Anemia', 'None or mild', 'Severe'],\n", " ['Albumin', '>3g/L', '<3g/L'],\n", " ['Abdominal pain', 'None or some', 'Severe']],\n", " 'md': '| Severity Level | Mild/Moderate Colitis | Severe Colitis |\\n|---------------------------|-----------------------------|-----------------------------|\\n| Temperature | <38°C | >38°C |\\n| Pulse | <90/min | >90/min |\\n| Diarrhea | Five per day or less | Six per day or more |\\n| Blood in stool | None or little | Large amounts |\\n| Anemia | None or mild | Severe |\\n| Albumin | >3g/L | <3g/L |\\n| Abdominal pain | None or some | Severe |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Severity Level\",\"Mild/Moderate Colitis\",\"Severe Colitis\"\\n\"Temperature\",\"<38°C\",\">38°C\"\\n\"Pulse\",\"<90/min\",\">90/min\"\\n\"Diarrhea\",\"Five per day or less\",\"Six per day or more\"\\n\"Blood in stool\",\"None or little\",\"Large amounts\"\\n\"Anemia\",\"None or mild\",\"Severe\"\\n\"Albumin\",\">3g/L\",\"<3g/L\"\\n\"Abdominal pain\",\"None or some\",\"Severe\"',\n", " 'bBox': {'x': 108.13, 'y': 399.45, 'w': 216.17, 'h': 15.82}},\n", " {'type': 'text',\n", " 'value': 'There are different algorithms for medically managing severe colitis, but from our point of view, if someone has severe colitis (moderate on the Truelove scale), we think that if they haven’t improved after 5 days of medical management (whichever drugs the gastroenterologists are using), they are not going to improve, and colectomy is recommended.\\n```',\n", " 'md': 'There are different algorithms for medically managing severe colitis, but from our point of view, if someone has severe colitis (moderate on the Truelove scale), we think that if they haven’t improved after 5 days of medical management (whichever drugs the gastroenterologists are using), they are not going to improve, and colectomy is recommended.\\n```',\n", " 'bBox': {'x': 72, 'y': 400.44, 'w': 466.72, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'version which is a helpful way of thinking about these patients.'}]},\n", " {'page': 445,\n", " 'text': ' With fulminant colitis (severe on the Truelove scale) we will allow 24\\nto 48 hours of further medical therapy with close observation, but will\\nrecommend surgery after that time or if they start to deteriorate. We\\nobtain daily X-rays on patients with fulminant colitis to look at their\\ntransverse colon and cecum to ensure they are not developing toxic\\nmegacolon. Patients with toxic megacolon belong in the operating\\nroom! As always, if a patient looks sick, or you feel they are\\ndeteriorating, and your little voice is saying “operate” — then\\noperate!\\n\\n When a patient is identified as having toxic megacolon, the colon\\nis thought to be at risk for imminent perforation. When toxic\\nmegacolon is suspected, an abdominal X-ray or CT scan should be\\nobtained as mentioned above. Particular attention should be paid to the\\ndiameter of the transverse colon (not the cecum!). A patient with colitis,\\nfever, tachycardia and distension of the transverse colon to greater\\nthan 6cm is at great risk for perforation and needs to be taken\\nimmediately to the operating room. Don’t be fooled by a benign\\nabdominal exam; by the time they develop peritoneal signs, it is\\nusually too late and they have already perforated. The cecum may\\nalso dilate but in acute colitis it is rare; however, a cecum greater than\\n9cm in diameter is also concerning. Indeed when we have encountered\\nperforations in patients with acute colitis, they have always been in the\\ntransverse colon. Why this occurs is a mystery to us.\\n\\n The operation for severe colitis, fulminant colitis, or toxic\\n megacolon\\n\\n These patients do not require bowel preparation; they are all usually\\nhaving diarrhea and haven’t been eating for a while (their colon contains\\nonly blood and mucus). If they are on steroids, and most of them are, or\\nhave received steroids in the last 6 months, they require a ‘stress dose’\\nof steroids at the time of induction of anesthesia. The patient should be\\nmarked for a right lower quadrant ileostomy prior to entering the\\noperating room by either the surgeon or an enterostomal therapist.\\n\\n In general, the procedure may be performed via either a laparoscopic',\n", " 'md': '```markdown\\n## Management of Fulminant Colitis and Toxic Megacolon\\n\\nWith fulminant colitis (severe on the Truelove scale), we will allow 24 to 48 hours of further medical therapy with close observation, but will recommend surgery after that time or if they start to deteriorate. We obtain daily X-rays on patients with fulminant colitis to look at their transverse colon and cecum to ensure they are not developing toxic megacolon. Patients with toxic megacolon belong in the operating room! As always, if a patient looks sick, or you feel they are deteriorating, and your little voice is saying “operate” — then operate!\\n\\nWhen a patient is identified as having toxic megacolon, the colon is thought to be at risk for imminent perforation. When toxic megacolon is suspected, an abdominal X-ray or CT scan should be obtained as mentioned above. Particular attention should be paid to the diameter of the transverse colon (not the cecum!). A patient with colitis, fever, tachycardia, and distension of the transverse colon to greater than 6 cm is at great risk for perforation and needs to be taken immediately to the operating room. Don’t be fooled by a benign abdominal exam; by the time they develop peritoneal signs, it is usually too late and they have already perforated. The cecum may also dilate but in acute colitis it is rare; however, a cecum greater than 9 cm in diameter is also concerning. Indeed, when we have encountered perforations in patients with acute colitis, they have always been in the transverse colon. Why this occurs is a mystery to us.\\n\\n### The Operation for Severe Colitis, Fulminant Colitis, or Toxic Megacolon\\n\\nThese patients do not require bowel preparation; they are all usually having diarrhea and haven’t been eating for a while (their colon contains only blood and mucus). If they are on steroids, and most of them are, or have received steroids in the last 6 months, they require a ‘stress dose’ of steroids at the time of induction of anesthesia. The patient should be marked for a right lower quadrant ileostomy prior to entering the operating room by either the surgeon or an enterostomal therapist.\\n\\nIn general, the procedure may be performed via either a laparoscopic...\\n```\\n\\n### Notes:\\n- No images or figures were identified on this page.\\n- All text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Fulminant Colitis and Toxic Megacolon',\n", " 'md': '## Management of Fulminant Colitis and Toxic Megacolon',\n", " 'bBox': {'x': 86, 'y': 531, 'w': 87.37, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'With fulminant colitis (severe on the Truelove scale), we will allow 24 to 48 hours of further medical therapy with close observation, but will recommend surgery after that time or if they start to deteriorate. We obtain daily X-rays on patients with fulminant colitis to look at their transverse colon and cecum to ensure they are not developing toxic megacolon. Patients with toxic megacolon belong in the operating room! As always, if a patient looks sick, or you feel they are deteriorating, and your little voice is saying “operate” — then operate!\\n\\nWhen a patient is identified as having toxic megacolon, the colon is thought to be at risk for imminent perforation. When toxic megacolon is suspected, an abdominal X-ray or CT scan should be obtained as mentioned above. Particular attention should be paid to the diameter of the transverse colon (not the cecum!). A patient with colitis, fever, tachycardia, and distension of the transverse colon to greater than 6 cm is at great risk for perforation and needs to be taken immediately to the operating room. Don’t be fooled by a benign abdominal exam; by the time they develop peritoneal signs, it is usually too late and they have already perforated. The cecum may also dilate but in acute colitis it is rare; however, a cecum greater than 9 cm in diameter is also concerning. Indeed, when we have encountered perforations in patients with acute colitis, they have always been in the transverse colon. Why this occurs is a mystery to us.',\n", " 'md': 'With fulminant colitis (severe on the Truelove scale), we will allow 24 to 48 hours of further medical therapy with close observation, but will recommend surgery after that time or if they start to deteriorate. We obtain daily X-rays on patients with fulminant colitis to look at their transverse colon and cecum to ensure they are not developing toxic megacolon. Patients with toxic megacolon belong in the operating room! As always, if a patient looks sick, or you feel they are deteriorating, and your little voice is saying “operate” — then operate!\\n\\nWhen a patient is identified as having toxic megacolon, the colon is thought to be at risk for imminent perforation. When toxic megacolon is suspected, an abdominal X-ray or CT scan should be obtained as mentioned above. Particular attention should be paid to the diameter of the transverse colon (not the cecum!). A patient with colitis, fever, tachycardia, and distension of the transverse colon to greater than 6 cm is at great risk for perforation and needs to be taken immediately to the operating room. Don’t be fooled by a benign abdominal exam; by the time they develop peritoneal signs, it is usually too late and they have already perforated. The cecum may also dilate but in acute colitis it is rare; however, a cecum greater than 9 cm in diameter is also concerning. Indeed, when we have encountered perforations in patients with acute colitis, they have always been in the transverse colon. Why this occurs is a mystery to us.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.86, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Operation for Severe Colitis, Fulminant Colitis, or Toxic Megacolon',\n", " 'md': '### The Operation for Severe Colitis, Fulminant Colitis, or Toxic Megacolon',\n", " 'bBox': {'x': 86, 'y': 512, 'w': 452.64, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'These patients do not require bowel preparation; they are all usually having diarrhea and haven’t been eating for a while (their colon contains only blood and mucus). If they are on steroids, and most of them are, or have received steroids in the last 6 months, they require a ‘stress dose’ of steroids at the time of induction of anesthesia. The patient should be marked for a right lower quadrant ileostomy prior to entering the operating room by either the surgeon or an enterostomal therapist.\\n\\nIn general, the procedure may be performed via either a laparoscopic...\\n```',\n", " 'md': 'These patients do not require bowel preparation; they are all usually having diarrhea and haven’t been eating for a while (their colon contains only blood and mucus). If they are on steroids, and most of them are, or have received steroids in the last 6 months, they require a ‘stress dose’ of steroids at the time of induction of anesthesia. The patient should be marked for a right lower quadrant ileostomy prior to entering the operating room by either the surgeon or an enterostomal therapist.\\n\\nIn general, the procedure may be performed via either a laparoscopic...\\n```',\n", " 'bBox': {'x': 72, 'y': 584, 'w': 467.98, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.\\n- All text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images or figures were identified on this page.\\n- All text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 446,\n", " 'text': 'or open technique. However, in septic patients, or those diagnosed\\nwith toxic megacolon, an open approach is quicker and safe, so the\\nword ‘laparoscope’ should not even enter into the conversation.\\nBut, if they are stable and are undergoing the procedure because of\\nfailed medical management, then we will attempt to remove the\\ncolon via a laparoscopic technique.\\n\\n The operation of choice for acute colitis is a total colectomy and\\nend ileostomy with division of the bowel at the rectosigmoid junction and\\nleaving the rectum as a ħartmann’s pouch that will be removed at a later\\ndate (when the patient is well) and an ileal J-pouch reconstruction is\\nperformed. There is no role for a restorative proctocolectomy with\\nileal pouch anal anastomosis or an ileorectal anastomosis in a\\npatient with acute colitis. Total abdominal colectomy is generally easier\\nin patients with ulcerative colitis as opposed to CD. The serosal surface\\nof the colon and mesentery in patients with ulcerative colitis is often, but\\nnot always, normal; whereas the mesentery in a patient with CD may be\\nthickened and quite difficult to manipulate or divide.\\n\\n A few words about technique\\n\\n The patient needs to be in either the modified lithotomy position or the\\nsplit-leg position to have access to the anus and rectum.\\n\\n The fact that a laparotomy is being performed indicates that the patient\\nis either sick or the colon or its mesentery is distended, thickened or\\ninflamed. Once the bowel is mobilized, division of a mesentery\\nthickened from CD can be difficult and bloody. We use Kocher\\nclamps with gentle clamping and large chromic sutures (zero or number\\none in thickness, i.e. liver sutures) placed in a u-stitch encompassing the\\nclamped mesentery.\\n\\n Who uses chromic nowadays? I thought it’s long out of the market… Danny\\n\\n Reply: I still use chromic for bad Crohn’s mesentery as described here. Jon\\n\\n Keep a hand under the clamp to catch and reclamp any bleeding that',\n", " 'md': \"```markdown\\n## Surgical Techniques for Acute Colitis\\n\\nIn septic patients or those diagnosed with toxic megacolon, an open approach is quicker and safer, so the word ‘laparoscope’ should not even enter into the conversation. However, if they are stable and are undergoing the procedure because of failed medical management, then we will attempt to remove the colon via a laparoscopic technique.\\n\\nThe operation of choice for acute colitis is a total colectomy and end ileostomy with division of the bowel at the rectosigmoid junction, leaving the rectum as a Hartmann’s pouch that will be removed at a later date (when the patient is well) and an ileal J-pouch reconstruction is performed. There is no role for a restorative proctocolectomy with ileal pouch anal anastomosis or an ileorectal anastomosis in a patient with acute colitis. Total abdominal colectomy is generally easier in patients with ulcerative colitis as opposed to Crohn's disease (CD). The serosal surface of the colon and mesentery in patients with ulcerative colitis is often, but not always, normal; whereas the mesentery in a patient with CD may be thickened and quite difficult to manipulate or divide.\\n\\n### A Few Words About Technique\\n\\nThe patient needs to be in either the modified lithotomy position or the split-leg position to have access to the anus and rectum.\\n\\nThe fact that a laparotomy is being performed indicates that the patient is either sick or the colon or its mesentery is distended, thickened, or inflamed. Once the bowel is mobilized, division of a mesentery thickened from CD can be difficult and bloody. We use Kocher clamps with gentle clamping and large chromic sutures (zero or number one in thickness, i.e., liver sutures) placed in a u-stitch encompassing the clamped mesentery.\\n\\n> **Discussion:**\\n>\\n> - **Danny:** Who uses chromic nowadays? I thought it’s long out of the market…\\n> - **Jon:** I still use chromic for bad Crohn’s mesentery as described here.\\n\\nKeep a hand under the clamp to catch and reclamp any bleeding that occurs.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Techniques for Acute Colitis',\n", " 'md': '## Surgical Techniques for Acute Colitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"In septic patients or those diagnosed with toxic megacolon, an open approach is quicker and safer, so the word ‘laparoscope’ should not even enter into the conversation. However, if they are stable and are undergoing the procedure because of failed medical management, then we will attempt to remove the colon via a laparoscopic technique.\\n\\nThe operation of choice for acute colitis is a total colectomy and end ileostomy with division of the bowel at the rectosigmoid junction, leaving the rectum as a Hartmann’s pouch that will be removed at a later date (when the patient is well) and an ileal J-pouch reconstruction is performed. There is no role for a restorative proctocolectomy with ileal pouch anal anastomosis or an ileorectal anastomosis in a patient with acute colitis. Total abdominal colectomy is generally easier in patients with ulcerative colitis as opposed to Crohn's disease (CD). The serosal surface of the colon and mesentery in patients with ulcerative colitis is often, but not always, normal; whereas the mesentery in a patient with CD may be thickened and quite difficult to manipulate or divide.\",\n", " 'md': \"In septic patients or those diagnosed with toxic megacolon, an open approach is quicker and safer, so the word ‘laparoscope’ should not even enter into the conversation. However, if they are stable and are undergoing the procedure because of failed medical management, then we will attempt to remove the colon via a laparoscopic technique.\\n\\nThe operation of choice for acute colitis is a total colectomy and end ileostomy with division of the bowel at the rectosigmoid junction, leaving the rectum as a Hartmann’s pouch that will be removed at a later date (when the patient is well) and an ileal J-pouch reconstruction is performed. There is no role for a restorative proctocolectomy with ileal pouch anal anastomosis or an ileorectal anastomosis in a patient with acute colitis. Total abdominal colectomy is generally easier in patients with ulcerative colitis as opposed to Crohn's disease (CD). The serosal surface of the colon and mesentery in patients with ulcerative colitis is often, but not always, normal; whereas the mesentery in a patient with CD may be thickened and quite difficult to manipulate or divide.\",\n", " 'bBox': {'x': 72, 'y': 168, 'w': 467.43, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'A Few Words About Technique',\n", " 'md': '### A Few Words About Technique',\n", " 'bBox': {'x': 86, 'y': 412, 'w': 229.25, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The patient needs to be in either the modified lithotomy position or the split-leg position to have access to the anus and rectum.\\n\\nThe fact that a laparotomy is being performed indicates that the patient is either sick or the colon or its mesentery is distended, thickened, or inflamed. Once the bowel is mobilized, division of a mesentery thickened from CD can be difficult and bloody. We use Kocher clamps with gentle clamping and large chromic sutures (zero or number one in thickness, i.e., liver sutures) placed in a u-stitch encompassing the clamped mesentery.\\n\\n> **Discussion:**\\n>\\n> - **Danny:** Who uses chromic nowadays? I thought it’s long out of the market…\\n> - **Jon:** I still use chromic for bad Crohn’s mesentery as described here.\\n\\nKeep a hand under the clamp to catch and reclamp any bleeding that occurs.\\n```',\n", " 'md': 'The patient needs to be in either the modified lithotomy position or the split-leg position to have access to the anus and rectum.\\n\\nThe fact that a laparotomy is being performed indicates that the patient is either sick or the colon or its mesentery is distended, thickened, or inflamed. Once the bowel is mobilized, division of a mesentery thickened from CD can be difficult and bloody. We use Kocher clamps with gentle clamping and large chromic sutures (zero or number one in thickness, i.e., liver sutures) placed in a u-stitch encompassing the clamped mesentery.\\n\\n> **Discussion:**\\n>\\n> - **Danny:** Who uses chromic nowadays? I thought it’s long out of the market…\\n> - **Jon:** I still use chromic for bad Crohn’s mesentery as described here.\\n\\nKeep a hand under the clamp to catch and reclamp any bleeding that occurs.\\n```',\n", " 'bBox': {'x': 72, 'y': 448, 'w': 468, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 447,\n", " 'text': 'occurs when securing the suture. Crohn’s blood vessels often retract and\\ncan quickly bleed into the mesentery creating a large mesenteric\\nhematoma that is difficult to manage.\\n\\n Management of the rectum in ulcerative and\\n indeterminate colitis\\n\\n The closure of the divided rectum (at the rectosigmoid junction) is\\nprone to leakage. When the rectum is severely inflamed the stapler will\\nactually cut its wall. Thus, we prefer to close the thickened and inflamed\\nwall with large absorbable sutures in an interrupted and simple fashion\\ntaking big, full-thickness bites of the bowel wall. We then irrigate the\\nstump and leave a rectal tube. In addition, we leave drains above the\\nstump.\\n\\n If we are really concerned about the rectal stump we sometimes look at\\nthe distal sigmoid colon to see whether it is less inflamed. If so, leaving\\n10cm of sigmoid generally does not cause issues for the patient and\\nallows us to exteriorize the colonic stump as a mucous fistula. At this\\npoint we would consider this a subtotal colectomy. We experience\\none or two rectal stump leaks a year and these patients often require\\nreoperation because of peritonitis, so if you are concerned, think\\nmucous fistula. We do not find leaving 10cm of sigmoid colon worsens\\nrectal drainage, bleeding, or septic symptoms. The dividing point should\\nbe soft and pliable if possible and should not tear when placing the\\nstapler. Some people would bring out the mucous fistula at the lowermost\\nend of the midline incision. But this could increase the risk of wound\\ncomplications and we recommend against this.\\n\\n Try not to leave a short rectal stump. Short ħartmann’s pouches are\\ndifficult to isolate, either to reverse with an ileorectal anastomosis, or to\\nexcise because of persistent symptoms (bleeding, drainage, or fistulizing\\ndisease). The bladder (right at the level of the trigone and therefore the\\nureters) tends to drape over the short stump making it difficult to find.\\nThis has resulted in bladder and ureteral injuries in our hands so we hate\\nshort rectal stumps!',\n", " 'md': '```markdown\\n## Management of the Rectum in Ulcerative and Indeterminate Colitis\\n\\nThe closure of the divided rectum (at the rectosigmoid junction) is prone to leakage. When the rectum is severely inflamed, the stapler will actually cut its wall. Thus, we prefer to close the thickened and inflamed wall with large absorbable sutures in an interrupted and simple fashion, taking big, full-thickness bites of the bowel wall. We then irrigate the stump and leave a rectal tube. In addition, we leave drains above the stump.\\n\\nIf we are really concerned about the rectal stump, we sometimes look at the distal sigmoid colon to see whether it is less inflamed. If so, leaving 10 cm of sigmoid generally does not cause issues for the patient and allows us to exteriorize the colonic stump as a mucous fistula. At this point, we would consider this a subtotal colectomy. We experience one or two rectal stump leaks a year, and these patients often require reoperation because of peritonitis, so if you are concerned, think mucous fistula. We do not find leaving 10 cm of sigmoid colon worsens rectal drainage, bleeding, or septic symptoms. The dividing point should be soft and pliable if possible and should not tear when placing the stapler. Some people would bring out the mucous fistula at the lowermost end of the midline incision. But this could increase the risk of wound complications, and we recommend against this.\\n\\nTry not to leave a short rectal stump. Short Hartmann’s pouches are difficult to isolate, either to reverse with an ileorectal anastomosis or to excise because of persistent symptoms (bleeding, drainage, or fistulizing disease). The bladder (right at the level of the trigone and therefore the ureters) tends to drape over the short stump, making it difficult to find. This has resulted in bladder and ureteral injuries in our hands, so we hate short rectal stumps!\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of the Rectum in Ulcerative and Indeterminate Colitis',\n", " 'md': '## Management of the Rectum in Ulcerative and Indeterminate Colitis',\n", " 'bBox': {'x': 86, 'y': 162, 'w': 160.9, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The closure of the divided rectum (at the rectosigmoid junction) is prone to leakage. When the rectum is severely inflamed, the stapler will actually cut its wall. Thus, we prefer to close the thickened and inflamed wall with large absorbable sutures in an interrupted and simple fashion, taking big, full-thickness bites of the bowel wall. We then irrigate the stump and leave a rectal tube. In addition, we leave drains above the stump.\\n\\nIf we are really concerned about the rectal stump, we sometimes look at the distal sigmoid colon to see whether it is less inflamed. If so, leaving 10 cm of sigmoid generally does not cause issues for the patient and allows us to exteriorize the colonic stump as a mucous fistula. At this point, we would consider this a subtotal colectomy. We experience one or two rectal stump leaks a year, and these patients often require reoperation because of peritonitis, so if you are concerned, think mucous fistula. We do not find leaving 10 cm of sigmoid colon worsens rectal drainage, bleeding, or septic symptoms. The dividing point should be soft and pliable if possible and should not tear when placing the stapler. Some people would bring out the mucous fistula at the lowermost end of the midline incision. But this could increase the risk of wound complications, and we recommend against this.\\n\\nTry not to leave a short rectal stump. Short Hartmann’s pouches are difficult to isolate, either to reverse with an ileorectal anastomosis or to excise because of persistent symptoms (bleeding, drainage, or fistulizing disease). The bladder (right at the level of the trigone and therefore the ureters) tends to drape over the short stump, making it difficult to find. This has resulted in bladder and ureteral injuries in our hands, so we hate short rectal stumps!\\n```',\n", " 'md': 'The closure of the divided rectum (at the rectosigmoid junction) is prone to leakage. When the rectum is severely inflamed, the stapler will actually cut its wall. Thus, we prefer to close the thickened and inflamed wall with large absorbable sutures in an interrupted and simple fashion, taking big, full-thickness bites of the bowel wall. We then irrigate the stump and leave a rectal tube. In addition, we leave drains above the stump.\\n\\nIf we are really concerned about the rectal stump, we sometimes look at the distal sigmoid colon to see whether it is less inflamed. If so, leaving 10 cm of sigmoid generally does not cause issues for the patient and allows us to exteriorize the colonic stump as a mucous fistula. At this point, we would consider this a subtotal colectomy. We experience one or two rectal stump leaks a year, and these patients often require reoperation because of peritonitis, so if you are concerned, think mucous fistula. We do not find leaving 10 cm of sigmoid colon worsens rectal drainage, bleeding, or septic symptoms. The dividing point should be soft and pliable if possible and should not tear when placing the stapler. Some people would bring out the mucous fistula at the lowermost end of the midline incision. But this could increase the risk of wound complications, and we recommend against this.\\n\\nTry not to leave a short rectal stump. Short Hartmann’s pouches are difficult to isolate, either to reverse with an ileorectal anastomosis or to excise because of persistent symptoms (bleeding, drainage, or fistulizing disease). The bladder (right at the level of the trigone and therefore the ureters) tends to drape over the short stump, making it difficult to find. This has resulted in bladder and ureteral injuries in our hands, so we hate short rectal stumps!\\n```',\n", " 'bBox': {'x': 72, 'y': 162, 'w': 467.94, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 448,\n", " 'text': ' Emergency surgery for Crohn’s disease (CD)\\n\\n The need for an emergency operation in CD should be rare indeed.\\nThere are a few patients with acute colitis, which is clinically\\nindistinguishable from acute ulcerative colitis and thus handled along the\\nsame lines as described above — unless the colitis is segmental (see\\nbelow). Most of the time, however, the course and anatomical\\nappearance of the colitis suggest that it is CD rather than ulcerative\\ncolitis. When small bowel is involved a diagnosis of CD is obvious.\\n\\n CD of any portion of the GI tract presents initially as inflammation\\nof a segment of bowel that eventually goes on to develop into either\\nperforating disease or obstructing disease. These two distinct\\nmanifestations are not independent of each other as some patients\\nperforate due to obstruction and others obstruct from severe\\ninflammation and infection.\\n\\n The principles of management are the same no matter which\\npiece of bowel is involved. Controlling sepsis is a most important\\nprinciple in the management of these patients, be it around the anus or in\\nthe abdomen. Another cardinal principle is the need for intestinal\\neconomy. CD patients will not be cured by the operation — only palliated\\n— and may need additional operations in the future. Thus, choosing the\\nmost ‘bowel-sparing’ operation and its timing makes a difference to the\\nfuture quality of life.\\n\\n Intestinal perforations in CD\\n\\n The management in such patients depends on the clinical presentation\\nand the imaging findings.\\n\\n Patients with localized perforation require percutaneous drainage\\nby interventional radiology as a first step. Once the acute perforation\\nis controlled, many patients are able to avoid an operation and may be\\nstarted on anti-Crohn’s therapy. If a fistula develops and becomes\\nchronic, surgery is inevitable. Recent data suggest that delaying\\nsurgery for perforating Crohn’s disease may in fact result in an increased',\n", " 'md': '```markdown\\n# Emergency Surgery for Crohn’s Disease (CD)\\n\\nThe need for an emergency operation in CD should be rare indeed. There are a few patients with acute colitis, which is clinically indistinguishable from acute ulcerative colitis and thus handled along the same lines as described above — unless the colitis is segmental (see below). Most of the time, however, the course and anatomical appearance of the colitis suggest that it is CD rather than ulcerative colitis. When small bowel is involved, a diagnosis of CD is obvious.\\n\\nCD of any portion of the GI tract presents initially as inflammation of a segment of bowel that eventually goes on to develop into either perforating disease or obstructing disease. These two distinct manifestations are not independent of each other as some patients perforate due to obstruction and others obstruct from severe inflammation and infection.\\n\\nThe principles of management are the same no matter which piece of bowel is involved. Controlling sepsis is a most important principle in the management of these patients, be it around the anus or in the abdomen. Another cardinal principle is the need for intestinal economy. CD patients will not be cured by the operation — only palliated — and may need additional operations in the future. Thus, choosing the most ‘bowel-sparing’ operation and its timing makes a difference to the future quality of life.\\n\\n## Intestinal Perforations in CD\\n\\nThe management in such patients depends on the clinical presentation and the imaging findings.\\n\\nPatients with localized perforation require percutaneous drainage by interventional radiology as a first step. Once the acute perforation is controlled, many patients are able to avoid an operation and may be started on anti-Crohn’s therapy. If a fistula develops and becomes chronic, surgery is inevitable. Recent data suggest that delaying surgery for perforating Crohn’s disease may in fact result in an increased...\\n```\\n\\n### Notes:\\n- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Emergency Surgery for Crohn’s Disease (CD)',\n", " 'md': '# Emergency Surgery for Crohn’s Disease (CD)',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 352.51, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The need for an emergency operation in CD should be rare indeed. There are a few patients with acute colitis, which is clinically indistinguishable from acute ulcerative colitis and thus handled along the same lines as described above — unless the colitis is segmental (see below). Most of the time, however, the course and anatomical appearance of the colitis suggest that it is CD rather than ulcerative colitis. When small bowel is involved, a diagnosis of CD is obvious.\\n\\nCD of any portion of the GI tract presents initially as inflammation of a segment of bowel that eventually goes on to develop into either perforating disease or obstructing disease. These two distinct manifestations are not independent of each other as some patients perforate due to obstruction and others obstruct from severe inflammation and infection.\\n\\nThe principles of management are the same no matter which piece of bowel is involved. Controlling sepsis is a most important principle in the management of these patients, be it around the anus or in the abdomen. Another cardinal principle is the need for intestinal economy. CD patients will not be cured by the operation — only palliated — and may need additional operations in the future. Thus, choosing the most ‘bowel-sparing’ operation and its timing makes a difference to the future quality of life.',\n", " 'md': 'The need for an emergency operation in CD should be rare indeed. There are a few patients with acute colitis, which is clinically indistinguishable from acute ulcerative colitis and thus handled along the same lines as described above — unless the colitis is segmental (see below). Most of the time, however, the course and anatomical appearance of the colitis suggest that it is CD rather than ulcerative colitis. When small bowel is involved, a diagnosis of CD is obvious.\\n\\nCD of any portion of the GI tract presents initially as inflammation of a segment of bowel that eventually goes on to develop into either perforating disease or obstructing disease. These two distinct manifestations are not independent of each other as some patients perforate due to obstruction and others obstruct from severe inflammation and infection.\\n\\nThe principles of management are the same no matter which piece of bowel is involved. Controlling sepsis is a most important principle in the management of these patients, be it around the anus or in the abdomen. Another cardinal principle is the need for intestinal economy. CD patients will not be cured by the operation — only palliated — and may need additional operations in the future. Thus, choosing the most ‘bowel-sparing’ operation and its timing makes a difference to the future quality of life.',\n", " 'bBox': {'x': 72, 'y': 157, 'w': 467.92, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Intestinal Perforations in CD',\n", " 'md': '## Intestinal Perforations in CD',\n", " 'bBox': {'x': 86, 'y': 535, 'w': 221.57, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The management in such patients depends on the clinical presentation and the imaging findings.\\n\\nPatients with localized perforation require percutaneous drainage by interventional radiology as a first step. Once the acute perforation is controlled, many patients are able to avoid an operation and may be started on anti-Crohn’s therapy. If a fistula develops and becomes chronic, surgery is inevitable. Recent data suggest that delaying surgery for perforating Crohn’s disease may in fact result in an increased...\\n```',\n", " 'md': 'The management in such patients depends on the clinical presentation and the imaging findings.\\n\\nPatients with localized perforation require percutaneous drainage by interventional radiology as a first step. Once the acute perforation is controlled, many patients are able to avoid an operation and may be started on anti-Crohn’s therapy. If a fistula develops and becomes chronic, surgery is inevitable. Recent data suggest that delaying surgery for perforating Crohn’s disease may in fact result in an increased...\\n```',\n", " 'bBox': {'x': 72, 'y': 324, 'w': 467.73, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 449,\n", " 'text': 'number of structures involved in the inflammatory mass and increased\\npostoperative septic complications, therefore prompting the\\ngastroenterologist to consider consulting a surgeon soon after the\\nperforation is diagnosed. In general, if the patient improves and the pain\\nresolves, with a follow-up CT showing resolution of the inflammatory\\nmass, then medical therapy can be started safely. If not, surgery should\\nbe considered sooner rather than later.\\n\\n Patients with diffuse peritonitis (lack of localization on CT) need\\nan urgent laparotomy. Also, complex abscesses, which fail\\npercutaneous drainage, should be operated upon; the involved\\nsegment of bowel has to be resected.\\n\\n Multiple studies have confirmed that resections for CD should be\\nlimited to the grossly diseased bowel — histologically-free margins are\\nnot required. Whether to restore bowel continuity with an anastomosis, or\\nexteriorize the bowel ends as a double-barrel stoma, depends on the\\ncondition of the patient, his abdomen and the bowel ( Chapter 14). The\\nrisk of anastomotic failure is clearly higher in CD than in ordinary\\ncolorectal surgery. This is particularly true in CD patients that are\\noperated on for intestinal fistula or abscess, and those with several\\nprevious operations because of the inherent complexity of the anatomy. It\\nis important to avoid any inadvertent bowel injury because this increases\\nthe risk of postoperative perforation and fistula formation.\\n\\n The best option is often to bring out the bowel ends in a\\ncombined ileo-ileal or ileocolic stoma for later closure. Most\\nanastomotic failures necessitate a reoperation with resection of the failed\\nanastomosis and stoma formation. Be mindful that a failed\\nanastomosis in a CD patient will wipe out a year of that patient’s\\nsocial life and add two more operations in that period (see also\\nChapter 47).\\n\\n Management of the rectum in Crohn’s disease\\n\\n Crohn’s patients may have segmental colitis or pan proctocolitis.\\nWhen we operate on a patient for acute colitis we try to leave the rectum',\n", " 'md': \"```markdown\\n# Management of Inflammatory Masses and Surgical Considerations\\n\\nThe number of structures involved in the inflammatory mass and increased postoperative septic complications prompts the gastroenterologist to consider consulting a surgeon soon after the perforation is diagnosed. In general, if the patient improves and the pain resolves, with a follow-up CT showing resolution of the inflammatory mass, then medical therapy can be started safely. If not, surgery should be considered sooner rather than later.\\n\\nPatients with diffuse peritonitis (lack of localization on CT) need an urgent laparotomy. Also, complex abscesses, which fail percutaneous drainage, should be operated upon; the involved segment of bowel has to be resected.\\n\\nMultiple studies have confirmed that resections for Crohn's Disease (CD) should be limited to the grossly diseased bowel — histologically-free margins are not required. Whether to restore bowel continuity with an anastomosis, or exteriorize the bowel ends as a double-barrel stoma, depends on the condition of the patient, his abdomen, and the bowel (Chapter 14). The risk of anastomotic failure is clearly higher in CD than in ordinary colorectal surgery. This is particularly true in CD patients that are operated on for intestinal fistula or abscess, and those with several previous operations because of the inherent complexity of the anatomy. It is important to avoid any inadvertent bowel injury because this increases the risk of postoperative perforation and fistula formation.\\n\\nThe best option is often to bring out the bowel ends in a combined ileo-ileal or ileocolic stoma for later closure. Most anastomotic failures necessitate a reoperation with resection of the failed anastomosis and stoma formation. Be mindful that a failed anastomosis in a CD patient will wipe out a year of that patient’s social life and add two more operations in that period (see also Chapter 47).\\n\\n## Management of the Rectum in Crohn’s Disease\\n\\nCrohn’s patients may have segmental colitis or pan proctocolitis. When we operate on a patient for acute colitis, we try to leave the rectum.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management of Inflammatory Masses and Surgical Considerations',\n", " 'md': '# Management of Inflammatory Masses and Surgical Considerations',\n", " 'bBox': {'x': 167, 'y': 556, 'w': 28, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': \"The number of structures involved in the inflammatory mass and increased postoperative septic complications prompts the gastroenterologist to consider consulting a surgeon soon after the perforation is diagnosed. In general, if the patient improves and the pain resolves, with a follow-up CT showing resolution of the inflammatory mass, then medical therapy can be started safely. If not, surgery should be considered sooner rather than later.\\n\\nPatients with diffuse peritonitis (lack of localization on CT) need an urgent laparotomy. Also, complex abscesses, which fail percutaneous drainage, should be operated upon; the involved segment of bowel has to be resected.\\n\\nMultiple studies have confirmed that resections for Crohn's Disease (CD) should be limited to the grossly diseased bowel — histologically-free margins are not required. Whether to restore bowel continuity with an anastomosis, or exteriorize the bowel ends as a double-barrel stoma, depends on the condition of the patient, his abdomen, and the bowel (Chapter 14). The risk of anastomotic failure is clearly higher in CD than in ordinary colorectal surgery. This is particularly true in CD patients that are operated on for intestinal fistula or abscess, and those with several previous operations because of the inherent complexity of the anatomy. It is important to avoid any inadvertent bowel injury because this increases the risk of postoperative perforation and fistula formation.\\n\\nThe best option is often to bring out the bowel ends in a combined ileo-ileal or ileocolic stoma for later closure. Most anastomotic failures necessitate a reoperation with resection of the failed anastomosis and stoma formation. Be mindful that a failed anastomosis in a CD patient will wipe out a year of that patient’s social life and add two more operations in that period (see also Chapter 47).\",\n", " 'md': \"The number of structures involved in the inflammatory mass and increased postoperative septic complications prompts the gastroenterologist to consider consulting a surgeon soon after the perforation is diagnosed. In general, if the patient improves and the pain resolves, with a follow-up CT showing resolution of the inflammatory mass, then medical therapy can be started safely. If not, surgery should be considered sooner rather than later.\\n\\nPatients with diffuse peritonitis (lack of localization on CT) need an urgent laparotomy. Also, complex abscesses, which fail percutaneous drainage, should be operated upon; the involved segment of bowel has to be resected.\\n\\nMultiple studies have confirmed that resections for Crohn's Disease (CD) should be limited to the grossly diseased bowel — histologically-free margins are not required. Whether to restore bowel continuity with an anastomosis, or exteriorize the bowel ends as a double-barrel stoma, depends on the condition of the patient, his abdomen, and the bowel (Chapter 14). The risk of anastomotic failure is clearly higher in CD than in ordinary colorectal surgery. This is particularly true in CD patients that are operated on for intestinal fistula or abscess, and those with several previous operations because of the inherent complexity of the anatomy. It is important to avoid any inadvertent bowel injury because this increases the risk of postoperative perforation and fistula formation.\\n\\nThe best option is often to bring out the bowel ends in a combined ileo-ileal or ileocolic stoma for later closure. Most anastomotic failures necessitate a reoperation with resection of the failed anastomosis and stoma formation. Be mindful that a failed anastomosis in a CD patient will wipe out a year of that patient’s social life and add two more operations in that period (see also Chapter 47).\",\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.85, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of the Rectum in Crohn’s Disease',\n", " 'md': '## Management of the Rectum in Crohn’s Disease',\n", " 'bBox': {'x': 86, 'y': 102, 'w': 453, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Crohn’s patients may have segmental colitis or pan proctocolitis. When we operate on a patient for acute colitis, we try to leave the rectum.\\n```',\n", " 'md': 'Crohn’s patients may have segmental colitis or pan proctocolitis. When we operate on a patient for acute colitis, we try to leave the rectum.\\n```',\n", " 'bBox': {'x': 86, 'y': 102, 'w': 453, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'risk of anastomotic failure is clearly higher in CD than in ordinary'},\n", " {'text': 'Chapter 47).'}]},\n", " {'page': 450,\n", " 'text': 'in place. The above mentioned techniques for closing the rectal stump\\nare very helpful when the rectum is inflamed from CD. Adding a\\nproctectomy to the colectomy in a Crohn’s patient with severe or\\nfulminant colitis adds to the operation and the blood loss and we try to\\nleave this for another time when the patient is healthy. If, however, you\\nare forced to perform an emergency proctectomy in a patient with\\nCD, then perform an intersphincteric dissection for the perineal part\\nof the operation. It requires a smaller incision with significantly improved\\nhealing. If you are planning to excise the rectum, make DAMN SURE the\\npatient has Crohn’s as you are committing this patient to a permanent\\nstoma.\\n\\n Special CD-related problems\\n\\n There are a few other instances, when emergency surgery is\\nconsidered in CD patients: small bowel obstruction, suspected\\nappendicitis and peri-anal disease.\\n\\n Small bowel obstruction (SBO)\\n SBO is common in patients with CD. Usually it is due to a narrow\\nsegment of diseased terminal ileum but it may be caused by a more\\nproximal stricture of a skip lesion. When the diagnosis of CD is known\\nyou should treat the obstructive episode conservatively: SBO in CD\\nis usually ‘simple obturation’ of the narrow segment and resolves\\nspontaneously — at least until the next exacerbation. In the absence of a\\nprevious diagnosis of CD, a careful history may reveal the typical\\nprevious abdominal symptoms, including episodes of transient\\nobstipation, and systemic signs of inflammation that are compatible with\\na diagnosis of CD. A CT showing typical segmental thickening of the\\nbowel wall and mesentery can provide the diagnosis. Conservative\\nmanagement of SBO is discussed in Chapter 21. Steroids will be\\nrequired.\\n\\n If you operate for SBO and find an inflamed and thickened\\nterminal ileum compatible with CD, what then? It is much better and\\nsimpler to operate on CD in the elective situation, when the bowel is\\nempty and its inside can be inspected for strictures with intra-operative',\n", " 'md': \"```markdown\\n## Current Page Content\\n\\nThe above mentioned techniques for closing the rectal stump are very helpful when the rectum is inflamed from Crohn's Disease (CD). Adding a proctectomy to the colectomy in a Crohn’s patient with severe or fulminant colitis adds to the operation and the blood loss, and we try to leave this for another time when the patient is healthy. If, however, you are forced to perform an emergency proctectomy in a patient with CD, then perform an intersphincteric dissection for the perineal part of the operation. It requires a smaller incision with significantly improved healing. If you are planning to excise the rectum, make DAMN SURE the patient has Crohn’s as you are committing this patient to a permanent stoma.\\n\\n### Special CD-related Problems\\n\\nThere are a few other instances when emergency surgery is considered in CD patients: small bowel obstruction, suspected appendicitis, and peri-anal disease.\\n\\n#### Small Bowel Obstruction (SBO)\\n\\nSBO is common in patients with CD. Usually, it is due to a narrow segment of diseased terminal ileum, but it may be caused by a more proximal stricture of a skip lesion. When the diagnosis of CD is known, you should treat the obstructive episode conservatively: SBO in CD is usually ‘simple obturation’ of the narrow segment and resolves spontaneously — at least until the next exacerbation. In the absence of a previous diagnosis of CD, a careful history may reveal the typical previous abdominal symptoms, including episodes of transient obstipation, and systemic signs of inflammation that are compatible with a diagnosis of CD. A CT showing typical segmental thickening of the bowel wall and mesentery can provide the diagnosis. Conservative management of SBO is discussed in Chapter 21. Steroids will be required.\\n\\nIf you operate for SBO and find an inflamed and thickened terminal ileum compatible with CD, what then? It is much better and simpler to operate on CD in the elective situation, when the bowel is empty and its inside can be inspected for strictures with intra-operative...\\n\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"The above mentioned techniques for closing the rectal stump are very helpful when the rectum is inflamed from Crohn's Disease (CD). Adding a proctectomy to the colectomy in a Crohn’s patient with severe or fulminant colitis adds to the operation and the blood loss, and we try to leave this for another time when the patient is healthy. If, however, you are forced to perform an emergency proctectomy in a patient with CD, then perform an intersphincteric dissection for the perineal part of the operation. It requires a smaller incision with significantly improved healing. If you are planning to excise the rectum, make DAMN SURE the patient has Crohn’s as you are committing this patient to a permanent stoma.\",\n", " 'md': \"The above mentioned techniques for closing the rectal stump are very helpful when the rectum is inflamed from Crohn's Disease (CD). Adding a proctectomy to the colectomy in a Crohn’s patient with severe or fulminant colitis adds to the operation and the blood loss, and we try to leave this for another time when the patient is healthy. If, however, you are forced to perform an emergency proctectomy in a patient with CD, then perform an intersphincteric dissection for the perineal part of the operation. It requires a smaller incision with significantly improved healing. If you are planning to excise the rectum, make DAMN SURE the patient has Crohn’s as you are committing this patient to a permanent stoma.\",\n", " 'bBox': {'x': 72, 'y': 152, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Special CD-related Problems',\n", " 'md': '### Special CD-related Problems',\n", " 'bBox': {'x': 86, 'y': 294, 'w': 225.3, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'There are a few other instances when emergency surgery is considered in CD patients: small bowel obstruction, suspected appendicitis, and peri-anal disease.',\n", " 'md': 'There are a few other instances when emergency surgery is considered in CD patients: small bowel obstruction, suspected appendicitis, and peri-anal disease.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Small Bowel Obstruction (SBO)',\n", " 'md': '#### Small Bowel Obstruction (SBO)',\n", " 'bBox': {'x': 86, 'y': 402, 'w': 211.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'SBO is common in patients with CD. Usually, it is due to a narrow segment of diseased terminal ileum, but it may be caused by a more proximal stricture of a skip lesion. When the diagnosis of CD is known, you should treat the obstructive episode conservatively: SBO in CD is usually ‘simple obturation’ of the narrow segment and resolves spontaneously — at least until the next exacerbation. In the absence of a previous diagnosis of CD, a careful history may reveal the typical previous abdominal symptoms, including episodes of transient obstipation, and systemic signs of inflammation that are compatible with a diagnosis of CD. A CT showing typical segmental thickening of the bowel wall and mesentery can provide the diagnosis. Conservative management of SBO is discussed in Chapter 21. Steroids will be required.\\n\\nIf you operate for SBO and find an inflamed and thickened terminal ileum compatible with CD, what then? It is much better and simpler to operate on CD in the elective situation, when the bowel is empty and its inside can be inspected for strictures with intra-operative...\\n\\n```',\n", " 'md': 'SBO is common in patients with CD. Usually, it is due to a narrow segment of diseased terminal ileum, but it may be caused by a more proximal stricture of a skip lesion. When the diagnosis of CD is known, you should treat the obstructive episode conservatively: SBO in CD is usually ‘simple obturation’ of the narrow segment and resolves spontaneously — at least until the next exacerbation. In the absence of a previous diagnosis of CD, a careful history may reveal the typical previous abdominal symptoms, including episodes of transient obstipation, and systemic signs of inflammation that are compatible with a diagnosis of CD. A CT showing typical segmental thickening of the bowel wall and mesentery can provide the diagnosis. Conservative management of SBO is discussed in Chapter 21. Steroids will be required.\\n\\nIf you operate for SBO and find an inflamed and thickened terminal ileum compatible with CD, what then? It is much better and simpler to operate on CD in the elective situation, when the bowel is empty and its inside can be inspected for strictures with intra-operative...\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 456, 'w': 467.39, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 451,\n", " 'text': 'endoscopy. But now the bowel is obstructed and distended. ‘Run’ the\\nbowel to identify any skip lesion that is more proximal and make sure\\nthere is a passage through it, i.e. it is non-obstructing. Record any\\nproximal skip lesion in your notes but leave them untouched. Your task is\\nto deal with the acute SBO. Obstruction in CD is very rarely complete or\\nstrangulating, therefore, your best option is to close up the abdomen\\nand start the patient on steroids — thus sparing his bowel.\\n\\n Rarely you’ll be called to operate upon an acutely obstructed patient\\nwho failed conservative treatment. ħere the operative options are:\\nresection of the ileocecal region, stricturoplasty or a temporary proximal\\nloop ileostomy. When the last of these options is adopted the\\ninflammation is medically treated until the acute phase resolves and an\\nelective operation can deal permanently with the affected bowel.\\n\\n Acute appendicitis in CD\\n If you operate for suspected acute appendicitis ( Chapter 23) and\\nencounter changes that are compatible with CD of the terminal\\nileum and cecum (e.g. serosal inflammation, thickened mesentery),\\nwhat then? If the cecum is involved but the appendix appears normal,\\nthe best option is probably to leave it alone as appendectomy may result\\nin an enterocutaneous fistula. The patient is then treated with steroids.\\nAn ileocecal resection in that situation may provide you with the\\nhistological diagnosis but is unnecessary or could at least have been\\npostponed for several years. Almost every patient with an ileocolic\\nresection will develop recurrent Crohn’s inflammation of the anastomosis,\\nusually within a year; yet another reason not to be blasé about the\\nresection. But let’s not forget that CD patients may develop acute\\nappendicitis — which is treated with an appendectomy. In any case,\\nit is extremely important that the patient be made aware whether the\\nappendix has been removed or still lurks in his belly!\\n\\n Perineal Crohn’s disease\\n About a fifth of the CD population will develop an anal fistula\\nand/or an abscess at some time. About half of the abscesses and\\nfistulae appear to be similar in character to those that affect the non-\\nCrohn’s population. In the typical ‘perineal Crohn’s’, the abscess is large',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nEndoscopy. But now the bowel is obstructed and distended. ‘Run’ the bowel to identify any skip lesion that is more proximal and make sure there is a passage through it, i.e. it is non-obstructing. Record any proximal skip lesion in your notes but leave them untouched. Your task is to deal with the acute SBO. Obstruction in CD is very rarely complete or strangulating, therefore, your best option is to close up the abdomen and start the patient on steroids — thus sparing his bowel.\\n\\nRarely you’ll be called to operate upon an acutely obstructed patient who failed conservative treatment. Here the operative options are: resection of the ileocecal region, stricturoplasty or a temporary proximal loop ileostomy. When the last of these options is adopted the inflammation is medically treated until the acute phase resolves and an elective operation can deal permanently with the affected bowel.\\n\\n### Acute Appendicitis in CD\\n\\nIf you operate for suspected acute appendicitis (Chapter 23) and encounter changes that are compatible with CD of the terminal ileum and cecum (e.g. serosal inflammation, thickened mesentery), what then? If the cecum is involved but the appendix appears normal, the best option is probably to leave it alone as appendectomy may result in an enterocutaneous fistula. The patient is then treated with steroids. An ileocecal resection in that situation may provide you with the histological diagnosis but is unnecessary or could at least have been postponed for several years. Almost every patient with an ileocolic resection will develop recurrent Crohn’s inflammation of the anastomosis, usually within a year; yet another reason not to be blasé about the resection. But let’s not forget that CD patients may develop acute appendicitis — which is treated with an appendectomy. In any case, it is extremely important that the patient be made aware whether the appendix has been removed or still lurks in his belly!\\n\\n### Perineal Crohn’s Disease\\n\\nAbout a fifth of the CD population will develop an anal fistula and/or an abscess at some time. About half of the abscesses and fistulae appear to be similar in character to those that affect the non-Crohn’s population. In the typical ‘perineal Crohn’s’, the abscess is large.\\n\\n## Image Identification and Description\\n\\n*No images or figures were identified on this page.*\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Endoscopy. But now the bowel is obstructed and distended. ‘Run’ the bowel to identify any skip lesion that is more proximal and make sure there is a passage through it, i.e. it is non-obstructing. Record any proximal skip lesion in your notes but leave them untouched. Your task is to deal with the acute SBO. Obstruction in CD is very rarely complete or strangulating, therefore, your best option is to close up the abdomen and start the patient on steroids — thus sparing his bowel.\\n\\nRarely you’ll be called to operate upon an acutely obstructed patient who failed conservative treatment. Here the operative options are: resection of the ileocecal region, stricturoplasty or a temporary proximal loop ileostomy. When the last of these options is adopted the inflammation is medically treated until the acute phase resolves and an elective operation can deal permanently with the affected bowel.',\n", " 'md': 'Endoscopy. But now the bowel is obstructed and distended. ‘Run’ the bowel to identify any skip lesion that is more proximal and make sure there is a passage through it, i.e. it is non-obstructing. Record any proximal skip lesion in your notes but leave them untouched. Your task is to deal with the acute SBO. Obstruction in CD is very rarely complete or strangulating, therefore, your best option is to close up the abdomen and start the patient on steroids — thus sparing his bowel.\\n\\nRarely you’ll be called to operate upon an acutely obstructed patient who failed conservative treatment. Here the operative options are: resection of the ileocecal region, stricturoplasty or a temporary proximal loop ileostomy. When the last of these options is adopted the inflammation is medically treated until the acute phase resolves and an elective operation can deal permanently with the affected bowel.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.9, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Acute Appendicitis in CD',\n", " 'md': '### Acute Appendicitis in CD',\n", " 'bBox': {'x': 86, 'y': 342, 'w': 169.44, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'If you operate for suspected acute appendicitis (Chapter 23) and encounter changes that are compatible with CD of the terminal ileum and cecum (e.g. serosal inflammation, thickened mesentery), what then? If the cecum is involved but the appendix appears normal, the best option is probably to leave it alone as appendectomy may result in an enterocutaneous fistula. The patient is then treated with steroids. An ileocecal resection in that situation may provide you with the histological diagnosis but is unnecessary or could at least have been postponed for several years. Almost every patient with an ileocolic resection will develop recurrent Crohn’s inflammation of the anastomosis, usually within a year; yet another reason not to be blasé about the resection. But let’s not forget that CD patients may develop acute appendicitis — which is treated with an appendectomy. In any case, it is extremely important that the patient be made aware whether the appendix has been removed or still lurks in his belly!',\n", " 'md': 'If you operate for suspected acute appendicitis (Chapter 23) and encounter changes that are compatible with CD of the terminal ileum and cecum (e.g. serosal inflammation, thickened mesentery), what then? If the cecum is involved but the appendix appears normal, the best option is probably to leave it alone as appendectomy may result in an enterocutaneous fistula. The patient is then treated with steroids. An ileocecal resection in that situation may provide you with the histological diagnosis but is unnecessary or could at least have been postponed for several years. Almost every patient with an ileocolic resection will develop recurrent Crohn’s inflammation of the anastomosis, usually within a year; yet another reason not to be blasé about the resection. But let’s not forget that CD patients may develop acute appendicitis — which is treated with an appendectomy. In any case, it is extremely important that the patient be made aware whether the appendix has been removed or still lurks in his belly!',\n", " 'bBox': {'x': 72, 'y': 363, 'w': 467.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Perineal Crohn’s Disease',\n", " 'md': '### Perineal Crohn’s Disease',\n", " 'bBox': {'x': 86, 'y': 633, 'w': 170.83, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'About a fifth of the CD population will develop an anal fistula and/or an abscess at some time. About half of the abscesses and fistulae appear to be similar in character to those that affect the non-Crohn’s population. In the typical ‘perineal Crohn’s’, the abscess is large.',\n", " 'md': 'About a fifth of the CD population will develop an anal fistula and/or an abscess at some time. About half of the abscesses and fistulae appear to be similar in character to those that affect the non-Crohn’s population. In the typical ‘perineal Crohn’s’, the abscess is large.',\n", " 'bBox': {'x': 72, 'y': 704, 'w': 467.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*\\n```',\n", " 'md': '*No images or figures were identified on this page.*\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'encounter changes that are compatible with CD of the terminal'}]},\n", " {'page': 452,\n", " 'text': 'with significant induration of the perianal area. The fistula is typically high,\\nabove the external sphincter, and has extensions. Not uncommonly, the\\nexternal opening is far away from the anal orifice, not the usual 3-4cm\\nseen in cryptogenic fistula. There may be more than one external\\nopening. There may be an undermining ‘sea of pus’. There is often\\nassociated proctitis — a reason to do rectoscopy as part of the pre-\\noperative evaluation. Pain can be significant and, if so, perform\\nrectoscopy in the operating room. The diagnosis of CD may have\\nbeen established previously and what you see around the anus is\\nobviously a chronic process.\\n\\n The anorectum in these patients is best evaluated and managed under\\ngeneral anesthesia. Do not attempt to do more than adequate\\ndrainage, which still may require quite an extensive incision. Avoid\\nincising close to the anus, because the wounds may not heal; incise\\nliberally over the peripheral abscess and external opening for adequate\\ndrainage. Place a loose draining Seton if the internal opening is\\nidentified and can be intubated. Your task is to provide source control of\\nthe abscess which can be difficult with inadequate incisions. Let the\\nperipheral extension of the fistula tract guide you. Just avoid bringing\\nthe incision too near the anal orifice.\\n\\n Clostridium difficile colitis (CDC — pseudomembranous\\n colitis)\\n\\n Clostridium difficile is a Gram-positive bacillus. It is the primary cause\\nof pseudomembranous colitis and is associated with antibiotic use. It is\\nimportant to remember that one dose of antibiotics is all it takes to\\ndevelop colitis. Clostridium difficile has two potent toxins that mediate\\ncolitis and diarrhea. Patients present with profuse diarrhea that is foul\\nsmelling, plus clinical and lab features of SIRS.\\n\\n The clinical spectrum of CDC is broad, ranging from mild diarrhea\\nwhich can be treated as an outpatient to septic shock. Most patients have\\na benign abdominal exam; however, in severe cases patients may have\\nperitonitis.',\n", " 'md': \"```markdown\\n## Clinical Considerations for Fistula and Clostridium Difficile Colitis\\n\\n### Fistula Management\\n- Significant induration of the perianal area is noted.\\n- The fistula is typically high, above the external sphincter, and may have extensions.\\n- External openings can be located far from the anal orifice, unlike the usual 3-4 cm seen in cryptogenic fistulas.\\n- There may be multiple external openings and an undermining ‘sea of pus’.\\n- Associated proctitis is common, necessitating rectoscopy as part of the pre-operative evaluation.\\n- Pain can be significant; if so, perform rectoscopy in the operating room.\\n- The diagnosis of Crohn's Disease (CD) may have been established previously, indicating a chronic process around the anus.\\n\\n#### Surgical Management\\n- The anorectum in these patients is best evaluated and managed under general anesthesia.\\n- Only perform adequate drainage, which may require extensive incision.\\n- Avoid incising close to the anus, as wounds may not heal; instead, incise liberally over the peripheral abscess and external opening for adequate drainage.\\n- If the internal opening is identified and can be intubated, place a loose draining Seton.\\n- The goal is to provide source control of the abscess, which can be challenging with inadequate incisions.\\n- Use the peripheral extension of the fistula tract as a guide, avoiding incisions too near the anal orifice.\\n\\n### Clostridium Difficile Colitis (CDC — Pseudomembranous Colitis)\\n- Clostridium difficile is a Gram-positive bacillus and the primary cause of pseudomembranous colitis, often associated with antibiotic use.\\n- It is crucial to note that even one dose of antibiotics can lead to colitis.\\n- Clostridium difficile produces two potent toxins that mediate colitis and diarrhea.\\n- Patients typically present with profuse, foul-smelling diarrhea, along with clinical and laboratory features of Systemic Inflammatory Response Syndrome (SIRS).\\n\\n#### Clinical Spectrum\\n- The clinical spectrum of CDC ranges from mild diarrhea, which can be treated as an outpatient, to septic shock.\\n- Most patients exhibit a benign abdominal exam; however, severe cases may present with peritonitis.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Considerations for Fistula and Clostridium Difficile Colitis',\n", " 'md': '## Clinical Considerations for Fistula and Clostridium Difficile Colitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Fistula Management',\n", " 'md': '### Fistula Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- Significant induration of the perianal area is noted.\\n- The fistula is typically high, above the external sphincter, and may have extensions.\\n- External openings can be located far from the anal orifice, unlike the usual 3-4 cm seen in cryptogenic fistulas.\\n- There may be multiple external openings and an undermining ‘sea of pus’.\\n- Associated proctitis is common, necessitating rectoscopy as part of the pre-operative evaluation.\\n- Pain can be significant; if so, perform rectoscopy in the operating room.\\n- The diagnosis of Crohn's Disease (CD) may have been established previously, indicating a chronic process around the anus.\",\n", " 'md': \"- Significant induration of the perianal area is noted.\\n- The fistula is typically high, above the external sphincter, and may have extensions.\\n- External openings can be located far from the anal orifice, unlike the usual 3-4 cm seen in cryptogenic fistulas.\\n- There may be multiple external openings and an undermining ‘sea of pus’.\\n- Associated proctitis is common, necessitating rectoscopy as part of the pre-operative evaluation.\\n- Pain can be significant; if so, perform rectoscopy in the operating room.\\n- The diagnosis of Crohn's Disease (CD) may have been established previously, indicating a chronic process around the anus.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Surgical Management',\n", " 'md': '#### Surgical Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The anorectum in these patients is best evaluated and managed under general anesthesia.\\n- Only perform adequate drainage, which may require extensive incision.\\n- Avoid incising close to the anus, as wounds may not heal; instead, incise liberally over the peripheral abscess and external opening for adequate drainage.\\n- If the internal opening is identified and can be intubated, place a loose draining Seton.\\n- The goal is to provide source control of the abscess, which can be challenging with inadequate incisions.\\n- Use the peripheral extension of the fistula tract as a guide, avoiding incisions too near the anal orifice.',\n", " 'md': '- The anorectum in these patients is best evaluated and managed under general anesthesia.\\n- Only perform adequate drainage, which may require extensive incision.\\n- Avoid incising close to the anus, as wounds may not heal; instead, incise liberally over the peripheral abscess and external opening for adequate drainage.\\n- If the internal opening is identified and can be intubated, place a loose draining Seton.\\n- The goal is to provide source control of the abscess, which can be challenging with inadequate incisions.\\n- Use the peripheral extension of the fistula tract as a guide, avoiding incisions too near the anal orifice.',\n", " 'bBox': {'x': 86, 'y': 270, 'w': 453.07, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Clostridium Difficile Colitis (CDC — Pseudomembranous Colitis)',\n", " 'md': '### Clostridium Difficile Colitis (CDC — Pseudomembranous Colitis)',\n", " 'bBox': {'x': 86, 'y': 481, 'w': 53.32, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Clostridium difficile is a Gram-positive bacillus and the primary cause of pseudomembranous colitis, often associated with antibiotic use.\\n- It is crucial to note that even one dose of antibiotics can lead to colitis.\\n- Clostridium difficile produces two potent toxins that mediate colitis and diarrhea.\\n- Patients typically present with profuse, foul-smelling diarrhea, along with clinical and laboratory features of Systemic Inflammatory Response Syndrome (SIRS).',\n", " 'md': '- Clostridium difficile is a Gram-positive bacillus and the primary cause of pseudomembranous colitis, often associated with antibiotic use.\\n- It is crucial to note that even one dose of antibiotics can lead to colitis.\\n- Clostridium difficile produces two potent toxins that mediate colitis and diarrhea.\\n- Patients typically present with profuse, foul-smelling diarrhea, along with clinical and laboratory features of Systemic Inflammatory Response Syndrome (SIRS).',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Clinical Spectrum',\n", " 'md': '#### Clinical Spectrum',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The clinical spectrum of CDC ranges from mild diarrhea, which can be treated as an outpatient, to septic shock.\\n- Most patients exhibit a benign abdominal exam; however, severe cases may present with peritonitis.\\n```',\n", " 'md': '- The clinical spectrum of CDC ranges from mild diarrhea, which can be treated as an outpatient, to septic shock.\\n- Most patients exhibit a benign abdominal exam; however, severe cases may present with peritonitis.\\n```',\n", " 'bBox': {'x': 72, 'y': 685, 'w': 65.56, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 453,\n", " 'text': ' The diagnosis is made by sending a stool sample to detect the C.\\ndifficile toxin and a bedside sigmoidoscopy revealing the typical\\npseudomembranes. In severe cases the CT reveals massive colonic\\nwall thickening. Sometimes (10-20% of the time) pseudomembranes\\nmay not be present in the rectum, but found in the more proximal\\ncolon, so don’t be fooled by a normal proctosocopy.\\n\\n The treatment consists of vigorous rehydration, stopping the\\n‘responsible’ antibiotic agent and bowel rest. First-line therapy includes\\noral metronidazole, with oral vancomycin as a second-line therapy.\\nIn patients with ileus the delivery of vancomycin to the colon might\\nrequire an enema in order to be effective. Metronidazole is equally\\neffective intravenously.\\n\\n Immunosuppressed patients who develop pseudomembranous colitis\\nmay have significant risk of mortality. Rising lactate, an increasing WBC\\ncount, worsening renal function and the need for the initiation of pre-\\noperative pressors are ominous signs.\\n Year2\\n ReRy?oll\\nFigure 26.2. Surgeon: “Anyone ready to serve as a s**t donor for this poor patient.”\\nStudent of the year: “Sir, what about an autotransplant?”',\n", " 'md': '```markdown\\n## Diagnosis and Treatment of Pseudomembranous Colitis\\n\\nThe diagnosis is made by sending a stool sample to detect the C. difficile toxin and a bedside sigmoidoscopy revealing the typical pseudomembranes. In severe cases, the CT reveals massive colonic wall thickening. Sometimes (10-20% of the time) pseudomembranes may not be present in the rectum, but found in the more proximal colon, so don’t be fooled by a normal proctosocopy.\\n\\nThe treatment consists of vigorous rehydration, stopping the ‘responsible’ antibiotic agent, and bowel rest. First-line therapy includes oral metronidazole, with oral vancomycin as a second-line therapy. In patients with ileus, the delivery of vancomycin to the colon might require an enema in order to be effective. Metronidazole is equally effective intravenously.\\n\\nImmunosuppressed patients who develop pseudomembranous colitis may have significant risk of mortality. Rising lactate, an increasing WBC count, worsening renal function, and the need for the initiation of pre-operative pressors are ominous signs.\\n\\n### Figure 26.2\\n**Caption:** Surgeon: “Anyone ready to serve as a s**t donor for this poor patient.”\\n**Student of the year:** “Sir, what about an autotransplant?”\\n\\n**Description:** This figure likely depicts a humorous or satirical illustration related to the context of pseudomembranous colitis treatment, possibly involving a surgeon and a student discussing organ donation in a light-hearted manner. The content suggests a serious medical situation juxtaposed with a comedic dialogue.\\n```',\n", " 'images': [{'name': 'img_p452_1.png',\n", " 'height': 563,\n", " 'width': 795,\n", " 'x': 109.4399999999996,\n", " 'y': 385.20000000000005,\n", " 'original_width': 1365,\n", " 'original_height': 967}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnosis and Treatment of Pseudomembranous Colitis',\n", " 'md': '## Diagnosis and Treatment of Pseudomembranous Colitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The diagnosis is made by sending a stool sample to detect the C. difficile toxin and a bedside sigmoidoscopy revealing the typical pseudomembranes. In severe cases, the CT reveals massive colonic wall thickening. Sometimes (10-20% of the time) pseudomembranes may not be present in the rectum, but found in the more proximal colon, so don’t be fooled by a normal proctosocopy.\\n\\nThe treatment consists of vigorous rehydration, stopping the ‘responsible’ antibiotic agent, and bowel rest. First-line therapy includes oral metronidazole, with oral vancomycin as a second-line therapy. In patients with ileus, the delivery of vancomycin to the colon might require an enema in order to be effective. Metronidazole is equally effective intravenously.\\n\\nImmunosuppressed patients who develop pseudomembranous colitis may have significant risk of mortality. Rising lactate, an increasing WBC count, worsening renal function, and the need for the initiation of pre-operative pressors are ominous signs.',\n", " 'md': 'The diagnosis is made by sending a stool sample to detect the C. difficile toxin and a bedside sigmoidoscopy revealing the typical pseudomembranes. In severe cases, the CT reveals massive colonic wall thickening. Sometimes (10-20% of the time) pseudomembranes may not be present in the rectum, but found in the more proximal colon, so don’t be fooled by a normal proctosocopy.\\n\\nThe treatment consists of vigorous rehydration, stopping the ‘responsible’ antibiotic agent, and bowel rest. First-line therapy includes oral metronidazole, with oral vancomycin as a second-line therapy. In patients with ileus, the delivery of vancomycin to the colon might require an enema in order to be effective. Metronidazole is equally effective intravenously.\\n\\nImmunosuppressed patients who develop pseudomembranous colitis may have significant risk of mortality. Rising lactate, an increasing WBC count, worsening renal function, and the need for the initiation of pre-operative pressors are ominous signs.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.71, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 26.2',\n", " 'md': '### Figure 26.2',\n", " 'bBox': {'x': 431.35, 'y': 522.29, 'w': 14.83, 'h': 6.93}},\n", " {'type': 'text',\n", " 'value': '**Caption:** Surgeon: “Anyone ready to serve as a s**t donor for this poor patient.”\\n**Student of the year:** “Sir, what about an autotransplant?”\\n\\n**Description:** This figure likely depicts a humorous or satirical illustration related to the context of pseudomembranous colitis treatment, possibly involving a surgeon and a student discussing organ donation in a light-hearted manner. The content suggests a serious medical situation juxtaposed with a comedic dialogue.\\n```',\n", " 'md': '**Caption:** Surgeon: “Anyone ready to serve as a s**t donor for this poor patient.”\\n**Student of the year:** “Sir, what about an autotransplant?”\\n\\n**Description:** This figure likely depicts a humorous or satirical illustration related to the context of pseudomembranous colitis treatment, possibly involving a surgeon and a student discussing organ donation in a light-hearted manner. The content suggests a serious medical situation juxtaposed with a comedic dialogue.\\n```',\n", " 'bBox': {'x': 420.97, 'y': 526.75, 'w': 22.75, 'h': 11.88}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 454,\n", " 'text': ' Surgical intervention before systemic decompensation improves\\nsurvival. The only surgical option in this setting is a total colectomy\\nwith an end ileostomy. The colon will appear deceivingly normal at the\\ntime of operation. This should never fool the surgeon into performing\\nanything less than a total colectomy. Some reports have recently been\\npublished suggesting that performing a loop ileostomy with direct\\ninstillation of vancomycin into the colon might be an effective\\nmethod of managing these patients. These reports are relatively new\\nand should be considered with caution. Patients who are septic and\\nrequiring systemic pharmacologic or respiratory support are not\\ncandidates for antecolic irrigation via a loop ileostomy.\\n\\n Fecal transplant is gaining popularity for the management of\\nrefractory or recurrent C. difficile colitis. Our results are mixed, but we\\ndo not see a role for fecal transplant in those patients who have\\nprogressed on to toxic megacolon Most are being performed as an\\noutpatient in the gastroenterologist’s office. (Anyway, we are seeking\\ndonors — to apply please email us... [ Figure 26.2].)\\n\\n The following section on neutropenic enterocolitis and ischemic colitis has been added by us.\\n The Editors\\n\\n Neutropenic enterocolitis\\n\\n This is a transmural inflammation of the large bowel in\\nmyelosuppressed and immunosuppressed patients — usually suffering\\nfrom myeloproliferative disorders, receiving chemotherapy or following\\nsolid organ or bone marrow transplantation. Profound neutropenia\\nappears to be the common denominator. The process involves mucosal\\ndamage and alteration in bacterial flora, which then invade the bowel\\nwall. The cecum is primarily affected but the process may extend to the\\nascending colon and even the ileum. The presentation may mimic acute\\nappendicitis; watery or bloody diarrhea is present in only half of the\\npatients. Right lower quadrant tenderness, a palpable cecum, peritoneal\\nsigns and features of ileus may be present. Neutropenia is a\\npathognomonic laboratory finding. Plain abdominal X-rays are usually\\nnon-specific, revealing an associated ileus but may show ‘thumbprinting’',\n", " 'md': '```markdown\\n# Surgical Intervention and Neutropenic Enterocolitis\\n\\nSurgical intervention before systemic decompensation improves survival. The only surgical option in this setting is a total colectomy with an end ileostomy. The colon will appear deceivingly normal at the time of operation. This should never fool the surgeon into performing anything less than a total colectomy. Some reports have recently been published suggesting that performing a loop ileostomy with direct instillation of vancomycin into the colon might be an effective method of managing these patients. These reports are relatively new and should be considered with caution. Patients who are septic and requiring systemic pharmacologic or respiratory support are not candidates for antecolic irrigation via a loop ileostomy.\\n\\nFecal transplant is gaining popularity for the management of refractory or recurrent C. difficile colitis. Our results are mixed, but we do not see a role for fecal transplant in those patients who have progressed on to toxic megacolon. Most are being performed as an outpatient in the gastroenterologist’s office. (Anyway, we are seeking donors — to apply please email us... [Figure 26.2].)\\n\\n## Neutropenic Enterocolitis\\n\\nThis is a transmural inflammation of the large bowel in myelosuppressed and immunosuppressed patients — usually suffering from myeloproliferative disorders, receiving chemotherapy or following solid organ or bone marrow transplantation. Profound neutropenia appears to be the common denominator. The process involves mucosal damage and alteration in bacterial flora, which then invade the bowel wall. The cecum is primarily affected but the process may extend to the ascending colon and even the ileum. The presentation may mimic acute appendicitis; watery or bloody diarrhea is present in only half of the patients. Right lower quadrant tenderness, a palpable cecum, peritoneal signs and features of ileus may be present. Neutropenia is a pathognomonic laboratory finding. Plain abdominal X-rays are usually non-specific, revealing an associated ileus but may show ‘thumbprinting’.\\n```\\n\\n### Figure Description\\n- **Figure 26.2**: This figure is referenced in the context of fecal transplant and is likely an image related to the topic. However, the content of the figure is not provided in the text, and thus cannot be described further. It is flagged as .',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Surgical Intervention and Neutropenic Enterocolitis',\n", " 'md': '# Surgical Intervention and Neutropenic Enterocolitis',\n", " 'bBox': {'x': 86, 'y': 480, 'w': 199.53, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Surgical intervention before systemic decompensation improves survival. The only surgical option in this setting is a total colectomy with an end ileostomy. The colon will appear deceivingly normal at the time of operation. This should never fool the surgeon into performing anything less than a total colectomy. Some reports have recently been published suggesting that performing a loop ileostomy with direct instillation of vancomycin into the colon might be an effective method of managing these patients. These reports are relatively new and should be considered with caution. Patients who are septic and requiring systemic pharmacologic or respiratory support are not candidates for antecolic irrigation via a loop ileostomy.\\n\\nFecal transplant is gaining popularity for the management of refractory or recurrent C. difficile colitis. Our results are mixed, but we do not see a role for fecal transplant in those patients who have progressed on to toxic megacolon. Most are being performed as an outpatient in the gastroenterologist’s office. (Anyway, we are seeking donors — to apply please email us... [Figure 26.2].)',\n", " 'md': 'Surgical intervention before systemic decompensation improves survival. The only surgical option in this setting is a total colectomy with an end ileostomy. The colon will appear deceivingly normal at the time of operation. This should never fool the surgeon into performing anything less than a total colectomy. Some reports have recently been published suggesting that performing a loop ileostomy with direct instillation of vancomycin into the colon might be an effective method of managing these patients. These reports are relatively new and should be considered with caution. Patients who are septic and requiring systemic pharmacologic or respiratory support are not candidates for antecolic irrigation via a loop ileostomy.\\n\\nFecal transplant is gaining popularity for the management of refractory or recurrent C. difficile colitis. Our results are mixed, but we do not see a role for fecal transplant in those patients who have progressed on to toxic megacolon. Most are being performed as an outpatient in the gastroenterologist’s office. (Anyway, we are seeking donors — to apply please email us... [Figure 26.2].)',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.23, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Neutropenic Enterocolitis',\n", " 'md': '## Neutropenic Enterocolitis',\n", " 'bBox': {'x': 86, 'y': 480, 'w': 199.53, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is a transmural inflammation of the large bowel in myelosuppressed and immunosuppressed patients — usually suffering from myeloproliferative disorders, receiving chemotherapy or following solid organ or bone marrow transplantation. Profound neutropenia appears to be the common denominator. The process involves mucosal damage and alteration in bacterial flora, which then invade the bowel wall. The cecum is primarily affected but the process may extend to the ascending colon and even the ileum. The presentation may mimic acute appendicitis; watery or bloody diarrhea is present in only half of the patients. Right lower quadrant tenderness, a palpable cecum, peritoneal signs and features of ileus may be present. Neutropenia is a pathognomonic laboratory finding. Plain abdominal X-rays are usually non-specific, revealing an associated ileus but may show ‘thumbprinting’.\\n```',\n", " 'md': 'This is a transmural inflammation of the large bowel in myelosuppressed and immunosuppressed patients — usually suffering from myeloproliferative disorders, receiving chemotherapy or following solid organ or bone marrow transplantation. Profound neutropenia appears to be the common denominator. The process involves mucosal damage and alteration in bacterial flora, which then invade the bowel wall. The cecum is primarily affected but the process may extend to the ascending colon and even the ileum. The presentation may mimic acute appendicitis; watery or bloody diarrhea is present in only half of the patients. Right lower quadrant tenderness, a palpable cecum, peritoneal signs and features of ileus may be present. Neutropenia is a pathognomonic laboratory finding. Plain abdominal X-rays are usually non-specific, revealing an associated ileus but may show ‘thumbprinting’.\\n```',\n", " 'bBox': {'x': 72, 'y': 516, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Description',\n", " 'md': '### Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 26.2**: This figure is referenced in the context of fecal transplant and is likely an image related to the topic. However, the content of the figure is not provided in the text, and thus cannot be described further. It is flagged as .',\n", " 'md': '- **Figure 26.2**: This figure is referenced in the context of fecal transplant and is likely an image related to the topic. However, the content of the figure is not provided in the text, and thus cannot be described further. It is flagged as .',\n", " 'bBox': {'x': 86, 'y': 516, 'w': 31.18, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 455,\n", " 'text': 'of the right colon and intramural air (pneumatosis) — denoting severe\\ninvolvement of the cecal wall. A CT scan of the abdomen is the\\ndiagnostic procedure of choice, showing thickening of the cecum\\nand free air if an underlying perforation exists.\\n\\n Management should be initially supportive, including broad-spectrum\\nantibiotics effective against colonic Gram-negative bacteria and\\nanaerobes; granulocyte colony-stimulating factor (G-CSF) may be\\nconsidered. Clinical deterioration, evidence of free perforation and, rarely,\\nsevere lower gastrointestinal hemorrhage may necessitate operation. At\\nlaparotomy, normal-looking serosal surfaces may hide mucosal\\nbreakdown and necrosis. Therefore, the whole involved segment of colon\\nshould be resected; anastomosis should be avoided in these debilitated\\npatients. Mortality is obviously high. The key is to recognize the\\ncondition and avoid an operation in the majority of patients.\\n\\n Ischemic colitis\\n\\n Ischemic colitis is a poorly defined entity, which encompasses a wide\\nvariety of conditions. Paradoxically, occlusion of the named arteries\\nsupplying the colon is not associated with ischemic colitis but local\\nvascular changes in the wall of the colon may play a role. Thus, a\\npatient with sigmoid colon gangrene following repair of an\\nabdominal aortic aneurysm and ligation of the inferior mesenteric\\nartery has colonic ischemia — not ischemic colitis.\\n\\n Ischemic colitis develops in two different clinical settings:\\n\\n • Spontaneous: in patients with underlying cardiac failure, chronic\\n lung disease, renal failure, diabetes, and collagen disease —\\n probably related to diseased intramural vessels.\\n • Shock-associated: in patients who have experienced sustained\\n shock regardless of etiology (e.g. ruptured aortic aneurysm).\\n\\n Typically, the colonic process involves a varying depth of penetration.\\nTransient mucosal involvement may or may not progress to partial-\\nthickness necrosis, which may recover with or without a stricture,',\n", " 'md': '```markdown\\n## Ischemic Colitis\\n\\nIschemic colitis is a poorly defined entity, which encompasses a wide variety of conditions. Paradoxically, occlusion of the named arteries supplying the colon is not associated with ischemic colitis but local vascular changes in the wall of the colon may play a role. Thus, a patient with sigmoid colon gangrene following repair of an abdominal aortic aneurysm and ligation of the inferior mesenteric artery has colonic ischemia — not ischemic colitis.\\n\\nIschemic colitis develops in two different clinical settings:\\n\\n- **Spontaneous:** in patients with underlying cardiac failure, chronic lung disease, renal failure, diabetes, and collagen disease — probably related to diseased intramural vessels.\\n- **Shock-associated:** in patients who have experienced sustained shock regardless of etiology (e.g. ruptured aortic aneurysm).\\n\\nTypically, the colonic process involves a varying depth of penetration. Transient mucosal involvement may or may not progress to partial-thickness necrosis, which may recover with or without a stricture.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Ischemic Colitis',\n", " 'md': '## Ischemic Colitis',\n", " 'bBox': {'x': 86, 'y': 363, 'w': 123.21, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Ischemic colitis is a poorly defined entity, which encompasses a wide variety of conditions. Paradoxically, occlusion of the named arteries supplying the colon is not associated with ischemic colitis but local vascular changes in the wall of the colon may play a role. Thus, a patient with sigmoid colon gangrene following repair of an abdominal aortic aneurysm and ligation of the inferior mesenteric artery has colonic ischemia — not ischemic colitis.\\n\\nIschemic colitis develops in two different clinical settings:\\n\\n- **Spontaneous:** in patients with underlying cardiac failure, chronic lung disease, renal failure, diabetes, and collagen disease — probably related to diseased intramural vessels.\\n- **Shock-associated:** in patients who have experienced sustained shock regardless of etiology (e.g. ruptured aortic aneurysm).\\n\\nTypically, the colonic process involves a varying depth of penetration. Transient mucosal involvement may or may not progress to partial-thickness necrosis, which may recover with or without a stricture.\\n```',\n", " 'md': 'Ischemic colitis is a poorly defined entity, which encompasses a wide variety of conditions. Paradoxically, occlusion of the named arteries supplying the colon is not associated with ischemic colitis but local vascular changes in the wall of the colon may play a role. Thus, a patient with sigmoid colon gangrene following repair of an abdominal aortic aneurysm and ligation of the inferior mesenteric artery has colonic ischemia — not ischemic colitis.\\n\\nIschemic colitis develops in two different clinical settings:\\n\\n- **Spontaneous:** in patients with underlying cardiac failure, chronic lung disease, renal failure, diabetes, and collagen disease — probably related to diseased intramural vessels.\\n- **Shock-associated:** in patients who have experienced sustained shock regardless of etiology (e.g. ruptured aortic aneurysm).\\n\\nTypically, the colonic process involves a varying depth of penetration. Transient mucosal involvement may or may not progress to partial-thickness necrosis, which may recover with or without a stricture.\\n```',\n", " 'bBox': {'x': 72, 'y': 187, 'w': 467.56, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 456,\n", " 'text': 'or progress to full-thickness gangrene. Although most common in the\\n‘watershed’ area of the splenic flexure and the left colon, the disease can\\ninvolve any part of the colon and the rectum, and rarely the entire colon;\\nalthough usually focal it may be patchy or diffuse.\\n\\n Patients with spontaneous ischemic colitis present typically with\\nnon-specific abdominal pain and lower gastrointestinal bleeding\\n(hematochezia). Those with shock-associated ischemic colitis develop\\nthese features on top of their underlying critical disease.\\n\\n As with mesenteric ischemia ( Chapter 24), the clinical picture — as\\nwell as laboratory findings — is entirely non-specific as is the commonly\\nassociated ileus. Abdominal X-rays may demonstrate an ileus and\\ncolonic dilation proximal to the area of ischemia or a dilated ischemic\\ncolon. In the rare, advanced transmural cases, pneumatosis coli or free\\ngas may be seen. Findings on CT include colonic wall thickening, free\\nfluid and pneumatosis coli. Lower GI endoscopy (often bedside) is the\\nbest diagnostic test, visualizing a spectrum of hemorrhagic and\\nischemic changes which, although non-specific and may be confused\\nwith CD colitis (see above), are highly suggestive in the specific clinical\\nsetting.\\n\\n Treatment\\n\\n Clinical and radiographic evidence of colonic perforation or an\\nendoscopic picture of dead bowel (black, paralyzed) necessitates a\\nlaparotomy and resection of the involved segment, but this is infrequently\\nneeded. Non-transmural ischemia is managed non-operatively with\\nsupportive measures and broad-spectrum antibiotics, as long as the\\npatient is not deteriorating. Increasing or persisting abdominal pain,\\nfever, ileus, leukocytosis, acidosis and progressive changes on\\nabdominal imaging may call for colonic resection.\\n\\n Although most patients recover from the acute insult, some may\\nprogress to develop a chronic ischemic stricture — but this is beyond the\\nscope of our story.',\n", " 'md': \"```markdown\\n## Ischemic Colitis\\n\\nIschemic colitis can progress to full-thickness gangrene. Although it is most common in the ‘watershed’ area of the splenic flexure and the left colon, the disease can involve any part of the colon and the rectum, and rarely the entire colon; it may be focal, patchy, or diffuse.\\n\\nPatients with spontaneous ischemic colitis typically present with non-specific abdominal pain and lower gastrointestinal bleeding (hematochezia). Those with shock-associated ischemic colitis develop these features on top of their underlying critical disease.\\n\\nAs with mesenteric ischemia (see Chapter 24), the clinical picture, as well as laboratory findings, is entirely non-specific, as is the commonly associated ileus. Abdominal X-rays may demonstrate an ileus and colonic dilation proximal to the area of ischemia or a dilated ischemic colon. In rare, advanced transmural cases, pneumatosis coli or free gas may be seen. Findings on CT include colonic wall thickening, free fluid, and pneumatosis coli. Lower GI endoscopy (often bedside) is the best diagnostic test, visualizing a spectrum of hemorrhagic and ischemic changes which, although non-specific and may be confused with Crohn's disease (CD) colitis, are highly suggestive in the specific clinical setting.\\n\\n### Treatment\\n\\nClinical and radiographic evidence of colonic perforation or an endoscopic picture of dead bowel (black, paralyzed) necessitates a laparotomy and resection of the involved segment, but this is infrequently needed. Non-transmural ischemia is managed non-operatively with supportive measures and broad-spectrum antibiotics, as long as the patient is not deteriorating. Increasing or persisting abdominal pain, fever, ileus, leukocytosis, acidosis, and progressive changes on abdominal imaging may call for colonic resection.\\n\\nAlthough most patients recover from the acute insult, some may progress to develop a chronic ischemic stricture — but this is beyond the scope of our story.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Ischemic Colitis',\n", " 'md': '## Ischemic Colitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"Ischemic colitis can progress to full-thickness gangrene. Although it is most common in the ‘watershed’ area of the splenic flexure and the left colon, the disease can involve any part of the colon and the rectum, and rarely the entire colon; it may be focal, patchy, or diffuse.\\n\\nPatients with spontaneous ischemic colitis typically present with non-specific abdominal pain and lower gastrointestinal bleeding (hematochezia). Those with shock-associated ischemic colitis develop these features on top of their underlying critical disease.\\n\\nAs with mesenteric ischemia (see Chapter 24), the clinical picture, as well as laboratory findings, is entirely non-specific, as is the commonly associated ileus. Abdominal X-rays may demonstrate an ileus and colonic dilation proximal to the area of ischemia or a dilated ischemic colon. In rare, advanced transmural cases, pneumatosis coli or free gas may be seen. Findings on CT include colonic wall thickening, free fluid, and pneumatosis coli. Lower GI endoscopy (often bedside) is the best diagnostic test, visualizing a spectrum of hemorrhagic and ischemic changes which, although non-specific and may be confused with Crohn's disease (CD) colitis, are highly suggestive in the specific clinical setting.\",\n", " 'md': \"Ischemic colitis can progress to full-thickness gangrene. Although it is most common in the ‘watershed’ area of the splenic flexure and the left colon, the disease can involve any part of the colon and the rectum, and rarely the entire colon; it may be focal, patchy, or diffuse.\\n\\nPatients with spontaneous ischemic colitis typically present with non-specific abdominal pain and lower gastrointestinal bleeding (hematochezia). Those with shock-associated ischemic colitis develop these features on top of their underlying critical disease.\\n\\nAs with mesenteric ischemia (see Chapter 24), the clinical picture, as well as laboratory findings, is entirely non-specific, as is the commonly associated ileus. Abdominal X-rays may demonstrate an ileus and colonic dilation proximal to the area of ischemia or a dilated ischemic colon. In rare, advanced transmural cases, pneumatosis coli or free gas may be seen. Findings on CT include colonic wall thickening, free fluid, and pneumatosis coli. Lower GI endoscopy (often bedside) is the best diagnostic test, visualizing a spectrum of hemorrhagic and ischemic changes which, although non-specific and may be confused with Crohn's disease (CD) colitis, are highly suggestive in the specific clinical setting.\",\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.56, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Treatment',\n", " 'md': '### Treatment',\n", " 'bBox': {'x': 86, 'y': 464, 'w': 79.1, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Clinical and radiographic evidence of colonic perforation or an endoscopic picture of dead bowel (black, paralyzed) necessitates a laparotomy and resection of the involved segment, but this is infrequently needed. Non-transmural ischemia is managed non-operatively with supportive measures and broad-spectrum antibiotics, as long as the patient is not deteriorating. Increasing or persisting abdominal pain, fever, ileus, leukocytosis, acidosis, and progressive changes on abdominal imaging may call for colonic resection.\\n\\nAlthough most patients recover from the acute insult, some may progress to develop a chronic ischemic stricture — but this is beyond the scope of our story.\\n```',\n", " 'md': 'Clinical and radiographic evidence of colonic perforation or an endoscopic picture of dead bowel (black, paralyzed) necessitates a laparotomy and resection of the involved segment, but this is infrequently needed. Non-transmural ischemia is managed non-operatively with supportive measures and broad-spectrum antibiotics, as long as the patient is not deteriorating. Increasing or persisting abdominal pain, fever, ileus, leukocytosis, acidosis, and progressive changes on abdominal imaging may call for colonic resection.\\n\\nAlthough most patients recover from the acute insult, some may progress to develop a chronic ischemic stricture — but this is beyond the scope of our story.\\n```',\n", " 'bBox': {'x': 72, 'y': 187, 'w': 467.94, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'well as laboratory findings — is entirely non-specific as is the commonly'}]},\n", " {'page': 457,\n", " 'text': ' The differentiation between ischemic colitis and colonic ischemia is inconsequential to the\\n management in my opinion. Jon\\n\\n Final words\\n\\n Acute colitis from any cause needs careful monitoring and a team\\napproach to ensure optimum care. As with most surgical emergencies,\\nintervention when the patient is not septic with peritonitis is preferable, so\\nget to know these patients early in their hospital course and keep an eye\\non them. Both laparoscopic and open approaches are appropriate,\\ndepending on the severity of the colitis and the overall health of the\\npatient. Temporizing procedures, primarily total colectomy with end\\nileostomy, are usually appropriate. Leave the rectum alone! You will\\nhave the opportunity to come back and deal with that much maligned\\norgan in the future.\\n\\n “We suffer and die through the defects that arise in our\\n sewerage and drainage systems.”\\n William A. Lane\\n\\n1 Dr. P. O. Nyström contributed to this chapter in the previous editions.',\n", " 'md': '```markdown\\n## Final Words\\n\\nThe differentiation between ischemic colitis and colonic ischemia is inconsequential to the management in my opinion. Jon\\n\\nAcute colitis from any cause needs careful monitoring and a team approach to ensure optimum care. As with most surgical emergencies, intervention when the patient is not septic with peritonitis is preferable, so get to know these patients early in their hospital course and keep an eye on them. Both laparoscopic and open approaches are appropriate, depending on the severity of the colitis and the overall health of the patient. Temporizing procedures, primarily total colectomy with end ileostomy, are usually appropriate. Leave the rectum alone! You will have the opportunity to come back and deal with that much maligned organ in the future.\\n\\n> “We suffer and die through the defects that arise in our sewerage and drainage systems.”\\n> — William A. Lane\\n\\n1. Dr. P. O. Nyström contributed to this chapter in the previous editions.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Final Words',\n", " 'md': '## Final Words',\n", " 'bBox': {'x': 86, 'y': 162, 'w': 91.94, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The differentiation between ischemic colitis and colonic ischemia is inconsequential to the management in my opinion. Jon\\n\\nAcute colitis from any cause needs careful monitoring and a team approach to ensure optimum care. As with most surgical emergencies, intervention when the patient is not septic with peritonitis is preferable, so get to know these patients early in their hospital course and keep an eye on them. Both laparoscopic and open approaches are appropriate, depending on the severity of the colitis and the overall health of the patient. Temporizing procedures, primarily total colectomy with end ileostomy, are usually appropriate. Leave the rectum alone! You will have the opportunity to come back and deal with that much maligned organ in the future.\\n\\n> “We suffer and die through the defects that arise in our sewerage and drainage systems.”\\n> — William A. Lane\\n\\n1. Dr. P. O. Nyström contributed to this chapter in the previous editions.\\n```',\n", " 'md': 'The differentiation between ischemic colitis and colonic ischemia is inconsequential to the management in my opinion. Jon\\n\\nAcute colitis from any cause needs careful monitoring and a team approach to ensure optimum care. As with most surgical emergencies, intervention when the patient is not septic with peritonitis is preferable, so get to know these patients early in their hospital course and keep an eye on them. Both laparoscopic and open approaches are appropriate, depending on the severity of the colitis and the overall health of the patient. Temporizing procedures, primarily total colectomy with end ileostomy, are usually appropriate. Leave the rectum alone! You will have the opportunity to come back and deal with that much maligned organ in the future.\\n\\n> “We suffer and die through the defects that arise in our sewerage and drainage systems.”\\n> — William A. Lane\\n\\n1. Dr. P. O. Nyström contributed to this chapter in the previous editions.\\n```',\n", " 'bBox': {'x': 72, 'y': 111, 'w': 467.77, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 458,\n", " 'text': 'Chapter 27\\nColonic obstruction\\nJonathan E. Efron\\n\\n The only time human beings wish they could fart and\\n defecate is when they are not able to do so.\\n\\n This chapter is mainly concerned with the most common cause of\\nacute obstruction of the colon — which is cancer; the next most frequent\\netiology is diverticular disease. You already know that obstruction due\\nto these conditions occurs mostly in the left colon — where the stool is\\nmore solid and the colon at its narrowest. We’ll also discuss the condition\\nthat mimics obstruction: pseudo-obstruction (Ogilvie’s syndrome).\\nFinally, we’ll deal with volvulus of the colon affecting the sigmoid and\\ncecum.\\n\\n Colonic obstruction is a true surgical emergency. There are only\\ntwo emergencies that should make a surgeon run, either to the\\noperating room or elsewhere, and that is fire and bleeding. All other\\nemergencies need to be assessed, evaluated, and ‘scheduled’ to\\nallow time for resuscitation of the patient. Colonic obstruction is at\\ntimes grouped in our subconscious with other bowel obstructions and this\\nmay lead to a state of complacency. But a patient with complete\\ncolonic obstruction and a competent ileocecal valve has a limited\\ntime before perforation or necrosis occurs, significantly changing\\nthe outcome for both you and the patient. So be aware that these\\npatients require active and attentive management.',\n", " 'md': '```markdown\\n# Chapter 27: Colonic Obstruction\\n**Author:** Jonathan E. Efron\\n\\nThe only time human beings wish they could fart and defecate is when they are not able to do so.\\n\\nThis chapter is mainly concerned with the most common cause of acute obstruction of the colon — which is cancer; the next most frequent etiology is diverticular disease. You already know that obstruction due to these conditions occurs mostly in the left colon — where the stool is more solid and the colon at its narrowest. We’ll also discuss the condition that mimics obstruction: pseudo-obstruction (Ogilvie’s syndrome). Finally, we’ll deal with volvulus of the colon affecting the sigmoid and cecum.\\n\\nColonic obstruction is a true surgical emergency. There are only two emergencies that should make a surgeon run, either to the operating room or elsewhere, and that is fire and bleeding. All other emergencies need to be assessed, evaluated, and ‘scheduled’ to allow time for resuscitation of the patient. Colonic obstruction is at times grouped in our subconscious with other bowel obstructions and this may lead to a state of complacency. But a patient with complete colonic obstruction and a competent ileocecal valve has a limited time before perforation or necrosis occurs, significantly changing the outcome for both you and the patient. So be aware that these patients require active and attentive management.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 27: Colonic Obstruction',\n", " 'md': '# Chapter 27: Colonic Obstruction',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 171.35, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Jonathan E. Efron\\n\\nThe only time human beings wish they could fart and defecate is when they are not able to do so.\\n\\nThis chapter is mainly concerned with the most common cause of acute obstruction of the colon — which is cancer; the next most frequent etiology is diverticular disease. You already know that obstruction due to these conditions occurs mostly in the left colon — where the stool is more solid and the colon at its narrowest. We’ll also discuss the condition that mimics obstruction: pseudo-obstruction (Ogilvie’s syndrome). Finally, we’ll deal with volvulus of the colon affecting the sigmoid and cecum.\\n\\nColonic obstruction is a true surgical emergency. There are only two emergencies that should make a surgeon run, either to the operating room or elsewhere, and that is fire and bleeding. All other emergencies need to be assessed, evaluated, and ‘scheduled’ to allow time for resuscitation of the patient. Colonic obstruction is at times grouped in our subconscious with other bowel obstructions and this may lead to a state of complacency. But a patient with complete colonic obstruction and a competent ileocecal valve has a limited time before perforation or necrosis occurs, significantly changing the outcome for both you and the patient. So be aware that these patients require active and attentive management.\\n```',\n", " 'md': '**Author:** Jonathan E. Efron\\n\\nThe only time human beings wish they could fart and defecate is when they are not able to do so.\\n\\nThis chapter is mainly concerned with the most common cause of acute obstruction of the colon — which is cancer; the next most frequent etiology is diverticular disease. You already know that obstruction due to these conditions occurs mostly in the left colon — where the stool is more solid and the colon at its narrowest. We’ll also discuss the condition that mimics obstruction: pseudo-obstruction (Ogilvie’s syndrome). Finally, we’ll deal with volvulus of the colon affecting the sigmoid and cecum.\\n\\nColonic obstruction is a true surgical emergency. There are only two emergencies that should make a surgeon run, either to the operating room or elsewhere, and that is fire and bleeding. All other emergencies need to be assessed, evaluated, and ‘scheduled’ to allow time for resuscitation of the patient. Colonic obstruction is at times grouped in our subconscious with other bowel obstructions and this may lead to a state of complacency. But a patient with complete colonic obstruction and a competent ileocecal valve has a limited time before perforation or necrosis occurs, significantly changing the outcome for both you and the patient. So be aware that these patients require active and attentive management.\\n```',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.97, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 459,\n", " 'text': ' Clinical approach\\n\\n A 52-year-old male with no past medical or surgical history presents to your emergency room\\n with significant abdominal distension and pain. He has not had a bowel movement or passed\\n gas for the last 3 days. Your emergency room, unlike most in the United States, has decided to\\n consult you before obtaining any work-up (oh yes, you are allowed to see a patient who hasn’t\\n undergone a CT as yet!).\\n\\n ħow do you approach this problem if you are the initial individual\\nevaluating the patient?\\n\\n Because you are a highly accomplished and competent surgeon you\\nstart with a history and physical examination. This history should\\ninclude questions like: Has he had a change in his bowel habits?\\nBlood in the stool? Any weight loss? A crucial question to be asked\\nis did he have a colonoscopy in the past — when and with what\\nfindings? In populations undergoing routine screening colonoscopy\\n(starting at the age of 50), obstructing colon carcinoma has become\\na rarity! You should enquire about a family history of colon and rectal\\ncancer, whether he has had any fevers or chills or an acute onset of pain\\nand discomfort, and whether he has noticed if this distension has been\\ngoing on for a longer period of time. The routine questions about\\ndiabetes, cardiac history, or any medical problems in general should also\\nof course be explored.\\n\\n Now you do a thorough physical examination, culminating with the\\never less popular rectal exam. The rectal exam is a dying art and is often\\nskipped completely by residents. ħowever, given his significant\\nabdominal distension and pain it is essential to determine that nothing in\\nthe distal part of the rectum could be contributing to this — an advanced\\nrectal cancer for example.\\n\\n So you find out that this patient has had a significant change in his\\nbowel movements over the last several months (no, he has never been\\ncolonoscoped — it has been offered to him by his doctor but he',\n", " 'md': '```markdown\\n# Clinical Approach\\n\\nA 52-year-old male with no past medical or surgical history presents to your emergency room with significant abdominal distension and pain. He has not had a bowel movement or passed gas for the last 3 days. Your emergency room, unlike most in the United States, has decided to consult you before obtaining any work-up (oh yes, you are allowed to see a patient who hasn’t undergone a CT as yet!).\\n\\n## Initial Evaluation\\n\\nHow do you approach this problem if you are the initial individual evaluating the patient?\\n\\nBecause you are a highly accomplished and competent surgeon, you start with a history and physical examination. This history should include questions like: Has he had a change in his bowel habits? Blood in the stool? Any weight loss? A crucial question to be asked is did he have a colonoscopy in the past — when and with what findings? In populations undergoing routine screening colonoscopy (starting at the age of 50), obstructing colon carcinoma has become a rarity! You should enquire about a family history of colon and rectal cancer, whether he has had any fevers or chills or an acute onset of pain and discomfort, and whether he has noticed if this distension has been going on for a longer period of time. The routine questions about diabetes, cardiac history, or any medical problems in general should also of course be explored.\\n\\n## Physical Examination\\n\\nNow you do a thorough physical examination, culminating with the ever less popular rectal exam. The rectal exam is a dying art and is often skipped completely by residents. However, given his significant abdominal distension and pain, it is essential to determine that nothing in the distal part of the rectum could be contributing to this — an advanced rectal cancer for example.\\n\\nSo you find out that this patient has had a significant change in his bowel movements over the last several months (no, he has never been colonoscoped — it has been offered to him by his doctor but he...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been structured into sections for clarity.\\n- All identifiable text has been extracted, and no hyperlinks or formulas were present.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Clinical Approach',\n", " 'md': '# Clinical Approach',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 137.93, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A 52-year-old male with no past medical or surgical history presents to your emergency room with significant abdominal distension and pain. He has not had a bowel movement or passed gas for the last 3 days. Your emergency room, unlike most in the United States, has decided to consult you before obtaining any work-up (oh yes, you are allowed to see a patient who hasn’t undergone a CT as yet!).',\n", " 'md': 'A 52-year-old male with no past medical or surgical history presents to your emergency room with significant abdominal distension and pain. He has not had a bowel movement or passed gas for the last 3 days. Your emergency room, unlike most in the United States, has decided to consult you before obtaining any work-up (oh yes, you are allowed to see a patient who hasn’t undergone a CT as yet!).',\n", " 'bBox': {'x': 79, 'y': 134, 'w': 453.53, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Initial Evaluation',\n", " 'md': '## Initial Evaluation',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'How do you approach this problem if you are the initial individual evaluating the patient?\\n\\nBecause you are a highly accomplished and competent surgeon, you start with a history and physical examination. This history should include questions like: Has he had a change in his bowel habits? Blood in the stool? Any weight loss? A crucial question to be asked is did he have a colonoscopy in the past — when and with what findings? In populations undergoing routine screening colonoscopy (starting at the age of 50), obstructing colon carcinoma has become a rarity! You should enquire about a family history of colon and rectal cancer, whether he has had any fevers or chills or an acute onset of pain and discomfort, and whether he has noticed if this distension has been going on for a longer period of time. The routine questions about diabetes, cardiac history, or any medical problems in general should also of course be explored.',\n", " 'md': 'How do you approach this problem if you are the initial individual evaluating the patient?\\n\\nBecause you are a highly accomplished and competent surgeon, you start with a history and physical examination. This history should include questions like: Has he had a change in his bowel habits? Blood in the stool? Any weight loss? A crucial question to be asked is did he have a colonoscopy in the past — when and with what findings? In populations undergoing routine screening colonoscopy (starting at the age of 50), obstructing colon carcinoma has become a rarity! You should enquire about a family history of colon and rectal cancer, whether he has had any fevers or chills or an acute onset of pain and discomfort, and whether he has noticed if this distension has been going on for a longer period of time. The routine questions about diabetes, cardiac history, or any medical problems in general should also of course be explored.',\n", " 'bBox': {'x': 72, 'y': 281, 'w': 467.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Physical Examination',\n", " 'md': '## Physical Examination',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Now you do a thorough physical examination, culminating with the ever less popular rectal exam. The rectal exam is a dying art and is often skipped completely by residents. However, given his significant abdominal distension and pain, it is essential to determine that nothing in the distal part of the rectum could be contributing to this — an advanced rectal cancer for example.\\n\\nSo you find out that this patient has had a significant change in his bowel movements over the last several months (no, he has never been colonoscoped — it has been offered to him by his doctor but he...\\n```',\n", " 'md': 'Now you do a thorough physical examination, culminating with the ever less popular rectal exam. The rectal exam is a dying art and is often skipped completely by residents. However, given his significant abdominal distension and pain, it is essential to determine that nothing in the distal part of the rectum could be contributing to this — an advanced rectal cancer for example.\\n\\nSo you find out that this patient has had a significant change in his bowel movements over the last several months (no, he has never been colonoscoped — it has been offered to him by his doctor but he...\\n```',\n", " 'bBox': {'x': 72, 'y': 550, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been structured into sections for clarity.\\n- All identifiable text has been extracted, and no hyperlinks or formulas were present.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been structured into sections for clarity.\\n- All identifiable text has been extracted, and no hyperlinks or formulas were present.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 460,\n", " 'text': 'declined). ħe has noticed them getting smaller, almost to a point of being\\npencil thin. Over the last week, he has not passed any bowel\\nmovements. And he has not passed flatus for the last 3 days. ħe has\\nintermittent crampy pain, but no nausea or vomiting, and his discomfort is\\nsignificant and constant.\\n\\n On physical exam, he is tachycardic with a pulse of 110 but his blood\\npressure is normal. The abdomen is significantly distended and tympanic.\\nIt is tender to palpation, predominantly on the right side, but he has no\\nrebound or guarding. Examination of the groins shows that he has no\\nevidence of a hernia. The emergency room is being incredibly efficient\\nand tells you that lab test results are all within normal limits with the\\nexception of his hemoglobin which is 7.2g/dL. What would be your next\\nstep?\\n\\n Obviously we would like to proceed with some sort of testing to\\ndetermine the cause of the distension and pain but it should be obvious\\nto most that this patient is suffering from a colonic obstruction;\\nadditionally, given his significant distension, the fact that he has\\nhad no nausea or vomiting suggests that his ileocecal valve is\\ncompetent. In my hospital, as in most hospitals in the United States, the\\nemergency department may have already obtained a CT scan before\\nthey consulted you. ħowever, this might be a problem in someone with\\ncolonic obstruction and a competent ileocecal valve. Oral Gastrografin®\\ncontrast given to these patients can result in a significant build-up\\nof fluid and gas within the colon (the valve is competent only in one\\ndirection...), increasing the risk of colonic ischemia and perforation\\n— taking those patients that are not acutely ill and making them\\ncritically so.\\n\\n Therefore, when faced with this question of what to do next, I\\nwould recommend a good old-fashioned abdominal X-ray — both\\nflat and upright. This will give you an idea as to whether the patient’s\\nileocecal valve is competent (e.g. no significant small bowel distension)\\nor not. If one sees significant colonic distension without distension\\nor air fluid levels in the small bowel or stomach, one can safely\\nassume, given the history and physical exam, that this patient has a\\ncolonic obstruction.',\n", " 'md': '```markdown\\n## Clinical Case Summary\\n\\nThe patient has experienced a decline in bowel movements, with no passage of flatus for the last 3 days. He reports intermittent crampy pain, significant and constant discomfort, but no nausea or vomiting.\\n\\n### Physical Examination Findings\\n- **Vital Signs**:\\n- Tachycardic with a pulse of 110\\n- Normal blood pressure\\n- **Abdominal Examination**:\\n- Significantly distended and tympanic abdomen\\n- Tender to palpation, predominantly on the right side\\n- No rebound or guarding\\n- **Groin Examination**:\\n- No evidence of a hernia\\n\\n### Laboratory Results\\n- All lab test results are within normal limits except for hemoglobin, which is 7.2 g/dL.\\n\\n### Clinical Assessment\\nThe patient is likely suffering from a colonic obstruction. The significant abdominal distension and absence of nausea or vomiting suggest that the ileocecal valve is competent.\\n\\n### Recommended Next Steps\\n- A CT scan may have already been performed in the emergency department, but this could pose a risk for patients with colonic obstruction and a competent ileocecal valve.\\n- Administering oral Gastrografin® contrast could lead to fluid and gas build-up in the colon, increasing the risk of colonic ischemia and perforation.\\n\\n### Conclusion\\nThe recommended next step is to perform an abdominal X-ray (both flat and upright) to assess the competency of the ileocecal valve. Significant colonic distension without small bowel or stomach distension or air fluid levels would indicate a colonic obstruction.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Case Summary',\n", " 'md': '## Clinical Case Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The patient has experienced a decline in bowel movements, with no passage of flatus for the last 3 days. He reports intermittent crampy pain, significant and constant discomfort, but no nausea or vomiting.',\n", " 'md': 'The patient has experienced a decline in bowel movements, with no passage of flatus for the last 3 days. He reports intermittent crampy pain, significant and constant discomfort, but no nausea or vomiting.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Physical Examination Findings',\n", " 'md': '### Physical Examination Findings',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Vital Signs**:\\n- Tachycardic with a pulse of 110\\n- Normal blood pressure\\n- **Abdominal Examination**:\\n- Significantly distended and tympanic abdomen\\n- Tender to palpation, predominantly on the right side\\n- No rebound or guarding\\n- **Groin Examination**:\\n- No evidence of a hernia',\n", " 'md': '- **Vital Signs**:\\n- Tachycardic with a pulse of 110\\n- Normal blood pressure\\n- **Abdominal Examination**:\\n- Significantly distended and tympanic abdomen\\n- Tender to palpation, predominantly on the right side\\n- No rebound or guarding\\n- **Groin Examination**:\\n- No evidence of a hernia',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Laboratory Results',\n", " 'md': '### Laboratory Results',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- All lab test results are within normal limits except for hemoglobin, which is 7.2 g/dL.',\n", " 'md': '- All lab test results are within normal limits except for hemoglobin, which is 7.2 g/dL.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Clinical Assessment',\n", " 'md': '### Clinical Assessment',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The patient is likely suffering from a colonic obstruction. The significant abdominal distension and absence of nausea or vomiting suggest that the ileocecal valve is competent.',\n", " 'md': 'The patient is likely suffering from a colonic obstruction. The significant abdominal distension and absence of nausea or vomiting suggest that the ileocecal valve is competent.',\n", " 'bBox': {'x': 72, 'y': 707, 'w': 137, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Recommended Next Steps',\n", " 'md': '### Recommended Next Steps',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- A CT scan may have already been performed in the emergency department, but this could pose a risk for patients with colonic obstruction and a competent ileocecal valve.\\n- Administering oral Gastrografin® contrast could lead to fluid and gas build-up in the colon, increasing the risk of colonic ischemia and perforation.',\n", " 'md': '- A CT scan may have already been performed in the emergency department, but this could pose a risk for patients with colonic obstruction and a competent ileocecal valve.\\n- Administering oral Gastrografin® contrast could lead to fluid and gas build-up in the colon, increasing the risk of colonic ischemia and perforation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Conclusion',\n", " 'md': '### Conclusion',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The recommended next step is to perform an abdominal X-ray (both flat and upright) to assess the competency of the ileocecal valve. Significant colonic distension without small bowel or stomach distension or air fluid levels would indicate a colonic obstruction.\\n\\n```',\n", " 'md': 'The recommended next step is to perform an abdominal X-ray (both flat and upright) to assess the competency of the ileocecal valve. Significant colonic distension without small bowel or stomach distension or air fluid levels would indicate a colonic obstruction.\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 707, 'w': 137, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 461,\n", " 'text': ' The next step in assessing this patient should be determining\\nwhere the obstruction is and the best test for that is a Gastrografin®\\nenema, although this may be difficult to obtain because it is often hard to\\nconvince a radiologist to do it. ħowever, it’s the safest and best test for\\nidentifying the location of the obstruction. I recommend that the surgeon\\nbe present when the test is performed, as it is a dynamic test and viewing\\nthe images themselves to see the location of the obstruction is best done\\nin real time with the radiologist. Your presence there may also motivate\\nthe radiologist to leave his nice comfy bed, as these emergencies always\\ntend to happen in the middle of the night. This investigation also helps\\ndetermine whether the obstruction is complete or partial and this in\\nturn may markedly influence your plan to manage the patient in the\\nimmediate future. A CT scan combined with an enema is also good\\nand has the added benefit of defining the surrounding structures and\\ndetecting any metastatic disease. These patients receive both i.v. and\\nrectal contrast. Whether a Gastrografin® enema or a CT-enema is\\nperformed will most likely depend on which test is offered at your hospital\\nand which test the radiologist feels more comfortable performing. In the\\nend, what is important is that they are inserting contrast via the\\nanus (not the mouth!) and imaging in some way!\\n\\n Differential diagnosis\\n\\n Dr. Gershon Efron, a very wise surgeon who has been a mentor to\\nmany (I am not biased even though he is my father), has often explained\\nthat the GI tract from the mouth to the anus is just a tube and that when\\nthinking about what causes a blockage in this tube, we need to think of\\nthings that can occur outside the lumen of the tube, in the wall of the\\ntube, and inside the lumen of the tube. This concept is depicted in\\nTable 27.1 which lists the various etiologies of colonic obstruction.\\n\\n A key differentiation to be made is whether this is a pseudo-\\n obstruction or a true mechanical obstruction. Pseudo-obstruction\\n (Ogilvie’s syndrome) is an adynamic ileus of the colon that rarely requires surgical\\n resection. Differentiation between a mechanical and pseudo-obstruction is done either with an\\n endoscope or in the department of radiology. Before operating on a colonic obstruction it is',\n", " 'md': '```markdown\\n## Assessment of Obstruction\\n\\nThe next step in assessing this patient should be determining where the obstruction is, and the best test for that is a Gastrografin® enema, although this may be difficult to obtain because it is often hard to convince a radiologist to do it. However, it’s the safest and best test for identifying the location of the obstruction. I recommend that the surgeon be present when the test is performed, as it is a dynamic test and viewing the images themselves to see the location of the obstruction is best done in real time with the radiologist. Your presence there may also motivate the radiologist to leave his nice comfy bed, as these emergencies always tend to happen in the middle of the night. This investigation also helps determine whether the obstruction is complete or partial, and this in turn may markedly influence your plan to manage the patient in the immediate future. A CT scan combined with an enema is also good and has the added benefit of defining the surrounding structures and detecting any metastatic disease. These patients receive both i.v. and rectal contrast. Whether a Gastrografin® enema or a CT-enema is performed will most likely depend on which test is offered at your hospital and which test the radiologist feels more comfortable performing. In the end, what is important is that they are inserting contrast via the anus (not the mouth!) and imaging in some way!\\n\\n## Differential Diagnosis\\n\\nDr. Gershon Efron, a very wise surgeon who has been a mentor to many (I am not biased even though he is my father), has often explained that the GI tract from the mouth to the anus is just a tube and that when thinking about what causes a blockage in this tube, we need to think of things that can occur outside the lumen of the tube, in the wall of the tube, and inside the lumen of the tube. This concept is depicted in Table 27.1 which lists the various etiologies of colonic obstruction.\\n\\nA key differentiation to be made is whether this is a pseudo-obstruction or a true mechanical obstruction. Pseudo-obstruction (Ogilvie’s syndrome) is an adynamic ileus of the colon that rarely requires surgical resection. Differentiation between a mechanical and pseudo-obstruction is done either with an endoscope or in the department of radiology. Before operating on a colonic obstruction it is...\\n\\n## Table 27.1: Etiologies of Colonic Obstruction\\n\\n| Etiology Type | Description |\\n|---------------|-------------|\\n| Outside the lumen | |\\n| Wall of the tube | |\\n| Inside the lumen | |\\n```\\n\\n### Notes:\\n- The text has been transcribed while excluding any headers, footers, and diagonal text.\\n- The table structure has been retained, but specific details within the table are marked as due to lack of clarity in the provided text.\\n- No images or figures were identified in the provided text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Assessment of Obstruction',\n", " 'md': '## Assessment of Obstruction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The next step in assessing this patient should be determining where the obstruction is, and the best test for that is a Gastrografin® enema, although this may be difficult to obtain because it is often hard to convince a radiologist to do it. However, it’s the safest and best test for identifying the location of the obstruction. I recommend that the surgeon be present when the test is performed, as it is a dynamic test and viewing the images themselves to see the location of the obstruction is best done in real time with the radiologist. Your presence there may also motivate the radiologist to leave his nice comfy bed, as these emergencies always tend to happen in the middle of the night. This investigation also helps determine whether the obstruction is complete or partial, and this in turn may markedly influence your plan to manage the patient in the immediate future. A CT scan combined with an enema is also good and has the added benefit of defining the surrounding structures and detecting any metastatic disease. These patients receive both i.v. and rectal contrast. Whether a Gastrografin® enema or a CT-enema is performed will most likely depend on which test is offered at your hospital and which test the radiologist feels more comfortable performing. In the end, what is important is that they are inserting contrast via the anus (not the mouth!) and imaging in some way!',\n", " 'md': 'The next step in assessing this patient should be determining where the obstruction is, and the best test for that is a Gastrografin® enema, although this may be difficult to obtain because it is often hard to convince a radiologist to do it. However, it’s the safest and best test for identifying the location of the obstruction. I recommend that the surgeon be present when the test is performed, as it is a dynamic test and viewing the images themselves to see the location of the obstruction is best done in real time with the radiologist. Your presence there may also motivate the radiologist to leave his nice comfy bed, as these emergencies always tend to happen in the middle of the night. This investigation also helps determine whether the obstruction is complete or partial, and this in turn may markedly influence your plan to manage the patient in the immediate future. A CT scan combined with an enema is also good and has the added benefit of defining the surrounding structures and detecting any metastatic disease. These patients receive both i.v. and rectal contrast. Whether a Gastrografin® enema or a CT-enema is performed will most likely depend on which test is offered at your hospital and which test the radiologist feels more comfortable performing. In the end, what is important is that they are inserting contrast via the anus (not the mouth!) and imaging in some way!',\n", " 'bBox': {'x': 72, 'y': 121, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Differential Diagnosis',\n", " 'md': '## Differential Diagnosis',\n", " 'bBox': {'x': 86, 'y': 448, 'w': 168.26, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Dr. Gershon Efron, a very wise surgeon who has been a mentor to many (I am not biased even though he is my father), has often explained that the GI tract from the mouth to the anus is just a tube and that when thinking about what causes a blockage in this tube, we need to think of things that can occur outside the lumen of the tube, in the wall of the tube, and inside the lumen of the tube. This concept is depicted in Table 27.1 which lists the various etiologies of colonic obstruction.\\n\\nA key differentiation to be made is whether this is a pseudo-obstruction or a true mechanical obstruction. Pseudo-obstruction (Ogilvie’s syndrome) is an adynamic ileus of the colon that rarely requires surgical resection. Differentiation between a mechanical and pseudo-obstruction is done either with an endoscope or in the department of radiology. Before operating on a colonic obstruction it is...',\n", " 'md': 'Dr. Gershon Efron, a very wise surgeon who has been a mentor to many (I am not biased even though he is my father), has often explained that the GI tract from the mouth to the anus is just a tube and that when thinking about what causes a blockage in this tube, we need to think of things that can occur outside the lumen of the tube, in the wall of the tube, and inside the lumen of the tube. This concept is depicted in Table 27.1 which lists the various etiologies of colonic obstruction.\\n\\nA key differentiation to be made is whether this is a pseudo-obstruction or a true mechanical obstruction. Pseudo-obstruction (Ogilvie’s syndrome) is an adynamic ileus of the colon that rarely requires surgical resection. Differentiation between a mechanical and pseudo-obstruction is done either with an endoscope or in the department of radiology. Before operating on a colonic obstruction it is...',\n", " 'bBox': {'x': 72, 'y': 500, 'w': 467.85, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 27.1: Etiologies of Colonic Obstruction',\n", " 'md': '## Table 27.1: Etiologies of Colonic Obstruction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Etiology Type', 'Description'],\n", " ['Outside the lumen', ''],\n", " ['Wall of the tube', ''],\n", " ['Inside the lumen', '']],\n", " 'md': '| Etiology Type | Description |\\n|---------------|-------------|\\n| Outside the lumen | |\\n| Wall of the tube | |\\n| Inside the lumen | |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Etiology Type\",\"Description\"\\n\"Outside the lumen\",\"\"\\n\"Wall of the tube\",\"\"\\n\"Inside the lumen\",\"\"',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text has been transcribed while excluding any headers, footers, and diagonal text.\\n- The table structure has been retained, but specific details within the table are marked as due to lack of clarity in the provided text.\\n- No images or figures were identified in the provided text.',\n", " 'md': '- The text has been transcribed while excluding any headers, footers, and diagonal text.\\n- The table structure has been retained, but specific details within the table are marked as due to lack of clarity in the provided text.\\n- No images or figures were identified in the provided text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Table 27.1 which lists the various etiologies of colonic obstruction.'}]},\n", " {'page': 462,\n", " 'text': \" imperative to rule out pseudo-obstruction (see below).\\n\\n But now let us return to our ‘classical patient’ who suffers from the most\\ncommon cause of colonic obstruction — cancer.\\n Table 27.1. Differential diagnosis for colonic obstruction. This list\\n is aguideline and_is byno means exhaustive:_\\n Outside the lumen of the bowel:\\n Hernias internal and external, groin and incisional (rare):\\n Adhesions (rare):\\n Abscesses causing external compression or kinking:\\n Volvulus:\\n Endometriosis (partially in the wall_)\\n Inside the wall of the bowel:\\n Congenital (short segment Hirschsprung's:\\n Traumatic (hematoma):\\n Neoplastic:\\n Inflammatory (diverticular stricture; IBD stricture):\\n Infectious (tubercular stricture)\\n Inside the lumen of the bowel:\\n Foreign body:\\n Fecal impaction.\\n Management\\n\\n The initial management should be undertaken in the emergency room.\\nEven though we do not think the patient has a small bowel\\ncomponent to his obstruction, placing a nasogastric tube will help\\nprevent further build-up of fluid and gases within his colon and\\nshould be undertaken in the ER. It is also crucial to ensure that he is\\nwell hydrated with i.v. fluids; it may also be prudent to correct any\\nsymptomatic anemia with blood products.\",\n", " 'md': \"```markdown\\n## Differential Diagnosis for Colonic Obstruction\\n\\nThis list is a guideline and is by no means exhaustive:\\n\\n### Outside the lumen of the bowel:\\n- Hernias: internal and external, groin and incisional (rare)\\n- Adhesions (rare)\\n- Abscesses: causing external compression or kinking\\n- Volvulus\\n- Endometriosis (partially in the wall)\\n\\n### Inside the wall of the bowel:\\n- Congenital: short segment Hirschsprung's\\n- Traumatic: hematoma\\n- Neoplastic\\n- Inflammatory: diverticular stricture; IBD stricture\\n- Infectious: tubercular stricture\\n\\n### Inside the lumen of the bowel:\\n- Foreign body\\n- Fecal impaction\\n\\n## Management\\n\\nThe initial management should be undertaken in the emergency room. Even though we do not think the patient has a small bowel component to his obstruction, placing a nasogastric tube will help prevent further build-up of fluid and gases within his colon and should be undertaken in the ER. It is also crucial to ensure that he is well hydrated with i.v. fluids; it may also be prudent to correct any symptomatic anemia with blood products.\\n```\",\n", " 'images': [{'name': 'img_p461_1.png',\n", " 'height': 731,\n", " 'width': 728,\n", " 'x': 126,\n", " 'y': 161.28000000000003,\n", " 'original_width': 1404,\n", " 'original_height': 1411}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Differential Diagnosis for Colonic Obstruction',\n", " 'md': '## Differential Diagnosis for Colonic Obstruction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This list is a guideline and is by no means exhaustive:',\n", " 'md': 'This list is a guideline and is by no means exhaustive:',\n", " 'bBox': {'x': 129.96, 'y': 182.05, 'w': 22.75, 'h': 12.86}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Outside the lumen of the bowel:',\n", " 'md': '### Outside the lumen of the bowel:',\n", " 'bBox': {'x': 133.91, 'y': 201.82, 'w': 158.24, 'h': 11.87}},\n", " {'type': 'text',\n", " 'value': '- Hernias: internal and external, groin and incisional (rare)\\n- Adhesions (rare)\\n- Abscesses: causing external compression or kinking\\n- Volvulus\\n- Endometriosis (partially in the wall)',\n", " 'md': '- Hernias: internal and external, groin and incisional (rare)\\n- Adhesions (rare)\\n- Abscesses: causing external compression or kinking\\n- Volvulus\\n- Endometriosis (partially in the wall)',\n", " 'bBox': {'x': 168.03, 'y': 233.96, 'w': 41.54, 'h': 9.89}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Inside the wall of the bowel:',\n", " 'md': '### Inside the wall of the bowel:',\n", " 'bBox': {'x': 133.91, 'y': 325.44, 'w': 138.46, 'h': 12.86}},\n", " {'type': 'text',\n", " 'value': \"- Congenital: short segment Hirschsprung's\\n- Traumatic: hematoma\\n- Neoplastic\\n- Inflammatory: diverticular stricture; IBD stricture\\n- Infectious: tubercular stricture\",\n", " 'md': \"- Congenital: short segment Hirschsprung's\\n- Traumatic: hematoma\\n- Neoplastic\\n- Inflammatory: diverticular stricture; IBD stricture\\n- Infectious: tubercular stricture\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Inside the lumen of the bowel:',\n", " 'md': '### Inside the lumen of the bowel:',\n", " 'bBox': {'x': 133.91, 'y': 450.53, 'w': 151.32, 'h': 13.84}},\n", " {'type': 'text',\n", " 'value': '- Foreign body\\n- Fecal impaction',\n", " 'md': '- Foreign body\\n- Fecal impaction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management',\n", " 'md': '## Management',\n", " 'bBox': {'x': 86, 'y': 563, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The initial management should be undertaken in the emergency room. Even though we do not think the patient has a small bowel component to his obstruction, placing a nasogastric tube will help prevent further build-up of fluid and gases within his colon and should be undertaken in the ER. It is also crucial to ensure that he is well hydrated with i.v. fluids; it may also be prudent to correct any symptomatic anemia with blood products.\\n```',\n", " 'md': 'The initial management should be undertaken in the emergency room. Even though we do not think the patient has a small bowel component to his obstruction, placing a nasogastric tube will help prevent further build-up of fluid and gases within his colon and should be undertaken in the ER. It is also crucial to ensure that he is well hydrated with i.v. fluids; it may also be prudent to correct any symptomatic anemia with blood products.\\n```',\n", " 'bBox': {'x': 72, 'y': 182.05, 'w': 467.61, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 463,\n", " 'text': ' Now you have to decide how to proceed and this depends on the level\\nof the obstruction and its assumed cause. It also depends on the degree\\nof the obstruction. Patients with complete obstruction and significant\\ncolonic distension resulting in a cecal diameter greater than 10cm\\nrequire urgent intervention — these patients are best served with an\\noperation. There is another option for patients with incomplete\\nobstruction, and that is the placement of a colonic stent.\\n\\n To stent or not to stent, that is the question!\\n\\n Colonic stents (if local expertise is available) are a reasonable\\noption for patients with a left-sided obstruction. However, patients\\nwith an obstruction proximal to the splenic flexure (uncommon\\nsituation) are usually better served by an extended right\\nhemicolectomy and ileocolic anastomosis. An exception to this rule is\\nthe presence of significant metastatic disease. In this situation insertion\\nof a stent may be attempted even for an obstruction proximal to the\\nsplenic flexure. This can limit morbidity and allow the patient to enter a\\npalliative pathway of care more rapidly.\\n\\n In those without metastatic disease we view colonic stenting as a\\ntemporizing intervention that allows decompression and\\nmechanical preparation of the colon prior to an elective resection.\\nStenting is a more definitive solution if the patient has a burden of\\nmetastatic disease that suggests a limited life span. ħowever, bear in\\nmind the following practical points:\\n\\n • Patients with a complete obstruction on Gastrografin® enema\\n are not eligible for stents as it is often not possible to pass\\n either a wire or the stent through the obstruction.\\n • If the point of obstruction is at the splenic flexure, or at a kink in the\\n sigmoid colon, placement of a stent is often not feasible. Stents are\\n inserted with a rather inflexible deployment mechanism, so while a\\n wire can be passed through the obstruction and around a curve,\\n passing the mechanism that will deploy the stent around this curve\\n is often not possible and indeed not advisable as it can lead to\\n perforation. Therefore, stenting is a good option when the',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nNow you have to decide how to proceed and this depends on the level of the obstruction and its assumed cause. It also depends on the degree of the obstruction. Patients with complete obstruction and significant colonic distension resulting in a cecal diameter greater than 10cm require urgent intervention — these patients are best served with an operation. There is another option for patients with incomplete obstruction, and that is the placement of a colonic stent.\\n\\nTo stent or not to stent, that is the question!\\n\\nColonic stents (if local expertise is available) are a reasonable option for patients with a left-sided obstruction. However, patients with an obstruction proximal to the splenic flexure (uncommon situation) are usually better served by an extended right hemicolectomy and ileocolic anastomosis. An exception to this rule is the presence of significant metastatic disease. In this situation insertion of a stent may be attempted even for an obstruction proximal to the splenic flexure. This can limit morbidity and allow the patient to enter a palliative pathway of care more rapidly.\\n\\nIn those without metastatic disease we view colonic stenting as a temporizing intervention that allows decompression and mechanical preparation of the colon prior to an elective resection. Stenting is a more definitive solution if the patient has a burden of metastatic disease that suggests a limited life span. However, bear in mind the following practical points:\\n\\n- Patients with a complete obstruction on Gastrografin® enema are not eligible for stents as it is often not possible to pass either a wire or the stent through the obstruction.\\n- If the point of obstruction is at the splenic flexure, or at a kink in the sigmoid colon, placement of a stent is often not feasible. Stents are inserted with a rather inflexible deployment mechanism, so while a wire can be passed through the obstruction and around a curve, passing the mechanism that will deploy the stent around this curve is often not possible and indeed not advisable as it can lead to perforation. Therefore, stenting is a good option when the...\\n\\n## Image Identification and Description\\n\\n*No images or graphs were identified on this page.*\\n\\n## Summary\\n\\nThis page discusses the management of colonic obstructions, emphasizing the decision-making process regarding the use of colonic stents versus surgical intervention. It outlines the conditions under which stenting may be appropriate, particularly in the context of left-sided obstructions and the presence of metastatic disease. Practical considerations regarding the feasibility of stenting in certain anatomical locations are also highlighted.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Now you have to decide how to proceed and this depends on the level of the obstruction and its assumed cause. It also depends on the degree of the obstruction. Patients with complete obstruction and significant colonic distension resulting in a cecal diameter greater than 10cm require urgent intervention — these patients are best served with an operation. There is another option for patients with incomplete obstruction, and that is the placement of a colonic stent.\\n\\nTo stent or not to stent, that is the question!\\n\\nColonic stents (if local expertise is available) are a reasonable option for patients with a left-sided obstruction. However, patients with an obstruction proximal to the splenic flexure (uncommon situation) are usually better served by an extended right hemicolectomy and ileocolic anastomosis. An exception to this rule is the presence of significant metastatic disease. In this situation insertion of a stent may be attempted even for an obstruction proximal to the splenic flexure. This can limit morbidity and allow the patient to enter a palliative pathway of care more rapidly.\\n\\nIn those without metastatic disease we view colonic stenting as a temporizing intervention that allows decompression and mechanical preparation of the colon prior to an elective resection. Stenting is a more definitive solution if the patient has a burden of metastatic disease that suggests a limited life span. However, bear in mind the following practical points:\\n\\n- Patients with a complete obstruction on Gastrografin® enema are not eligible for stents as it is often not possible to pass either a wire or the stent through the obstruction.\\n- If the point of obstruction is at the splenic flexure, or at a kink in the sigmoid colon, placement of a stent is often not feasible. Stents are inserted with a rather inflexible deployment mechanism, so while a wire can be passed through the obstruction and around a curve, passing the mechanism that will deploy the stent around this curve is often not possible and indeed not advisable as it can lead to perforation. Therefore, stenting is a good option when the...',\n", " 'md': 'Now you have to decide how to proceed and this depends on the level of the obstruction and its assumed cause. It also depends on the degree of the obstruction. Patients with complete obstruction and significant colonic distension resulting in a cecal diameter greater than 10cm require urgent intervention — these patients are best served with an operation. There is another option for patients with incomplete obstruction, and that is the placement of a colonic stent.\\n\\nTo stent or not to stent, that is the question!\\n\\nColonic stents (if local expertise is available) are a reasonable option for patients with a left-sided obstruction. However, patients with an obstruction proximal to the splenic flexure (uncommon situation) are usually better served by an extended right hemicolectomy and ileocolic anastomosis. An exception to this rule is the presence of significant metastatic disease. In this situation insertion of a stent may be attempted even for an obstruction proximal to the splenic flexure. This can limit morbidity and allow the patient to enter a palliative pathway of care more rapidly.\\n\\nIn those without metastatic disease we view colonic stenting as a temporizing intervention that allows decompression and mechanical preparation of the colon prior to an elective resection. Stenting is a more definitive solution if the patient has a burden of metastatic disease that suggests a limited life span. However, bear in mind the following practical points:\\n\\n- Patients with a complete obstruction on Gastrografin® enema are not eligible for stents as it is often not possible to pass either a wire or the stent through the obstruction.\\n- If the point of obstruction is at the splenic flexure, or at a kink in the sigmoid colon, placement of a stent is often not feasible. Stents are inserted with a rather inflexible deployment mechanism, so while a wire can be passed through the obstruction and around a curve, passing the mechanism that will deploy the stent around this curve is often not possible and indeed not advisable as it can lead to perforation. Therefore, stenting is a good option when the...',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.77, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 513, 'y': 448, 'w': 25.58, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '*No images or graphs were identified on this page.*',\n", " 'md': '*No images or graphs were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the management of colonic obstructions, emphasizing the decision-making process regarding the use of colonic stents versus surgical intervention. It outlines the conditions under which stenting may be appropriate, particularly in the context of left-sided obstructions and the presence of metastatic disease. Practical considerations regarding the feasibility of stenting in certain anatomical locations are also highlighted.\\n```',\n", " 'md': 'This page discusses the management of colonic obstructions, emphasizing the decision-making process regarding the use of colonic stents versus surgical intervention. It outlines the conditions under which stenting may be appropriate, particularly in the context of left-sided obstructions and the presence of metastatic disease. Practical considerations regarding the feasibility of stenting in certain anatomical locations are also highlighted.\\n```',\n", " 'bBox': {'x': 151, 'y': 314, 'w': 25.6, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 464,\n", " 'text': ' obstruction is located in a relatively straight piece of colon and\\n when the patient does not have a complete obstruction.\\n\\n Stenting for obstructing carcinoma of the rectum?\\n\\n Placing rectal stents is controversial. I do not like placing stents in\\nthe rectum if the patient has an obstruction from cancer even if\\ntechnically feasible. Modern management of rectal cancer dictates\\nthat if we have a large obstructing tumor it should be treated with\\nneoadjuvant therapy. In patients treated this way, the combination of\\ntumor necrosis from the neoadjuvant therapy and pressure from the stent\\nmay lead to perforation, converting a curable patient to one with\\ndisseminated disease. These perforations generally occur 4-6 weeks\\nafter completing the radiation, as the cancer continues to undergo\\nnecrosis. Therefore, in obstructing rectal cancer, my preference is to\\nperform a laparoscopic diverting stoma to decompress the colon,\\nand permit neoadjuvant therapy prior to surgery.\\n\\n There is debate as to whether an ileostomy or colostomy should\\nbe performed. I think that the colon should be decompressed and\\ntherefore a colostomy should be made. Ideally the colostomy should\\nbe placed as distally in the sigmoid colon as possible to permit this\\narea to be resected when the definitive operation is performed.\\nħowever, this may not be feasible and a more proximal stoma, even at\\nthe transverse colon, may be needed. If the obstruction is not complete\\nand the patient is symptomatic, then a diverting loop ileostomy is an\\nattractive option as gas and some stool will still decompress past the\\nrectal lesion and the tumor itself should shrink — and the lumen of the\\nbowel widen — as the radiation and chemotherapy are delivered.\\n\\n Another difficulty with colonic stents, particularly in the rectum, is\\nthat they can migrate. If this happens they can come to rest on the\\npelvic floor musculature at the level of the anorectal ring and this causes\\nsignificant pain and irritation. They can also migrate into the anal canal\\nand out of the anus. Once a stent is deployed it is very difficult to remove\\nwithout significant trauma and therefore operations are often required to\\nremove migrated stents. So to avoid converting a stage II or stage III',\n", " 'md': '```markdown\\n## Stenting for Obstructing Carcinoma of the Rectum\\n\\nPlacing rectal stents is controversial. I do not like placing stents in the rectum if the patient has an obstruction from cancer even if technically feasible. Modern management of rectal cancer dictates that if we have a large obstructing tumor it should be treated with neoadjuvant therapy. In patients treated this way, the combination of tumor necrosis from the neoadjuvant therapy and pressure from the stent may lead to perforation, converting a curable patient to one with disseminated disease. These perforations generally occur 4-6 weeks after completing the radiation, as the cancer continues to undergo necrosis. Therefore, in obstructing rectal cancer, my preference is to perform a laparoscopic diverting stoma to decompress the colon, and permit neoadjuvant therapy prior to surgery.\\n\\nThere is debate as to whether an ileostomy or colostomy should be performed. I think that the colon should be decompressed and therefore a colostomy should be made. Ideally, the colostomy should be placed as distally in the sigmoid colon as possible to permit this area to be resected when the definitive operation is performed. However, this may not be feasible and a more proximal stoma, even at the transverse colon, may be needed. If the obstruction is not complete and the patient is symptomatic, then a diverting loop ileostomy is an attractive option as gas and some stool will still decompress past the rectal lesion and the tumor itself should shrink — and the lumen of the bowel widen — as the radiation and chemotherapy are delivered.\\n\\nAnother difficulty with colonic stents, particularly in the rectum, is that they can migrate. If this happens they can come to rest on the pelvic floor musculature at the level of the anorectal ring and this causes significant pain and irritation. They can also migrate into the anal canal and out of the anus. Once a stent is deployed it is very difficult to remove without significant trauma and therefore operations are often required to remove migrated stents. So to avoid converting a stage II or stage III...\\n```\\n\\n### Notes:\\n- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Stenting for Obstructing Carcinoma of the Rectum',\n", " 'md': '## Stenting for Obstructing Carcinoma of the Rectum',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Placing rectal stents is controversial. I do not like placing stents in the rectum if the patient has an obstruction from cancer even if technically feasible. Modern management of rectal cancer dictates that if we have a large obstructing tumor it should be treated with neoadjuvant therapy. In patients treated this way, the combination of tumor necrosis from the neoadjuvant therapy and pressure from the stent may lead to perforation, converting a curable patient to one with disseminated disease. These perforations generally occur 4-6 weeks after completing the radiation, as the cancer continues to undergo necrosis. Therefore, in obstructing rectal cancer, my preference is to perform a laparoscopic diverting stoma to decompress the colon, and permit neoadjuvant therapy prior to surgery.\\n\\nThere is debate as to whether an ileostomy or colostomy should be performed. I think that the colon should be decompressed and therefore a colostomy should be made. Ideally, the colostomy should be placed as distally in the sigmoid colon as possible to permit this area to be resected when the definitive operation is performed. However, this may not be feasible and a more proximal stoma, even at the transverse colon, may be needed. If the obstruction is not complete and the patient is symptomatic, then a diverting loop ileostomy is an attractive option as gas and some stool will still decompress past the rectal lesion and the tumor itself should shrink — and the lumen of the bowel widen — as the radiation and chemotherapy are delivered.\\n\\nAnother difficulty with colonic stents, particularly in the rectum, is that they can migrate. If this happens they can come to rest on the pelvic floor musculature at the level of the anorectal ring and this causes significant pain and irritation. They can also migrate into the anal canal and out of the anus. Once a stent is deployed it is very difficult to remove without significant trauma and therefore operations are often required to remove migrated stents. So to avoid converting a stage II or stage III...\\n```',\n", " 'md': 'Placing rectal stents is controversial. I do not like placing stents in the rectum if the patient has an obstruction from cancer even if technically feasible. Modern management of rectal cancer dictates that if we have a large obstructing tumor it should be treated with neoadjuvant therapy. In patients treated this way, the combination of tumor necrosis from the neoadjuvant therapy and pressure from the stent may lead to perforation, converting a curable patient to one with disseminated disease. These perforations generally occur 4-6 weeks after completing the radiation, as the cancer continues to undergo necrosis. Therefore, in obstructing rectal cancer, my preference is to perform a laparoscopic diverting stoma to decompress the colon, and permit neoadjuvant therapy prior to surgery.\\n\\nThere is debate as to whether an ileostomy or colostomy should be performed. I think that the colon should be decompressed and therefore a colostomy should be made. Ideally, the colostomy should be placed as distally in the sigmoid colon as possible to permit this area to be resected when the definitive operation is performed. However, this may not be feasible and a more proximal stoma, even at the transverse colon, may be needed. If the obstruction is not complete and the patient is symptomatic, then a diverting loop ileostomy is an attractive option as gas and some stool will still decompress past the rectal lesion and the tumor itself should shrink — and the lumen of the bowel widen — as the radiation and chemotherapy are delivered.\\n\\nAnother difficulty with colonic stents, particularly in the rectum, is that they can migrate. If this happens they can come to rest on the pelvic floor musculature at the level of the anorectal ring and this causes significant pain and irritation. They can also migrate into the anal canal and out of the anus. Once a stent is deployed it is very difficult to remove without significant trauma and therefore operations are often required to remove migrated stents. So to avoid converting a stage II or stage III...\\n```',\n", " 'bBox': {'x': 72, 'y': 183, 'w': 467.73, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 465,\n", " 'text': 'rectal cancer to a stage IV rectal cancer with a perforation, and also\\nbecause of the difficulties of stent migration in the rectum, I would not\\nrecommend using a stent for a rectal obstruction.\\n\\n In summary — I apologize for tiring you with such a long spiel — I\\nthink the opportunity to stent these patients with mechanical\\ncolorectal obstruction is rare. They need to have the obstruction in\\na relatively straight piece of colon, distal to the splenic flexure, and\\nnot within the rectum. It also requires a small opening to be present to\\nplace the stent. Studies looking at the risks and complications of stenting\\nversus surgery have been varied in their results; however, the one\\nrandomized controlled trial that was initiated to compare colonic stenting\\nversus surgery for acute obstruction was discontinued early because of\\nthe complication rates in the stented patients.\\n\\n With all the above in mind, and assuming that colonic stenting is\\nnot available to you, the management of patients diagnosed with\\nmechanical colonic obstruction will be surgical.\\n\\n The operation\\n\\n Well, we’ve made the diagnosis of colonic obstruction and are now\\nproceeding to the operating room. This particular patient has a complete\\nobstruction ® enema; his cecum is 12cm in diameter and he is fairly\\nGastrografin in the sigmoid colon (non-stentable) confirmed by\\ntender, so his operation should not be delayed. On the other hand, in a\\npatient with an incompetent ileocecal valve, without significant\\ncecal distension I would prefer to operate during the day time…\\n\\n Now what should we do in the operating room? When operating on\\nthese patients, I like to sort them into two groups, the sick ones and\\nthe not so sick ones. Our patient is in relatively good shape — with fluid\\nresuscitation, he has become less dehydrated, his tachycardia has\\nresolved, and he has a good urine output — therefore, we could attempt\\nto perform a definitive procedure as will be detailed later.\\n\\n Operating on ‘sick’ patients',\n", " 'md': \"```markdown\\n## Summary of Colonic Stenting and Surgical Management\\n\\nRectal cancer can progress to stage IV with complications such as perforation. Due to the challenges associated with stent migration in the rectum, it is not recommended to use a stent for rectal obstruction.\\n\\nIn summary, the opportunity to stent patients with mechanical colorectal obstruction is rare. The obstruction must occur in a relatively straight section of the colon, distal to the splenic flexure, and a small opening must be present for stent placement. Studies comparing the risks and complications of stenting versus surgery have yielded varied results. Notably, a randomized controlled trial comparing colonic stenting to surgery for acute obstruction was discontinued early due to high complication rates in stented patients.\\n\\nAssuming colonic stenting is not an option, the management of patients diagnosed with mechanical colonic obstruction will be surgical.\\n\\n### The Operation\\n\\nAfter diagnosing colonic obstruction, the patient is taken to the operating room. In this case, the patient has a complete obstruction with a cecum measuring 12 cm in diameter and is fairly tender, indicating that the operation should not be delayed. Conversely, in a patient with an incompetent ileocecal valve and without significant cecal distension, it is preferable to schedule the operation during the daytime.\\n\\nWhen operating on these patients, they can be categorized into two groups: the sick ones and the not-so-sick ones. The current patient is in relatively good condition; following fluid resuscitation, he has become less dehydrated, his tachycardia has resolved, and he has a good urine output. Therefore, a definitive procedure can be attempted, as will be detailed later.\\n\\n### Operating on 'Sick' Patients\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary of Colonic Stenting and Surgical Management',\n", " 'md': '## Summary of Colonic Stenting and Surgical Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Rectal cancer can progress to stage IV with complications such as perforation. Due to the challenges associated with stent migration in the rectum, it is not recommended to use a stent for rectal obstruction.\\n\\nIn summary, the opportunity to stent patients with mechanical colorectal obstruction is rare. The obstruction must occur in a relatively straight section of the colon, distal to the splenic flexure, and a small opening must be present for stent placement. Studies comparing the risks and complications of stenting versus surgery have yielded varied results. Notably, a randomized controlled trial comparing colonic stenting to surgery for acute obstruction was discontinued early due to high complication rates in stented patients.\\n\\nAssuming colonic stenting is not an option, the management of patients diagnosed with mechanical colonic obstruction will be surgical.',\n", " 'md': 'Rectal cancer can progress to stage IV with complications such as perforation. Due to the challenges associated with stent migration in the rectum, it is not recommended to use a stent for rectal obstruction.\\n\\nIn summary, the opportunity to stent patients with mechanical colorectal obstruction is rare. The obstruction must occur in a relatively straight section of the colon, distal to the splenic flexure, and a small opening must be present for stent placement. Studies comparing the risks and complications of stenting versus surgery have yielded varied results. Notably, a randomized controlled trial comparing colonic stenting to surgery for acute obstruction was discontinued early due to high complication rates in stented patients.\\n\\nAssuming colonic stenting is not an option, the management of patients diagnosed with mechanical colonic obstruction will be surgical.',\n", " 'bBox': {'x': 72, 'y': 371, 'w': 326, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Operation',\n", " 'md': '### The Operation',\n", " 'bBox': {'x': 86, 'y': 414, 'w': 109.42, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'After diagnosing colonic obstruction, the patient is taken to the operating room. In this case, the patient has a complete obstruction with a cecum measuring 12 cm in diameter and is fairly tender, indicating that the operation should not be delayed. Conversely, in a patient with an incompetent ileocecal valve and without significant cecal distension, it is preferable to schedule the operation during the daytime.\\n\\nWhen operating on these patients, they can be categorized into two groups: the sick ones and the not-so-sick ones. The current patient is in relatively good condition; following fluid resuscitation, he has become less dehydrated, his tachycardia has resolved, and he has a good urine output. Therefore, a definitive procedure can be attempted, as will be detailed later.',\n", " 'md': 'After diagnosing colonic obstruction, the patient is taken to the operating room. In this case, the patient has a complete obstruction with a cecum measuring 12 cm in diameter and is fairly tender, indicating that the operation should not be delayed. Conversely, in a patient with an incompetent ileocecal valve and without significant cecal distension, it is preferable to schedule the operation during the daytime.\\n\\nWhen operating on these patients, they can be categorized into two groups: the sick ones and the not-so-sick ones. The current patient is in relatively good condition; following fluid resuscitation, he has become less dehydrated, his tachycardia has resolved, and he has a good urine output. Therefore, a definitive procedure can be attempted, as will be detailed later.',\n", " 'bBox': {'x': 86, 'y': 414, 'w': 109.42, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': \"Operating on 'Sick' Patients\",\n", " 'md': \"### Operating on 'Sick' Patients\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 466,\n", " 'text': ' When patients are sick we first must resuscitate them adequately (\\nChapter 6). This may require a trip to the intensive care unit for more\\ninvasive monitoring, such as arterial lines and even (the controversial)\\nSwan Ganz catheter placement.\\n\\n For sick patients, we really must do the quickest, safest thing. If it\\nis safe to resect the obstructing lesion, that should be done and an end\\ncolostomy formed. In other words, Hartmann’s procedure is the way\\nto go. There are patients who are too ill even to undergo a\\nHartmann’s procedure and therefore a diverting loop colostomy\\nshould be fashioned.\\n\\n Evaluation of the rest of the abdomen including the viability of the\\ncolon is essential. For massive distension with necrosis either in the\\ncecum or in other parts of the colon, the patient may require a total\\ncolectomy regardless of how sick they are at the time of presentation.\\nPerforation of the cecum secondary to distension found in\\nassociation with a left-sided lesion requires total colectomy — with\\nan end ileostomy and closure of the rectal stump.\\n\\n A few words about stomas (see also Chapter 14)\\n Stomas can either be end stomas, loop stomas, or end loop\\nstomas. A fourth kind of stoma that can be created in the colon is a blow-\\nhole colostomy. Finally, a cecostomy is also an option, though not\\npreferred in this situation. My choice in forming stomas would be an end\\ncolostomy if possible (part of the ħartmann’s procedure). ħowever, if the\\npatient cannot undergo resection of the primary mass, a loop colostomy\\nshould be fashioned. These may be quite large given the distension of\\nthe proximal colon and may be difficult to manage because of their size.\\nThey also are prone to prolapse which can cause further complications in\\nthe future. Therefore, we like to avoid loop colostomies, if possible.\\n\\n When you have a really sick patient who will not tolerate much of\\nanything, a blow-hole colostomy — where you merely fashion an\\nopening in the transverse colon, to either the right or left of the midline,\\nmaturing the anti-mesenteric colonic wall to the dermis — can be\\nperformed. It will allow for decompression of gas and stool, and perhaps\\npermit the patient to recover somewhat, so that they may eventually',\n", " 'md': '```markdown\\n# Page Content\\n\\nWhen patients are sick we first must resuscitate them adequately. This may require a trip to the intensive care unit for more invasive monitoring, such as arterial lines and even (the controversial) Swan Ganz catheter placement.\\n\\nFor sick patients, we really must do the quickest, safest thing. If it is safe to resect the obstructing lesion, that should be done and an end colostomy formed. In other words, Hartmann’s procedure is the way to go. There are patients who are too ill even to undergo a Hartmann’s procedure and therefore a diverting loop colostomy should be fashioned.\\n\\nEvaluation of the rest of the abdomen including the viability of the colon is essential. For massive distension with necrosis either in the cecum or in other parts of the colon, the patient may require a total colectomy regardless of how sick they are at the time of presentation. Perforation of the cecum secondary to distension found in association with a left-sided lesion requires total colectomy — with an end ileostomy and closure of the rectal stump.\\n\\nA few words about stomas (see also Chapter 14). Stomas can either be end stomas, loop stomas, or end loop stomas. A fourth kind of stoma that can be created in the colon is a blow-hole colostomy. Finally, a cecostomy is also an option, though not preferred in this situation. My choice in forming stomas would be an end colostomy if possible (part of the Hartmann’s procedure). However, if the patient cannot undergo resection of the primary mass, a loop colostomy should be fashioned. These may be quite large given the distension of the proximal colon and may be difficult to manage because of their size. They also are prone to prolapse which can cause further complications in the future. Therefore, we like to avoid loop colostomies, if possible.\\n\\nWhen you have a really sick patient who will not tolerate much of anything, a blow-hole colostomy — where you merely fashion an opening in the transverse colon, to either the right or left of the midline, maturing the anti-mesenteric colonic wall to the dermis — can be performed. It will allow for decompression of gas and stool, and perhaps permit the patient to recover somewhat, so that they may eventually...\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'When patients are sick we first must resuscitate them adequately. This may require a trip to the intensive care unit for more invasive monitoring, such as arterial lines and even (the controversial) Swan Ganz catheter placement.\\n\\nFor sick patients, we really must do the quickest, safest thing. If it is safe to resect the obstructing lesion, that should be done and an end colostomy formed. In other words, Hartmann’s procedure is the way to go. There are patients who are too ill even to undergo a Hartmann’s procedure and therefore a diverting loop colostomy should be fashioned.\\n\\nEvaluation of the rest of the abdomen including the viability of the colon is essential. For massive distension with necrosis either in the cecum or in other parts of the colon, the patient may require a total colectomy regardless of how sick they are at the time of presentation. Perforation of the cecum secondary to distension found in association with a left-sided lesion requires total colectomy — with an end ileostomy and closure of the rectal stump.\\n\\nA few words about stomas (see also Chapter 14). Stomas can either be end stomas, loop stomas, or end loop stomas. A fourth kind of stoma that can be created in the colon is a blow-hole colostomy. Finally, a cecostomy is also an option, though not preferred in this situation. My choice in forming stomas would be an end colostomy if possible (part of the Hartmann’s procedure). However, if the patient cannot undergo resection of the primary mass, a loop colostomy should be fashioned. These may be quite large given the distension of the proximal colon and may be difficult to manage because of their size. They also are prone to prolapse which can cause further complications in the future. Therefore, we like to avoid loop colostomies, if possible.\\n\\nWhen you have a really sick patient who will not tolerate much of anything, a blow-hole colostomy — where you merely fashion an opening in the transverse colon, to either the right or left of the midline, maturing the anti-mesenteric colonic wall to the dermis — can be performed. It will allow for decompression of gas and stool, and perhaps permit the patient to recover somewhat, so that they may eventually...\\n\\n```',\n", " 'md': 'When patients are sick we first must resuscitate them adequately. This may require a trip to the intensive care unit for more invasive monitoring, such as arterial lines and even (the controversial) Swan Ganz catheter placement.\\n\\nFor sick patients, we really must do the quickest, safest thing. If it is safe to resect the obstructing lesion, that should be done and an end colostomy formed. In other words, Hartmann’s procedure is the way to go. There are patients who are too ill even to undergo a Hartmann’s procedure and therefore a diverting loop colostomy should be fashioned.\\n\\nEvaluation of the rest of the abdomen including the viability of the colon is essential. For massive distension with necrosis either in the cecum or in other parts of the colon, the patient may require a total colectomy regardless of how sick they are at the time of presentation. Perforation of the cecum secondary to distension found in association with a left-sided lesion requires total colectomy — with an end ileostomy and closure of the rectal stump.\\n\\nA few words about stomas (see also Chapter 14). Stomas can either be end stomas, loop stomas, or end loop stomas. A fourth kind of stoma that can be created in the colon is a blow-hole colostomy. Finally, a cecostomy is also an option, though not preferred in this situation. My choice in forming stomas would be an end colostomy if possible (part of the Hartmann’s procedure). However, if the patient cannot undergo resection of the primary mass, a loop colostomy should be fashioned. These may be quite large given the distension of the proximal colon and may be difficult to manage because of their size. They also are prone to prolapse which can cause further complications in the future. Therefore, we like to avoid loop colostomies, if possible.\\n\\nWhen you have a really sick patient who will not tolerate much of anything, a blow-hole colostomy — where you merely fashion an opening in the transverse colon, to either the right or left of the midline, maturing the anti-mesenteric colonic wall to the dermis — can be performed. It will allow for decompression of gas and stool, and perhaps permit the patient to recover somewhat, so that they may eventually...\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.82, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 6). This may require a trip to the intensive care unit for more invasive monitoring, such as arterial lines and even (the controversial)'},\n", " {'text': ''}]},\n", " {'page': 467,\n", " 'text': 'undergo a more definitive procedure. Finally, cecostomies are not easy\\nto manage and are not favoured in this situation. If a cecal perforation is\\nfound, and it is felt not to be safe to perform a total colectomy, then a\\nbetter option than a cecostomy would be a quick ileocolic resection with\\nthe formation of an end ileostomy and a mucous fistula, to allow for\\ndecompression.\\n\\n We, on the other hand, have had a favorable experience with cecostomy to decompress the\\n colon in sick patients with big obstructive masses — cancer or diverticular — as the first stage\\n of their management. (See Chapter 14 and Figure 14.5.) Moshe and Danny\\n\\n When you are not so sure what is causing the obstruction…\\n Sometimes you don’t know whether cancer (common) or diverticular\\ndisease (rare) is the cause of the obstruction. Diverticular obstruction\\nmay be caused by a phlegmon that is stuck to everything in the\\npelvis and this can look very much like cancer. Before undertaking a\\n‘mass resection’ involving ovaries, ureters or the uterus, I like to make\\nabsolutely sure that this is necessary. Such a resection for benign\\ndisease would be rash. If the patient is not sick then performing a\\nflexible endoscopy in the operating room and visualizing the lumen\\nof the obstructed colon gives you a good idea of the cause of\\nobstruction. If I can’t tell if the mass is benign or malignant (and it is\\nstuck to other structures) then I divert proximally, take multiple\\nbiopsies and return to address the mass at a later date — just as I\\nmight do if the patient were too sick to withstand a major resection.\\n\\n Operating on ‘fit’ patients — the definitive operation\\n What to do with the fit patient? This depends on the level of the\\nobstruction:\\n\\n • When the obstruction is found proximal to the splenic flexure,\\n the best operation is an extended right hemicolectomy — usually\\n with an ileocolic anastomosis to the descending colon.\\n • When the obstruction is found distally in the colon, the options\\n for management are:\\n resection with primary anastomosis;',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nUndergo a more definitive procedure. Finally, cecostomies are not easy to manage and are not favoured in this situation. If a cecal perforation is found, and it is felt not to be safe to perform a total colectomy, then a better option than a cecostomy would be a quick ileocolic resection with the formation of an end ileostomy and a mucous fistula, to allow for decompression.\\n\\nWe, on the other hand, have had a favorable experience with cecostomy to decompress the colon in sick patients with big obstructive masses — cancer or diverticular — as the first stage of their management. (See Chapter 14 and Figure 14.5.) Moshe and Danny\\n\\nWhen you are not so sure what is causing the obstruction… Sometimes you don’t know whether cancer (common) or diverticular disease (rare) is the cause of the obstruction. Diverticular obstruction may be caused by a phlegmon that is stuck to everything in the pelvis and this can look very much like cancer. Before undertaking a ‘mass resection’ involving ovaries, ureters or the uterus, I like to make absolutely sure that this is necessary. Such a resection for benign disease would be rash. If the patient is not sick then performing a flexible endoscopy in the operating room and visualizing the lumen of the obstructed colon gives you a good idea of the cause of obstruction. If I can’t tell if the mass is benign or malignant (and it is stuck to other structures) then I divert proximally, take multiple biopsies and return to address the mass at a later date — just as I might do if the patient were too sick to withstand a major resection.\\n\\nOperating on ‘fit’ patients — the definitive operation What to do with the fit patient? This depends on the level of the obstruction:\\n\\n- When the obstruction is found proximal to the splenic flexure, the best operation is an extended right hemicolectomy — usually with an ileocolic anastomosis to the descending colon.\\n- When the obstruction is found distally in the colon, the options for management are: resection with primary anastomosis;\\n\\n## Image Identification and Description\\n\\n**Figure 14.5**: (Description not provided in the text, but it is referenced. Please refer to the original document for details.)\\n\\n### Summary\\nThe text discusses the management of bowel obstructions, particularly in the context of cecostomies and ileocolic resections. It emphasizes the importance of determining the cause of obstruction before proceeding with surgical interventions, especially in patients who may have benign conditions. The management strategies differ based on the location of the obstruction within the colon.\\n```',\n", " 'images': [{'name': 'img_p466_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 207.35999999999967,\n", " 'y': 239.04}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Undergo a more definitive procedure. Finally, cecostomies are not easy to manage and are not favoured in this situation. If a cecal perforation is found, and it is felt not to be safe to perform a total colectomy, then a better option than a cecostomy would be a quick ileocolic resection with the formation of an end ileostomy and a mucous fistula, to allow for decompression.\\n\\nWe, on the other hand, have had a favorable experience with cecostomy to decompress the colon in sick patients with big obstructive masses — cancer or diverticular — as the first stage of their management. (See Chapter 14 and Figure 14.5.) Moshe and Danny\\n\\nWhen you are not so sure what is causing the obstruction… Sometimes you don’t know whether cancer (common) or diverticular disease (rare) is the cause of the obstruction. Diverticular obstruction may be caused by a phlegmon that is stuck to everything in the pelvis and this can look very much like cancer. Before undertaking a ‘mass resection’ involving ovaries, ureters or the uterus, I like to make absolutely sure that this is necessary. Such a resection for benign disease would be rash. If the patient is not sick then performing a flexible endoscopy in the operating room and visualizing the lumen of the obstructed colon gives you a good idea of the cause of obstruction. If I can’t tell if the mass is benign or malignant (and it is stuck to other structures) then I divert proximally, take multiple biopsies and return to address the mass at a later date — just as I might do if the patient were too sick to withstand a major resection.\\n\\nOperating on ‘fit’ patients — the definitive operation What to do with the fit patient? This depends on the level of the obstruction:\\n\\n- When the obstruction is found proximal to the splenic flexure, the best operation is an extended right hemicolectomy — usually with an ileocolic anastomosis to the descending colon.\\n- When the obstruction is found distally in the colon, the options for management are: resection with primary anastomosis;',\n", " 'md': 'Undergo a more definitive procedure. Finally, cecostomies are not easy to manage and are not favoured in this situation. If a cecal perforation is found, and it is felt not to be safe to perform a total colectomy, then a better option than a cecostomy would be a quick ileocolic resection with the formation of an end ileostomy and a mucous fistula, to allow for decompression.\\n\\nWe, on the other hand, have had a favorable experience with cecostomy to decompress the colon in sick patients with big obstructive masses — cancer or diverticular — as the first stage of their management. (See Chapter 14 and Figure 14.5.) Moshe and Danny\\n\\nWhen you are not so sure what is causing the obstruction… Sometimes you don’t know whether cancer (common) or diverticular disease (rare) is the cause of the obstruction. Diverticular obstruction may be caused by a phlegmon that is stuck to everything in the pelvis and this can look very much like cancer. Before undertaking a ‘mass resection’ involving ovaries, ureters or the uterus, I like to make absolutely sure that this is necessary. Such a resection for benign disease would be rash. If the patient is not sick then performing a flexible endoscopy in the operating room and visualizing the lumen of the obstructed colon gives you a good idea of the cause of obstruction. If I can’t tell if the mass is benign or malignant (and it is stuck to other structures) then I divert proximally, take multiple biopsies and return to address the mass at a later date — just as I might do if the patient were too sick to withstand a major resection.\\n\\nOperating on ‘fit’ patients — the definitive operation What to do with the fit patient? This depends on the level of the obstruction:\\n\\n- When the obstruction is found proximal to the splenic flexure, the best operation is an extended right hemicolectomy — usually with an ileocolic anastomosis to the descending colon.\\n- When the obstruction is found distally in the colon, the options for management are: resection with primary anastomosis;',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 14.5**: (Description not provided in the text, but it is referenced. Please refer to the original document for details.)',\n", " 'md': '**Figure 14.5**: (Description not provided in the text, but it is referenced. Please refer to the original document for details.)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the management of bowel obstructions, particularly in the context of cecostomies and ileocolic resections. It emphasizes the importance of determining the cause of obstruction before proceeding with surgical interventions, especially in patients who may have benign conditions. The management strategies differ based on the location of the obstruction within the colon.\\n```',\n", " 'md': 'The text discusses the management of bowel obstructions, particularly in the context of cecostomies and ileocolic resections. It emphasizes the importance of determining the cause of obstruction before proceeding with surgical interventions, especially in patients who may have benign conditions. The management strategies differ based on the location of the obstruction within the colon.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 468,\n", " 'text': ' resection with intra-operative colonic lavage and primary\\n anastomosis;\\n a ħartmann’s procedure (like in ‘sick’ patients…);\\n when performing a primary anastomosis there is always the\\n option of adding a diverting loop ileostomy to protect your\\n anastomosis.\\n\\n Of course, before the operation you have discussed with the patient\\nthat placing a stoma may be necessary. But whether to construct a\\nprimary anastomosis or do a stoma is sometimes not an easy decision as\\ndepicted in Figures 27.1a and 27.1b.\\n LeakINs colo-Rectalanstomosis\\n ReRz42o14\\n Figure 27.1a. “Idiot! Why did you anastomose?”',\n", " 'md': '```markdown\\n## Page Content\\n\\n- Resection with intra-operative colonic lavage and primary anastomosis.\\n- A Hartmann’s procedure (like in ‘sick’ patients…).\\n- When performing a primary anastomosis, there is always the option of adding a diverting loop ileostomy to protect your anastomosis.\\n\\nOf course, before the operation, you have discussed with the patient that placing a stoma may be necessary. But whether to construct a primary anastomosis or do a stoma is sometimes not an easy decision as depicted in Figures 27.1a and 27.1b.\\n\\n### Figure Descriptions\\n\\n#### Figure 27.1a\\n- **Description**: This figure features a humorous illustration with the caption “Idiot! Why did you anastomose?” It likely depicts a scenario related to the decision-making process in surgical procedures involving anastomosis.\\n- **Summary**: The image emphasizes the potential complications or mistakes that can occur during surgical anastomosis, highlighting the importance of careful consideration in surgical decisions.\\n\\n#### Figure 27.1b\\n- **Description**: \\n- **Summary**: \\n```',\n", " 'images': [{'name': 'img_p467_1.png',\n", " 'height': 575,\n", " 'width': 819,\n", " 'x': 103.67999999999938,\n", " 'y': 277.91999999999996,\n", " 'original_width': 1408,\n", " 'original_height': 988}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Resection with intra-operative colonic lavage and primary anastomosis.\\n- A Hartmann’s procedure (like in ‘sick’ patients…).\\n- When performing a primary anastomosis, there is always the option of adding a diverting loop ileostomy to protect your anastomosis.\\n\\nOf course, before the operation, you have discussed with the patient that placing a stoma may be necessary. But whether to construct a primary anastomosis or do a stoma is sometimes not an easy decision as depicted in Figures 27.1a and 27.1b.',\n", " 'md': '- Resection with intra-operative colonic lavage and primary anastomosis.\\n- A Hartmann’s procedure (like in ‘sick’ patients…).\\n- When performing a primary anastomosis, there is always the option of adding a diverting loop ileostomy to protect your anastomosis.\\n\\nOf course, before the operation, you have discussed with the patient that placing a stoma may be necessary. But whether to construct a primary anastomosis or do a stoma is sometimes not an easy decision as depicted in Figures 27.1a and 27.1b.',\n", " 'bBox': {'x': 72, 'y': 177, 'w': 467.7, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Descriptions',\n", " 'md': '### Figure Descriptions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Figure 27.1a',\n", " 'md': '#### Figure 27.1a',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure features a humorous illustration with the caption “Idiot! Why did you anastomose?” It likely depicts a scenario related to the decision-making process in surgical procedures involving anastomosis.\\n- **Summary**: The image emphasizes the potential complications or mistakes that can occur during surgical anastomosis, highlighting the importance of careful consideration in surgical decisions.',\n", " 'md': '- **Description**: This figure features a humorous illustration with the caption “Idiot! Why did you anastomose?” It likely depicts a scenario related to the decision-making process in surgical procedures involving anastomosis.\\n- **Summary**: The image emphasizes the potential complications or mistakes that can occur during surgical anastomosis, highlighting the importance of careful consideration in surgical decisions.',\n", " 'bBox': {'x': 133, 'y': 177, 'w': 84.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Figure 27.1b',\n", " 'md': '#### Figure 27.1b',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: \\n- **Summary**: \\n```',\n", " 'md': '- **Description**: \\n- **Summary**: \\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 469,\n", " 'text': ' ( ( (\\n Rolstowee/\\n 7\\n PeRyA2o14\\nFigure 27.1b. “Idiot! Why didn’t you do an anastomosis?”\\n\\n The conduct of the operation\\n Decompression of the colon\\n I do a midline laparotomy because I don’t find a role for laparoscopy in\\ncolonic obstruction. It is advisable to have a means of rapidly\\ndecompressing the colon. The abdominal wall provides counter\\npressure to the colon during obstruction and on entering the abdomen at\\noperation the colon, relieved of this counter pressure, will significantly\\ndistend and may even perforate. Serosal tears can certainly happen\\nrather quickly.\\n\\n I always have available a 2-0 silk to place a purse string, together\\nwith a large 14-gauge Angiocath™ connected to suction, to perform\\na decompression. It is the rapid expansion of colonic gas, not stool, that\\ncauses perforation or serosal tears when opening up the abdomen.\\nTherefore, it is imperative to evacuate the gas rapidly. So on opening the\\nabdomen, we drape blue towels around the bowel and insert a purse-',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Figure 27.1b\\n**Caption:** “Idiot! Why didn’t you do an anastomosis?”\\n\\n### The conduct of the operation\\n**Decompression of the colon**\\n\\nI do a midline laparotomy because I don’t find a role for laparoscopy in colonic obstruction. It is advisable to have a means of rapidly decompressing the colon. The abdominal wall provides counter pressure to the colon during obstruction and on entering the abdomen at operation the colon, relieved of this counter pressure, will significantly distend and may even perforate. Serosal tears can certainly happen rather quickly.\\n\\nI always have available a 2-0 silk to place a purse string, together with a large 14-gauge Angiocath™ connected to suction, to perform a decompression. It is the rapid expansion of colonic gas, not stool, that causes perforation or serosal tears when opening up the abdomen. Therefore, it is imperative to evacuate the gas rapidly. So on opening the abdomen, we drape blue towels around the bowel and insert a purse string.\\n\\n### Summary\\nThis section discusses the procedure for decompressing the colon during surgery, emphasizing the importance of rapid gas evacuation to prevent perforation or serosal tears. The author describes the tools and techniques used in the process.\\n\\n### Note\\n- No formulas or tables were identified on this page.\\n- The figure (Figure 27.1b) is referenced but not visually described in the text.\\n```',\n", " 'images': [{'name': 'img_p468_1.png',\n", " 'height': 598,\n", " 'width': 799,\n", " 'x': 108.72000000000025,\n", " 'y': 82.79999999999995,\n", " 'original_width': 1372,\n", " 'original_height': 1028}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 27.1b',\n", " 'md': '## Figure 27.1b',\n", " 'bBox': {'x': 121.58, 'y': 294.6, 'w': 13.85, 'h': 16.82}},\n", " {'type': 'text',\n", " 'value': '**Caption:** “Idiot! Why didn’t you do an anastomosis?”',\n", " 'md': '**Caption:** “Idiot! Why didn’t you do an anastomosis?”',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The conduct of the operation',\n", " 'md': '### The conduct of the operation',\n", " 'bBox': {'x': 86, 'y': 449, 'w': 198.18, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '**Decompression of the colon**\\n\\nI do a midline laparotomy because I don’t find a role for laparoscopy in colonic obstruction. It is advisable to have a means of rapidly decompressing the colon. The abdominal wall provides counter pressure to the colon during obstruction and on entering the abdomen at operation the colon, relieved of this counter pressure, will significantly distend and may even perforate. Serosal tears can certainly happen rather quickly.\\n\\nI always have available a 2-0 silk to place a purse string, together with a large 14-gauge Angiocath™ connected to suction, to perform a decompression. It is the rapid expansion of colonic gas, not stool, that causes perforation or serosal tears when opening up the abdomen. Therefore, it is imperative to evacuate the gas rapidly. So on opening the abdomen, we drape blue towels around the bowel and insert a purse string.',\n", " 'md': '**Decompression of the colon**\\n\\nI do a midline laparotomy because I don’t find a role for laparoscopy in colonic obstruction. It is advisable to have a means of rapidly decompressing the colon. The abdominal wall provides counter pressure to the colon during obstruction and on entering the abdomen at operation the colon, relieved of this counter pressure, will significantly distend and may even perforate. Serosal tears can certainly happen rather quickly.\\n\\nI always have available a 2-0 silk to place a purse string, together with a large 14-gauge Angiocath™ connected to suction, to perform a decompression. It is the rapid expansion of colonic gas, not stool, that causes perforation or serosal tears when opening up the abdomen. Therefore, it is imperative to evacuate the gas rapidly. So on opening the abdomen, we drape blue towels around the bowel and insert a purse string.',\n", " 'bBox': {'x': 72, 'y': 465, 'w': 467.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This section discusses the procedure for decompressing the colon during surgery, emphasizing the importance of rapid gas evacuation to prevent perforation or serosal tears. The author describes the tools and techniques used in the process.',\n", " 'md': 'This section discusses the procedure for decompressing the colon during surgery, emphasizing the importance of rapid gas evacuation to prevent perforation or serosal tears. The author describes the tools and techniques used in the process.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Note',\n", " 'md': '### Note',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No formulas or tables were identified on this page.\\n- The figure (Figure 27.1b) is referenced but not visually described in the text.\\n```',\n", " 'md': '- No formulas or tables were identified on this page.\\n- The figure (Figure 27.1b) is referenced but not visually described in the text.\\n```',\n", " 'bBox': {'x': 121.58, 'y': 294.6, 'w': 13.85, 'h': 16.82}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 470,\n", " 'text': 'string suture on the anti-mesenteric taenia — just above the level of\\nobstruction, as this area will be resected with the specimen. Sometimes\\nthis is not possible and then we have to do it more proximally, in the\\ntransverse colon. We also have Poole suction 1 available in case the 14-\\ngauge Angiocath™ is not large enough to decompress effectively. Once\\nwe place the purse-string suture, we just stab the Angiocath™ into the\\ncolon, remove the needle and decompress using the suction attached to\\nthe catheter. If the needle is rapidly occluded by thin fluidy s**t, we make\\na small colotomy within the purse-string suture and insert the sucker —\\nand watch with great satisfaction as the suction bottle rapidly fills with\\nliters of brown effluent. Once the needle or sucker is removed, the purse-\\nstring suture is secured down, and inverted — if this section is not to be\\nresected. This procedure prevents further distension of the colon and\\ngreatly reduces the risk of serosal tears and perforation of the cecum.\\n\\n Commonly, in less advanced obstruction, the colon is distended mainly with gas: take a large-\\n bore needle, insert it hole facing up through the tenia coli about 4cm, turn 180° so that the hole\\n faces down, push it through mucosa and let the air out. The smell tells you that it works!\\n Remove the needle and the valve effect seals the hole, with no need for sutures. Ari\\n\\n Decompression also helps with mobilization of the colon, which is\\notherwise difficult in the face of massive distension. Once that has\\nbeen completed, we can proceed.\\n\\n If the obstruction is from a cancer that is not fixed to other\\nstructures; if the patient is stable and healthy and in reasonable\\nnutritional status; if the condition of the proximal bowel is optimal\\n— it is not significantly thinned or inflamed — then resection and\\nprimary anastomosis are possible.\\n\\n I usually initiate mobilization of the colon away from the affected\\narea. This means first mobilizing the descending colon if the obstruction\\nis in the sigmoid. This is especially true if there is an inflammatory\\nprocess in the colon causing it to adhere to the left lateral abdominal wall\\nor pelvic side wall.\\n\\n If the colon is massively distended, but viable and healthy and a',\n", " 'md': '```markdown\\n## Page Content\\n\\nThe text discusses a surgical procedure involving the management of bowel obstruction. Key points include:\\n\\n- A **purse-string suture** is placed on the anti-mesenteric taenia just above the level of obstruction, which will be resected with the specimen.\\n- If this is not possible, the procedure may be performed more proximally in the transverse colon.\\n- **Poole suction** is available in case the 14-gauge Angiocath™ is insufficient for effective decompression.\\n- The Angiocath™ is stabbed into the colon after placing the purse-string suture, allowing for decompression using suction.\\n- If the needle is occluded by fluid, a small colotomy is made within the purse-string suture to insert the sucker, leading to rapid filling of the suction bottle with effluent.\\n- Once the needle or sucker is removed, the purse-string suture is secured and inverted to prevent further distension of the colon, reducing the risk of serosal tears and perforation of the cecum.\\n\\n### Additional Notes\\n\\n- In cases of less advanced obstruction, the colon may be distended mainly with gas. A large-bore needle can be used to release the gas by inserting it through the tenia coli.\\n- Decompression aids in the mobilization of the colon, which is crucial in cases of massive distension.\\n- If the obstruction is due to cancer that is not fixed to other structures, and the patient is stable and healthy, resection and primary anastomosis may be possible.\\n- Mobilization of the colon away from the affected area is initiated, particularly the descending colon if the obstruction is in the sigmoid.\\n\\n### Summary\\n\\nThe procedure described is aimed at managing bowel obstruction through decompression and mobilization, with specific techniques for suturing and suctioning to prevent complications.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses a surgical procedure involving the management of bowel obstruction. Key points include:\\n\\n- A **purse-string suture** is placed on the anti-mesenteric taenia just above the level of obstruction, which will be resected with the specimen.\\n- If this is not possible, the procedure may be performed more proximally in the transverse colon.\\n- **Poole suction** is available in case the 14-gauge Angiocath™ is insufficient for effective decompression.\\n- The Angiocath™ is stabbed into the colon after placing the purse-string suture, allowing for decompression using suction.\\n- If the needle is occluded by fluid, a small colotomy is made within the purse-string suture to insert the sucker, leading to rapid filling of the suction bottle with effluent.\\n- Once the needle or sucker is removed, the purse-string suture is secured and inverted to prevent further distension of the colon, reducing the risk of serosal tears and perforation of the cecum.',\n", " 'md': 'The text discusses a surgical procedure involving the management of bowel obstruction. Key points include:\\n\\n- A **purse-string suture** is placed on the anti-mesenteric taenia just above the level of obstruction, which will be resected with the specimen.\\n- If this is not possible, the procedure may be performed more proximally in the transverse colon.\\n- **Poole suction** is available in case the 14-gauge Angiocath™ is insufficient for effective decompression.\\n- The Angiocath™ is stabbed into the colon after placing the purse-string suture, allowing for decompression using suction.\\n- If the needle is occluded by fluid, a small colotomy is made within the purse-string suture to insert the sucker, leading to rapid filling of the suction bottle with effluent.\\n- Once the needle or sucker is removed, the purse-string suture is secured and inverted to prevent further distension of the colon, reducing the risk of serosal tears and perforation of the cecum.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Additional Notes',\n", " 'md': '### Additional Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- In cases of less advanced obstruction, the colon may be distended mainly with gas. A large-bore needle can be used to release the gas by inserting it through the tenia coli.\\n- Decompression aids in the mobilization of the colon, which is crucial in cases of massive distension.\\n- If the obstruction is due to cancer that is not fixed to other structures, and the patient is stable and healthy, resection and primary anastomosis may be possible.\\n- Mobilization of the colon away from the affected area is initiated, particularly the descending colon if the obstruction is in the sigmoid.',\n", " 'md': '- In cases of less advanced obstruction, the colon may be distended mainly with gas. A large-bore needle can be used to release the gas by inserting it through the tenia coli.\\n- Decompression aids in the mobilization of the colon, which is crucial in cases of massive distension.\\n- If the obstruction is due to cancer that is not fixed to other structures, and the patient is stable and healthy, resection and primary anastomosis may be possible.\\n- Mobilization of the colon away from the affected area is initiated, particularly the descending colon if the obstruction is in the sigmoid.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The procedure described is aimed at managing bowel obstruction through decompression and mobilization, with specific techniques for suturing and suctioning to prevent complications.\\n\\n```',\n", " 'md': 'The procedure described is aimed at managing bowel obstruction through decompression and mobilization, with specific techniques for suturing and suctioning to prevent complications.\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 471,\n", " 'text': 'primary anastomosis is what I want to do, then I perform intra-\\noperative colonic lavage. It allows decompression of the colon and\\nmakes bowel anastomosis easier. If you are not planning intra-operative\\nlavage (some think it is a gimmick…) you can just mobilize the colon to\\nensure that you have adequate length once the resection is performed,\\nand do a primary anastomosis. This may need to include take down of\\nthe splenic flexure with high ligation of the mesenteric vessels to provide\\nan adequate length of colon to perform a tension-free anastomosis.\\n\\n As mentioned previously, a lesion proximal to the splenic flexure\\nor at the splenic flexure should undergo resection with primary\\nileocolic anastomosis.\\n\\n You should ensure that a proper cancer operation with adequate\\nlymph node removal is performed if the lesion is an obstructing\\ncancer or suspected of being so.\\n Mobilization and resection\\n The entire colon, both right and left, needs to be mobilized to\\nperform an effective lavage. The decompression of colon you have\\nalready done will help with this. Great care should be taken not to\\ninjure retroperitoneal structures on the left side such as the ureter\\nor gonadal vessels. Identifying these structures away from the inflamed\\nor obstructed portion of the colon and then ensuring that they are\\nmobilized laterally is recommended. Once you have full mobilization,\\ndecide on the level of distal resection. If this is a left colonic cancer,\\nperforming a high ligation of the inferior mesenteric artery (IMA) will\\nensure that adequate lymph node removal and retrieval is undertaken. (If\\nthe patient does not have a significant history of peripheral vascular\\ndisease, then the rectum should be well perfused despite high ligation of\\nthe IMA.) If the lesion is in the descending colon or proximal sigmoid\\ncolon and the surgeon thinks it necessary to preserve more colon, then a\\nmore isolated selective ligation of the blood vessels supplying the lesion\\nshould be performed. A 7-8cm proximal margin is required but I would be\\nhappy with a 5cm distal margin. I also include another 3cm of proximal\\ncolon to be used as the site to secure exit tubing for the lavage. Once\\nthe colonic segment is mobilized and devascularized I divide it distally —\\nwhich usually is at the rectosigmoid junction — with a linear stapler. Now',\n", " 'md': '```markdown\\n## Colonic Surgery Overview\\n\\n### Intra-operative Colonic Lavage\\n- Primary anastomosis is preferred; intra-operative colonic lavage is performed to allow decompression of the colon, making bowel anastomosis easier.\\n- If intra-operative lavage is not planned, mobilizing the colon is essential to ensure adequate length for resection and primary anastomosis.\\n- This may involve taking down the splenic flexure and high ligation of the mesenteric vessels to achieve a tension-free anastomosis.\\n\\n### Resection Considerations\\n- Lesions proximal to the splenic flexure or at the splenic flexure should undergo resection with primary ileocolic anastomosis.\\n- A proper cancer operation with adequate lymph node removal is crucial if the lesion is an obstructing cancer or suspected to be so.\\n\\n### Mobilization and Resection\\n- The entire colon, both right and left, must be mobilized for effective lavage.\\n- Care should be taken to avoid injuring retroperitoneal structures on the left side, such as the ureter or gonadal vessels.\\n- Identifying these structures away from the inflamed or obstructed portion of the colon is recommended.\\n- After full mobilization, determine the level of distal resection.\\n- For left colonic cancer, high ligation of the inferior mesenteric artery (IMA) ensures adequate lymph node removal.\\n- If the patient has no significant history of peripheral vascular disease, the rectum should be well perfused despite high ligation of the IMA.\\n- For lesions in the descending colon or proximal sigmoid colon, a selective ligation of the blood vessels supplying the lesion may be necessary.\\n- A 7-8 cm proximal margin is required, with a 5 cm distal margin being acceptable.\\n- An additional 3 cm of proximal colon is included for securing exit tubing for lavage.\\n- Once the colonic segment is mobilized and devascularized, it is divided distally, usually at the rectosigmoid junction, using a linear stapler.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Colonic Surgery Overview',\n", " 'md': '## Colonic Surgery Overview',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Intra-operative Colonic Lavage',\n", " 'md': '### Intra-operative Colonic Lavage',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Primary anastomosis is preferred; intra-operative colonic lavage is performed to allow decompression of the colon, making bowel anastomosis easier.\\n- If intra-operative lavage is not planned, mobilizing the colon is essential to ensure adequate length for resection and primary anastomosis.\\n- This may involve taking down the splenic flexure and high ligation of the mesenteric vessels to achieve a tension-free anastomosis.',\n", " 'md': '- Primary anastomosis is preferred; intra-operative colonic lavage is performed to allow decompression of the colon, making bowel anastomosis easier.\\n- If intra-operative lavage is not planned, mobilizing the colon is essential to ensure adequate length for resection and primary anastomosis.\\n- This may involve taking down the splenic flexure and high ligation of the mesenteric vessels to achieve a tension-free anastomosis.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Resection Considerations',\n", " 'md': '### Resection Considerations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Lesions proximal to the splenic flexure or at the splenic flexure should undergo resection with primary ileocolic anastomosis.\\n- A proper cancer operation with adequate lymph node removal is crucial if the lesion is an obstructing cancer or suspected to be so.',\n", " 'md': '- Lesions proximal to the splenic flexure or at the splenic flexure should undergo resection with primary ileocolic anastomosis.\\n- A proper cancer operation with adequate lymph node removal is crucial if the lesion is an obstructing cancer or suspected to be so.',\n", " 'bBox': {'x': 72, 'y': 270, 'w': 153, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Mobilization and Resection',\n", " 'md': '### Mobilization and Resection',\n", " 'bBox': {'x': 82, 'y': 368, 'w': 135.43, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': '- The entire colon, both right and left, must be mobilized for effective lavage.\\n- Care should be taken to avoid injuring retroperitoneal structures on the left side, such as the ureter or gonadal vessels.\\n- Identifying these structures away from the inflamed or obstructed portion of the colon is recommended.\\n- After full mobilization, determine the level of distal resection.\\n- For left colonic cancer, high ligation of the inferior mesenteric artery (IMA) ensures adequate lymph node removal.\\n- If the patient has no significant history of peripheral vascular disease, the rectum should be well perfused despite high ligation of the IMA.\\n- For lesions in the descending colon or proximal sigmoid colon, a selective ligation of the blood vessels supplying the lesion may be necessary.\\n- A 7-8 cm proximal margin is required, with a 5 cm distal margin being acceptable.\\n- An additional 3 cm of proximal colon is included for securing exit tubing for lavage.\\n- Once the colonic segment is mobilized and devascularized, it is divided distally, usually at the rectosigmoid junction, using a linear stapler.\\n```',\n", " 'md': '- The entire colon, both right and left, must be mobilized for effective lavage.\\n- Care should be taken to avoid injuring retroperitoneal structures on the left side, such as the ureter or gonadal vessels.\\n- Identifying these structures away from the inflamed or obstructed portion of the colon is recommended.\\n- After full mobilization, determine the level of distal resection.\\n- For left colonic cancer, high ligation of the inferior mesenteric artery (IMA) ensures adequate lymph node removal.\\n- If the patient has no significant history of peripheral vascular disease, the rectum should be well perfused despite high ligation of the IMA.\\n- For lesions in the descending colon or proximal sigmoid colon, a selective ligation of the blood vessels supplying the lesion may be necessary.\\n- A 7-8 cm proximal margin is required, with a 5 cm distal margin being acceptable.\\n- An additional 3 cm of proximal colon is included for securing exit tubing for lavage.\\n- Once the colonic segment is mobilized and devascularized, it is divided distally, usually at the rectosigmoid junction, using a linear stapler.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 472,\n", " 'text': 'we are ready for the lavage…\\n\\n Intra-operative lavage\\n If you have decided before the operation that you might do this then\\nyou should speak with your circulating nurse to get all the equipment\\nneeded. This will prevent annoying delays and swearing by yourself as\\nyou wait for various items to be brought in. Some wealthy institutions\\nhave dedicated ‘lavage kits’ — I do not work at one of these institutions\\nand therefore do not know how to either assemble or utilize them. But I\\ndo know how to do this with simple pieces of kit.\\n\\n The equipment needed is as follows:\\n\\n • 3L bags of warm normal saline (utilized by the urologist for\\n cystoscopies). Ask the circulating nurse to get two bags and put\\n them in the fluid warmer before starting the case.\\n • Sterile corrugated tubing (from the anesthetic machine).\\n • Two pieces of umbilical tape.\\n • A 16-gauge Foley catheter.\\n • 0 silk ties.\\n • Cysto tubing to connect the 3L bag to the Foley catheter.\\n With this simple array of equipment ( Figure 27.2) you can proceed\\nwith the colonic lavage.',\n", " 'md': '```markdown\\n## Intra-operative Lavage\\n\\nIf you have decided before the operation that you might do this then you should speak with your circulating nurse to get all the equipment needed. This will prevent annoying delays and swearing by yourself as you wait for various items to be brought in. Some wealthy institutions have dedicated ‘lavage kits’ — I do not work at one of these institutions and therefore do not know how to either assemble or utilize them. But I do know how to do this with simple pieces of kit.\\n\\n### Equipment Needed\\n\\n- 3L bags of warm normal saline (utilized by the urologist for cystoscopies). Ask the circulating nurse to get two bags and put them in the fluid warmer before starting the case.\\n- Sterile corrugated tubing (from the anesthetic machine).\\n- Two pieces of umbilical tape.\\n- A 16-gauge Foley catheter.\\n- 0 silk ties.\\n- Cysto tubing to connect the 3L bag to the Foley catheter.\\n\\nWith this simple array of equipment (Figure 27.2) you can proceed with the colonic lavage.\\n\\n### Figure 27.2\\n**Description:** This figure illustrates the simple array of equipment needed for intra-operative lavage. The equipment includes bags of saline, tubing, a Foley catheter, and other necessary items.\\n\\n**Summary:** The figure provides a visual representation of the essential tools required for performing colonic lavage during surgery.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Intra-operative Lavage',\n", " 'md': '## Intra-operative Lavage',\n", " 'bBox': {'x': 82, 'y': 116, 'w': 111.47, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': 'If you have decided before the operation that you might do this then you should speak with your circulating nurse to get all the equipment needed. This will prevent annoying delays and swearing by yourself as you wait for various items to be brought in. Some wealthy institutions have dedicated ‘lavage kits’ — I do not work at one of these institutions and therefore do not know how to either assemble or utilize them. But I do know how to do this with simple pieces of kit.',\n", " 'md': 'If you have decided before the operation that you might do this then you should speak with your circulating nurse to get all the equipment needed. This will prevent annoying delays and swearing by yourself as you wait for various items to be brought in. Some wealthy institutions have dedicated ‘lavage kits’ — I do not work at one of these institutions and therefore do not know how to either assemble or utilize them. But I do know how to do this with simple pieces of kit.',\n", " 'bBox': {'x': 72, 'y': 201, 'w': 467.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Equipment Needed',\n", " 'md': '### Equipment Needed',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 3L bags of warm normal saline (utilized by the urologist for cystoscopies). Ask the circulating nurse to get two bags and put them in the fluid warmer before starting the case.\\n- Sterile corrugated tubing (from the anesthetic machine).\\n- Two pieces of umbilical tape.\\n- A 16-gauge Foley catheter.\\n- 0 silk ties.\\n- Cysto tubing to connect the 3L bag to the Foley catheter.\\n\\nWith this simple array of equipment (Figure 27.2) you can proceed with the colonic lavage.',\n", " 'md': '- 3L bags of warm normal saline (utilized by the urologist for cystoscopies). Ask the circulating nurse to get two bags and put them in the fluid warmer before starting the case.\\n- Sterile corrugated tubing (from the anesthetic machine).\\n- Two pieces of umbilical tape.\\n- A 16-gauge Foley catheter.\\n- 0 silk ties.\\n- Cysto tubing to connect the 3L bag to the Foley catheter.\\n\\nWith this simple array of equipment (Figure 27.2) you can proceed with the colonic lavage.',\n", " 'bBox': {'x': 72, 'y': 339, 'w': 397.29, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 27.2',\n", " 'md': '### Figure 27.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure illustrates the simple array of equipment needed for intra-operative lavage. The equipment includes bags of saline, tubing, a Foley catheter, and other necessary items.\\n\\n**Summary:** The figure provides a visual representation of the essential tools required for performing colonic lavage during surgery.\\n```',\n", " 'md': '**Description:** This figure illustrates the simple array of equipment needed for intra-operative lavage. The equipment includes bags of saline, tubing, a Foley catheter, and other necessary items.\\n\\n**Summary:** The figure provides a visual representation of the essential tools required for performing colonic lavage during surgery.\\n```',\n", " 'bBox': {'x': 82, 'y': 116, 'w': 111.47, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 473,\n", " 'text': ' I ] 3\\n 8\\n Figure 27.2. Equipment needed for intra-operative colonic lavage: see text.\\n\\n I now identify and divide the colon at the proximal margin and remove\\nthe specimen. Prior to doing this I milk the stool away from the point of\\ndivision and place a soft bowel clamp across the colon — at least 10cm\\nproximal to the site of transection — so I don’t have stool spilling\\neverywhere when the colon is opened, and there is enough room to\\ninsert the corrugated tubing that acts as our sewer pipe. The sterile\\ncorrugated tubing is inserted into the end of the colon and secured with\\ntwo umbilical tapes — tying them around the colon tightly so that the\\ncolon is dimpled in the grooves of the tubing. The other end of the tubing\\nis then passed off to the nurse. If you like the circulator you instruct her to\\nplace it in a large plastic bag within a bucket placed on the floor near the\\noperating field and tape the bag around the tubing (this last maneuver will\\nhelp to keep the stink in the OR at an acceptable level). If you don’t like\\nthe circulator you can have her place it wherever she wants, but it’s best\\nnot to make a mess.\\n\\n Now we need to take the 16Fr Foley and insert it either through',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\nI now identify and divide the colon at the proximal margin and remove the specimen. Prior to doing this I milk the stool away from the point of division and place a soft bowel clamp across the colon — at least 10cm proximal to the site of transection — so I don’t have stool spilling everywhere when the colon is opened, and there is enough room to insert the corrugated tubing that acts as our sewer pipe. The sterile corrugated tubing is inserted into the end of the colon and secured with two umbilical tapes — tying them around the colon tightly so that the colon is dimpled in the grooves of the tubing. The other end of the tubing is then passed off to the nurse. If you like the circulator you instruct her to place it in a large plastic bag within a bucket placed on the floor near the operating field and tape the bag around the tubing (this last maneuver will help to keep the stink in the OR at an acceptable level). If you don’t like the circulator you can have her place it wherever she wants, but it’s best not to make a mess.\\n\\nNow we need to take the 16Fr Foley and insert it either through...\\n\\n## Figures\\n\\n### Figure 27.2\\n**Description:** Equipment needed for intra-operative colonic lavage. The figure likely illustrates various tools and equipment used during the procedure, although the specific items are not detailed in the text.\\n\\n**Summary:** This figure provides a visual representation of the necessary equipment for performing colonic lavage during surgery, emphasizing the importance of proper tools in maintaining hygiene and efficiency in the operating room.\\n```',\n", " 'images': [{'name': 'img_p472_1.png',\n", " 'height': 579,\n", " 'width': 603,\n", " 'x': 156.96000000000004,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1036,\n", " 'original_height': 996}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'I now identify and divide the colon at the proximal margin and remove the specimen. Prior to doing this I milk the stool away from the point of division and place a soft bowel clamp across the colon — at least 10cm proximal to the site of transection — so I don’t have stool spilling everywhere when the colon is opened, and there is enough room to insert the corrugated tubing that acts as our sewer pipe. The sterile corrugated tubing is inserted into the end of the colon and secured with two umbilical tapes — tying them around the colon tightly so that the colon is dimpled in the grooves of the tubing. The other end of the tubing is then passed off to the nurse. If you like the circulator you instruct her to place it in a large plastic bag within a bucket placed on the floor near the operating field and tape the bag around the tubing (this last maneuver will help to keep the stink in the OR at an acceptable level). If you don’t like the circulator you can have her place it wherever she wants, but it’s best not to make a mess.\\n\\nNow we need to take the 16Fr Foley and insert it either through...',\n", " 'md': 'I now identify and divide the colon at the proximal margin and remove the specimen. Prior to doing this I milk the stool away from the point of division and place a soft bowel clamp across the colon — at least 10cm proximal to the site of transection — so I don’t have stool spilling everywhere when the colon is opened, and there is enough room to insert the corrugated tubing that acts as our sewer pipe. The sterile corrugated tubing is inserted into the end of the colon and secured with two umbilical tapes — tying them around the colon tightly so that the colon is dimpled in the grooves of the tubing. The other end of the tubing is then passed off to the nurse. If you like the circulator you instruct her to place it in a large plastic bag within a bucket placed on the floor near the operating field and tape the bag around the tubing (this last maneuver will help to keep the stink in the OR at an acceptable level). If you don’t like the circulator you can have her place it wherever she wants, but it’s best not to make a mess.\\n\\nNow we need to take the 16Fr Foley and insert it either through...',\n", " 'bBox': {'x': 72, 'y': 436, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures',\n", " 'md': '## Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 27.2',\n", " 'md': '### Figure 27.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** Equipment needed for intra-operative colonic lavage. The figure likely illustrates various tools and equipment used during the procedure, although the specific items are not detailed in the text.\\n\\n**Summary:** This figure provides a visual representation of the necessary equipment for performing colonic lavage during surgery, emphasizing the importance of proper tools in maintaining hygiene and efficiency in the operating room.\\n```',\n", " 'md': '**Description:** Equipment needed for intra-operative colonic lavage. The figure likely illustrates various tools and equipment used during the procedure, although the specific items are not detailed in the text.\\n\\n**Summary:** This figure provides a visual representation of the necessary equipment for performing colonic lavage during surgery, emphasizing the importance of proper tools in maintaining hygiene and efficiency in the operating room.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 474,\n", " 'text': 'the appendix or the terminal ileum. If the patient has an appendix, then\\nuse it: divide the mesoappendix and make an enterotomy at the mid-\\nappendix. Gently dilate the appendix and pass the catheter through the\\nappendiceal lumen; once it enters the cecum blow up the Foley balloon\\nwith 10cc of water and pull it back so that it abuts the appendiceal orifice\\nand then use a 0 silk tie to secure it to the devascularized appendix.\\n\\n Attach the 3L bag via the sterile cysto tubing to the Foley catheter and\\nlet it flow! Now start gently milking the stool-irrigant cocktail, starting at\\nthe cecum, around the transverse colon and then out of the descending\\ncolon into the sterile tubing and out into the collection bag. Stop the\\nlavage when the effluent is clear — no, you do not need to be able read a\\nnewspaper through the fluid… Now remove the Foley catheter and\\ncomplete the appendectomy. If the patient previously had an\\nappendectomy and you have placed the catheter through a small ileal\\nenterotomy — remove the Foley and close the enterotomy. I don’t bother\\ntrying to extricate the tubing from the colon; I just resect the 2 or 3cm of\\ncolon that were needed to secure the tubing and hand it all off to the very\\nhappy nurse who now has to deal with 10 pounds of stool! A picture is\\nworth a thousand words and a diagram of the set-up is depicted in (\\nFigure 27.3).',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nThe appendix or the terminal ileum. If the patient has an appendix, then use it: divide the mesoappendix and make an enterotomy at the mid-appendix. Gently dilate the appendix and pass the catheter through the appendiceal lumen; once it enters the cecum blow up the Foley balloon with 10cc of water and pull it back so that it abuts the appendiceal orifice and then use a 0 silk tie to secure it to the devascularized appendix.\\n\\nAttach the 3L bag via the sterile cysto tubing to the Foley catheter and let it flow! Now start gently milking the stool-irrigant cocktail, starting at the cecum, around the transverse colon and then out of the descending colon into the sterile tubing and out into the collection bag. Stop the lavage when the effluent is clear — no, you do not need to be able to read a newspaper through the fluid… Now remove the Foley catheter and complete the appendectomy. If the patient previously had an appendectomy and you have placed the catheter through a small ileal enterotomy — remove the Foley and close the enterotomy. I don’t bother trying to extricate the tubing from the colon; I just resect the 2 or 3cm of colon that were needed to secure the tubing and hand it all off to the very happy nurse who now has to deal with 10 pounds of stool! A picture is worth a thousand words and a diagram of the set-up is depicted in (Figure 27.3).\\n\\n## Image Identification and Description\\n\\n**Figure 27.3**: A diagram of the set-up for the procedure described. The diagram illustrates the placement of the Foley catheter in relation to the appendix and the flow of the stool-irrigant cocktail. The image provides a visual representation of the surgical setup, which aids in understanding the described procedure.\\n\\n### Summary\\nThe text describes a surgical procedure involving the appendix and the use of a Foley catheter for stool irrigation. It emphasizes the importance of proper setup and technique, and references a diagram (Figure 27.3) that visually represents the procedure.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The appendix or the terminal ileum. If the patient has an appendix, then use it: divide the mesoappendix and make an enterotomy at the mid-appendix. Gently dilate the appendix and pass the catheter through the appendiceal lumen; once it enters the cecum blow up the Foley balloon with 10cc of water and pull it back so that it abuts the appendiceal orifice and then use a 0 silk tie to secure it to the devascularized appendix.\\n\\nAttach the 3L bag via the sterile cysto tubing to the Foley catheter and let it flow! Now start gently milking the stool-irrigant cocktail, starting at the cecum, around the transverse colon and then out of the descending colon into the sterile tubing and out into the collection bag. Stop the lavage when the effluent is clear — no, you do not need to be able to read a newspaper through the fluid… Now remove the Foley catheter and complete the appendectomy. If the patient previously had an appendectomy and you have placed the catheter through a small ileal enterotomy — remove the Foley and close the enterotomy. I don’t bother trying to extricate the tubing from the colon; I just resect the 2 or 3cm of colon that were needed to secure the tubing and hand it all off to the very happy nurse who now has to deal with 10 pounds of stool! A picture is worth a thousand words and a diagram of the set-up is depicted in (Figure 27.3).',\n", " 'md': 'The appendix or the terminal ileum. If the patient has an appendix, then use it: divide the mesoappendix and make an enterotomy at the mid-appendix. Gently dilate the appendix and pass the catheter through the appendiceal lumen; once it enters the cecum blow up the Foley balloon with 10cc of water and pull it back so that it abuts the appendiceal orifice and then use a 0 silk tie to secure it to the devascularized appendix.\\n\\nAttach the 3L bag via the sterile cysto tubing to the Foley catheter and let it flow! Now start gently milking the stool-irrigant cocktail, starting at the cecum, around the transverse colon and then out of the descending colon into the sterile tubing and out into the collection bag. Stop the lavage when the effluent is clear — no, you do not need to be able to read a newspaper through the fluid… Now remove the Foley catheter and complete the appendectomy. If the patient previously had an appendectomy and you have placed the catheter through a small ileal enterotomy — remove the Foley and close the enterotomy. I don’t bother trying to extricate the tubing from the colon; I just resect the 2 or 3cm of colon that were needed to secure the tubing and hand it all off to the very happy nurse who now has to deal with 10 pounds of stool! A picture is worth a thousand words and a diagram of the set-up is depicted in (Figure 27.3).',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 523, 'y': 303, 'w': 16.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '**Figure 27.3**: A diagram of the set-up for the procedure described. The diagram illustrates the placement of the Foley catheter in relation to the appendix and the flow of the stool-irrigant cocktail. The image provides a visual representation of the surgical setup, which aids in understanding the described procedure.',\n", " 'md': '**Figure 27.3**: A diagram of the set-up for the procedure described. The diagram illustrates the placement of the Foley catheter in relation to the appendix and the flow of the stool-irrigant cocktail. The image provides a visual representation of the surgical setup, which aids in understanding the described procedure.',\n", " 'bBox': {'x': 144, 'y': 303, 'w': 23.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text describes a surgical procedure involving the appendix and the use of a Foley catheter for stool irrigation. It emphasizes the importance of proper setup and technique, and references a diagram (Figure 27.3) that visually represents the procedure.\\n```',\n", " 'md': 'The text describes a surgical procedure involving the appendix and the use of a Foley catheter for stool irrigation. It emphasizes the importance of proper setup and technique, and references a diagram (Figure 27.3) that visually represents the procedure.\\n```',\n", " 'bBox': {'x': 144, 'y': 303, 'w': 23.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Figure 27.3).'}]},\n", " {'page': 475,\n", " 'text': ' FeRy42615\\nFigure 27.3. Intra-operative colonic lavage.\\n\\n A final note about the lavage… I know that some surgeons would\\nsimply milk out/suck out the stool from the colon and proceed with a\\nprimary anastomosis — without the lavage. I contend, however, that\\nmobilizing the whole colon is required for any adequate colonic\\ndecompression — I just can’t get the colon decompressed without full\\nmobilization. I find the lavage does not add much in time to the process\\nand is a much cleaner procedure. If you are going to decompress the\\ncolon prior to doing an anastomosis, I would lavage it as well. Try it!\\n\\n Anastomosis\\n I generally prefer the side-to-end anastomosis for these patients\\nbecause there is a significant size discrepancy between the dilated colon\\nand rectum. In my hands the anastomosis is usually stapled: I insert',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Figure 27.3\\n**Intra-operative colonic lavage.**\\n\\nA final note about the lavage… I know that some surgeons would simply milk out/suck out the stool from the colon and proceed with a primary anastomosis — without the lavage. I contend, however, that mobilizing the whole colon is required for any adequate colonic decompression — I just can’t get the colon decompressed without full mobilization. I find the lavage does not add much in time to the process and is a much cleaner procedure. If you are going to decompress the colon prior to doing an anastomosis, I would lavage it as well. Try it!\\n\\n### Anastomosis\\nI generally prefer the side-to-end anastomosis for these patients because there is a significant size discrepancy between the dilated colon and rectum. In my hands, the anastomosis is usually stapled: I insert...\\n\\n----\\n\\n### Image Description\\n- **Figure 27.3**: This figure illustrates the process of intra-operative colonic lavage. The image likely depicts a surgical scene where the lavage technique is being performed, emphasizing the importance of mobilizing the colon for effective decompression. The caption suggests a discussion on the benefits of lavage in surgical procedures.\\n\\n### Summary\\nThe text discusses the importance of colonic lavage during surgery, advocating for full mobilization of the colon to ensure adequate decompression. It also mentions a preference for side-to-end anastomosis due to size discrepancies between the colon and rectum.\\n```',\n", " 'images': [{'name': 'img_p474_1.png',\n", " 'height': 723,\n", " 'width': 533,\n", " 'x': 174.23999999999978,\n", " 'y': 82.80000000000001,\n", " 'original_width': 916,\n", " 'original_height': 1244}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 27.3',\n", " 'md': '## Figure 27.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Intra-operative colonic lavage.**\\n\\nA final note about the lavage… I know that some surgeons would simply milk out/suck out the stool from the colon and proceed with a primary anastomosis — without the lavage. I contend, however, that mobilizing the whole colon is required for any adequate colonic decompression — I just can’t get the colon decompressed without full mobilization. I find the lavage does not add much in time to the process and is a much cleaner procedure. If you are going to decompress the colon prior to doing an anastomosis, I would lavage it as well. Try it!',\n", " 'md': '**Intra-operative colonic lavage.**\\n\\nA final note about the lavage… I know that some surgeons would simply milk out/suck out the stool from the colon and proceed with a primary anastomosis — without the lavage. I contend, however, that mobilizing the whole colon is required for any adequate colonic decompression — I just can’t get the colon decompressed without full mobilization. I find the lavage does not add much in time to the process and is a much cleaner procedure. If you are going to decompress the colon prior to doing an anastomosis, I would lavage it as well. Try it!',\n", " 'bBox': {'x': 72, 'y': 590, 'w': 467.74, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Anastomosis',\n", " 'md': '### Anastomosis',\n", " 'bBox': {'x': 82, 'y': 654, 'w': 67.74, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': 'I generally prefer the side-to-end anastomosis for these patients because there is a significant size discrepancy between the dilated colon and rectum. In my hands, the anastomosis is usually stapled: I insert...\\n\\n----',\n", " 'md': 'I generally prefer the side-to-end anastomosis for these patients because there is a significant size discrepancy between the dilated colon and rectum. In my hands, the anastomosis is usually stapled: I insert...\\n\\n----',\n", " 'bBox': {'x': 72, 'y': 654, 'w': 467.32, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 27.3**: This figure illustrates the process of intra-operative colonic lavage. The image likely depicts a surgical scene where the lavage technique is being performed, emphasizing the importance of mobilizing the colon for effective decompression. The caption suggests a discussion on the benefits of lavage in surgical procedures.',\n", " 'md': '- **Figure 27.3**: This figure illustrates the process of intra-operative colonic lavage. The image likely depicts a surgical scene where the lavage technique is being performed, emphasizing the importance of mobilizing the colon for effective decompression. The caption suggests a discussion on the benefits of lavage in surgical procedures.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the importance of colonic lavage during surgery, advocating for full mobilization of the colon to ensure adequate decompression. It also mentions a preference for side-to-end anastomosis due to size discrepancies between the colon and rectum.\\n```',\n", " 'md': 'The text discusses the importance of colonic lavage during surgery, advocating for full mobilization of the colon to ensure adequate decompression. It also mentions a preference for side-to-end anastomosis due to size discrepancies between the colon and rectum.\\n```',\n", " 'bBox': {'x': 82, 'y': 654, 'w': 67.74, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 476,\n", " 'text': 'the anvil of an EEA™ stapler into the open end of the colon and out\\nthrough a stab wound — secured with a purse-string suture — at the anti-\\nmesenteric taenia. I close the open end of the colon with a linear stapler\\nor two layers of sutures. I then bring the EEA™ stapler up through the\\nstapled-off rectum and perform the anastomosis. In a complete\\nobstruction there is rarely stool within the rectum. As an alternative you\\ncan perform a hand-sewn anastomosis, but again I would recommend a\\nside-to-end anastomosis as opposed to an end-to-end given the size\\ndiscrepancy that is often seen with these patients.\\n Divert or not?\\n The decision to perform a proximal diversion, regardless of intra-\\noperative lavage, should be based on the patient’s overall health\\nand the condition of the bowel at the time of surgery. Patients with\\nmultiple comorbidities who are ‘stable’ during the operative procedure\\ncan still undergo a primary anastomosis but a proximal diversion may be\\nrecommended especially if the bowel that is remaining is distended and\\nedematous. The crucial factor is whether the patient will tolerate an\\nanastomotic leak and its sequelae. As you know, diverting stomas\\ndo not prevent anastomotic leaks but reduce their morbid\\nconsequences, making them easier to manage — preventing ‘failure\\nto rescue’. Which means — as the adage goes: if you think about\\ndiverting, then divert!\\n\\n You may ask: if I plan to divert, why bother with colonic lavage?\\nWell, having a column of stool proximal to an anastomosis, even if it is\\ndiverted more proximally, can often lead to significant problems if a leak\\ndevelops. So — lavage is good!\\n\\n My favored diversion is a loop ileostomy. It is easier to construct\\nand close than a colostomy, although associated with more complications\\nsuch as dehydration and skin irritation.\\n\\n Volvulus of the colon\\n\\n Though sometimes in a person who is fat\\n The diagnosis is not clear as that\\n ‘Tis then you get help from plain X-ray',\n", " 'md': '```markdown\\n## Surgical Procedure Overview\\n\\nThe anvil of an EEA™ stapler is inserted into the open end of the colon and out through a stab wound — secured with a purse-string suture — at the anti-mesenteric taenia. The open end of the colon is closed with a linear stapler or two layers of sutures. The EEA™ stapler is then brought up through the stapled-off rectum to perform the anastomosis. In cases of complete obstruction, stool is rarely present within the rectum. An alternative method is to perform a hand-sewn anastomosis; however, a side-to-end anastomosis is recommended over an end-to-end due to the size discrepancy often seen in these patients.\\n\\n### Divert or Not?\\n\\nThe decision to perform a proximal diversion, regardless of intra-operative lavage, should be based on the patient’s overall health and the condition of the bowel at the time of surgery. Patients with multiple comorbidities who are ‘stable’ during the operative procedure can still undergo a primary anastomosis, but a proximal diversion may be recommended, especially if the remaining bowel is distended and edematous. The crucial factor is whether the patient will tolerate an anastomotic leak and its sequelae. Diverting stomas do not prevent anastomotic leaks but reduce their morbid consequences, making them easier to manage — preventing ‘failure to rescue’. As the adage goes: if you think about diverting, then divert!\\n\\nYou may ask: if I plan to divert, why bother with colonic lavage? Well, having a column of stool proximal to an anastomosis, even if it is diverted more proximally, can often lead to significant problems if a leak develops. Therefore, lavage is beneficial!\\n\\nMy favored diversion is a loop ileostomy. It is easier to construct and close than a colostomy, although it is associated with more complications such as dehydration and skin irritation.\\n\\n### Volvulus of the Colon\\n\\n> Though sometimes in a person who is fat\\n> The diagnosis is not clear as that\\n> ‘Tis then you get help from plain X-ray\\n```\\n\\n### Notes:\\n- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been structured into sections for clarity.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Procedure Overview',\n", " 'md': '## Surgical Procedure Overview',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The anvil of an EEA™ stapler is inserted into the open end of the colon and out through a stab wound — secured with a purse-string suture — at the anti-mesenteric taenia. The open end of the colon is closed with a linear stapler or two layers of sutures. The EEA™ stapler is then brought up through the stapled-off rectum to perform the anastomosis. In cases of complete obstruction, stool is rarely present within the rectum. An alternative method is to perform a hand-sewn anastomosis; however, a side-to-end anastomosis is recommended over an end-to-end due to the size discrepancy often seen in these patients.',\n", " 'md': 'The anvil of an EEA™ stapler is inserted into the open end of the colon and out through a stab wound — secured with a purse-string suture — at the anti-mesenteric taenia. The open end of the colon is closed with a linear stapler or two layers of sutures. The EEA™ stapler is then brought up through the stapled-off rectum to perform the anastomosis. In cases of complete obstruction, stool is rarely present within the rectum. An alternative method is to perform a hand-sewn anastomosis; however, a side-to-end anastomosis is recommended over an end-to-end due to the size discrepancy often seen in these patients.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.76, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Divert or Not?',\n", " 'md': '### Divert or Not?',\n", " 'bBox': {'x': 82, 'y': 248, 'w': 70.71, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': 'The decision to perform a proximal diversion, regardless of intra-operative lavage, should be based on the patient’s overall health and the condition of the bowel at the time of surgery. Patients with multiple comorbidities who are ‘stable’ during the operative procedure can still undergo a primary anastomosis, but a proximal diversion may be recommended, especially if the remaining bowel is distended and edematous. The crucial factor is whether the patient will tolerate an anastomotic leak and its sequelae. Diverting stomas do not prevent anastomotic leaks but reduce their morbid consequences, making them easier to manage — preventing ‘failure to rescue’. As the adage goes: if you think about diverting, then divert!\\n\\nYou may ask: if I plan to divert, why bother with colonic lavage? Well, having a column of stool proximal to an anastomosis, even if it is diverted more proximally, can often lead to significant problems if a leak develops. Therefore, lavage is beneficial!\\n\\nMy favored diversion is a loop ileostomy. It is easier to construct and close than a colostomy, although it is associated with more complications such as dehydration and skin irritation.',\n", " 'md': 'The decision to perform a proximal diversion, regardless of intra-operative lavage, should be based on the patient’s overall health and the condition of the bowel at the time of surgery. Patients with multiple comorbidities who are ‘stable’ during the operative procedure can still undergo a primary anastomosis, but a proximal diversion may be recommended, especially if the remaining bowel is distended and edematous. The crucial factor is whether the patient will tolerate an anastomotic leak and its sequelae. Diverting stomas do not prevent anastomotic leaks but reduce their morbid consequences, making them easier to manage — preventing ‘failure to rescue’. As the adage goes: if you think about diverting, then divert!\\n\\nYou may ask: if I plan to divert, why bother with colonic lavage? Well, having a column of stool proximal to an anastomosis, even if it is diverted more proximally, can often lead to significant problems if a leak develops. Therefore, lavage is beneficial!\\n\\nMy favored diversion is a loop ileostomy. It is easier to construct and close than a colostomy, although it is associated with more complications such as dehydration and skin irritation.',\n", " 'bBox': {'x': 72, 'y': 268, 'w': 467.62, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Volvulus of the Colon',\n", " 'md': '### Volvulus of the Colon',\n", " 'bBox': {'x': 86, 'y': 646, 'w': 166.1, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '> Though sometimes in a person who is fat\\n> The diagnosis is not clear as that\\n> ‘Tis then you get help from plain X-ray\\n```',\n", " 'md': '> Though sometimes in a person who is fat\\n> The diagnosis is not clear as that\\n> ‘Tis then you get help from plain X-ray\\n```',\n", " 'bBox': {'x': 136, 'y': 682, 'w': 262.27, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been structured into sections for clarity.',\n", " 'md': '- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been structured into sections for clarity.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 477,\n", " 'text': ' Which gas within the gut should well display\\n So that the coil you see in the radiogram\\n Reaching from pelvis to the diaphragm.\\n Zachary Cope, The Acute Abdomen in Rhyme\\n\\n While volvulus accounts for only one-tenth of all instances of colonic\\nobstruction, we tend to remember those patients. It is probably because\\nof the spectacular appearance on abdominal X-rays and the equally\\nspectacular way it is treated. Volvulus of the sigmoid colon is much\\nmore common than cecal volvulus. There is also volvulus of the\\ntransverse colon but it is so rare that you will probably not see a case\\nduring your surgical life.\\n\\n Volvulus of the sigmoid colon\\n\\n In affected patients the sigmoid is long, with a redundant mesentery\\nthat allows the sigmoid to rotate around its mesenteric axis, usually\\ncounter-clockwise. It commonly occurs after patients have reached\\nseniority. It does happen in younger ages but then typically in an\\ninstitutionalized patient. The rotation must be at least 180° to be\\nsymptomatic for obstruction, but if the rotation is 360° there is also a risk\\nof strangulation. These circumstances account for two types of volvulus:\\na ‘slow’ form where obstruction develops gradually and a ‘rapid’ form\\nwhere strangulation dominates. As the obstructing point is distally at the\\nrectosigmoid junction, the propulsion of the proximal colon will blow up\\nthe obstructed sigmoid loop to impressive dimensions.\\n\\n The typical patient presents with a history of recent onset constipation\\nand lack of flatus and a grossly distended belly. Because half of the\\npatients have recurrent episodes of volvulus the diagnosis may\\nalready be known. A plain abdominal film will suggest the diagnosis —\\na tremendously large loop of colon fills the abdomen from the pelvis to\\nthe upper abdomen. A contrast enema with Gastrografin® will show the\\nobstruction at the rectosigmoid junction. Typically, the contrast ends in a\\ncharacteristic ‘bird’s beak’ sign. The lower twist causes this image. And of\\ncourse, a CT would show the huge loop of sigmoid, including the\\nwhirl sign — typical for an intestinal volvulus — developing at the',\n", " 'md': '```markdown\\n## Volvulus of the Sigmoid Colon\\n\\n> \"Which gas within the gut should well display\\n> So that the coil you see in the radiogram\\n> Reaching from pelvis to the diaphragm.\"\\n> — Zachary Cope, *The Acute Abdomen in Rhyme*\\n\\nWhile volvulus accounts for only one-tenth of all instances of colonic obstruction, we tend to remember those patients. It is probably because of the spectacular appearance on abdominal X-rays and the equally spectacular way it is treated. Volvulus of the sigmoid colon is much more common than cecal volvulus. There is also volvulus of the transverse colon, but it is so rare that you will probably not see a case during your surgical life.\\n\\n### Volvulus of the Sigmoid Colon\\n\\nIn affected patients, the sigmoid is long, with a redundant mesentery that allows the sigmoid to rotate around its mesenteric axis, usually counter-clockwise. It commonly occurs after patients have reached seniority. It does happen in younger ages but then typically in an institutionalized patient. The rotation must be at least \\\\(180^\\\\circ\\\\) to be symptomatic for obstruction, but if the rotation is \\\\(360^\\\\circ\\\\) there is also a risk of strangulation. These circumstances account for two types of volvulus: a ‘slow’ form where obstruction develops gradually and a ‘rapid’ form where strangulation dominates. As the obstructing point is distally at the rectosigmoid junction, the propulsion of the proximal colon will blow up the obstructed sigmoid loop to impressive dimensions.\\n\\nThe typical patient presents with a history of recent onset constipation and lack of flatus and a grossly distended belly. Because half of the patients have recurrent episodes of volvulus, the diagnosis may already be known. A plain abdominal film will suggest the diagnosis — a tremendously large loop of colon fills the abdomen from the pelvis to the upper abdomen. A contrast enema with Gastrografin® will show the obstruction at the rectosigmoid junction. Typically, the contrast ends in a characteristic ‘bird’s beak’ sign. The lower twist causes this image. And of course, a CT would show the huge loop of sigmoid, including the whirl sign — typical for an intestinal volvulus — developing at the...\\n\\n### Figures and Images\\n\\n- **Figure 1**: [Description of the image not provided in the text, but it likely depicts the characteristic appearance of a volvulus on an abdominal X-ray or CT scan.]\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Volvulus of the Sigmoid Colon',\n", " 'md': '## Volvulus of the Sigmoid Colon',\n", " 'bBox': {'x': 86, 'y': 313, 'w': 234.13, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '> \"Which gas within the gut should well display\\n> So that the coil you see in the radiogram\\n> Reaching from pelvis to the diaphragm.\"\\n> — Zachary Cope, *The Acute Abdomen in Rhyme*\\n\\nWhile volvulus accounts for only one-tenth of all instances of colonic obstruction, we tend to remember those patients. It is probably because of the spectacular appearance on abdominal X-rays and the equally spectacular way it is treated. Volvulus of the sigmoid colon is much more common than cecal volvulus. There is also volvulus of the transverse colon, but it is so rare that you will probably not see a case during your surgical life.',\n", " 'md': '> \"Which gas within the gut should well display\\n> So that the coil you see in the radiogram\\n> Reaching from pelvis to the diaphragm.\"\\n> — Zachary Cope, *The Acute Abdomen in Rhyme*\\n\\nWhile volvulus accounts for only one-tenth of all instances of colonic obstruction, we tend to remember those patients. It is probably because of the spectacular appearance on abdominal X-rays and the equally spectacular way it is treated. Volvulus of the sigmoid colon is much more common than cecal volvulus. There is also volvulus of the transverse colon, but it is so rare that you will probably not see a case during your surgical life.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 468.01, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Volvulus of the Sigmoid Colon',\n", " 'md': '### Volvulus of the Sigmoid Colon',\n", " 'bBox': {'x': 86, 'y': 313, 'w': 234.13, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In affected patients, the sigmoid is long, with a redundant mesentery that allows the sigmoid to rotate around its mesenteric axis, usually counter-clockwise. It commonly occurs after patients have reached seniority. It does happen in younger ages but then typically in an institutionalized patient. The rotation must be at least \\\\(180^\\\\circ\\\\) to be symptomatic for obstruction, but if the rotation is \\\\(360^\\\\circ\\\\) there is also a risk of strangulation. These circumstances account for two types of volvulus: a ‘slow’ form where obstruction develops gradually and a ‘rapid’ form where strangulation dominates. As the obstructing point is distally at the rectosigmoid junction, the propulsion of the proximal colon will blow up the obstructed sigmoid loop to impressive dimensions.\\n\\nThe typical patient presents with a history of recent onset constipation and lack of flatus and a grossly distended belly. Because half of the patients have recurrent episodes of volvulus, the diagnosis may already be known. A plain abdominal film will suggest the diagnosis — a tremendously large loop of colon fills the abdomen from the pelvis to the upper abdomen. A contrast enema with Gastrografin® will show the obstruction at the rectosigmoid junction. Typically, the contrast ends in a characteristic ‘bird’s beak’ sign. The lower twist causes this image. And of course, a CT would show the huge loop of sigmoid, including the whirl sign — typical for an intestinal volvulus — developing at the...',\n", " 'md': 'In affected patients, the sigmoid is long, with a redundant mesentery that allows the sigmoid to rotate around its mesenteric axis, usually counter-clockwise. It commonly occurs after patients have reached seniority. It does happen in younger ages but then typically in an institutionalized patient. The rotation must be at least \\\\(180^\\\\circ\\\\) to be symptomatic for obstruction, but if the rotation is \\\\(360^\\\\circ\\\\) there is also a risk of strangulation. These circumstances account for two types of volvulus: a ‘slow’ form where obstruction develops gradually and a ‘rapid’ form where strangulation dominates. As the obstructing point is distally at the rectosigmoid junction, the propulsion of the proximal colon will blow up the obstructed sigmoid loop to impressive dimensions.\\n\\nThe typical patient presents with a history of recent onset constipation and lack of flatus and a grossly distended belly. Because half of the patients have recurrent episodes of volvulus, the diagnosis may already be known. A plain abdominal film will suggest the diagnosis — a tremendously large loop of colon fills the abdomen from the pelvis to the upper abdomen. A contrast enema with Gastrografin® will show the obstruction at the rectosigmoid junction. Typically, the contrast ends in a characteristic ‘bird’s beak’ sign. The lower twist causes this image. And of course, a CT would show the huge loop of sigmoid, including the whirl sign — typical for an intestinal volvulus — developing at the...',\n", " 'bBox': {'x': 72, 'y': 448, 'w': 467.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures and Images',\n", " 'md': '### Figures and Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: [Description of the image not provided in the text, but it likely depicts the characteristic appearance of a volvulus on an abdominal X-ray or CT scan.]\\n```',\n", " 'md': '- **Figure 1**: [Description of the image not provided in the text, but it likely depicts the characteristic appearance of a volvulus on an abdominal X-ray or CT scan.]\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 478,\n", " 'text': 'twisting point of the mesentery.\\n\\n Treatment of sigmoid volvulus\\n As opposed to cecal volvulus (see below), sigmoid volvulus is\\ninitially treated with an attempt at endoscopic decompression. This\\nis usually feasible and allows the surgeon to visualize the mucosa to\\nensure the bowel is viable. This may be done with a rigid proctoscope\\n(historically, at the bedside — and, when successful, with a rush of\\ns**t hitting the surgeon’s face), but success rates, and patient and\\nsurgeon comfort, are best when this is done with a flexible\\nsigmoidoscopy in the endoscopy suite. Other methods of non-\\noperative management (e.g. hydrostatic decompression with barium) now\\nbelong to history ( Figure 27.4).\\n feRr444\\n Figure 27.4. Non-operative management of sigmoid volvulus.\\n\\n When scoping the volvulus there are two points of obstruction\\nthat the endoscopist must pass to ensure the blockage is\\ncompletely relieved. The first twist of the bird’s beak gets the\\nendoscope into the dilated and twisted sigmoid colon. The second twist\\nor point of blockage needs to be passed to ensure the colon is untwisted',\n", " 'md': '```markdown\\n## Treatment of Sigmoid Volvulus\\n\\nAs opposed to cecal volvulus (see below), sigmoid volvulus is initially treated with an attempt at endoscopic decompression. This is usually feasible and allows the surgeon to visualize the mucosa to ensure the bowel is viable. This may be done with a rigid proctoscope (historically, at the bedside — and, when successful, with a rush of hitting the surgeon’s face), but success rates, and patient and surgeon comfort, are best when this is done with a flexible sigmoidoscopy in the endoscopy suite. Other methods of non-operative management (e.g. hydrostatic decompression with barium) now belong to history (Figure 27.4).\\n\\nWhen scoping the volvulus there are two points of obstruction that the endoscopist must pass to ensure the blockage is completely relieved. The first twist of the bird’s beak gets the endoscope into the dilated and twisted sigmoid colon. The second twist or point of blockage needs to be passed to ensure the colon is untwisted.\\n\\n### Figure 27.4\\n**Caption:** Non-operative management of sigmoid volvulus.\\n\\n**Description:** This figure illustrates the non-operative management techniques for sigmoid volvulus. The image likely depicts the endoscopic procedure or tools used in the management of this condition. The specific details of the image are not provided, but it is essential for understanding the treatment approach.\\n```',\n", " 'images': [{'name': 'img_p477_1.png',\n", " 'height': 529,\n", " 'width': 819,\n", " 'x': 103.68000000000029,\n", " 'y': 308.15999999999997,\n", " 'original_width': 1408,\n", " 'original_height': 908}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Treatment of Sigmoid Volvulus',\n", " 'md': '## Treatment of Sigmoid Volvulus',\n", " 'bBox': {'x': 86, 'y': 124, 'w': 208.36, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'As opposed to cecal volvulus (see below), sigmoid volvulus is initially treated with an attempt at endoscopic decompression. This is usually feasible and allows the surgeon to visualize the mucosa to ensure the bowel is viable. This may be done with a rigid proctoscope (historically, at the bedside — and, when successful, with a rush of hitting the surgeon’s face), but success rates, and patient and surgeon comfort, are best when this is done with a flexible sigmoidoscopy in the endoscopy suite. Other methods of non-operative management (e.g. hydrostatic decompression with barium) now belong to history (Figure 27.4).\\n\\nWhen scoping the volvulus there are two points of obstruction that the endoscopist must pass to ensure the blockage is completely relieved. The first twist of the bird’s beak gets the endoscope into the dilated and twisted sigmoid colon. The second twist or point of blockage needs to be passed to ensure the colon is untwisted.',\n", " 'md': 'As opposed to cecal volvulus (see below), sigmoid volvulus is initially treated with an attempt at endoscopic decompression. This is usually feasible and allows the surgeon to visualize the mucosa to ensure the bowel is viable. This may be done with a rigid proctoscope (historically, at the bedside — and, when successful, with a rush of hitting the surgeon’s face), but success rates, and patient and surgeon comfort, are best when this is done with a flexible sigmoidoscopy in the endoscopy suite. Other methods of non-operative management (e.g. hydrostatic decompression with barium) now belong to history (Figure 27.4).\\n\\nWhen scoping the volvulus there are two points of obstruction that the endoscopist must pass to ensure the blockage is completely relieved. The first twist of the bird’s beak gets the endoscope into the dilated and twisted sigmoid colon. The second twist or point of blockage needs to be passed to ensure the colon is untwisted.',\n", " 'bBox': {'x': 72, 'y': 162, 'w': 467.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 27.4',\n", " 'md': '### Figure 27.4',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** Non-operative management of sigmoid volvulus.\\n\\n**Description:** This figure illustrates the non-operative management techniques for sigmoid volvulus. The image likely depicts the endoscopic procedure or tools used in the management of this condition. The specific details of the image are not provided, but it is essential for understanding the treatment approach.\\n```',\n", " 'md': '**Caption:** Non-operative management of sigmoid volvulus.\\n\\n**Description:** This figure illustrates the non-operative management techniques for sigmoid volvulus. The image likely depicts the endoscopic procedure or tools used in the management of this condition. The specific details of the image are not provided, but it is essential for understanding the treatment approach.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 479,\n", " 'text': 'and the obstruction relieved. Once the colon is detorted, and the bowel is\\nseen to be viable, the patient can be admitted and ‘prepped’ to undergo a\\nsemi-elective sigmoid resection.\\n\\n If the colon cannot be untwisted, then the patient requires an\\nimmediate operation with resection and stoma formation\\n(Hartmann’s) or primary anastomosis — again, the decision whether\\nto anastomose or not depends on the condition of the patient, his\\nbowel and your expertise.\\n\\n After successful non-operative decompression\\n There is no general agreement when patients should be offered a\\nsigmoidectomy to prevent a recurrence. About half of the patients will\\nhave only one episode but those with two episodes will frequently have a\\nthird. Most surgeons therefore offer resection after the second episode —\\nI offer it after the first episode!\\n\\n Elective sigmoid resections for volvulus may be performed with\\nminimal mobilization of the colon, resecting just the redundant sigmoid\\nthat has an elongated mesentery. It can be completed through a small\\nlower midline incision, a Pfannenstiel incision, or a small LLQ transverse,\\nmuscle-splitting incision. Once the incision is made, the colon just pops\\nout, and because we aren’t mobilizing much, I find really no need to\\nutilize the laparoscope for this resection. Placing a laparoscope for this\\nreally just wastes time and money.\\n\\n Finally, sigmoidopexy (i.e. fixing the viable sigmoid and its mesentery\\nto the abdominal wall to prevent recurrence), which has been advocated\\nby some authors over the years, should be relegated to the history\\nbooks.\\n\\n Volvulus of the cecum\\n\\n This is a relatively rare condition — you probably won’t see more than\\na few cases during your career — but it will usually require an operation.\\nIt can cause intermittent symptoms that are vague and not easily\\nidentified until the patient presents with features suggesting intestinal',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nThe obstruction is relieved. Once the colon is detorted, and the bowel is seen to be viable, the patient can be admitted and ‘prepped’ to undergo a semi-elective sigmoid resection.\\n\\nIf the colon cannot be untwisted, then the patient requires an immediate operation with resection and stoma formation (Hartmann’s) or primary anastomosis — again, the decision whether to anastomose or not depends on the condition of the patient, his bowel, and your expertise.\\n\\nAfter successful non-operative decompression, there is no general agreement on when patients should be offered a sigmoidectomy to prevent a recurrence. About half of the patients will have only one episode, but those with two episodes will frequently have a third. Most surgeons, therefore, offer resection after the second episode — I offer it after the first episode!\\n\\nElective sigmoid resections for volvulus may be performed with minimal mobilization of the colon, resecting just the redundant sigmoid that has an elongated mesentery. It can be completed through a small lower midline incision, a Pfannenstiel incision, or a small LLQ transverse, muscle-splitting incision. Once the incision is made, the colon just pops out, and because we aren’t mobilizing much, I find really no need to utilize the laparoscope for this resection. Placing a laparoscope for this really just wastes time and money.\\n\\nFinally, sigmoidopexy (i.e., fixing the viable sigmoid and its mesentery to the abdominal wall to prevent recurrence), which has been advocated by some authors over the years, should be relegated to the history books.\\n\\n### Volvulus of the Cecum\\n\\nThis is a relatively rare condition — you probably won’t see more than a few cases during your career — but it will usually require an operation. It can cause intermittent symptoms that are vague and not easily identified until the patient presents with features suggesting intestinal obstruction.\\n\\n## Image Identification and Description\\n\\n*No images or figures were identified on this page.*\\n\\n## Summary\\n\\nThe text discusses the management of sigmoid volvulus, including the options for surgical intervention and the considerations for resection. It emphasizes the importance of timely intervention and the varying opinions among surgeons regarding the necessity of sigmoidectomy after episodes of volvulus. The section on cecal volvulus highlights its rarity and the need for surgical treatment.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The obstruction is relieved. Once the colon is detorted, and the bowel is seen to be viable, the patient can be admitted and ‘prepped’ to undergo a semi-elective sigmoid resection.\\n\\nIf the colon cannot be untwisted, then the patient requires an immediate operation with resection and stoma formation (Hartmann’s) or primary anastomosis — again, the decision whether to anastomose or not depends on the condition of the patient, his bowel, and your expertise.\\n\\nAfter successful non-operative decompression, there is no general agreement on when patients should be offered a sigmoidectomy to prevent a recurrence. About half of the patients will have only one episode, but those with two episodes will frequently have a third. Most surgeons, therefore, offer resection after the second episode — I offer it after the first episode!\\n\\nElective sigmoid resections for volvulus may be performed with minimal mobilization of the colon, resecting just the redundant sigmoid that has an elongated mesentery. It can be completed through a small lower midline incision, a Pfannenstiel incision, or a small LLQ transverse, muscle-splitting incision. Once the incision is made, the colon just pops out, and because we aren’t mobilizing much, I find really no need to utilize the laparoscope for this resection. Placing a laparoscope for this really just wastes time and money.\\n\\nFinally, sigmoidopexy (i.e., fixing the viable sigmoid and its mesentery to the abdominal wall to prevent recurrence), which has been advocated by some authors over the years, should be relegated to the history books.',\n", " 'md': 'The obstruction is relieved. Once the colon is detorted, and the bowel is seen to be viable, the patient can be admitted and ‘prepped’ to undergo a semi-elective sigmoid resection.\\n\\nIf the colon cannot be untwisted, then the patient requires an immediate operation with resection and stoma formation (Hartmann’s) or primary anastomosis — again, the decision whether to anastomose or not depends on the condition of the patient, his bowel, and your expertise.\\n\\nAfter successful non-operative decompression, there is no general agreement on when patients should be offered a sigmoidectomy to prevent a recurrence. About half of the patients will have only one episode, but those with two episodes will frequently have a third. Most surgeons, therefore, offer resection after the second episode — I offer it after the first episode!\\n\\nElective sigmoid resections for volvulus may be performed with minimal mobilization of the colon, resecting just the redundant sigmoid that has an elongated mesentery. It can be completed through a small lower midline incision, a Pfannenstiel incision, or a small LLQ transverse, muscle-splitting incision. Once the incision is made, the colon just pops out, and because we aren’t mobilizing much, I find really no need to utilize the laparoscope for this resection. Placing a laparoscope for this really just wastes time and money.\\n\\nFinally, sigmoidopexy (i.e., fixing the viable sigmoid and its mesentery to the abdominal wall to prevent recurrence), which has been advocated by some authors over the years, should be relegated to the history books.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.81, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Volvulus of the Cecum',\n", " 'md': '### Volvulus of the Cecum',\n", " 'bBox': {'x': 86, 'y': 625, 'w': 174.4, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is a relatively rare condition — you probably won’t see more than a few cases during your career — but it will usually require an operation. It can cause intermittent symptoms that are vague and not easily identified until the patient presents with features suggesting intestinal obstruction.',\n", " 'md': 'This is a relatively rare condition — you probably won’t see more than a few cases during your career — but it will usually require an operation. It can cause intermittent symptoms that are vague and not easily identified until the patient presents with features suggesting intestinal obstruction.',\n", " 'bBox': {'x': 72, 'y': 170, 'w': 467.67, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 370, 'y': 170, 'w': 29.57, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*',\n", " 'md': '*No images or figures were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the management of sigmoid volvulus, including the options for surgical intervention and the considerations for resection. It emphasizes the importance of timely intervention and the varying opinions among surgeons regarding the necessity of sigmoidectomy after episodes of volvulus. The section on cecal volvulus highlights its rarity and the need for surgical treatment.\\n```',\n", " 'md': 'The text discusses the management of sigmoid volvulus, including the options for surgical intervention and the considerations for resection. It emphasizes the importance of timely intervention and the varying opinions among surgeons regarding the necessity of sigmoidectomy after episodes of volvulus. The section on cecal volvulus highlights its rarity and the need for surgical treatment.\\n```',\n", " 'bBox': {'x': 370, 'y': 170, 'w': 29.57, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 480,\n", " 'text': 'obstruction.\\n\\n The underlying cause is a redundant mesentery and lack of fixation of\\nthe cecum: it flips and twists (usually) clockwise, which results in\\nobstruction and compromise of the blood supply. A rare variant of cecal\\nvolvulus is cecal bascule — involving upwards and anterior folding of the\\nright colon.\\n\\n These patients have clinical and radiographic signs of small\\nbowel obstruction. In addition, typically, the cecal ‘shadow’ is\\nabsent from the right lower quadrant. Instead, the poorly attached\\nand redundant cecum — which has flipped to the left and upwards\\n— is visualized in the epigastrium or the left hypochondrium, with\\nits concavity pointing to the right lower quadrant. On abdominal\\nradiographs a single fluid level may be seen, representing the dislocated\\ncecum and is often confused with the gastric shadow. If in doubt (there is\\nalways some ‘doubt’) and in the absence of peritoneal signs, you may\\norder a Gastrografin® enema, which will demonstrate the characteristic\\n‘beak’ in the right colon. But today a CT is the easiest and most\\naccurate route to a diagnosis.\\n\\n There are isolated reports of colonoscopic decompression of\\ncecal volvulus but the complexity of such a procedure and its\\ndoubtful results suggest that an operation is the treatment of\\nchoice.\\n\\n What to do? There is an eternal controversy — probably never to be\\nsolved — between the proponents of cecal fixation (cecopexy), and the\\nadvocates of mandatory resection. This is our selective approach: first\\ndetort the cecum; if after detorsion the bowel appears gangrenous or of\\ndoubtful viability, then proceed with a right hemicolectomy. A primary\\nanastomosis should usually be permissible but occasionally\\ncircumstances suggest that a stoma is preferable. If so, bring out the\\nsmall bowel as an end ileostomy and a corner of the closed colon\\nend through the same hole. This ‘double-barrel’ stoma allows simple\\nclosure and restoration of bowel continuity through the site of the stoma.',\n", " 'md': '```markdown\\n## Cecal Volvulus\\n\\nThe underlying cause is a redundant mesentery and lack of fixation of the cecum: it flips and twists (usually) clockwise, which results in obstruction and compromise of the blood supply. A rare variant of cecal volvulus is cecal bascule — involving upwards and anterior folding of the right colon.\\n\\nThese patients have clinical and radiographic signs of small bowel obstruction. In addition, typically, the cecal ‘shadow’ is absent from the right lower quadrant. Instead, the poorly attached and redundant cecum — which has flipped to the left and upwards — is visualized in the epigastrium or the left hypochondrium, with its concavity pointing to the right lower quadrant. On abdominal radiographs, a single fluid level may be seen, representing the dislocated cecum and is often confused with the gastric shadow. If in doubt (there is always some ‘doubt’) and in the absence of peritoneal signs, you may order a Gastrografin® enema, which will demonstrate the characteristic ‘beak’ in the right colon. But today a CT is the easiest and most accurate route to a diagnosis.\\n\\nThere are isolated reports of colonoscopic decompression of cecal volvulus but the complexity of such a procedure and its doubtful results suggest that an operation is the treatment of choice.\\n\\n### Treatment Approach\\n\\nWhat to do? There is an eternal controversy — probably never to be solved — between the proponents of cecal fixation (cecopexy) and the advocates of mandatory resection. This is our selective approach: first detort the cecum; if after detorsion the bowel appears gangrenous or of doubtful viability, then proceed with a right hemicolectomy. A primary anastomosis should usually be permissible but occasionally circumstances suggest that a stoma is preferable. If so, bring out the small bowel as an end ileostomy and a corner of the closed colon end through the same hole. This ‘double-barrel’ stoma allows simple closure and restoration of bowel continuity through the site of the stoma.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Cecal Volvulus',\n", " 'md': '## Cecal Volvulus',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The underlying cause is a redundant mesentery and lack of fixation of the cecum: it flips and twists (usually) clockwise, which results in obstruction and compromise of the blood supply. A rare variant of cecal volvulus is cecal bascule — involving upwards and anterior folding of the right colon.\\n\\nThese patients have clinical and radiographic signs of small bowel obstruction. In addition, typically, the cecal ‘shadow’ is absent from the right lower quadrant. Instead, the poorly attached and redundant cecum — which has flipped to the left and upwards — is visualized in the epigastrium or the left hypochondrium, with its concavity pointing to the right lower quadrant. On abdominal radiographs, a single fluid level may be seen, representing the dislocated cecum and is often confused with the gastric shadow. If in doubt (there is always some ‘doubt’) and in the absence of peritoneal signs, you may order a Gastrografin® enema, which will demonstrate the characteristic ‘beak’ in the right colon. But today a CT is the easiest and most accurate route to a diagnosis.\\n\\nThere are isolated reports of colonoscopic decompression of cecal volvulus but the complexity of such a procedure and its doubtful results suggest that an operation is the treatment of choice.',\n", " 'md': 'The underlying cause is a redundant mesentery and lack of fixation of the cecum: it flips and twists (usually) clockwise, which results in obstruction and compromise of the blood supply. A rare variant of cecal volvulus is cecal bascule — involving upwards and anterior folding of the right colon.\\n\\nThese patients have clinical and radiographic signs of small bowel obstruction. In addition, typically, the cecal ‘shadow’ is absent from the right lower quadrant. Instead, the poorly attached and redundant cecum — which has flipped to the left and upwards — is visualized in the epigastrium or the left hypochondrium, with its concavity pointing to the right lower quadrant. On abdominal radiographs, a single fluid level may be seen, representing the dislocated cecum and is often confused with the gastric shadow. If in doubt (there is always some ‘doubt’) and in the absence of peritoneal signs, you may order a Gastrografin® enema, which will demonstrate the characteristic ‘beak’ in the right colon. But today a CT is the easiest and most accurate route to a diagnosis.\\n\\nThere are isolated reports of colonoscopic decompression of cecal volvulus but the complexity of such a procedure and its doubtful results suggest that an operation is the treatment of choice.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.98, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Treatment Approach',\n", " 'md': '### Treatment Approach',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'What to do? There is an eternal controversy — probably never to be solved — between the proponents of cecal fixation (cecopexy) and the advocates of mandatory resection. This is our selective approach: first detort the cecum; if after detorsion the bowel appears gangrenous or of doubtful viability, then proceed with a right hemicolectomy. A primary anastomosis should usually be permissible but occasionally circumstances suggest that a stoma is preferable. If so, bring out the small bowel as an end ileostomy and a corner of the closed colon end through the same hole. This ‘double-barrel’ stoma allows simple closure and restoration of bowel continuity through the site of the stoma.\\n```',\n", " 'md': 'What to do? There is an eternal controversy — probably never to be solved — between the proponents of cecal fixation (cecopexy) and the advocates of mandatory resection. This is our selective approach: first detort the cecum; if after detorsion the bowel appears gangrenous or of doubtful viability, then proceed with a right hemicolectomy. A primary anastomosis should usually be permissible but occasionally circumstances suggest that a stoma is preferable. If so, bring out the small bowel as an end ileostomy and a corner of the closed colon end through the same hole. This ‘double-barrel’ stoma allows simple closure and restoration of bowel continuity through the site of the stoma.\\n```',\n", " 'bBox': {'x': 72, 'y': 527, 'w': 467.68, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 481,\n", " 'text': ' You can also do a ‘loop-stoma’ by suturing the back walls of the two loops together and bring\\n this up as a loop; subsequent stoma closure is then even easier. Ari\\n\\n If the cecum is viable there are some that would advocate a cecopexy,\\nasking “why remove a healthy organ that can be fixed?” To prevent\\nrecurrence of the volvulus fix the mobile cecum to the lateral\\nabdominal wall (cecopexy). Start with decompression of the cecum by\\nmilking its contents towards a rectal tube, for sutures hold poorly in a\\ndistended bowel wall. Cecopexy is accomplished by suturing the entire\\nlength of the cecum to the lateral abdominal wall. Use non-absorbable\\nmaterial and take big seromuscular bites on the bowel and big-deep bites\\non the abdominal side. Some surgeons elevate a flap of parietal\\nperitoneum that is sutured to the anterior wall of the cecum. Myself, I am\\nmore of a ‘resector’ than a ‘pexer’, because I think cecopexies fail.\\nSo in a fit patient I resect, but in a risky patient I will pexy.\\n\\n Cecostomy, either a tube or matured to the skin, is an option that is\\nmentioned in the literature as an alternative to cecopexy. To me it seems\\na bad idea (why convert a simple and clean procedure (i.e. cecopexy) to\\na contaminated and potentially complicated one (i.e. cecostomy)? It\\nshould be considered only in desperate situations.\\n\\n Sometimes a bowel-coil gets out of place\\n By twisting round a narrow base\\n With gradual strangulating of the blood supply\\n And danger that th’ affected coil will die.\\n This is a VOLVULUS which you should learn\\n Is from the Latin — volvere — to turn.\\n Zachary Cope, The Acute Abdomen in Rhyme\\n\\n Acute colonic pseudo-obstruction (Ogilvie’s syndrome)\\n\\n William ħeneage Ogilvie (1887-1971) was not only a great British\\nsurgeon but also a keen surgical aphorist. For example: “Personal\\nstatistics are at the bottom of all unsound teaching; they are either too\\ngood to be true or too true to be good.”',\n", " 'md': '```markdown\\n# Page Content\\n\\nYou can also do a ‘loop-stoma’ by suturing the back walls of the two loops together and bring this up as a loop; subsequent stoma closure is then even easier.\\n\\nIf the cecum is viable there are some that would advocate a cecopexy, asking “why remove a healthy organ that can be fixed?” To prevent recurrence of the volvulus fix the mobile cecum to the lateral abdominal wall (cecopexy). Start with decompression of the cecum by milking its contents towards a rectal tube, for sutures hold poorly in a distended bowel wall. Cecopexy is accomplished by suturing the entire length of the cecum to the lateral abdominal wall. Use non-absorbable material and take big seromuscular bites on the bowel and big-deep bites on the abdominal side. Some surgeons elevate a flap of parietal peritoneum that is sutured to the anterior wall of the cecum. Myself, I am more of a ‘resector’ than a ‘pexer’, because I think cecopexies fail. So in a fit patient I resect, but in a risky patient I will pexy.\\n\\nCecostomy, either a tube or matured to the skin, is an option that is mentioned in the literature as an alternative to cecopexy. To me it seems a bad idea (why convert a simple and clean procedure (i.e. cecopexy) to a contaminated and potentially complicated one (i.e. cecostomy)? It should be considered only in desperate situations.\\n\\nSometimes a bowel-coil gets out of place\\nBy twisting round a narrow base\\nWith gradual strangulating of the blood supply\\nAnd danger that th’ affected coil will die.\\nThis is a VOLVULUS which you should learn\\nIs from the Latin — volvere — to turn.\\nZachary Cope, The Acute Abdomen in Rhyme\\n\\nAcute colonic pseudo-obstruction (Ogilvie’s syndrome)\\n\\nWilliam Heneage Ogilvie (1887-1971) was not only a great British surgeon but also a keen surgical aphorist. For example: “Personal statistics are at the bottom of all unsound teaching; they are either too good to be true or too true to be good.”\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'You can also do a ‘loop-stoma’ by suturing the back walls of the two loops together and bring this up as a loop; subsequent stoma closure is then even easier.\\n\\nIf the cecum is viable there are some that would advocate a cecopexy, asking “why remove a healthy organ that can be fixed?” To prevent recurrence of the volvulus fix the mobile cecum to the lateral abdominal wall (cecopexy). Start with decompression of the cecum by milking its contents towards a rectal tube, for sutures hold poorly in a distended bowel wall. Cecopexy is accomplished by suturing the entire length of the cecum to the lateral abdominal wall. Use non-absorbable material and take big seromuscular bites on the bowel and big-deep bites on the abdominal side. Some surgeons elevate a flap of parietal peritoneum that is sutured to the anterior wall of the cecum. Myself, I am more of a ‘resector’ than a ‘pexer’, because I think cecopexies fail. So in a fit patient I resect, but in a risky patient I will pexy.\\n\\nCecostomy, either a tube or matured to the skin, is an option that is mentioned in the literature as an alternative to cecopexy. To me it seems a bad idea (why convert a simple and clean procedure (i.e. cecopexy) to a contaminated and potentially complicated one (i.e. cecostomy)? It should be considered only in desperate situations.\\n\\nSometimes a bowel-coil gets out of place\\nBy twisting round a narrow base\\nWith gradual strangulating of the blood supply\\nAnd danger that th’ affected coil will die.\\nThis is a VOLVULUS which you should learn\\nIs from the Latin — volvere — to turn.\\nZachary Cope, The Acute Abdomen in Rhyme\\n\\nAcute colonic pseudo-obstruction (Ogilvie’s syndrome)\\n\\nWilliam Heneage Ogilvie (1887-1971) was not only a great British surgeon but also a keen surgical aphorist. For example: “Personal statistics are at the bottom of all unsound teaching; they are either too good to be true or too true to be good.”\\n```',\n", " 'md': 'You can also do a ‘loop-stoma’ by suturing the back walls of the two loops together and bring this up as a loop; subsequent stoma closure is then even easier.\\n\\nIf the cecum is viable there are some that would advocate a cecopexy, asking “why remove a healthy organ that can be fixed?” To prevent recurrence of the volvulus fix the mobile cecum to the lateral abdominal wall (cecopexy). Start with decompression of the cecum by milking its contents towards a rectal tube, for sutures hold poorly in a distended bowel wall. Cecopexy is accomplished by suturing the entire length of the cecum to the lateral abdominal wall. Use non-absorbable material and take big seromuscular bites on the bowel and big-deep bites on the abdominal side. Some surgeons elevate a flap of parietal peritoneum that is sutured to the anterior wall of the cecum. Myself, I am more of a ‘resector’ than a ‘pexer’, because I think cecopexies fail. So in a fit patient I resect, but in a risky patient I will pexy.\\n\\nCecostomy, either a tube or matured to the skin, is an option that is mentioned in the literature as an alternative to cecopexy. To me it seems a bad idea (why convert a simple and clean procedure (i.e. cecopexy) to a contaminated and potentially complicated one (i.e. cecostomy)? It should be considered only in desperate situations.\\n\\nSometimes a bowel-coil gets out of place\\nBy twisting round a narrow base\\nWith gradual strangulating of the blood supply\\nAnd danger that th’ affected coil will die.\\nThis is a VOLVULUS which you should learn\\nIs from the Latin — volvere — to turn.\\nZachary Cope, The Acute Abdomen in Rhyme\\n\\nAcute colonic pseudo-obstruction (Ogilvie’s syndrome)\\n\\nWilliam Heneage Ogilvie (1887-1971) was not only a great British surgeon but also a keen surgical aphorist. For example: “Personal statistics are at the bottom of all unsound teaching; they are either too good to be true or too true to be good.”\\n```',\n", " 'bBox': {'x': 72, 'y': 91, 'w': 467.83, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 482,\n", " 'text': ' This is an important differential diagnosis of colonic obstruction.\\nPseudo-obstruction has the symptoms, signs, and radiographic\\nappearances of acute large bowel obstruction but there is no\\nmechanical blockage. The X-ray films are suggestive but a contrast\\nstudy or colonoscopy finds no obstruction. This pseudo-obstruction can\\nbe so intense that the right colon becomes ischemic and perforates due\\nto the high intramural pressure. The distension may be extreme,\\nresulting in acute, rapidly lethal, abdominal compartment syndrome.\\n\\n The mechanisms behind pseudo-obstruction are not known. It has\\nbeen proposed that the condition may be due to sympathetic over-\\nactivity, parasympathetic suppression, or both. Most patients are already\\nin hospital for other reasons when the pseudo-obstruction develops. It is\\na rare but well-recognized sequel to giving birth, but more commonly is\\nseen after major non-intestinal surgery or trauma, or on the background\\nof serious medical illnesses.\\n\\n This entity is the reason why you should not operate on a\\nsuspected colonic obstruction without a pre-operative colonoscopy,\\ncontrast enema or CT. Taking an elderly patient with multiple pre-\\nmorbid conditions for a laparotomy to find ‘only’ a distended colon,\\nwithout an obstructing lesion, is a cardinal error. Avoid it! These\\npatients should not have surgery but be treated medically or\\ndecompressed with colonoscopy:\\n\\n • For medical treatment it is suggested that neostigmine (2mg)\\n intravenously will effectively induce bowel movements and colonic\\n emptying within a few minutes. There are side effects to the\\n neostigmine, including bradycardia, salivation, nausea and\\n abdominal cramps. The patient should therefore be under close\\n surveillance during the treatment. We have tried this a few times —\\n it doesn’t always work but when it does you look like a superstar!\\n • If medical treatment is ineffective, a colonoscopy may decompress\\n the bowel. The target is decompression of the grossly distended\\n cecum; occasionally, repeated colonoscopic decompressions may\\n be needed. A large and long rectal tube can be left in situ after the\\n colonoscopy for a few days. The diagnostic Gastrografin® enema\\n may occasionally also be therapeutic with the hyperosmolar',\n", " 'md': '```markdown\\n# Differential Diagnosis of Colonic Obstruction\\n\\nThis is an important differential diagnosis of colonic obstruction. Pseudo-obstruction has the symptoms, signs, and radiographic appearances of acute large bowel obstruction but there is no mechanical blockage. The X-ray films are suggestive but a contrast study or colonoscopy finds no obstruction. This pseudo-obstruction can be so intense that the right colon becomes ischemic and perforates due to the high intramural pressure. The distension may be extreme, resulting in acute, rapidly lethal, abdominal compartment syndrome.\\n\\nThe mechanisms behind pseudo-obstruction are not known. It has been proposed that the condition may be due to sympathetic over-activity, parasympathetic suppression, or both. Most patients are already in hospital for other reasons when the pseudo-obstruction develops. It is a rare but well-recognized sequel to giving birth, but more commonly is seen after major non-intestinal surgery or trauma, or on the background of serious medical illnesses.\\n\\nThis entity is the reason why you should not operate on a suspected colonic obstruction without a pre-operative colonoscopy, contrast enema, or CT. Taking an elderly patient with multiple pre-morbid conditions for a laparotomy to find ‘only’ a distended colon, without an obstructing lesion, is a cardinal error. Avoid it! These patients should not have surgery but be treated medically or decompressed with colonoscopy:\\n\\n- For medical treatment, it is suggested that neostigmine (2mg) intravenously will effectively induce bowel movements and colonic emptying within a few minutes. There are side effects to the neostigmine, including bradycardia, salivation, nausea, and abdominal cramps. The patient should therefore be under close surveillance during the treatment. We have tried this a few times — it doesn’t always work but when it does you look like a superstar!\\n- If medical treatment is ineffective, a colonoscopy may decompress the bowel. The target is decompression of the grossly distended cecum; occasionally, repeated colonoscopic decompressions may be needed. A large and long rectal tube can be left in situ after the colonoscopy for a few days. The diagnostic Gastrografin® enema may occasionally also be therapeutic with the hyperosmolar.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Differential Diagnosis of Colonic Obstruction',\n", " 'md': '# Differential Diagnosis of Colonic Obstruction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This is an important differential diagnosis of colonic obstruction. Pseudo-obstruction has the symptoms, signs, and radiographic appearances of acute large bowel obstruction but there is no mechanical blockage. The X-ray films are suggestive but a contrast study or colonoscopy finds no obstruction. This pseudo-obstruction can be so intense that the right colon becomes ischemic and perforates due to the high intramural pressure. The distension may be extreme, resulting in acute, rapidly lethal, abdominal compartment syndrome.\\n\\nThe mechanisms behind pseudo-obstruction are not known. It has been proposed that the condition may be due to sympathetic over-activity, parasympathetic suppression, or both. Most patients are already in hospital for other reasons when the pseudo-obstruction develops. It is a rare but well-recognized sequel to giving birth, but more commonly is seen after major non-intestinal surgery or trauma, or on the background of serious medical illnesses.\\n\\nThis entity is the reason why you should not operate on a suspected colonic obstruction without a pre-operative colonoscopy, contrast enema, or CT. Taking an elderly patient with multiple pre-morbid conditions for a laparotomy to find ‘only’ a distended colon, without an obstructing lesion, is a cardinal error. Avoid it! These patients should not have surgery but be treated medically or decompressed with colonoscopy:\\n\\n- For medical treatment, it is suggested that neostigmine (2mg) intravenously will effectively induce bowel movements and colonic emptying within a few minutes. There are side effects to the neostigmine, including bradycardia, salivation, nausea, and abdominal cramps. The patient should therefore be under close surveillance during the treatment. We have tried this a few times — it doesn’t always work but when it does you look like a superstar!\\n- If medical treatment is ineffective, a colonoscopy may decompress the bowel. The target is decompression of the grossly distended cecum; occasionally, repeated colonoscopic decompressions may be needed. A large and long rectal tube can be left in situ after the colonoscopy for a few days. The diagnostic Gastrografin® enema may occasionally also be therapeutic with the hyperosmolar.\\n```',\n", " 'md': 'This is an important differential diagnosis of colonic obstruction. Pseudo-obstruction has the symptoms, signs, and radiographic appearances of acute large bowel obstruction but there is no mechanical blockage. The X-ray films are suggestive but a contrast study or colonoscopy finds no obstruction. This pseudo-obstruction can be so intense that the right colon becomes ischemic and perforates due to the high intramural pressure. The distension may be extreme, resulting in acute, rapidly lethal, abdominal compartment syndrome.\\n\\nThe mechanisms behind pseudo-obstruction are not known. It has been proposed that the condition may be due to sympathetic over-activity, parasympathetic suppression, or both. Most patients are already in hospital for other reasons when the pseudo-obstruction develops. It is a rare but well-recognized sequel to giving birth, but more commonly is seen after major non-intestinal surgery or trauma, or on the background of serious medical illnesses.\\n\\nThis entity is the reason why you should not operate on a suspected colonic obstruction without a pre-operative colonoscopy, contrast enema, or CT. Taking an elderly patient with multiple pre-morbid conditions for a laparotomy to find ‘only’ a distended colon, without an obstructing lesion, is a cardinal error. Avoid it! These patients should not have surgery but be treated medically or decompressed with colonoscopy:\\n\\n- For medical treatment, it is suggested that neostigmine (2mg) intravenously will effectively induce bowel movements and colonic emptying within a few minutes. There are side effects to the neostigmine, including bradycardia, salivation, nausea, and abdominal cramps. The patient should therefore be under close surveillance during the treatment. We have tried this a few times — it doesn’t always work but when it does you look like a superstar!\\n- If medical treatment is ineffective, a colonoscopy may decompress the bowel. The target is decompression of the grossly distended cecum; occasionally, repeated colonoscopic decompressions may be needed. A large and long rectal tube can be left in situ after the colonoscopy for a few days. The diagnostic Gastrografin® enema may occasionally also be therapeutic with the hyperosmolar.\\n```',\n", " 'bBox': {'x': 72, 'y': 168, 'w': 467.94, 'h': 19.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 483,\n", " 'text': ' contrast medium promoting colonic peristalsis.\\n\\n Surgical treatment is required if the cecum perforates or, very rarely, if\\nmedical treatment fails and the cecum reaches a gigantic size. If the\\ncecum becomes necrotic or perforates, a right hemicolectomy is\\nnecessary. Because the functional obstruction must be in the left colon,\\na primary anastomosis is inappropriate. It is better to fashion an end\\nileostomy and bring out the distal end of the colon through the same\\ncolostomy hole, fashioning a ‘double-barrel’ stoma. This arrangement\\nmakes it easy to restore bowel continuity later at the site of the colostomy\\nwithout the need to reopen the abdomen.\\n\\n When at laparotomy the cecum is distended but viable, most\\nsurgeons would opt for a cecostomy. Tube cecostomy is messy; it is\\nassociated with a high incidence of local complications such as a fecal\\nleak around it or even into the abdomen. To minimize these risks use a\\nsoft large-bore tube and surround its insertion site in the cecum with a\\ndouble purse-string suture; the cecostomy site should then be carefully\\nattached to the abdominal wall (as you do with a gastrostomy).\\nCecostomy tubes tend to obstruct with fecal matter and need regular\\nflushing. A viable alternative to tube cecostomy is the formal — ‘matured’\\n— cecostomy: simply exteriorize a portion of the cecum above the skin\\nlevel and suture it to the surrounding skin (as depicted in Figure 14.5).\\nThis, in medically ill patients with pseudo-obstruction, can be performed\\nunder local anesthesia.\\n\\n To recap…\\n\\n We have reviewed the initial diagnosis, work-up and management of a\\ncolonic obstruction. This has included generating a differential diagnosis\\nas well as initial management and the intra-operative decision making\\nthat should take place. We focused primarily on cancer for this\\ndiscussion, as other chapters will deal with the emergencies that\\nare caused by inflammatory bowel disease and diverticulitis.\\n\\n A colonic obstruction is a true general surgical emergency and\\nthe sun should not rise and set on a complete colonic obstruction',\n", " 'md': '```markdown\\n## Colonic Obstruction Management\\n\\nSurgical treatment is required if the cecum perforates or, very rarely, if medical treatment fails and the cecum reaches a gigantic size. If the cecum becomes necrotic or perforates, a right hemicolectomy is necessary. Because the functional obstruction must be in the left colon, a primary anastomosis is inappropriate. It is better to fashion an end ileostomy and bring out the distal end of the colon through the same colostomy hole, fashioning a ‘double-barrel’ stoma. This arrangement makes it easy to restore bowel continuity later at the site of the colostomy without the need to reopen the abdomen.\\n\\nWhen at laparotomy the cecum is distended but viable, most surgeons would opt for a cecostomy. Tube cecostomy is messy; it is associated with a high incidence of local complications such as a fecal leak around it or even into the abdomen. To minimize these risks, use a soft large-bore tube and surround its insertion site in the cecum with a double purse-string suture; the cecostomy site should then be carefully attached to the abdominal wall (as you do with a gastrostomy). Cecostomy tubes tend to obstruct with fecal matter and need regular flushing. A viable alternative to tube cecostomy is the formal — ‘matured’ — cecostomy: simply exteriorize a portion of the cecum above the skin level and suture it to the surrounding skin (as depicted in Figure 14.5). This, in medically ill patients with pseudo-obstruction, can be performed under local anesthesia.\\n\\n### Summary\\n\\nTo recap, we have reviewed the initial diagnosis, work-up, and management of a colonic obstruction. This has included generating a differential diagnosis as well as initial management and the intra-operative decision making that should take place. We focused primarily on cancer for this discussion, as other chapters will deal with the emergencies that are caused by inflammatory bowel disease and diverticulitis.\\n\\nA colonic obstruction is a true general surgical emergency and the sun should not rise and set on a complete colonic obstruction.\\n\\n### Figure 14.5 Description\\n\\nFigure 14.5 illustrates the process of a matured cecostomy, where a portion of the cecum is exteriorized above the skin level and sutured to the surrounding skin. This method is depicted as a viable alternative to tube cecostomy, particularly in medically ill patients with pseudo-obstruction, and can be performed under local anesthesia.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Colonic Obstruction Management',\n", " 'md': '## Colonic Obstruction Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Surgical treatment is required if the cecum perforates or, very rarely, if medical treatment fails and the cecum reaches a gigantic size. If the cecum becomes necrotic or perforates, a right hemicolectomy is necessary. Because the functional obstruction must be in the left colon, a primary anastomosis is inappropriate. It is better to fashion an end ileostomy and bring out the distal end of the colon through the same colostomy hole, fashioning a ‘double-barrel’ stoma. This arrangement makes it easy to restore bowel continuity later at the site of the colostomy without the need to reopen the abdomen.\\n\\nWhen at laparotomy the cecum is distended but viable, most surgeons would opt for a cecostomy. Tube cecostomy is messy; it is associated with a high incidence of local complications such as a fecal leak around it or even into the abdomen. To minimize these risks, use a soft large-bore tube and surround its insertion site in the cecum with a double purse-string suture; the cecostomy site should then be carefully attached to the abdominal wall (as you do with a gastrostomy). Cecostomy tubes tend to obstruct with fecal matter and need regular flushing. A viable alternative to tube cecostomy is the formal — ‘matured’ — cecostomy: simply exteriorize a portion of the cecum above the skin level and suture it to the surrounding skin (as depicted in Figure 14.5). This, in medically ill patients with pseudo-obstruction, can be performed under local anesthesia.',\n", " 'md': 'Surgical treatment is required if the cecum perforates or, very rarely, if medical treatment fails and the cecum reaches a gigantic size. If the cecum becomes necrotic or perforates, a right hemicolectomy is necessary. Because the functional obstruction must be in the left colon, a primary anastomosis is inappropriate. It is better to fashion an end ileostomy and bring out the distal end of the colon through the same colostomy hole, fashioning a ‘double-barrel’ stoma. This arrangement makes it easy to restore bowel continuity later at the site of the colostomy without the need to reopen the abdomen.\\n\\nWhen at laparotomy the cecum is distended but viable, most surgeons would opt for a cecostomy. Tube cecostomy is messy; it is associated with a high incidence of local complications such as a fecal leak around it or even into the abdomen. To minimize these risks, use a soft large-bore tube and surround its insertion site in the cecum with a double purse-string suture; the cecostomy site should then be carefully attached to the abdominal wall (as you do with a gastrostomy). Cecostomy tubes tend to obstruct with fecal matter and need regular flushing. A viable alternative to tube cecostomy is the formal — ‘matured’ — cecostomy: simply exteriorize a portion of the cecum above the skin level and suture it to the surrounding skin (as depicted in Figure 14.5). This, in medically ill patients with pseudo-obstruction, can be performed under local anesthesia.',\n", " 'bBox': {'x': 72, 'y': 123, 'w': 467.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'To recap, we have reviewed the initial diagnosis, work-up, and management of a colonic obstruction. This has included generating a differential diagnosis as well as initial management and the intra-operative decision making that should take place. We focused primarily on cancer for this discussion, as other chapters will deal with the emergencies that are caused by inflammatory bowel disease and diverticulitis.\\n\\nA colonic obstruction is a true general surgical emergency and the sun should not rise and set on a complete colonic obstruction.',\n", " 'md': 'To recap, we have reviewed the initial diagnosis, work-up, and management of a colonic obstruction. This has included generating a differential diagnosis as well as initial management and the intra-operative decision making that should take place. We focused primarily on cancer for this discussion, as other chapters will deal with the emergencies that are caused by inflammatory bowel disease and diverticulitis.\\n\\nA colonic obstruction is a true general surgical emergency and the sun should not rise and set on a complete colonic obstruction.',\n", " 'bBox': {'x': 72, 'y': 585, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 14.5 Description',\n", " 'md': '### Figure 14.5 Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 14.5 illustrates the process of a matured cecostomy, where a portion of the cecum is exteriorized above the skin level and sutured to the surrounding skin. This method is depicted as a viable alternative to tube cecostomy, particularly in medically ill patients with pseudo-obstruction, and can be performed under local anesthesia.\\n```',\n", " 'md': 'Figure 14.5 illustrates the process of a matured cecostomy, where a portion of the cecum is exteriorized above the skin level and sutured to the surrounding skin. This method is depicted as a viable alternative to tube cecostomy, particularly in medically ill patients with pseudo-obstruction, and can be performed under local anesthesia.\\n```',\n", " 'bBox': {'x': 72, 'y': 489, 'w': 147.95, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'This, in medically ill patients with pseudo-obstruction, can be performed'}]},\n", " {'page': 484,\n", " 'text': 'when the diagnosis is made. When evaluating and managing these\\npatients, especially in cancer, remembering what future therapies are\\nrequired for the patient is essential. Finally, as with any surgical\\nintervention, the extent of the surgery is really dependent on the overall\\nhealth of the patient as well as their acute condition.\\n\\n “Surgical judgment can be a battle between the brain and\\n the heart.”\\n David Dent\\n\\n1 By the way the name of this suction is not ‘pool’ as many think but Poole, after the name of\\n the inventor Herman Poole, an American mechanical engineer from the end of the 19th\\n century.',\n", " 'md': '```markdown\\nWhen the diagnosis is made. When evaluating and managing these patients, especially in cancer, remembering what future therapies are required for the patient is essential. Finally, as with any surgical intervention, the extent of the surgery is really dependent on the overall health of the patient as well as their acute condition.\\n\\n> “Surgical judgment can be a battle between the brain and the heart.”\\n> — David Dent\\n\\n1. By the way, the name of this suction is not ‘pool’ as many think but Poole, after the name of the inventor Herman Poole, an American mechanical engineer from the end of the 19th century.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nWhen the diagnosis is made. When evaluating and managing these patients, especially in cancer, remembering what future therapies are required for the patient is essential. Finally, as with any surgical intervention, the extent of the surgery is really dependent on the overall health of the patient as well as their acute condition.\\n\\n> “Surgical judgment can be a battle between the brain and the heart.”\\n> — David Dent\\n\\n1. By the way, the name of this suction is not ‘pool’ as many think but Poole, after the name of the inventor Herman Poole, an American mechanical engineer from the end of the 19th century.\\n```',\n", " 'md': '```markdown\\nWhen the diagnosis is made. When evaluating and managing these patients, especially in cancer, remembering what future therapies are required for the patient is essential. Finally, as with any surgical intervention, the extent of the surgery is really dependent on the overall health of the patient as well as their acute condition.\\n\\n> “Surgical judgment can be a battle between the brain and the heart.”\\n> — David Dent\\n\\n1. By the way, the name of this suction is not ‘pool’ as many think but Poole, after the name of the inventor Herman Poole, an American mechanical engineer from the end of the 19th century.\\n```',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.68, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 485,\n", " 'text': 'Chapter 28\\nAcute diverticulitis\\nJonathan E. Efron 1\\n\\n The British have such trouble with their diverticula because\\n no one is allowed to fart!\\n Harold Ellis (as told to my Dad — Gershon Efron)\\n\\n The Western lifestyle and dietary habits lead to much morbidity\\n(obesity, diabetes… you know what) but for the general surgeon, the\\nformation of colonic diverticula is particularly problematic. These\\noutpouchings, starting to form early in life from the notorious ‘meat and\\npotatoes diet’, can result in pain and misery for patients, and sleepless\\nnights for surgeons.\\n\\n Colonic diverticula are protrusions of mucosa at points of\\nweakness in the colon’s muscular wall where the vasa recta enter.\\nThey are not ‘true’ diverticula like Meckel’s diverticulum, but rather\\nprotrusions of the mucosa. The Western diet leads to less bulky stools.\\nSmall, hard stools require greater intraluminal pressures to propel and\\nevacuate them (remember Laplace’s law?). These high pressures\\nproduce the diverticula and also lead to hypertrophy of the bowel wall.\\n\\n Diverticulosis (some call it diverticular disease) — the mere\\ndevelopment of diverticula (mainly in the sigmoid colon) — is\\nextremely prevalent in the developed world (and in some ‘third world’\\npopulations adopting such poor Western dietary habits). In the vast\\nmajority of people diverticulosis causes no problems at all. In some,',\n", " 'md': '```markdown\\n# Chapter 28: Acute Diverticulitis\\n**Author:** Jonathan E. Efron\\n\\n> \"The British have such trouble with their diverticula because no one is allowed to fart!\"\\n> — Harold Ellis (as told to my Dad — Gershon Efron)\\n\\nThe Western lifestyle and dietary habits lead to much morbidity (obesity, diabetes… you know what) but for the general surgeon, the formation of colonic diverticula is particularly problematic. These outpouchings, starting to form early in life from the notorious ‘meat and potatoes diet’, can result in pain and misery for patients, and sleepless nights for surgeons.\\n\\nColonic diverticula are protrusions of mucosa at points of weakness in the colon’s muscular wall where the vasa recta enter. They are not ‘true’ diverticula like Meckel’s diverticulum, but rather protrusions of the mucosa. The Western diet leads to less bulky stools. Small, hard stools require greater intraluminal pressures to propel and evacuate them (remember Laplace’s law?). These high pressures produce the diverticula and also lead to hypertrophy of the bowel wall.\\n\\nDiverticulosis (some call it diverticular disease) — the mere development of diverticula (mainly in the sigmoid colon) — is extremely prevalent in the developed world (and in some ‘third world’ populations adopting such poor Western dietary habits). In the vast majority of people, diverticulosis causes no problems at all. In some,\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 28: Acute Diverticulitis',\n", " 'md': '# Chapter 28: Acute Diverticulitis',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 161.25, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Jonathan E. Efron\\n\\n> \"The British have such trouble with their diverticula because no one is allowed to fart!\"\\n> — Harold Ellis (as told to my Dad — Gershon Efron)\\n\\nThe Western lifestyle and dietary habits lead to much morbidity (obesity, diabetes… you know what) but for the general surgeon, the formation of colonic diverticula is particularly problematic. These outpouchings, starting to form early in life from the notorious ‘meat and potatoes diet’, can result in pain and misery for patients, and sleepless nights for surgeons.\\n\\nColonic diverticula are protrusions of mucosa at points of weakness in the colon’s muscular wall where the vasa recta enter. They are not ‘true’ diverticula like Meckel’s diverticulum, but rather protrusions of the mucosa. The Western diet leads to less bulky stools. Small, hard stools require greater intraluminal pressures to propel and evacuate them (remember Laplace’s law?). These high pressures produce the diverticula and also lead to hypertrophy of the bowel wall.\\n\\nDiverticulosis (some call it diverticular disease) — the mere development of diverticula (mainly in the sigmoid colon) — is extremely prevalent in the developed world (and in some ‘third world’ populations adopting such poor Western dietary habits). In the vast majority of people, diverticulosis causes no problems at all. In some,\\n```',\n", " 'md': '**Author:** Jonathan E. Efron\\n\\n> \"The British have such trouble with their diverticula because no one is allowed to fart!\"\\n> — Harold Ellis (as told to my Dad — Gershon Efron)\\n\\nThe Western lifestyle and dietary habits lead to much morbidity (obesity, diabetes… you know what) but for the general surgeon, the formation of colonic diverticula is particularly problematic. These outpouchings, starting to form early in life from the notorious ‘meat and potatoes diet’, can result in pain and misery for patients, and sleepless nights for surgeons.\\n\\nColonic diverticula are protrusions of mucosa at points of weakness in the colon’s muscular wall where the vasa recta enter. They are not ‘true’ diverticula like Meckel’s diverticulum, but rather protrusions of the mucosa. The Western diet leads to less bulky stools. Small, hard stools require greater intraluminal pressures to propel and evacuate them (remember Laplace’s law?). These high pressures produce the diverticula and also lead to hypertrophy of the bowel wall.\\n\\nDiverticulosis (some call it diverticular disease) — the mere development of diverticula (mainly in the sigmoid colon) — is extremely prevalent in the developed world (and in some ‘third world’ populations adopting such poor Western dietary habits). In the vast majority of people, diverticulosis causes no problems at all. In some,\\n```',\n", " 'bBox': {'x': 72, 'y': 309, 'w': 467.55, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Jonathan E. Efron 1'}]},\n", " {'page': 486,\n", " 'text': 'however, diverticula may become inflamed leading to acute\\ndiverticulitis — and this is what we will be talking about here.\\n\\n Diverticular emergencies\\n\\n Diverticular emergencies of the colon manifest in three different\\nways:\\n\\n • They can become inflamed or burst — this is acute diverticulitis\\n as discussed below…\\n • They can bleed — diverticular bleeding generally leads to\\n significant lower GI bleeding and can be life-threatening as\\n discussed in Chapter 29. However, acute diverticulitis does\\n occasionally present with rectal bleeding. If a patient presents\\n with left lower quadrant (LLQ) pain and tenderness associated\\n with rectal bleeding, first think about ischemic colitis, then\\n think infectious colitis or IBD; but always keep acute\\n diverticulitis as a possible diagnosis.\\n • They can block. This is uncommon — rarely will acute diverticulitis\\n cause an acute obstruction. ħowever, chronic diverticular disease\\n may cause a (sigmoid) stricture and eventually, obstruct the colon —\\n see Chapter 27.\\n\\n What causes acute diverticulitis (surgical pathology)?\\n\\n The term ‘acute diverticulitis’ covers a wide spectrum of pathological\\nconditions — each correlating with a specific clinical scenario, each of\\nwhich in turn necessitates selective management.\\n\\n At operation for acute diverticulitis the sigmoid usually feels like a thick\\nfusiform tumor, with only a few diverticula. ħowever, there are also cases\\nof minor thickening with many diverticula, one of which has perforated\\nand is the cause of the acute inflammation. Such observations make\\none think about the basic pathology of acute diverticulitis.\\n\\n Basil Morson, the famous pathologist at St Mark’s, London,',\n", " 'md': '```markdown\\n## Diverticular Emergencies\\n\\nDiverticular emergencies of the colon manifest in three different ways:\\n\\n- They can become inflamed or burst — this is acute diverticulitis as discussed below…\\n- They can bleed — diverticular bleeding generally leads to significant lower GI bleeding and can be life-threatening as discussed in Chapter 29. However, acute diverticulitis does occasionally present with rectal bleeding. If a patient presents with left lower quadrant (LLQ) pain and tenderness associated with rectal bleeding, first think about ischemic colitis, then think infectious colitis or IBD; but always keep acute diverticulitis as a possible diagnosis.\\n- They can block. This is uncommon — rarely will acute diverticulitis cause an acute obstruction. However, chronic diverticular disease may cause a (sigmoid) stricture and eventually obstruct the colon — see Chapter 27.\\n\\n### What Causes Acute Diverticulitis (Surgical Pathology)?\\n\\nThe term ‘acute diverticulitis’ covers a wide spectrum of pathological conditions — each correlating with a specific clinical scenario, each of which in turn necessitates selective management.\\n\\nAt operation for acute diverticulitis, the sigmoid usually feels like a thick fusiform tumor, with only a few diverticula. However, there are also cases of minor thickening with many diverticula, one of which has perforated and is the cause of the acute inflammation. Such observations make one think about the basic pathology of acute diverticulitis.\\n\\nBasil Morson, the famous pathologist at St Mark’s, London,\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diverticular Emergencies',\n", " 'md': '## Diverticular Emergencies',\n", " 'bBox': {'x': 86, 'y': 145, 'w': 196.81, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Diverticular emergencies of the colon manifest in three different ways:\\n\\n- They can become inflamed or burst — this is acute diverticulitis as discussed below…\\n- They can bleed — diverticular bleeding generally leads to significant lower GI bleeding and can be life-threatening as discussed in Chapter 29. However, acute diverticulitis does occasionally present with rectal bleeding. If a patient presents with left lower quadrant (LLQ) pain and tenderness associated with rectal bleeding, first think about ischemic colitis, then think infectious colitis or IBD; but always keep acute diverticulitis as a possible diagnosis.\\n- They can block. This is uncommon — rarely will acute diverticulitis cause an acute obstruction. However, chronic diverticular disease may cause a (sigmoid) stricture and eventually obstruct the colon — see Chapter 27.',\n", " 'md': 'Diverticular emergencies of the colon manifest in three different ways:\\n\\n- They can become inflamed or burst — this is acute diverticulitis as discussed below…\\n- They can bleed — diverticular bleeding generally leads to significant lower GI bleeding and can be life-threatening as discussed in Chapter 29. However, acute diverticulitis does occasionally present with rectal bleeding. If a patient presents with left lower quadrant (LLQ) pain and tenderness associated with rectal bleeding, first think about ischemic colitis, then think infectious colitis or IBD; but always keep acute diverticulitis as a possible diagnosis.\\n- They can block. This is uncommon — rarely will acute diverticulitis cause an acute obstruction. However, chronic diverticular disease may cause a (sigmoid) stricture and eventually obstruct the colon — see Chapter 27.',\n", " 'bBox': {'x': 72, 'y': 145, 'w': 437.08, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'What Causes Acute Diverticulitis (Surgical Pathology)?',\n", " 'md': '### What Causes Acute Diverticulitis (Surgical Pathology)?',\n", " 'bBox': {'x': 86, 'y': 500, 'w': 423.88, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The term ‘acute diverticulitis’ covers a wide spectrum of pathological conditions — each correlating with a specific clinical scenario, each of which in turn necessitates selective management.\\n\\nAt operation for acute diverticulitis, the sigmoid usually feels like a thick fusiform tumor, with only a few diverticula. However, there are also cases of minor thickening with many diverticula, one of which has perforated and is the cause of the acute inflammation. Such observations make one think about the basic pathology of acute diverticulitis.\\n\\nBasil Morson, the famous pathologist at St Mark’s, London,\\n```',\n", " 'md': 'The term ‘acute diverticulitis’ covers a wide spectrum of pathological conditions — each correlating with a specific clinical scenario, each of which in turn necessitates selective management.\\n\\nAt operation for acute diverticulitis, the sigmoid usually feels like a thick fusiform tumor, with only a few diverticula. However, there are also cases of minor thickening with many diverticula, one of which has perforated and is the cause of the acute inflammation. Such observations make one think about the basic pathology of acute diverticulitis.\\n\\nBasil Morson, the famous pathologist at St Mark’s, London,\\n```',\n", " 'bBox': {'x': 72, 'y': 569, 'w': 397, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'occasionally present with rectal bleeding. If a patient presents'},\n", " {'text': ''}]},\n", " {'page': 487,\n", " 'text': 'highlighted the hypertrophy of the bowel wall as the primary pathology\\nand we are inclined to accept this, with the addition that the mesenteric\\nfat tissue also plays a role. It is this fat that creeps up the bowel wall,\\nbecomes inflamed, produces the phlegmon or abscess, and heals with\\nfibrosis. It is believed that many cases of acute diverticulitis might\\nbetter be termed acute sigmoiditis — recognizing that it is an acute\\ninflammation of the thickened bowel wall and mesentery.\\n\\n On the other hand, when it is a diverticulum that has been eroded\\nby a fecalith, one finds a localized inflammation, which identifies the\\nsite of the perforation. In cases of free fecal peritonitis, a perforated\\ndiverticulum is the cause although more often it has been walled off\\nby the mesentery or epiploic appendices to produce a pericolic\\nabscess.\\n\\n Sometimes, the perforation occurs entirely within the mesentery,\\nforming a mesenteric phlegmon or abscess. The latter may secondarily\\nperforate into the free peritoneal cavity but usually this variety only gives\\nrise to minor abdominal and systemic signs. Occasionally, it can produce\\nsepticemia in a patient who is unable to contain the perforation.\\n\\n There is a strong tendency for diverticulitis and sigmoiditis to\\nadhere locally and fistulate. The formation of fistulas has an obscure\\nmechanism, and most patients with such a fistula present as non-\\nemergency cases and often do not even give a history of previous\\nattacks of acute diverticulitis. Most often the fistulas are into the\\nbladder. The patient seeks attention for pneumaturia or persistent\\nurinary tract infection. Fistulas can also communicate with the fallopian\\ntubes, the uterus, small bowel or the skin. It is usually thought that the\\nfistula is the sequel of an abscess but commonly there is no sign of\\nan associated abscess; if there had been one it must have been\\nsilent and drained spontaneously via the fistulous tract.\\n\\n We find it convenient to think about the clinical scenarios of acute\\n diverticulitis in order of increasing severity:\\n\\n Simple diverticulitis.',\n", " 'md': '```markdown\\n# Page Content\\n\\nHighlighted the hypertrophy of the bowel wall as the primary pathology and we are inclined to accept this, with the addition that the mesenteric fat tissue also plays a role. It is this fat that creeps up the bowel wall, becomes inflamed, produces the phlegmon or abscess, and heals with fibrosis. It is believed that many cases of acute diverticulitis might better be termed acute sigmoiditis — recognizing that it is an acute inflammation of the thickened bowel wall and mesentery.\\n\\nOn the other hand, when it is a diverticulum that has been eroded by a fecalith, one finds a localized inflammation, which identifies the site of the perforation. In cases of free fecal peritonitis, a perforated diverticulum is the cause although more often it has been walled off by the mesentery or epiploic appendices to produce a pericolic abscess.\\n\\nSometimes, the perforation occurs entirely within the mesentery, forming a mesenteric phlegmon or abscess. The latter may secondarily perforate into the free peritoneal cavity but usually this variety only gives rise to minor abdominal and systemic signs. Occasionally, it can produce septicemia in a patient who is unable to contain the perforation.\\n\\nThere is a strong tendency for diverticulitis and sigmoiditis to adhere locally and fistulate. The formation of fistulas has an obscure mechanism, and most patients with such a fistula present as non-emergency cases and often do not even give a history of previous attacks of acute diverticulitis. Most often the fistulas are into the bladder. The patient seeks attention for pneumaturia or persistent urinary tract infection. Fistulas can also communicate with the fallopian tubes, the uterus, small bowel or the skin. It is usually thought that the fistula is the sequel of an abscess but commonly there is no sign of an associated abscess; if there had been one it must have been silent and drained spontaneously via the fistulous tract.\\n\\nWe find it convenient to think about the clinical scenarios of acute diverticulitis in order of increasing severity:\\n\\n- Simple diverticulitis.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [{'name': 'img_p486_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999997,\n", " 'y': 692.64}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Highlighted the hypertrophy of the bowel wall as the primary pathology and we are inclined to accept this, with the addition that the mesenteric fat tissue also plays a role. It is this fat that creeps up the bowel wall, becomes inflamed, produces the phlegmon or abscess, and heals with fibrosis. It is believed that many cases of acute diverticulitis might better be termed acute sigmoiditis — recognizing that it is an acute inflammation of the thickened bowel wall and mesentery.\\n\\nOn the other hand, when it is a diverticulum that has been eroded by a fecalith, one finds a localized inflammation, which identifies the site of the perforation. In cases of free fecal peritonitis, a perforated diverticulum is the cause although more often it has been walled off by the mesentery or epiploic appendices to produce a pericolic abscess.\\n\\nSometimes, the perforation occurs entirely within the mesentery, forming a mesenteric phlegmon or abscess. The latter may secondarily perforate into the free peritoneal cavity but usually this variety only gives rise to minor abdominal and systemic signs. Occasionally, it can produce septicemia in a patient who is unable to contain the perforation.\\n\\nThere is a strong tendency for diverticulitis and sigmoiditis to adhere locally and fistulate. The formation of fistulas has an obscure mechanism, and most patients with such a fistula present as non-emergency cases and often do not even give a history of previous attacks of acute diverticulitis. Most often the fistulas are into the bladder. The patient seeks attention for pneumaturia or persistent urinary tract infection. Fistulas can also communicate with the fallopian tubes, the uterus, small bowel or the skin. It is usually thought that the fistula is the sequel of an abscess but commonly there is no sign of an associated abscess; if there had been one it must have been silent and drained spontaneously via the fistulous tract.\\n\\nWe find it convenient to think about the clinical scenarios of acute diverticulitis in order of increasing severity:\\n\\n- Simple diverticulitis.\\n```',\n", " 'md': 'Highlighted the hypertrophy of the bowel wall as the primary pathology and we are inclined to accept this, with the addition that the mesenteric fat tissue also plays a role. It is this fat that creeps up the bowel wall, becomes inflamed, produces the phlegmon or abscess, and heals with fibrosis. It is believed that many cases of acute diverticulitis might better be termed acute sigmoiditis — recognizing that it is an acute inflammation of the thickened bowel wall and mesentery.\\n\\nOn the other hand, when it is a diverticulum that has been eroded by a fecalith, one finds a localized inflammation, which identifies the site of the perforation. In cases of free fecal peritonitis, a perforated diverticulum is the cause although more often it has been walled off by the mesentery or epiploic appendices to produce a pericolic abscess.\\n\\nSometimes, the perforation occurs entirely within the mesentery, forming a mesenteric phlegmon or abscess. The latter may secondarily perforate into the free peritoneal cavity but usually this variety only gives rise to minor abdominal and systemic signs. Occasionally, it can produce septicemia in a patient who is unable to contain the perforation.\\n\\nThere is a strong tendency for diverticulitis and sigmoiditis to adhere locally and fistulate. The formation of fistulas has an obscure mechanism, and most patients with such a fistula present as non-emergency cases and often do not even give a history of previous attacks of acute diverticulitis. Most often the fistulas are into the bladder. The patient seeks attention for pneumaturia or persistent urinary tract infection. Fistulas can also communicate with the fallopian tubes, the uterus, small bowel or the skin. It is usually thought that the fistula is the sequel of an abscess but commonly there is no sign of an associated abscess; if there had been one it must have been silent and drained spontaneously via the fistulous tract.\\n\\nWe find it convenient to think about the clinical scenarios of acute diverticulitis in order of increasing severity:\\n\\n- Simple diverticulitis.\\n```',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 488,\n", " 'text': ' Complicated diverticulitis:\\n\\n • pericolic abscess;\\n • free perforation with purulent peritonitis;\\n • free perforation with fecal peritonitis.\\n\\n So it seems that ‘simple’ diverticulitis and ‘complicated’ or ‘perforative’ diverticulitis may be two\\n different entities — the former not progressing to the latter — which is similar to the case of\\n simple and complicated acute appendicitis, which are almost two different diseases ( Chapter\\n 23). The Editors\\n\\n Simple diverticulitis\\n\\n Simple diverticulitis describes inflammation that occurs without\\nany associated complication (no abscess, free perforation, or\\nfistula).\\n\\n These patients present with LLQ pain. Usually there is some local\\ntenderness and guarding. The magnitude of associated SIRS varies and\\nso do the white blood cell count and C-reactive protein (CRP) levels. The\\nimaging of choice for initial diagnosis is a CT scan and in most instances\\n(I am talking about the USA) this test will have already been performed\\nby the emergency room physicians before you are called.\\n\\n Initial treatment is conservative with hydration and antibiotics — I\\nuse a fluoroquinolone and metronidazole. If the patient is otherwise\\nhealthy without nausea and has only localized pain and tenderness, I will\\nsend them home, after a dose of i.v. antibiotics in the emergency room, to\\ncontinue on oral agents. If they are not tolerating liquids, have\\nassociated comorbidities, or are immunosuppressed, I will admit\\nthem for hydration, i.v. antibiotics, and observation. When their\\npain/tenderness has resolved, they have defervesced, and are\\ntolerating oral intake, we discharge them on a 10-day course of\\nantibiotics. The vast majority of patients respond well to this\\nconservative regimen.',\n", " 'md': '```markdown\\n# Complicated Diverticulitis\\n\\n- **Complications include:**\\n- Pericolic abscess\\n- Free perforation with purulent peritonitis\\n- Free perforation with fecal peritonitis\\n\\nIt seems that ‘simple’ diverticulitis and ‘complicated’ or ‘perforative’ diverticulitis may be two different entities — the former not progressing to the latter — which is similar to the case of simple and complicated acute appendicitis, which are almost two different diseases (Chapter 23). The Editors\\n\\n## Simple Diverticulitis\\n\\nSimple diverticulitis describes inflammation that occurs without any associated complication (no abscess, free perforation, or fistula).\\n\\nThese patients present with LLQ pain. Usually, there is some local tenderness and guarding. The magnitude of associated SIRS varies and so do the white blood cell count and C-reactive protein (CRP) levels. The imaging of choice for initial diagnosis is a CT scan and in most instances (I am talking about the USA) this test will have already been performed by the emergency room physicians before you are called.\\n\\nInitial treatment is conservative with hydration and antibiotics — I use a fluoroquinolone and metronidazole. If the patient is otherwise healthy without nausea and has only localized pain and tenderness, I will send them home, after a dose of i.v. antibiotics in the emergency room, to continue on oral agents. If they are not tolerating liquids, have associated comorbidities, or are immunosuppressed, I will admit them for hydration, i.v. antibiotics, and observation. When their pain/tenderness has resolved, they have defervesced, and are tolerating oral intake, we discharge them on a 10-day course of antibiotics. The vast majority of patients respond well to this conservative regimen.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Complicated Diverticulitis',\n", " 'md': '# Complicated Diverticulitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Complications include:**\\n- Pericolic abscess\\n- Free perforation with purulent peritonitis\\n- Free perforation with fecal peritonitis\\n\\nIt seems that ‘simple’ diverticulitis and ‘complicated’ or ‘perforative’ diverticulitis may be two different entities — the former not progressing to the latter — which is similar to the case of simple and complicated acute appendicitis, which are almost two different diseases (Chapter 23). The Editors',\n", " 'md': '- **Complications include:**\\n- Pericolic abscess\\n- Free perforation with purulent peritonitis\\n- Free perforation with fecal peritonitis\\n\\nIt seems that ‘simple’ diverticulitis and ‘complicated’ or ‘perforative’ diverticulitis may be two different entities — the former not progressing to the latter — which is similar to the case of simple and complicated acute appendicitis, which are almost two different diseases (Chapter 23). The Editors',\n", " 'bBox': {'x': 77, 'y': 248, 'w': 403.34, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Simple Diverticulitis',\n", " 'md': '## Simple Diverticulitis',\n", " 'bBox': {'x': 86, 'y': 319, 'w': 156.29, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Simple diverticulitis describes inflammation that occurs without any associated complication (no abscess, free perforation, or fistula).\\n\\nThese patients present with LLQ pain. Usually, there is some local tenderness and guarding. The magnitude of associated SIRS varies and so do the white blood cell count and C-reactive protein (CRP) levels. The imaging of choice for initial diagnosis is a CT scan and in most instances (I am talking about the USA) this test will have already been performed by the emergency room physicians before you are called.\\n\\nInitial treatment is conservative with hydration and antibiotics — I use a fluoroquinolone and metronidazole. If the patient is otherwise healthy without nausea and has only localized pain and tenderness, I will send them home, after a dose of i.v. antibiotics in the emergency room, to continue on oral agents. If they are not tolerating liquids, have associated comorbidities, or are immunosuppressed, I will admit them for hydration, i.v. antibiotics, and observation. When their pain/tenderness has resolved, they have defervesced, and are tolerating oral intake, we discharge them on a 10-day course of antibiotics. The vast majority of patients respond well to this conservative regimen.\\n```',\n", " 'md': 'Simple diverticulitis describes inflammation that occurs without any associated complication (no abscess, free perforation, or fistula).\\n\\nThese patients present with LLQ pain. Usually, there is some local tenderness and guarding. The magnitude of associated SIRS varies and so do the white blood cell count and C-reactive protein (CRP) levels. The imaging of choice for initial diagnosis is a CT scan and in most instances (I am talking about the USA) this test will have already been performed by the emergency room physicians before you are called.\\n\\nInitial treatment is conservative with hydration and antibiotics — I use a fluoroquinolone and metronidazole. If the patient is otherwise healthy without nausea and has only localized pain and tenderness, I will send them home, after a dose of i.v. antibiotics in the emergency room, to continue on oral agents. If they are not tolerating liquids, have associated comorbidities, or are immunosuppressed, I will admit them for hydration, i.v. antibiotics, and observation. When their pain/tenderness has resolved, they have defervesced, and are tolerating oral intake, we discharge them on a 10-day course of antibiotics. The vast majority of patients respond well to this conservative regimen.\\n```',\n", " 'bBox': {'x': 72, 'y': 319, 'w': 467.72, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'simple and complicated acute appendicitis, which are almost two different diseases ( Chapter 23). The Editors'}]},\n", " {'page': 489,\n", " 'text': ' Is it really acute diverticulitis?\\n\\n Some authors (there are a few good randomized studies from\\nScandinavia proving this point) have questioned the need for any\\nantibiotics in these patients, especially when they present with pain and\\ntenderness but no fever or other septic signs and symptoms. I feel that\\nlower abdominal pain without any manifestations of SIRS should be\\ntreated more as irritable bowel syndrome than diverticulitis and do\\nnot necessarily treat with antibiotics. So not each and every old\\nman with some mild LLQ pain and tenderness, and a CT report of\\n“possible mild diverticulitis”, should be condemned to 10 days of\\nantibiotics.\\n\\n Every other year or so, what I am convinced is a diverticulitis\\nattack, turns out to be a cancer. Therefore, I perform a colonoscopy\\non all of these patients 6 to 8 weeks after the first acute attack,\\nunless they have had a colonscopy within a year of the\\npresentation.\\n\\n Our recent study has shown that the risk of cancer after uncomplicated diverticulitis is\\n minimal, so we have stopped routine colonoscopies for these patients unless there is some\\n other reason or cause for suspicion. Surg Endosc 2014; 28: 961-6. Ari\\n “Miss one colon cancer and the lawyers have a field day.” Jon\\n\\n Elective surgery after attack(s) of simple acute\\n diverticulitis?\\n\\n What are the pros and cons? Only 20-30% of the patients who\\npresent with acute diverticulitis will ever have another attack so no\\nfurther therapy (after colonoscopy) is necessary. Recurrent attacks\\nof simple diverticulitis do not automatically require resection. Each\\npatient should be assessed on an individual basis (e.g. age, operative\\nrisks) and common sense used in making a decision. If a patient is in\\nyour office with fever, and left lower quadrant pain every 3 months after\\nan initial attack of diverticulitis, you should remove that section of sigmoid',\n", " 'md': '```markdown\\n# Is it really acute diverticulitis?\\n\\nSome authors (there are a few good randomized studies from Scandinavia proving this point) have questioned the need for any antibiotics in these patients, especially when they present with pain and tenderness but no fever or other septic signs and symptoms. I feel that lower abdominal pain without any manifestations of SIRS should be treated more as irritable bowel syndrome than diverticulitis and do not necessarily treat with antibiotics. So not each and every old man with some mild LLQ pain and tenderness, and a CT report of “possible mild diverticulitis”, should be condemned to 10 days of antibiotics.\\n\\nEvery other year or so, what I am convinced is a diverticulitis attack, turns out to be a cancer. Therefore, I perform a colonoscopy on all of these patients 6 to 8 weeks after the first acute attack, unless they have had a colonoscopy within a year of the presentation.\\n\\nOur recent study has shown that the risk of cancer after uncomplicated diverticulitis is minimal, so we have stopped routine colonoscopies for these patients unless there is some other reason or cause for suspicion. Surg Endosc 2014; 28: 961-6. Ari “Miss one colon cancer and the lawyers have a field day.” Jon\\n\\n## Elective surgery after attack(s) of simple acute diverticulitis?\\n\\nWhat are the pros and cons? Only 20-30% of the patients who present with acute diverticulitis will ever have another attack so no further therapy (after colonoscopy) is necessary. Recurrent attacks of simple diverticulitis do not automatically require resection. Each patient should be assessed on an individual basis (e.g. age, operative risks) and common sense used in making a decision. If a patient is in your office with fever, and left lower quadrant pain every 3 months after an initial attack of diverticulitis, you should remove that section of sigmoid.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Is it really acute diverticulitis?',\n", " 'md': '# Is it really acute diverticulitis?',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 236.28, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Some authors (there are a few good randomized studies from Scandinavia proving this point) have questioned the need for any antibiotics in these patients, especially when they present with pain and tenderness but no fever or other septic signs and symptoms. I feel that lower abdominal pain without any manifestations of SIRS should be treated more as irritable bowel syndrome than diverticulitis and do not necessarily treat with antibiotics. So not each and every old man with some mild LLQ pain and tenderness, and a CT report of “possible mild diverticulitis”, should be condemned to 10 days of antibiotics.\\n\\nEvery other year or so, what I am convinced is a diverticulitis attack, turns out to be a cancer. Therefore, I perform a colonoscopy on all of these patients 6 to 8 weeks after the first acute attack, unless they have had a colonoscopy within a year of the presentation.\\n\\nOur recent study has shown that the risk of cancer after uncomplicated diverticulitis is minimal, so we have stopped routine colonoscopies for these patients unless there is some other reason or cause for suspicion. Surg Endosc 2014; 28: 961-6. Ari “Miss one colon cancer and the lawyers have a field day.” Jon',\n", " 'md': 'Some authors (there are a few good randomized studies from Scandinavia proving this point) have questioned the need for any antibiotics in these patients, especially when they present with pain and tenderness but no fever or other septic signs and symptoms. I feel that lower abdominal pain without any manifestations of SIRS should be treated more as irritable bowel syndrome than diverticulitis and do not necessarily treat with antibiotics. So not each and every old man with some mild LLQ pain and tenderness, and a CT report of “possible mild diverticulitis”, should be condemned to 10 days of antibiotics.\\n\\nEvery other year or so, what I am convinced is a diverticulitis attack, turns out to be a cancer. Therefore, I perform a colonoscopy on all of these patients 6 to 8 weeks after the first acute attack, unless they have had a colonoscopy within a year of the presentation.\\n\\nOur recent study has shown that the risk of cancer after uncomplicated diverticulitis is minimal, so we have stopped routine colonoscopies for these patients unless there is some other reason or cause for suspicion. Surg Endosc 2014; 28: 961-6. Ari “Miss one colon cancer and the lawyers have a field day.” Jon',\n", " 'bBox': {'x': 72, 'y': 157, 'w': 467.87, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Elective surgery after attack(s) of simple acute diverticulitis?',\n", " 'md': '## Elective surgery after attack(s) of simple acute diverticulitis?',\n", " 'bBox': {'x': 86, 'y': 537, 'w': 107.57, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'What are the pros and cons? Only 20-30% of the patients who present with acute diverticulitis will ever have another attack so no further therapy (after colonoscopy) is necessary. Recurrent attacks of simple diverticulitis do not automatically require resection. Each patient should be assessed on an individual basis (e.g. age, operative risks) and common sense used in making a decision. If a patient is in your office with fever, and left lower quadrant pain every 3 months after an initial attack of diverticulitis, you should remove that section of sigmoid.\\n```',\n", " 'md': 'What are the pros and cons? Only 20-30% of the patients who present with acute diverticulitis will ever have another attack so no further therapy (after colonoscopy) is necessary. Recurrent attacks of simple diverticulitis do not automatically require resection. Each patient should be assessed on an individual basis (e.g. age, operative risks) and common sense used in making a decision. If a patient is in your office with fever, and left lower quadrant pain every 3 months after an initial attack of diverticulitis, you should remove that section of sigmoid.\\n```',\n", " 'bBox': {'x': 72, 'y': 537, 'w': 467.58, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 490,\n", " 'text': 'colon. If they have an attack every 3 years, then ensure that they are on\\nfiber supplementation (the only medication ever to be shown to prevent\\nrecurrent attacks of diverticulitis) and treat the individual attacks\\nconservatively. Notably, recurrent attacks of acute diverticulitis tend\\nto be mild and rarely are complicated. On the other hand, we should\\nnot forget that elective colectomies (even the laparoscopic ones) are not\\nfree of complications and patients still may develop acute diverticulitis\\nabove the resected sigmoid (~5% of the time).\\n\\n Patients in whom I do recommend surgery even after one attack\\nof uncomplicated diverticulitis are the chronically\\nimmunosuppressed (e.g. rheumatoid arthritis or transplant\\npatients). These patients will continue to have issues with diverticulitis\\nthat will become complicated. It is better to perform an elective\\nresection than deal with a complication such as a fistula or\\nperforation. BTW, I am very liberal in performing a proximal diversion in\\nthese patients when I do operate on them for complicated acute\\ndiverticulitis (see below). Immunosuppressed patients don’t tolerate\\nleaks well.\\n\\n There is no doubt that by far the most common presentation is\\nacute non-complicated diverticulitis. But, working in a large ‘ivory\\ntower’, I rarely see that anymore because it’s usually recognized and\\nmanaged by the patient’s medical doctor or gastroenterologist without my\\ninput. The exception to this is the immunosuppressed patient, who I\\nsee four or five times a year with acute diverticulitis.\\n\\n Complicated diverticulitis\\n\\n Complicated acute diverticulitis means a more serious ‘septic’\\ndisease: an associated abscess or a free perforation of either pus or\\nstool — sometimes both. Fistula formation is a not-so-acute\\ncomplication — but I will discuss it below as a bonus… (Obstruction due\\nto diverticular disease is mentioned in Chapter 27.)\\n\\n A convenient, albeit older classification system for complicated\\ndiverticulitis, that associates complication with outcomes, was proposed',\n", " 'md': '```markdown\\n## Complicated Diverticulitis\\n\\nIf patients have an attack every 3 years, then ensure that they are on fiber supplementation (the only medication ever to be shown to prevent recurrent attacks of diverticulitis) and treat the individual attacks conservatively. Notably, recurrent attacks of acute diverticulitis tend to be mild and rarely are complicated. On the other hand, we should not forget that elective colectomies (even the laparoscopic ones) are not free of complications, and patients still may develop acute diverticulitis above the resected sigmoid (~5% of the time).\\n\\nPatients in whom I do recommend surgery even after one attack of uncomplicated diverticulitis are the chronically immunosuppressed (e.g., rheumatoid arthritis or transplant patients). These patients will continue to have issues with diverticulitis that will become complicated. It is better to perform an elective resection than deal with a complication such as a fistula or perforation. By the way, I am very liberal in performing a proximal diversion in these patients when I do operate on them for complicated acute diverticulitis. Immunosuppressed patients don’t tolerate leaks well.\\n\\nThere is no doubt that by far the most common presentation is acute non-complicated diverticulitis. However, working in a large ‘ivory tower’, I rarely see that anymore because it’s usually recognized and managed by the patient’s medical doctor or gastroenterologist without my input. The exception to this is the immunosuppressed patient, who I see four or five times a year with acute diverticulitis.\\n\\n### Complicated Diverticulitis\\n\\nComplicated acute diverticulitis means a more serious ‘septic’ disease: an associated abscess or a free perforation of either pus or stool — sometimes both. Fistula formation is a not-so-acute complication — but I will discuss it below as a bonus… (Obstruction due to diverticular disease is mentioned in Chapter 27.)\\n\\nA convenient, albeit older classification system for complicated diverticulitis, that associates complication with outcomes, was proposed.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Complicated Diverticulitis',\n", " 'md': '## Complicated Diverticulitis',\n", " 'bBox': {'x': 86, 'y': 547, 'w': 201.36, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'If patients have an attack every 3 years, then ensure that they are on fiber supplementation (the only medication ever to be shown to prevent recurrent attacks of diverticulitis) and treat the individual attacks conservatively. Notably, recurrent attacks of acute diverticulitis tend to be mild and rarely are complicated. On the other hand, we should not forget that elective colectomies (even the laparoscopic ones) are not free of complications, and patients still may develop acute diverticulitis above the resected sigmoid (~5% of the time).\\n\\nPatients in whom I do recommend surgery even after one attack of uncomplicated diverticulitis are the chronically immunosuppressed (e.g., rheumatoid arthritis or transplant patients). These patients will continue to have issues with diverticulitis that will become complicated. It is better to perform an elective resection than deal with a complication such as a fistula or perforation. By the way, I am very liberal in performing a proximal diversion in these patients when I do operate on them for complicated acute diverticulitis. Immunosuppressed patients don’t tolerate leaks well.\\n\\nThere is no doubt that by far the most common presentation is acute non-complicated diverticulitis. However, working in a large ‘ivory tower’, I rarely see that anymore because it’s usually recognized and managed by the patient’s medical doctor or gastroenterologist without my input. The exception to this is the immunosuppressed patient, who I see four or five times a year with acute diverticulitis.',\n", " 'md': 'If patients have an attack every 3 years, then ensure that they are on fiber supplementation (the only medication ever to be shown to prevent recurrent attacks of diverticulitis) and treat the individual attacks conservatively. Notably, recurrent attacks of acute diverticulitis tend to be mild and rarely are complicated. On the other hand, we should not forget that elective colectomies (even the laparoscopic ones) are not free of complications, and patients still may develop acute diverticulitis above the resected sigmoid (~5% of the time).\\n\\nPatients in whom I do recommend surgery even after one attack of uncomplicated diverticulitis are the chronically immunosuppressed (e.g., rheumatoid arthritis or transplant patients). These patients will continue to have issues with diverticulitis that will become complicated. It is better to perform an elective resection than deal with a complication such as a fistula or perforation. By the way, I am very liberal in performing a proximal diversion in these patients when I do operate on them for complicated acute diverticulitis. Immunosuppressed patients don’t tolerate leaks well.\\n\\nThere is no doubt that by far the most common presentation is acute non-complicated diverticulitis. However, working in a large ‘ivory tower’, I rarely see that anymore because it’s usually recognized and managed by the patient’s medical doctor or gastroenterologist without my input. The exception to this is the immunosuppressed patient, who I see four or five times a year with acute diverticulitis.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.62, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Complicated Diverticulitis',\n", " 'md': '### Complicated Diverticulitis',\n", " 'bBox': {'x': 86, 'y': 547, 'w': 201.36, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Complicated acute diverticulitis means a more serious ‘septic’ disease: an associated abscess or a free perforation of either pus or stool — sometimes both. Fistula formation is a not-so-acute complication — but I will discuss it below as a bonus… (Obstruction due to diverticular disease is mentioned in Chapter 27.)\\n\\nA convenient, albeit older classification system for complicated diverticulitis, that associates complication with outcomes, was proposed.\\n```',\n", " 'md': 'Complicated acute diverticulitis means a more serious ‘septic’ disease: an associated abscess or a free perforation of either pus or stool — sometimes both. Fistula formation is a not-so-acute complication — but I will discuss it below as a bonus… (Obstruction due to diverticular disease is mentioned in Chapter 27.)\\n\\nA convenient, albeit older classification system for complicated diverticulitis, that associates complication with outcomes, was proposed.\\n```',\n", " 'bBox': {'x': 72, 'y': 253, 'w': 467.54, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 491,\n", " 'text': 'by E. John Hinchey of Montreal, Canada (see Table 28.1). I find that\\nthis classification helps me and my residents to individualize our\\nmanagement approach to these patients (see the algorithm Figure\\n28.1). Dr. ħinchey documented increased mortality for advanced stages;\\nbut this is intuitive — today we have better tools to measure the patients’\\nseverity of acute disease and outcome, the APACħE II 2 scoring system,\\nfor example.\\n Table 28.1. The Hinchey classification:\\n Stage I: Pericolonic abscess.\\n Stage II: Pelvic, intra-abdominal, or retroperitoneal abscess:\\n Stage III: Generalized purulent peritonitis.\\n Stage IV: Generalized feculent peritonitis.\\n We have recently developed a classification system based on clinical, radiological and\\n physiological parameters where the patient can be graded pre-operatively (J Trauma Acute\\n Care Surg 2015; 78: 543-51). It has five stages — defined in Table 28.2.\\n\\n With this classification taking into account pre-operative parameters only, the predicted need for\\n surgery and outcome parameters are shown in Table 28.3.\\n\\n You can find an online calculator for the system here: http://www.pmidcalc.org/?\\n sid=25710425&newtest=Y.\\n\\n Ari',\n", " 'md': '```markdown\\n## Page Content\\n\\nThis classification helps me and my residents to individualize our management approach to these patients (see the algorithm Figure 28.1). Dr. Hinchey documented increased mortality for advanced stages; but this is intuitive — today we have better tools to measure the patients’ severity of acute disease and outcome, the APACHE II scoring system, for example.\\n\\n### Table 28.1. The Hinchey classification:\\n\\n| Stage | Description |\\n|-------|--------------------------------------------------|\\n| I | Pericolonic abscess. |\\n| II | Pelvic, intra-abdominal, or retroperitoneal abscess. |\\n| III | Generalized purulent peritonitis. |\\n| IV | Generalized feculent peritonitis. |\\n\\nWe have recently developed a classification system based on clinical, radiological and physiological parameters where the patient can be graded pre-operatively (J Trauma Acute Care Surg 2015; 78: 543-51). It has five stages — defined in Table 28.2.\\n\\nWith this classification taking into account pre-operative parameters only, the predicted need for surgery and outcome parameters are shown in Table 28.3.\\n\\nYou can find an online calculator for the system here: [http://www.pmidcalc.org/?sid=25710425&newtest=Y](http://www.pmidcalc.org/?sid=25710425&newtest=Y).\\n\\n### Figures and Images\\n\\n- **Figure 28.1**: Algorithm related to the Hinchey classification (description not provided in the text).\\n```',\n", " 'images': [{'name': 'img_p490_1.png',\n", " 'height': 249,\n", " 'width': 806,\n", " 'x': 106.55999999999995,\n", " 'y': 200.88,\n", " 'original_width': 1386,\n", " 'original_height': 428}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This classification helps me and my residents to individualize our management approach to these patients (see the algorithm Figure 28.1). Dr. Hinchey documented increased mortality for advanced stages; but this is intuitive — today we have better tools to measure the patients’ severity of acute disease and outcome, the APACHE II scoring system, for example.',\n", " 'md': 'This classification helps me and my residents to individualize our management approach to these patients (see the algorithm Figure 28.1). Dr. Hinchey documented increased mortality for advanced stages; but this is intuitive — today we have better tools to measure the patients’ severity of acute disease and outcome, the APACHE II scoring system, for example.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.82, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 28.1. The Hinchey classification:',\n", " 'md': '### Table 28.1. The Hinchey classification:',\n", " 'bBox': {'x': 111.01, 'y': 202.36, 'w': 237.55, 'h': 19.78}},\n", " {'type': 'table',\n", " 'rows': [['Stage', 'Description'],\n", " ['I', 'Pericolonic abscess.'],\n", " ['II', 'Pelvic, intra-abdominal, or retroperitoneal abscess.'],\n", " ['III', 'Generalized purulent peritonitis.'],\n", " ['IV', 'Generalized feculent peritonitis.']],\n", " 'md': '| Stage | Description |\\n|-------|--------------------------------------------------|\\n| I | Pericolonic abscess. |\\n| II | Pelvic, intra-abdominal, or retroperitoneal abscess. |\\n| III | Generalized purulent peritonitis. |\\n| IV | Generalized feculent peritonitis. |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Stage\",\"Description\"\\n\"I\",\"Pericolonic abscess.\"\\n\"II\",\"Pelvic, intra-abdominal, or retroperitoneal abscess.\"\\n\"III\",\"Generalized purulent peritonitis.\"\\n\"IV\",\"Generalized feculent peritonitis.\"',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'We have recently developed a classification system based on clinical, radiological and physiological parameters where the patient can be graded pre-operatively (J Trauma Acute Care Surg 2015; 78: 543-51). It has five stages — defined in Table 28.2.\\n\\nWith this classification taking into account pre-operative parameters only, the predicted need for surgery and outcome parameters are shown in Table 28.3.\\n\\nYou can find an online calculator for the system here: [http://www.pmidcalc.org/?sid=25710425&newtest=Y](http://www.pmidcalc.org/?sid=25710425&newtest=Y).',\n", " 'md': 'We have recently developed a classification system based on clinical, radiological and physiological parameters where the patient can be graded pre-operatively (J Trauma Acute Care Surg 2015; 78: 543-51). It has five stages — defined in Table 28.2.\\n\\nWith this classification taking into account pre-operative parameters only, the predicted need for surgery and outcome parameters are shown in Table 28.3.\\n\\nYou can find an online calculator for the system here: [http://www.pmidcalc.org/?sid=25710425&newtest=Y](http://www.pmidcalc.org/?sid=25710425&newtest=Y).',\n", " 'bBox': {'x': 77, 'y': 431, 'w': 457.49, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures and Images',\n", " 'md': '### Figures and Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 28.1**: Algorithm related to the Hinchey classification (description not provided in the text).\\n```',\n", " 'md': '- **Figure 28.1**: Algorithm related to the Hinchey classification (description not provided in the text).\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'this classification helps me and my residents to individualize our'},\n", " {'text': 'management approach to these patients (see the algorithm Figure 28.1). Dr. ħinchey documented increased mortality for advanced stages; but this is intuitive — today we have better tools to measure the patients’'},\n", " {'text': '2'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'url': 'http://www.pmidcalc.org/?sid=25710425&newtest=Y',\n", " 'text': 'You can find an online calculator for the system here: http://www.pmidcalc.org/? sid=25710425&newtest=Y.'}]},\n", " {'page': 492,\n", " 'text': \" Complicated diverticulitis\\n Patient presents with fever; pain, elevated WBC\\n CT scan\\n Hinchey | Hinchey II Hinchey III Hinchey IV\\n Not sick Sick Sick or not__.\\n Antibiotics Antibiotics and Laparoscopic\\n lavage and drainage\\n percutaneous\\n drainage\\n Resolution Resolution and No resolution procedure\\n Open Hartmann's\\n remove drain\\n colonoscopy;\\n Repeat CT if needed,\\n no surgery!\\nFigure 28.1. Algorithm for the management of complicated diverticulitis.\",\n", " 'md': \"```markdown\\n# Complicated Diverticulitis\\n\\nPatient presents with fever; pain, elevated WBC.\\n\\n## CT Scan\\n\\n| Hinchey | Hinchey II | Hinchey III | Hinchey IV |\\n|---------|------------|-------------|------------|\\n| Not sick | Sick | Sick or not | Sick |\\n| Antibiotics | Antibiotics and lavage and drainage | Laparoscopic percutaneous drainage | Open Hartmann's procedure |\\n| Resolution | Resolution and remove drain | No resolution | |\\n\\n- Repeat CT if needed, no surgery!\\n\\n**Figure 28.1**: Algorithm for the management of complicated diverticulitis.\\n```\",\n", " 'images': [{'name': 'img_p491_1.png',\n", " 'height': 928,\n", " 'width': 761,\n", " 'x': 118.07999999999993,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1308,\n", " 'original_height': 1596}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Complicated Diverticulitis',\n", " 'md': '# Complicated Diverticulitis',\n", " 'bBox': {'x': 226.45, 'y': 91.22, 'w': 135.58, 'h': 15.84}},\n", " {'type': 'text',\n", " 'value': 'Patient presents with fever; pain, elevated WBC.',\n", " 'md': 'Patient presents with fever; pain, elevated WBC.',\n", " 'bBox': {'x': 180.43, 'y': 110.52, 'w': 231.58, 'h': 14.85}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'CT Scan',\n", " 'md': '## CT Scan',\n", " 'bBox': {'x': 273.45, 'y': 172.89, 'w': 56.41, 'h': 14.85}},\n", " {'type': 'table',\n", " 'rows': [['Hinchey', 'Hinchey II', 'Hinchey III', 'Hinchey IV'],\n", " ['Not sick', 'Sick', 'Sick or not', 'Sick'],\n", " ['Antibiotics',\n", " 'Antibiotics and lavage and drainage',\n", " 'Laparoscopic percutaneous drainage',\n", " \"Open Hartmann's procedure\"],\n", " ['Resolution',\n", " 'Resolution and remove drain',\n", " 'No resolution',\n", " '']],\n", " 'md': \"| Hinchey | Hinchey II | Hinchey III | Hinchey IV |\\n|---------|------------|-------------|------------|\\n| Not sick | Sick | Sick or not | Sick |\\n| Antibiotics | Antibiotics and lavage and drainage | Laparoscopic percutaneous drainage | Open Hartmann's procedure |\\n| Resolution | Resolution and remove drain | No resolution | |\",\n", " 'isPerfectTable': True,\n", " 'csv': '\"Hinchey\",\"Hinchey II\",\"Hinchey III\",\"Hinchey IV\"\\n\"Not sick\",\"Sick\",\"Sick or not\",\"Sick\"\\n\"Antibiotics\",\"Antibiotics and lavage and drainage\",\"Laparoscopic percutaneous drainage\",\"Open Hartmann\\'s procedure\"\\n\"Resolution\",\"Resolution and remove drain\",\"No resolution\",\"\"',\n", " 'bBox': {'x': 120.06, 'y': 196.16, 'w': 144.49, 'h': 17.82}},\n", " {'type': 'text',\n", " 'value': '- Repeat CT if needed, no surgery!\\n\\n**Figure 28.1**: Algorithm for the management of complicated diverticulitis.\\n```',\n", " 'md': '- Repeat CT if needed, no surgery!\\n\\n**Figure 28.1**: Algorithm for the management of complicated diverticulitis.\\n```',\n", " 'bBox': {'x': 124.51, 'y': 91.22, 'w': 237.51, 'h': 15.84}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 493,\n", " 'text': ' Table 28.2. Our (Ari and friends) classification system for\\n complicated diverticulitis:\\n Stage Complicated Abscess >6cm or Generalized Organ\\n diverticulitis distant free air peritonitis dysfunction\\n Stage 1 NO\\n Stage 2 YES NO NO NO\\n Stage 3 YES YES NO NO\\n Stage 4 YES YES YES NO\\n Stage 5 YES YES YES YES\\n Table 28.3. Results according to the stage of disease:\\n Stage 1 Stage 2 Stage 3 Stage 4 Stage 5\\n Mortality 0% 1% 3% 5% 37%\\n 30 days\\n Need 1% 7% 54% 98% 100%\\n surgery\\n ICU 8% 12% 58%\\n admission\\n Pericolonic abscesses (Hinchey I & II)\\n\\n So the patient presents with the typical LLQ/lower abdominal\\nsymptoms and signs plus features of SIRS. CT shows a pericolic\\nabscess.\\n\\n These are defined on a CT scan by:\\n\\n • Size: I use the arbitrary diameter of 5cm to determine the\\n management of an abscess. Small abscesses (<5cm) will',\n", " 'md': '```markdown\\n## Table 28.2: Our (Ari and friends) classification system for complicated diverticulitis\\n\\n| Stage | Complicated diverticulitis | Abscess >6cm or distant free air | Generalized peritonitis | Organ dysfunction |\\n|---------|-----------------------------|-----------------------------------|-------------------------|-------------------|\\n| Stage 1 | NO | NO | NO | NO |\\n| Stage 2 | YES | NO | NO | NO |\\n| Stage 3 | YES | YES | NO | NO |\\n| Stage 4 | YES | YES | YES | NO |\\n| Stage 5 | YES | YES | YES | YES |\\n\\n## Table 28.3: Results according to the stage of disease\\n\\n| Stage | Stage 1 | Stage 2 | Stage 3 | Stage 4 | Stage 5 |\\n|---------|---------|---------|---------|---------|---------|\\n| Mortality (30 days) | 0% | 1% | 3% | 5% | 37% |\\n| Need surgery | 1% | 7% | 54% | 98% | 100% |\\n| ICU admission | | 8% | 12% | 58% | |\\n\\n## Pericolonic abscesses (Hinchey I & II)\\n\\nThe patient presents with the typical LLQ/lower abdominal symptoms and signs plus features of SIRS. CT shows a pericolic abscess.\\n\\nThese are defined on a CT scan by:\\n\\n- **Size**: I use the arbitrary diameter of 5cm to determine the management of an abscess. Small abscesses (<5cm) will...\\n```',\n", " 'images': [{'name': 'img_p492_1.png',\n", " 'height': 402,\n", " 'width': 812,\n", " 'x': 105.11999999999989,\n", " 'y': 71.99999999999997,\n", " 'original_width': 1396,\n", " 'original_height': 691},\n", " {'name': 'img_p492_2.png',\n", " 'height': 451,\n", " 'width': 811,\n", " 'x': 105.83999999999969,\n", " 'y': 281.52,\n", " 'original_width': 1392,\n", " 'original_height': 774}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 28.2: Our (Ari and friends) classification system for complicated diverticulitis',\n", " 'md': '## Table 28.2: Our (Ari and friends) classification system for complicated diverticulitis',\n", " 'bBox': {'x': 109.8, 'y': 76.94, 'w': 73.5, 'h': 15.82}},\n", " {'type': 'table',\n", " 'rows': [['Stage',\n", " 'Complicated diverticulitis',\n", " 'Abscess >6cm or distant free air',\n", " 'Generalized peritonitis',\n", " 'Organ dysfunction'],\n", " ['Stage 1', 'NO', 'NO', 'NO', 'NO'],\n", " ['Stage 2', 'YES', 'NO', 'NO', 'NO'],\n", " ['Stage 3', 'YES', 'YES', 'NO', 'NO'],\n", " ['Stage 4', 'YES', 'YES', 'YES', 'NO'],\n", " ['Stage 5', 'YES', 'YES', 'YES', 'YES']],\n", " 'md': '| Stage | Complicated diverticulitis | Abscess >6cm or distant free air | Generalized peritonitis | Organ dysfunction |\\n|---------|-----------------------------|-----------------------------------|-------------------------|-------------------|\\n| Stage 1 | NO | NO | NO | NO |\\n| Stage 2 | YES | NO | NO | NO |\\n| Stage 3 | YES | YES | NO | NO |\\n| Stage 4 | YES | YES | YES | NO |\\n| Stage 5 | YES | YES | YES | YES |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Stage\",\"Complicated diverticulitis\",\"Abscess >6cm or distant free air\",\"Generalized peritonitis\",\"Organ dysfunction\"\\n\"Stage 1\",\"NO\",\"NO\",\"NO\",\"NO\"\\n\"Stage 2\",\"YES\",\"NO\",\"NO\",\"NO\"\\n\"Stage 3\",\"YES\",\"YES\",\"NO\",\"NO\"\\n\"Stage 4\",\"YES\",\"YES\",\"YES\",\"NO\"\\n\"Stage 5\",\"YES\",\"YES\",\"YES\",\"YES\"',\n", " 'bBox': {'x': 108.58, 'y': 115.01, 'w': 94.01, 'h': 19.28}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 28.3: Results according to the stage of disease',\n", " 'md': '## Table 28.3: Results according to the stage of disease',\n", " 'bBox': {'x': 108.58, 'y': 76.94, 'w': 40.08, 'h': 17.8}},\n", " {'type': 'table',\n", " 'rows': [['Stage', 'Stage 1', 'Stage 2', 'Stage 3', 'Stage 4', 'Stage 5'],\n", " ['Mortality (30 days)', '0%', '1%', '3%', '5%', '37%'],\n", " ['Need surgery', '1%', '7%', '54%', '98%', '100%'],\n", " ['ICU admission',\n", " '',\n", " '8%',\n", " '12%',\n", " '58%',\n", " '']],\n", " 'md': '| Stage | Stage 1 | Stage 2 | Stage 3 | Stage 4 | Stage 5 |\\n|---------|---------|---------|---------|---------|---------|\\n| Mortality (30 days) | 0% | 1% | 3% | 5% | 37% |\\n| Need surgery | 1% | 7% | 54% | 98% | 100% |\\n| ICU admission | | 8% | 12% | 58% | |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Stage\",\"Stage 1\",\"Stage 2\",\"Stage 3\",\"Stage 4\",\"Stage 5\"\\n\"Mortality (30 days)\",\"0%\",\"1%\",\"3%\",\"5%\",\"37%\"\\n\"Need surgery\",\"1%\",\"7%\",\"54%\",\"98%\",\"100%\"\\n\"ICU admission\",\"\",\"8%\",\"12%\",\"58%\",\"\"',\n", " 'bBox': {'x': 108.58, 'y': 115.5, 'w': 49.94, 'h': 18.31}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Pericolonic abscesses (Hinchey I & II)',\n", " 'md': '## Pericolonic abscesses (Hinchey I & II)',\n", " 'bBox': {'x': 86, 'y': 545, 'w': 297.01, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The patient presents with the typical LLQ/lower abdominal symptoms and signs plus features of SIRS. CT shows a pericolic abscess.\\n\\nThese are defined on a CT scan by:\\n\\n- **Size**: I use the arbitrary diameter of 5cm to determine the management of an abscess. Small abscesses (<5cm) will...\\n```',\n", " 'md': 'The patient presents with the typical LLQ/lower abdominal symptoms and signs plus features of SIRS. CT shows a pericolic abscess.\\n\\nThese are defined on a CT scan by:\\n\\n- **Size**: I use the arbitrary diameter of 5cm to determine the management of an abscess. Small abscesses (<5cm) will...\\n```',\n", " 'bBox': {'x': 72, 'y': 614, 'w': 228.43, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 494,\n", " 'text': ' usually resolve with antibiotics. Anything less than 5cm is\\n usually too small to put a drain in anyway (or so my\\n radiologists tell me). Those >5cm I drain if accessible.\\n • Location: adjacent to the colon or within the mesentery (ħinchey I)\\n or extending into the pelvic, abdominal and retroperitoneal spaces\\n (ħinchey II).\\n\\n Hinchey I patients\\n\\n This in my experience is the most common variant of\\n‘complicated diverticulitis’ but far rarer than ‘simple diverticulitis’ —\\nI see 10 to 15 such cases a year.\\n\\n The CT shows features of acute sigmoid diverticulitis with a ‘pericolic’\\nabscess, some free fluid around it, and often a few bubbles of\\nextraluminal air. What to do?\\n\\n BTW, the finding of extraluminal air on CT should not automatically trigger an operation due to\\n ‘perforation’. Patients with only pericolic air and no abscess can be managed non-operatively\\n with a 99% success rate and no mortality. The risk of failure of non-operative treatment in\\n patients with a small amount of distant intraperitoneal air and no peritonitis is small, but much\\n higher if there is abundant intraperitoneal air and fluid in the pouch of Douglas — as\\n documented in yet another of our recent studies (Dis Colon Rectum 2014; 57: 875-81). Ari\\n\\n These individuals tend to have small abscesses which mostly respond\\nto conservative management with i.v. antibiotics and hydration. They are\\nnot amenable to percutaneous drainage and do not need it! Instead,\\nthey will resolve with conservative management.\\n\\n I treat these patients as I do those with non-complicated acute\\ndiverticulitis — as long as the clinical features are improving. I often\\nobtain a repeat CT scan 2 weeks after completing antibiotic therapy\\nto demonstrate the abscess has resolved. If this is the case, and the\\npatient is asymptomatic, then I don’t feel that there is a need for any\\nfurther intervention.',\n", " 'md': '```markdown\\n## Hinchey I Patients\\n\\n- Usually resolve with antibiotics. Anything less than 5 cm is usually too small to put a drain in anyway (or so my radiologists tell me). Those >5 cm I drain if accessible.\\n- **Location**: adjacent to the colon or within the mesentery (Hinchey I) or extending into the pelvic, abdominal, and retroperitoneal spaces (Hinchey II).\\n\\nThis, in my experience, is the most common variant of ‘complicated diverticulitis’ but far rarer than ‘simple diverticulitis’ — I see 10 to 15 such cases a year.\\n\\nThe CT shows features of acute sigmoid diverticulitis with a ‘pericolic’ abscess, some free fluid around it, and often a few bubbles of extraluminal air. What to do?\\n\\n> **Note**: The finding of extraluminal air on CT should not automatically trigger an operation due to ‘perforation’. Patients with only pericolic air and no abscess can be managed non-operatively with a 99% success rate and no mortality. The risk of failure of non-operative treatment in patients with a small amount of distant intraperitoneal air and no peritonitis is small, but much higher if there is abundant intraperitoneal air and fluid in the pouch of Douglas — as documented in yet another of our recent studies (Dis Colon Rectum 2014; 57: 875-81).\\n\\nThese individuals tend to have small abscesses which mostly respond to conservative management with i.v. antibiotics and hydration. They are not amenable to percutaneous drainage and do not need it! Instead, they will resolve with conservative management.\\n\\nI treat these patients as I do those with non-complicated acute diverticulitis — as long as the clinical features are improving. I often obtain a repeat CT scan 2 weeks after completing antibiotic therapy to demonstrate the abscess has resolved. If this is the case, and the patient is asymptomatic, then I don’t feel that there is a need for any further intervention.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Hinchey I Patients',\n", " 'md': '## Hinchey I Patients',\n", " 'bBox': {'x': 86, 'y': 216, 'w': 141.61, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Usually resolve with antibiotics. Anything less than 5 cm is usually too small to put a drain in anyway (or so my radiologists tell me). Those >5 cm I drain if accessible.\\n- **Location**: adjacent to the colon or within the mesentery (Hinchey I) or extending into the pelvic, abdominal, and retroperitoneal spaces (Hinchey II).\\n\\nThis, in my experience, is the most common variant of ‘complicated diverticulitis’ but far rarer than ‘simple diverticulitis’ — I see 10 to 15 such cases a year.\\n\\nThe CT shows features of acute sigmoid diverticulitis with a ‘pericolic’ abscess, some free fluid around it, and often a few bubbles of extraluminal air. What to do?\\n\\n> **Note**: The finding of extraluminal air on CT should not automatically trigger an operation due to ‘perforation’. Patients with only pericolic air and no abscess can be managed non-operatively with a 99% success rate and no mortality. The risk of failure of non-operative treatment in patients with a small amount of distant intraperitoneal air and no peritonitis is small, but much higher if there is abundant intraperitoneal air and fluid in the pouch of Douglas — as documented in yet another of our recent studies (Dis Colon Rectum 2014; 57: 875-81).\\n\\nThese individuals tend to have small abscesses which mostly respond to conservative management with i.v. antibiotics and hydration. They are not amenable to percutaneous drainage and do not need it! Instead, they will resolve with conservative management.\\n\\nI treat these patients as I do those with non-complicated acute diverticulitis — as long as the clinical features are improving. I often obtain a repeat CT scan 2 weeks after completing antibiotic therapy to demonstrate the abscess has resolved. If this is the case, and the patient is asymptomatic, then I don’t feel that there is a need for any further intervention.\\n```',\n", " 'md': '- Usually resolve with antibiotics. Anything less than 5 cm is usually too small to put a drain in anyway (or so my radiologists tell me). Those >5 cm I drain if accessible.\\n- **Location**: adjacent to the colon or within the mesentery (Hinchey I) or extending into the pelvic, abdominal, and retroperitoneal spaces (Hinchey II).\\n\\nThis, in my experience, is the most common variant of ‘complicated diverticulitis’ but far rarer than ‘simple diverticulitis’ — I see 10 to 15 such cases a year.\\n\\nThe CT shows features of acute sigmoid diverticulitis with a ‘pericolic’ abscess, some free fluid around it, and often a few bubbles of extraluminal air. What to do?\\n\\n> **Note**: The finding of extraluminal air on CT should not automatically trigger an operation due to ‘perforation’. Patients with only pericolic air and no abscess can be managed non-operatively with a 99% success rate and no mortality. The risk of failure of non-operative treatment in patients with a small amount of distant intraperitoneal air and no peritonitis is small, but much higher if there is abundant intraperitoneal air and fluid in the pouch of Douglas — as documented in yet another of our recent studies (Dis Colon Rectum 2014; 57: 875-81).\\n\\nThese individuals tend to have small abscesses which mostly respond to conservative management with i.v. antibiotics and hydration. They are not amenable to percutaneous drainage and do not need it! Instead, they will resolve with conservative management.\\n\\nI treat these patients as I do those with non-complicated acute diverticulitis — as long as the clinical features are improving. I often obtain a repeat CT scan 2 weeks after completing antibiotic therapy to demonstrate the abscess has resolved. If this is the case, and the patient is asymptomatic, then I don’t feel that there is a need for any further intervention.\\n```',\n", " 'bBox': {'x': 72, 'y': 252, 'w': 467.93, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 495,\n", " 'text': ' ħowever, if the abscess has not completely resolved, I would repeat\\nthe CT scan in 4 to 6 weeks to ensure it is decreasing or has resolved. If\\nthere is no change, than I discuss surgical resection with the\\npatient. If the abscess has resolved and they have no further\\nsymptoms, we are done and I do not recommend elective resection\\n— there is no need unless they have multiple recurrent attacks or\\nare in persistent pain — (the latter, hopefully, not caused by irritable\\nbowel syndrome…).\\n\\n Hinchey II patients\\n\\n Even less common than Hinchey I, but I see five or six\\npatients/year.\\n\\n To remind you: in these cases the abscess is extending into the pelvis,\\nabdominal cavity or retroperitoneal spaces — beyond the colonic wall.\\nAgain, commonly there is free localized fluid and free air. These patients\\nrequire drainage if the abscess is large (>5cm). This hastens\\nrecovery.\\n\\n Usually this is achieved with interventional radiology and the\\nplacement of a percutaneous pigtail catheter, under either\\nultrasound or CT guidance ( Chapter 46). Once the drain is\\nremoved, if the patient is asymptomatic and has no recurrent\\nattacks, I will continue to observe. Some advocate automatic elective\\nresection for all patients with resolving complicated acute diverticulitis —\\nhowever, without further symptoms, I think this is unnecessary!\\n\\n A few points on percutaneous drainage\\n\\n Interventional radiologists can drain almost anything — so use them.\\nAfter a drain is placed, leave it in until the output has decreased and\\nthe cavity has collapsed. I will often repeat the CT to ensure that the\\ncavity has collapsed prior to pulling out the drain, otherwise I find we are\\nback putting in another drain the next week.\\n\\n An exception to this is pelvic abscesses. Deep pelvic abscesses',\n", " 'md': '```markdown\\n## Current Page Content\\n\\nHowever, if the abscess has not completely resolved, I would repeat the CT scan in 4 to 6 weeks to ensure it is decreasing or has resolved. If there is no change, then I discuss surgical resection with the patient. If the abscess has resolved and they have no further symptoms, we are done and I do not recommend elective resection — there is no need unless they have multiple recurrent attacks or are in persistent pain — (the latter, hopefully, not caused by irritable bowel syndrome…).\\n\\n### Hinchey II Patients\\n\\nEven less common than Hinchey I, but I see five or six patients/year.\\n\\nTo remind you: in these cases the abscess is extending into the pelvis, abdominal cavity or retroperitoneal spaces — beyond the colonic wall. Again, commonly there is free localized fluid and free air. These patients require drainage if the abscess is large (>5cm). This hastens recovery.\\n\\nUsually, this is achieved with interventional radiology and the placement of a percutaneous pigtail catheter, under either ultrasound or CT guidance (Chapter 46). Once the drain is removed, if the patient is asymptomatic and has no recurrent attacks, I will continue to observe. Some advocate automatic elective resection for all patients with resolving complicated acute diverticulitis — however, without further symptoms, I think this is unnecessary!\\n\\n### A Few Points on Percutaneous Drainage\\n\\nInterventional radiologists can drain almost anything — so use them. After a drain is placed, leave it in until the output has decreased and the cavity has collapsed. I will often repeat the CT to ensure that the cavity has collapsed prior to pulling out the drain, otherwise I find we are back putting in another drain the next week.\\n\\nAn exception to this is pelvic abscesses. Deep pelvic abscesses\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'However, if the abscess has not completely resolved, I would repeat the CT scan in 4 to 6 weeks to ensure it is decreasing or has resolved. If there is no change, then I discuss surgical resection with the patient. If the abscess has resolved and they have no further symptoms, we are done and I do not recommend elective resection — there is no need unless they have multiple recurrent attacks or are in persistent pain — (the latter, hopefully, not caused by irritable bowel syndrome…).',\n", " 'md': 'However, if the abscess has not completely resolved, I would repeat the CT scan in 4 to 6 weeks to ensure it is decreasing or has resolved. If there is no change, then I discuss surgical resection with the patient. If the abscess has resolved and they have no further symptoms, we are done and I do not recommend elective resection — there is no need unless they have multiple recurrent attacks or are in persistent pain — (the latter, hopefully, not caused by irritable bowel syndrome…).',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 466.82, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Hinchey II Patients',\n", " 'md': '### Hinchey II Patients',\n", " 'bBox': {'x': 86, 'y': 245, 'w': 146.2, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Even less common than Hinchey I, but I see five or six patients/year.\\n\\nTo remind you: in these cases the abscess is extending into the pelvis, abdominal cavity or retroperitoneal spaces — beyond the colonic wall. Again, commonly there is free localized fluid and free air. These patients require drainage if the abscess is large (>5cm). This hastens recovery.\\n\\nUsually, this is achieved with interventional radiology and the placement of a percutaneous pigtail catheter, under either ultrasound or CT guidance (Chapter 46). Once the drain is removed, if the patient is asymptomatic and has no recurrent attacks, I will continue to observe. Some advocate automatic elective resection for all patients with resolving complicated acute diverticulitis — however, without further symptoms, I think this is unnecessary!',\n", " 'md': 'Even less common than Hinchey I, but I see five or six patients/year.\\n\\nTo remind you: in these cases the abscess is extending into the pelvis, abdominal cavity or retroperitoneal spaces — beyond the colonic wall. Again, commonly there is free localized fluid and free air. These patients require drainage if the abscess is large (>5cm). This hastens recovery.\\n\\nUsually, this is achieved with interventional radiology and the placement of a percutaneous pigtail catheter, under either ultrasound or CT guidance (Chapter 46). Once the drain is removed, if the patient is asymptomatic and has no recurrent attacks, I will continue to observe. Some advocate automatic elective resection for all patients with resolving complicated acute diverticulitis — however, without further symptoms, I think this is unnecessary!',\n", " 'bBox': {'x': 72, 'y': 297, 'w': 467.86, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'A Few Points on Percutaneous Drainage',\n", " 'md': '### A Few Points on Percutaneous Drainage',\n", " 'bBox': {'x': 86, 'y': 576, 'w': 309.26, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Interventional radiologists can drain almost anything — so use them. After a drain is placed, leave it in until the output has decreased and the cavity has collapsed. I will often repeat the CT to ensure that the cavity has collapsed prior to pulling out the drain, otherwise I find we are back putting in another drain the next week.\\n\\nAn exception to this is pelvic abscesses. Deep pelvic abscesses\\n```',\n", " 'md': 'Interventional radiologists can drain almost anything — so use them. After a drain is placed, leave it in until the output has decreased and the cavity has collapsed. I will often repeat the CT to ensure that the cavity has collapsed prior to pulling out the drain, otherwise I find we are back putting in another drain the next week.\\n\\nAn exception to this is pelvic abscesses. Deep pelvic abscesses\\n```',\n", " 'bBox': {'x': 72, 'y': 629, 'w': 467.58, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted as per the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'removed, if the patient is asymptomatic and has no recurrent'}]},\n", " {'page': 496,\n", " 'text': '(those at the base of the cul-de-sac) may be better served by\\nsurgical drainage:\\n\\n • If a low pelvic abscess is suspected in a woman, and can be\\n palpated on vaginal exam, I will drain these in the operating room\\n under general anesthesia. Place the patient in the lithotomy position\\n and using a speculum or Pratt bivalve retractor examine the vagina.\\n If you see or palpate a bulge, incise and drain the abscess. If you\\n wish you may leave a Penrose drain for a few days, but that is\\n mostly not necessary. Rarely will the patient develop a (colovaginal)\\n fistula and even if it does develop it resolves quickly.\\n • Similarly, if you palpate the abscess on rectal exam, drain it in\\n the operating room through the rectum. You will relieve the sepsis\\n and the rectum heals rapidly. If a fistula develops from the\\n sigmoid colon to the rectum, who cares? It is usually\\n asymptomatic. Most of the time the cavity collapses and\\n nothing else needs to be done.\\n\\n Finally, if the patient has an abscess that is surrounded by\\nintestine making percutaneous drainage impossible, consider\\nlaparoscopic drainage. If you are able to laparoscopically drain the\\nabscess, and no colon perforation is seen, then clean out the cavity and\\nleave a drain; if the patient recovers you are done — nothing else is\\nneeded. If symptoms persist you can come back in 8 weeks to perform a\\nlaparoscopic colectomy.\\n\\n So, as you see, the majority of complicated Hinchey I or II patients do not need any surgery —\\n not during the acute episode, nor later on. That you can do a lap colectomy… and it is\\n ‘soooooooo easy’ does not mean that you should use your skills indiscriminately!\\n\\n Peritonitis (Hinchey III & IV)\\n\\n These are patients with ‘real’ perforated diverticulitis — there is a\\n‘hole’ in the colon at the site of the (sigmoid) diverticulum letting out\\ncolonic contents to invade the adjacent tissues.',\n", " 'md': '```markdown\\n## Surgical Drainage of Pelvic Abscesses\\n\\n- If a low pelvic abscess is suspected in a woman and can be palpated on vaginal exam, I will drain these in the operating room under general anesthesia. Place the patient in the lithotomy position and using a speculum or Pratt bivalve retractor examine the vagina. If you see or palpate a bulge, incise and drain the abscess. If you wish, you may leave a Penrose drain for a few days, but that is mostly not necessary. Rarely will the patient develop a (colovaginal) fistula and even if it does develop it resolves quickly.\\n\\n- Similarly, if you palpate the abscess on rectal exam, drain it in the operating room through the rectum. You will relieve the sepsis and the rectum heals rapidly. If a fistula develops from the sigmoid colon to the rectum, who cares? It is usually asymptomatic. Most of the time the cavity collapses and nothing else needs to be done.\\n\\nFinally, if the patient has an abscess that is surrounded by intestine making percutaneous drainage impossible, consider laparoscopic drainage. If you are able to laparoscopically drain the abscess, and no colon perforation is seen, then clean out the cavity and leave a drain; if the patient recovers you are done — nothing else is needed. If symptoms persist you can come back in 8 weeks to perform a laparoscopic colectomy.\\n\\nSo, as you see, the majority of complicated Hinchey I or II patients do not need any surgery — not during the acute episode, nor later on. That you can do a lap colectomy… and it is ‘soooooooo easy’ does not mean that you should use your skills indiscriminately!\\n\\n## Peritonitis (Hinchey III & IV)\\n\\nThese are patients with ‘real’ perforated diverticulitis — there is a ‘hole’ in the colon at the site of the (sigmoid) diverticulum letting out colonic contents to invade the adjacent tissues.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Drainage of Pelvic Abscesses',\n", " 'md': '## Surgical Drainage of Pelvic Abscesses',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- If a low pelvic abscess is suspected in a woman and can be palpated on vaginal exam, I will drain these in the operating room under general anesthesia. Place the patient in the lithotomy position and using a speculum or Pratt bivalve retractor examine the vagina. If you see or palpate a bulge, incise and drain the abscess. If you wish, you may leave a Penrose drain for a few days, but that is mostly not necessary. Rarely will the patient develop a (colovaginal) fistula and even if it does develop it resolves quickly.\\n\\n- Similarly, if you palpate the abscess on rectal exam, drain it in the operating room through the rectum. You will relieve the sepsis and the rectum heals rapidly. If a fistula develops from the sigmoid colon to the rectum, who cares? It is usually asymptomatic. Most of the time the cavity collapses and nothing else needs to be done.\\n\\nFinally, if the patient has an abscess that is surrounded by intestine making percutaneous drainage impossible, consider laparoscopic drainage. If you are able to laparoscopically drain the abscess, and no colon perforation is seen, then clean out the cavity and leave a drain; if the patient recovers you are done — nothing else is needed. If symptoms persist you can come back in 8 weeks to perform a laparoscopic colectomy.\\n\\nSo, as you see, the majority of complicated Hinchey I or II patients do not need any surgery — not during the acute episode, nor later on. That you can do a lap colectomy… and it is ‘soooooooo easy’ does not mean that you should use your skills indiscriminately!',\n", " 'md': '- If a low pelvic abscess is suspected in a woman and can be palpated on vaginal exam, I will drain these in the operating room under general anesthesia. Place the patient in the lithotomy position and using a speculum or Pratt bivalve retractor examine the vagina. If you see or palpate a bulge, incise and drain the abscess. If you wish, you may leave a Penrose drain for a few days, but that is mostly not necessary. Rarely will the patient develop a (colovaginal) fistula and even if it does develop it resolves quickly.\\n\\n- Similarly, if you palpate the abscess on rectal exam, drain it in the operating room through the rectum. You will relieve the sepsis and the rectum heals rapidly. If a fistula develops from the sigmoid colon to the rectum, who cares? It is usually asymptomatic. Most of the time the cavity collapses and nothing else needs to be done.\\n\\nFinally, if the patient has an abscess that is surrounded by intestine making percutaneous drainage impossible, consider laparoscopic drainage. If you are able to laparoscopically drain the abscess, and no colon perforation is seen, then clean out the cavity and leave a drain; if the patient recovers you are done — nothing else is needed. If symptoms persist you can come back in 8 weeks to perform a laparoscopic colectomy.\\n\\nSo, as you see, the majority of complicated Hinchey I or II patients do not need any surgery — not during the acute episode, nor later on. That you can do a lap colectomy… and it is ‘soooooooo easy’ does not mean that you should use your skills indiscriminately!',\n", " 'bBox': {'x': 72, 'y': 155, 'w': 467.86, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Peritonitis (Hinchey III & IV)',\n", " 'md': '## Peritonitis (Hinchey III & IV)',\n", " 'bBox': {'x': 86, 'y': 630, 'w': 216.02, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'These are patients with ‘real’ perforated diverticulitis — there is a ‘hole’ in the colon at the site of the (sigmoid) diverticulum letting out colonic contents to invade the adjacent tissues.\\n```',\n", " 'md': 'These are patients with ‘real’ perforated diverticulitis — there is a ‘hole’ in the colon at the site of the (sigmoid) diverticulum letting out colonic contents to invade the adjacent tissues.\\n```',\n", " 'bBox': {'x': 72, 'y': 666, 'w': 467.47, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 497,\n", " 'text': ' Hinchey III patients\\n\\n Very rare — I’m only seeing one to two patients a year. What\\nabout you?\\n\\n These patients suffer from purulent peritonitis or PID (“pus in der\\nBauch …” as we say in Baltimore, with its rich German heritage). They\\npresent with generalized abdominal pain and peritonitis. A CT scan\\nwill show a variable quantity and distribution of free air and free\\nfluid. In addition, an inflamed segment of large intestine is seen,\\nusually the sigmoid colon, and there may still be a recognizable\\nabscess, either pericolonic or pelvic. The patient is usually sick and\\nmay be severely septic. Initial management begins with fluid\\nresuscitation, broad-spectrum antibiotics, and pain control.\\n\\n How we manage these patients is then decided based on the\\nseverity of their septic state. Practically speaking I define ‘ill’ (related to\\nthe patient’s sepsis and comorbid medical conditions) as those patients\\nwho are in a monitored setting, requiring pharmacological support for\\ntheir blood pressure, and/or demonstrating another system failure such\\nas renal or respiratory deterioration. A patient’s comorbid medical\\nconditions also factor into my classification of ‘ill’. If the patient suffers\\nfrom heart failure, is malnourished (albumin <3.0g/dL), or is\\nimmunosuppressed (transplant or chemotherapy patients), I consider him\\nto be at higher risk. Age is less of a factor in my opinion; a 45-year-old\\nkidney transplant patient is more worrisome than a 75- year-old guy that\\nruns marathons. So let’s look at how we deal with the ill and non-ill.\\n\\n Not very ill\\n These patients have pain, peritoneal signs and fever but have no other\\nseptic sequelae. I have colleagues that will manage these patients\\nwith i.v. antibiotics, bowel rest and — selectively — placement of\\none or more percutaneous drains in larger collections. I think this is a\\nreasonable approach, especially if the CT findings are localized rather\\nthan diffuse. Of course, such patients must be closely watched to ensure\\nthat they don’t deteriorate. I am also convinced that this management\\nchoice results in prolonged hospital stays. I am, therefore, an',\n", " 'md': '```markdown\\n# Hinchey III Patients\\n\\nVery rare — I’m only seeing one to two patients a year. What about you?\\n\\nThese patients suffer from purulent peritonitis or PID (“pus in der Bauch …” as we say in Baltimore, with its rich German heritage). They present with generalized abdominal pain and peritonitis. A CT scan will show a variable quantity and distribution of free air and free fluid. In addition, an inflamed segment of large intestine is seen, usually the sigmoid colon, and there may still be a recognizable abscess, either pericolonic or pelvic. The patient is usually sick and may be severely septic. Initial management begins with fluid resuscitation, broad-spectrum antibiotics, and pain control.\\n\\nHow we manage these patients is then decided based on the severity of their septic state. Practically speaking I define ‘ill’ (related to the patient’s sepsis and comorbid medical conditions) as those patients who are in a monitored setting, requiring pharmacological support for their blood pressure, and/or demonstrating another system failure such as renal or respiratory deterioration. A patient’s comorbid medical conditions also factor into my classification of ‘ill’. If the patient suffers from heart failure, is malnourished (albumin <3.0g/dL), or is immunosuppressed (transplant or chemotherapy patients), I consider him to be at higher risk. Age is less of a factor in my opinion; a 45-year-old kidney transplant patient is more worrisome than a 75-year-old guy that runs marathons. So let’s look at how we deal with the ill and non-ill.\\n\\n## Not Very Ill\\n\\nThese patients have pain, peritoneal signs and fever but have no other septic sequelae. I have colleagues that will manage these patients with i.v. antibiotics, bowel rest and — selectively — placement of one or more percutaneous drains in larger collections. I think this is a reasonable approach, especially if the CT findings are localized rather than diffuse. Of course, such patients must be closely watched to ensure that they don’t deteriorate. I am also convinced that this management choice results in prolonged hospital stays. I am, therefore, an\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Hinchey III Patients',\n", " 'md': '# Hinchey III Patients',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 150.79, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Very rare — I’m only seeing one to two patients a year. What about you?\\n\\nThese patients suffer from purulent peritonitis or PID (“pus in der Bauch …” as we say in Baltimore, with its rich German heritage). They present with generalized abdominal pain and peritonitis. A CT scan will show a variable quantity and distribution of free air and free fluid. In addition, an inflamed segment of large intestine is seen, usually the sigmoid colon, and there may still be a recognizable abscess, either pericolonic or pelvic. The patient is usually sick and may be severely septic. Initial management begins with fluid resuscitation, broad-spectrum antibiotics, and pain control.\\n\\nHow we manage these patients is then decided based on the severity of their septic state. Practically speaking I define ‘ill’ (related to the patient’s sepsis and comorbid medical conditions) as those patients who are in a monitored setting, requiring pharmacological support for their blood pressure, and/or demonstrating another system failure such as renal or respiratory deterioration. A patient’s comorbid medical conditions also factor into my classification of ‘ill’. If the patient suffers from heart failure, is malnourished (albumin <3.0g/dL), or is immunosuppressed (transplant or chemotherapy patients), I consider him to be at higher risk. Age is less of a factor in my opinion; a 45-year-old kidney transplant patient is more worrisome than a 75-year-old guy that runs marathons. So let’s look at how we deal with the ill and non-ill.',\n", " 'md': 'Very rare — I’m only seeing one to two patients a year. What about you?\\n\\nThese patients suffer from purulent peritonitis or PID (“pus in der Bauch …” as we say in Baltimore, with its rich German heritage). They present with generalized abdominal pain and peritonitis. A CT scan will show a variable quantity and distribution of free air and free fluid. In addition, an inflamed segment of large intestine is seen, usually the sigmoid colon, and there may still be a recognizable abscess, either pericolonic or pelvic. The patient is usually sick and may be severely septic. Initial management begins with fluid resuscitation, broad-spectrum antibiotics, and pain control.\\n\\nHow we manage these patients is then decided based on the severity of their septic state. Practically speaking I define ‘ill’ (related to the patient’s sepsis and comorbid medical conditions) as those patients who are in a monitored setting, requiring pharmacological support for their blood pressure, and/or demonstrating another system failure such as renal or respiratory deterioration. A patient’s comorbid medical conditions also factor into my classification of ‘ill’. If the patient suffers from heart failure, is malnourished (albumin <3.0g/dL), or is immunosuppressed (transplant or chemotherapy patients), I consider him to be at higher risk. Age is less of a factor in my opinion; a 45-year-old kidney transplant patient is more worrisome than a 75-year-old guy that runs marathons. So let’s look at how we deal with the ill and non-ill.',\n", " 'bBox': {'x': 72, 'y': 140, 'w': 467.6, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Not Very Ill',\n", " 'md': '## Not Very Ill',\n", " 'bBox': {'x': 86, 'y': 564, 'w': 73.55, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'These patients have pain, peritoneal signs and fever but have no other septic sequelae. I have colleagues that will manage these patients with i.v. antibiotics, bowel rest and — selectively — placement of one or more percutaneous drains in larger collections. I think this is a reasonable approach, especially if the CT findings are localized rather than diffuse. Of course, such patients must be closely watched to ensure that they don’t deteriorate. I am also convinced that this management choice results in prolonged hospital stays. I am, therefore, an\\n```',\n", " 'md': 'These patients have pain, peritoneal signs and fever but have no other septic sequelae. I have colleagues that will manage these patients with i.v. antibiotics, bowel rest and — selectively — placement of one or more percutaneous drains in larger collections. I think this is a reasonable approach, especially if the CT findings are localized rather than diffuse. Of course, such patients must be closely watched to ensure that they don’t deteriorate. I am also convinced that this management choice results in prolonged hospital stays. I am, therefore, an\\n```',\n", " 'bBox': {'x': 72, 'y': 459, 'w': 467.68, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 498,\n", " 'text': 'advocate of a diagnostic laparoscopy and peritoneal lavage with\\ndrainage (to be described below). I think the patients recover faster\\nand have minimal morbidity from the procedure. There is no need to\\nresect the colon at this time as long as you don’t identify a\\nperforation. Again, conservative treatment with antibiotics may achieve\\nthe same results but in my experience is associated with a longer\\nmorbidity and hospital stay.\\n\\n Septic but not critical\\n These patients are sicker — tachycardia, fever, pain, tenderness, and\\nlook to be in distress. I think it is perfectly reasonable to approach these\\npatients laparoscopically as well; of course, after optimal resuscitation\\nand i.v. antibiotics. If they don’t tolerate pneumoperitoneum (which\\nshould not happen if hypovolemia has been corrected) then convert\\nto a laparotomy. At laparoscopy do as described below…\\n\\n Critically ill\\n These are the patients that are hemodynamically unstable, requiring\\npressor support, or in respiratory distress. I don’t mess about with\\nthese patients! After stabilizing them in the ICU, I proceed\\nimmediately to the operating room, make a large incision and resect\\nthe diverticular segment (if possible), clean the belly out, and\\nmature an end colostomy. If I can’t resect (rarely) then I drain and\\ndivert. Their best chance for survival is a quick, safe operation for source\\ncontrol combined with the skilled care of a well-trained surgical\\nintensivist.\\n\\n Hinchey IV patients\\n\\n This is a complication I see every 2 to 3 years.\\n\\n These are the patients with feculent peritonitis. Pre-operatively it is\\nhard to differentiate these patients from those we classify as ħinchey III,\\nbut they tend to be sicker. A tip-off on the CT scan is the finding of\\noral contrast in the peritoneal cavity — if the contrast is there, the\\nchances are that s**t has exited with it!',\n", " 'md': '```markdown\\n## Diagnostic Laparoscopy and Peritoneal Lavage\\n\\nThe advocate of a diagnostic laparoscopy and peritoneal lavage with drainage (to be described below). I think the patients recover faster and have minimal morbidity from the procedure. There is no need to resect the colon at this time as long as you don’t identify a perforation. Again, conservative treatment with antibiotics may achieve the same results but in my experience is associated with a longer morbidity and hospital stay.\\n\\n### Septic but not Critical\\n\\nThese patients are sicker — tachycardia, fever, pain, tenderness, and look to be in distress. I think it is perfectly reasonable to approach these patients laparoscopically as well; of course, after optimal resuscitation and i.v. antibiotics. If they don’t tolerate pneumoperitoneum (which should not happen if hypovolemia has been corrected) then convert to a laparotomy. At laparoscopy do as described below…\\n\\n### Critically Ill\\n\\nThese are the patients that are hemodynamically unstable, requiring pressor support, or in respiratory distress. I don’t mess about with these patients! After stabilizing them in the ICU, I proceed immediately to the operating room, make a large incision and resect the diverticular segment (if possible), clean the belly out, and mature an end colostomy. If I can’t resect (rarely) then I drain and divert. Their best chance for survival is a quick, safe operation for source control combined with the skilled care of a well-trained surgical intensivist.\\n\\n### Hinchey IV Patients\\n\\nThis is a complication I see every 2 to 3 years. These are the patients with feculent peritonitis. Pre-operatively it is hard to differentiate these patients from those we classify as Hinchey III, but they tend to be sicker. A tip-off on the CT scan is the finding of oral contrast in the peritoneal cavity — if the contrast is there, the chances are that s**t has exited with it!\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnostic Laparoscopy and Peritoneal Lavage',\n", " 'md': '## Diagnostic Laparoscopy and Peritoneal Lavage',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The advocate of a diagnostic laparoscopy and peritoneal lavage with drainage (to be described below). I think the patients recover faster and have minimal morbidity from the procedure. There is no need to resect the colon at this time as long as you don’t identify a perforation. Again, conservative treatment with antibiotics may achieve the same results but in my experience is associated with a longer morbidity and hospital stay.',\n", " 'md': 'The advocate of a diagnostic laparoscopy and peritoneal lavage with drainage (to be described below). I think the patients recover faster and have minimal morbidity from the procedure. There is no need to resect the colon at this time as long as you don’t identify a perforation. Again, conservative treatment with antibiotics may achieve the same results but in my experience is associated with a longer morbidity and hospital stay.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.44, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Septic but not Critical',\n", " 'md': '### Septic but not Critical',\n", " 'bBox': {'x': 86, 'y': 224, 'w': 146.26, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'These patients are sicker — tachycardia, fever, pain, tenderness, and look to be in distress. I think it is perfectly reasonable to approach these patients laparoscopically as well; of course, after optimal resuscitation and i.v. antibiotics. If they don’t tolerate pneumoperitoneum (which should not happen if hypovolemia has been corrected) then convert to a laparotomy. At laparoscopy do as described below…',\n", " 'md': 'These patients are sicker — tachycardia, fever, pain, tenderness, and look to be in distress. I think it is perfectly reasonable to approach these patients laparoscopically as well; of course, after optimal resuscitation and i.v. antibiotics. If they don’t tolerate pneumoperitoneum (which should not happen if hypovolemia has been corrected) then convert to a laparotomy. At laparoscopy do as described below…',\n", " 'bBox': {'x': 72, 'y': 245, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Critically Ill',\n", " 'md': '### Critically Ill',\n", " 'bBox': {'x': 86, 'y': 366, 'w': 76.75, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'These are the patients that are hemodynamically unstable, requiring pressor support, or in respiratory distress. I don’t mess about with these patients! After stabilizing them in the ICU, I proceed immediately to the operating room, make a large incision and resect the diverticular segment (if possible), clean the belly out, and mature an end colostomy. If I can’t resect (rarely) then I drain and divert. Their best chance for survival is a quick, safe operation for source control combined with the skilled care of a well-trained surgical intensivist.',\n", " 'md': 'These are the patients that are hemodynamically unstable, requiring pressor support, or in respiratory distress. I don’t mess about with these patients! After stabilizing them in the ICU, I proceed immediately to the operating room, make a large incision and resect the diverticular segment (if possible), clean the belly out, and mature an end colostomy. If I can’t resect (rarely) then I drain and divert. Their best chance for survival is a quick, safe operation for source control combined with the skilled care of a well-trained surgical intensivist.',\n", " 'bBox': {'x': 72, 'y': 437, 'w': 467.38, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Hinchey IV Patients',\n", " 'md': '### Hinchey IV Patients',\n", " 'bBox': {'x': 86, 'y': 563, 'w': 152.64, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is a complication I see every 2 to 3 years. These are the patients with feculent peritonitis. Pre-operatively it is hard to differentiate these patients from those we classify as Hinchey III, but they tend to be sicker. A tip-off on the CT scan is the finding of oral contrast in the peritoneal cavity — if the contrast is there, the chances are that s**t has exited with it!\\n```',\n", " 'md': 'This is a complication I see every 2 to 3 years. These are the patients with feculent peritonitis. Pre-operatively it is hard to differentiate these patients from those we classify as Hinchey III, but they tend to be sicker. A tip-off on the CT scan is the finding of oral contrast in the peritoneal cavity — if the contrast is there, the chances are that s**t has exited with it!\\n```',\n", " 'bBox': {'x': 72, 'y': 599, 'w': 467.47, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 499,\n", " 'text': ' I still follow the above course based on the patient’s septic status. But\\nif I find feculent peritonitis on laparoscopy, I will convert to a\\nlaparotomy and perform a resection and end colostomy — a\\nHartmann’s procedure and ‘peritoneal toilet’. Older studies have\\nrelayed a ~30% mortality associated with feculent peritonitis. Newer\\nstudies have questioned this, and some even go on to advocate the use\\nof laparoscopic lavage combined with repair of the colon perforation with\\ndrainage — as opposed to resection. I am not comfortable with such an\\napproach — I have found that I can’t adequately clean the abdomen of\\nstool with the laparoscopic suction irrigator and that the colonic wall in a\\npatient with perforated diverticulitis and feculent peritonitis never holds\\nsutures. So I beseech you: if you see stool, don’t f…, sorry, muck\\nabout. Make an incision and get on with it and get them to the ICU.\\n\\n The operations\\n\\n Whether performing a laparoscopic procedure or an open\\nresection, the principles for operating on acute diverticulitis are the\\nsame. ħere are a few rules to live by:\\n\\n • Always initiate dissection away from the area of inflammation. Don’t\\n go near the phlegmon until you have identified key structures.\\n • After initiating the dissection in a clean plane, locate the ureter.\\n • After finding the ureter, always ensure it is lateral to your plane of\\n dissection. Be cognizant of the iliac and gonadal vessels, but\\n above the sacral promontory, as long as the ureter is in view\\n and lateral to where you are working, you should not injure the\\n other two.\\n • Less is more when patients are sick. So If the patient is septic\\n and not doing well, perform a proximal diversion, clean out and\\n drain, and come back to fight another day.\\n\\n Laparoscopic lavage, drainage (and possible resection)\\n\\n I perform these operations with the patient in the modified lithotomy\\nposition. You never know what you will find and if you start in the supine',\n", " 'md': '```markdown\\n# Current Page\\n\\nI still follow the above course based on the patient’s septic status. But if I find feculent peritonitis on laparoscopy, I will convert to a laparotomy and perform a resection and end colostomy — a Hartmann’s procedure and ‘peritoneal toilet’. Older studies have relayed a ~30% mortality associated with feculent peritonitis. Newer studies have questioned this, and some even go on to advocate the use of laparoscopic lavage combined with repair of the colon perforation with drainage — as opposed to resection. I am not comfortable with such an approach — I have found that I can’t adequately clean the abdomen of stool with the laparoscopic suction irrigator and that the colonic wall in a patient with perforated diverticulitis and feculent peritonitis never holds sutures. So I beseech you: if you see stool, don’t f…, sorry, muck about. Make an incision and get on with it and get them to the ICU.\\n\\n## The operations\\n\\nWhether performing a laparoscopic procedure or an open resection, the principles for operating on acute diverticulitis are the same. Here are a few rules to live by:\\n\\n- Always initiate dissection away from the area of inflammation. Don’t go near the phlegmon until you have identified key structures.\\n- After initiating the dissection in a clean plane, locate the ureter.\\n- After finding the ureter, always ensure it is lateral to your plane of dissection. Be cognizant of the iliac and gonadal vessels, but above the sacral promontory, as long as the ureter is in view and lateral to where you are working, you should not injure the other two.\\n- Less is more when patients are sick. So if the patient is septic and not doing well, perform a proximal diversion, clean out and drain, and come back to fight another day.\\n\\n## Laparoscopic lavage, drainage (and possible resection)\\n\\nI perform these operations with the patient in the modified lithotomy position. You never know what you will find and if you start in the supine.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Current Page',\n", " 'md': '# Current Page',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'I still follow the above course based on the patient’s septic status. But if I find feculent peritonitis on laparoscopy, I will convert to a laparotomy and perform a resection and end colostomy — a Hartmann’s procedure and ‘peritoneal toilet’. Older studies have relayed a ~30% mortality associated with feculent peritonitis. Newer studies have questioned this, and some even go on to advocate the use of laparoscopic lavage combined with repair of the colon perforation with drainage — as opposed to resection. I am not comfortable with such an approach — I have found that I can’t adequately clean the abdomen of stool with the laparoscopic suction irrigator and that the colonic wall in a patient with perforated diverticulitis and feculent peritonitis never holds sutures. So I beseech you: if you see stool, don’t f…, sorry, muck about. Make an incision and get on with it and get them to the ICU.',\n", " 'md': 'I still follow the above course based on the patient’s septic status. But if I find feculent peritonitis on laparoscopy, I will convert to a laparotomy and perform a resection and end colostomy — a Hartmann’s procedure and ‘peritoneal toilet’. Older studies have relayed a ~30% mortality associated with feculent peritonitis. Newer studies have questioned this, and some even go on to advocate the use of laparoscopic lavage combined with repair of the colon perforation with drainage — as opposed to resection. I am not comfortable with such an approach — I have found that I can’t adequately clean the abdomen of stool with the laparoscopic suction irrigator and that the colonic wall in a patient with perforated diverticulitis and feculent peritonitis never holds sutures. So I beseech you: if you see stool, don’t f…, sorry, muck about. Make an incision and get on with it and get them to the ICU.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The operations',\n", " 'md': '## The operations',\n", " 'bBox': {'x': 86, 'y': 327, 'w': 118.62, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Whether performing a laparoscopic procedure or an open resection, the principles for operating on acute diverticulitis are the same. Here are a few rules to live by:\\n\\n- Always initiate dissection away from the area of inflammation. Don’t go near the phlegmon until you have identified key structures.\\n- After initiating the dissection in a clean plane, locate the ureter.\\n- After finding the ureter, always ensure it is lateral to your plane of dissection. Be cognizant of the iliac and gonadal vessels, but above the sacral promontory, as long as the ureter is in view and lateral to where you are working, you should not injure the other two.\\n- Less is more when patients are sick. So if the patient is septic and not doing well, perform a proximal diversion, clean out and drain, and come back to fight another day.',\n", " 'md': 'Whether performing a laparoscopic procedure or an open resection, the principles for operating on acute diverticulitis are the same. Here are a few rules to live by:\\n\\n- Always initiate dissection away from the area of inflammation. Don’t go near the phlegmon until you have identified key structures.\\n- After initiating the dissection in a clean plane, locate the ureter.\\n- After finding the ureter, always ensure it is lateral to your plane of dissection. Be cognizant of the iliac and gonadal vessels, but above the sacral promontory, as long as the ureter is in view and lateral to where you are working, you should not injure the other two.\\n- Less is more when patients are sick. So if the patient is septic and not doing well, perform a proximal diversion, clean out and drain, and come back to fight another day.',\n", " 'bBox': {'x': 72, 'y': 380, 'w': 467.66, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Laparoscopic lavage, drainage (and possible resection)',\n", " 'md': '## Laparoscopic lavage, drainage (and possible resection)',\n", " 'bBox': {'x': 86, 'y': 661, 'w': 436.79, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'I perform these operations with the patient in the modified lithotomy position. You never know what you will find and if you start in the supine.\\n```',\n", " 'md': 'I perform these operations with the patient in the modified lithotomy position. You never know what you will find and if you start in the supine.\\n```',\n", " 'bBox': {'x': 72, 'y': 697, 'w': 467.11, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 500,\n", " 'text': 'position you will most assuredly wish you had access to the anus (it’s a\\ncolorectal surgeon thing…). Tuck both arms with padding and secure the\\npatient to the table — to adequately examine and lavage these\\npatients you often need to tilt to the extreme left and right and place\\nin a steep Trendelenburg position.\\n\\n I place an umbilical port first (Hasson) and look for feces; if I see\\n(and smell) it, I am done with the laparoscope and I make a midline\\nincision. If I find pus, I will place two other 5mm trocars — a right lower\\nquadrant and a suprapubic one. This is often all that is needed to perform\\nthe lavage and examination of the colon. If needed, I will add a left lower\\nquadrant trocar.\\n\\n Initially I examine the inflamed colon. Usually you see a perforated\\nabscess cavity and no opening to the colon. Sometimes you see no\\ncavity and just the inflamed bowel. If you don’t see an obvious hole in\\nthe colon, for God’s sake do not go poking for it! In other words\\ndon’t mobilize the colon unless you plan on resecting it. Most of the\\ntime you just see the inflamed colon with a part of the abscess cavity; in\\nthese cases I irrigate the abdomen — all four quadrants and the pelvis\\nuntil clean and then leave a closed suction drain (I love the fat round\\nBlake drain, Danny prefers the slender 7mm Jackson-Pratt...) in the\\nabscess cavity or near the colon, bringing it out through the suprapubic\\ntrocar site. The purpose of this drain is not to drain the general peritoneal\\ncavity, which is a ‘mission impossible’, but to drain any colonic hole which\\nwe may have missed. The truth, however, is that we almost never see\\nany feces from such drains after lap lavage for purulent peritonitis\\n— the reason being that the perforations in such cases are minute\\nand self-sealing rapidly; this is why lap lavage is successful…\\n\\n In the rare case when I see the colonic perforation I resect the\\ncolon — even in the absence of visible feces. I don’t trust that sutures\\nwill hold in inflamed colon and I hate to leave an open hole within the\\nabdomen, drained or not.\\n\\n In the ‘not-very-ill-patient’ and under optimal conditions I will\\nattempt the resection laparoscopically rather than convert\\nimmediately. (However, if you are not very well trained in elective',\n", " 'md': \"```markdown\\n## Page Content\\n\\nIn this section, the author discusses the surgical procedure for examining and lavaging patients with suspected colorectal issues. The following points are highlighted:\\n\\n1. **Positioning the Patient**:\\n- The patient is secured to the table with padding to allow for extreme tilting and steep Trendelenburg positioning.\\n\\n2. **Initial Port Placement**:\\n- An umbilical port (Hasson technique) is placed first. If feces are observed, the laparoscope is removed, and a midline incision is made. If pus is found, two additional 5mm trocars are placed in the right lower quadrant and suprapubic area.\\n\\n3. **Examination of the Colon**:\\n- The inflamed colon is examined. A perforated abscess cavity may be visible, or just inflamed bowel without an obvious opening. The author advises against mobilizing the colon unless resection is planned.\\n\\n4. **Irrigation and Drain Placement**:\\n- The abdomen is irrigated until clean, and a closed suction drain (preferably a Blake drain or a Jackson-Pratt drain) is placed in the abscess cavity or near the colon, exiting through the suprapubic trocar site. The drain's purpose is to capture any missed colonic perforations.\\n\\n5. **Handling Colonic Perforations**:\\n- If a colonic perforation is visible, resection is performed, as sutures may not hold in inflamed tissue. Leaving an open hole in the abdomen is avoided.\\n\\n6. **Laparoscopic Resection**:\\n- In less severe cases and under optimal conditions, the author prefers to attempt laparoscopic resection rather than converting to an open procedure immediately.\\n\\n### Summary\\nThe text provides a detailed overview of the surgical approach to managing patients with suspected colorectal issues, emphasizing the importance of careful examination, irrigation, and drainage, as well as the decision-making process regarding resection.\\n\\n### Note\\nNo images, graphs, or tables were identified on this page.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"In this section, the author discusses the surgical procedure for examining and lavaging patients with suspected colorectal issues. The following points are highlighted:\\n\\n1. **Positioning the Patient**:\\n- The patient is secured to the table with padding to allow for extreme tilting and steep Trendelenburg positioning.\\n\\n2. **Initial Port Placement**:\\n- An umbilical port (Hasson technique) is placed first. If feces are observed, the laparoscope is removed, and a midline incision is made. If pus is found, two additional 5mm trocars are placed in the right lower quadrant and suprapubic area.\\n\\n3. **Examination of the Colon**:\\n- The inflamed colon is examined. A perforated abscess cavity may be visible, or just inflamed bowel without an obvious opening. The author advises against mobilizing the colon unless resection is planned.\\n\\n4. **Irrigation and Drain Placement**:\\n- The abdomen is irrigated until clean, and a closed suction drain (preferably a Blake drain or a Jackson-Pratt drain) is placed in the abscess cavity or near the colon, exiting through the suprapubic trocar site. The drain's purpose is to capture any missed colonic perforations.\\n\\n5. **Handling Colonic Perforations**:\\n- If a colonic perforation is visible, resection is performed, as sutures may not hold in inflamed tissue. Leaving an open hole in the abdomen is avoided.\\n\\n6. **Laparoscopic Resection**:\\n- In less severe cases and under optimal conditions, the author prefers to attempt laparoscopic resection rather than converting to an open procedure immediately.\",\n", " 'md': \"In this section, the author discusses the surgical procedure for examining and lavaging patients with suspected colorectal issues. The following points are highlighted:\\n\\n1. **Positioning the Patient**:\\n- The patient is secured to the table with padding to allow for extreme tilting and steep Trendelenburg positioning.\\n\\n2. **Initial Port Placement**:\\n- An umbilical port (Hasson technique) is placed first. If feces are observed, the laparoscope is removed, and a midline incision is made. If pus is found, two additional 5mm trocars are placed in the right lower quadrant and suprapubic area.\\n\\n3. **Examination of the Colon**:\\n- The inflamed colon is examined. A perforated abscess cavity may be visible, or just inflamed bowel without an obvious opening. The author advises against mobilizing the colon unless resection is planned.\\n\\n4. **Irrigation and Drain Placement**:\\n- The abdomen is irrigated until clean, and a closed suction drain (preferably a Blake drain or a Jackson-Pratt drain) is placed in the abscess cavity or near the colon, exiting through the suprapubic trocar site. The drain's purpose is to capture any missed colonic perforations.\\n\\n5. **Handling Colonic Perforations**:\\n- If a colonic perforation is visible, resection is performed, as sutures may not hold in inflamed tissue. Leaving an open hole in the abdomen is avoided.\\n\\n6. **Laparoscopic Resection**:\\n- In less severe cases and under optimal conditions, the author prefers to attempt laparoscopic resection rather than converting to an open procedure immediately.\",\n", " 'bBox': {'x': 72, 'y': 690, 'w': 67.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text provides a detailed overview of the surgical approach to managing patients with suspected colorectal issues, emphasizing the importance of careful examination, irrigation, and drainage, as well as the decision-making process regarding resection.',\n", " 'md': 'The text provides a detailed overview of the surgical approach to managing patients with suspected colorectal issues, emphasizing the importance of careful examination, irrigation, and drainage, as well as the decision-making process regarding resection.',\n", " 'bBox': {'x': 139, 'y': 690, 'w': 25.58, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Note',\n", " 'md': '### Note',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'No images, graphs, or tables were identified on this page.\\n```',\n", " 'md': 'No images, graphs, or tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 501,\n", " 'text': 'laparoscopic colon surgery, please do not decide to experiment on\\nit at night under adverse conditions: Convert! Convert! Convert!)\\n\\n I initiate the mobilization away from the area of inflammation and\\nidentify the ureter. Laparoscopically, this is best accomplished by\\napproaching the mobilization medially. First score the left colonic\\nmesentery on its medial aspect at or near the sacral promontory; then\\nmobilize the colonic mesentery off of the retroperitoneum. You should be\\nable to identify the ureter in this manner.\\n\\n Once the ureter is identified, isolate and ligate the inferior\\nmesenteric artery. Mobilize the remainder of the colonic mesentery and\\nfree the splenic flexure if you think it is needed. If the ureter cannot be\\nidentified or you are having difficulty performing the dissection,\\nthen convert to a laparotomy — better to cut the abdominal wall\\nthan to cut the ureter.\\n\\n Next I approach the area of inflammation and free the colon from\\nthe lateral inflammatory attachments (again if difficult I convert). Once\\nthe colon is free, I divide the mesentery at the rectosigmoid junction\\n(always lower than you think laparoscopically) which is found at the\\nsacral promontory, or where the colonic tinea splay. I divide the rectum\\nwith an Endo GIA™ stapler. Always divide the rectum at an area free of\\ninflammation. Once divided, I extend the small midline incision used for\\nthe ħasson trocar usually around the umbilicus, place a wound protector\\nand eviscerate the specimen.\\n\\n And now I ask myself the same old question (relevant also when\\ndealing with other colonic emergencies) — to anastomose or not?\\n\\n If the patient is healthy (no diabetes, immunosuppression, no\\nmalnutrition, or cardiac disease), not septic (hemodynamically\\nstable, not requiring vasopressors), and most importantly — the two\\npieces of intestine to be anastomosed are soft, pliable, and well\\nperfused; then I anastomose. Otherwise I proceed with a colostomy: in\\nthe end, an end colostomy is the safest option for any perforated\\npatient, so all of the stars have to align if I am going to perform an\\nanastomosis.',\n", " 'md': '```markdown\\n## Laparoscopic Colon Surgery Procedure\\n\\n1. **Mobilization**: Initiate the mobilization away from the area of inflammation and identify the ureter. Laparoscopically, this is best accomplished by approaching the mobilization medially. First, score the left colonic mesentery on its medial aspect at or near the sacral promontory; then mobilize the colonic mesentery off of the retroperitoneum. You should be able to identify the ureter in this manner.\\n\\n2. **Ureter Identification**: Once the ureter is identified, isolate and ligate the inferior mesenteric artery. Mobilize the remainder of the colonic mesentery and free the splenic flexure if you think it is needed. If the ureter cannot be identified or you are having difficulty performing the dissection, then convert to a laparotomy — better to cut the abdominal wall than to cut the ureter.\\n\\n3. **Area of Inflammation**: Next, approach the area of inflammation and free the colon from the lateral inflammatory attachments (again if difficult, convert). Once the colon is free, divide the mesentery at the rectosigmoid junction (always lower than you think laparoscopically) which is found at the sacral promontory, or where the colonic tinea splay. Divide the rectum with an Endo GIA™ stapler. Always divide the rectum at an area free of inflammation. Once divided, extend the small midline incision used for the Hasson trocar usually around the umbilicus, place a wound protector, and eviscerate the specimen.\\n\\n4. **Anastomosis Decision**: Ask yourself the same old question (relevant also when dealing with other colonic emergencies) — to anastomose or not? If the patient is healthy (no diabetes, immunosuppression, no malnutrition, or cardiac disease), not septic (hemodynamically stable, not requiring vasopressors), and most importantly — the two pieces of intestine to be anastomosed are soft, pliable, and well perfused; then anastomose. Otherwise, proceed with a colostomy: in the end, an end colostomy is the safest option for any perforated patient, so all of the stars have to align if performing an anastomosis.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Laparoscopic Colon Surgery Procedure',\n", " 'md': '## Laparoscopic Colon Surgery Procedure',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. **Mobilization**: Initiate the mobilization away from the area of inflammation and identify the ureter. Laparoscopically, this is best accomplished by approaching the mobilization medially. First, score the left colonic mesentery on its medial aspect at or near the sacral promontory; then mobilize the colonic mesentery off of the retroperitoneum. You should be able to identify the ureter in this manner.\\n\\n2. **Ureter Identification**: Once the ureter is identified, isolate and ligate the inferior mesenteric artery. Mobilize the remainder of the colonic mesentery and free the splenic flexure if you think it is needed. If the ureter cannot be identified or you are having difficulty performing the dissection, then convert to a laparotomy — better to cut the abdominal wall than to cut the ureter.\\n\\n3. **Area of Inflammation**: Next, approach the area of inflammation and free the colon from the lateral inflammatory attachments (again if difficult, convert). Once the colon is free, divide the mesentery at the rectosigmoid junction (always lower than you think laparoscopically) which is found at the sacral promontory, or where the colonic tinea splay. Divide the rectum with an Endo GIA™ stapler. Always divide the rectum at an area free of inflammation. Once divided, extend the small midline incision used for the Hasson trocar usually around the umbilicus, place a wound protector, and eviscerate the specimen.\\n\\n4. **Anastomosis Decision**: Ask yourself the same old question (relevant also when dealing with other colonic emergencies) — to anastomose or not? If the patient is healthy (no diabetes, immunosuppression, no malnutrition, or cardiac disease), not septic (hemodynamically stable, not requiring vasopressors), and most importantly — the two pieces of intestine to be anastomosed are soft, pliable, and well perfused; then anastomose. Otherwise, proceed with a colostomy: in the end, an end colostomy is the safest option for any perforated patient, so all of the stars have to align if performing an anastomosis.\\n```',\n", " 'md': '1. **Mobilization**: Initiate the mobilization away from the area of inflammation and identify the ureter. Laparoscopically, this is best accomplished by approaching the mobilization medially. First, score the left colonic mesentery on its medial aspect at or near the sacral promontory; then mobilize the colonic mesentery off of the retroperitoneum. You should be able to identify the ureter in this manner.\\n\\n2. **Ureter Identification**: Once the ureter is identified, isolate and ligate the inferior mesenteric artery. Mobilize the remainder of the colonic mesentery and free the splenic flexure if you think it is needed. If the ureter cannot be identified or you are having difficulty performing the dissection, then convert to a laparotomy — better to cut the abdominal wall than to cut the ureter.\\n\\n3. **Area of Inflammation**: Next, approach the area of inflammation and free the colon from the lateral inflammatory attachments (again if difficult, convert). Once the colon is free, divide the mesentery at the rectosigmoid junction (always lower than you think laparoscopically) which is found at the sacral promontory, or where the colonic tinea splay. Divide the rectum with an Endo GIA™ stapler. Always divide the rectum at an area free of inflammation. Once divided, extend the small midline incision used for the Hasson trocar usually around the umbilicus, place a wound protector, and eviscerate the specimen.\\n\\n4. **Anastomosis Decision**: Ask yourself the same old question (relevant also when dealing with other colonic emergencies) — to anastomose or not? If the patient is healthy (no diabetes, immunosuppression, no malnutrition, or cardiac disease), not septic (hemodynamically stable, not requiring vasopressors), and most importantly — the two pieces of intestine to be anastomosed are soft, pliable, and well perfused; then anastomose. Otherwise, proceed with a colostomy: in the end, an end colostomy is the safest option for any perforated patient, so all of the stars have to align if performing an anastomosis.\\n```',\n", " 'bBox': {'x': 72, 'y': 204, 'w': 467.78, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 502,\n", " 'text': ' Some additional perspective\\n\\n As mentioned, purulent peritonitis is a rare complication and\\nfeculent peritonitis is even rarer. Our success in managing purulent\\nperitonitis with laparoscopic washout and drainage has been very good in\\nthose patients without prior surgery. We almost always (90% of the\\ntime) complete the laparoscopic lavage and drain placement without\\nconverting. No patients have developed a fecal fistula and generally\\nthey leave the hospital on oral antibiotics after 3 to 5 days. This may\\nbe because of my ‘selection bias’. I identify these patients by CT scan:\\nthey have free air with some ascites that does not contain contrast.\\nThey also are not ill (defined above). Again, if I see contrast in the\\nperitoneal cavity, I make an incision as I think these patients have\\nfeculent peritonitis and know I will have difficulty cleaning out the stool\\nwith the laparoscope.\\n\\n With a large transplant program at my institution, I see many\\nimmunosuppressed patients with complicated diverticulitis, and it is\\nin this patient population where I have not had much success with\\nthe laparoscopic lavage technique. The transplant patients often have\\nother incisions and adhesions that interfere with the lavage; and I found\\nthat these are the individuals we have had to return to perform a\\nresection on post-op day 3 or 4 because their sepsis does not\\nresolve. If you are operating emergently on an immunosuppressed\\npatient for any diverticular complication, the colon should be resected, so\\nif they are perforated, just go ahead and make an incision, clean them\\nout and resect the colon. If they are stable and the tissue looks healthy,\\nanastomose and divert. If they are not stable, bring out a colostomy.\\n\\n Like with ħinchey I and II patients I do not recommend resection\\nafter laparoscopic lavage unless these patients have persistent\\nsymptoms. A repeat attack of diverticulitis after having had a perforation\\nmakes me nervous, so I recommend elective resection to those patients\\nafter they have recovered from their recurrent attack. But very few\\npatients will go on to have repeat attacks of diverticulitis after the\\nlavage.',\n", " 'md': '```markdown\\n# Some Additional Perspective\\n\\nAs mentioned, purulent peritonitis is a rare complication and feculent peritonitis is even rarer. Our success in managing purulent peritonitis with laparoscopic washout and drainage has been very good in those patients without prior surgery. We almost always (90% of the time) complete the laparoscopic lavage and drain placement without converting. No patients have developed a fecal fistula and generally they leave the hospital on oral antibiotics after 3 to 5 days. This may be because of my ‘selection bias’. I identify these patients by CT scan: they have free air with some ascites that does not contain contrast. They also are not ill (defined above). Again, if I see contrast in the peritoneal cavity, I make an incision as I think these patients have feculent peritonitis and know I will have difficulty cleaning out the stool with the laparoscope.\\n\\nWith a large transplant program at my institution, I see many immunosuppressed patients with complicated diverticulitis, and it is in this patient population where I have not had much success with the laparoscopic lavage technique. The transplant patients often have other incisions and adhesions that interfere with the lavage; and I found that these are the individuals we have had to return to perform a resection on post-op day 3 or 4 because their sepsis does not resolve. If you are operating emergently on an immunosuppressed patient for any diverticular complication, the colon should be resected, so if they are perforated, just go ahead and make an incision, clean them out and resect the colon. If they are stable and the tissue looks healthy, anastomose and divert. If they are not stable, bring out a colostomy.\\n\\nLike with Hinchey I and II patients I do not recommend resection after laparoscopic lavage unless these patients have persistent symptoms. A repeat attack of diverticulitis after having had a perforation makes me nervous, so I recommend elective resection to those patients after they have recovered from their recurrent attack. But very few patients will go on to have repeat attacks of diverticulitis after the lavage.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Some Additional Perspective',\n", " 'md': '# Some Additional Perspective',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 224.37, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As mentioned, purulent peritonitis is a rare complication and feculent peritonitis is even rarer. Our success in managing purulent peritonitis with laparoscopic washout and drainage has been very good in those patients without prior surgery. We almost always (90% of the time) complete the laparoscopic lavage and drain placement without converting. No patients have developed a fecal fistula and generally they leave the hospital on oral antibiotics after 3 to 5 days. This may be because of my ‘selection bias’. I identify these patients by CT scan: they have free air with some ascites that does not contain contrast. They also are not ill (defined above). Again, if I see contrast in the peritoneal cavity, I make an incision as I think these patients have feculent peritonitis and know I will have difficulty cleaning out the stool with the laparoscope.\\n\\nWith a large transplant program at my institution, I see many immunosuppressed patients with complicated diverticulitis, and it is in this patient population where I have not had much success with the laparoscopic lavage technique. The transplant patients often have other incisions and adhesions that interfere with the lavage; and I found that these are the individuals we have had to return to perform a resection on post-op day 3 or 4 because their sepsis does not resolve. If you are operating emergently on an immunosuppressed patient for any diverticular complication, the colon should be resected, so if they are perforated, just go ahead and make an incision, clean them out and resect the colon. If they are stable and the tissue looks healthy, anastomose and divert. If they are not stable, bring out a colostomy.\\n\\nLike with Hinchey I and II patients I do not recommend resection after laparoscopic lavage unless these patients have persistent symptoms. A repeat attack of diverticulitis after having had a perforation makes me nervous, so I recommend elective resection to those patients after they have recovered from their recurrent attack. But very few patients will go on to have repeat attacks of diverticulitis after the lavage.\\n```',\n", " 'md': 'As mentioned, purulent peritonitis is a rare complication and feculent peritonitis is even rarer. Our success in managing purulent peritonitis with laparoscopic washout and drainage has been very good in those patients without prior surgery. We almost always (90% of the time) complete the laparoscopic lavage and drain placement without converting. No patients have developed a fecal fistula and generally they leave the hospital on oral antibiotics after 3 to 5 days. This may be because of my ‘selection bias’. I identify these patients by CT scan: they have free air with some ascites that does not contain contrast. They also are not ill (defined above). Again, if I see contrast in the peritoneal cavity, I make an incision as I think these patients have feculent peritonitis and know I will have difficulty cleaning out the stool with the laparoscope.\\n\\nWith a large transplant program at my institution, I see many immunosuppressed patients with complicated diverticulitis, and it is in this patient population where I have not had much success with the laparoscopic lavage technique. The transplant patients often have other incisions and adhesions that interfere with the lavage; and I found that these are the individuals we have had to return to perform a resection on post-op day 3 or 4 because their sepsis does not resolve. If you are operating emergently on an immunosuppressed patient for any diverticular complication, the colon should be resected, so if they are perforated, just go ahead and make an incision, clean them out and resect the colon. If they are stable and the tissue looks healthy, anastomose and divert. If they are not stable, bring out a colostomy.\\n\\nLike with Hinchey I and II patients I do not recommend resection after laparoscopic lavage unless these patients have persistent symptoms. A repeat attack of diverticulitis after having had a perforation makes me nervous, so I recommend elective resection to those patients after they have recovered from their recurrent attack. But very few patients will go on to have repeat attacks of diverticulitis after the lavage.\\n```',\n", " 'bBox': {'x': 72, 'y': 157, 'w': 467.91, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 503,\n", " 'text': ' Open resection\\n\\n Again, place the patient in the modified lithotomy position — this time\\nwith the arms out. I make a generous incision. If I am starting with an\\nopen approach it means the patient is sick and/or the inflammatory\\nmass is substantial. Either way I want to be efficient and safe and that\\nrequires a generous exposure.\\n\\n I initiate the mobilization of the colon in a clean, non-inflamed plane.\\nMobilize the colon along the white line of Toldt and identify the ureter.\\nOnce the ureter is identified you can now mobilize towards the phlegmon.\\nI always keep the ureter lateral (lateral to my hand) to the plane of\\ndissection and in that way know that the iliac vessels and ureter will\\nremain safe and unharmed.\\n\\n Often the inflammation is such that the inflammatory mass is fused to\\nthe bladder, uterus or left pelvic side wall. Using your fingers to\\nfracture the tissue and separate the mass from healthy tissue is not\\nonly extremely satisfying (albeit a bit rough on the tissues) but also\\nthe safest way to separate the phlegmon from other structures. I am\\nalways cognizant of the location of the ureter when performing this\\ndissection especially at the sacral promontory and around the pelvic side\\nwall. When it is a ‘complete mess’ at the pelvic inlet, I will often look\\nfor a clean virgin plane not affected by the inflammation — this I\\ncommonly find at the presacral space that may be accessed on the\\nright side of the rectum. Entering into the avascular presacral space will\\nallow you to proceed with the dissection safely, preventing injury to the\\nvital structures you are trying to protect.\\n\\n Once the colon is mobilized, I divide the mesentery. As described\\nabove, resect the diseased bowel proximally to healthy soft colon. Make\\nsure you resect all colon distal to the phlegmon as leaving distal\\nsigmoid significantly increases the risk of recurrent diverticulitis —\\nso divide the bowel distally at the rectosigmoid junction. Sometimes\\nthe colonic mesentery is severely inflamed and you are not required to\\nresect all the inflamed mesentery; however, the inflamed mesentery often\\nforeshortens the colon and I have found it necessary, especially in\\nobese patients, to mobilize the splenic flexure and perform a high',\n", " 'md': '```markdown\\n# Open Resection\\n\\nAgain, place the patient in the modified lithotomy position — this time with the arms out. I make a generous incision. If I am starting with an open approach it means the patient is sick and/or the inflammatory mass is substantial. Either way I want to be efficient and safe and that requires a generous exposure.\\n\\nI initiate the mobilization of the colon in a clean, non-inflamed plane. Mobilize the colon along the white line of Toldt and identify the ureter. Once the ureter is identified you can now mobilize towards the phlegmon. I always keep the ureter lateral (lateral to my hand) to the plane of dissection and in that way know that the iliac vessels and ureter will remain safe and unharmed.\\n\\nOften the inflammation is such that the inflammatory mass is fused to the bladder, uterus or left pelvic side wall. Using your fingers to fracture the tissue and separate the mass from healthy tissue is not only extremely satisfying (albeit a bit rough on the tissues) but also the safest way to separate the phlegmon from other structures. I am always cognizant of the location of the ureter when performing this dissection especially at the sacral promontory and around the pelvic side wall. When it is a ‘complete mess’ at the pelvic inlet, I will often look for a clean virgin plane not affected by the inflammation — this I commonly find at the presacral space that may be accessed on the right side of the rectum. Entering into the avascular presacral space will allow you to proceed with the dissection safely, preventing injury to the vital structures you are trying to protect.\\n\\nOnce the colon is mobilized, I divide the mesentery. As described above, resect the diseased bowel proximally to healthy soft colon. Make sure you resect all colon distal to the phlegmon as leaving distal sigmoid significantly increases the risk of recurrent diverticulitis — so divide the bowel distally at the rectosigmoid junction. Sometimes the colonic mesentery is severely inflamed and you are not required to resect all the inflamed mesentery; however, the inflamed mesentery often foreshortens the colon and I have found it necessary, especially in obese patients, to mobilize the splenic flexure and perform a high.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Open Resection',\n", " 'md': '# Open Resection',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 120.47, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Again, place the patient in the modified lithotomy position — this time with the arms out. I make a generous incision. If I am starting with an open approach it means the patient is sick and/or the inflammatory mass is substantial. Either way I want to be efficient and safe and that requires a generous exposure.\\n\\nI initiate the mobilization of the colon in a clean, non-inflamed plane. Mobilize the colon along the white line of Toldt and identify the ureter. Once the ureter is identified you can now mobilize towards the phlegmon. I always keep the ureter lateral (lateral to my hand) to the plane of dissection and in that way know that the iliac vessels and ureter will remain safe and unharmed.\\n\\nOften the inflammation is such that the inflammatory mass is fused to the bladder, uterus or left pelvic side wall. Using your fingers to fracture the tissue and separate the mass from healthy tissue is not only extremely satisfying (albeit a bit rough on the tissues) but also the safest way to separate the phlegmon from other structures. I am always cognizant of the location of the ureter when performing this dissection especially at the sacral promontory and around the pelvic side wall. When it is a ‘complete mess’ at the pelvic inlet, I will often look for a clean virgin plane not affected by the inflammation — this I commonly find at the presacral space that may be accessed on the right side of the rectum. Entering into the avascular presacral space will allow you to proceed with the dissection safely, preventing injury to the vital structures you are trying to protect.\\n\\nOnce the colon is mobilized, I divide the mesentery. As described above, resect the diseased bowel proximally to healthy soft colon. Make sure you resect all colon distal to the phlegmon as leaving distal sigmoid significantly increases the risk of recurrent diverticulitis — so divide the bowel distally at the rectosigmoid junction. Sometimes the colonic mesentery is severely inflamed and you are not required to resect all the inflamed mesentery; however, the inflamed mesentery often foreshortens the colon and I have found it necessary, especially in obese patients, to mobilize the splenic flexure and perform a high.\\n```',\n", " 'md': 'Again, place the patient in the modified lithotomy position — this time with the arms out. I make a generous incision. If I am starting with an open approach it means the patient is sick and/or the inflammatory mass is substantial. Either way I want to be efficient and safe and that requires a generous exposure.\\n\\nI initiate the mobilization of the colon in a clean, non-inflamed plane. Mobilize the colon along the white line of Toldt and identify the ureter. Once the ureter is identified you can now mobilize towards the phlegmon. I always keep the ureter lateral (lateral to my hand) to the plane of dissection and in that way know that the iliac vessels and ureter will remain safe and unharmed.\\n\\nOften the inflammation is such that the inflammatory mass is fused to the bladder, uterus or left pelvic side wall. Using your fingers to fracture the tissue and separate the mass from healthy tissue is not only extremely satisfying (albeit a bit rough on the tissues) but also the safest way to separate the phlegmon from other structures. I am always cognizant of the location of the ureter when performing this dissection especially at the sacral promontory and around the pelvic side wall. When it is a ‘complete mess’ at the pelvic inlet, I will often look for a clean virgin plane not affected by the inflammation — this I commonly find at the presacral space that may be accessed on the right side of the rectum. Entering into the avascular presacral space will allow you to proceed with the dissection safely, preventing injury to the vital structures you are trying to protect.\\n\\nOnce the colon is mobilized, I divide the mesentery. As described above, resect the diseased bowel proximally to healthy soft colon. Make sure you resect all colon distal to the phlegmon as leaving distal sigmoid significantly increases the risk of recurrent diverticulitis — so divide the bowel distally at the rectosigmoid junction. Sometimes the colonic mesentery is severely inflamed and you are not required to resect all the inflamed mesentery; however, the inflamed mesentery often foreshortens the colon and I have found it necessary, especially in obese patients, to mobilize the splenic flexure and perform a high.\\n```',\n", " 'bBox': {'x': 72, 'y': 124, 'w': 467.94, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 504,\n", " 'text': 'ligation of the inferior mesenteric artery to facilitate colostomy\\nformation.\\n\\n So at the end of the day most resected patients end up with a Hartmann’s procedure — that\\n means that you have closed the rectum at the level of the promontory. This we do mostly with a\\n linear stapler but occasionally — in an obese male patient with a narrow pelvis — you will find it\\n hard to manipulate the stapler. This is when your dormant hand-suturing skills will have to be\\n awakened. Don’t forget, however, that in desperate situations it is alright to leave the rectal\\n stump open, with a rectal tube or drain within it — it will function as a pelvic drain! This has been\\n shown by the great John Goligher of Leeds many years ago. Moshe\\n\\n Incidental finding of acute diverticulitis during operation\\n for an ‘acute abdomen’\\n\\n Say you find yourself operating on a patient for right-sided pain and\\nperitonitis that you think is acute appendicitis, or some other entity, and\\nend up finding a complicated diverticulitis such as a ħinchey II or III. This\\nis rare (unless you live somewhere where CT scans are not routinely\\nperformed), but not unheard of.\\n\\n So if you find yourself staring at the sigmoid colon looped over\\nand stuck to the right pelvic side wall or the cecum, then wash out\\nany pus (if it is a Hinchey III patient) or drain a large abscess if\\nfound. Leave drains and leave the colon; these patients will do quite well\\nand need no further therapy. ħopefully you are looking at this aberrant\\nright-sided inflamed sigmoid with a laparoscope. I find I feel better after\\nmaking a wrong diagnosis if the incisions are small. The same is true if\\nyou were intending to perform an open appendectomy: clean, drain and\\nget out. Treat with antibiotics and scope the colon later.\\n\\n If you find ‘only’ a sigmoid phlegmon — no pus, no nothing — then do nothing at all. Just close\\n up and continue i.v. antibiotics. I would then go to the changing room, look in the mirror and say:\\n “Stupid… why didn’t you CT this guy?” Then I would ponder how to ‘sell’ the news to the family\\n waiting outside. Moshe',\n", " 'md': '```markdown\\n## Ligation of the Inferior Mesenteric Artery\\n\\nLigation of the inferior mesenteric artery to facilitate colostomy formation.\\n\\nAt the end of the day, most resected patients end up with a Hartmann’s procedure — this means that you have closed the rectum at the level of the promontory. This is mostly done with a linear stapler, but occasionally — in an obese male patient with a narrow pelvis — you will find it hard to manipulate the stapler. This is when your dormant hand-suturing skills will have to be awakened. Don’t forget, however, that in desperate situations it is alright to leave the rectal stump open, with a rectal tube or drain within it — it will function as a pelvic drain! This has been shown by the great John Goligher of Leeds many years ago.\\n\\n### Incidental Finding of Acute Diverticulitis\\n\\nIncidental finding of acute diverticulitis during operation for an ‘acute abdomen’.\\n\\nSay you find yourself operating on a patient for right-sided pain and peritonitis that you think is acute appendicitis, or some other entity, and end up finding a complicated diverticulitis such as a Hinchey II or III. This is rare (unless you live somewhere where CT scans are not routinely performed), but not unheard of.\\n\\nIf you find yourself staring at the sigmoid colon looped over and stuck to the right pelvic side wall or the cecum, then wash out any pus (if it is a Hinchey III patient) or drain a large abscess if found. Leave drains and leave the colon; these patients will do quite well and need no further therapy. Hopefully, you are looking at this aberrant right-sided inflamed sigmoid with a laparoscope. I find I feel better after making a wrong diagnosis if the incisions are small. The same is true if you were intending to perform an open appendectomy: clean, drain, and get out. Treat with antibiotics and scope the colon later.\\n\\nIf you find ‘only’ a sigmoid phlegmon — no pus, no nothing — then do nothing at all. Just close up and continue i.v. antibiotics. I would then go to the changing room, look in the mirror and say: “Stupid… why didn’t you CT this guy?” Then I would ponder how to ‘sell’ the news to the family waiting outside.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Ligation of the Inferior Mesenteric Artery',\n", " 'md': '## Ligation of the Inferior Mesenteric Artery',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Ligation of the inferior mesenteric artery to facilitate colostomy formation.\\n\\nAt the end of the day, most resected patients end up with a Hartmann’s procedure — this means that you have closed the rectum at the level of the promontory. This is mostly done with a linear stapler, but occasionally — in an obese male patient with a narrow pelvis — you will find it hard to manipulate the stapler. This is when your dormant hand-suturing skills will have to be awakened. Don’t forget, however, that in desperate situations it is alright to leave the rectal stump open, with a rectal tube or drain within it — it will function as a pelvic drain! This has been shown by the great John Goligher of Leeds many years ago.',\n", " 'md': 'Ligation of the inferior mesenteric artery to facilitate colostomy formation.\\n\\nAt the end of the day, most resected patients end up with a Hartmann’s procedure — this means that you have closed the rectum at the level of the promontory. This is mostly done with a linear stapler, but occasionally — in an obese male patient with a narrow pelvis — you will find it hard to manipulate the stapler. This is when your dormant hand-suturing skills will have to be awakened. Don’t forget, however, that in desperate situations it is alright to leave the rectal stump open, with a rectal tube or drain within it — it will function as a pelvic drain! This has been shown by the great John Goligher of Leeds many years ago.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 457.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Incidental Finding of Acute Diverticulitis',\n", " 'md': '### Incidental Finding of Acute Diverticulitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Incidental finding of acute diverticulitis during operation for an ‘acute abdomen’.\\n\\nSay you find yourself operating on a patient for right-sided pain and peritonitis that you think is acute appendicitis, or some other entity, and end up finding a complicated diverticulitis such as a Hinchey II or III. This is rare (unless you live somewhere where CT scans are not routinely performed), but not unheard of.\\n\\nIf you find yourself staring at the sigmoid colon looped over and stuck to the right pelvic side wall or the cecum, then wash out any pus (if it is a Hinchey III patient) or drain a large abscess if found. Leave drains and leave the colon; these patients will do quite well and need no further therapy. Hopefully, you are looking at this aberrant right-sided inflamed sigmoid with a laparoscope. I find I feel better after making a wrong diagnosis if the incisions are small. The same is true if you were intending to perform an open appendectomy: clean, drain, and get out. Treat with antibiotics and scope the colon later.\\n\\nIf you find ‘only’ a sigmoid phlegmon — no pus, no nothing — then do nothing at all. Just close up and continue i.v. antibiotics. I would then go to the changing room, look in the mirror and say: “Stupid… why didn’t you CT this guy?” Then I would ponder how to ‘sell’ the news to the family waiting outside.\\n```',\n", " 'md': 'Incidental finding of acute diverticulitis during operation for an ‘acute abdomen’.\\n\\nSay you find yourself operating on a patient for right-sided pain and peritonitis that you think is acute appendicitis, or some other entity, and end up finding a complicated diverticulitis such as a Hinchey II or III. This is rare (unless you live somewhere where CT scans are not routinely performed), but not unheard of.\\n\\nIf you find yourself staring at the sigmoid colon looped over and stuck to the right pelvic side wall or the cecum, then wash out any pus (if it is a Hinchey III patient) or drain a large abscess if found. Leave drains and leave the colon; these patients will do quite well and need no further therapy. Hopefully, you are looking at this aberrant right-sided inflamed sigmoid with a laparoscope. I find I feel better after making a wrong diagnosis if the incisions are small. The same is true if you were intending to perform an open appendectomy: clean, drain, and get out. Treat with antibiotics and scope the colon later.\\n\\nIf you find ‘only’ a sigmoid phlegmon — no pus, no nothing — then do nothing at all. Just close up and continue i.v. antibiotics. I would then go to the changing room, look in the mirror and say: “Stupid… why didn’t you CT this guy?” Then I would ponder how to ‘sell’ the news to the family waiting outside.\\n```',\n", " 'bBox': {'x': 72, 'y': 311, 'w': 467.55, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 505,\n", " 'text': ' A few words about fistulas…\\n\\n The most common fistulas are either to the urinary bladder\\n(colovesical) or the vagina (colovaginal). In some cases the colon may\\nfistulate to the skin, the uterus, fallopian tubes, small intestine or even\\nanother segment of the colon. Such fistulas are usually evaluated and\\ntreated electively — with resection of the origin in the sigmoid colon.\\n\\n Occasionally, however, you may have to operate on patients with\\neither colovaginal or colovesical fistulas urgently. If a colovaginal\\nfistula forms immediately after an acute perforation, the patient will\\nexperience a sudden release of pus, blood, and stool from the vagina\\nthat, in most instances, stops quickly. ħowever, if the fistula is large and\\npersistent, stool continues draining from the vagina. If this is the case I\\nwill perform a laparoscopic loop ileostomy to divert the fecal flow. Let the\\nacute disease settle down and remove the offending colonic segment a\\nfew months later.\\n\\n Colovesical fistulas very rarely need an emergency procedure except\\nperhaps if developing in transplant patients (particularly kidney\\ntransplant) who develop persistent urosepsis. Early diversion or resection\\nmay be indicated to stop the flow of s**t into the bladder. In patients who\\nrespond initially to antibiotics I would keep them on maintenance\\nantibiotics for 6 to 8 weeks until the ‘elective’ operation.\\n\\n Other forms of acute diverticulitis\\n\\n Though sigmoid diverticulitis is so common in our daily practice,\\nother forms of diverticulitis should be kept in mind:\\n\\n • With the horrendous amount of junk food consumed by ‘western\\n societies’ we see a growing number of younger patients with colonic\\n pandiverticulosis extending from the rectosigmoid junction to the\\n ileocecal valve. Some of these present with acute diverticulitis in\\n the right or transverse colon, which may mimic acute cholecystitis\\n or acute appendicitis. The key to diagnosis here is an abdominal CT\\n scan finding of a localized colonic phlegmon. This avoids',\n", " 'md': '```markdown\\n# A Few Words About Fistulas\\n\\nThe most common fistulas are either to the urinary bladder (colovesical) or the vagina (colovaginal). In some cases, the colon may fistulate to the skin, the uterus, fallopian tubes, small intestine, or even another segment of the colon. Such fistulas are usually evaluated and treated electively — with resection of the origin in the sigmoid colon.\\n\\nOccasionally, however, you may have to operate on patients with either colovaginal or colovesical fistulas urgently. If a colovaginal fistula forms immediately after an acute perforation, the patient will experience a sudden release of pus, blood, and stool from the vagina that, in most instances, stops quickly. However, if the fistula is large and persistent, stool continues draining from the vagina. If this is the case, I will perform a laparoscopic loop ileostomy to divert the fecal flow. Let the acute disease settle down and remove the offending colonic segment a few months later.\\n\\nColovesical fistulas very rarely need an emergency procedure except perhaps if developing in transplant patients (particularly kidney transplant) who develop persistent urosepsis. Early diversion or resection may be indicated to stop the flow of waste into the bladder. In patients who respond initially to antibiotics, I would keep them on maintenance antibiotics for 6 to 8 weeks until the ‘elective’ operation.\\n\\n## Other Forms of Acute Diverticulitis\\n\\nThough sigmoid diverticulitis is so common in our daily practice, other forms of diverticulitis should be kept in mind:\\n\\n- With the horrendous amount of junk food consumed by ‘western societies’, we see a growing number of younger patients with colonic pandiverticulosis extending from the rectosigmoid junction to the ileocecal valve. Some of these present with acute diverticulitis in the right or transverse colon, which may mimic acute cholecystitis or acute appendicitis. The key to diagnosis here is an abdominal CT scan finding of a localized colonic phlegmon. This avoids...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'A Few Words About Fistulas',\n", " 'md': '# A Few Words About Fistulas',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The most common fistulas are either to the urinary bladder (colovesical) or the vagina (colovaginal). In some cases, the colon may fistulate to the skin, the uterus, fallopian tubes, small intestine, or even another segment of the colon. Such fistulas are usually evaluated and treated electively — with resection of the origin in the sigmoid colon.\\n\\nOccasionally, however, you may have to operate on patients with either colovaginal or colovesical fistulas urgently. If a colovaginal fistula forms immediately after an acute perforation, the patient will experience a sudden release of pus, blood, and stool from the vagina that, in most instances, stops quickly. However, if the fistula is large and persistent, stool continues draining from the vagina. If this is the case, I will perform a laparoscopic loop ileostomy to divert the fecal flow. Let the acute disease settle down and remove the offending colonic segment a few months later.\\n\\nColovesical fistulas very rarely need an emergency procedure except perhaps if developing in transplant patients (particularly kidney transplant) who develop persistent urosepsis. Early diversion or resection may be indicated to stop the flow of waste into the bladder. In patients who respond initially to antibiotics, I would keep them on maintenance antibiotics for 6 to 8 weeks until the ‘elective’ operation.',\n", " 'md': 'The most common fistulas are either to the urinary bladder (colovesical) or the vagina (colovaginal). In some cases, the colon may fistulate to the skin, the uterus, fallopian tubes, small intestine, or even another segment of the colon. Such fistulas are usually evaluated and treated electively — with resection of the origin in the sigmoid colon.\\n\\nOccasionally, however, you may have to operate on patients with either colovaginal or colovesical fistulas urgently. If a colovaginal fistula forms immediately after an acute perforation, the patient will experience a sudden release of pus, blood, and stool from the vagina that, in most instances, stops quickly. However, if the fistula is large and persistent, stool continues draining from the vagina. If this is the case, I will perform a laparoscopic loop ileostomy to divert the fecal flow. Let the acute disease settle down and remove the offending colonic segment a few months later.\\n\\nColovesical fistulas very rarely need an emergency procedure except perhaps if developing in transplant patients (particularly kidney transplant) who develop persistent urosepsis. Early diversion or resection may be indicated to stop the flow of waste into the bladder. In patients who respond initially to antibiotics, I would keep them on maintenance antibiotics for 6 to 8 weeks until the ‘elective’ operation.',\n", " 'bBox': {'x': 72, 'y': 190, 'w': 467.72, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Other Forms of Acute Diverticulitis',\n", " 'md': '## Other Forms of Acute Diverticulitis',\n", " 'bBox': {'x': 86, 'y': 519, 'w': 264.78, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Though sigmoid diverticulitis is so common in our daily practice, other forms of diverticulitis should be kept in mind:\\n\\n- With the horrendous amount of junk food consumed by ‘western societies’, we see a growing number of younger patients with colonic pandiverticulosis extending from the rectosigmoid junction to the ileocecal valve. Some of these present with acute diverticulitis in the right or transverse colon, which may mimic acute cholecystitis or acute appendicitis. The key to diagnosis here is an abdominal CT scan finding of a localized colonic phlegmon. This avoids...\\n```',\n", " 'md': 'Though sigmoid diverticulitis is so common in our daily practice, other forms of diverticulitis should be kept in mind:\\n\\n- With the horrendous amount of junk food consumed by ‘western societies’, we see a growing number of younger patients with colonic pandiverticulosis extending from the rectosigmoid junction to the ileocecal valve. Some of these present with acute diverticulitis in the right or transverse colon, which may mimic acute cholecystitis or acute appendicitis. The key to diagnosis here is an abdominal CT scan finding of a localized colonic phlegmon. This avoids...\\n```',\n", " 'bBox': {'x': 72, 'y': 555, 'w': 467.09, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 506,\n", " 'text': ' unnecessary operation and the temptation to proceed with colonic\\n resection when the vast majority would respond to conservative\\n treatment with antibiotics.\\n• ‘Solitary’ cecal diverticulitis. This is a different entity: young,\\n mostly male, patients with one or two diverticula in the cecum — in\\n the absence of diverticula distally. Once or twice a year you will see\\n a patient presenting with what you think to be ‘classical’ acute\\n appendicitis but at operation you’ll find a cecal inflammatory mass or\\n phlegmon of variable size. Free perforation and localized peritonitis\\n are uncommon. This misadventure will happen to you only if you\\n skip the CT, on which a good radiologist should be able to\\n distinguish cecal diverticulitis from acute appendicitis; if this is\\n the case, you can treat conservatively as these patients would\\n respond to antibiotics exactly like those with sigmoid diverticulitis.\\n And, of course, recurrent cecal diverticulitis has been reported in\\n conservatively treated patients. Many patients, however, come to\\n operation, either because CT is not done or its findings are mistaken\\n for acute appendicitis. What to do at operation depends on the\\n size of the process, ranging from diverticulectomy (place a linear\\n stapler across the base of the diverticulum — including healthy cecal\\n wall — and fire) to partial cecectomy (again, fire a stapler across\\n and be careful not to narrow the ileocecal junction). Occasionally,\\n when the diverticulum is situated just off the ileocecal valve it is\\n safer to excise and close the cecal hole by hand. Surgeons who are\\n not aware of this condition or cannot recognize it often get carried\\n away and perform a right hemicolectomy. But now you know that\\n they may not understand what they see (manual palpation helps…)\\n and have to convert.\\n• For the sake of completeness let us mention here that acute\\n diverticulitis very rarely affects patients with jejunal diverticulosis.\\n These patients present with systemic signs of inflammation as well\\n as with local peritoneal signs in the center of the abdomen. The key\\n to diagnosis and subsequent non-operative management and\\n treatment with antibiotics (usually successful) is a CT scan —\\n showing an inflammatory mass affecting a segment of the\\n jejunum and its mesentery. If forced to operate, all you have to do\\n is a segmental small bowel resection and anastomosis.\\n• Diverticular-associated colitis. I have only seen a few cases —',\n", " 'md': '```markdown\\n## Page Content\\n\\n- Unnecessary operation and the temptation to proceed with colonic resection when the vast majority would respond to conservative treatment with antibiotics.\\n- **‘Solitary’ cecal diverticulitis**: This is a different entity: young, mostly male, patients with one or two diverticula in the cecum — in the absence of diverticula distally. Once or twice a year you will see a patient presenting with what you think to be ‘classical’ acute appendicitis but at operation you’ll find a cecal inflammatory mass or phlegmon of variable size. Free perforation and localized peritonitis are uncommon. This misadventure will happen to you only if you skip the CT, on which a good radiologist should be able to distinguish cecal diverticulitis from acute appendicitis; if this is the case, you can treat conservatively as these patients would respond to antibiotics exactly like those with sigmoid diverticulitis. And, of course, recurrent cecal diverticulitis has been reported in conservatively treated patients. Many patients, however, come to operation, either because CT is not done or its findings are mistaken for acute appendicitis. What to do at operation depends on the size of the process, ranging from diverticulectomy (place a linear stapler across the base of the diverticulum — including healthy cecal wall — and fire) to partial cecectomy (again, fire a stapler across and be careful not to narrow the ileocecal junction). Occasionally, when the diverticulum is situated just off the ileocecal valve it is safer to excise and close the cecal hole by hand. Surgeons who are not aware of this condition or cannot recognize it often get carried away and perform a right hemicolectomy. But now you know that they may not understand what they see (manual palpation helps…) and have to convert.\\n- For the sake of completeness let us mention here that acute diverticulitis very rarely affects patients with jejunal diverticulosis. These patients present with systemic signs of inflammation as well as with local peritoneal signs in the center of the abdomen. The key to diagnosis and subsequent non-operative management and treatment with antibiotics (usually successful) is a CT scan — showing an inflammatory mass affecting a segment of the jejunum and its mesentery. If forced to operate, all you have to do is a segmental small bowel resection and anastomosis.\\n- Diverticular-associated colitis. I have only seen a few cases —\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Unnecessary operation and the temptation to proceed with colonic resection when the vast majority would respond to conservative treatment with antibiotics.\\n- **‘Solitary’ cecal diverticulitis**: This is a different entity: young, mostly male, patients with one or two diverticula in the cecum — in the absence of diverticula distally. Once or twice a year you will see a patient presenting with what you think to be ‘classical’ acute appendicitis but at operation you’ll find a cecal inflammatory mass or phlegmon of variable size. Free perforation and localized peritonitis are uncommon. This misadventure will happen to you only if you skip the CT, on which a good radiologist should be able to distinguish cecal diverticulitis from acute appendicitis; if this is the case, you can treat conservatively as these patients would respond to antibiotics exactly like those with sigmoid diverticulitis. And, of course, recurrent cecal diverticulitis has been reported in conservatively treated patients. Many patients, however, come to operation, either because CT is not done or its findings are mistaken for acute appendicitis. What to do at operation depends on the size of the process, ranging from diverticulectomy (place a linear stapler across the base of the diverticulum — including healthy cecal wall — and fire) to partial cecectomy (again, fire a stapler across and be careful not to narrow the ileocecal junction). Occasionally, when the diverticulum is situated just off the ileocecal valve it is safer to excise and close the cecal hole by hand. Surgeons who are not aware of this condition or cannot recognize it often get carried away and perform a right hemicolectomy. But now you know that they may not understand what they see (manual palpation helps…) and have to convert.\\n- For the sake of completeness let us mention here that acute diverticulitis very rarely affects patients with jejunal diverticulosis. These patients present with systemic signs of inflammation as well as with local peritoneal signs in the center of the abdomen. The key to diagnosis and subsequent non-operative management and treatment with antibiotics (usually successful) is a CT scan — showing an inflammatory mass affecting a segment of the jejunum and its mesentery. If forced to operate, all you have to do is a segmental small bowel resection and anastomosis.\\n- Diverticular-associated colitis. I have only seen a few cases —\\n\\n```',\n", " 'md': '- Unnecessary operation and the temptation to proceed with colonic resection when the vast majority would respond to conservative treatment with antibiotics.\\n- **‘Solitary’ cecal diverticulitis**: This is a different entity: young, mostly male, patients with one or two diverticula in the cecum — in the absence of diverticula distally. Once or twice a year you will see a patient presenting with what you think to be ‘classical’ acute appendicitis but at operation you’ll find a cecal inflammatory mass or phlegmon of variable size. Free perforation and localized peritonitis are uncommon. This misadventure will happen to you only if you skip the CT, on which a good radiologist should be able to distinguish cecal diverticulitis from acute appendicitis; if this is the case, you can treat conservatively as these patients would respond to antibiotics exactly like those with sigmoid diverticulitis. And, of course, recurrent cecal diverticulitis has been reported in conservatively treated patients. Many patients, however, come to operation, either because CT is not done or its findings are mistaken for acute appendicitis. What to do at operation depends on the size of the process, ranging from diverticulectomy (place a linear stapler across the base of the diverticulum — including healthy cecal wall — and fire) to partial cecectomy (again, fire a stapler across and be careful not to narrow the ileocecal junction). Occasionally, when the diverticulum is situated just off the ileocecal valve it is safer to excise and close the cecal hole by hand. Surgeons who are not aware of this condition or cannot recognize it often get carried away and perform a right hemicolectomy. But now you know that they may not understand what they see (manual palpation helps…) and have to convert.\\n- For the sake of completeness let us mention here that acute diverticulitis very rarely affects patients with jejunal diverticulosis. These patients present with systemic signs of inflammation as well as with local peritoneal signs in the center of the abdomen. The key to diagnosis and subsequent non-operative management and treatment with antibiotics (usually successful) is a CT scan — showing an inflammatory mass affecting a segment of the jejunum and its mesentery. If forced to operate, all you have to do is a segmental small bowel resection and anastomosis.\\n- Diverticular-associated colitis. I have only seen a few cases —\\n\\n```',\n", " 'bBox': {'x': 100, 'y': 119, 'w': 437.29, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 507,\n", " 'text': ' the etiology is unknown. This horrendous condition behaves exactly\\n like severe Crohn’s disease or ulcerative colitis. The patients may\\n have severe diarrhea and on CT have a badly inflamed colon,\\n usually extending from the rectum up to and even past the splenic\\n flexure. The mucosa, however, is normal and they have\\n diverticulosis in the inflamed colonic segments. Patients behave\\n like other colitis patients and can be sick and catabolic. They\\n may respond to empiric i.v. antibiotics, but the few I have cared for\\n have not responded well to medical therapy and have required\\n resection. The operation is a miserable experience as the mesentery\\n is as inflamed as Crohn’s mesentery, thickened, and difficult to\\n manage. Finding clear planes of dissection is also difficult. A formal\\n left colectomy is usually required and if things are bad, consider\\n getting a partner to help and, as with other difficult phlegmons, think\\n of performing a proximal diversion without resection to let the\\n inflammation resolve.\\n\\n Final thoughts\\n\\n Most patients with acute diverticulitis respond to conservative\\ntherapy; it is estimated that around one-fourth will experience a\\nrecurrence. Somewhat confusingly this is variably interpreted as either\\nconfirming the need for elective surgery or indicating that the majority of\\npatients do not require an operation. According to tradition, the second\\nattack has been considered an indication for an elective sigmoidectomy,\\nthis being particularly true in the younger patient. This approach too has\\nbeen recently questioned. Patients undergoing such elective sigmoid\\nresections do not fare symptomatically better compared to patients\\nwho have no surgery. In general it is the initial attack which tends to\\ncomplicate with free perforation, abscess formation or fistula. Recurrent\\nattacks tend to be relatively benign and to respond to medical\\ntreatment. The reasonable approach is to individualize the management.\\nThere will be a few in need of a sigmoid resection for persisting\\nsymptoms of fibrotic stenosis or complicating fistula but the large majority\\nwould not benefit from elective surgery.\\n\\n Looking at the ‘whole picture’ it appears that we operate too early in acute diverticulitis, perform',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nThe etiology is unknown. This horrendous condition behaves exactly like severe Crohn’s disease or ulcerative colitis. The patients may have severe diarrhea and on CT have a badly inflamed colon, usually extending from the rectum up to and even past the splenic flexure. The mucosa, however, is normal and they have diverticulosis in the inflamed colonic segments. Patients behave like other colitis patients and can be sick and catabolic. They may respond to empiric i.v. antibiotics, but the few I have cared for have not responded well to medical therapy and have required resection. The operation is a miserable experience as the mesentery is as inflamed as Crohn’s mesentery, thickened, and difficult to manage. Finding clear planes of dissection is also difficult. A formal left colectomy is usually required and if things are bad, consider getting a partner to help and, as with other difficult phlegmons, think of performing a proximal diversion without resection to let the inflammation resolve.\\n\\n### Final Thoughts\\n\\nMost patients with acute diverticulitis respond to conservative therapy; it is estimated that around one-fourth will experience a recurrence. Somewhat confusingly this is variably interpreted as either confirming the need for elective surgery or indicating that the majority of patients do not require an operation. According to tradition, the second attack has been considered an indication for an elective sigmoidectomy, this being particularly true in the younger patient. This approach too has been recently questioned. Patients undergoing such elective sigmoid resections do not fare symptomatically better compared to patients who have no surgery. In general it is the initial attack which tends to complicate with free perforation, abscess formation or fistula. Recurrent attacks tend to be relatively benign and to respond to medical treatment. The reasonable approach is to individualize the management. There will be a few in need of a sigmoid resection for persisting symptoms of fibrotic stenosis or complicating fistula but the large majority would not benefit from elective surgery.\\n\\nLooking at the ‘whole picture’ it appears that we operate too early in acute diverticulitis, perform...\\n```\\n\\n### Image Identification and Description\\n\\n- **Figure 1**: No images or graphs were identified on this page.\\n\\n### Summary\\n\\nThe text discusses the clinical presentation and management of acute diverticulitis, emphasizing the challenges in diagnosis and treatment. It highlights the variability in patient responses to conservative therapy and the implications of recurrent attacks on surgical decisions. The final thoughts suggest a need for individualized management strategies rather than a one-size-fits-all approach to surgery.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The etiology is unknown. This horrendous condition behaves exactly like severe Crohn’s disease or ulcerative colitis. The patients may have severe diarrhea and on CT have a badly inflamed colon, usually extending from the rectum up to and even past the splenic flexure. The mucosa, however, is normal and they have diverticulosis in the inflamed colonic segments. Patients behave like other colitis patients and can be sick and catabolic. They may respond to empiric i.v. antibiotics, but the few I have cared for have not responded well to medical therapy and have required resection. The operation is a miserable experience as the mesentery is as inflamed as Crohn’s mesentery, thickened, and difficult to manage. Finding clear planes of dissection is also difficult. A formal left colectomy is usually required and if things are bad, consider getting a partner to help and, as with other difficult phlegmons, think of performing a proximal diversion without resection to let the inflammation resolve.',\n", " 'md': 'The etiology is unknown. This horrendous condition behaves exactly like severe Crohn’s disease or ulcerative colitis. The patients may have severe diarrhea and on CT have a badly inflamed colon, usually extending from the rectum up to and even past the splenic flexure. The mucosa, however, is normal and they have diverticulosis in the inflamed colonic segments. Patients behave like other colitis patients and can be sick and catabolic. They may respond to empiric i.v. antibiotics, but the few I have cared for have not responded well to medical therapy and have required resection. The operation is a miserable experience as the mesentery is as inflamed as Crohn’s mesentery, thickened, and difficult to manage. Finding clear planes of dissection is also difficult. A formal left colectomy is usually required and if things are bad, consider getting a partner to help and, as with other difficult phlegmons, think of performing a proximal diversion without resection to let the inflammation resolve.',\n", " 'bBox': {'x': 100, 'y': 86, 'w': 437.57, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Final Thoughts',\n", " 'md': '### Final Thoughts',\n", " 'bBox': {'x': 86, 'y': 379, 'w': 114, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Most patients with acute diverticulitis respond to conservative therapy; it is estimated that around one-fourth will experience a recurrence. Somewhat confusingly this is variably interpreted as either confirming the need for elective surgery or indicating that the majority of patients do not require an operation. According to tradition, the second attack has been considered an indication for an elective sigmoidectomy, this being particularly true in the younger patient. This approach too has been recently questioned. Patients undergoing such elective sigmoid resections do not fare symptomatically better compared to patients who have no surgery. In general it is the initial attack which tends to complicate with free perforation, abscess formation or fistula. Recurrent attacks tend to be relatively benign and to respond to medical treatment. The reasonable approach is to individualize the management. There will be a few in need of a sigmoid resection for persisting symptoms of fibrotic stenosis or complicating fistula but the large majority would not benefit from elective surgery.\\n\\nLooking at the ‘whole picture’ it appears that we operate too early in acute diverticulitis, perform...\\n```',\n", " 'md': 'Most patients with acute diverticulitis respond to conservative therapy; it is estimated that around one-fourth will experience a recurrence. Somewhat confusingly this is variably interpreted as either confirming the need for elective surgery or indicating that the majority of patients do not require an operation. According to tradition, the second attack has been considered an indication for an elective sigmoidectomy, this being particularly true in the younger patient. This approach too has been recently questioned. Patients undergoing such elective sigmoid resections do not fare symptomatically better compared to patients who have no surgery. In general it is the initial attack which tends to complicate with free perforation, abscess formation or fistula. Recurrent attacks tend to be relatively benign and to respond to medical treatment. The reasonable approach is to individualize the management. There will be a few in need of a sigmoid resection for persisting symptoms of fibrotic stenosis or complicating fistula but the large majority would not benefit from elective surgery.\\n\\nLooking at the ‘whole picture’ it appears that we operate too early in acute diverticulitis, perform...\\n```',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.98, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 426, 'y': 152, 'w': 28, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: No images or graphs were identified on this page.',\n", " 'md': '- **Figure 1**: No images or graphs were identified on this page.',\n", " 'bBox': {'x': 342, 'y': 152, 'w': 14.4, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the clinical presentation and management of acute diverticulitis, emphasizing the challenges in diagnosis and treatment. It highlights the variability in patient responses to conservative therapy and the implications of recurrent attacks on surgical decisions. The final thoughts suggest a need for individualized management strategies rather than a one-size-fits-all approach to surgery.',\n", " 'md': 'The text discusses the clinical presentation and management of acute diverticulitis, emphasizing the challenges in diagnosis and treatment. It highlights the variability in patient responses to conservative therapy and the implications of recurrent attacks on surgical decisions. The final thoughts suggest a need for individualized management strategies rather than a one-size-fits-all approach to surgery.',\n", " 'bBox': {'x': 86, 'y': 152, 'w': 114, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 508,\n", " 'text': ' too many CTs, carry out too many PC drainage procedures, remove too many colons, raise too\\n many colostomies, reoperate electively on too many patients, treat too many with antibiotics,\\n and perform too few randomized controlled trials in order to know what is right and what is\\n wrong.\\n\\n Figure 28.2 will remind you that intestinal diverticula affect all of us;\\nthey may produce complications but most can be treated without an\\noperation. But if you need to operate you have to select the correct\\nprocedure to fit the patient (Figure 28.3). In the heart of Africa you will\\nrarely see a case of acute diverticulitis: people there do not yet eat the\\njunk that we do.\\n\\n Figure 28.2. “Which of these do we have to remove?”',\n", " 'md': '```markdown\\n## Page Content\\n\\nToo many CTs, carry out too many PC drainage procedures, remove too many colons, raise too many colostomies, reoperate electively on too many patients, treat too many with antibiotics, and perform too few randomized controlled trials in order to know what is right and what is wrong.\\n\\n### Figure 28.2\\n**Caption:** “Which of these do we have to remove?”\\n**Description:** This figure likely presents a visual representation related to intestinal diverticula, possibly showing various types of diverticula or related complications. The content suggests that it addresses the question of which diverticula may require surgical removal.\\n**Summary:** The figure emphasizes the prevalence of intestinal diverticula and the importance of understanding which cases necessitate surgical intervention.\\n\\n### Figure 28.3\\n**Description:** This figure is referenced but not described in detail. It likely illustrates the correct surgical procedure for treating diverticulitis or related conditions, emphasizing the need for appropriate selection based on patient circumstances.\\n```',\n", " 'images': [{'name': 'img_p507_1.png',\n", " 'height': 515,\n", " 'width': 805,\n", " 'x': 107.27999999999884,\n", " 'y': 285.84000000000003,\n", " 'original_width': 1383,\n", " 'original_height': 886}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Too many CTs, carry out too many PC drainage procedures, remove too many colons, raise too many colostomies, reoperate electively on too many patients, treat too many with antibiotics, and perform too few randomized controlled trials in order to know what is right and what is wrong.',\n", " 'md': 'Too many CTs, carry out too many PC drainage procedures, remove too many colons, raise too many colostomies, reoperate electively on too many patients, treat too many with antibiotics, and perform too few randomized controlled trials in order to know what is right and what is wrong.',\n", " 'bBox': {'x': 79, 'y': 87, 'w': 453.39, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 28.2',\n", " 'md': '### Figure 28.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** “Which of these do we have to remove?”\\n**Description:** This figure likely presents a visual representation related to intestinal diverticula, possibly showing various types of diverticula or related complications. The content suggests that it addresses the question of which diverticula may require surgical removal.\\n**Summary:** The figure emphasizes the prevalence of intestinal diverticula and the importance of understanding which cases necessitate surgical intervention.',\n", " 'md': '**Caption:** “Which of these do we have to remove?”\\n**Description:** This figure likely presents a visual representation related to intestinal diverticula, possibly showing various types of diverticula or related complications. The content suggests that it addresses the question of which diverticula may require surgical removal.\\n**Summary:** The figure emphasizes the prevalence of intestinal diverticula and the importance of understanding which cases necessitate surgical intervention.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 28.3',\n", " 'md': '### Figure 28.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure is referenced but not described in detail. It likely illustrates the correct surgical procedure for treating diverticulitis or related conditions, emphasizing the need for appropriate selection based on patient circumstances.\\n```',\n", " 'md': '**Description:** This figure is referenced but not described in detail. It likely illustrates the correct surgical procedure for treating diverticulitis or related conditions, emphasizing the need for appropriate selection based on patient circumstances.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'they may produce complications but most can be treated without an'},\n", " {'text': 'rarely see a case of acute diverticulitis: people there do not yet eat the'}]},\n", " {'page': 509,\n", " 'text': ' 08\\n 71\\nFigure 28.3. Chief surgeon thinks: “Hartmann’s…” First assistant thinks: “Resection and\\nanastomosis...” Second assistant thinks: “They should have done laparoscopic\\nperitoneal lavage…” Medical student (the one with big glasses): “Why didn’t you get a\\nCT? This would have responded to antibiotics…”\\n\\n Figure 28.4 will prove that my life is not entirely spent between the\\nileocecal valve and 2cm below the dentate line!',\n", " 'md': '```markdown\\n## Page 8\\n\\n### Text\\nFigure 28.3. Chief surgeon thinks: “Hartmann’s…” First assistant thinks: “Resection and anastomosis...” Second assistant thinks: “They should have done laparoscopic peritoneal lavage…” Medical student (the one with big glasses): “Why didn’t you get a CT? This would have responded to antibiotics…”\\n\\nFigure 28.4 will prove that my life is not entirely spent between the ileocecal valve and 2cm below the dentate line!\\n\\n### Images and Graphs\\n- **Figure 28.3**: This image likely depicts a thought bubble or a comic-style illustration showing the thoughts of various medical professionals during a surgical procedure. The chief surgeon, first assistant, second assistant, and a medical student are represented, each with their respective thoughts about the situation. The image captures the diverse perspectives and considerations in a surgical context.\\n\\n- **Figure 28.4**: This image seems to relate to the statement about the ileocecal valve and the dentate line, possibly illustrating a surgical or anatomical concept. The exact content is not identifiable from the text provided, hence flagged as .\\n\\n### Summary\\nThe page contains two figures that reflect on surgical thoughts and experiences. Figure 28.3 illustrates the internal dialogue of medical professionals during a procedure, while Figure 28.4 hints at a broader context of surgical practice, though its specific content is not clear.\\n```',\n", " 'images': [{'name': 'img_p508_1.png',\n", " 'height': 581,\n", " 'width': 815,\n", " 'x': 104.39999999999964,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1401,\n", " 'original_height': 997}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page 8',\n", " 'md': '## Page 8',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 28.3. Chief surgeon thinks: “Hartmann’s…” First assistant thinks: “Resection and anastomosis...” Second assistant thinks: “They should have done laparoscopic peritoneal lavage…” Medical student (the one with big glasses): “Why didn’t you get a CT? This would have responded to antibiotics…”\\n\\nFigure 28.4 will prove that my life is not entirely spent between the ileocecal valve and 2cm below the dentate line!',\n", " 'md': 'Figure 28.3. Chief surgeon thinks: “Hartmann’s…” First assistant thinks: “Resection and anastomosis...” Second assistant thinks: “They should have done laparoscopic peritoneal lavage…” Medical student (the one with big glasses): “Why didn’t you get a CT? This would have responded to antibiotics…”\\n\\nFigure 28.4 will prove that my life is not entirely spent between the ileocecal valve and 2cm below the dentate line!',\n", " 'bBox': {'x': 72, 'y': 390, 'w': 463.48, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Images and Graphs',\n", " 'md': '### Images and Graphs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 28.3**: This image likely depicts a thought bubble or a comic-style illustration showing the thoughts of various medical professionals during a surgical procedure. The chief surgeon, first assistant, second assistant, and a medical student are represented, each with their respective thoughts about the situation. The image captures the diverse perspectives and considerations in a surgical context.\\n\\n- **Figure 28.4**: This image seems to relate to the statement about the ileocecal valve and the dentate line, possibly illustrating a surgical or anatomical concept. The exact content is not identifiable from the text provided, hence flagged as .',\n", " 'md': '- **Figure 28.3**: This image likely depicts a thought bubble or a comic-style illustration showing the thoughts of various medical professionals during a surgical procedure. The chief surgeon, first assistant, second assistant, and a medical student are represented, each with their respective thoughts about the situation. The image captures the diverse perspectives and considerations in a surgical context.\\n\\n- **Figure 28.4**: This image seems to relate to the statement about the ileocecal valve and the dentate line, possibly illustrating a surgical or anatomical concept. The exact content is not identifiable from the text provided, hence flagged as .',\n", " 'bBox': {'x': 165, 'y': 402, 'w': 46.75, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The page contains two figures that reflect on surgical thoughts and experiences. Figure 28.3 illustrates the internal dialogue of medical professionals during a procedure, while Figure 28.4 hints at a broader context of surgical practice, though its specific content is not clear.\\n```',\n", " 'md': 'The page contains two figures that reflect on surgical thoughts and experiences. Figure 28.3 illustrates the internal dialogue of medical professionals during a procedure, while Figure 28.4 hints at a broader context of surgical practice, though its specific content is not clear.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'ileocecal valve and 2cm below the dentate line!'}]},\n", " {'page': 510,\n", " 'text': ' n Dieao@\\n Figure 28.4. The author away from the colon and rectum.\\n\\n1 Dr. P. O. Nyström contributed to this chapter in the previous editions of this book.\\n2 Acute Physiology and Chronic Health Evaluation (APACHE II).',\n", " 'md': \"```markdown\\n# Page Content\\n\\n- Dr. P. O. Nyström contributed to this chapter in the previous editions of this book.\\n- Acute Physiology and Chronic Health Evaluation (APACHE II).\\n\\n## Images and Figures\\n\\n### Figure 28.4\\n- Description: The image depicts the anatomical location of the colon and rectum, illustrating the author's position away from these structures.\\n- Summary: This figure provides a visual representation of the anatomical relationship between the author and the colon and rectum.\\n\\n```\",\n", " 'images': [{'name': 'img_p509_1.png',\n", " 'height': 559,\n", " 'width': 473,\n", " 'x': 189.35999999999876,\n", " 'y': 82.79999999999995,\n", " 'original_width': 812,\n", " 'original_height': 960}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Dr. P. O. Nyström contributed to this chapter in the previous editions of this book.\\n- Acute Physiology and Chronic Health Evaluation (APACHE II).',\n", " 'md': '- Dr. P. O. Nyström contributed to this chapter in the previous editions of this book.\\n- Acute Physiology and Chronic Health Evaluation (APACHE II).',\n", " 'bBox': {'x': 97, 'y': 450, 'w': 384.59, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images and Figures',\n", " 'md': '## Images and Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 28.4',\n", " 'md': '### Figure 28.4',\n", " 'bBox': {'x': 73, 'y': 464, 'w': 4.8, 'h': 8.64}},\n", " {'type': 'text',\n", " 'value': \"- Description: The image depicts the anatomical location of the colon and rectum, illustrating the author's position away from these structures.\\n- Summary: This figure provides a visual representation of the anatomical relationship between the author and the colon and rectum.\\n\\n```\",\n", " 'md': \"- Description: The image depicts the anatomical location of the colon and rectum, illustrating the author's position away from these structures.\\n- Summary: This figure provides a visual representation of the anatomical relationship between the author and the colon and rectum.\\n\\n```\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}, {'text': '2'}]},\n", " {'page': 511,\n", " 'text': 'Chapter 29\\nMassive lower GI bleeding\\nJonathan E. Efron\\n\\n The only weapon with which the unconscious patient can\\n immediately retaliate on the incompetent surgeon is\\n hemorrhage.\\n William Stewart Halsted\\n\\n Bleeding in the belly is like fire on a ship — you run towards\\n it.\\n Jeffery Young\\n\\n I define massive lower gastrointestinal bleeding as any bleeding\\nthat originates distal to the ligament of Treitz and causes significant\\nbright red blood to flow from the anus. Massive implies ‘a lot of\\nbleeding’ so these patients often present with hemodynamic instability.\\nGenerally speaking we categorize these patients as having a\\nmassive bleed if they require transfusion of more than four units of\\nblood within 24 hours. ħowever, definitions vary from author to author\\n— some would talk about six units and others would include even a low\\nhemoglobin level. But we know what is ‘massive’ or not. Don’t we?\\n\\n The key to managing lower gastrointestinal hemorrhage is recognizing\\nthe degree of the bleeding and isolating its source. Precisely localizing\\nthe source of bleeding is essential, but at times can be frustrating as\\nbleeding tends to start and stop randomly.',\n", " 'md': '```markdown\\n# Chapter 29\\n## Massive Lower GI Bleeding\\n### Jonathan E. Efron\\n\\n> \"The only weapon with which the unconscious patient can immediately retaliate on the incompetent surgeon is hemorrhage.\"\\n> — William Stewart Halsted\\n\\n> \"Bleeding in the belly is like fire on a ship — you run towards it.\"\\n> — Jeffery Young\\n\\nI define massive lower gastrointestinal bleeding as any bleeding that originates distal to the ligament of Treitz and causes significant bright red blood to flow from the anus. Massive implies ‘a lot of bleeding’ so these patients often present with hemodynamic instability. Generally speaking, we categorize these patients as having a massive bleed if they require transfusion of more than four units of blood within 24 hours. However, definitions vary from author to author — some would talk about six units and others would include even a low hemoglobin level. But we know what is ‘massive’ or not. Don’t we?\\n\\nThe key to managing lower gastrointestinal hemorrhage is recognizing the degree of the bleeding and isolating its source. Precisely localizing the source of bleeding is essential, but at times can be frustrating as bleeding tends to start and stop randomly.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 29',\n", " 'md': '# Chapter 29',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 148.79, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Massive Lower GI Bleeding',\n", " 'md': '## Massive Lower GI Bleeding',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 236.29, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Jonathan E. Efron',\n", " 'md': '### Jonathan E. Efron',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 115.15, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '> \"The only weapon with which the unconscious patient can immediately retaliate on the incompetent surgeon is hemorrhage.\"\\n> — William Stewart Halsted\\n\\n> \"Bleeding in the belly is like fire on a ship — you run towards it.\"\\n> — Jeffery Young\\n\\nI define massive lower gastrointestinal bleeding as any bleeding that originates distal to the ligament of Treitz and causes significant bright red blood to flow from the anus. Massive implies ‘a lot of bleeding’ so these patients often present with hemodynamic instability. Generally speaking, we categorize these patients as having a massive bleed if they require transfusion of more than four units of blood within 24 hours. However, definitions vary from author to author — some would talk about six units and others would include even a low hemoglobin level. But we know what is ‘massive’ or not. Don’t we?\\n\\nThe key to managing lower gastrointestinal hemorrhage is recognizing the degree of the bleeding and isolating its source. Precisely localizing the source of bleeding is essential, but at times can be frustrating as bleeding tends to start and stop randomly.\\n```',\n", " 'md': '> \"The only weapon with which the unconscious patient can immediately retaliate on the incompetent surgeon is hemorrhage.\"\\n> — William Stewart Halsted\\n\\n> \"Bleeding in the belly is like fire on a ship — you run towards it.\"\\n> — Jeffery Young\\n\\nI define massive lower gastrointestinal bleeding as any bleeding that originates distal to the ligament of Treitz and causes significant bright red blood to flow from the anus. Massive implies ‘a lot of bleeding’ so these patients often present with hemodynamic instability. Generally speaking, we categorize these patients as having a massive bleed if they require transfusion of more than four units of blood within 24 hours. However, definitions vary from author to author — some would talk about six units and others would include even a low hemoglobin level. But we know what is ‘massive’ or not. Don’t we?\\n\\nThe key to managing lower gastrointestinal hemorrhage is recognizing the degree of the bleeding and isolating its source. Precisely localizing the source of bleeding is essential, but at times can be frustrating as bleeding tends to start and stop randomly.\\n```',\n", " 'bBox': {'x': 72, 'y': 342, 'w': 467.95, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 512,\n", " 'text': ' Fortunately, truly massive bleeding from the colon and rectum is\\nunusual. The vast majority of episodes of lower gastrointestinal bleeding\\n(LGIB) are self-limiting and not hemodynamically significant — I won’t\\ndiscuss this entity further. ħowever, as with all types of gastrointestinal\\nbleeding, never neglect it or think it trivial until a period of vigilant\\nobservation tells you whether the bleeding is minor or major, whether it is\\nlikely to have ceased or is protracted.\\n\\n In this section I shall review the initial approach to, and management\\nof, the massively bleeding patient, offering the most sensible approaches\\nto diagnosing the location, and the best method of treatment.\\n\\n Initial presentation — what to do in the emergency room?\\n\\n Patients who present with large amounts of blood from the anus are\\nusually unstable and should be treated like a trauma patient, meaning\\nthat on entering the emergency room they are given priority. We begin\\nwith the ABCs of resuscitation — you know all of this and don’t want me\\nto elaborate… While placing IVs, blood should be drawn for laboratory\\nevaluation and the patient should be typed and crossed for blood\\nproducts. If the patient remains hypotensive after initial fluid resuscitation\\nand is continuing to pour blood from the anus, you should start\\ntransfusing him.\\n\\n While efforts are being made to stabilize the patient, it is\\nimportant to confirm this is truly a LGIB and not an upper GI (UGI)\\none; in about a third of patients the alleged LGIB represents bleeding\\noriginating from an upper GI source ( Figure 29.1). The easiest way of\\ndoing this is to insert a nasogastric tube: if there is evidence of active\\n(fresh blood) or recent (old blood) bleeding, then proceed with UGI\\nendoscopy as detailed in Chapter 17. If clear bile is aspirated I am\\nthen fairly confident that the source of bleeding is distal to the\\nligament of Treitz. If neither bile nor blood is seen, I start with upper\\nGI endoscopy — to exclude a bleeding duodenal ulcer with a\\nspastic pylorus. Often I must persuade the gastroenterologists that it is\\nnecessary given the patient is bleeding per rectum. But blood is an\\nexcellent cathartic, especially large volumes of blood, so it is quite\\npossible for the patient with a bleeding duodenal ulcer to present with',\n", " 'md': '```markdown\\n# Management of Massive Lower Gastrointestinal Bleeding\\n\\nFortunately, truly massive bleeding from the colon and rectum is unusual. The vast majority of episodes of lower gastrointestinal bleeding (LGIB) are self-limiting and not hemodynamically significant — I won’t discuss this entity further. However, as with all types of gastrointestinal bleeding, never neglect it or think it trivial until a period of vigilant observation tells you whether the bleeding is minor or major, whether it is likely to have ceased or is protracted.\\n\\nIn this section, I shall review the initial approach to, and management of, the massively bleeding patient, offering the most sensible approaches to diagnosing the location, and the best method of treatment.\\n\\n## Initial Presentation — What to Do in the Emergency Room?\\n\\nPatients who present with large amounts of blood from the anus are usually unstable and should be treated like a trauma patient, meaning that on entering the emergency room they are given priority. We begin with the ABCs of resuscitation — you know all of this and don’t want me to elaborate… While placing IVs, blood should be drawn for laboratory evaluation and the patient should be typed and crossed for blood products. If the patient remains hypotensive after initial fluid resuscitation and is continuing to pour blood from the anus, you should start transfusing him.\\n\\nWhile efforts are being made to stabilize the patient, it is important to confirm this is truly a LGIB and not an upper GI (UGI) one; in about a third of patients the alleged LGIB represents bleeding originating from an upper GI source (Figure 29.1). The easiest way of doing this is to insert a nasogastric tube: if there is evidence of active (fresh blood) or recent (old blood) bleeding, then proceed with UGI endoscopy as detailed in Chapter 17. If clear bile is aspirated I am then fairly confident that the source of bleeding is distal to the ligament of Treitz. If neither bile nor blood is seen, I start with upper GI endoscopy — to exclude a bleeding duodenal ulcer with a spastic pylorus. Often I must persuade the gastroenterologists that it is necessary given the patient is bleeding per rectum. But blood is an excellent cathartic, especially large volumes of blood, so it is quite possible for the patient with a bleeding duodenal ulcer to present with...\\n```\\n\\n### Figure 29.1\\n- **Description**: This figure likely illustrates the distinction between lower gastrointestinal bleeding (LGIB) and upper gastrointestinal bleeding (UGI). It may include a flowchart or diagram that helps in identifying the source of bleeding based on clinical signs or diagnostic procedures.\\n- **Summary**: The figure serves as a visual aid to assist healthcare professionals in determining the origin of gastrointestinal bleeding, emphasizing the importance of accurate diagnosis in emergency situations.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management of Massive Lower Gastrointestinal Bleeding',\n", " 'md': '# Management of Massive Lower Gastrointestinal Bleeding',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Fortunately, truly massive bleeding from the colon and rectum is unusual. The vast majority of episodes of lower gastrointestinal bleeding (LGIB) are self-limiting and not hemodynamically significant — I won’t discuss this entity further. However, as with all types of gastrointestinal bleeding, never neglect it or think it trivial until a period of vigilant observation tells you whether the bleeding is minor or major, whether it is likely to have ceased or is protracted.\\n\\nIn this section, I shall review the initial approach to, and management of, the massively bleeding patient, offering the most sensible approaches to diagnosing the location, and the best method of treatment.',\n", " 'md': 'Fortunately, truly massive bleeding from the colon and rectum is unusual. The vast majority of episodes of lower gastrointestinal bleeding (LGIB) are self-limiting and not hemodynamically significant — I won’t discuss this entity further. However, as with all types of gastrointestinal bleeding, never neglect it or think it trivial until a period of vigilant observation tells you whether the bleeding is minor or major, whether it is likely to have ceased or is protracted.\\n\\nIn this section, I shall review the initial approach to, and management of, the massively bleeding patient, offering the most sensible approaches to diagnosing the location, and the best method of treatment.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Initial Presentation — What to Do in the Emergency Room?',\n", " 'md': '## Initial Presentation — What to Do in the Emergency Room?',\n", " 'bBox': {'x': 86, 'y': 296, 'w': 452.34, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Patients who present with large amounts of blood from the anus are usually unstable and should be treated like a trauma patient, meaning that on entering the emergency room they are given priority. We begin with the ABCs of resuscitation — you know all of this and don’t want me to elaborate… While placing IVs, blood should be drawn for laboratory evaluation and the patient should be typed and crossed for blood products. If the patient remains hypotensive after initial fluid resuscitation and is continuing to pour blood from the anus, you should start transfusing him.\\n\\nWhile efforts are being made to stabilize the patient, it is important to confirm this is truly a LGIB and not an upper GI (UGI) one; in about a third of patients the alleged LGIB represents bleeding originating from an upper GI source (Figure 29.1). The easiest way of doing this is to insert a nasogastric tube: if there is evidence of active (fresh blood) or recent (old blood) bleeding, then proceed with UGI endoscopy as detailed in Chapter 17. If clear bile is aspirated I am then fairly confident that the source of bleeding is distal to the ligament of Treitz. If neither bile nor blood is seen, I start with upper GI endoscopy — to exclude a bleeding duodenal ulcer with a spastic pylorus. Often I must persuade the gastroenterologists that it is necessary given the patient is bleeding per rectum. But blood is an excellent cathartic, especially large volumes of blood, so it is quite possible for the patient with a bleeding duodenal ulcer to present with...\\n```',\n", " 'md': 'Patients who present with large amounts of blood from the anus are usually unstable and should be treated like a trauma patient, meaning that on entering the emergency room they are given priority. We begin with the ABCs of resuscitation — you know all of this and don’t want me to elaborate… While placing IVs, blood should be drawn for laboratory evaluation and the patient should be typed and crossed for blood products. If the patient remains hypotensive after initial fluid resuscitation and is continuing to pour blood from the anus, you should start transfusing him.\\n\\nWhile efforts are being made to stabilize the patient, it is important to confirm this is truly a LGIB and not an upper GI (UGI) one; in about a third of patients the alleged LGIB represents bleeding originating from an upper GI source (Figure 29.1). The easiest way of doing this is to insert a nasogastric tube: if there is evidence of active (fresh blood) or recent (old blood) bleeding, then proceed with UGI endoscopy as detailed in Chapter 17. If clear bile is aspirated I am then fairly confident that the source of bleeding is distal to the ligament of Treitz. If neither bile nor blood is seen, I start with upper GI endoscopy — to exclude a bleeding duodenal ulcer with a spastic pylorus. Often I must persuade the gastroenterologists that it is necessary given the patient is bleeding per rectum. But blood is an excellent cathartic, especially large volumes of blood, so it is quite possible for the patient with a bleeding duodenal ulcer to present with...\\n```',\n", " 'bBox': {'x': 72, 'y': 382, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 29.1',\n", " 'md': '### Figure 29.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure likely illustrates the distinction between lower gastrointestinal bleeding (LGIB) and upper gastrointestinal bleeding (UGI). It may include a flowchart or diagram that helps in identifying the source of bleeding based on clinical signs or diagnostic procedures.\\n- **Summary**: The figure serves as a visual aid to assist healthcare professionals in determining the origin of gastrointestinal bleeding, emphasizing the importance of accurate diagnosis in emergency situations.',\n", " 'md': '- **Description**: This figure likely illustrates the distinction between lower gastrointestinal bleeding (LGIB) and upper gastrointestinal bleeding (UGI). It may include a flowchart or diagram that helps in identifying the source of bleeding based on clinical signs or diagnostic procedures.\\n- **Summary**: The figure serves as a visual aid to assist healthcare professionals in determining the origin of gastrointestinal bleeding, emphasizing the importance of accurate diagnosis in emergency situations.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'doing this is to insert a nasogastric tube: if there is evidence of active'},\n", " {'text': 'then fairly confident that the source of bleeding is distal to the'}]},\n", " {'page': 513,\n", " 'text': 'bright red blood per rectum. It is essential that I am satisfied there is\\nno upper GI source before I take an unstable patient to the\\noperating room for a colectomy. Imagine the nightmare: delivering a\\npatient’s colon to the pathologist and seeing bright red blood continuing\\nto pour from the transected ileum. Shudder.\\n PeRYX 231y\\nFigure 29.1. “Hey, are you sure that all of this is coming from the rectum?”\\n\\n In the same vein it is essential to make sure there is not a\\nbleeding source in the rectum or anus. ħemorrhoids can bleed, I\\nmean really bleed, so in addition to placing a nasogastric tube, all\\npatients should have a digital rectal exam, followed by a rigid\\nsigmoidoscopy. If an anal source is suspected after performing the rigid\\nsigmoidoscopy, then I perform an anoscopy. Again, there are few things\\nworse in the colorectal world than removing a patient’s colon and seeing\\npersistent bleeding coming from the massive internal hemorrhoids and\\nanal varices. So you always need to check that the bleeding source\\nis not in the upper GI tract, anus, or rectum, while making sure the\\npatient is adequately resuscitated.',\n", " 'md': '```markdown\\n## Page Content\\n\\nBright red blood per rectum. It is essential that I am satisfied there is no upper GI source before I take an unstable patient to the operating room for a colectomy. Imagine the nightmare: delivering a patient’s colon to the pathologist and seeing bright red blood continuing to pour from the transected ileum. Shudder.\\n\\nIn the same vein, it is essential to make sure there is not a bleeding source in the rectum or anus. Hemorrhoids can bleed, I mean really bleed, so in addition to placing a nasogastric tube, all patients should have a digital rectal exam, followed by a rigid sigmoidoscopy. If an anal source is suspected after performing the rigid sigmoidoscopy, then I perform an anoscopy. Again, there are few things worse in the colorectal world than removing a patient’s colon and seeing persistent bleeding coming from the massive internal hemorrhoids and anal varices. So you always need to check that the bleeding source is not in the upper GI tract, anus, or rectum, while making sure the patient is adequately resuscitated.\\n\\n## Figures\\n\\n### Figure 29.1\\n**Caption:** “Hey, are you sure that all of this is coming from the rectum?”\\n\\n**Description:** This figure likely depicts a humorous or illustrative representation related to the topic of rectal bleeding, possibly showing a patient or a medical professional questioning the source of the bleeding. The context suggests a focus on the importance of identifying the source of bleeding accurately.\\n\\n**Summary:** The figure emphasizes the critical nature of diagnosing the source of rectal bleeding before proceeding with surgical interventions, highlighting the potential complications that can arise if the source is not correctly identified.\\n```',\n", " 'images': [{'name': 'img_p512_1.png',\n", " 'height': 566,\n", " 'width': 760,\n", " 'x': 118.07999999999993,\n", " 'y': 165.60000000000002,\n", " 'original_width': 1304,\n", " 'original_height': 972}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Bright red blood per rectum. It is essential that I am satisfied there is no upper GI source before I take an unstable patient to the operating room for a colectomy. Imagine the nightmare: delivering a patient’s colon to the pathologist and seeing bright red blood continuing to pour from the transected ileum. Shudder.\\n\\nIn the same vein, it is essential to make sure there is not a bleeding source in the rectum or anus. Hemorrhoids can bleed, I mean really bleed, so in addition to placing a nasogastric tube, all patients should have a digital rectal exam, followed by a rigid sigmoidoscopy. If an anal source is suspected after performing the rigid sigmoidoscopy, then I perform an anoscopy. Again, there are few things worse in the colorectal world than removing a patient’s colon and seeing persistent bleeding coming from the massive internal hemorrhoids and anal varices. So you always need to check that the bleeding source is not in the upper GI tract, anus, or rectum, while making sure the patient is adequately resuscitated.',\n", " 'md': 'Bright red blood per rectum. It is essential that I am satisfied there is no upper GI source before I take an unstable patient to the operating room for a colectomy. Imagine the nightmare: delivering a patient’s colon to the pathologist and seeing bright red blood continuing to pour from the transected ileum. Shudder.\\n\\nIn the same vein, it is essential to make sure there is not a bleeding source in the rectum or anus. Hemorrhoids can bleed, I mean really bleed, so in addition to placing a nasogastric tube, all patients should have a digital rectal exam, followed by a rigid sigmoidoscopy. If an anal source is suspected after performing the rigid sigmoidoscopy, then I perform an anoscopy. Again, there are few things worse in the colorectal world than removing a patient’s colon and seeing persistent bleeding coming from the massive internal hemorrhoids and anal varices. So you always need to check that the bleeding source is not in the upper GI tract, anus, or rectum, while making sure the patient is adequately resuscitated.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.58, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures',\n", " 'md': '## Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 29.1',\n", " 'md': '### Figure 29.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** “Hey, are you sure that all of this is coming from the rectum?”\\n\\n**Description:** This figure likely depicts a humorous or illustrative representation related to the topic of rectal bleeding, possibly showing a patient or a medical professional questioning the source of the bleeding. The context suggests a focus on the importance of identifying the source of bleeding accurately.\\n\\n**Summary:** The figure emphasizes the critical nature of diagnosing the source of rectal bleeding before proceeding with surgical interventions, highlighting the potential complications that can arise if the source is not correctly identified.\\n```',\n", " 'md': '**Caption:** “Hey, are you sure that all of this is coming from the rectum?”\\n\\n**Description:** This figure likely depicts a humorous or illustrative representation related to the topic of rectal bleeding, possibly showing a patient or a medical professional questioning the source of the bleeding. The context suggests a focus on the importance of identifying the source of bleeding accurately.\\n\\n**Summary:** The figure emphasizes the critical nature of diagnosing the source of rectal bleeding before proceeding with surgical interventions, highlighting the potential complications that can arise if the source is not correctly identified.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 514,\n", " 'text': ' Where to go from the emergency room?\\n\\n There are essentially two philosophies when it comes to the work-\\nup of LGIB patients: you are either in the radiology camp — believing\\nthe best way to localize the source of bleeding is with ‘bleeding’ scans,\\nCT scans, or angiograms. Or you are in the endoscopic camp —\\nthinking the best way to localize and treat a lower GI bleed is with a\\ncolonoscope.\\n\\n I am an impartial individual and therefore favor both camps. Please\\ndon’t call me Charlie Brown — I am not wishy-washy (look it up if you do\\nnot understand), but I feel that both approaches are valuable and play a\\nrole in managing LGIB.\\n\\n LGIB bleeds come in two flavors: those that present\\nhemodynamically stable and those that do not. Colonoscopy really\\nmay only be performed on the hemodynamically stable individual. The\\nreason for this is the need to perform a bowel preparation prior to the\\ncolonoscopy. Scoping an unprepped colon is useless. Patients who\\nhave some hemodynamic instability, but are responsive to\\nresuscitation, should be taken to have the bleeding source isolated\\nin radiology. Those patients who are hemodynamically unstable,\\nand do not respond to fluid or blood resuscitation, belong in the\\noperating room — but they are a very small minority.\\n\\n Colonoscopy\\n\\n The majority of patients who have LGIB will undergo a\\ncolonoscopy. It can be effectively performed even in those patients with\\nmassive bleeding as long as the patient is hemodynamically stable. The\\ngreatest chance the endoscopist has for identifying the bleeding\\nsite and stopping the bleeding is to perform the scope as close as\\npossible to the initial presentation. This means that as soon as the\\npatient is stabilized a rapid colonic preparation should be given and\\nthe scope performed.\\n\\n Preparation',\n", " 'md': '```markdown\\n# Where to go from the emergency room?\\n\\nThere are essentially two philosophies when it comes to the work-up of LGIB patients: you are either in the radiology camp — believing the best way to localize the source of bleeding is with ‘bleeding’ scans, CT scans, or angiograms. Or you are in the endoscopic camp — thinking the best way to localize and treat a lower GI bleed is with a colonoscope.\\n\\nI am an impartial individual and therefore favor both camps. Please don’t call me Charlie Brown — I am not wishy-washy (look it up if you do not understand), but I feel that both approaches are valuable and play a role in managing LGIB.\\n\\nLGIB bleeds come in two flavors: those that present hemodynamically stable and those that do not. Colonoscopy really may only be performed on the hemodynamically stable individual. The reason for this is the need to perform a bowel preparation prior to the colonoscopy. Scoping an unprepped colon is useless. Patients who have some hemodynamic instability, but are responsive to resuscitation, should be taken to have the bleeding source isolated in radiology. Those patients who are hemodynamically unstable, and do not respond to fluid or blood resuscitation, belong in the operating room — but they are a very small minority.\\n\\n## Colonoscopy\\n\\nThe majority of patients who have LGIB will undergo a colonoscopy. It can be effectively performed even in those patients with massive bleeding as long as the patient is hemodynamically stable. The greatest chance the endoscopist has for identifying the bleeding site and stopping the bleeding is to perform the scope as close as possible to the initial presentation. This means that as soon as the patient is stabilized a rapid colonic preparation should be given and the scope performed.\\n\\n## Preparation\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Where to go from the emergency room?',\n", " 'md': '# Where to go from the emergency room?',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 314.46, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'There are essentially two philosophies when it comes to the work-up of LGIB patients: you are either in the radiology camp — believing the best way to localize the source of bleeding is with ‘bleeding’ scans, CT scans, or angiograms. Or you are in the endoscopic camp — thinking the best way to localize and treat a lower GI bleed is with a colonoscope.\\n\\nI am an impartial individual and therefore favor both camps. Please don’t call me Charlie Brown — I am not wishy-washy (look it up if you do not understand), but I feel that both approaches are valuable and play a role in managing LGIB.\\n\\nLGIB bleeds come in two flavors: those that present hemodynamically stable and those that do not. Colonoscopy really may only be performed on the hemodynamically stable individual. The reason for this is the need to perform a bowel preparation prior to the colonoscopy. Scoping an unprepped colon is useless. Patients who have some hemodynamic instability, but are responsive to resuscitation, should be taken to have the bleeding source isolated in radiology. Those patients who are hemodynamically unstable, and do not respond to fluid or blood resuscitation, belong in the operating room — but they are a very small minority.',\n", " 'md': 'There are essentially two philosophies when it comes to the work-up of LGIB patients: you are either in the radiology camp — believing the best way to localize the source of bleeding is with ‘bleeding’ scans, CT scans, or angiograms. Or you are in the endoscopic camp — thinking the best way to localize and treat a lower GI bleed is with a colonoscope.\\n\\nI am an impartial individual and therefore favor both camps. Please don’t call me Charlie Brown — I am not wishy-washy (look it up if you do not understand), but I feel that both approaches are valuable and play a role in managing LGIB.\\n\\nLGIB bleeds come in two flavors: those that present hemodynamically stable and those that do not. Colonoscopy really may only be performed on the hemodynamically stable individual. The reason for this is the need to perform a bowel preparation prior to the colonoscopy. Scoping an unprepped colon is useless. Patients who have some hemodynamic instability, but are responsive to resuscitation, should be taken to have the bleeding source isolated in radiology. Those patients who are hemodynamically unstable, and do not respond to fluid or blood resuscitation, belong in the operating room — but they are a very small minority.',\n", " 'bBox': {'x': 72, 'y': 124, 'w': 467.66, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Colonoscopy',\n", " 'md': '## Colonoscopy',\n", " 'bBox': {'x': 86, 'y': 519, 'w': 104.84, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The majority of patients who have LGIB will undergo a colonoscopy. It can be effectively performed even in those patients with massive bleeding as long as the patient is hemodynamically stable. The greatest chance the endoscopist has for identifying the bleeding site and stopping the bleeding is to perform the scope as close as possible to the initial presentation. This means that as soon as the patient is stabilized a rapid colonic preparation should be given and the scope performed.',\n", " 'md': 'The majority of patients who have LGIB will undergo a colonoscopy. It can be effectively performed even in those patients with massive bleeding as long as the patient is hemodynamically stable. The greatest chance the endoscopist has for identifying the bleeding site and stopping the bleeding is to perform the scope as close as possible to the initial presentation. This means that as soon as the patient is stabilized a rapid colonic preparation should be given and the scope performed.',\n", " 'bBox': {'x': 72, 'y': 327, 'w': 467.93, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Preparation',\n", " 'md': '## Preparation',\n", " 'bBox': {'x': 86, 'y': 714, 'w': 91.96, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 515,\n", " 'text': ' The fastest way to deliver a rapid preparation is to place a nasogastric\\ntube, confirm placement and then flush a gallon of polyethylene glycol\\nsolution through the tube over 4 hours. Needless to say I am not very\\npopular with either the patient or the nurses in the intensive care unit\\nwhen these orders enter the computer system, but it gets the colon clean\\nenough so that the endoscopist can see. I always ask the emergency\\nroom to maintain the nasogastric tube in the patient after it has been\\nplaced to rule out an UGI source — it is not good having to tell a patient\\nthat the tube needs to be replaced just after it has been removed.\\n\\n Timing\\n\\n Numerous studies have demonstrated that the highest diagnostic\\nyield from colonoscopy for GI bleeding occurs when the scope is\\nperformed closest to the patient’s initial presentation. It is best if it\\ncan be completed within 8 to 12 hours of the patient’s presentation, but\\nyields are still high if done within 24 hours of presentation. If waiting\\npast 24 hours, and the bleeding has stopped, colonoscopy rarely\\nfinds the source unless it is from a less common etiology such as\\ncancer or ischemia — while these can cause significant (massive)\\nbleeding, it is rare. Massive LGIB is most commonly caused by either\\na bleeding diverticulum or an arteriovenous malformation\\n(angiodysplasia). Both of these entities can be endoscopically treated\\nwith a variety of neat gadgets, but are difficult to identify as the source\\nunless you see them squirting. Therefore, I plead with you — if\\nscoping, scope early.\\n\\n The procedure\\n\\n As in all emergency situations, a good team is vital. ħaving an\\nanesthesia colleague to monitor the patient (who can become unstable),\\nan endoscopy nurse and an endoscopy technologist who are all well\\ntrained in what they do increases the chances of success. Developing a\\nstandardized protocol and GI bleed response team helps to ensure\\nthe colonoscopy is performed as close to presentation as possible,\\nthereby increasing your yield. Having the ability to clip, inject, and\\ncauterize during the scope is essential to being able to stop the',\n", " 'md': '```markdown\\n# Rapid Preparation for Colonoscopy\\n\\nThe fastest way to deliver a rapid preparation is to place a nasogastric tube, confirm placement and then flush a gallon of polyethylene glycol solution through the tube over 4 hours. Needless to say, I am not very popular with either the patient or the nurses in the intensive care unit when these orders enter the computer system, but it gets the colon clean enough so that the endoscopist can see. I always ask the emergency room to maintain the nasogastric tube in the patient after it has been placed to rule out an UGI source — it is not good having to tell a patient that the tube needs to be replaced just after it has been removed.\\n\\n## Timing\\n\\nNumerous studies have demonstrated that the highest diagnostic yield from colonoscopy for GI bleeding occurs when the scope is performed closest to the patient’s initial presentation. It is best if it can be completed within 8 to 12 hours of the patient’s presentation, but yields are still high if done within 24 hours of presentation. If waiting past 24 hours, and the bleeding has stopped, colonoscopy rarely finds the source unless it is from a less common etiology such as cancer or ischemia — while these can cause significant (massive) bleeding, it is rare. Massive LGIB is most commonly caused by either a bleeding diverticulum or an arteriovenous malformation (angiodysplasia). Both of these entities can be endoscopically treated with a variety of neat gadgets, but are difficult to identify as the source unless you see them squirting. Therefore, I plead with you — if scoping, scope early.\\n\\n## The Procedure\\n\\nAs in all emergency situations, a good team is vital. Having an anesthesia colleague to monitor the patient (who can become unstable), an endoscopy nurse, and an endoscopy technologist who are all well trained in what they do increases the chances of success. Developing a standardized protocol and GI bleed response team helps to ensure the colonoscopy is performed as close to presentation as possible, thereby increasing your yield. Having the ability to clip, inject, and cauterize during the scope is essential to being able to stop the bleeding.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Rapid Preparation for Colonoscopy',\n", " 'md': '# Rapid Preparation for Colonoscopy',\n", " 'bBox': {'x': 273, 'y': 446, 'w': 18.39, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The fastest way to deliver a rapid preparation is to place a nasogastric tube, confirm placement and then flush a gallon of polyethylene glycol solution through the tube over 4 hours. Needless to say, I am not very popular with either the patient or the nurses in the intensive care unit when these orders enter the computer system, but it gets the colon clean enough so that the endoscopist can see. I always ask the emergency room to maintain the nasogastric tube in the patient after it has been placed to rule out an UGI source — it is not good having to tell a patient that the tube needs to be replaced just after it has been removed.',\n", " 'md': 'The fastest way to deliver a rapid preparation is to place a nasogastric tube, confirm placement and then flush a gallon of polyethylene glycol solution through the tube over 4 hours. Needless to say, I am not very popular with either the patient or the nurses in the intensive care unit when these orders enter the computer system, but it gets the colon clean enough so that the endoscopist can see. I always ask the emergency room to maintain the nasogastric tube in the patient after it has been placed to rule out an UGI source — it is not good having to tell a patient that the tube needs to be replaced just after it has been removed.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Timing',\n", " 'md': '## Timing',\n", " 'bBox': {'x': 86, 'y': 261, 'w': 53.94, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Numerous studies have demonstrated that the highest diagnostic yield from colonoscopy for GI bleeding occurs when the scope is performed closest to the patient’s initial presentation. It is best if it can be completed within 8 to 12 hours of the patient’s presentation, but yields are still high if done within 24 hours of presentation. If waiting past 24 hours, and the bleeding has stopped, colonoscopy rarely finds the source unless it is from a less common etiology such as cancer or ischemia — while these can cause significant (massive) bleeding, it is rare. Massive LGIB is most commonly caused by either a bleeding diverticulum or an arteriovenous malformation (angiodysplasia). Both of these entities can be endoscopically treated with a variety of neat gadgets, but are difficult to identify as the source unless you see them squirting. Therefore, I plead with you — if scoping, scope early.',\n", " 'md': 'Numerous studies have demonstrated that the highest diagnostic yield from colonoscopy for GI bleeding occurs when the scope is performed closest to the patient’s initial presentation. It is best if it can be completed within 8 to 12 hours of the patient’s presentation, but yields are still high if done within 24 hours of presentation. If waiting past 24 hours, and the bleeding has stopped, colonoscopy rarely finds the source unless it is from a less common etiology such as cancer or ischemia — while these can cause significant (massive) bleeding, it is rare. Massive LGIB is most commonly caused by either a bleeding diverticulum or an arteriovenous malformation (angiodysplasia). Both of these entities can be endoscopically treated with a variety of neat gadgets, but are difficult to identify as the source unless you see them squirting. Therefore, I plead with you — if scoping, scope early.',\n", " 'bBox': {'x': 72, 'y': 297, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Procedure',\n", " 'md': '## The Procedure',\n", " 'bBox': {'x': 86, 'y': 556, 'w': 114.96, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As in all emergency situations, a good team is vital. Having an anesthesia colleague to monitor the patient (who can become unstable), an endoscopy nurse, and an endoscopy technologist who are all well trained in what they do increases the chances of success. Developing a standardized protocol and GI bleed response team helps to ensure the colonoscopy is performed as close to presentation as possible, thereby increasing your yield. Having the ability to clip, inject, and cauterize during the scope is essential to being able to stop the bleeding.\\n```',\n", " 'md': 'As in all emergency situations, a good team is vital. Having an anesthesia colleague to monitor the patient (who can become unstable), an endoscopy nurse, and an endoscopy technologist who are all well trained in what they do increases the chances of success. Developing a standardized protocol and GI bleed response team helps to ensure the colonoscopy is performed as close to presentation as possible, thereby increasing your yield. Having the ability to clip, inject, and cauterize during the scope is essential to being able to stop the bleeding.\\n```',\n", " 'bBox': {'x': 72, 'y': 446, 'w': 467.91, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 516,\n", " 'text': 'bleeding.\\n\\n When I perform a colonoscopy for significant LGIB, I am conflicted as\\nto whether I do this in the intensive care unit or the endoscopy suite. If\\nthe patient is stable (and we only do this in stable patients…) I\\nprefer to be in the endoscopy suite with an anesthetist providing\\nsedation. I have better access to all the equipment I need to stop the\\nbleeding, whereas when performing this in the intensive care unit, there\\nis always something missing from the cart that requires a runner to sprint\\nto the endoscopy suite to pick up what is needed. I also alert the\\ninterventional radiology team that we are performing the\\ncolonoscopy and if things don’t go well and the patient is still\\nbleeding after the scope that their services will be needed.\\n\\n I work with a scope that allows for irrigation, suction and intervention all\\nat the same time. When I have identified the bleeding spot, my choice\\nof intervention depends on the etiology of the bleed. When a\\nbleeding diverticulum is identified, it can be difficult to see the precise\\nbleeding inside it. If I do see it, I attempt injecting it with epinephrine to\\ninitially stop the bleeding, then place clips either inside the diverticulum, if\\npossible, or at the opening to the diverticulum — thereby closing the\\ndiverticulum’s opening to the colon. If the bleeding is coming from the\\ndiverticular opening and I cannot see inside the ‘tic’, I will clip the opening\\nof the diverticulum to attempt to clot and tamponade the bleed. If this\\ndoes not succeed, I call the interventional radiologist and have them\\nembolize the bleeding site which I have conveniently marked with\\nthe clips.\\n\\n If the bleed is from an arteriovenous malformation (AVM) I will inject\\nit to slow the flow of blood and then place clips across the AVM. An\\nErbe™ coagulator may be used to cauterize the AVM if neither injection\\nnor clips have stopped the bleed. It may be difficult to coagulate once the\\nclips are placed, so if I think I will need to use coagulation, I will do this\\nprior to placing the clips. I am very reluctant to coagulate a\\ndiverticulum; given the tic’s lack of serosa, they have a higher\\nlikelihood of necrosis and perforation.\\n\\n The major risk from the colonoscopy is perforation which is not',\n", " 'md': '```markdown\\n## Colonoscopy for Significant Lower Gastrointestinal Bleeding (LGIB)\\n\\nWhen I perform a colonoscopy for significant LGIB, I am conflicted as to whether I do this in the intensive care unit or the endoscopy suite. If the patient is stable (and we only do this in stable patients…), I prefer to be in the endoscopy suite with an anesthetist providing sedation. I have better access to all the equipment I need to stop the bleeding, whereas when performing this in the intensive care unit, there is always something missing from the cart that requires a runner to sprint to the endoscopy suite to pick up what is needed. I also alert the interventional radiology team that we are performing the colonoscopy and if things don’t go well and the patient is still bleeding after the scope that their services will be needed.\\n\\nI work with a scope that allows for irrigation, suction, and intervention all at the same time. When I have identified the bleeding spot, my choice of intervention depends on the etiology of the bleed. When a bleeding diverticulum is identified, it can be difficult to see the precise bleeding inside it. If I do see it, I attempt injecting it with epinephrine to initially stop the bleeding, then place clips either inside the diverticulum, if possible, or at the opening to the diverticulum — thereby closing the diverticulum’s opening to the colon. If the bleeding is coming from the diverticular opening and I cannot see inside the ‘tic’, I will clip the opening of the diverticulum to attempt to clot and tamponade the bleed. If this does not succeed, I call the interventional radiologist and have them embolize the bleeding site which I have conveniently marked with the clips.\\n\\nIf the bleed is from an arteriovenous malformation (AVM) I will inject it to slow the flow of blood and then place clips across the AVM. An Erbe™ coagulator may be used to cauterize the AVM if neither injection nor clips have stopped the bleed. It may be difficult to coagulate once the clips are placed, so if I think I will need to use coagulation, I will do this prior to placing the clips. I am very reluctant to coagulate a diverticulum; given the tic’s lack of serosa, they have a higher likelihood of necrosis and perforation.\\n\\nThe major risk from the colonoscopy is perforation which is not...\\n```\\n\\n### Notes:\\n- The text has been extracted without any headers, footers, or diagonal text.\\n- There are no images, graphs, or tables identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Colonoscopy for Significant Lower Gastrointestinal Bleeding (LGIB)',\n", " 'md': '## Colonoscopy for Significant Lower Gastrointestinal Bleeding (LGIB)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'When I perform a colonoscopy for significant LGIB, I am conflicted as to whether I do this in the intensive care unit or the endoscopy suite. If the patient is stable (and we only do this in stable patients…), I prefer to be in the endoscopy suite with an anesthetist providing sedation. I have better access to all the equipment I need to stop the bleeding, whereas when performing this in the intensive care unit, there is always something missing from the cart that requires a runner to sprint to the endoscopy suite to pick up what is needed. I also alert the interventional radiology team that we are performing the colonoscopy and if things don’t go well and the patient is still bleeding after the scope that their services will be needed.\\n\\nI work with a scope that allows for irrigation, suction, and intervention all at the same time. When I have identified the bleeding spot, my choice of intervention depends on the etiology of the bleed. When a bleeding diverticulum is identified, it can be difficult to see the precise bleeding inside it. If I do see it, I attempt injecting it with epinephrine to initially stop the bleeding, then place clips either inside the diverticulum, if possible, or at the opening to the diverticulum — thereby closing the diverticulum’s opening to the colon. If the bleeding is coming from the diverticular opening and I cannot see inside the ‘tic’, I will clip the opening of the diverticulum to attempt to clot and tamponade the bleed. If this does not succeed, I call the interventional radiologist and have them embolize the bleeding site which I have conveniently marked with the clips.\\n\\nIf the bleed is from an arteriovenous malformation (AVM) I will inject it to slow the flow of blood and then place clips across the AVM. An Erbe™ coagulator may be used to cauterize the AVM if neither injection nor clips have stopped the bleed. It may be difficult to coagulate once the clips are placed, so if I think I will need to use coagulation, I will do this prior to placing the clips. I am very reluctant to coagulate a diverticulum; given the tic’s lack of serosa, they have a higher likelihood of necrosis and perforation.\\n\\nThe major risk from the colonoscopy is perforation which is not...\\n```',\n", " 'md': 'When I perform a colonoscopy for significant LGIB, I am conflicted as to whether I do this in the intensive care unit or the endoscopy suite. If the patient is stable (and we only do this in stable patients…), I prefer to be in the endoscopy suite with an anesthetist providing sedation. I have better access to all the equipment I need to stop the bleeding, whereas when performing this in the intensive care unit, there is always something missing from the cart that requires a runner to sprint to the endoscopy suite to pick up what is needed. I also alert the interventional radiology team that we are performing the colonoscopy and if things don’t go well and the patient is still bleeding after the scope that their services will be needed.\\n\\nI work with a scope that allows for irrigation, suction, and intervention all at the same time. When I have identified the bleeding spot, my choice of intervention depends on the etiology of the bleed. When a bleeding diverticulum is identified, it can be difficult to see the precise bleeding inside it. If I do see it, I attempt injecting it with epinephrine to initially stop the bleeding, then place clips either inside the diverticulum, if possible, or at the opening to the diverticulum — thereby closing the diverticulum’s opening to the colon. If the bleeding is coming from the diverticular opening and I cannot see inside the ‘tic’, I will clip the opening of the diverticulum to attempt to clot and tamponade the bleed. If this does not succeed, I call the interventional radiologist and have them embolize the bleeding site which I have conveniently marked with the clips.\\n\\nIf the bleed is from an arteriovenous malformation (AVM) I will inject it to slow the flow of blood and then place clips across the AVM. An Erbe™ coagulator may be used to cauterize the AVM if neither injection nor clips have stopped the bleed. It may be difficult to coagulate once the clips are placed, so if I think I will need to use coagulation, I will do this prior to placing the clips. I am very reluctant to coagulate a diverticulum; given the tic’s lack of serosa, they have a higher likelihood of necrosis and perforation.\\n\\nThe major risk from the colonoscopy is perforation which is not...\\n```',\n", " 'bBox': {'x': 72, 'y': 121, 'w': 467.98, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text has been extracted without any headers, footers, or diagonal text.\\n- There are no images, graphs, or tables identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'md': '- The text has been extracted without any headers, footers, or diagonal text.\\n- There are no images, graphs, or tables identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 388, 'y': 253, 'w': 25.6, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 517,\n", " 'text': 'something I relish in a bleeding patient. The perforation can occur at\\nthe site of intervention and is usually from excessive coagulation. It is\\nalso possible to perforate the colon from over-distension which occurs\\nwhen the colonoscopy is difficult due to redundancy or excessive\\nbleeding, making it difficult to see. If the bleeding is not stopping with the\\ndescribed interventions and I have reached the site of bleeding, I mark it\\nwith several clips and call the radiologist. Similarly, if scoping is difficult\\nbecause of a large a flow of blood and I can’t locate the bleed, I swallow\\nmy pride and call the radiologist. It is safer to have them embolize the\\nbleeding point than to struggle with a difficult colonoscopy.\\n\\n If I identify a bleeding site and am successful in stopping the bleeding, I\\nalways mark the site of bleeding with either India ink or SPOT (carbon-\\nbased permanent marker). This is helpful if the patient rebleeds and\\nrequires repeat endoscopy or surgical resection. As I tell all my\\npatients, I know when the colonoscope is in the rectum and the\\nileum but ensuring any location anywhere else in the colon is a\\ncrapshoot. So even if you are God’s gift to colonoscopy, mark the\\nsite of bleeding. (There is also something very soothing about clearly\\nseeing the tattoo mark when resecting a segment of colon, providing one\\nwith confidence and well-being.)\\n\\n One final (smart) endoscopic tip: do not remove other polyps or\\nlesions when performing a colonoscopy for massive colonic\\nbleeding. Any polypectomy can be complicated by a bleed and Murphy’s\\nlaw guarantees that if I remove a polyp at the same time as performing a\\ndiagnostic scope for acute LGIB, the polypectomy site will bleed. If the\\npatient rebleeds 2 to 3 days later, you won’t know where the bleeding is\\ncoming from. If concerned about finding polyps in a follow-up scope,\\nmark them.\\n\\n Radiology\\n\\n The radiology options include a nuclear scan, CT angiography and\\nangiography.\\n\\n Nuclear medicine scans',\n", " 'md': '```markdown\\n## Current Page Content\\n\\n### Text\\nSomething I relish in a bleeding patient. The perforation can occur at the site of intervention and is usually from excessive coagulation. It is also possible to perforate the colon from over-distension which occurs when the colonoscopy is difficult due to redundancy or excessive bleeding, making it difficult to see. If the bleeding is not stopping with the described interventions and I have reached the site of bleeding, I mark it with several clips and call the radiologist. Similarly, if scoping is difficult because of a large flow of blood and I can’t locate the bleed, I swallow my pride and call the radiologist. It is safer to have them embolize the bleeding point than to struggle with a difficult colonoscopy.\\n\\nIf I identify a bleeding site and am successful in stopping the bleeding, I always mark the site of bleeding with either India ink or SPOT (carbon-based permanent marker). This is helpful if the patient rebleeds and requires repeat endoscopy or surgical resection. As I tell all my patients, I know when the colonoscope is in the rectum and the ileum but ensuring any location anywhere else in the colon is a crapshoot. So even if you are God’s gift to colonoscopy, mark the site of bleeding. (There is also something very soothing about clearly seeing the tattoo mark when resecting a segment of colon, providing one with confidence and well-being.)\\n\\nOne final (smart) endoscopic tip: do not remove other polyps or lesions when performing a colonoscopy for massive colonic bleeding. Any polypectomy can be complicated by a bleed and Murphy’s law guarantees that if I remove a polyp at the same time as performing a diagnostic scope for acute LGIB, the polypectomy site will bleed. If the patient rebleeds 2 to 3 days later, you won’t know where the bleeding is coming from. If concerned about finding polyps in a follow-up scope, mark them.\\n\\n### Radiology\\nThe radiology options include a nuclear scan, CT angiography, and angiography.\\n\\n#### Nuclear Medicine Scans\\n\\n```\\n\\n### Notes\\n- No images or figures were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- There are no formulas present on this page.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Something I relish in a bleeding patient. The perforation can occur at the site of intervention and is usually from excessive coagulation. It is also possible to perforate the colon from over-distension which occurs when the colonoscopy is difficult due to redundancy or excessive bleeding, making it difficult to see. If the bleeding is not stopping with the described interventions and I have reached the site of bleeding, I mark it with several clips and call the radiologist. Similarly, if scoping is difficult because of a large flow of blood and I can’t locate the bleed, I swallow my pride and call the radiologist. It is safer to have them embolize the bleeding point than to struggle with a difficult colonoscopy.\\n\\nIf I identify a bleeding site and am successful in stopping the bleeding, I always mark the site of bleeding with either India ink or SPOT (carbon-based permanent marker). This is helpful if the patient rebleeds and requires repeat endoscopy or surgical resection. As I tell all my patients, I know when the colonoscope is in the rectum and the ileum but ensuring any location anywhere else in the colon is a crapshoot. So even if you are God’s gift to colonoscopy, mark the site of bleeding. (There is also something very soothing about clearly seeing the tattoo mark when resecting a segment of colon, providing one with confidence and well-being.)\\n\\nOne final (smart) endoscopic tip: do not remove other polyps or lesions when performing a colonoscopy for massive colonic bleeding. Any polypectomy can be complicated by a bleed and Murphy’s law guarantees that if I remove a polyp at the same time as performing a diagnostic scope for acute LGIB, the polypectomy site will bleed. If the patient rebleeds 2 to 3 days later, you won’t know where the bleeding is coming from. If concerned about finding polyps in a follow-up scope, mark them.',\n", " 'md': 'Something I relish in a bleeding patient. The perforation can occur at the site of intervention and is usually from excessive coagulation. It is also possible to perforate the colon from over-distension which occurs when the colonoscopy is difficult due to redundancy or excessive bleeding, making it difficult to see. If the bleeding is not stopping with the described interventions and I have reached the site of bleeding, I mark it with several clips and call the radiologist. Similarly, if scoping is difficult because of a large flow of blood and I can’t locate the bleed, I swallow my pride and call the radiologist. It is safer to have them embolize the bleeding point than to struggle with a difficult colonoscopy.\\n\\nIf I identify a bleeding site and am successful in stopping the bleeding, I always mark the site of bleeding with either India ink or SPOT (carbon-based permanent marker). This is helpful if the patient rebleeds and requires repeat endoscopy or surgical resection. As I tell all my patients, I know when the colonoscope is in the rectum and the ileum but ensuring any location anywhere else in the colon is a crapshoot. So even if you are God’s gift to colonoscopy, mark the site of bleeding. (There is also something very soothing about clearly seeing the tattoo mark when resecting a segment of colon, providing one with confidence and well-being.)\\n\\nOne final (smart) endoscopic tip: do not remove other polyps or lesions when performing a colonoscopy for massive colonic bleeding. Any polypectomy can be complicated by a bleed and Murphy’s law guarantees that if I remove a polyp at the same time as performing a diagnostic scope for acute LGIB, the polypectomy site will bleed. If the patient rebleeds 2 to 3 days later, you won’t know where the bleeding is coming from. If concerned about finding polyps in a follow-up scope, mark them.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.85, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Radiology',\n", " 'md': '### Radiology',\n", " 'bBox': {'x': 86, 'y': 613, 'w': 80, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The radiology options include a nuclear scan, CT angiography, and angiography.',\n", " 'md': 'The radiology options include a nuclear scan, CT angiography, and angiography.',\n", " 'bBox': {'x': 72, 'y': 613, 'w': 94, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Nuclear Medicine Scans',\n", " 'md': '#### Nuclear Medicine Scans',\n", " 'bBox': {'x': 86, 'y': 709, 'w': 188.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '\\n```',\n", " 'md': '\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- There are no formulas present on this page.',\n", " 'md': '- No images or figures were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- There are no formulas present on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 518,\n", " 'text': ' Nuclear medicine scans are (in some hospitals) the first line of therapy\\nin patients who are stable and not having a colonoscopy. Often the\\ninterventional radiologists will require the bleeding scan to ‘guide’ their\\nangiogram. The test was originally performed with technetium sulfur\\ncolloid, but now is universally performed by labeling red blood cells with\\ntechnetium. At my institution, it is virtually impossible to have the patient\\n‘bypass’ nuclear medicine and proceed directly to an angiogram unless\\nthey are truly unstable. Tagged red blood cells (RBCs) are helpful in\\ndetermining the general location of a bleed, but I do not feel the test\\nis sensitive enough to guide me in a resection if warranted. Blood\\nactively flows between the left and right side of the colon. The\\nearlier the blood is detected in the colon, the more likely the scan\\nhas correctly isolated the source of bleeding. If the red cells are seen\\nin a specific portion of the colon within 15 or 20 minutes of injection, I am\\nfairly confident that we have defined the location of the bleed. If this is\\nthe case, it usually indicates a substantial bleed and the patient\\nshould be taken to interventional radiology for embolization (and\\nprobably should have been there from the start). The benefit of RBC\\nscanning is that it can detect very slow bleeds in the range of 0.05 to\\n0.1ml/min of bleeding. The radioactivity also lasts so if the bleeding site is\\nnot seen in the first 2 to 3 hours, the patient can be brought back at 6- or\\n12-hour intervals to see if the blood has started to pool in the colon. In\\nthese instances, the test really is just telling me whether the bleeding is\\nintermittently continuing or has stopped. A tagged red cell scan helps\\nguide the interventional radiologist and for those radiologists who\\nadvocate their use prior to an angiogram — they claim it guides their\\nprocedure and decreases the contrast load that is required. Well, if you\\nwant to belong to a ‘multi-specialty team’, you have to pay the price.\\n\\n CT angiography\\n\\n There are those who advocate CT angiography to help\\ndemonstrate LGIB; however, I am not a great fan. It seems to me that\\nit adds an unnecessary step on the path to an angiogram and increases\\nthe contrast load required for the patient — significantly increasing their\\nrisk of renal insufficiency. If the CT angiogram is negative, the stable\\npatient will most likely proceed to either a tagged red blood cell scan or\\ncolonoscopy. If the scan is positive, then the patient (stable or',\n", " 'md': '```markdown\\n# Nuclear Medicine Scans and CT Angiography\\n\\nNuclear medicine scans are (in some hospitals) the first line of therapy in patients who are stable and not having a colonoscopy. Often the interventional radiologists will require the bleeding scan to ‘guide’ their angiogram. The test was originally performed with technetium sulfur colloid, but now is universally performed by labeling red blood cells with technetium. At my institution, it is virtually impossible to have the patient ‘bypass’ nuclear medicine and proceed directly to an angiogram unless they are truly unstable.\\n\\nTagged red blood cells (RBCs) are helpful in determining the general location of a bleed, but I do not feel the test is sensitive enough to guide me in a resection if warranted. Blood actively flows between the left and right side of the colon. The earlier the blood is detected in the colon, the more likely the scan has correctly isolated the source of bleeding. If the red cells are seen in a specific portion of the colon within 15 or 20 minutes of injection, I am fairly confident that we have defined the location of the bleed. If this is the case, it usually indicates a substantial bleed and the patient should be taken to interventional radiology for embolization (and probably should have been there from the start).\\n\\nThe benefit of RBC scanning is that it can detect very slow bleeds in the range of 0.05 to 0.1 ml/min of bleeding. The radioactivity also lasts so if the bleeding site is not seen in the first 2 to 3 hours, the patient can be brought back at 6- or 12-hour intervals to see if the blood has started to pool in the colon. In these instances, the test really is just telling me whether the bleeding is intermittently continuing or has stopped. A tagged red cell scan helps guide the interventional radiologist and for those radiologists who advocate their use prior to an angiogram — they claim it guides their procedure and decreases the contrast load that is required. Well, if you want to belong to a ‘multi-specialty team’, you have to pay the price.\\n\\n## CT Angiography\\n\\nThere are those who advocate CT angiography to help demonstrate LGIB; however, I am not a great fan. It seems to me that it adds an unnecessary step on the path to an angiogram and increases the contrast load required for the patient — significantly increasing their risk of renal insufficiency. If the CT angiogram is negative, the stable patient will most likely proceed to either a tagged red blood cell scan or colonoscopy. If the scan is positive, then the patient (stable or...\\n```\\n\\n### Notes:\\n- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Nuclear Medicine Scans and CT Angiography',\n", " 'md': '# Nuclear Medicine Scans and CT Angiography',\n", " 'bBox': {'x': 86, 'y': 576, 'w': 125.98, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Nuclear medicine scans are (in some hospitals) the first line of therapy in patients who are stable and not having a colonoscopy. Often the interventional radiologists will require the bleeding scan to ‘guide’ their angiogram. The test was originally performed with technetium sulfur colloid, but now is universally performed by labeling red blood cells with technetium. At my institution, it is virtually impossible to have the patient ‘bypass’ nuclear medicine and proceed directly to an angiogram unless they are truly unstable.\\n\\nTagged red blood cells (RBCs) are helpful in determining the general location of a bleed, but I do not feel the test is sensitive enough to guide me in a resection if warranted. Blood actively flows between the left and right side of the colon. The earlier the blood is detected in the colon, the more likely the scan has correctly isolated the source of bleeding. If the red cells are seen in a specific portion of the colon within 15 or 20 minutes of injection, I am fairly confident that we have defined the location of the bleed. If this is the case, it usually indicates a substantial bleed and the patient should be taken to interventional radiology for embolization (and probably should have been there from the start).\\n\\nThe benefit of RBC scanning is that it can detect very slow bleeds in the range of 0.05 to 0.1 ml/min of bleeding. The radioactivity also lasts so if the bleeding site is not seen in the first 2 to 3 hours, the patient can be brought back at 6- or 12-hour intervals to see if the blood has started to pool in the colon. In these instances, the test really is just telling me whether the bleeding is intermittently continuing or has stopped. A tagged red cell scan helps guide the interventional radiologist and for those radiologists who advocate their use prior to an angiogram — they claim it guides their procedure and decreases the contrast load that is required. Well, if you want to belong to a ‘multi-specialty team’, you have to pay the price.',\n", " 'md': 'Nuclear medicine scans are (in some hospitals) the first line of therapy in patients who are stable and not having a colonoscopy. Often the interventional radiologists will require the bleeding scan to ‘guide’ their angiogram. The test was originally performed with technetium sulfur colloid, but now is universally performed by labeling red blood cells with technetium. At my institution, it is virtually impossible to have the patient ‘bypass’ nuclear medicine and proceed directly to an angiogram unless they are truly unstable.\\n\\nTagged red blood cells (RBCs) are helpful in determining the general location of a bleed, but I do not feel the test is sensitive enough to guide me in a resection if warranted. Blood actively flows between the left and right side of the colon. The earlier the blood is detected in the colon, the more likely the scan has correctly isolated the source of bleeding. If the red cells are seen in a specific portion of the colon within 15 or 20 minutes of injection, I am fairly confident that we have defined the location of the bleed. If this is the case, it usually indicates a substantial bleed and the patient should be taken to interventional radiology for embolization (and probably should have been there from the start).\\n\\nThe benefit of RBC scanning is that it can detect very slow bleeds in the range of 0.05 to 0.1 ml/min of bleeding. The radioactivity also lasts so if the bleeding site is not seen in the first 2 to 3 hours, the patient can be brought back at 6- or 12-hour intervals to see if the blood has started to pool in the colon. In these instances, the test really is just telling me whether the bleeding is intermittently continuing or has stopped. A tagged red cell scan helps guide the interventional radiologist and for those radiologists who advocate their use prior to an angiogram — they claim it guides their procedure and decreases the contrast load that is required. Well, if you want to belong to a ‘multi-specialty team’, you have to pay the price.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'CT Angiography',\n", " 'md': '## CT Angiography',\n", " 'bBox': {'x': 86, 'y': 576, 'w': 125.98, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'There are those who advocate CT angiography to help demonstrate LGIB; however, I am not a great fan. It seems to me that it adds an unnecessary step on the path to an angiogram and increases the contrast load required for the patient — significantly increasing their risk of renal insufficiency. If the CT angiogram is negative, the stable patient will most likely proceed to either a tagged red blood cell scan or colonoscopy. If the scan is positive, then the patient (stable or...\\n```',\n", " 'md': 'There are those who advocate CT angiography to help demonstrate LGIB; however, I am not a great fan. It seems to me that it adds an unnecessary step on the path to an angiogram and increases the contrast load required for the patient — significantly increasing their risk of renal insufficiency. If the CT angiogram is negative, the stable patient will most likely proceed to either a tagged red blood cell scan or colonoscopy. If the scan is positive, then the patient (stable or...\\n```',\n", " 'bBox': {'x': 72, 'y': 576, 'w': 467.74, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 481, 'y': 612, 'w': 17.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 519,\n", " 'text': 'otherwise) will proceed to angiography where he or she should\\nhave been in the first place! The role of CT angiography is very limited\\nbecause it is purely diagnostic and not therapeutic. It may play a useful\\nrole in those patients who are having recurrent bleeding episodes that\\nhave not been localized.\\n\\n Angiography\\n\\n This is where I like my patients to be if they are having a\\nsignificant bleed. Modern day angiography suites are operating rooms\\nand bleeding patients are just as safely treated there as elsewhere.\\nThese patients should be treated like they are having an operation which\\nmeans with a good anesthetist and surgeon in the room during the\\nprocedure. Patients who are having massive bleeds can be adequately\\nresuscitated and managed while a skilled radiologist identifies and\\nembolizes the bleeding source. Again, the best chance of identifying\\nand treating the patient is when they are actively bleeding, so — use\\nyour common sense — get the patients and the interventional\\nradiologist to the suite when the bleeding is active.\\n\\n Once the patient is in the angiography suite, if the site of bleeding is\\nidentified then an attempt to embolize the bleeding vessel should be\\nmade. This is successful in diverticular bleeds approximately 85% of the\\ntime, with a very low rebleed rate. In patients with AVMs, the success\\nrate of embolization is lower — approximately 50% with a higher rebleed\\nrate. The most commonly used products are coils, micro coils, polyvinyl\\nalcohol, and gel foam. Micro catheters allow for highly selective\\nembolization of the vessels responsible for the bleed.\\n\\n If angiography is not successful at stopping the bleeding point, I\\nwill proceed to the operating room and perform a segmental resection\\nwith or without a stoma depending on the patient’s hemodynamic status\\nand their associated medical comorbidities. If the bleeding has stopped\\nwe will leave a catheter in place for 24 to 48 hours after embolization\\nto allow for easy access to the bleeding site if the patient rebleeds.\\nInfusion of vasopressin is possible through this catheter if the bleeding\\ncontinues or recurs after embolization, although this therapy cannot be\\nused in patients with cardiovascular disease.',\n", " 'md': '```markdown\\n## Angiography\\n\\nThis is where I like my patients to be if they are having a significant bleed. Modern day angiography suites are operating rooms and bleeding patients are just as safely treated there as elsewhere. These patients should be treated like they are having an operation which means with a good anesthetist and surgeon in the room during the procedure. Patients who are having massive bleeds can be adequately resuscitated and managed while a skilled radiologist identifies and embolizes the bleeding source. Again, the best chance of identifying and treating the patient is when they are actively bleeding, so — use your common sense — get the patients and the interventional radiologist to the suite when the bleeding is active.\\n\\nOnce the patient is in the angiography suite, if the site of bleeding is identified then an attempt to embolize the bleeding vessel should be made. This is successful in diverticular bleeds approximately 85% of the time, with a very low rebleed rate. In patients with AVMs, the success rate of embolization is lower — approximately 50% with a higher rebleed rate. The most commonly used products are coils, micro coils, polyvinyl alcohol, and gel foam. Micro catheters allow for highly selective embolization of the vessels responsible for the bleed.\\n\\nIf angiography is not successful at stopping the bleeding point, I will proceed to the operating room and perform a segmental resection with or without a stoma depending on the patient’s hemodynamic status and their associated medical comorbidities. If the bleeding has stopped we will leave a catheter in place for 24 to 48 hours after embolization to allow for easy access to the bleeding site if the patient rebleeds. Infusion of vasopressin is possible through this catheter if the bleeding continues or recurs after embolization, although this therapy cannot be used in patients with cardiovascular disease.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Angiography',\n", " 'md': '## Angiography',\n", " 'bBox': {'x': 86, 'y': 195, 'w': 102.08, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is where I like my patients to be if they are having a significant bleed. Modern day angiography suites are operating rooms and bleeding patients are just as safely treated there as elsewhere. These patients should be treated like they are having an operation which means with a good anesthetist and surgeon in the room during the procedure. Patients who are having massive bleeds can be adequately resuscitated and managed while a skilled radiologist identifies and embolizes the bleeding source. Again, the best chance of identifying and treating the patient is when they are actively bleeding, so — use your common sense — get the patients and the interventional radiologist to the suite when the bleeding is active.\\n\\nOnce the patient is in the angiography suite, if the site of bleeding is identified then an attempt to embolize the bleeding vessel should be made. This is successful in diverticular bleeds approximately 85% of the time, with a very low rebleed rate. In patients with AVMs, the success rate of embolization is lower — approximately 50% with a higher rebleed rate. The most commonly used products are coils, micro coils, polyvinyl alcohol, and gel foam. Micro catheters allow for highly selective embolization of the vessels responsible for the bleed.\\n\\nIf angiography is not successful at stopping the bleeding point, I will proceed to the operating room and perform a segmental resection with or without a stoma depending on the patient’s hemodynamic status and their associated medical comorbidities. If the bleeding has stopped we will leave a catheter in place for 24 to 48 hours after embolization to allow for easy access to the bleeding site if the patient rebleeds. Infusion of vasopressin is possible through this catheter if the bleeding continues or recurs after embolization, although this therapy cannot be used in patients with cardiovascular disease.\\n```',\n", " 'md': 'This is where I like my patients to be if they are having a significant bleed. Modern day angiography suites are operating rooms and bleeding patients are just as safely treated there as elsewhere. These patients should be treated like they are having an operation which means with a good anesthetist and surgeon in the room during the procedure. Patients who are having massive bleeds can be adequately resuscitated and managed while a skilled radiologist identifies and embolizes the bleeding source. Again, the best chance of identifying and treating the patient is when they are actively bleeding, so — use your common sense — get the patients and the interventional radiologist to the suite when the bleeding is active.\\n\\nOnce the patient is in the angiography suite, if the site of bleeding is identified then an attempt to embolize the bleeding vessel should be made. This is successful in diverticular bleeds approximately 85% of the time, with a very low rebleed rate. In patients with AVMs, the success rate of embolization is lower — approximately 50% with a higher rebleed rate. The most commonly used products are coils, micro coils, polyvinyl alcohol, and gel foam. Micro catheters allow for highly selective embolization of the vessels responsible for the bleed.\\n\\nIf angiography is not successful at stopping the bleeding point, I will proceed to the operating room and perform a segmental resection with or without a stoma depending on the patient’s hemodynamic status and their associated medical comorbidities. If the bleeding has stopped we will leave a catheter in place for 24 to 48 hours after embolization to allow for easy access to the bleeding site if the patient rebleeds. Infusion of vasopressin is possible through this catheter if the bleeding continues or recurs after embolization, although this therapy cannot be used in patients with cardiovascular disease.\\n```',\n", " 'bBox': {'x': 72, 'y': 195, 'w': 467.94, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 520,\n", " 'text': ' The main complications related to embolization are injury to the\\nfemoral vessel that was accessed for the angiogram (most commonly\\npseudoaneurysm); renal insufficiency from the dye injected (10% or less);\\nor ischemia of the embolized colon. Ischemia is rare with highly\\nselective angiography and can be treated with i.v. antibiotics and\\nobservation. I will intervene with a resection if the patient deteriorates or\\nhas persistent symptoms of ischemia. My patients who are embolized are\\nobserved for 3 days after embolization to ensure they do not have signs\\nand symptoms of ischemia. Perforation is rare and really should not\\nhappen.\\n\\n Operating room\\n Whenever you encounter massive bleeding, the first thing\\n to remember is that it is not your blood.\\n\\n When the patient is on his fifth or sixth unit and blood is still\\ndripping from his rectum — after all your radiological or endoscopic\\nhemostatic efforts — it is time to take him to the operating room.\\nThis is not a common operation! With the advent of interventional\\nradiology and expert endoscopists, the need to operate on a massive\\nlower GI bleed is very rare. We perform no more than one or two of these\\noperations a year, but if you do need to operate this is how I recommend\\nyou approach the surgery.\\n\\n Be prepared. ħave blood available and the appropriate equipment.\\nThe patient should already have adequate i.v. access, but ensure you\\nhave adequate blood resources available in the room. ħave an\\nendoscope to perform either an esophagogastroduodenoscopy (EGD), if\\nneeded, or proctoscopy (a rigid sigmoidoscope will also work for the\\nproctoscopy). Finally, have an anorectal set with an anoscope.\\n\\n I position the patient in the lithotomy position even when they are\\nhypotensive. After intubation I will perform rigid or flexible\\nproctoscopy and anoscopy. It takes 2 minutes to look in the rectum\\nand the anus and will avoid you making a terrible mistake (as alluded to\\nabove). Remember that bleeding from the upper anal canal and\\nlower rectum will reflux at least to the rectosigmoid junction, so do',\n", " 'md': '```markdown\\n## Complications Related to Embolization\\n\\nThe main complications related to embolization are:\\n- Injury to the femoral vessel that was accessed for the angiogram (most commonly pseudoaneurysm).\\n- Renal insufficiency from the dye injected (10% or less).\\n- Ischemia of the embolized colon.\\n\\nIschemia is rare with highly selective angiography and can be treated with i.v. antibiotics and observation. I will intervene with a resection if the patient deteriorates or has persistent symptoms of ischemia. My patients who are embolized are observed for 3 days after embolization to ensure they do not have signs and symptoms of ischemia. Perforation is rare and really should not happen.\\n\\n## Operating Room\\n\\nWhenever you encounter massive bleeding, the first thing to remember is that it is not your blood.\\n\\nWhen the patient is on his fifth or sixth unit and blood is still dripping from his rectum — after all your radiological or endoscopic hemostatic efforts — it is time to take him to the operating room. This is not a common operation! With the advent of interventional radiology and expert endoscopists, the need to operate on a massive lower GI bleed is very rare. We perform no more than one or two of these operations a year, but if you do need to operate this is how I recommend you approach the surgery.\\n\\n### Preparation\\n\\n- Be prepared. Have blood available and the appropriate equipment.\\n- The patient should already have adequate i.v. access, but ensure you have adequate blood resources available in the room.\\n- Have an endoscope to perform either an esophagogastroduodenoscopy (EGD), if needed, or proctoscopy (a rigid sigmoidoscope will also work for the proctoscopy).\\n- Finally, have an anorectal set with an anoscope.\\n\\nI position the patient in the lithotomy position even when they are hypotensive. After intubation, I will perform rigid or flexible proctoscopy and anoscopy. It takes 2 minutes to look in the rectum and the anus and will avoid you making a terrible mistake (as alluded to above). Remember that bleeding from the upper anal canal and lower rectum will reflux at least to the rectosigmoid junction, so do...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Complications Related to Embolization',\n", " 'md': '## Complications Related to Embolization',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The main complications related to embolization are:\\n- Injury to the femoral vessel that was accessed for the angiogram (most commonly pseudoaneurysm).\\n- Renal insufficiency from the dye injected (10% or less).\\n- Ischemia of the embolized colon.\\n\\nIschemia is rare with highly selective angiography and can be treated with i.v. antibiotics and observation. I will intervene with a resection if the patient deteriorates or has persistent symptoms of ischemia. My patients who are embolized are observed for 3 days after embolization to ensure they do not have signs and symptoms of ischemia. Perforation is rare and really should not happen.',\n", " 'md': 'The main complications related to embolization are:\\n- Injury to the femoral vessel that was accessed for the angiogram (most commonly pseudoaneurysm).\\n- Renal insufficiency from the dye injected (10% or less).\\n- Ischemia of the embolized colon.\\n\\nIschemia is rare with highly selective angiography and can be treated with i.v. antibiotics and observation. I will intervene with a resection if the patient deteriorates or has persistent symptoms of ischemia. My patients who are embolized are observed for 3 days after embolization to ensure they do not have signs and symptoms of ischemia. Perforation is rare and really should not happen.',\n", " 'bBox': {'x': 72, 'y': 168, 'w': 467.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Operating Room',\n", " 'md': '## Operating Room',\n", " 'bBox': {'x': 86, 'y': 278, 'w': 124.13, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Whenever you encounter massive bleeding, the first thing to remember is that it is not your blood.\\n\\nWhen the patient is on his fifth or sixth unit and blood is still dripping from his rectum — after all your radiological or endoscopic hemostatic efforts — it is time to take him to the operating room. This is not a common operation! With the advent of interventional radiology and expert endoscopists, the need to operate on a massive lower GI bleed is very rare. We perform no more than one or two of these operations a year, but if you do need to operate this is how I recommend you approach the surgery.',\n", " 'md': 'Whenever you encounter massive bleeding, the first thing to remember is that it is not your blood.\\n\\nWhen the patient is on his fifth or sixth unit and blood is still dripping from his rectum — after all your radiological or endoscopic hemostatic efforts — it is time to take him to the operating room. This is not a common operation! With the advent of interventional radiology and expert endoscopists, the need to operate on a massive lower GI bleed is very rare. We perform no more than one or two of these operations a year, but if you do need to operate this is how I recommend you approach the surgery.',\n", " 'bBox': {'x': 72, 'y': 278, 'w': 467.76, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Preparation',\n", " 'md': '### Preparation',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Be prepared. Have blood available and the appropriate equipment.\\n- The patient should already have adequate i.v. access, but ensure you have adequate blood resources available in the room.\\n- Have an endoscope to perform either an esophagogastroduodenoscopy (EGD), if needed, or proctoscopy (a rigid sigmoidoscope will also work for the proctoscopy).\\n- Finally, have an anorectal set with an anoscope.\\n\\nI position the patient in the lithotomy position even when they are hypotensive. After intubation, I will perform rigid or flexible proctoscopy and anoscopy. It takes 2 minutes to look in the rectum and the anus and will avoid you making a terrible mistake (as alluded to above). Remember that bleeding from the upper anal canal and lower rectum will reflux at least to the rectosigmoid junction, so do...\\n```',\n", " 'md': '- Be prepared. Have blood available and the appropriate equipment.\\n- The patient should already have adequate i.v. access, but ensure you have adequate blood resources available in the room.\\n- Have an endoscope to perform either an esophagogastroduodenoscopy (EGD), if needed, or proctoscopy (a rigid sigmoidoscope will also work for the proctoscopy).\\n- Finally, have an anorectal set with an anoscope.\\n\\nI position the patient in the lithotomy position even when they are hypotensive. After intubation, I will perform rigid or flexible proctoscopy and anoscopy. It takes 2 minutes to look in the rectum and the anus and will avoid you making a terrible mistake (as alluded to above). Remember that bleeding from the upper anal canal and lower rectum will reflux at least to the rectosigmoid junction, so do...\\n```',\n", " 'bBox': {'x': 72, 'y': 562, 'w': 467.98, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 521,\n", " 'text': 'not be fooled by finding fresh blood at that level.\\n\\n I then perform a laparotomy through a long midline incision. There\\nis no role for the laparoscope or for a small incision in a bleeding patient.\\nI proceed to perform a quick exploration of the abdomen, looking for\\nblood in the small intestine. Blood in the proximal small bowel should\\nset off warning lights that perhaps there is actually bleeding coming\\nfrom an upper source (at this point you will be very happy to have the\\nupper endoscope set up and ready to go!). Make sure you don’t see a\\nMeckel’s diverticulum or a small bowel mass.\\n\\n Another option to locate bleeding in the small bowel is to have a sterile colonoscope — make a\\n small enterotomy half way in the small bowel and do an intra-operative enteroscopy. Ari\\n\\n If you are not absolutely sure of the location of the bleed in the colon, and I mean 100%\\n sure, then I suggest you perform a total colectomy. Any segmental resection of the\\n colon without definitive localization of the bleeding is gambling with the patient’s life\\n and well-being.\\n\\n Another point (call me dogmatic if you wish): if the patient has been\\nunstable during the operation or received (during the operation)\\nmore than two units of blood, then they will wake up with a stoma of\\nsome kind. Don’t gamble that they will heal an anastomosis. They will\\nforgive you the stoma.\\n\\n The extent of resection depends on the location of the bleed. As\\nmentioned, I only perform a segmental resection when I have clearly\\nlocated the bleeding point. If on the left side, and the bleeding is from\\ndiverticulosis, I will perform a resection as I would for a patient with\\ndiverticulitis. Resect the bleeding site and anything distal to that point\\ndown to the upper rectum, aiming to anastomose healthy colon to the\\nrectum. I have no data to support this recommendation, but do not relish\\nhaving to reoperate on an individual for diverticulitis or another bleed.\\nRight colectomies are adequate for bleeding from a site in the cecum or\\nascending colon. I would recommend an extended right colectomy for',\n", " 'md': '```markdown\\n## Surgical Approach to Bleeding in the Abdomen\\n\\n- Do not be fooled by finding fresh blood at that level.\\n- Perform a laparotomy through a long midline incision; there is no role for the laparoscope or for a small incision in a bleeding patient.\\n- Proceed to perform a quick exploration of the abdomen, looking for blood in the small intestine. Blood in the proximal small bowel should raise concerns about potential bleeding from an upper source. It is advisable to have the upper endoscope set up and ready to go.\\n- Ensure that you do not see a Meckel’s diverticulum or a small bowel mass.\\n\\n### Alternative Methods\\n- Another option to locate bleeding in the small bowel is to use a sterile colonoscope. Make a small enterotomy halfway in the small bowel and perform an intra-operative enteroscopy.\\n\\n### Colectomy Recommendations\\n- If you are not absolutely sure of the location of the bleed in the colon, I suggest performing a total colectomy. Any segmental resection of the colon without definitive localization of the bleeding is gambling with the patient’s life and well-being.\\n- If the patient has been unstable during the operation or has received more than two units of blood during the operation, they will wake up with a stoma of some kind. It is better to be cautious than to gamble on the healing of an anastomosis.\\n\\n### Resection Guidelines\\n- The extent of resection depends on the location of the bleed. Segmental resection is only performed when the bleeding point is clearly located.\\n- For bleeding on the left side from diverticulosis, perform a resection similar to that for diverticulitis. Resection should include the bleeding site and anything distal to that point down to the upper rectum, aiming to anastomose healthy colon to the rectum.\\n- Right colectomies are adequate for bleeding from a site in the cecum or ascending colon. An extended right colectomy is recommended for more extensive bleeding.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Approach to Bleeding in the Abdomen',\n", " 'md': '## Surgical Approach to Bleeding in the Abdomen',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Do not be fooled by finding fresh blood at that level.\\n- Perform a laparotomy through a long midline incision; there is no role for the laparoscope or for a small incision in a bleeding patient.\\n- Proceed to perform a quick exploration of the abdomen, looking for blood in the small intestine. Blood in the proximal small bowel should raise concerns about potential bleeding from an upper source. It is advisable to have the upper endoscope set up and ready to go.\\n- Ensure that you do not see a Meckel’s diverticulum or a small bowel mass.',\n", " 'md': '- Do not be fooled by finding fresh blood at that level.\\n- Perform a laparotomy through a long midline incision; there is no role for the laparoscope or for a small incision in a bleeding patient.\\n- Proceed to perform a quick exploration of the abdomen, looking for blood in the small intestine. Blood in the proximal small bowel should raise concerns about potential bleeding from an upper source. It is advisable to have the upper endoscope set up and ready to go.\\n- Ensure that you do not see a Meckel’s diverticulum or a small bowel mass.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.82, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Alternative Methods',\n", " 'md': '### Alternative Methods',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Another option to locate bleeding in the small bowel is to use a sterile colonoscope. Make a small enterotomy halfway in the small bowel and perform an intra-operative enteroscopy.',\n", " 'md': '- Another option to locate bleeding in the small bowel is to use a sterile colonoscope. Make a small enterotomy halfway in the small bowel and perform an intra-operative enteroscopy.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Colectomy Recommendations',\n", " 'md': '### Colectomy Recommendations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- If you are not absolutely sure of the location of the bleed in the colon, I suggest performing a total colectomy. Any segmental resection of the colon without definitive localization of the bleeding is gambling with the patient’s life and well-being.\\n- If the patient has been unstable during the operation or has received more than two units of blood during the operation, they will wake up with a stoma of some kind. It is better to be cautious than to gamble on the healing of an anastomosis.',\n", " 'md': '- If you are not absolutely sure of the location of the bleed in the colon, I suggest performing a total colectomy. Any segmental resection of the colon without definitive localization of the bleeding is gambling with the patient’s life and well-being.\\n- If the patient has been unstable during the operation or has received more than two units of blood during the operation, they will wake up with a stoma of some kind. It is better to be cautious than to gamble on the healing of an anastomosis.',\n", " 'bBox': {'x': 79, 'y': 390, 'w': 453.41, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Resection Guidelines',\n", " 'md': '### Resection Guidelines',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The extent of resection depends on the location of the bleed. Segmental resection is only performed when the bleeding point is clearly located.\\n- For bleeding on the left side from diverticulosis, perform a resection similar to that for diverticulitis. Resection should include the bleeding site and anything distal to that point down to the upper rectum, aiming to anastomose healthy colon to the rectum.\\n- Right colectomies are adequate for bleeding from a site in the cecum or ascending colon. An extended right colectomy is recommended for more extensive bleeding.\\n\\n```',\n", " 'md': '- The extent of resection depends on the location of the bleed. Segmental resection is only performed when the bleeding point is clearly located.\\n- For bleeding on the left side from diverticulosis, perform a resection similar to that for diverticulitis. Resection should include the bleeding site and anything distal to that point down to the upper rectum, aiming to anastomose healthy colon to the rectum.\\n- Right colectomies are adequate for bleeding from a site in the cecum or ascending colon. An extended right colectomy is recommended for more extensive bleeding.\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 688, 'w': 467.91, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 522,\n", " 'text': \"those patients with bleeding from anywhere in the transverse colon,\\nanastomosing the ileum to the distal transverse or proximal descending\\ncolon.\\n\\n Specific etiologies of LGIB ( Table 29.1)\\n\\n Diverticulosis and arteriovenous malformations (AVMs)\\n\\n Diverticulosis and arteriovenous malformations (AVMs) are the\\ntwo most common causes of LGIB and vie for the number one spot.\\nDiverticular bleeds are more common on the left, while AVMs are\\nmore common on the right. Diverticular bleeds tend to be more\\ncommonly seen than AVMs. AVMs are thought to be associated with\\ncardiac valvular disease so make sure those patients are not on\\nantiplatelet medications or anticoagulation.\\n Table 29.1. Etiologies of lower GI bleeding:\\n Diverticulosis diverticulitis_\\n Vascular malformation angiodysplasia_\\n Ischemic colitis\\n Neoplasm.\\n Inflammatory bowel disease:\\n Hemorrhoids\\n Postoperative anastomotic.\\n Meckel's diverticulum:\\n Infectious.\\n Malignancies\\n\\n Colon or rectal cancer are common bleeding entities, but rarely cause\\nmassive bleeding. Rectal cancer may be associated with other symptoms\\nand will be seen at proctoscopy. The obvious management for colon\\ncancer is resection. For rectal cancer, if the bleeding is not massive (or, if\\nmassive, has stopped), I would proceed with neoadjuvant therapy prior to\",\n", " 'md': \"```markdown\\n## Lower Gastrointestinal Bleeding (LGIB)\\n\\nThose patients with bleeding from anywhere in the transverse colon, anastomosing the ileum to the distal transverse or proximal descending colon.\\n\\n### Specific Etiologies of LGIB\\n\\n#### Diverticulosis and Arteriovenous Malformations (AVMs)\\n\\nDiverticulosis and arteriovenous malformations (AVMs) are the two most common causes of LGIB and vie for the number one spot. Diverticular bleeds are more common on the left, while AVMs are more common on the right. Diverticular bleeds tend to be more commonly seen than AVMs. AVMs are thought to be associated with cardiac valvular disease, so make sure those patients are not on antiplatelet medications or anticoagulation.\\n\\n### Table 29.1. Etiologies of Lower GI Bleeding\\n\\n| Etiology |\\n|---------------------------------|\\n| Diverticulosis |\\n| Diverticulitis |\\n| Vascular malformation |\\n| Angiodysplasia |\\n| Ischemic colitis |\\n| Neoplasm |\\n| Inflammatory bowel disease |\\n| Hemorrhoids |\\n| Postoperative anastomotic |\\n| Meckel's diverticulum |\\n| Infectious |\\n\\n### Malignancies\\n\\nColon or rectal cancer are common bleeding entities, but rarely cause massive bleeding. Rectal cancer may be associated with other symptoms and will be seen at proctoscopy. The obvious management for colon cancer is resection. For rectal cancer, if the bleeding is not massive (or, if massive, has stopped), I would proceed with neoadjuvant therapy prior to...\\n```\",\n", " 'images': [{'name': 'img_p521_1.png',\n", " 'height': 430,\n", " 'width': 811,\n", " 'x': 105.84000000000015,\n", " 'y': 354.96000000000004,\n", " 'original_width': 1392,\n", " 'original_height': 736}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Lower Gastrointestinal Bleeding (LGIB)',\n", " 'md': '## Lower Gastrointestinal Bleeding (LGIB)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Those patients with bleeding from anywhere in the transverse colon, anastomosing the ileum to the distal transverse or proximal descending colon.',\n", " 'md': 'Those patients with bleeding from anywhere in the transverse colon, anastomosing the ileum to the distal transverse or proximal descending colon.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 38.39, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Specific Etiologies of LGIB',\n", " 'md': '### Specific Etiologies of LGIB',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Diverticulosis and Arteriovenous Malformations (AVMs)',\n", " 'md': '#### Diverticulosis and Arteriovenous Malformations (AVMs)',\n", " 'bBox': {'x': 86, 'y': 206, 'w': 435.55, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Diverticulosis and arteriovenous malformations (AVMs) are the two most common causes of LGIB and vie for the number one spot. Diverticular bleeds are more common on the left, while AVMs are more common on the right. Diverticular bleeds tend to be more commonly seen than AVMs. AVMs are thought to be associated with cardiac valvular disease, so make sure those patients are not on antiplatelet medications or anticoagulation.',\n", " 'md': 'Diverticulosis and arteriovenous malformations (AVMs) are the two most common causes of LGIB and vie for the number one spot. Diverticular bleeds are more common on the left, while AVMs are more common on the right. Diverticular bleeds tend to be more commonly seen than AVMs. AVMs are thought to be associated with cardiac valvular disease, so make sure those patients are not on antiplatelet medications or anticoagulation.',\n", " 'bBox': {'x': 72, 'y': 206, 'w': 449.55, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 29.1. Etiologies of Lower GI Bleeding',\n", " 'md': '### Table 29.1. Etiologies of Lower GI Bleeding',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Etiology'],\n", " ['Diverticulosis'],\n", " ['Diverticulitis'],\n", " ['Vascular malformation'],\n", " ['Angiodysplasia'],\n", " ['Ischemic colitis'],\n", " ['Neoplasm'],\n", " ['Inflammatory bowel disease'],\n", " ['Hemorrhoids'],\n", " ['Postoperative anastomotic'],\n", " [\"Meckel's diverticulum\"],\n", " ['Infectious']],\n", " 'md': \"| Etiology |\\n|---------------------------------|\\n| Diverticulosis |\\n| Diverticulitis |\\n| Vascular malformation |\\n| Angiodysplasia |\\n| Ischemic colitis |\\n| Neoplasm |\\n| Inflammatory bowel disease |\\n| Hemorrhoids |\\n| Postoperative anastomotic |\\n| Meckel's diverticulum |\\n| Infectious |\",\n", " 'isPerfectTable': True,\n", " 'csv': '\"Etiology\"\\n\"Diverticulosis\"\\n\"Diverticulitis\"\\n\"Vascular malformation\"\\n\"Angiodysplasia\"\\n\"Ischemic colitis\"\\n\"Neoplasm\"\\n\"Inflammatory bowel disease\"\\n\"Hemorrhoids\"\\n\"Postoperative anastomotic\"\\n\"Meckel\\'s diverticulum\"\\n\"Infectious\"',\n", " 'bBox': {'x': 152.32, 'y': 402.38, 'w': 105.82, 'h': 12.84}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Malignancies',\n", " 'md': '### Malignancies',\n", " 'bBox': {'x': 86, 'y': 607, 'w': 103.92, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Colon or rectal cancer are common bleeding entities, but rarely cause massive bleeding. Rectal cancer may be associated with other symptoms and will be seen at proctoscopy. The obvious management for colon cancer is resection. For rectal cancer, if the bleeding is not massive (or, if massive, has stopped), I would proceed with neoadjuvant therapy prior to...\\n```',\n", " 'md': 'Colon or rectal cancer are common bleeding entities, but rarely cause massive bleeding. Rectal cancer may be associated with other symptoms and will be seen at proctoscopy. The obvious management for colon cancer is resection. For rectal cancer, if the bleeding is not massive (or, if massive, has stopped), I would proceed with neoadjuvant therapy prior to...\\n```',\n", " 'bBox': {'x': 72, 'y': 643, 'w': 467.71, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 523,\n", " 'text': 'surgery.\\n\\n Bleeding from a rectal cancer that cannot be controlled\\nendoscopically with fulgarization often must be managed in the\\noperating room. If a distal tumor is present then a transanal approach to\\ncauterize, fulgarize, or suture the bleeding point should be used. If the\\nbleeding cannot be stopped in this manner, then packing the rectum\\nwith epinephrine-saturated gauze will almost always control the\\nbleeding. I like to use vaginal packing for this, and have found that this\\nwill often stop the bleeding to allow for a more elective resection.\\nUltimately, the best therapy for a bleeding rectal tumor is to remove the\\ntumor, and if bleeding cannot be stopped by the above methods, then an\\nemergent resection is required. If the acute bleed can be stopped or\\nslowed, then treating with neoadjuvant radiation therapy will stop any\\nchronic bleeding, prevent a massive rebleed, and allow for a less urgent\\nresection.\\n\\n Inflammatory bowel disease (IBD)\\n\\n It is very rare for bleeding to be the initial presentation of either Crohn’s\\nor ulcerative colitis and equally rare for it to be the cause of significant\\nLGIB. Most patients will present with a history of IBD and if they do\\nsustain massive bleeding from colitis the treatment of choice is total\\ncolectomy with ileostomy. A massive bleed in the face of colitis is, in\\nmy opinion, a failure of medical management and the colon belongs\\nwith the pathologist. Ensure the patient does not have an infectious\\ncondition causing the bleeding, especially if it is intermittent.\\n\\n Ischemic colitis\\n\\n Ischemic colitis may present with a massive bleed, although it usually\\noccurs in a slower and steadier pace. Diagnostic steps are as mentioned\\nabove but this group of patients, if stable, benefits from a pre-operative\\nCT angiogram. Colonic ischemia may be related to other mesenteric\\nvascular insufficiencies and the angiogram may help identify this. At\\noperation just resect the ischemic segment of colon. If you choose to\\nmaintain intestinal continuity then be sure of the viability of the intestine',\n", " 'md': '```markdown\\n# Management of Bleeding in Rectal Cancer and Related Conditions\\n\\n## Bleeding from Rectal Cancer\\nBleeding from a rectal cancer that cannot be controlled endoscopically with fulgarization often must be managed in the operating room. If a distal tumor is present, then a transanal approach to cauterize, fulgarize, or suture the bleeding point should be used. If the bleeding cannot be stopped in this manner, then packing the rectum with epinephrine-saturated gauze will almost always control the bleeding. I like to use vaginal packing for this, and have found that this will often stop the bleeding to allow for a more elective resection. Ultimately, the best therapy for a bleeding rectal tumor is to remove the tumor, and if bleeding cannot be stopped by the above methods, then an emergent resection is required. If the acute bleed can be stopped or slowed, then treating with neoadjuvant radiation therapy will stop any chronic bleeding, prevent a massive rebleed, and allow for a less urgent resection.\\n\\n## Inflammatory Bowel Disease (IBD)\\nIt is very rare for bleeding to be the initial presentation of either Crohn’s or ulcerative colitis and equally rare for it to be the cause of significant lower gastrointestinal bleeding (LGIB). Most patients will present with a history of IBD, and if they do sustain massive bleeding from colitis, the treatment of choice is total colectomy with ileostomy. A massive bleed in the face of colitis is, in my opinion, a failure of medical management and the colon belongs with the pathologist. Ensure the patient does not have an infectious condition causing the bleeding, especially if it is intermittent.\\n\\n## Ischemic Colitis\\nIschemic colitis may present with a massive bleed, although it usually occurs in a slower and steadier pace. Diagnostic steps are as mentioned above, but this group of patients, if stable, benefits from a pre-operative CT angiogram. Colonic ischemia may be related to other mesenteric vascular insufficiencies, and the angiogram may help identify this. At operation, just resect the ischemic segment of colon. If you choose to maintain intestinal continuity, then be sure of the viability of the intestine.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management of Bleeding in Rectal Cancer and Related Conditions',\n", " 'md': '# Management of Bleeding in Rectal Cancer and Related Conditions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Bleeding from Rectal Cancer',\n", " 'md': '## Bleeding from Rectal Cancer',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Bleeding from a rectal cancer that cannot be controlled endoscopically with fulgarization often must be managed in the operating room. If a distal tumor is present, then a transanal approach to cauterize, fulgarize, or suture the bleeding point should be used. If the bleeding cannot be stopped in this manner, then packing the rectum with epinephrine-saturated gauze will almost always control the bleeding. I like to use vaginal packing for this, and have found that this will often stop the bleeding to allow for a more elective resection. Ultimately, the best therapy for a bleeding rectal tumor is to remove the tumor, and if bleeding cannot be stopped by the above methods, then an emergent resection is required. If the acute bleed can be stopped or slowed, then treating with neoadjuvant radiation therapy will stop any chronic bleeding, prevent a massive rebleed, and allow for a less urgent resection.',\n", " 'md': 'Bleeding from a rectal cancer that cannot be controlled endoscopically with fulgarization often must be managed in the operating room. If a distal tumor is present, then a transanal approach to cauterize, fulgarize, or suture the bleeding point should be used. If the bleeding cannot be stopped in this manner, then packing the rectum with epinephrine-saturated gauze will almost always control the bleeding. I like to use vaginal packing for this, and have found that this will often stop the bleeding to allow for a more elective resection. Ultimately, the best therapy for a bleeding rectal tumor is to remove the tumor, and if bleeding cannot be stopped by the above methods, then an emergent resection is required. If the acute bleed can be stopped or slowed, then treating with neoadjuvant radiation therapy will stop any chronic bleeding, prevent a massive rebleed, and allow for a less urgent resection.',\n", " 'bBox': {'x': 72, 'y': 187, 'w': 467.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Inflammatory Bowel Disease (IBD)',\n", " 'md': '## Inflammatory Bowel Disease (IBD)',\n", " 'bBox': {'x': 86, 'y': 379, 'w': 264.82, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'It is very rare for bleeding to be the initial presentation of either Crohn’s or ulcerative colitis and equally rare for it to be the cause of significant lower gastrointestinal bleeding (LGIB). Most patients will present with a history of IBD, and if they do sustain massive bleeding from colitis, the treatment of choice is total colectomy with ileostomy. A massive bleed in the face of colitis is, in my opinion, a failure of medical management and the colon belongs with the pathologist. Ensure the patient does not have an infectious condition causing the bleeding, especially if it is intermittent.',\n", " 'md': 'It is very rare for bleeding to be the initial presentation of either Crohn’s or ulcerative colitis and equally rare for it to be the cause of significant lower gastrointestinal bleeding (LGIB). Most patients will present with a history of IBD, and if they do sustain massive bleeding from colitis, the treatment of choice is total colectomy with ileostomy. A massive bleed in the face of colitis is, in my opinion, a failure of medical management and the colon belongs with the pathologist. Ensure the patient does not have an infectious condition causing the bleeding, especially if it is intermittent.',\n", " 'bBox': {'x': 72, 'y': 415, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Ischemic Colitis',\n", " 'md': '## Ischemic Colitis',\n", " 'bBox': {'x': 86, 'y': 574, 'w': 123.21, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Ischemic colitis may present with a massive bleed, although it usually occurs in a slower and steadier pace. Diagnostic steps are as mentioned above, but this group of patients, if stable, benefits from a pre-operative CT angiogram. Colonic ischemia may be related to other mesenteric vascular insufficiencies, and the angiogram may help identify this. At operation, just resect the ischemic segment of colon. If you choose to maintain intestinal continuity, then be sure of the viability of the intestine.\\n```',\n", " 'md': 'Ischemic colitis may present with a massive bleed, although it usually occurs in a slower and steadier pace. Diagnostic steps are as mentioned above, but this group of patients, if stable, benefits from a pre-operative CT angiogram. Colonic ischemia may be related to other mesenteric vascular insufficiencies, and the angiogram may help identify this. At operation, just resect the ischemic segment of colon. If you choose to maintain intestinal continuity, then be sure of the viability of the intestine.\\n```',\n", " 'bBox': {'x': 72, 'y': 574, 'w': 467.95, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 524,\n", " 'text': 'you are anastomosing. But this is yet another group of patients in\\nwhom I favor bringing out a stoma.\\n\\n Anorectal conditions\\n\\n All of these conditions can bleed profusely and may be difficult to deal\\nwith. If your patient is hypotensive from a distal rectal or anal site of\\nbleeding and you need to obtain temporary control, place a 30cc\\nballoon Foley catheter in the rectum, blow up the balloon and pull\\ntight against the anus. This should tamponade the bleeding until the\\npatient can reach the operating room. ħave a medical student or resident\\nhold the pressure while you get the patient to the OR. I would approach\\nall of these patients in the prone jack-knife position. It gives you a\\nbetter ability to suction away the blood, thereby giving you better visibility,\\nand a better ability to ligate the bleeding source.\\n\\n Radiation proctitis\\n\\n The history of radiation therapy to the prostate or cervix should\\nlead you to identify these patients. Bleeding can be brisk at times and\\nmay require intervention with either cauterization or suture. Simple\\npressure can often stop the bleeding acutely although for massive\\nbleeding a stitch is usually required. If the bleeding is coming from a\\nsource high in the rectum, an endoscopic approach may be required and\\nI would follow the guidelines described above. Topical formalin therapy\\nfor less severe bleeding from radiation proctitis works well, but will not\\nwork for a massive bleed. For lesser bleeds treated with formalin, several\\napplications may be required and I perform this in the office using an\\nanoscope and large q-tip applicator and 3% formalin. Coagulation may\\nalso be used for bleeding from radiation proctitis. Argon beam\\ncoagulation has been used by some effectively.\\n\\n Postoperative anastomotic bleed\\n\\n If the patient has significant persistent bleeding from a colonic,\\nileocolic, or colorectal anastomosis, then they should undergo early',\n", " 'md': '```markdown\\n## Anorectal Conditions\\n\\nAll of these conditions can bleed profusely and may be difficult to deal with. If your patient is hypotensive from a distal rectal or anal site of bleeding and you need to obtain temporary control, place a 30cc balloon Foley catheter in the rectum, blow up the balloon and pull tight against the anus. This should tamponade the bleeding until the patient can reach the operating room. Have a medical student or resident hold the pressure while you get the patient to the OR. I would approach all of these patients in the prone jack-knife position. It gives you a better ability to suction away the blood, thereby giving you better visibility, and a better ability to ligate the bleeding source.\\n\\n## Radiation Proctitis\\n\\nThe history of radiation therapy to the prostate or cervix should lead you to identify these patients. Bleeding can be brisk at times and may require intervention with either cauterization or suture. Simple pressure can often stop the bleeding acutely although for massive bleeding a stitch is usually required. If the bleeding is coming from a source high in the rectum, an endoscopic approach may be required and I would follow the guidelines described above. Topical formalin therapy for less severe bleeding from radiation proctitis works well, but will not work for a massive bleed. For lesser bleeds treated with formalin, several applications may be required and I perform this in the office using an anoscope and large q-tip applicator and 3% formalin. Coagulation may also be used for bleeding from radiation proctitis. Argon beam coagulation has been used by some effectively.\\n\\n## Postoperative Anastomotic Bleed\\n\\nIf the patient has significant persistent bleeding from a colonic, ileocolic, or colorectal anastomosis, then they should undergo early intervention.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Anorectal Conditions',\n", " 'md': '## Anorectal Conditions',\n", " 'bBox': {'x': 86, 'y': 145, 'w': 164.59, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'All of these conditions can bleed profusely and may be difficult to deal with. If your patient is hypotensive from a distal rectal or anal site of bleeding and you need to obtain temporary control, place a 30cc balloon Foley catheter in the rectum, blow up the balloon and pull tight against the anus. This should tamponade the bleeding until the patient can reach the operating room. Have a medical student or resident hold the pressure while you get the patient to the OR. I would approach all of these patients in the prone jack-knife position. It gives you a better ability to suction away the blood, thereby giving you better visibility, and a better ability to ligate the bleeding source.',\n", " 'md': 'All of these conditions can bleed profusely and may be difficult to deal with. If your patient is hypotensive from a distal rectal or anal site of bleeding and you need to obtain temporary control, place a 30cc balloon Foley catheter in the rectum, blow up the balloon and pull tight against the anus. This should tamponade the bleeding until the patient can reach the operating room. Have a medical student or resident hold the pressure while you get the patient to the OR. I would approach all of these patients in the prone jack-knife position. It gives you a better ability to suction away the blood, thereby giving you better visibility, and a better ability to ligate the bleeding source.',\n", " 'bBox': {'x': 72, 'y': 181, 'w': 467.72, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Radiation Proctitis',\n", " 'md': '## Radiation Proctitis',\n", " 'bBox': {'x': 86, 'y': 373, 'w': 145.26, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The history of radiation therapy to the prostate or cervix should lead you to identify these patients. Bleeding can be brisk at times and may require intervention with either cauterization or suture. Simple pressure can often stop the bleeding acutely although for massive bleeding a stitch is usually required. If the bleeding is coming from a source high in the rectum, an endoscopic approach may be required and I would follow the guidelines described above. Topical formalin therapy for less severe bleeding from radiation proctitis works well, but will not work for a massive bleed. For lesser bleeds treated with formalin, several applications may be required and I perform this in the office using an anoscope and large q-tip applicator and 3% formalin. Coagulation may also be used for bleeding from radiation proctitis. Argon beam coagulation has been used by some effectively.',\n", " 'md': 'The history of radiation therapy to the prostate or cervix should lead you to identify these patients. Bleeding can be brisk at times and may require intervention with either cauterization or suture. Simple pressure can often stop the bleeding acutely although for massive bleeding a stitch is usually required. If the bleeding is coming from a source high in the rectum, an endoscopic approach may be required and I would follow the guidelines described above. Topical formalin therapy for less severe bleeding from radiation proctitis works well, but will not work for a massive bleed. For lesser bleeds treated with formalin, several applications may be required and I perform this in the office using an anoscope and large q-tip applicator and 3% formalin. Coagulation may also be used for bleeding from radiation proctitis. Argon beam coagulation has been used by some effectively.',\n", " 'bBox': {'x': 72, 'y': 373, 'w': 467.96, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Postoperative Anastomotic Bleed',\n", " 'md': '## Postoperative Anastomotic Bleed',\n", " 'bBox': {'x': 86, 'y': 651, 'w': 259.33, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'If the patient has significant persistent bleeding from a colonic, ileocolic, or colorectal anastomosis, then they should undergo early intervention.\\n```',\n", " 'md': 'If the patient has significant persistent bleeding from a colonic, ileocolic, or colorectal anastomosis, then they should undergo early intervention.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 525,\n", " 'text': 'colonoscopy. Early endoscopic intervention avoids significant blood\\ntransfusions and can be accomplished safely in the early postoperative\\nperiod (make sure the endoscopist is skilled and either you are\\nperforming the scope or are present at the procedure). For these\\npatients I will attempt injection with epinephrine and then placement\\nof clips, or just clips if it is easy to identify and place the clip. I try to\\navoid cauterization, but it can be used sparingly to gain initial control\\nbefore placing a clip.\\n\\n Summary of our approach\\n\\n • Start with supportive care. Exclude UGI bleeding by inserting a\\n nasogastric tube. There is no need for a routine UGI endoscopy —\\n as fresh blood per rectum in a stable patient means that the source\\n is not in the UGI tract. Do a rectoscopy to rule out an anorectal\\n source.\\n • When the patient requires the second and third unit of blood it\\n is time to get a little excited. Angiography at this stage is indicated\\n — if it localizes the source of bleeding in the left or right colon so\\n much the better. If it fails — not a big deal. If you must obtain a\\n nuclear scan to proceed to angiogram, than do what you must, but\\n remember only those scans that are positive in the first 30 minutes\\n mean anything (nuclear medicine = unclear medicine).\\n • When the patient is on his fifth or sixth unit and blood is still\\n dripping from his rectum — it is time to take him to the\\n operating room. If angiography has localized the source in either\\n the left or right colon proceed with a segmental colectomy — either\\n right or left hemicolectomy. If angiography is not available or is\\n non-localizing, then do a subtotal colectomy with ileorectal\\n anastomosis or a stoma based on the stability and health of the\\n patient, and on how much blood he required — in our hands,\\n most such patients would end up with a stoma! ‘Blind’\\n segmental colectomy may produce a rebleeder in patients who\\n won’t tolerate a major reoperation.\\n • A few authors have described intra-operative colonoscopy after ‘on-\\n table’ colonic lavage. Theoretically it appears attractive but\\n practically it is messy and time consuming. If the hemorrhage has',\n", " 'md': '```markdown\\n## Summary of Our Approach\\n\\n- Start with supportive care. Exclude UGI bleeding by inserting a nasogastric tube. There is no need for a routine UGI endoscopy — as fresh blood per rectum in a stable patient means that the source is not in the UGI tract. Do a rectoscopy to rule out an anorectal source.\\n- When the patient requires the second and third unit of blood it is time to get a little excited. Angiography at this stage is indicated — if it localizes the source of bleeding in the left or right colon so much the better. If it fails — not a big deal. If you must obtain a nuclear scan to proceed to angiogram, then do what you must, but remember only those scans that are positive in the first 30 minutes mean anything (nuclear medicine = unclear medicine).\\n- When the patient is on his fifth or sixth unit and blood is still dripping from his rectum — it is time to take him to the operating room. If angiography has localized the source in either the left or right colon proceed with a segmental colectomy — either right or left hemicolectomy. If angiography is not available or is non-localizing, then do a subtotal colectomy with ileorectal anastomosis or a stoma based on the stability and health of the patient, and on how much blood he required — in our hands, most such patients would end up with a stoma! ‘Blind’ segmental colectomy may produce a rebleeder in patients who won’t tolerate a major reoperation.\\n- A few authors have described intra-operative colonoscopy after ‘on-table’ colonic lavage. Theoretically it appears attractive but practically it is messy and time consuming. If the hemorrhage has...\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary of Our Approach',\n", " 'md': '## Summary of Our Approach',\n", " 'bBox': {'x': 86, 'y': 245, 'w': 205.98, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Start with supportive care. Exclude UGI bleeding by inserting a nasogastric tube. There is no need for a routine UGI endoscopy — as fresh blood per rectum in a stable patient means that the source is not in the UGI tract. Do a rectoscopy to rule out an anorectal source.\\n- When the patient requires the second and third unit of blood it is time to get a little excited. Angiography at this stage is indicated — if it localizes the source of bleeding in the left or right colon so much the better. If it fails — not a big deal. If you must obtain a nuclear scan to proceed to angiogram, then do what you must, but remember only those scans that are positive in the first 30 minutes mean anything (nuclear medicine = unclear medicine).\\n- When the patient is on his fifth or sixth unit and blood is still dripping from his rectum — it is time to take him to the operating room. If angiography has localized the source in either the left or right colon proceed with a segmental colectomy — either right or left hemicolectomy. If angiography is not available or is non-localizing, then do a subtotal colectomy with ileorectal anastomosis or a stoma based on the stability and health of the patient, and on how much blood he required — in our hands, most such patients would end up with a stoma! ‘Blind’ segmental colectomy may produce a rebleeder in patients who won’t tolerate a major reoperation.\\n- A few authors have described intra-operative colonoscopy after ‘on-table’ colonic lavage. Theoretically it appears attractive but practically it is messy and time consuming. If the hemorrhage has...\\n\\n```',\n", " 'md': '- Start with supportive care. Exclude UGI bleeding by inserting a nasogastric tube. There is no need for a routine UGI endoscopy — as fresh blood per rectum in a stable patient means that the source is not in the UGI tract. Do a rectoscopy to rule out an anorectal source.\\n- When the patient requires the second and third unit of blood it is time to get a little excited. Angiography at this stage is indicated — if it localizes the source of bleeding in the left or right colon so much the better. If it fails — not a big deal. If you must obtain a nuclear scan to proceed to angiogram, then do what you must, but remember only those scans that are positive in the first 30 minutes mean anything (nuclear medicine = unclear medicine).\\n- When the patient is on his fifth or sixth unit and blood is still dripping from his rectum — it is time to take him to the operating room. If angiography has localized the source in either the left or right colon proceed with a segmental colectomy — either right or left hemicolectomy. If angiography is not available or is non-localizing, then do a subtotal colectomy with ileorectal anastomosis or a stoma based on the stability and health of the patient, and on how much blood he required — in our hands, most such patients would end up with a stoma! ‘Blind’ segmental colectomy may produce a rebleeder in patients who won’t tolerate a major reoperation.\\n- A few authors have described intra-operative colonoscopy after ‘on-table’ colonic lavage. Theoretically it appears attractive but practically it is messy and time consuming. If the hemorrhage has...\\n\\n```',\n", " 'bBox': {'x': 100, 'y': 298, 'w': 437.72, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 526,\n", " 'text': ' stopped it won’t show us much; try it and see what angiodysplasia is\\n and what just some old clotted blood looks like!\\n• There is no doubt that in practice we are over-investigating\\n these patients and often waiting too long prior to operation. The\\n bleeding either stops or continues; when it continues you must\\n operate — on a well-resuscitated patient who has not been allowed\\n to deteriorate in a medical ward. A fast subtotal colectomy is a\\n safe, definitive, and life-saving procedure.\\n\\n“Beware: in lower gastrointestinal bleeding, removing the\\nwrong side of the colon is embarrassing. Removing any\\nsegment of the colon while the bleeding source is in the\\nanorectum — or the small bowel — is shameful.”',\n", " 'md': '```markdown\\n## Page Content\\n\\nThere is no doubt that in practice we are over-investigating these patients and often waiting too long prior to operation. The bleeding either stops or continues; when it continues you must operate — on a well-resuscitated patient who has not been allowed to deteriorate in a medical ward. A fast subtotal colectomy is a safe, definitive, and life-saving procedure.\\n\\n> \"Beware: in lower gastrointestinal bleeding, removing the wrong side of the colon is embarrassing. Removing any segment of the colon while the bleeding source is in the anorectum — or the small bowel — is shameful.\"\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'There is no doubt that in practice we are over-investigating these patients and often waiting too long prior to operation. The bleeding either stops or continues; when it continues you must operate — on a well-resuscitated patient who has not been allowed to deteriorate in a medical ward. A fast subtotal colectomy is a safe, definitive, and life-saving procedure.\\n\\n> \"Beware: in lower gastrointestinal bleeding, removing the wrong side of the colon is embarrassing. Removing any segment of the colon while the bleeding source is in the anorectum — or the small bowel — is shameful.\"\\n```',\n", " 'md': 'There is no doubt that in practice we are over-investigating these patients and often waiting too long prior to operation. The bleeding either stops or continues; when it continues you must operate — on a well-resuscitated patient who has not been allowed to deteriorate in a medical ward. A fast subtotal colectomy is a safe, definitive, and life-saving procedure.\\n\\n> \"Beware: in lower gastrointestinal bleeding, removing the wrong side of the colon is embarrassing. Removing any segment of the colon while the bleeding source is in the anorectum — or the small bowel — is shameful.\"\\n```',\n", " 'bBox': {'x': 79, 'y': 138, 'w': 458.5, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 527,\n", " 'text': 'Chapter 30\\nAnorectal emergencies\\nJonathan E. Efron 1\\n\\n We suffer and die through the defects that arise in our\\n sewerage and drainage system.\\n William A. Lane\\n\\n Why have a chapter about anorectal emergencies in a book about\\nemergency abdominal surgery? The easiest answer would be one based\\non anatomy: the rectum is an abdominal viscus and the anus, although\\nnot strictly abdominal, belongs to the perineum, which sensu lato is the\\nfloor of the abdominal cavity. But the main reason for inclusion is\\npragmatic: anorectal emergencies are managed by the general surgeon\\non duty, who has to provide optimal care to these frequent emergencies (\\n Figure 30.1).\\n\\n There are but a few things that are as satisfying as well-formed\\nbowel movement. Anorectal emergencies interfere with this joy and\\ngenerally make a patient’s life misery. All anorectal emergencies deal\\nwith either trapped pus (abscess), trapped clot (thrombosed\\nhemorrhoid), or tears in the anoderm (fissure), result in severe pain\\nand in the case of infections may result in serious morbidity or even\\nmortality. A surgeon’s approach to these emergencies should be to\\ndecrease the pain and eliminate risk from infection while minimizing\\ncollateral damage to the anal complex. In this chapter, we will discuss\\nseveral different anorectal emergencies.',\n", " 'md': '```markdown\\n# Chapter 30: Anorectal Emergencies\\n\\n**Jonathan E. Efron**\\n\\n> \"We suffer and die through the defects that arise in our sewerage and drainage system.\"\\n> — William A. Lane\\n\\n## Introduction\\n\\nWhy have a chapter about anorectal emergencies in a book about emergency abdominal surgery? The easiest answer would be one based on anatomy: the rectum is an abdominal viscus and the anus, although not strictly abdominal, belongs to the perineum, which sensu lato is the floor of the abdominal cavity. But the main reason for inclusion is pragmatic: anorectal emergencies are managed by the general surgeon on duty, who has to provide optimal care to these frequent emergencies (Figure 30.1).\\n\\nThere are but a few things that are as satisfying as well-formed bowel movement. Anorectal emergencies interfere with this joy and generally make a patient’s life misery. All anorectal emergencies deal with either trapped pus (abscess), trapped clot (thrombosed hemorrhoid), or tears in the anoderm (fissure), resulting in severe pain and, in the case of infections, may result in serious morbidity or even mortality. A surgeon’s approach to these emergencies should be to decrease the pain and eliminate risk from infection while minimizing collateral damage to the anal complex. In this chapter, we will discuss several different anorectal emergencies.\\n\\n## Figure Descriptions\\n\\n### Figure 30.1\\n- **Description**: This figure likely illustrates the anatomical relationships or common conditions associated with anorectal emergencies.\\n- **Summary**: The figure serves to provide visual context for the discussion of anorectal emergencies, emphasizing the importance of understanding the anatomy involved in these conditions.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 30: Anorectal Emergencies',\n", " 'md': '# Chapter 30: Anorectal Emergencies',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 206.07, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Jonathan E. Efron**\\n\\n> \"We suffer and die through the defects that arise in our sewerage and drainage system.\"\\n> — William A. Lane',\n", " 'md': '**Jonathan E. Efron**\\n\\n> \"We suffer and die through the defects that arise in our sewerage and drainage system.\"\\n> — William A. Lane',\n", " 'bBox': {'x': 108, 'y': 326, 'w': 203.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Introduction',\n", " 'md': '## Introduction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Why have a chapter about anorectal emergencies in a book about emergency abdominal surgery? The easiest answer would be one based on anatomy: the rectum is an abdominal viscus and the anus, although not strictly abdominal, belongs to the perineum, which sensu lato is the floor of the abdominal cavity. But the main reason for inclusion is pragmatic: anorectal emergencies are managed by the general surgeon on duty, who has to provide optimal care to these frequent emergencies (Figure 30.1).\\n\\nThere are but a few things that are as satisfying as well-formed bowel movement. Anorectal emergencies interfere with this joy and generally make a patient’s life misery. All anorectal emergencies deal with either trapped pus (abscess), trapped clot (thrombosed hemorrhoid), or tears in the anoderm (fissure), resulting in severe pain and, in the case of infections, may result in serious morbidity or even mortality. A surgeon’s approach to these emergencies should be to decrease the pain and eliminate risk from infection while minimizing collateral damage to the anal complex. In this chapter, we will discuss several different anorectal emergencies.',\n", " 'md': 'Why have a chapter about anorectal emergencies in a book about emergency abdominal surgery? The easiest answer would be one based on anatomy: the rectum is an abdominal viscus and the anus, although not strictly abdominal, belongs to the perineum, which sensu lato is the floor of the abdominal cavity. But the main reason for inclusion is pragmatic: anorectal emergencies are managed by the general surgeon on duty, who has to provide optimal care to these frequent emergencies (Figure 30.1).\\n\\nThere are but a few things that are as satisfying as well-formed bowel movement. Anorectal emergencies interfere with this joy and generally make a patient’s life misery. All anorectal emergencies deal with either trapped pus (abscess), trapped clot (thrombosed hemorrhoid), or tears in the anoderm (fissure), resulting in severe pain and, in the case of infections, may result in serious morbidity or even mortality. A surgeon’s approach to these emergencies should be to decrease the pain and eliminate risk from infection while minimizing collateral damage to the anal complex. In this chapter, we will discuss several different anorectal emergencies.',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.89, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure Descriptions',\n", " 'md': '## Figure Descriptions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 30.1',\n", " 'md': '### Figure 30.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure likely illustrates the anatomical relationships or common conditions associated with anorectal emergencies.\\n- **Summary**: The figure serves to provide visual context for the discussion of anorectal emergencies, emphasizing the importance of understanding the anatomy involved in these conditions.\\n```',\n", " 'md': '- **Description**: This figure likely illustrates the anatomical relationships or common conditions associated with anorectal emergencies.\\n- **Summary**: The figure serves to provide visual context for the discussion of anorectal emergencies, emphasizing the importance of understanding the anatomy involved in these conditions.\\n```',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 206.07, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Jonathan E. Efron 1'}, {'text': ''}]},\n", " {'page': 528,\n", " 'text': ' 85\\n X\\n Pe 2 044\\nFigure 30.1. “I know I’m a pain in the ass, but please help me!”\\n\\n Some basics…\\n Before going into details I should mention that the differential diagnosis of the common\\n conditions responsible for anal emergencies is easy and possible even before examining the\\n patient. Figure 30.2 shows that each of the three conditions has a typical pattern of\\n pain:\\n\\n In an anal fissure the pain is sharp and intermittent — aggravated by\\n defecation, relieved thereafter, but sometimes lasting for 3 or 4 hours as a dull\\n ache. The patient begins to fear the act of defecation and frequently tries to\\n postpone it, aggravating the symptoms.\\n In a perianal abscess the pain is constant, dull and gradually increasing —\\n until surgical or spontaneous drainage of the pus. Fever and chills may be',\n", " 'md': '```markdown\\n# Page 85\\n\\n## Text\\nBefore going into details I should mention that the differential diagnosis of the common conditions responsible for anal emergencies is easy and possible even before examining the patient.\\n\\nFigure 30.2 shows that each of the three conditions has a typical pattern of pain:\\n\\n- In an anal fissure the pain is sharp and intermittent — aggravated by defecation, relieved thereafter, but sometimes lasting for 3 or 4 hours as a dull ache. The patient begins to fear the act of defecation and frequently tries to postpone it, aggravating the symptoms.\\n- In a perianal abscess the pain is constant, dull and gradually increasing — until surgical or spontaneous drainage of the pus. Fever and chills may be...\\n\\n## Images\\n\\n### Figure 30.1\\n**Description:** This image features a humorous illustration with the caption “I know I’m a pain in the ass, but please help me!” It likely serves to lighten the mood while discussing a serious medical topic.\\n\\n### Figure 30.2\\n**Description:** This figure illustrates the typical patterns of pain associated with three common anal conditions. The image likely includes a graphical representation of the pain characteristics for anal fissures, perianal abscesses, and possibly another condition. The details of the graph are not extractable, but it visually summarizes the differences in pain experiences for these conditions.\\n```',\n", " 'images': [{'name': 'img_p527_1.png',\n", " 'height': 636,\n", " 'width': 819,\n", " 'x': 103.68,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1407,\n", " 'original_height': 1093}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page 85',\n", " 'md': '# Page 85',\n", " 'bBox': {'x': 380.35, 'y': 166.41, 'w': 24.75, 'h': 6.93}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 229.89, 'y': 241.6, 'w': 19.8, 'h': 19.79}},\n", " {'type': 'text',\n", " 'value': 'Before going into details I should mention that the differential diagnosis of the common conditions responsible for anal emergencies is easy and possible even before examining the patient.\\n\\nFigure 30.2 shows that each of the three conditions has a typical pattern of pain:\\n\\n- In an anal fissure the pain is sharp and intermittent — aggravated by defecation, relieved thereafter, but sometimes lasting for 3 or 4 hours as a dull ache. The patient begins to fear the act of defecation and frequently tries to postpone it, aggravating the symptoms.\\n- In a perianal abscess the pain is constant, dull and gradually increasing — until surgical or spontaneous drainage of the pus. Fever and chills may be...',\n", " 'md': 'Before going into details I should mention that the differential diagnosis of the common conditions responsible for anal emergencies is easy and possible even before examining the patient.\\n\\nFigure 30.2 shows that each of the three conditions has a typical pattern of pain:\\n\\n- In an anal fissure the pain is sharp and intermittent — aggravated by defecation, relieved thereafter, but sometimes lasting for 3 or 4 hours as a dull ache. The patient begins to fear the act of defecation and frequently tries to postpone it, aggravating the symptoms.\\n- In a perianal abscess the pain is constant, dull and gradually increasing — until surgical or spontaneous drainage of the pus. Fever and chills may be...',\n", " 'bBox': {'x': 79, 'y': 241.6, 'w': 453.57, 'h': 19.79}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 30.1',\n", " 'md': '### Figure 30.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This image features a humorous illustration with the caption “I know I’m a pain in the ass, but please help me!” It likely serves to lighten the mood while discussing a serious medical topic.',\n", " 'md': '**Description:** This image features a humorous illustration with the caption “I know I’m a pain in the ass, but please help me!” It likely serves to lighten the mood while discussing a serious medical topic.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 30.2',\n", " 'md': '### Figure 30.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure illustrates the typical patterns of pain associated with three common anal conditions. The image likely includes a graphical representation of the pain characteristics for anal fissures, perianal abscesses, and possibly another condition. The details of the graph are not extractable, but it visually summarizes the differences in pain experiences for these conditions.\\n```',\n", " 'md': '**Description:** This figure illustrates the typical patterns of pain associated with three common anal conditions. The image likely includes a graphical representation of the pain characteristics for anal fissures, perianal abscesses, and possibly another condition. The details of the graph are not extractable, but it visually summarizes the differences in pain experiences for these conditions.\\n```',\n", " 'bBox': {'x': 229.89, 'y': 241.6, 'w': 19.8, 'h': 19.79}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 529,\n", " 'text': 'accompanying symptoms but do not wait for them to make the diagnosis.\\nIn an external thrombosed hemorrhoid (also called acute perianal\\nhematoma) the pain is more often than not already abating when the patient\\npresents to you, rarely lasting for more than 2-3 days.\\n Defecation\\n Acute anal fissure\\n Acute thrombosed hemorrhoid',\n", " 'md': '```markdown\\n### Text\\n- Accompanying symptoms but do not wait for them to make the diagnosis.\\n- In an external thrombosed hemorrhoid (also called acute perianal hematoma) the pain is more often than not already abating when the patient presents to you, rarely lasting for more than 2-3 days.\\n\\n### Images\\n- **Figure 1**: The page contains a diagram illustrating the conditions related to anal health, including \"Defecation,\" \"Acute anal fissure,\" and \"Acute thrombosed hemorrhoid.\" The diagram visually represents the anatomical locations and conditions but contains .\\n\\n### Summary\\nThis page discusses the diagnosis of external thrombosed hemorrhoids and their symptoms, emphasizing that pain typically subsides within a few days. It also includes a diagram that outlines related conditions.\\n```',\n", " 'images': [{'name': 'img_p528_1.png',\n", " 'height': 411,\n", " 'width': 639,\n", " 'x': 148.31999999999994,\n", " 'y': 171.35999999999999,\n", " 'original_width': 1098,\n", " 'original_height': 705},\n", " {'name': 'img_p528_2.png',\n", " 'height': 387,\n", " 'width': 639,\n", " 'x': 148.31999999999994,\n", " 'y': 385.20000000000005,\n", " 'original_width': 1098,\n", " 'original_height': 666}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Accompanying symptoms but do not wait for them to make the diagnosis.\\n- In an external thrombosed hemorrhoid (also called acute perianal hematoma) the pain is more often than not already abating when the patient presents to you, rarely lasting for more than 2-3 days.',\n", " 'md': '- Accompanying symptoms but do not wait for them to make the diagnosis.\\n- In an external thrombosed hemorrhoid (also called acute perianal hematoma) the pain is more often than not already abating when the patient presents to you, rarely lasting for more than 2-3 days.',\n", " 'bBox': {'x': 132, 'y': 85, 'w': 348.26, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Images',\n", " 'md': '### Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: The page contains a diagram illustrating the conditions related to anal health, including \"Defecation,\" \"Acute anal fissure,\" and \"Acute thrombosed hemorrhoid.\" The diagram visually represents the anatomical locations and conditions but contains .',\n", " 'md': '- **Figure 1**: The page contains a diagram illustrating the conditions related to anal health, including \"Defecation,\" \"Acute anal fissure,\" and \"Acute thrombosed hemorrhoid.\" The diagram visually represents the anatomical locations and conditions but contains .',\n", " 'bBox': {'x': 234.39, 'y': 187.17, 'w': 157.79, 'h': 15.81}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the diagnosis of external thrombosed hemorrhoids and their symptoms, emphasizing that pain typically subsides within a few days. It also includes a diagram that outlines related conditions.\\n```',\n", " 'md': 'This page discusses the diagnosis of external thrombosed hemorrhoids and their symptoms, emphasizing that pain typically subsides within a few days. It also includes a diagram that outlines related conditions.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 530,\n", " 'text': ' Perianal abscess\\n Figure 30.2. Pattern of acute anal pain.\\n\\n Next, you want to examine the patient. This is done without resorting\\nto a painful digital rectal examination Place the patient in the lateral\\ndecubitus position or let him stand flexed forwards with you sitting behind\\nhis or her buttocks. Gently spread the buttocks and look at the perianal\\nregion — now you can easily visualize any perianal hematoma and often\\nany fissure, sometimes even an abscess. If you see nothing then assume\\nthat you are dealing with a perianal abscess and continue as discussed\\nbelow.\\n\\n Not always so simple in our supersize population: to visualize the anus one has to use a\\n periscope or learn how to dive. Moshe\\n\\n Anal fissures\\n\\n The most common cause of anal pain is an anal fissure. Fissures\\nhurt and most patients describe it as the worse pain they have\\nexperienced. The pain is worse with bowel movement and continues at\\ntimes for hours after moving the bowels. The pain is not limited to bowel\\nmovements and also occurs with sitting or walking. Always suspect\\nfissures when a patient’s main complaint is pain. However, associated\\nbright rectal bleeding is not uncommon.',\n", " 'md': '```markdown\\n# Perianal Abscess\\n\\n**Figure 30.2.** Pattern of acute anal pain.\\n\\nNext, you want to examine the patient. This is done without resorting to a painful digital rectal examination. Place the patient in the lateral decubitus position or let him stand flexed forwards with you sitting behind his or her buttocks. Gently spread the buttocks and look at the perianal region — now you can easily visualize any perianal hematoma and often any fissure, sometimes even an abscess. If you see nothing then assume that you are dealing with a perianal abscess and continue as discussed below.\\n\\nNot always so simple in our supersize population: to visualize the anus one has to use a periscope or learn how to dive. Moshe\\n\\n## Anal Fissures\\n\\nThe most common cause of anal pain is an anal fissure. Fissures hurt and most patients describe it as the worse pain they have experienced. The pain is worse with bowel movement and continues at times for hours after moving the bowels. The pain is not limited to bowel movements and also occurs with sitting or walking. Always suspect fissures when a patient’s main complaint is pain. However, associated bright rectal bleeding is not uncommon.\\n```\\n\\n### Image Description\\n- **Figure 30.2**: This figure illustrates the pattern of acute anal pain, likely depicting the anatomical areas affected by conditions such as perianal abscesses and anal fissures. The graphical representation may include indications of pain locations and possibly the anatomical structures involved. The exact details of the image are not provided in the text, but it serves to visually summarize the discussion on anal pain.',\n", " 'images': [{'name': 'img_p529_1.png',\n", " 'height': 379,\n", " 'width': 639,\n", " 'x': 148.31999999999994,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1098,\n", " 'original_height': 651}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Perianal Abscess',\n", " 'md': '# Perianal Abscess',\n", " 'bBox': {'x': 257.14, 'y': 251.72, 'w': 90.03, 'h': 12.84}},\n", " {'type': 'text',\n", " 'value': '**Figure 30.2.** Pattern of acute anal pain.\\n\\nNext, you want to examine the patient. This is done without resorting to a painful digital rectal examination. Place the patient in the lateral decubitus position or let him stand flexed forwards with you sitting behind his or her buttocks. Gently spread the buttocks and look at the perianal region — now you can easily visualize any perianal hematoma and often any fissure, sometimes even an abscess. If you see nothing then assume that you are dealing with a perianal abscess and continue as discussed below.\\n\\nNot always so simple in our supersize population: to visualize the anus one has to use a periscope or learn how to dive. Moshe',\n", " 'md': '**Figure 30.2.** Pattern of acute anal pain.\\n\\nNext, you want to examine the patient. This is done without resorting to a painful digital rectal examination. Place the patient in the lateral decubitus position or let him stand flexed forwards with you sitting behind his or her buttocks. Gently spread the buttocks and look at the perianal region — now you can easily visualize any perianal hematoma and often any fissure, sometimes even an abscess. If you see nothing then assume that you are dealing with a perianal abscess and continue as discussed below.\\n\\nNot always so simple in our supersize population: to visualize the anus one has to use a periscope or learn how to dive. Moshe',\n", " 'bBox': {'x': 72, 'y': 251.72, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Anal Fissures',\n", " 'md': '## Anal Fissures',\n", " 'bBox': {'x': 86, 'y': 553, 'w': 103.92, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The most common cause of anal pain is an anal fissure. Fissures hurt and most patients describe it as the worse pain they have experienced. The pain is worse with bowel movement and continues at times for hours after moving the bowels. The pain is not limited to bowel movements and also occurs with sitting or walking. Always suspect fissures when a patient’s main complaint is pain. However, associated bright rectal bleeding is not uncommon.\\n```',\n", " 'md': 'The most common cause of anal pain is an anal fissure. Fissures hurt and most patients describe it as the worse pain they have experienced. The pain is worse with bowel movement and continues at times for hours after moving the bowels. The pain is not limited to bowel movements and also occurs with sitting or walking. Always suspect fissures when a patient’s main complaint is pain. However, associated bright rectal bleeding is not uncommon.\\n```',\n", " 'bBox': {'x': 72, 'y': 589, 'w': 467.32, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 30.2**: This figure illustrates the pattern of acute anal pain, likely depicting the anatomical areas affected by conditions such as perianal abscesses and anal fissures. The graphical representation may include indications of pain locations and possibly the anatomical structures involved. The exact details of the image are not provided in the text, but it serves to visually summarize the discussion on anal pain.',\n", " 'md': '- **Figure 30.2**: This figure illustrates the pattern of acute anal pain, likely depicting the anatomical areas affected by conditions such as perianal abscesses and anal fissures. The graphical representation may include indications of pain locations and possibly the anatomical structures involved. The exact details of the image are not provided in the text, but it serves to visually summarize the discussion on anal pain.',\n", " 'bBox': {'x': 86, 'y': 251.72, 'w': 261.17, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 531,\n", " 'text': ' Don’t be in a hurry to do a digital exam if you suspect a fissure,\\nfirst look. Inspection of the anus with the patient in the prone jack-knife\\nposition (or the lateral decubitus one), while spreading the buttock\\ncheeks will most of the time allow you to see the fissure. The common\\n(‘primary’) fissures are usually (90% of the time) posterior, situated at\\nanal six o’clock — but may be anterior as well (9% of the time) — this is\\nmore common in females. If you see a lateral fissure, beware! These\\nare mostly from a more sinister pathology than the usual tight ass.\\n(See Table 30.1 for etiologies of lateral, ‘secondary’, fissures.)\\n Table 30.1. Alternative causes of fissures.\\n Inflammatory bowel disease:\\n Infections_\\n HIV:\\n Cancer:\\n Trauma\\n The acute fissure will be visualized as a linear superficial tear\\nextending from the anoderm to the dentate line. The sentinel skin tag\\nand hypertrophied papilla, typical of chronic fissure — which tends\\nto be deeper, with the sphincter’s fibers visible at its base — will be\\nabsent in acute fissures.\\n\\n After diagnosing a ‘benign’ fissure don’t bother performing a\\ndigital exam, unless you wish to torture the patient. ħowever, if you are\\nunsure — sometimes the anal spasm and pain elicited by the simple\\nseparation of the buttocks make visual confirmation difficult, especially in\\nobese patients — or feel the need to perform a digital exam or anoscopy,\\nthen apply some lidocaine jelly 2% at the site of the anal verge\\ntenderness, leaving it for several minutes. This usually provides enough\\nanesthesia for a humane exam or anoscopy.\\n\\n Treatment of fissures\\n\\n ‘Primary’ fissures are caused by hypertonicity of the anus — a\\ntight ass. Thus, all therapies are geared towards decreasing the anal',\n", " 'md': '```markdown\\n## Diagnosis and Treatment of Anal Fissures\\n\\nDon’t be in a hurry to do a digital exam if you suspect a fissure; first look. Inspection of the anus with the patient in the prone jack-knife position (or the lateral decubitus one), while spreading the buttock cheeks will most of the time allow you to see the fissure. The common (‘primary’) fissures are usually (90% of the time) posterior, situated at anal six o’clock — but may be anterior as well (9% of the time) — this is more common in females. If you see a lateral fissure, beware! These are mostly from a more sinister pathology than the usual tight ass. (See Table 30.1 for etiologies of lateral, ‘secondary’, fissures.)\\n\\n### Table 30.1. Alternative causes of fissures\\n| Causes |\\n|---------------------------------|\\n| Inflammatory bowel disease |\\n| Infections |\\n| HIV |\\n| Cancer |\\n| Trauma |\\n\\nThe acute fissure will be visualized as a linear superficial tear extending from the anoderm to the dentate line. The sentinel skin tag and hypertrophied papilla, typical of chronic fissure — which tends to be deeper, with the sphincter’s fibers visible at its base — will be absent in acute fissures.\\n\\nAfter diagnosing a ‘benign’ fissure don’t bother performing a digital exam, unless you wish to torture the patient. However, if you are unsure — sometimes the anal spasm and pain elicited by the simple separation of the buttocks make visual confirmation difficult, especially in obese patients — or feel the need to perform a digital exam or anoscopy, then apply some lidocaine jelly 2% at the site of the anal verge tenderness, leaving it for several minutes. This usually provides enough anesthesia for a humane exam or anoscopy.\\n\\n### Treatment of fissures\\n\\n‘Primary’ fissures are caused by hypertonicity of the anus — a tight ass. Thus, all therapies are geared towards decreasing the anal...\\n```',\n", " 'images': [{'name': 'img_p530_1.png',\n", " 'height': 271,\n", " 'width': 808,\n", " 'x': 106.55999999999995,\n", " 'y': 231.84,\n", " 'original_width': 1388,\n", " 'original_height': 464}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnosis and Treatment of Anal Fissures',\n", " 'md': '## Diagnosis and Treatment of Anal Fissures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Don’t be in a hurry to do a digital exam if you suspect a fissure; first look. Inspection of the anus with the patient in the prone jack-knife position (or the lateral decubitus one), while spreading the buttock cheeks will most of the time allow you to see the fissure. The common (‘primary’) fissures are usually (90% of the time) posterior, situated at anal six o’clock — but may be anterior as well (9% of the time) — this is more common in females. If you see a lateral fissure, beware! These are mostly from a more sinister pathology than the usual tight ass. (See Table 30.1 for etiologies of lateral, ‘secondary’, fissures.)',\n", " 'md': 'Don’t be in a hurry to do a digital exam if you suspect a fissure; first look. Inspection of the anus with the patient in the prone jack-knife position (or the lateral decubitus one), while spreading the buttock cheeks will most of the time allow you to see the fissure. The common (‘primary’) fissures are usually (90% of the time) posterior, situated at anal six o’clock — but may be anterior as well (9% of the time) — this is more common in females. If you see a lateral fissure, beware! These are mostly from a more sinister pathology than the usual tight ass. (See Table 30.1 for etiologies of lateral, ‘secondary’, fissures.)',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.98, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 30.1. Alternative causes of fissures',\n", " 'md': '### Table 30.1. Alternative causes of fissures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Causes'],\n", " ['Inflammatory bowel disease'],\n", " ['Infections'],\n", " ['HIV'],\n", " ['Cancer'],\n", " ['Trauma']],\n", " 'md': '| Causes |\\n|---------------------------------|\\n| Inflammatory bowel disease |\\n| Infections |\\n| HIV |\\n| Cancer |\\n| Trauma |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Causes\"\\n\"Inflammatory bowel disease\"\\n\"Infections\"\\n\"HIV\"\\n\"Cancer\"\\n\"Trauma\"',\n", " 'bBox': {'x': 152.06, 'y': 342.53, 'w': 38.58, 'h': 11.86}},\n", " {'type': 'text',\n", " 'value': 'The acute fissure will be visualized as a linear superficial tear extending from the anoderm to the dentate line. The sentinel skin tag and hypertrophied papilla, typical of chronic fissure — which tends to be deeper, with the sphincter’s fibers visible at its base — will be absent in acute fissures.\\n\\nAfter diagnosing a ‘benign’ fissure don’t bother performing a digital exam, unless you wish to torture the patient. However, if you are unsure — sometimes the anal spasm and pain elicited by the simple separation of the buttocks make visual confirmation difficult, especially in obese patients — or feel the need to perform a digital exam or anoscopy, then apply some lidocaine jelly 2% at the site of the anal verge tenderness, leaving it for several minutes. This usually provides enough anesthesia for a humane exam or anoscopy.',\n", " 'md': 'The acute fissure will be visualized as a linear superficial tear extending from the anoderm to the dentate line. The sentinel skin tag and hypertrophied papilla, typical of chronic fissure — which tends to be deeper, with the sphincter’s fibers visible at its base — will be absent in acute fissures.\\n\\nAfter diagnosing a ‘benign’ fissure don’t bother performing a digital exam, unless you wish to torture the patient. However, if you are unsure — sometimes the anal spasm and pain elicited by the simple separation of the buttocks make visual confirmation difficult, especially in obese patients — or feel the need to perform a digital exam or anoscopy, then apply some lidocaine jelly 2% at the site of the anal verge tenderness, leaving it for several minutes. This usually provides enough anesthesia for a humane exam or anoscopy.',\n", " 'bBox': {'x': 72, 'y': 464, 'w': 467.82, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Treatment of fissures',\n", " 'md': '### Treatment of fissures',\n", " 'bBox': {'x': 86, 'y': 659, 'w': 167.37, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '‘Primary’ fissures are caused by hypertonicity of the anus — a tight ass. Thus, all therapies are geared towards decreasing the anal...\\n```',\n", " 'md': '‘Primary’ fissures are caused by hypertonicity of the anus — a tight ass. Thus, all therapies are geared towards decreasing the anal...\\n```',\n", " 'bBox': {'x': 72, 'y': 711, 'w': 467.49, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 532,\n", " 'text': 'tone.\\n\\n Acute fissures\\n My initial treatment for acute fissure is to keep the stool soft with fiber\\nsupplementation and stool softener, warm sitz baths, and a topical cream\\nto decrease tone — such as 2% diltiazem or 0.2% nifedipine gel (the use\\nof nitroglycerin ointment should be avoided as it causes significant\\nheadaches). The majority of acute fissures heal spontaneously\\nwithin a few weeks.\\n\\n Occasionally, you will encounter a patient who screams because of the anal pain. Your task is to\\n interrupt the pain-spasm-pain cycle; the pain caused by the fissure — resulting in spasm of the\\n internal sphincter — which in turn increases the pain. I would inject, using a fine needle, a few\\n milliliters of local anesthetic solution (e.g. Marcaine®) just under the fissure. The pain will\\n disappear instantly and with it the anal spasm. Now the patient will allow you to insert a gloved\\n finger into the anus. Gently introduce your finger coated with a generous dose of local\\n anesthetic cream, dilating the anal canal. Do not try to make a further dilatation. Continue as\\n above… Moshe\\n\\n Chronic fissures\\n Around half of the chronic fissures would heal on conservative\\ntreatment. Management of recurrent, persisting or chronic fissures\\ndepends again on the patients and their anal sphincters. Almost all of\\nthese patients have hypertonic anal sphincters and in male patients\\nthe most definitive and clearly recommended therapy would be\\nperforming a lateral internal sphincterotomy. Some patients, however,\\nare concerned about the risk of having incontinence after a\\nsphincterotomy — a risk which is more common in women with smaller\\nanal canals or patients that have undergone prior anorectal surgery.\\n\\n If this is the case one can consider botulinum toxin injections,\\nwhich are costly for the patient, as most insurance companies do not pay\\nfor the Botox®. The toxin is injected into the intersphincteric groove\\non both sides of the anal fissure. The number of units of Botox® used\\nvaries but I start 20 units of botulinum toxin, mixed in a very small amount',\n", " 'md': '```markdown\\n## Treatment of Anal Fissures\\n\\n### Acute Fissures\\nMy initial treatment for acute fissure is to keep the stool soft with fiber supplementation and stool softener, warm sitz baths, and a topical cream to decrease tone — such as 2% diltiazem or 0.2% nifedipine gel (the use of nitroglycerin ointment should be avoided as it causes significant headaches). The majority of acute fissures heal spontaneously within a few weeks.\\n\\nOccasionally, you will encounter a patient who screams because of the anal pain. Your task is to interrupt the pain-spasm-pain cycle; the pain caused by the fissure — resulting in spasm of the internal sphincter — which in turn increases the pain. I would inject, using a fine needle, a few milliliters of local anesthetic solution (e.g. Marcaine®) just under the fissure. The pain will disappear instantly and with it the anal spasm. Now the patient will allow you to insert a gloved finger into the anus. Gently introduce your finger coated with a generous dose of local anesthetic cream, dilating the anal canal. Do not try to make a further dilatation. Continue as above… Moshe\\n\\n### Chronic Fissures\\nAround half of the chronic fissures would heal on conservative treatment. Management of recurrent, persisting or chronic fissures depends again on the patients and their anal sphincters. Almost all of these patients have hypertonic anal sphincters and in male patients the most definitive and clearly recommended therapy would be performing a lateral internal sphincterotomy. Some patients, however, are concerned about the risk of having incontinence after a sphincterotomy — a risk which is more common in women with smaller anal canals or patients that have undergone prior anorectal surgery.\\n\\nIf this is the case one can consider botulinum toxin injections, which are costly for the patient, as most insurance companies do not pay for the Botox®. The toxin is injected into the intersphincteric groove on both sides of the anal fissure. The number of units of Botox® used varies but I start with 20 units of botulinum toxin, mixed in a very small amount.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 531, 'y': 572, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Treatment of Anal Fissures',\n", " 'md': '## Treatment of Anal Fissures',\n", " 'bBox': {'x': 309, 'y': 572, 'w': 16, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Acute Fissures',\n", " 'md': '### Acute Fissures',\n", " 'bBox': {'x': 86, 'y': 124, 'w': 99.14, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'My initial treatment for acute fissure is to keep the stool soft with fiber supplementation and stool softener, warm sitz baths, and a topical cream to decrease tone — such as 2% diltiazem or 0.2% nifedipine gel (the use of nitroglycerin ointment should be avoided as it causes significant headaches). The majority of acute fissures heal spontaneously within a few weeks.\\n\\nOccasionally, you will encounter a patient who screams because of the anal pain. Your task is to interrupt the pain-spasm-pain cycle; the pain caused by the fissure — resulting in spasm of the internal sphincter — which in turn increases the pain. I would inject, using a fine needle, a few milliliters of local anesthetic solution (e.g. Marcaine®) just under the fissure. The pain will disappear instantly and with it the anal spasm. Now the patient will allow you to insert a gloved finger into the anus. Gently introduce your finger coated with a generous dose of local anesthetic cream, dilating the anal canal. Do not try to make a further dilatation. Continue as above… Moshe',\n", " 'md': 'My initial treatment for acute fissure is to keep the stool soft with fiber supplementation and stool softener, warm sitz baths, and a topical cream to decrease tone — such as 2% diltiazem or 0.2% nifedipine gel (the use of nitroglycerin ointment should be avoided as it causes significant headaches). The majority of acute fissures heal spontaneously within a few weeks.\\n\\nOccasionally, you will encounter a patient who screams because of the anal pain. Your task is to interrupt the pain-spasm-pain cycle; the pain caused by the fissure — resulting in spasm of the internal sphincter — which in turn increases the pain. I would inject, using a fine needle, a few milliliters of local anesthetic solution (e.g. Marcaine®) just under the fissure. The pain will disappear instantly and with it the anal spasm. Now the patient will allow you to insert a gloved finger into the anus. Gently introduce your finger coated with a generous dose of local anesthetic cream, dilating the anal canal. Do not try to make a further dilatation. Continue as above… Moshe',\n", " 'bBox': {'x': 72, 'y': 124, 'w': 467.44, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Chronic Fissures',\n", " 'md': '### Chronic Fissures',\n", " 'bBox': {'x': 86, 'y': 452, 'w': 113.52, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Around half of the chronic fissures would heal on conservative treatment. Management of recurrent, persisting or chronic fissures depends again on the patients and their anal sphincters. Almost all of these patients have hypertonic anal sphincters and in male patients the most definitive and clearly recommended therapy would be performing a lateral internal sphincterotomy. Some patients, however, are concerned about the risk of having incontinence after a sphincterotomy — a risk which is more common in women with smaller anal canals or patients that have undergone prior anorectal surgery.\\n\\nIf this is the case one can consider botulinum toxin injections, which are costly for the patient, as most insurance companies do not pay for the Botox®. The toxin is injected into the intersphincteric groove on both sides of the anal fissure. The number of units of Botox® used varies but I start with 20 units of botulinum toxin, mixed in a very small amount.\\n```',\n", " 'md': 'Around half of the chronic fissures would heal on conservative treatment. Management of recurrent, persisting or chronic fissures depends again on the patients and their anal sphincters. Almost all of these patients have hypertonic anal sphincters and in male patients the most definitive and clearly recommended therapy would be performing a lateral internal sphincterotomy. Some patients, however, are concerned about the risk of having incontinence after a sphincterotomy — a risk which is more common in women with smaller anal canals or patients that have undergone prior anorectal surgery.\\n\\nIf this is the case one can consider botulinum toxin injections, which are costly for the patient, as most insurance companies do not pay for the Botox®. The toxin is injected into the intersphincteric groove on both sides of the anal fissure. The number of units of Botox® used varies but I start with 20 units of botulinum toxin, mixed in a very small amount.\\n```',\n", " 'bBox': {'x': 72, 'y': 452, 'w': 467.83, 'h': 19.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 533,\n", " 'text': 'of normal saline so that the injection is less than or equal to 1cc on either\\nside. I use a 25-gauge needle and no local anesthesia. A small\\npercentage of these patients may develop post-injection fecal\\nincontinence; however, this will resolve in approximately 6-8 weeks when\\nthe Botox® wears off. Botox® injection heals up to 60% of the fissures but\\npatients may develop recurrences when the sphincter tone returns to\\nbaseline.\\n\\n Lateral internal sphincterotomies are effective procedures for anal\\nfissures in 90% of cases, relieving the pain immediately and\\nallowing the fissure to heal. The risk of incontinence to stool in patients\\nwith anal hypertonicity is small; however, up to 20% of patients may have\\ntrouble controlling flatus. The incision is generally made on the right\\n(or left) lateral aspect and can be done through either an open or\\nclosed technique — cutting the internal sphincter for the length of\\nthe identified fissure — never divide the internal sphincter past the\\ndentate line as this significantly increases the risk of fecal\\nincontinence. I’m very restrained when doing a sphincterotomy on a\\nfemale patient and will exercise all other therapies prior to performing the\\nsurgery. Even young women who may do very well initially are at\\nsignificant risk of developing incontinence later in life, especially after\\nhaving children.\\n\\n Hemorrhoids\\n\\n Under this heading two conditions should be discussed: the first and\\nmuch more common being the thrombosed external hemorrhoid, also\\nknown by the Brits as ‘perianal hematoma’ (in fact, the term\\n‘thrombosed external hemorrhoid’ may be inaccurate because it is\\nbelieved to represent a clotted perianal vein of unknown etiology). The\\nsecond condition is acute strangulated internal hemorrhoids — less\\ncommon but more painful.\\n\\n Thrombosed external hemorrhoid\\n\\n You will recognize it immediately after the buttocks are separated — a\\nswelling the size and shape of a grape, bluish, tense and situated at the',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nThe injection is less than or equal to 1cc on either side. I use a 25-gauge needle and no local anesthesia. A small percentage of these patients may develop post-injection fecal incontinence; however, this will resolve in approximately 6-8 weeks when the Botox® wears off. Botox® injection heals up to 60% of the fissures but patients may develop recurrences when the sphincter tone returns to baseline.\\n\\nLateral internal sphincterotomies are effective procedures for anal fissures in 90% of cases, relieving the pain immediately and allowing the fissure to heal. The risk of incontinence to stool in patients with anal hypertonicity is small; however, up to 20% of patients may have trouble controlling flatus. The incision is generally made on the right (or left) lateral aspect and can be done through either an open or closed technique — cutting the internal sphincter for the length of the identified fissure — never divide the internal sphincter past the dentate line as this significantly increases the risk of fecal incontinence. I’m very restrained when doing a sphincterotomy on a female patient and will exercise all other therapies prior to performing the surgery. Even young women who may do very well initially are at significant risk of developing incontinence later in life, especially after having children.\\n\\n### Hemorrhoids\\n\\nUnder this heading two conditions should be discussed: the first and much more common being the thrombosed external hemorrhoid, also known by the Brits as ‘perianal hematoma’ (in fact, the term ‘thrombosed external hemorrhoid’ may be inaccurate because it is believed to represent a clotted perianal vein of unknown etiology). The second condition is acute strangulated internal hemorrhoids — less common but more painful.\\n\\n#### Thrombosed external hemorrhoid\\n\\nYou will recognize it immediately after the buttocks are separated — a swelling the size and shape of a grape, bluish, tense and situated at the\\n```\\n\\n## Image Identification and Description\\n\\n*No images or graphs were identified on this page.*\\n\\n## Summary\\n\\nThe text discusses various medical procedures and conditions related to anal fissures and hemorrhoids. It highlights the effectiveness of Botox® injections and lateral internal sphincterotomies for treating anal fissures, as well as the risks associated with these procedures, particularly in female patients. The section on hemorrhoids distinguishes between thrombosed external hemorrhoids and acute strangulated internal hemorrhoids, noting the commonality and characteristics of each condition.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The injection is less than or equal to 1cc on either side. I use a 25-gauge needle and no local anesthesia. A small percentage of these patients may develop post-injection fecal incontinence; however, this will resolve in approximately 6-8 weeks when the Botox® wears off. Botox® injection heals up to 60% of the fissures but patients may develop recurrences when the sphincter tone returns to baseline.\\n\\nLateral internal sphincterotomies are effective procedures for anal fissures in 90% of cases, relieving the pain immediately and allowing the fissure to heal. The risk of incontinence to stool in patients with anal hypertonicity is small; however, up to 20% of patients may have trouble controlling flatus. The incision is generally made on the right (or left) lateral aspect and can be done through either an open or closed technique — cutting the internal sphincter for the length of the identified fissure — never divide the internal sphincter past the dentate line as this significantly increases the risk of fecal incontinence. I’m very restrained when doing a sphincterotomy on a female patient and will exercise all other therapies prior to performing the surgery. Even young women who may do very well initially are at significant risk of developing incontinence later in life, especially after having children.',\n", " 'md': 'The injection is less than or equal to 1cc on either side. I use a 25-gauge needle and no local anesthesia. A small percentage of these patients may develop post-injection fecal incontinence; however, this will resolve in approximately 6-8 weeks when the Botox® wears off. Botox® injection heals up to 60% of the fissures but patients may develop recurrences when the sphincter tone returns to baseline.\\n\\nLateral internal sphincterotomies are effective procedures for anal fissures in 90% of cases, relieving the pain immediately and allowing the fissure to heal. The risk of incontinence to stool in patients with anal hypertonicity is small; however, up to 20% of patients may have trouble controlling flatus. The incision is generally made on the right (or left) lateral aspect and can be done through either an open or closed technique — cutting the internal sphincter for the length of the identified fissure — never divide the internal sphincter past the dentate line as this significantly increases the risk of fecal incontinence. I’m very restrained when doing a sphincterotomy on a female patient and will exercise all other therapies prior to performing the surgery. Even young women who may do very well initially are at significant risk of developing incontinence later in life, especially after having children.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.91, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Hemorrhoids',\n", " 'md': '### Hemorrhoids',\n", " 'bBox': {'x': 86, 'y': 481, 'w': 103, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Under this heading two conditions should be discussed: the first and much more common being the thrombosed external hemorrhoid, also known by the Brits as ‘perianal hematoma’ (in fact, the term ‘thrombosed external hemorrhoid’ may be inaccurate because it is believed to represent a clotted perianal vein of unknown etiology). The second condition is acute strangulated internal hemorrhoids — less common but more painful.',\n", " 'md': 'Under this heading two conditions should be discussed: the first and much more common being the thrombosed external hemorrhoid, also known by the Brits as ‘perianal hematoma’ (in fact, the term ‘thrombosed external hemorrhoid’ may be inaccurate because it is believed to represent a clotted perianal vein of unknown etiology). The second condition is acute strangulated internal hemorrhoids — less common but more painful.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 466.83, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Thrombosed external hemorrhoid',\n", " 'md': '#### Thrombosed external hemorrhoid',\n", " 'bBox': {'x': 86, 'y': 659, 'w': 264.83, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'You will recognize it immediately after the buttocks are separated — a swelling the size and shape of a grape, bluish, tense and situated at the\\n```',\n", " 'md': 'You will recognize it immediately after the buttocks are separated — a swelling the size and shape of a grape, bluish, tense and situated at the\\n```',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.41, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or graphs were identified on this page.*',\n", " 'md': '*No images or graphs were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses various medical procedures and conditions related to anal fissures and hemorrhoids. It highlights the effectiveness of Botox® injections and lateral internal sphincterotomies for treating anal fissures, as well as the risks associated with these procedures, particularly in female patients. The section on hemorrhoids distinguishes between thrombosed external hemorrhoids and acute strangulated internal hemorrhoids, noting the commonality and characteristics of each condition.',\n", " 'md': 'The text discusses various medical procedures and conditions related to anal fissures and hemorrhoids. It highlights the effectiveness of Botox® injections and lateral internal sphincterotomies for treating anal fissures, as well as the risks associated with these procedures, particularly in female patients. The section on hemorrhoids distinguishes between thrombosed external hemorrhoids and acute strangulated internal hemorrhoids, noting the commonality and characteristics of each condition.',\n", " 'bBox': {'x': 86, 'y': 119, 'w': 264.83, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 534,\n", " 'text': 'anal verge. If left untreated, the pain will subside gradually within a\\nday or two and the swelling will disappear within a week or so. From\\nour own very personal experience we know that stool softeners and local\\nanesthetic cream alleviate symptoms rapidly. But if the patient is in\\nmuch pain and demands immediate relief then you can be more\\naggressive.\\n\\n Immediate operation for this condition is effective if done within the first\\n24-48 hours of the patient developing symptoms. After that — when the\\nsymptoms are already improving spontaneously — the procedure\\nwould only increase the pain. A simple evacuation of an external\\nthrombosed hemorrhoid rarely completely alleviates the problem.\\nInstead, the whole ‘grape’ has to be excised — not incised — as\\nincision and protrusion of the clot often leaves clot located between the\\ncorrugator cutis ani muscular fibers of the anal skin, and the pain\\npersists. Another advantage is that the incidence of a residual anal skin\\ntag may be lower after excision rather than incision…\\n\\n Many authors would disagree with this, including myself, preferring to simply I+D the clot rather\\n than excising the pile. Anyway, it has been said that the difference is that if you let it subside\\n spontaneously the patient will have pain for 7 days; but if you operate... his pain will last a week.\\n Moshe\\n\\n Acute strangulated internal hemorrhoids\\n\\n Despite the commonly held opinion of family doctors, internal\\nhaemorrhoids do not usually cause acute anal pain. Acute perianal\\nhematoma, which we mentioned above, is not a complication of pre-\\nexisting haemorrhoids, although sometimes they coexist. But there is an\\nexception to this rule: acute strangulated internal haemorrhoids.\\n\\n This occurs in patients with grade III or IV hemorrhoids. The prolapsed\\nhemorrhoids become irreducible because of swelling and thrombosis\\nfrequently develops. The patient experiences intense pain and has\\nserious difficulties sitting and walking. On examination you see the\\nprolapsed piles (this is what the Brits call hemorrhoids) — blue with areas',\n", " 'md': '```markdown\\n# Page Content\\n\\nIf left untreated, the pain will subside gradually within a day or two and the swelling will disappear within a week or so. From our own very personal experience, we know that stool softeners and local anesthetic cream alleviate symptoms rapidly. But if the patient is in much pain and demands immediate relief, then you can be more aggressive.\\n\\nImmediate operation for this condition is effective if done within the first 24-48 hours of the patient developing symptoms. After that — when the symptoms are already improving spontaneously — the procedure would only increase the pain. A simple evacuation of an external thrombosed hemorrhoid rarely completely alleviates the problem. Instead, the whole ‘grape’ has to be excised — not incised — as incision and protrusion of the clot often leaves clot located between the corrugator cutis ani muscular fibers of the anal skin, and the pain persists. Another advantage is that the incidence of a residual anal skin tag may be lower after excision rather than incision.\\n\\nMany authors would disagree with this, including myself, preferring to simply I+D the clot rather than excising the pile. Anyway, it has been said that the difference is that if you let it subside spontaneously the patient will have pain for 7 days; but if you operate... his pain will last a week.\\n\\n**Moshe**\\n\\n## Acute strangulated internal hemorrhoids\\n\\nDespite the commonly held opinion of family doctors, internal hemorrhoids do not usually cause acute anal pain. Acute perianal hematoma, which we mentioned above, is not a complication of pre-existing hemorrhoids, although sometimes they coexist. But there is an exception to this rule: acute strangulated internal hemorrhoids.\\n\\nThis occurs in patients with grade III or IV hemorrhoids. The prolapsed hemorrhoids become irreducible because of swelling and thrombosis frequently develops. The patient experiences intense pain and has serious difficulties sitting and walking. On examination, you see the prolapsed piles (this is what the Brits call hemorrhoids) — blue with areas.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'If left untreated, the pain will subside gradually within a day or two and the swelling will disappear within a week or so. From our own very personal experience, we know that stool softeners and local anesthetic cream alleviate symptoms rapidly. But if the patient is in much pain and demands immediate relief, then you can be more aggressive.\\n\\nImmediate operation for this condition is effective if done within the first 24-48 hours of the patient developing symptoms. After that — when the symptoms are already improving spontaneously — the procedure would only increase the pain. A simple evacuation of an external thrombosed hemorrhoid rarely completely alleviates the problem. Instead, the whole ‘grape’ has to be excised — not incised — as incision and protrusion of the clot often leaves clot located between the corrugator cutis ani muscular fibers of the anal skin, and the pain persists. Another advantage is that the incidence of a residual anal skin tag may be lower after excision rather than incision.\\n\\nMany authors would disagree with this, including myself, preferring to simply I+D the clot rather than excising the pile. Anyway, it has been said that the difference is that if you let it subside spontaneously the patient will have pain for 7 days; but if you operate... his pain will last a week.\\n\\n**Moshe**',\n", " 'md': 'If left untreated, the pain will subside gradually within a day or two and the swelling will disappear within a week or so. From our own very personal experience, we know that stool softeners and local anesthetic cream alleviate symptoms rapidly. But if the patient is in much pain and demands immediate relief, then you can be more aggressive.\\n\\nImmediate operation for this condition is effective if done within the first 24-48 hours of the patient developing symptoms. After that — when the symptoms are already improving spontaneously — the procedure would only increase the pain. A simple evacuation of an external thrombosed hemorrhoid rarely completely alleviates the problem. Instead, the whole ‘grape’ has to be excised — not incised — as incision and protrusion of the clot often leaves clot located between the corrugator cutis ani muscular fibers of the anal skin, and the pain persists. Another advantage is that the incidence of a residual anal skin tag may be lower after excision rather than incision.\\n\\nMany authors would disagree with this, including myself, preferring to simply I+D the clot rather than excising the pile. Anyway, it has been said that the difference is that if you let it subside spontaneously the patient will have pain for 7 days; but if you operate... his pain will last a week.\\n\\n**Moshe**',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.77, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Acute strangulated internal hemorrhoids',\n", " 'md': '## Acute strangulated internal hemorrhoids',\n", " 'bBox': {'x': 86, 'y': 502, 'w': 319.99, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Despite the commonly held opinion of family doctors, internal hemorrhoids do not usually cause acute anal pain. Acute perianal hematoma, which we mentioned above, is not a complication of pre-existing hemorrhoids, although sometimes they coexist. But there is an exception to this rule: acute strangulated internal hemorrhoids.\\n\\nThis occurs in patients with grade III or IV hemorrhoids. The prolapsed hemorrhoids become irreducible because of swelling and thrombosis frequently develops. The patient experiences intense pain and has serious difficulties sitting and walking. On examination, you see the prolapsed piles (this is what the Brits call hemorrhoids) — blue with areas.\\n```',\n", " 'md': 'Despite the commonly held opinion of family doctors, internal hemorrhoids do not usually cause acute anal pain. Acute perianal hematoma, which we mentioned above, is not a complication of pre-existing hemorrhoids, although sometimes they coexist. But there is an exception to this rule: acute strangulated internal hemorrhoids.\\n\\nThis occurs in patients with grade III or IV hemorrhoids. The prolapsed hemorrhoids become irreducible because of swelling and thrombosis frequently develops. The patient experiences intense pain and has serious difficulties sitting and walking. On examination, you see the prolapsed piles (this is what the Brits call hemorrhoids) — blue with areas.\\n```',\n", " 'bBox': {'x': 72, 'y': 502, 'w': 467.5, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 535,\n", " 'text': 'of mucosal necrosis.\\n\\n In this situation an immediate operation is effective only if done\\nwithin the first 24-48 hours of the patient developing symptoms.\\nAfter that, proceeding to surgery only increases the pain for the patient\\nand therefore for you.\\n\\n I would consider an emergency hemorrhoidectomy only if one quadrant\\nis involved. If you have a three-quadrant prolapse, it is best to\\nmanage that patient with pain medication, sitz baths and stool\\nsofteners to allow them to get through the initial phase — allow the\\nswelling to decrease and then consider an elective procedure if needed.\\nIf you do operate the patient will have pain and need time to recover; if\\nyou don’t operate the patient will have pain and need time to recover —\\neither way they have pain so why operate?\\n\\n Conservative management\\n I think even admitting the patients and treating them conservatively will\\nresult in a quicker recovery than an extensive hemorrhoid excision. Such\\ntreatment includes bed rest (with the buttocks elevated), i.v. pain\\nmedications and laxatives; local application of diltiazem cream may\\nreduce anal spasm as warm sitz baths do.\\n\\n We use plain white sugar to coat the prolapsed tissue. The hygroscopic sugar rapidly reduces\\n the tissue edema — shrinking the prolapsed tissues and allowing manual reduction. Simply\\n place the patient prone and pour a generous quantity of sugar on the strangulated parts until the\\n tortured anus looks like a cake covered with icing. Repeat as necessary following any sitz bath\\n — you won’t believe how fast the swelling will subside. The Editors\\n\\n Operative management\\n The danger of doing a large excision for prolapsed, thrombosed\\ninternal and external hemorrhoids is that you will end up with anal\\nstenosis. So, only if you feel confident about your training in anal\\nsurgery, proceed to early hemorrhoidectomy but always consider that a\\nfew residual skin tags resulting from insufficient removal of perianal and\\nmucosal folds is a better result than stenosis as a consequence of an',\n", " 'md': '```markdown\\n## Mucosal Necrosis Management\\n\\nIn this situation, an immediate operation is effective only if done within the first 24-48 hours of the patient developing symptoms. After that, proceeding to surgery only increases the pain for the patient and therefore for you.\\n\\nI would consider an emergency hemorrhoidectomy only if one quadrant is involved. If you have a three-quadrant prolapse, it is best to manage that patient with pain medication, sitz baths, and stool softeners to allow them to get through the initial phase — allow the swelling to decrease and then consider an elective procedure if needed. If you do operate, the patient will have pain and need time to recover; if you don’t operate, the patient will have pain and need time to recover — either way, they have pain, so why operate?\\n\\n### Conservative Management\\n\\nI think even admitting the patients and treating them conservatively will result in a quicker recovery than an extensive hemorrhoid excision. Such treatment includes bed rest (with the buttocks elevated), i.v. pain medications, and laxatives; local application of diltiazem cream may reduce anal spasm as warm sitz baths do.\\n\\nWe use plain white sugar to coat the prolapsed tissue. The hygroscopic sugar rapidly reduces the tissue edema — shrinking the prolapsed tissues and allowing manual reduction. Simply place the patient prone and pour a generous quantity of sugar on the strangulated parts until the tortured anus looks like a cake covered with icing. Repeat as necessary following any sitz bath — you won’t believe how fast the swelling will subside.\\n\\n*The Editors*\\n\\n### Operative Management\\n\\nThe danger of doing a large excision for prolapsed, thrombosed internal and external hemorrhoids is that you will end up with anal stenosis. So, only if you feel confident about your training in anal surgery, proceed to early hemorrhoidectomy but always consider that a few residual skin tags resulting from insufficient removal of perianal and mucosal folds is a better result than stenosis as a consequence of an extensive excision.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Mucosal Necrosis Management',\n", " 'md': '## Mucosal Necrosis Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In this situation, an immediate operation is effective only if done within the first 24-48 hours of the patient developing symptoms. After that, proceeding to surgery only increases the pain for the patient and therefore for you.\\n\\nI would consider an emergency hemorrhoidectomy only if one quadrant is involved. If you have a three-quadrant prolapse, it is best to manage that patient with pain medication, sitz baths, and stool softeners to allow them to get through the initial phase — allow the swelling to decrease and then consider an elective procedure if needed. If you do operate, the patient will have pain and need time to recover; if you don’t operate, the patient will have pain and need time to recover — either way, they have pain, so why operate?',\n", " 'md': 'In this situation, an immediate operation is effective only if done within the first 24-48 hours of the patient developing symptoms. After that, proceeding to surgery only increases the pain for the patient and therefore for you.\\n\\nI would consider an emergency hemorrhoidectomy only if one quadrant is involved. If you have a three-quadrant prolapse, it is best to manage that patient with pain medication, sitz baths, and stool softeners to allow them to get through the initial phase — allow the swelling to decrease and then consider an elective procedure if needed. If you do operate, the patient will have pain and need time to recover; if you don’t operate, the patient will have pain and need time to recover — either way, they have pain, so why operate?',\n", " 'bBox': {'x': 72, 'y': 170, 'w': 467.48, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Conservative Management',\n", " 'md': '### Conservative Management',\n", " 'bBox': {'x': 86, 'y': 360, 'w': 183.1, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'I think even admitting the patients and treating them conservatively will result in a quicker recovery than an extensive hemorrhoid excision. Such treatment includes bed rest (with the buttocks elevated), i.v. pain medications, and laxatives; local application of diltiazem cream may reduce anal spasm as warm sitz baths do.\\n\\nWe use plain white sugar to coat the prolapsed tissue. The hygroscopic sugar rapidly reduces the tissue edema — shrinking the prolapsed tissues and allowing manual reduction. Simply place the patient prone and pour a generous quantity of sugar on the strangulated parts until the tortured anus looks like a cake covered with icing. Repeat as necessary following any sitz bath — you won’t believe how fast the swelling will subside.\\n\\n*The Editors*',\n", " 'md': 'I think even admitting the patients and treating them conservatively will result in a quicker recovery than an extensive hemorrhoid excision. Such treatment includes bed rest (with the buttocks elevated), i.v. pain medications, and laxatives; local application of diltiazem cream may reduce anal spasm as warm sitz baths do.\\n\\nWe use plain white sugar to coat the prolapsed tissue. The hygroscopic sugar rapidly reduces the tissue edema — shrinking the prolapsed tissues and allowing manual reduction. Simply place the patient prone and pour a generous quantity of sugar on the strangulated parts until the tortured anus looks like a cake covered with icing. Repeat as necessary following any sitz bath — you won’t believe how fast the swelling will subside.\\n\\n*The Editors*',\n", " 'bBox': {'x': 72, 'y': 381, 'w': 467.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Operative Management',\n", " 'md': '### Operative Management',\n", " 'bBox': {'x': 86, 'y': 613, 'w': 159.11, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The danger of doing a large excision for prolapsed, thrombosed internal and external hemorrhoids is that you will end up with anal stenosis. So, only if you feel confident about your training in anal surgery, proceed to early hemorrhoidectomy but always consider that a few residual skin tags resulting from insufficient removal of perianal and mucosal folds is a better result than stenosis as a consequence of an extensive excision.\\n```',\n", " 'md': 'The danger of doing a large excision for prolapsed, thrombosed internal and external hemorrhoids is that you will end up with anal stenosis. So, only if you feel confident about your training in anal surgery, proceed to early hemorrhoidectomy but always consider that a few residual skin tags resulting from insufficient removal of perianal and mucosal folds is a better result than stenosis as a consequence of an extensive excision.\\n```',\n", " 'bBox': {'x': 72, 'y': 651, 'w': 467.64, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 536,\n", " 'text': 'over-enthusiastic excision.\\n\\n Perianal abscess\\n\\n Perianal abscesses are painful. They start small and grow, and\\npatients always seem to seek attention for them at the most inopportune\\ntimes. They are defined as either simple or complex, depending on the\\netiology of the infection and where the abscess forms. Simple\\nabscesses (common) are caused by an infection in the anal crypts\\nand develop superficially. Complex abscesses (rare) are deep and\\nmay be caused by other etiologies such as Crohn’s disease.\\nRegardless of the cause, the initial management of a perianal\\nabscess is always the same: drainage.\\n\\n Work-up\\n\\n Work-up for perianal abscess is essentially a physical\\nexamination. Digital examination can be considered, if tolerated, but\\nthere is no need to torture these poor people, who are in excessive\\npain. If the abscess is clearly identified externally, it should be dealt\\nwith without significant pain. CT scans are often done well before the\\nsurgical consult takes place. These scans are unnecessary 9 times out of\\n10 for perianal abscesses and I do not obtain them. Exceptions to this\\nwould include patients that are at higher risk for necrotizing infections or\\nthose where the diagnosis of an abscess is suspected but is not\\nclearly identifiable on physical examination (see below).\\n\\n Subcutaneous or intersphincteric abscesses\\n\\n These are clearly seen and felt (tender!) on external examination\\nand can easily be handled by incision and drainage. Where and how\\nthe incision and drainage takes place (your office under local anesthesia\\nor in the OR under regional or general anesthesia) is directly dependent\\non the patient’s ability to tolerate the ‘obligatory’ pain and discomfort and\\nhis preferences. However, remember that local anesthesia does not\\nwork well in infected tissue (affected by local tissue pH) and most',\n", " 'md': \"```markdown\\n# Perianal Abscess\\n\\n## Overview\\nPerianal abscesses are painful conditions that start small and grow, often prompting patients to seek medical attention at inconvenient times. They can be classified as either simple or complex based on the etiology of the infection and the location of the abscess.\\n\\n### Simple Abscesses\\n- **Definition**: Commonly caused by an infection in the anal crypts.\\n- **Characteristics**: Develop superficially.\\n\\n### Complex Abscesses\\n- **Definition**: Rare and deep abscesses.\\n- **Etiology**: May be caused by conditions such as Crohn’s disease.\\n\\n### Initial Management\\nRegardless of the cause, the initial management of a perianal abscess is always drainage.\\n\\n## Work-up\\nThe work-up for a perianal abscess primarily involves a physical examination.\\n\\n- **Digital Examination**: Can be considered if tolerated, but it is important to avoid causing excessive pain to the patient.\\n- **CT Scans**: Often performed before surgical consultation but are unnecessary in 9 out of 10 cases for perianal abscesses. Exceptions include:\\n- Patients at higher risk for necrotizing infections.\\n- Cases where the diagnosis of an abscess is suspected but not clearly identifiable on physical examination.\\n\\n## Subcutaneous or Intersphincteric Abscesses\\nThese abscesses are typically visible and palpable (tender) during external examination and can be managed through incision and drainage.\\n\\n- **Procedure Location**: The choice of where to perform the incision and drainage (office under local anesthesia or in the OR under regional or general anesthesia) depends on:\\n- The patient's ability to tolerate pain and discomfort.\\n- Patient preferences.\\n\\n### Note on Anesthesia\\nLocal anesthesia may not be effective in infected tissue due to the altered local tissue pH.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Perianal Abscess',\n", " 'md': '# Perianal Abscess',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 134.3, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Overview',\n", " 'md': '## Overview',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Perianal abscesses are painful conditions that start small and grow, often prompting patients to seek medical attention at inconvenient times. They can be classified as either simple or complex based on the etiology of the infection and the location of the abscess.',\n", " 'md': 'Perianal abscesses are painful conditions that start small and grow, often prompting patients to seek medical attention at inconvenient times. They can be classified as either simple or complex based on the etiology of the infection and the location of the abscess.',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 134.3, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Simple Abscesses',\n", " 'md': '### Simple Abscesses',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Definition**: Commonly caused by an infection in the anal crypts.\\n- **Characteristics**: Develop superficially.',\n", " 'md': '- **Definition**: Commonly caused by an infection in the anal crypts.\\n- **Characteristics**: Develop superficially.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Complex Abscesses',\n", " 'md': '### Complex Abscesses',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Definition**: Rare and deep abscesses.\\n- **Etiology**: May be caused by conditions such as Crohn’s disease.',\n", " 'md': '- **Definition**: Rare and deep abscesses.\\n- **Etiology**: May be caused by conditions such as Crohn’s disease.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Initial Management',\n", " 'md': '### Initial Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Regardless of the cause, the initial management of a perianal abscess is always drainage.',\n", " 'md': 'Regardless of the cause, the initial management of a perianal abscess is always drainage.',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 134.3, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Work-up',\n", " 'md': '## Work-up',\n", " 'bBox': {'x': 86, 'y': 340, 'w': 66.82, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The work-up for a perianal abscess primarily involves a physical examination.\\n\\n- **Digital Examination**: Can be considered if tolerated, but it is important to avoid causing excessive pain to the patient.\\n- **CT Scans**: Often performed before surgical consultation but are unnecessary in 9 out of 10 cases for perianal abscesses. Exceptions include:\\n- Patients at higher risk for necrotizing infections.\\n- Cases where the diagnosis of an abscess is suspected but not clearly identifiable on physical examination.',\n", " 'md': 'The work-up for a perianal abscess primarily involves a physical examination.\\n\\n- **Digital Examination**: Can be considered if tolerated, but it is important to avoid causing excessive pain to the patient.\\n- **CT Scans**: Often performed before surgical consultation but are unnecessary in 9 out of 10 cases for perianal abscesses. Exceptions include:\\n- Patients at higher risk for necrotizing infections.\\n- Cases where the diagnosis of an abscess is suspected but not clearly identifiable on physical examination.',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 134.3, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Subcutaneous or Intersphincteric Abscesses',\n", " 'md': '## Subcutaneous or Intersphincteric Abscesses',\n", " 'bBox': {'x': 86, 'y': 568, 'w': 352.23, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': \"These abscesses are typically visible and palpable (tender) during external examination and can be managed through incision and drainage.\\n\\n- **Procedure Location**: The choice of where to perform the incision and drainage (office under local anesthesia or in the OR under regional or general anesthesia) depends on:\\n- The patient's ability to tolerate pain and discomfort.\\n- Patient preferences.\",\n", " 'md': \"These abscesses are typically visible and palpable (tender) during external examination and can be managed through incision and drainage.\\n\\n- **Procedure Location**: The choice of where to perform the incision and drainage (office under local anesthesia or in the OR under regional or general anesthesia) depends on:\\n- The patient's ability to tolerate pain and discomfort.\\n- Patient preferences.\",\n", " 'bBox': {'x': 457, 'y': 376, 'w': 12, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Note on Anesthesia',\n", " 'md': '### Note on Anesthesia',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Local anesthesia may not be effective in infected tissue due to the altered local tissue pH.\\n```',\n", " 'md': 'Local anesthesia may not be effective in infected tissue due to the altered local tissue pH.\\n```',\n", " 'bBox': {'x': 457, 'y': 376, 'w': 12, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 537,\n", " 'text': 'people are in considerable pain making it difficult to perform an\\nadequate drainage. But if it is a small abscess that is easily\\nidentified and accessed, then incision and drainage in the\\nemergency room or in your office is possible and provides instant\\nrelief.\\n\\n Abscesses in ‘deeper’ locations\\n\\n Abscesses can occur in several other and ‘deeper’ locations —\\nischiorectal, supralevator, submucosal, post-anal space; and a\\ncombination of all of these is possible. For instance, the infamous\\nhorseshoe abscess starts in the posterior anal space and extends to both\\nischiorectal spaces.\\n\\n When a patient does not have significant external findings, or just\\nhas some generalized redness without a clear localization of the\\nabscess, this usually indicates a deeper abscess that would be\\ndifficult to drain without general anesthesia. Occasionally, when the\\nabscess is situated above the levator ani or is retrorectal, with the\\npatient presenting with dull perianal pain but no local findings on\\nexamination, then a CT or MRI of the pelvis may be diagnostic —\\nproviding a road map to surgery.\\n\\n The operation\\n\\n Place an incision in the zone of the swelling — if the incision is lateral\\nto the external sphincter it doesn’t matter in what direction you incise it as\\nlong as you stay superficial to the muscle; for intersphincteric abscesses I\\nalways make a circumferential incision. If a deeper abscess is not easily\\nlocalized, tap it with a needle in search of pus. Ischiorectal and perianal\\nabscesses should be drained cutaneously, making incisions as close to\\nthe anal sphincter as possible to allow for adequate drainage. There are\\ntwo philosophies to draining abscesses: one is to excise a disc of skin\\nto facilitate adequate drainage (avoiding the need for drains) and healing\\nof the abscess cavity; a second is to make a smaller incision and place a\\nsmall drain in the area that can then be removed at a later date.\\nħowever, these drains often fall out on their own and are uncomfortable.',\n", " 'md': '```markdown\\n## Abscess Management\\n\\n### Pain and Drainage\\nPeople are in considerable pain, making it difficult to perform an adequate drainage. But if it is a small abscess that is easily identified and accessed, then incision and drainage in the emergency room or in your office is possible and provides instant relief.\\n\\n### Abscesses in ‘Deeper’ Locations\\nAbscesses can occur in several other and ‘deeper’ locations — ischiorectal, supralevator, submucosal, post-anal space; and a combination of all of these is possible. For instance, the infamous horseshoe abscess starts in the posterior anal space and extends to both ischiorectal spaces.\\n\\nWhen a patient does not have significant external findings, or just has some generalized redness without a clear localization of the abscess, this usually indicates a deeper abscess that would be difficult to drain without general anesthesia. Occasionally, when the abscess is situated above the levator ani or is retrorectal, with the patient presenting with dull perianal pain but no local findings on examination, then a CT or MRI of the pelvis may be diagnostic — providing a road map to surgery.\\n\\n### The Operation\\nPlace an incision in the zone of the swelling — if the incision is lateral to the external sphincter it doesn’t matter in what direction you incise it as long as you stay superficial to the muscle; for intersphincteric abscesses, I always make a circumferential incision. If a deeper abscess is not easily localized, tap it with a needle in search of pus. Ischiorectal and perianal abscesses should be drained cutaneously, making incisions as close to the anal sphincter as possible to allow for adequate drainage.\\n\\nThere are two philosophies to draining abscesses: one is to excise a disc of skin to facilitate adequate drainage (avoiding the need for drains) and healing of the abscess cavity; a second is to make a smaller incision and place a small drain in the area that can then be removed at a later date. However, these drains often fall out on their own and are uncomfortable.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 531, 'y': 247, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abscess Management',\n", " 'md': '## Abscess Management',\n", " 'bBox': {'x': 531, 'y': 247, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Pain and Drainage',\n", " 'md': '### Pain and Drainage',\n", " 'bBox': {'x': 492, 'y': 247, 'w': 28, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'People are in considerable pain, making it difficult to perform an adequate drainage. But if it is a small abscess that is easily identified and accessed, then incision and drainage in the emergency room or in your office is possible and provides instant relief.',\n", " 'md': 'People are in considerable pain, making it difficult to perform an adequate drainage. But if it is a small abscess that is easily identified and accessed, then incision and drainage in the emergency room or in your office is possible and provides instant relief.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 38, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Abscesses in ‘Deeper’ Locations',\n", " 'md': '### Abscesses in ‘Deeper’ Locations',\n", " 'bBox': {'x': 86, 'y': 195, 'w': 250.77, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Abscesses can occur in several other and ‘deeper’ locations — ischiorectal, supralevator, submucosal, post-anal space; and a combination of all of these is possible. For instance, the infamous horseshoe abscess starts in the posterior anal space and extends to both ischiorectal spaces.\\n\\nWhen a patient does not have significant external findings, or just has some generalized redness without a clear localization of the abscess, this usually indicates a deeper abscess that would be difficult to drain without general anesthesia. Occasionally, when the abscess is situated above the levator ani or is retrorectal, with the patient presenting with dull perianal pain but no local findings on examination, then a CT or MRI of the pelvis may be diagnostic — providing a road map to surgery.',\n", " 'md': 'Abscesses can occur in several other and ‘deeper’ locations — ischiorectal, supralevator, submucosal, post-anal space; and a combination of all of these is possible. For instance, the infamous horseshoe abscess starts in the posterior anal space and extends to both ischiorectal spaces.\\n\\nWhen a patient does not have significant external findings, or just has some generalized redness without a clear localization of the abscess, this usually indicates a deeper abscess that would be difficult to drain without general anesthesia. Occasionally, when the abscess is situated above the levator ani or is retrorectal, with the patient presenting with dull perianal pain but no local findings on examination, then a CT or MRI of the pelvis may be diagnostic — providing a road map to surgery.',\n", " 'bBox': {'x': 72, 'y': 247, 'w': 467.65, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Operation',\n", " 'md': '### The Operation',\n", " 'bBox': {'x': 86, 'y': 247, 'w': 453.01, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Place an incision in the zone of the swelling — if the incision is lateral to the external sphincter it doesn’t matter in what direction you incise it as long as you stay superficial to the muscle; for intersphincteric abscesses, I always make a circumferential incision. If a deeper abscess is not easily localized, tap it with a needle in search of pus. Ischiorectal and perianal abscesses should be drained cutaneously, making incisions as close to the anal sphincter as possible to allow for adequate drainage.\\n\\nThere are two philosophies to draining abscesses: one is to excise a disc of skin to facilitate adequate drainage (avoiding the need for drains) and healing of the abscess cavity; a second is to make a smaller incision and place a small drain in the area that can then be removed at a later date. However, these drains often fall out on their own and are uncomfortable.\\n```',\n", " 'md': 'Place an incision in the zone of the swelling — if the incision is lateral to the external sphincter it doesn’t matter in what direction you incise it as long as you stay superficial to the muscle; for intersphincteric abscesses, I always make a circumferential incision. If a deeper abscess is not easily localized, tap it with a needle in search of pus. Ischiorectal and perianal abscesses should be drained cutaneously, making incisions as close to the anal sphincter as possible to allow for adequate drainage.\\n\\nThere are two philosophies to draining abscesses: one is to excise a disc of skin to facilitate adequate drainage (avoiding the need for drains) and healing of the abscess cavity; a second is to make a smaller incision and place a small drain in the area that can then be removed at a later date. However, these drains often fall out on their own and are uncomfortable.\\n```',\n", " 'bBox': {'x': 72, 'y': 247, 'w': 467.95, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 538,\n", " 'text': 'Be that as it may, larger abscesses need bigger incisions — I am a big\\nguy and go for bigger ones. Whatever you do, the incision must be\\nwide enough to permit introduction of your finger to gently debride\\nthe cavity and look for unexpected extensions. Irrigation with normal\\nsaline is useful to remove residual pus or blood from the cavity. General\\nor regional anesthesia also allows you to search for an associated\\nfistula in ano — which should be present in up to half of the patients\\n— and perform a primary fistulotomy or placement of a seton, depending\\non the type of fistula. The collected evidence shows that this line of\\nmanagement leads to fewer recurrences.\\n\\n But if you don’t consider yourself a big expert in anal fistula surgery then do not poke\\n the skunk (which may result in iatrogenic fistula tracts or damage to the sphincters) — just\\n drain the pus, leaving the potential fistula for the future.\\n\\n There is no need to pack the cavity of the well-drained abscess.\\nThe patient will experience almost an immediate disappearance of the\\npain and will be most thankful, though in subsequent months — if you\\nhave omitted the search for it — approximately up to half will develop a\\nfistula in ano — to be dealt with electively. Therefore, warn the patient\\nabout the probability of developing a fistula and schedule to see\\nhim a month or so after the operation.\\n\\n Special considerations\\n\\n Abscesses in the post-anal space\\n In this scenario, patients have severe perianal pain and no ‘localizing’\\nfindings on either digital examination or anoscopy. Most of the time they\\nwon’t tolerate a digital exam. So, if they swing round to punch you\\nduring the anal exam and you don’t find anything, think post-anal\\nspace abscess. These are difficult to diagnose and identify but when\\nsuspected an examination under anesthesia in the operating room to\\nclearly define and drain these abscesses is needed. A pre-operative CT\\nscan may be helpful, but often these abscesses are small and not seen\\non imaging. In the operating room after induction of anesthesia, I place\\nthe patient in the lithotomy position, perform an anoscopy and then pass',\n", " 'md': '```markdown\\n## Surgical Management of Abscesses\\n\\nBe that as it may, larger abscesses need bigger incisions — I am a big guy and go for bigger ones. Whatever you do, the incision must be wide enough to permit introduction of your finger to gently debride the cavity and look for unexpected extensions. Irrigation with normal saline is useful to remove residual pus or blood from the cavity. General or regional anesthesia also allows you to search for an associated fistula in ano — which should be present in up to half of the patients — and perform a primary fistulotomy or placement of a seton, depending on the type of fistula. The collected evidence shows that this line of management leads to fewer recurrences.\\n\\nBut if you don’t consider yourself a big expert in anal fistula surgery then do not poke the skunk (which may result in iatrogenic fistula tracts or damage to the sphincters) — just drain the pus, leaving the potential fistula for the future.\\n\\nThere is no need to pack the cavity of the well-drained abscess. The patient will experience almost an immediate disappearance of the pain and will be most thankful, though in subsequent months — if you have omitted the search for it — approximately up to half will develop a fistula in ano — to be dealt with electively. Therefore, warn the patient about the probability of developing a fistula and schedule to see him a month or so after the operation.\\n\\n### Special Considerations\\n\\n#### Abscesses in the Post-Anal Space\\n\\nIn this scenario, patients have severe perianal pain and no ‘localizing’ findings on either digital examination or anoscopy. Most of the time they won’t tolerate a digital exam. So, if they swing round to punch you during the anal exam and you don’t find anything, think post-anal space abscess. These are difficult to diagnose and identify but when suspected an examination under anesthesia in the operating room to clearly define and drain these abscesses is needed. A pre-operative CT scan may be helpful, but often these abscesses are small and not seen on imaging. In the operating room after induction of anesthesia, I place the patient in the lithotomy position, perform an anoscopy and then pass.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Management of Abscesses',\n", " 'md': '## Surgical Management of Abscesses',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Be that as it may, larger abscesses need bigger incisions — I am a big guy and go for bigger ones. Whatever you do, the incision must be wide enough to permit introduction of your finger to gently debride the cavity and look for unexpected extensions. Irrigation with normal saline is useful to remove residual pus or blood from the cavity. General or regional anesthesia also allows you to search for an associated fistula in ano — which should be present in up to half of the patients — and perform a primary fistulotomy or placement of a seton, depending on the type of fistula. The collected evidence shows that this line of management leads to fewer recurrences.\\n\\nBut if you don’t consider yourself a big expert in anal fistula surgery then do not poke the skunk (which may result in iatrogenic fistula tracts or damage to the sphincters) — just drain the pus, leaving the potential fistula for the future.\\n\\nThere is no need to pack the cavity of the well-drained abscess. The patient will experience almost an immediate disappearance of the pain and will be most thankful, though in subsequent months — if you have omitted the search for it — approximately up to half will develop a fistula in ano — to be dealt with electively. Therefore, warn the patient about the probability of developing a fistula and schedule to see him a month or so after the operation.',\n", " 'md': 'Be that as it may, larger abscesses need bigger incisions — I am a big guy and go for bigger ones. Whatever you do, the incision must be wide enough to permit introduction of your finger to gently debride the cavity and look for unexpected extensions. Irrigation with normal saline is useful to remove residual pus or blood from the cavity. General or regional anesthesia also allows you to search for an associated fistula in ano — which should be present in up to half of the patients — and perform a primary fistulotomy or placement of a seton, depending on the type of fistula. The collected evidence shows that this line of management leads to fewer recurrences.\\n\\nBut if you don’t consider yourself a big expert in anal fistula surgery then do not poke the skunk (which may result in iatrogenic fistula tracts or damage to the sphincters) — just drain the pus, leaving the potential fistula for the future.\\n\\nThere is no need to pack the cavity of the well-drained abscess. The patient will experience almost an immediate disappearance of the pain and will be most thankful, though in subsequent months — if you have omitted the search for it — approximately up to half will develop a fistula in ano — to be dealt with electively. Therefore, warn the patient about the probability of developing a fistula and schedule to see him a month or so after the operation.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Special Considerations',\n", " 'md': '### Special Considerations',\n", " 'bBox': {'x': 86, 'y': 507, 'w': 180.24, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Abscesses in the Post-Anal Space',\n", " 'md': '#### Abscesses in the Post-Anal Space',\n", " 'bBox': {'x': 86, 'y': 546, 'w': 230.23, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'In this scenario, patients have severe perianal pain and no ‘localizing’ findings on either digital examination or anoscopy. Most of the time they won’t tolerate a digital exam. So, if they swing round to punch you during the anal exam and you don’t find anything, think post-anal space abscess. These are difficult to diagnose and identify but when suspected an examination under anesthesia in the operating room to clearly define and drain these abscesses is needed. A pre-operative CT scan may be helpful, but often these abscesses are small and not seen on imaging. In the operating room after induction of anesthesia, I place the patient in the lithotomy position, perform an anoscopy and then pass.\\n```',\n", " 'md': 'In this scenario, patients have severe perianal pain and no ‘localizing’ findings on either digital examination or anoscopy. Most of the time they won’t tolerate a digital exam. So, if they swing round to punch you during the anal exam and you don’t find anything, think post-anal space abscess. These are difficult to diagnose and identify but when suspected an examination under anesthesia in the operating room to clearly define and drain these abscesses is needed. A pre-operative CT scan may be helpful, but often these abscesses are small and not seen on imaging. In the operating room after induction of anesthesia, I place the patient in the lithotomy position, perform an anoscopy and then pass.\\n```',\n", " 'bBox': {'x': 72, 'y': 567, 'w': 467.72, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 539,\n", " 'text': 'a 16- or 18-gauge needle on a 10cc syringe into the post-anal space at\\nthe level of the dentate line. This helps to isolate the cavity and once I\\naspirate some pus, I enter the space by incising the internal sphincter\\nand poking a finger into the cavity. For an isolated post-anal space\\nabscess I do not make a counter incision on the skin. A counter\\nincision on the skin is only made if the abscess tracks elsewhere,\\nas this second incision creates a posterior fistula in ano.\\n\\n Horseshoe abscess\\n These originate from a post-anal space abscess that has lateralized to\\nboth ischiorectal fossas. Adequate drainage of both the right and left\\nischiorectal fossa is required as well as drainage of the post-anal\\nspace. This is performed through a posterior incision between the\\ncoccyx and the anal sphincters as well as creating an opening in the\\nposterior internal sphincter to facilitate drainage. Lateral drainage of\\nthe ischiorectal space is added to allow for complete drainage of the\\nabscess cavities. These patients will require some sort of management of\\ntheir posterior fistula at a later date.\\n\\n Suprasphincteric abscess\\n These generally are not caused by cryptoglandular infections. Instead,\\nthey usually develop secondary to an intra-abdominal pathology that has\\nformed an abscess deep in the pelvis at the level of the anorectal ring\\n(e.g. diverticular abscess). CT is required for diagnosis and drainage\\nis performed transrectally.\\n\\n Immunocompromised patients\\n Patients who are immunocompromised (e.g. those with diabetes,\\ninflammatory bowel disease, transplants, receiving immunosuppressants,\\nor on chemotherapy) require extra care. Often, especially in leukopenic\\npatients, there are no physical findings to indicate a significant\\nperianal infection.\\n\\n Don’t be fooled — these patients’ abscesses need to be incised\\nand drained (even for just a cc or two of pus) or debrided in the\\noperating room to ensure that the infection does not spread or become\\nnecrotizing.',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Post-Anal Space Abscess Management\\n\\nA 16- or 18-gauge needle on a 10cc syringe is inserted into the post-anal space at the level of the dentate line. This helps to isolate the cavity, and once pus is aspirated, the space is entered by incising the internal sphincter and inserting a finger into the cavity. For an isolated post-anal space abscess, a counter incision on the skin is not made. A counter incision is only made if the abscess tracks elsewhere, as this second incision creates a posterior fistula in ano.\\n\\n### Horseshoe Abscess\\n\\nThese originate from a post-anal space abscess that has lateralized to both ischiorectal fossas. Adequate drainage of both the right and left ischiorectal fossa is required, as well as drainage of the post-anal space. This is performed through a posterior incision between the coccyx and the anal sphincters, along with creating an opening in the posterior internal sphincter to facilitate drainage. Lateral drainage of the ischiorectal space is added to allow for complete drainage of the abscess cavities. Patients will require some form of management of their posterior fistula at a later date.\\n\\n### Suprasphincteric Abscess\\n\\nThese abscesses are generally not caused by cryptoglandular infections. Instead, they usually develop secondary to an intra-abdominal pathology that has formed an abscess deep in the pelvis at the level of the anorectal ring (e.g., diverticular abscess). CT is required for diagnosis, and drainage is performed transrectally.\\n\\n### Immunocompromised Patients\\n\\nPatients who are immunocompromised (e.g., those with diabetes, inflammatory bowel disease, transplants, receiving immunosuppressants, or on chemotherapy) require extra care. Often, especially in leukopenic patients, there are no physical findings to indicate a significant perianal infection.\\n\\nDon’t be fooled — these patients’ abscesses need to be incised and drained (even for just a cc or two of pus) or debrided in the operating room to ensure that the infection does not spread or become necrotizing.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Post-Anal Space Abscess Management',\n", " 'md': '### Post-Anal Space Abscess Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A 16- or 18-gauge needle on a 10cc syringe is inserted into the post-anal space at the level of the dentate line. This helps to isolate the cavity, and once pus is aspirated, the space is entered by incising the internal sphincter and inserting a finger into the cavity. For an isolated post-anal space abscess, a counter incision on the skin is not made. A counter incision is only made if the abscess tracks elsewhere, as this second incision creates a posterior fistula in ano.',\n", " 'md': 'A 16- or 18-gauge needle on a 10cc syringe is inserted into the post-anal space at the level of the dentate line. This helps to isolate the cavity, and once pus is aspirated, the space is entered by incising the internal sphincter and inserting a finger into the cavity. For an isolated post-anal space abscess, a counter incision on the skin is not made. A counter incision is only made if the abscess tracks elsewhere, as this second incision creates a posterior fistula in ano.',\n", " 'bBox': {'x': 72, 'y': 185, 'w': 387, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Horseshoe Abscess',\n", " 'md': '### Horseshoe Abscess',\n", " 'bBox': {'x': 86, 'y': 224, 'w': 135.13, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'These originate from a post-anal space abscess that has lateralized to both ischiorectal fossas. Adequate drainage of both the right and left ischiorectal fossa is required, as well as drainage of the post-anal space. This is performed through a posterior incision between the coccyx and the anal sphincters, along with creating an opening in the posterior internal sphincter to facilitate drainage. Lateral drainage of the ischiorectal space is added to allow for complete drainage of the abscess cavities. Patients will require some form of management of their posterior fistula at a later date.',\n", " 'md': 'These originate from a post-anal space abscess that has lateralized to both ischiorectal fossas. Adequate drainage of both the right and left ischiorectal fossa is required, as well as drainage of the post-anal space. This is performed through a posterior incision between the coccyx and the anal sphincters, along with creating an opening in the posterior internal sphincter to facilitate drainage. Lateral drainage of the ischiorectal space is added to allow for complete drainage of the abscess cavities. Patients will require some form of management of their posterior fistula at a later date.',\n", " 'bBox': {'x': 72, 'y': 245, 'w': 467.51, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Suprasphincteric Abscess',\n", " 'md': '### Suprasphincteric Abscess',\n", " 'bBox': {'x': 86, 'y': 416, 'w': 178.29, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'These abscesses are generally not caused by cryptoglandular infections. Instead, they usually develop secondary to an intra-abdominal pathology that has formed an abscess deep in the pelvis at the level of the anorectal ring (e.g., diverticular abscess). CT is required for diagnosis, and drainage is performed transrectally.',\n", " 'md': 'These abscesses are generally not caused by cryptoglandular infections. Instead, they usually develop secondary to an intra-abdominal pathology that has formed an abscess deep in the pelvis at the level of the anorectal ring (e.g., diverticular abscess). CT is required for diagnosis, and drainage is performed transrectally.',\n", " 'bBox': {'x': 72, 'y': 453, 'w': 467.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Immunocompromised Patients',\n", " 'md': '### Immunocompromised Patients',\n", " 'bBox': {'x': 86, 'y': 542, 'w': 209.45, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Patients who are immunocompromised (e.g., those with diabetes, inflammatory bowel disease, transplants, receiving immunosuppressants, or on chemotherapy) require extra care. Often, especially in leukopenic patients, there are no physical findings to indicate a significant perianal infection.\\n\\nDon’t be fooled — these patients’ abscesses need to be incised and drained (even for just a cc or two of pus) or debrided in the operating room to ensure that the infection does not spread or become necrotizing.\\n```',\n", " 'md': 'Patients who are immunocompromised (e.g., those with diabetes, inflammatory bowel disease, transplants, receiving immunosuppressants, or on chemotherapy) require extra care. Often, especially in leukopenic patients, there are no physical findings to indicate a significant perianal infection.\\n\\nDon’t be fooled — these patients’ abscesses need to be incised and drained (even for just a cc or two of pus) or debrided in the operating room to ensure that the infection does not spread or become necrotizing.\\n```',\n", " 'bBox': {'x': 72, 'y': 579, 'w': 467.63, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 540,\n", " 'text': ' However, in some of these post-transplant or other ‘zero-neutrophil’ patients there’s really\\n nothing to drain. We get a CT to exclude a collection or air bubbles, and if negative would start\\n with antibiotics and follow up. Danny\\n\\n These patients may also require i.v. antibiotics whereas other\\nhealthy patients with perianal abscesses are easily managed by\\nincision and drainage alone, and if there is a reactive cellulitis, oral\\nantibiotics only. (A caveat: the incidence of community-acquired\\nperianal abscesses caused by methicilllin-resistant Staphyloccocus\\naureus (MRSA) is on the rise. You should suspect them when you find\\nintense pain and extensive local inflammation but very little drainable\\npus. Take a swab for bacteriology and start anti-MRSA antibiotics.)\\n\\n Concluding tips\\n\\n • The use of packing in any drained perianal abscess is not\\n necessary, and should be used primarily for hemostasis. If you\\n want to keep the abscess open to drain, make the external\\n opening large enough or place a drain.\\n • Adequately drain the abscess. Ensure that all the loculations that\\n can form within the cavity itself are broken up either with a clamp or\\n your finger.\\n • In most patients perform the drainage in the operating room.\\n Your practice and reputation will suffer if you make the patient suffer.\\n • Beware the immunosuppressed patient. They can become very\\n septic very quickly from a perianal infection.\\n\\n An abscess near the anus should not be left to burst by\\n itself, but… be boldly opened with a very sharp lancette, so\\n that pus and the corrupt blood may go out. Or else… the\\n gut which is called rectum… will burst… for then may it…\\n be called fistula. And I have seen some who have seven or\\n nine holes on one side of the buttocks… none of which\\n except one pierce the rectum.\\n John of Arderne',\n", " 'md': '```markdown\\n## Current Page Content\\n\\nHowever, in some of these post-transplant or other ‘zero-neutrophil’ patients there’s really nothing to drain. We get a CT to exclude a collection or air bubbles, and if negative would start with antibiotics and follow up. Danny\\n\\nThese patients may also require i.v. antibiotics whereas other healthy patients with perianal abscesses are easily managed by incision and drainage alone, and if there is a reactive cellulitis, oral antibiotics only. (A caveat: the incidence of community-acquired perianal abscesses caused by methicillin-resistant Staphylococcus aureus (MRSA) is on the rise. You should suspect them when you find intense pain and extensive local inflammation but very little drainable pus. Take a swab for bacteriology and start anti-MRSA antibiotics.)\\n\\n### Concluding Tips\\n\\n- The use of packing in any drained perianal abscess is not necessary, and should be used primarily for hemostasis. If you want to keep the abscess open to drain, make the external opening large enough or place a drain.\\n- Adequately drain the abscess. Ensure that all the loculations that can form within the cavity itself are broken up either with a clamp or your finger.\\n- In most patients perform the drainage in the operating room. Your practice and reputation will suffer if you make the patient suffer.\\n- Beware the immunosuppressed patient. They can become very septic very quickly from a perianal infection.\\n\\nAn abscess near the anus should not be left to burst by itself, but… be boldly opened with a very sharp lancette, so that pus and the corrupt blood may go out. Or else… the gut which is called rectum… will burst… for then may it… be called fistula. And I have seen some who have seven or nine holes on one side of the buttocks… none of which except one pierce the rectum.\\n— John of Arderne\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'However, in some of these post-transplant or other ‘zero-neutrophil’ patients there’s really nothing to drain. We get a CT to exclude a collection or air bubbles, and if negative would start with antibiotics and follow up. Danny\\n\\nThese patients may also require i.v. antibiotics whereas other healthy patients with perianal abscesses are easily managed by incision and drainage alone, and if there is a reactive cellulitis, oral antibiotics only. (A caveat: the incidence of community-acquired perianal abscesses caused by methicillin-resistant Staphylococcus aureus (MRSA) is on the rise. You should suspect them when you find intense pain and extensive local inflammation but very little drainable pus. Take a swab for bacteriology and start anti-MRSA antibiotics.)',\n", " 'md': 'However, in some of these post-transplant or other ‘zero-neutrophil’ patients there’s really nothing to drain. We get a CT to exclude a collection or air bubbles, and if negative would start with antibiotics and follow up. Danny\\n\\nThese patients may also require i.v. antibiotics whereas other healthy patients with perianal abscesses are easily managed by incision and drainage alone, and if there is a reactive cellulitis, oral antibiotics only. (A caveat: the incidence of community-acquired perianal abscesses caused by methicillin-resistant Staphylococcus aureus (MRSA) is on the rise. You should suspect them when you find intense pain and extensive local inflammation but very little drainable pus. Take a swab for bacteriology and start anti-MRSA antibiotics.)',\n", " 'bBox': {'x': 72, 'y': 111, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Concluding Tips',\n", " 'md': '### Concluding Tips',\n", " 'bBox': {'x': 86, 'y': 332, 'w': 125.04, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- The use of packing in any drained perianal abscess is not necessary, and should be used primarily for hemostasis. If you want to keep the abscess open to drain, make the external opening large enough or place a drain.\\n- Adequately drain the abscess. Ensure that all the loculations that can form within the cavity itself are broken up either with a clamp or your finger.\\n- In most patients perform the drainage in the operating room. Your practice and reputation will suffer if you make the patient suffer.\\n- Beware the immunosuppressed patient. They can become very septic very quickly from a perianal infection.\\n\\nAn abscess near the anus should not be left to burst by itself, but… be boldly opened with a very sharp lancette, so that pus and the corrupt blood may go out. Or else… the gut which is called rectum… will burst… for then may it… be called fistula. And I have seen some who have seven or nine holes on one side of the buttocks… none of which except one pierce the rectum.\\n— John of Arderne\\n```',\n", " 'md': '- The use of packing in any drained perianal abscess is not necessary, and should be used primarily for hemostasis. If you want to keep the abscess open to drain, make the external opening large enough or place a drain.\\n- Adequately drain the abscess. Ensure that all the loculations that can form within the cavity itself are broken up either with a clamp or your finger.\\n- In most patients perform the drainage in the operating room. Your practice and reputation will suffer if you make the patient suffer.\\n- Beware the immunosuppressed patient. They can become very septic very quickly from a perianal infection.\\n\\nAn abscess near the anus should not be left to burst by itself, but… be boldly opened with a very sharp lancette, so that pus and the corrupt blood may go out. Or else… the gut which is called rectum… will burst… for then may it… be called fistula. And I have seen some who have seven or nine holes on one side of the buttocks… none of which except one pierce the rectum.\\n— John of Arderne\\n```',\n", " 'bBox': {'x': 100, 'y': 419, 'w': 437.07, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 541,\n", " 'text': ' Postoperative problems after anal operations\\n\\n Bleeding after hemorrhoidectomy and other anal\\n operations\\n\\n A minor degree of bleeding is common after any anal surgery and\\nthis should be relayed to your patient to avoid telephone calls in the\\nmiddle of the night. It is rare to require packing in the anal canal unless\\nthere is some small amount of oozing. Removal of packing is painful so if\\npacking is required in the canal for a short period to help tamponade\\nminor oozing, then a dissolvable cellulose-based material (e.g.\\nGelfoam®) should be used.\\n\\n When significant bleeding occurs after anal surgery, it may be obvious\\nwith significant blood pouring from the anus, or not so obvious — with\\nblood pooling in the base of the rectum. When patients are in pain,\\nhave excellent sphincter tone and the sphincter is in spasm then\\nquite a large amount of blood can pool in the lower rectum with\\nminimal signs of bleeding. These patients may even present with\\nhemodynamic compromise — tachycardia and pallor. It is virtually\\nimpossible to deal with these bleeding issues in the emergency room and\\nthe patients should be taken to the operating room, placed under general\\nendotracheal anesthesia, where adequate exposure and control of the\\nbleeding vessel can be performed.\\n\\n Some of these patients will require fluid resuscitation prior to\\ngoing to the operating room and will have some active bleeding that\\nneeds to be stemmed immediately. I have controlled this bleeding by\\ninserting a Foley catheter with a 30cc balloon gently into the rectum,\\nblowing up the balloon to its full extent and then pulling on the Foley with\\ngentle traction to provide pressure at the site of bleeding at the top of the\\nanal canal.\\n\\n At surgery, if the bleeding site is identified usually a figure-of-\\neight suture will suffice to control the bleeding. (When performing\\nexcisional hemorrhoidectomies, if sutures have been used to ligate the\\nbase of the hemorrhoidal complex, these sutures should be left long so',\n", " 'md': '# Postoperative Problems After Anal Operations\\n\\n## Bleeding After Hemorrhoidectomy and Other Anal Operations\\n\\nA minor degree of bleeding is common after any anal surgery, and this should be relayed to your patient to avoid telephone calls in the middle of the night. It is rare to require packing in the anal canal unless there is some small amount of oozing. Removal of packing is painful, so if packing is required in the canal for a short period to help tamponade minor oozing, then a dissolvable cellulose-based material (e.g., Gelfoam®) should be used.\\n\\nWhen significant bleeding occurs after anal surgery, it may be obvious with significant blood pouring from the anus, or not so obvious—with blood pooling in the base of the rectum. When patients are in pain, have excellent sphincter tone, and the sphincter is in spasm, then quite a large amount of blood can pool in the lower rectum with minimal signs of bleeding. These patients may even present with hemodynamic compromise—tachycardia and pallor. It is virtually impossible to deal with these bleeding issues in the emergency room, and the patients should be taken to the operating room, placed under general endotracheal anesthesia, where adequate exposure and control of the bleeding vessel can be performed.\\n\\nSome of these patients will require fluid resuscitation prior to going to the operating room and will have some active bleeding that needs to be stemmed immediately. I have controlled this bleeding by inserting a Foley catheter with a 30cc balloon gently into the rectum, blowing up the balloon to its full extent, and then pulling on the Foley with gentle traction to provide pressure at the site of bleeding at the top of the anal canal.\\n\\nAt surgery, if the bleeding site is identified, usually a figure-of-eight suture will suffice to control the bleeding. (When performing excisional hemorrhoidectomies, if sutures have been used to ligate the base of the hemorrhoidal complex, these sutures should be left long so...)\\n\\n----\\n\\n*Note: There are no figures, tables, or images identified on this page.*',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Postoperative Problems After Anal Operations',\n", " 'md': '# Postoperative Problems After Anal Operations',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 355.86, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Bleeding After Hemorrhoidectomy and Other Anal Operations',\n", " 'md': '## Bleeding After Hemorrhoidectomy and Other Anal Operations',\n", " 'bBox': {'x': 86, 'y': 132, 'w': 149.9, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A minor degree of bleeding is common after any anal surgery, and this should be relayed to your patient to avoid telephone calls in the middle of the night. It is rare to require packing in the anal canal unless there is some small amount of oozing. Removal of packing is painful, so if packing is required in the canal for a short period to help tamponade minor oozing, then a dissolvable cellulose-based material (e.g., Gelfoam®) should be used.\\n\\nWhen significant bleeding occurs after anal surgery, it may be obvious with significant blood pouring from the anus, or not so obvious—with blood pooling in the base of the rectum. When patients are in pain, have excellent sphincter tone, and the sphincter is in spasm, then quite a large amount of blood can pool in the lower rectum with minimal signs of bleeding. These patients may even present with hemodynamic compromise—tachycardia and pallor. It is virtually impossible to deal with these bleeding issues in the emergency room, and the patients should be taken to the operating room, placed under general endotracheal anesthesia, where adequate exposure and control of the bleeding vessel can be performed.\\n\\nSome of these patients will require fluid resuscitation prior to going to the operating room and will have some active bleeding that needs to be stemmed immediately. I have controlled this bleeding by inserting a Foley catheter with a 30cc balloon gently into the rectum, blowing up the balloon to its full extent, and then pulling on the Foley with gentle traction to provide pressure at the site of bleeding at the top of the anal canal.\\n\\nAt surgery, if the bleeding site is identified, usually a figure-of-eight suture will suffice to control the bleeding. (When performing excisional hemorrhoidectomies, if sutures have been used to ligate the base of the hemorrhoidal complex, these sutures should be left long so...)\\n\\n----\\n\\n*Note: There are no figures, tables, or images identified on this page.*',\n", " 'md': 'A minor degree of bleeding is common after any anal surgery, and this should be relayed to your patient to avoid telephone calls in the middle of the night. It is rare to require packing in the anal canal unless there is some small amount of oozing. Removal of packing is painful, so if packing is required in the canal for a short period to help tamponade minor oozing, then a dissolvable cellulose-based material (e.g., Gelfoam®) should be used.\\n\\nWhen significant bleeding occurs after anal surgery, it may be obvious with significant blood pouring from the anus, or not so obvious—with blood pooling in the base of the rectum. When patients are in pain, have excellent sphincter tone, and the sphincter is in spasm, then quite a large amount of blood can pool in the lower rectum with minimal signs of bleeding. These patients may even present with hemodynamic compromise—tachycardia and pallor. It is virtually impossible to deal with these bleeding issues in the emergency room, and the patients should be taken to the operating room, placed under general endotracheal anesthesia, where adequate exposure and control of the bleeding vessel can be performed.\\n\\nSome of these patients will require fluid resuscitation prior to going to the operating room and will have some active bleeding that needs to be stemmed immediately. I have controlled this bleeding by inserting a Foley catheter with a 30cc balloon gently into the rectum, blowing up the balloon to its full extent, and then pulling on the Foley with gentle traction to provide pressure at the site of bleeding at the top of the anal canal.\\n\\nAt surgery, if the bleeding site is identified, usually a figure-of-eight suture will suffice to control the bleeding. (When performing excisional hemorrhoidectomies, if sutures have been used to ligate the base of the hemorrhoidal complex, these sutures should be left long so...)\\n\\n----\\n\\n*Note: There are no figures, tables, or images identified on this page.*',\n", " 'bBox': {'x': 72, 'y': 132, 'w': 467.99, 'h': 19.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 542,\n", " 'text': 'that if postoperative bleeding occurs they can be grasped to help identify\\nthe site of bleeding.) Using adequate instrumentation to visualize the\\nanus is a requirement. If the patient has had a stapled hemorrhoidectomy\\nand identification of the bleeding site is clearly witnessed then a simple\\nsuture ligation of this point is adequate. If, however, there is generalized\\noozing or one does not see a clear point of bleeding, I oversew the entire\\nstaple line with a continuous suture. Sometimes it is difficult to access\\nand see the staple line that is above the dentate line when there is active\\nbleeding. The stapled hemorrhoidectomy kits come with an excellent\\nclear anoscope that allows visualization of the entire staple line and a kit\\nshould be available, not to perform a restapling but to utilize the\\nanoscope as needed (at this point in time with a return to the operating\\nroom I don’t worry about cost!)\\n\\n As with any postoperative bleeding, occasionally when you re-explore the operative site, all you\\n find is some oozing and it is impossible to guess from where all this blood has originated. This\\n is when anal packing has some value. I use a home-made tampon by rolling a large piece of\\n Vaseline gauze, coated generously with lidocaine jelly. A day later it slides out without too much\\n discomfort… Moshe\\n\\n The unhealed perianal wound\\n\\n All perianal wounds should heal within 6-8 weeks and most patients\\nshould see relief of their pain anywhere from 1-3 weeks. I choose to see\\npatients back in follow-up at 3-4 weeks, hoping by this point in time that\\ntheir pain has subsided. If a hemorrhoidal or any perianal wound has not\\nhealed after a 6-8 week period of time, usually the optimal treatment for\\nthese patients is best described with the acronym MICLO (masterly\\ninactivity with cat-like observation). ħere again, less is more and doing\\nnothing but trying to keep the patient happy and satisfied is an ideal\\napproach. All wounds will eventually heal unless there is some\\nunderlying cause such as sepsis or the very rare case where\\npatients may have had undiagnosed Crohn’s disease at the time of\\ntheir surgery. Even in these patients, medical therapy is warranted and\\nnot further surgical intervention.',\n", " 'md': '```markdown\\n## Postoperative Bleeding Management\\n\\nIf postoperative bleeding occurs, it can be grasped to help identify the site of bleeding. Using adequate instrumentation to visualize the anus is a requirement. If the patient has had a stapled hemorrhoidectomy and identification of the bleeding site is clearly witnessed, then a simple suture ligation of this point is adequate. If, however, there is generalized oozing or one does not see a clear point of bleeding, I oversew the entire staple line with a continuous suture. Sometimes it is difficult to access and see the staple line that is above the dentate line when there is active bleeding. The stapled hemorrhoidectomy kits come with an excellent clear anoscope that allows visualization of the entire staple line, and a kit should be available, not to perform a restapling but to utilize the anoscope as needed (at this point in time with a return to the operating room I don’t worry about cost!).\\n\\nAs with any postoperative bleeding, occasionally when you re-explore the operative site, all you find is some oozing, and it is impossible to guess from where all this blood has originated. This is when anal packing has some value. I use a homemade tampon by rolling a large piece of Vaseline gauze, coated generously with lidocaine jelly. A day later it slides out without too much discomfort.\\n\\n### The Unhealed Perianal Wound\\n\\nAll perianal wounds should heal within 6-8 weeks, and most patients should see relief of their pain anywhere from 1-3 weeks. I choose to see patients back in follow-up at 3-4 weeks, hoping by this point in time that their pain has subsided. If a hemorrhoidal or any perianal wound has not healed after a 6-8 week period of time, usually the optimal treatment for these patients is best described with the acronym **MICLO** (masterly inactivity with cat-like observation). Here again, less is more, and doing nothing but trying to keep the patient happy and satisfied is an ideal approach. All wounds will eventually heal unless there is some underlying cause such as sepsis or the very rare case where patients may have had undiagnosed Crohn’s disease at the time of their surgery. Even in these patients, medical therapy is warranted and not further surgical intervention.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Postoperative Bleeding Management',\n", " 'md': '## Postoperative Bleeding Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'If postoperative bleeding occurs, it can be grasped to help identify the site of bleeding. Using adequate instrumentation to visualize the anus is a requirement. If the patient has had a stapled hemorrhoidectomy and identification of the bleeding site is clearly witnessed, then a simple suture ligation of this point is adequate. If, however, there is generalized oozing or one does not see a clear point of bleeding, I oversew the entire staple line with a continuous suture. Sometimes it is difficult to access and see the staple line that is above the dentate line when there is active bleeding. The stapled hemorrhoidectomy kits come with an excellent clear anoscope that allows visualization of the entire staple line, and a kit should be available, not to perform a restapling but to utilize the anoscope as needed (at this point in time with a return to the operating room I don’t worry about cost!).\\n\\nAs with any postoperative bleeding, occasionally when you re-explore the operative site, all you find is some oozing, and it is impossible to guess from where all this blood has originated. This is when anal packing has some value. I use a homemade tampon by rolling a large piece of Vaseline gauze, coated generously with lidocaine jelly. A day later it slides out without too much discomfort.',\n", " 'md': 'If postoperative bleeding occurs, it can be grasped to help identify the site of bleeding. Using adequate instrumentation to visualize the anus is a requirement. If the patient has had a stapled hemorrhoidectomy and identification of the bleeding site is clearly witnessed, then a simple suture ligation of this point is adequate. If, however, there is generalized oozing or one does not see a clear point of bleeding, I oversew the entire staple line with a continuous suture. Sometimes it is difficult to access and see the staple line that is above the dentate line when there is active bleeding. The stapled hemorrhoidectomy kits come with an excellent clear anoscope that allows visualization of the entire staple line, and a kit should be available, not to perform a restapling but to utilize the anoscope as needed (at this point in time with a return to the operating room I don’t worry about cost!).\\n\\nAs with any postoperative bleeding, occasionally when you re-explore the operative site, all you find is some oozing, and it is impossible to guess from where all this blood has originated. This is when anal packing has some value. I use a homemade tampon by rolling a large piece of Vaseline gauze, coated generously with lidocaine jelly. A day later it slides out without too much discomfort.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 468.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Unhealed Perianal Wound',\n", " 'md': '### The Unhealed Perianal Wound',\n", " 'bBox': {'x': 86, 'y': 454, 'w': 232.63, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'All perianal wounds should heal within 6-8 weeks, and most patients should see relief of their pain anywhere from 1-3 weeks. I choose to see patients back in follow-up at 3-4 weeks, hoping by this point in time that their pain has subsided. If a hemorrhoidal or any perianal wound has not healed after a 6-8 week period of time, usually the optimal treatment for these patients is best described with the acronym **MICLO** (masterly inactivity with cat-like observation). Here again, less is more, and doing nothing but trying to keep the patient happy and satisfied is an ideal approach. All wounds will eventually heal unless there is some underlying cause such as sepsis or the very rare case where patients may have had undiagnosed Crohn’s disease at the time of their surgery. Even in these patients, medical therapy is warranted and not further surgical intervention.\\n```',\n", " 'md': 'All perianal wounds should heal within 6-8 weeks, and most patients should see relief of their pain anywhere from 1-3 weeks. I choose to see patients back in follow-up at 3-4 weeks, hoping by this point in time that their pain has subsided. If a hemorrhoidal or any perianal wound has not healed after a 6-8 week period of time, usually the optimal treatment for these patients is best described with the acronym **MICLO** (masterly inactivity with cat-like observation). Here again, less is more, and doing nothing but trying to keep the patient happy and satisfied is an ideal approach. All wounds will eventually heal unless there is some underlying cause such as sepsis or the very rare case where patients may have had undiagnosed Crohn’s disease at the time of their surgery. Even in these patients, medical therapy is warranted and not further surgical intervention.\\n```',\n", " 'bBox': {'x': 72, 'y': 507, 'w': 467.8, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 543,\n", " 'text': ' Patients’ position and choice of anesthesia for anal\\n operations\\n\\n Providing perianal anesthesia with a perianal block is a true art. If you\\nhave not mastered this art, you should perform these procedures under\\ngeneral or spinal anesthesia. The procedures can be performed either in\\nthe lithotomy or the prone jack-knife position. I perform them under\\ngeneral anesthesia as most of my anesthesia colleagues are not\\nskilled in locoregional anesthesia and most patients nowadays are\\nquite jumpy and do not tolerate perianal block. A quick general\\nanesthetic (our gas pushers use propofol), if the patient is healthy, is\\nefficient and well tolerated.\\n\\n Both the lithotomy and prone jack-knife positions have their\\nbenefits. In the prone position it is easier to deal with bleeding and\\nmaintain access and visualization in the field. This quote by Angus G.\\nMaciver best assesses positioning for anorectal surgery: “Rectal surgery\\nis a bit like sex. There are proponents of various positions and unique\\ninstances when some are much more enjoyable (depending on whether\\nthe pathology is anterior or posterior). Most people experiment with a\\nvariety of approaches, but generally stick to the one which offers them\\nconsistently predictable and satisfying results.” I opt for the lithotomy\\nposition in most patients as it is quick and easy and I have adequate\\nexposure.\\n\\n If you wish to give a perianal block (with or without i.v. sedation), here is how to do it. Use a\\n mixture of 2ml of 0.5% bupivacaine, with 10ml of 1% lidocaine and 10ml of normal saline, and\\n a 6cm intramuscular needle. Inject 5cc of the mixture deeply behind the anus, peripheral to the\\n external sphincter. Then without totally removing the needle, repeat the injection on both sides,\\n with a 45° inclination ( Figure 30.3 — steps 1, 2, 3). A second injection is done anteriorly (\\n Figure 30.3 — steps 4, 5, 6), with the same fanning. And finally, two more injections following a\\n similar pattern at 3 and 9 o’clock ( Figure 30.3 — steps 7, 8). Professor Luis A.\\n Carriquiry',\n", " 'md': '# Patients’ Position and Choice of Anesthesia for Anal Operations\\n\\nProviding perianal anesthesia with a perianal block is a true art. If you have not mastered this art, you should perform these procedures under general or spinal anesthesia. The procedures can be performed either in the lithotomy or the prone jack-knife position. I perform them under general anesthesia as most of my anesthesia colleagues are not skilled in locoregional anesthesia and most patients nowadays are quite jumpy and do not tolerate perianal block. A quick general anesthetic (our gas pushers use propofol), if the patient is healthy, is efficient and well tolerated.\\n\\nBoth the lithotomy and prone jack-knife positions have their benefits. In the prone position, it is easier to deal with bleeding and maintain access and visualization in the field. This quote by Angus G. Maciver best assesses positioning for anorectal surgery:\\n\\n> “Rectal surgery is a bit like sex. There are proponents of various positions and unique instances when some are much more enjoyable (depending on whether the pathology is anterior or posterior). Most people experiment with a variety of approaches, but generally stick to the one which offers them consistently predictable and satisfying results.”\\n\\nI opt for the lithotomy position in most patients as it is quick and easy and I have adequate exposure.\\n\\nIf you wish to give a perianal block (with or without i.v. sedation), here is how to do it. Use a mixture of \\\\(2 \\\\, \\\\text{ml}\\\\) of \\\\(0.5\\\\%\\\\) bupivacaine, with \\\\(10 \\\\, \\\\text{ml}\\\\) of \\\\(1\\\\%\\\\) lidocaine and \\\\(10 \\\\, \\\\text{ml}\\\\) of normal saline, and a \\\\(6 \\\\, \\\\text{cm}\\\\) intramuscular needle. Inject \\\\(5 \\\\, \\\\text{cc}\\\\) of the mixture deeply behind the anus, peripheral to the external sphincter. Then without totally removing the needle, repeat the injection on both sides, with a \\\\(45^\\\\circ\\\\) inclination (Figure 30.3 — steps 1, 2, 3). A second injection is done anteriorly (Figure 30.3 — steps 4, 5, 6), with the same fanning. And finally, two more injections following a similar pattern at \\\\(3\\\\) and \\\\(9\\\\) o’clock (Figure 30.3 — steps 7, 8).\\n\\n**Professor Luis A. Carriquiry**\\n\\n----\\n\\n### Figures\\n\\n**Figure 30.3**: This figure illustrates the steps for administering a perianal block. It includes a series of images showing the injection technique, with specific steps numbered for clarity. The images depict the positioning of the needle and the injection sites around the anus, demonstrating the fanning technique used for effective anesthesia delivery.\\n\\n- **Step 1**: Injection behind the anus.\\n- **Step 2**: Injection on both sides at a \\\\(45^\\\\circ\\\\) angle.\\n- **Step 3**: Anterior injection.\\n- **Step 4**: Additional injections at \\\\(3\\\\) and \\\\(9\\\\) o’clock positions.\\n\\nThe figure serves as a visual guide for practitioners to follow the described procedure accurately.',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Patients’ Position and Choice of Anesthesia for Anal Operations',\n", " 'md': '# Patients’ Position and Choice of Anesthesia for Anal Operations',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 85.55, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Providing perianal anesthesia with a perianal block is a true art. If you have not mastered this art, you should perform these procedures under general or spinal anesthesia. The procedures can be performed either in the lithotomy or the prone jack-knife position. I perform them under general anesthesia as most of my anesthesia colleagues are not skilled in locoregional anesthesia and most patients nowadays are quite jumpy and do not tolerate perianal block. A quick general anesthetic (our gas pushers use propofol), if the patient is healthy, is efficient and well tolerated.\\n\\nBoth the lithotomy and prone jack-knife positions have their benefits. In the prone position, it is easier to deal with bleeding and maintain access and visualization in the field. This quote by Angus G. Maciver best assesses positioning for anorectal surgery:\\n\\n> “Rectal surgery is a bit like sex. There are proponents of various positions and unique instances when some are much more enjoyable (depending on whether the pathology is anterior or posterior). Most people experiment with a variety of approaches, but generally stick to the one which offers them consistently predictable and satisfying results.”\\n\\nI opt for the lithotomy position in most patients as it is quick and easy and I have adequate exposure.\\n\\nIf you wish to give a perianal block (with or without i.v. sedation), here is how to do it. Use a mixture of \\\\(2 \\\\, \\\\text{ml}\\\\) of \\\\(0.5\\\\%\\\\) bupivacaine, with \\\\(10 \\\\, \\\\text{ml}\\\\) of \\\\(1\\\\%\\\\) lidocaine and \\\\(10 \\\\, \\\\text{ml}\\\\) of normal saline, and a \\\\(6 \\\\, \\\\text{cm}\\\\) intramuscular needle. Inject \\\\(5 \\\\, \\\\text{cc}\\\\) of the mixture deeply behind the anus, peripheral to the external sphincter. Then without totally removing the needle, repeat the injection on both sides, with a \\\\(45^\\\\circ\\\\) inclination (Figure 30.3 — steps 1, 2, 3). A second injection is done anteriorly (Figure 30.3 — steps 4, 5, 6), with the same fanning. And finally, two more injections following a similar pattern at \\\\(3\\\\) and \\\\(9\\\\) o’clock (Figure 30.3 — steps 7, 8).\\n\\n**Professor Luis A. Carriquiry**\\n\\n----',\n", " 'md': 'Providing perianal anesthesia with a perianal block is a true art. If you have not mastered this art, you should perform these procedures under general or spinal anesthesia. The procedures can be performed either in the lithotomy or the prone jack-knife position. I perform them under general anesthesia as most of my anesthesia colleagues are not skilled in locoregional anesthesia and most patients nowadays are quite jumpy and do not tolerate perianal block. A quick general anesthetic (our gas pushers use propofol), if the patient is healthy, is efficient and well tolerated.\\n\\nBoth the lithotomy and prone jack-knife positions have their benefits. In the prone position, it is easier to deal with bleeding and maintain access and visualization in the field. This quote by Angus G. Maciver best assesses positioning for anorectal surgery:\\n\\n> “Rectal surgery is a bit like sex. There are proponents of various positions and unique instances when some are much more enjoyable (depending on whether the pathology is anterior or posterior). Most people experiment with a variety of approaches, but generally stick to the one which offers them consistently predictable and satisfying results.”\\n\\nI opt for the lithotomy position in most patients as it is quick and easy and I have adequate exposure.\\n\\nIf you wish to give a perianal block (with or without i.v. sedation), here is how to do it. Use a mixture of \\\\(2 \\\\, \\\\text{ml}\\\\) of \\\\(0.5\\\\%\\\\) bupivacaine, with \\\\(10 \\\\, \\\\text{ml}\\\\) of \\\\(1\\\\%\\\\) lidocaine and \\\\(10 \\\\, \\\\text{ml}\\\\) of normal saline, and a \\\\(6 \\\\, \\\\text{cm}\\\\) intramuscular needle. Inject \\\\(5 \\\\, \\\\text{cc}\\\\) of the mixture deeply behind the anus, peripheral to the external sphincter. Then without totally removing the needle, repeat the injection on both sides, with a \\\\(45^\\\\circ\\\\) inclination (Figure 30.3 — steps 1, 2, 3). A second injection is done anteriorly (Figure 30.3 — steps 4, 5, 6), with the same fanning. And finally, two more injections following a similar pattern at \\\\(3\\\\) and \\\\(9\\\\) o’clock (Figure 30.3 — steps 7, 8).\\n\\n**Professor Luis A. Carriquiry**\\n\\n----',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.78, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 30.3**: This figure illustrates the steps for administering a perianal block. It includes a series of images showing the injection technique, with specific steps numbered for clarity. The images depict the positioning of the needle and the injection sites around the anus, demonstrating the fanning technique used for effective anesthesia delivery.\\n\\n- **Step 1**: Injection behind the anus.\\n- **Step 2**: Injection on both sides at a \\\\(45^\\\\circ\\\\) angle.\\n- **Step 3**: Anterior injection.\\n- **Step 4**: Additional injections at \\\\(3\\\\) and \\\\(9\\\\) o’clock positions.\\n\\nThe figure serves as a visual guide for practitioners to follow the described procedure accurately.',\n", " 'md': '**Figure 30.3**: This figure illustrates the steps for administering a perianal block. It includes a series of images showing the injection technique, with specific steps numbered for clarity. The images depict the positioning of the needle and the injection sites around the anus, demonstrating the fanning technique used for effective anesthesia delivery.\\n\\n- **Step 1**: Injection behind the anus.\\n- **Step 2**: Injection on both sides at a \\\\(45^\\\\circ\\\\) angle.\\n- **Step 3**: Anterior injection.\\n- **Step 4**: Additional injections at \\\\(3\\\\) and \\\\(9\\\\) o’clock positions.\\n\\nThe figure serves as a visual guide for practitioners to follow the described procedure accurately.',\n", " 'bBox': {'x': 166, 'y': 88, 'w': 85.55, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'Figure 30.3 — steps 4, 5, 6), with the same fanning. And finally, two more injections following a'},\n", " {'text': ''}]},\n", " {'page': 544,\n", " 'text': ' 459 2\\n Figure 30.3. Perianal local anesthesia. Courtesy of Professor Luis A. Carriquiry.\\n\\n The following section has been updated by us from the chapter in the previous edition by\\n Professor Luis A. Carriquiry. The Editors\\n\\n Acute incarcerated full-thickness rectal prolapse\\n\\n Before going on to the more serious conditions, a brief mention of a\\nrare situation: acute incarcerated full-thickness rectal prolapse. This\\nis an uncommon condition but most painful and distressing for the\\npatient. It develops usually in individuals with weak sphincters.\\n\\n Examination makes the diagnosis quite obvious: you see the\\nbulge of the prolapse with the typical rectal mucosa and concentric\\nfolds, which must be differentiated from the above mentioned acute\\nprolapse of haemorrhoids (more irregular, with radial folds).\\n\\n Try to reduce the prolapse with local or general anesthesia. The use of\\nsugar has been recommended also for this condition; it works by\\nosmotically reducing the edema of the mucosa and thus allows an easier\\nreduction. When this fails or where there is extensive mucosal necrosis,\\noperative treatment is a better option; my choice is a perineal\\nrectosigmoidectomy with a coloanal hand-sutured anastomosis',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Figure 30.3\\n**Description:** This figure illustrates the concept of perianal local anesthesia. It is credited to Professor Luis A. Carriquiry.\\n\\n----\\n\\n### Acute Incarcerated Full-Thickness Rectal Prolapse\\n\\nBefore going on to the more serious conditions, a brief mention of a rare situation: acute incarcerated full-thickness rectal prolapse. This is an uncommon condition but most painful and distressing for the patient. It develops usually in individuals with weak sphincters.\\n\\nExamination makes the diagnosis quite obvious: you see the bulge of the prolapse with the typical rectal mucosa and concentric folds, which must be differentiated from the above mentioned acute prolapse of hemorrhoids (more irregular, with radial folds).\\n\\nTry to reduce the prolapse with local or general anesthesia. The use of sugar has been recommended also for this condition; it works by osmotically reducing the edema of the mucosa and thus allows an easier reduction. When this fails or where there is extensive mucosal necrosis, operative treatment is a better option; my choice is a perineal rectosigmoidectomy with a coloanal hand-sutured anastomosis.\\n```',\n", " 'images': [{'name': 'img_p543_1.png',\n", " 'height': 409,\n", " 'width': 414,\n", " 'x': 203.7599999999993,\n", " 'y': 82.80000000000001,\n", " 'original_width': 948,\n", " 'original_height': 937}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 30.3',\n", " 'md': '## Figure 30.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure illustrates the concept of perianal local anesthesia. It is credited to Professor Luis A. Carriquiry.\\n\\n----',\n", " 'md': '**Description:** This figure illustrates the concept of perianal local anesthesia. It is credited to Professor Luis A. Carriquiry.\\n\\n----',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Acute Incarcerated Full-Thickness Rectal Prolapse',\n", " 'md': '### Acute Incarcerated Full-Thickness Rectal Prolapse',\n", " 'bBox': {'x': 86, 'y': 428, 'w': 382.55, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Before going on to the more serious conditions, a brief mention of a rare situation: acute incarcerated full-thickness rectal prolapse. This is an uncommon condition but most painful and distressing for the patient. It develops usually in individuals with weak sphincters.\\n\\nExamination makes the diagnosis quite obvious: you see the bulge of the prolapse with the typical rectal mucosa and concentric folds, which must be differentiated from the above mentioned acute prolapse of hemorrhoids (more irregular, with radial folds).\\n\\nTry to reduce the prolapse with local or general anesthesia. The use of sugar has been recommended also for this condition; it works by osmotically reducing the edema of the mucosa and thus allows an easier reduction. When this fails or where there is extensive mucosal necrosis, operative treatment is a better option; my choice is a perineal rectosigmoidectomy with a coloanal hand-sutured anastomosis.\\n```',\n", " 'md': 'Before going on to the more serious conditions, a brief mention of a rare situation: acute incarcerated full-thickness rectal prolapse. This is an uncommon condition but most painful and distressing for the patient. It develops usually in individuals with weak sphincters.\\n\\nExamination makes the diagnosis quite obvious: you see the bulge of the prolapse with the typical rectal mucosa and concentric folds, which must be differentiated from the above mentioned acute prolapse of hemorrhoids (more irregular, with radial folds).\\n\\nTry to reduce the prolapse with local or general anesthesia. The use of sugar has been recommended also for this condition; it works by osmotically reducing the edema of the mucosa and thus allows an easier reduction. When this fails or where there is extensive mucosal necrosis, operative treatment is a better option; my choice is a perineal rectosigmoidectomy with a coloanal hand-sutured anastomosis.\\n```',\n", " 'bBox': {'x': 72, 'y': 428, 'w': 468.01, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 545,\n", " 'text': '(Altemeier operation). This is a major, specialized surgery and therefore\\noutside the scope of this small book.\\n\\n And now to the really life-endangering anorectal emergencies: trauma\\nto the rectum and anus and necrotizing infections of the perineum.\\n\\n Trauma to the rectum and anus\\n\\n Trauma to the anorectum results from penetrating injuries (almost\\nexclusively from missile wounds), from perineal lacerations due to falls on\\nirregular and pointed surfaces, or as a consequence of impalement or\\nsexual abuse.\\n\\n The exact assessment of damage following such injuries is best\\nperformed in the operating room, under general anesthesia with the\\npatient in the lithotomy position, using your fingers and a\\nproctosigmoidoscope. There is no need to remind you of the usual\\npriorities of trauma care; oxygenation, hemostasis and vital organs\\ncome before the torn ass. Do not forget to ‘prep’ the abdomen should a\\nlaparotomy or colostomy prove to be necessary.\\n\\n It is practical to discuss injuries to the intraperitoneal and\\nextraperitoneal rectum separately.\\n\\n Injuries to the intraperitoneal rectum\\n\\n These are usually caused by gunshot wounds. They must be carefully\\nlooked for in the course of an exploratory laparotomy, especially when\\nthe bullet trajectory is within the pelvis. Such injuries occur also after\\nimpalement with long poles, where perforation of the high rectum or even\\nthe sigmoid is not exceptional and other abdominal organs can be\\ninjured. Intraperitoneal injuries can be treated almost always with\\nsimple suture, as with any colonic injury. Exceptionally, facing severe\\ndamage to the rectum that is not safely repairable, a proximal colostomy\\nor a ħartmann’s operation may be necessary. Be that as it may, don’t be\\nafraid to suture the rectum with unprepared bowel… the rectum should\\nbe no more intimidating than, say, the cecum.',\n", " 'md': '```markdown\\n## Trauma to the Rectum and Anus\\n\\nTrauma to the anorectum results from penetrating injuries (almost exclusively from missile wounds), from perineal lacerations due to falls on irregular and pointed surfaces, or as a consequence of impalement or sexual abuse.\\n\\nThe exact assessment of damage following such injuries is best performed in the operating room, under general anesthesia with the patient in the lithotomy position, using your fingers and a proctosigmoidoscope. There is no need to remind you of the usual priorities of trauma care; oxygenation, hemostasis, and vital organs come before the torn ass. Do not forget to ‘prep’ the abdomen should a laparotomy or colostomy prove to be necessary.\\n\\nIt is practical to discuss injuries to the intraperitoneal and extraperitoneal rectum separately.\\n\\n### Injuries to the Intraperitoneal Rectum\\n\\nThese are usually caused by gunshot wounds. They must be carefully looked for in the course of an exploratory laparotomy, especially when the bullet trajectory is within the pelvis. Such injuries occur also after impalement with long poles, where perforation of the high rectum or even the sigmoid is not exceptional and other abdominal organs can be injured. Intraperitoneal injuries can be treated almost always with simple suture, as with any colonic injury. Exceptionally, facing severe damage to the rectum that is not safely repairable, a proximal colostomy or a Hartmann’s operation may be necessary. Be that as it may, don’t be afraid to suture the rectum with unprepared bowel… the rectum should be no more intimidating than, say, the cecum.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Trauma to the Rectum and Anus',\n", " 'md': '## Trauma to the Rectum and Anus',\n", " 'bBox': {'x': 86, 'y': 197, 'w': 245.52, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Trauma to the anorectum results from penetrating injuries (almost exclusively from missile wounds), from perineal lacerations due to falls on irregular and pointed surfaces, or as a consequence of impalement or sexual abuse.\\n\\nThe exact assessment of damage following such injuries is best performed in the operating room, under general anesthesia with the patient in the lithotomy position, using your fingers and a proctosigmoidoscope. There is no need to remind you of the usual priorities of trauma care; oxygenation, hemostasis, and vital organs come before the torn ass. Do not forget to ‘prep’ the abdomen should a laparotomy or colostomy prove to be necessary.\\n\\nIt is practical to discuss injuries to the intraperitoneal and extraperitoneal rectum separately.',\n", " 'md': 'Trauma to the anorectum results from penetrating injuries (almost exclusively from missile wounds), from perineal lacerations due to falls on irregular and pointed surfaces, or as a consequence of impalement or sexual abuse.\\n\\nThe exact assessment of damage following such injuries is best performed in the operating room, under general anesthesia with the patient in the lithotomy position, using your fingers and a proctosigmoidoscope. There is no need to remind you of the usual priorities of trauma care; oxygenation, hemostasis, and vital organs come before the torn ass. Do not forget to ‘prep’ the abdomen should a laparotomy or colostomy prove to be necessary.\\n\\nIt is practical to discuss injuries to the intraperitoneal and extraperitoneal rectum separately.',\n", " 'bBox': {'x': 72, 'y': 250, 'w': 467.82, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Injuries to the Intraperitoneal Rectum',\n", " 'md': '### Injuries to the Intraperitoneal Rectum',\n", " 'bBox': {'x': 86, 'y': 512, 'w': 287.77, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'These are usually caused by gunshot wounds. They must be carefully looked for in the course of an exploratory laparotomy, especially when the bullet trajectory is within the pelvis. Such injuries occur also after impalement with long poles, where perforation of the high rectum or even the sigmoid is not exceptional and other abdominal organs can be injured. Intraperitoneal injuries can be treated almost always with simple suture, as with any colonic injury. Exceptionally, facing severe damage to the rectum that is not safely repairable, a proximal colostomy or a Hartmann’s operation may be necessary. Be that as it may, don’t be afraid to suture the rectum with unprepared bowel… the rectum should be no more intimidating than, say, the cecum.\\n```',\n", " 'md': 'These are usually caused by gunshot wounds. They must be carefully looked for in the course of an exploratory laparotomy, especially when the bullet trajectory is within the pelvis. Such injuries occur also after impalement with long poles, where perforation of the high rectum or even the sigmoid is not exceptional and other abdominal organs can be injured. Intraperitoneal injuries can be treated almost always with simple suture, as with any colonic injury. Exceptionally, facing severe damage to the rectum that is not safely repairable, a proximal colostomy or a Hartmann’s operation may be necessary. Be that as it may, don’t be afraid to suture the rectum with unprepared bowel… the rectum should be no more intimidating than, say, the cecum.\\n```',\n", " 'bBox': {'x': 72, 'y': 548, 'w': 467.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 546,\n", " 'text': ' An elegant way to close a low rectal perforation when access is limited due to obesity and a\\n narrow pelvis: insert through the anus a circular EEA™ stapler, connected to the anvil and in\\n the open position; then slowly close it to ‘side-bite’ the perforation — the edges of which are\\n inverted into the open stapler. Two corner stitches help this manipulation. Finally, close and fire\\n the stapler, thus excising the hole and stapling it closed. Danny\\n\\n Injuries to the extraperitoneal rectum\\n\\n These are more challenging. Any suspicion of extraperitoneal rectal\\ninjury suggested by the bullet trajectory must be confirmed or refuted by\\nclinical examination. Discharge of blood and palpation of a hole in the\\nrectal wall are confirmatory. Until recently, management was based on\\nthree basic principles developed for war injuries and demonstrated to be\\nvery effective in reducing mortality and morbidity: diverting\\nsigmoidostomy, presacral drainage and rectal washout. (Repair of the\\nactual rectal wound was added when technically possible.)\\n\\n However, the routine use of these dogmas in civil injuries has\\nbeen challenged in recent years. Suture repair of the rectum is a nice\\nconcept, but has little to recommend it. Doing so through a transanal\\napproach is not easy and everybody agrees that opening the pelvic\\nperitoneum during abdominal exploration is indicated only to arrest\\nhemorrhage from major vessels or for debridement in the face of\\nextensive bony and soft-tissue damage. In most civilian rectal injuries,\\nsuture repair can be omitted without affecting morbidity and mortality (a\\nsimilar situation exists in the case of full-thickness local excision of rectal\\ntumors without suturing the rectal defect). Rectal washout has become\\nthe second victim of iconoclasts. Most recent series have omitted it with\\nno change in results. The value of presacral drainage has also been\\nquestioned. Only proximal fecal diversion seems to remain a firm\\nprinciple. The colostomy should be created as distally as possible; a\\nproperly constructed loop sigmoid colostomy, with an adequate spur, has\\nbeen demonstrated to be completely diverting, with no need for an end\\ncolostomy (see Chapter 14). The only recent development to be\\nconsidered is the laparoscopic approach to look for associated\\nintraperitoneal injuries and to exteriorize the sigmoid, without a formal',\n", " 'md': '```markdown\\n# Page Content\\n\\nAn elegant way to close a low rectal perforation when access is limited due to obesity and a narrow pelvis: insert through the anus a circular EEA™ stapler, connected to the anvil and in the open position; then slowly close it to ‘side-bite’ the perforation — the edges of which are inverted into the open stapler. Two corner stitches help this manipulation. Finally, close and fire the stapler, thus excising the hole and stapling it closed.\\n\\n## Injuries to the extraperitoneal rectum\\n\\nThese are more challenging. Any suspicion of extraperitoneal rectal injury suggested by the bullet trajectory must be confirmed or refuted by clinical examination. Discharge of blood and palpation of a hole in the rectal wall are confirmatory. Until recently, management was based on three basic principles developed for war injuries and demonstrated to be very effective in reducing mortality and morbidity: diverting sigmoidostomy, presacral drainage, and rectal washout. (Repair of the actual rectal wound was added when technically possible.)\\n\\nHowever, the routine use of these dogmas in civil injuries has been challenged in recent years. Suture repair of the rectum is a nice concept, but has little to recommend it. Doing so through a transanal approach is not easy and everybody agrees that opening the pelvic peritoneum during abdominal exploration is indicated only to arrest hemorrhage from major vessels or for debridement in the face of extensive bony and soft-tissue damage. In most civilian rectal injuries, suture repair can be omitted without affecting morbidity and mortality (a similar situation exists in the case of full-thickness local excision of rectal tumors without suturing the rectal defect). Rectal washout has become the second victim of iconoclasts. Most recent series have omitted it with no change in results. The value of presacral drainage has also been questioned. Only proximal fecal diversion seems to remain a firm principle. The colostomy should be created as distally as possible; a properly constructed loop sigmoid colostomy, with an adequate spur, has been demonstrated to be completely diverting, with no need for an end colostomy (see Chapter 14). The only recent development to be considered is the laparoscopic approach to look for associated intraperitoneal injuries and to exteriorize the sigmoid, without a formal.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'An elegant way to close a low rectal perforation when access is limited due to obesity and a narrow pelvis: insert through the anus a circular EEA™ stapler, connected to the anvil and in the open position; then slowly close it to ‘side-bite’ the perforation — the edges of which are inverted into the open stapler. Two corner stitches help this manipulation. Finally, close and fire the stapler, thus excising the hole and stapling it closed.',\n", " 'md': 'An elegant way to close a low rectal perforation when access is limited due to obesity and a narrow pelvis: insert through the anus a circular EEA™ stapler, connected to the anvil and in the open position; then slowly close it to ‘side-bite’ the perforation — the edges of which are inverted into the open stapler. Two corner stitches help this manipulation. Finally, close and fire the stapler, thus excising the hole and stapling it closed.',\n", " 'bBox': {'x': 77, 'y': 150, 'w': 456.86, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Injuries to the extraperitoneal rectum',\n", " 'md': '## Injuries to the extraperitoneal rectum',\n", " 'bBox': {'x': 86, 'y': 220, 'w': 291.47, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'These are more challenging. Any suspicion of extraperitoneal rectal injury suggested by the bullet trajectory must be confirmed or refuted by clinical examination. Discharge of blood and palpation of a hole in the rectal wall are confirmatory. Until recently, management was based on three basic principles developed for war injuries and demonstrated to be very effective in reducing mortality and morbidity: diverting sigmoidostomy, presacral drainage, and rectal washout. (Repair of the actual rectal wound was added when technically possible.)\\n\\nHowever, the routine use of these dogmas in civil injuries has been challenged in recent years. Suture repair of the rectum is a nice concept, but has little to recommend it. Doing so through a transanal approach is not easy and everybody agrees that opening the pelvic peritoneum during abdominal exploration is indicated only to arrest hemorrhage from major vessels or for debridement in the face of extensive bony and soft-tissue damage. In most civilian rectal injuries, suture repair can be omitted without affecting morbidity and mortality (a similar situation exists in the case of full-thickness local excision of rectal tumors without suturing the rectal defect). Rectal washout has become the second victim of iconoclasts. Most recent series have omitted it with no change in results. The value of presacral drainage has also been questioned. Only proximal fecal diversion seems to remain a firm principle. The colostomy should be created as distally as possible; a properly constructed loop sigmoid colostomy, with an adequate spur, has been demonstrated to be completely diverting, with no need for an end colostomy (see Chapter 14). The only recent development to be considered is the laparoscopic approach to look for associated intraperitoneal injuries and to exteriorize the sigmoid, without a formal.\\n\\n```',\n", " 'md': 'These are more challenging. Any suspicion of extraperitoneal rectal injury suggested by the bullet trajectory must be confirmed or refuted by clinical examination. Discharge of blood and palpation of a hole in the rectal wall are confirmatory. Until recently, management was based on three basic principles developed for war injuries and demonstrated to be very effective in reducing mortality and morbidity: diverting sigmoidostomy, presacral drainage, and rectal washout. (Repair of the actual rectal wound was added when technically possible.)\\n\\nHowever, the routine use of these dogmas in civil injuries has been challenged in recent years. Suture repair of the rectum is a nice concept, but has little to recommend it. Doing so through a transanal approach is not easy and everybody agrees that opening the pelvic peritoneum during abdominal exploration is indicated only to arrest hemorrhage from major vessels or for debridement in the face of extensive bony and soft-tissue damage. In most civilian rectal injuries, suture repair can be omitted without affecting morbidity and mortality (a similar situation exists in the case of full-thickness local excision of rectal tumors without suturing the rectal defect). Rectal washout has become the second victim of iconoclasts. Most recent series have omitted it with no change in results. The value of presacral drainage has also been questioned. Only proximal fecal diversion seems to remain a firm principle. The colostomy should be created as distally as possible; a properly constructed loop sigmoid colostomy, with an adequate spur, has been demonstrated to be completely diverting, with no need for an end colostomy (see Chapter 14). The only recent development to be considered is the laparoscopic approach to look for associated intraperitoneal injuries and to exteriorize the sigmoid, without a formal.\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 273, 'w': 467.91, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 547,\n", " 'text': 'laparotomy.\\n\\n Injuries to the anal canal\\n\\n ħemostasis is achieved and lacerations are debrided while taking care\\nto spare as much of the sphincter muscles as possible. The wounds are\\nthen left open. A sigmoid colostomy is recommended only for very\\nextensive anal and perineal lacerations; in minor cases it is not\\nnecessary. You can repair a partialy torn sphincter when the injury is\\nlimited; however, avoid attempts at sphincter reconstruction in grossly\\ndestructive injuries — sutures do not hold well in the traumatized muscle,\\nand nerves can be damaged during difficult dissection in a bloody field.\\nAll this can lead to failure, compromising the success of further\\nreconstruction. It is better to leave the job of anal canal\\nreconstruction to the specialized surgeon, who can in due course\\nperform a sphincteroplasty or even think about more complex techniques\\nsuch as implantation of either an artificial sphincter or a sacral nerve\\nstimulator after anal reconstruction.\\n\\n Rectal foreign bodies\\n\\n This is a particular kind of anal and rectal trauma ( Figure 30.4). In the\\nrarest cases, they may result from accidental ingestion, with the foreign\\nbody making its way through the whole digestive tract and impacting on\\nthe rectal or anal walls (e.g. a toothpick impacted in the anal canal, giving\\norigin to bilateral anal abscesses). Most of them are inserted per anum\\nand almost always by the patient attempting sexual gratification. By\\nthe way, do not assume this occurs only with flamboyantly gay people —\\nin many cases you will find middle-aged or even senior married men, who\\ngive the most incredible explanations for the unfortunate location of the\\nforeign body. Self-inserted foreign bodies, whatever their shape and\\nsize, do not ordinarily cause rectal lesions that go deeper than the\\nmucosa, but the same cannot be said when insertion is due to\\nsexual assault, where perforation at the level of peritoneal reflection\\nor even at the rectosigmoid junction is not exceptional.',\n", " 'md': '```markdown\\n## Injuries to the Anal Canal\\n\\nHemostasis is achieved and lacerations are debrided while taking care to spare as much of the sphincter muscles as possible. The wounds are then left open. A sigmoid colostomy is recommended only for very extensive anal and perineal lacerations; in minor cases, it is not necessary. You can repair a partially torn sphincter when the injury is limited; however, avoid attempts at sphincter reconstruction in grossly destructive injuries — sutures do not hold well in the traumatized muscle, and nerves can be damaged during difficult dissection in a bloody field. All this can lead to failure, compromising the success of further reconstruction. It is better to leave the job of anal canal reconstruction to the specialized surgeon, who can in due course perform a sphincteroplasty or even think about more complex techniques such as implantation of either an artificial sphincter or a sacral nerve stimulator after anal reconstruction.\\n\\n## Rectal Foreign Bodies\\n\\nThis is a particular kind of anal and rectal trauma (Figure 30.4). In the rarest cases, they may result from accidental ingestion, with the foreign body making its way through the whole digestive tract and impacting on the rectal or anal walls (e.g., a toothpick impacted in the anal canal, giving origin to bilateral anal abscesses). Most of them are inserted per anum and almost always by the patient attempting sexual gratification. By the way, do not assume this occurs only with flamboyantly gay people — in many cases, you will find middle-aged or even senior married men, who give the most incredible explanations for the unfortunate location of the foreign body. Self-inserted foreign bodies, whatever their shape and size, do not ordinarily cause rectal lesions that go deeper than the mucosa, but the same cannot be said when insertion is due to sexual assault, where perforation at the level of peritoneal reflection or even at the rectosigmoid junction is not exceptional.\\n\\n### Figure 30.4\\n- **Description**: This figure illustrates a case of rectal foreign bodies, highlighting the types of injuries that can occur due to self-insertion or accidental ingestion. The image likely depicts the anatomical location of the foreign body and its potential impact on the rectal or anal walls.\\n- **Summary**: The figure serves to visually represent the trauma associated with rectal foreign bodies, emphasizing the risks involved in both self-insertion and accidental ingestion.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Injuries to the Anal Canal',\n", " 'md': '## Injuries to the Anal Canal',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 193.09, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Hemostasis is achieved and lacerations are debrided while taking care to spare as much of the sphincter muscles as possible. The wounds are then left open. A sigmoid colostomy is recommended only for very extensive anal and perineal lacerations; in minor cases, it is not necessary. You can repair a partially torn sphincter when the injury is limited; however, avoid attempts at sphincter reconstruction in grossly destructive injuries — sutures do not hold well in the traumatized muscle, and nerves can be damaged during difficult dissection in a bloody field. All this can lead to failure, compromising the success of further reconstruction. It is better to leave the job of anal canal reconstruction to the specialized surgeon, who can in due course perform a sphincteroplasty or even think about more complex techniques such as implantation of either an artificial sphincter or a sacral nerve stimulator after anal reconstruction.',\n", " 'md': 'Hemostasis is achieved and lacerations are debrided while taking care to spare as much of the sphincter muscles as possible. The wounds are then left open. A sigmoid colostomy is recommended only for very extensive anal and perineal lacerations; in minor cases, it is not necessary. You can repair a partially torn sphincter when the injury is limited; however, avoid attempts at sphincter reconstruction in grossly destructive injuries — sutures do not hold well in the traumatized muscle, and nerves can be damaged during difficult dissection in a bloody field. All this can lead to failure, compromising the success of further reconstruction. It is better to leave the job of anal canal reconstruction to the specialized surgeon, who can in due course perform a sphincteroplasty or even think about more complex techniques such as implantation of either an artificial sphincter or a sacral nerve stimulator after anal reconstruction.',\n", " 'bBox': {'x': 72, 'y': 181, 'w': 467.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Rectal Foreign Bodies',\n", " 'md': '## Rectal Foreign Bodies',\n", " 'bBox': {'x': 86, 'y': 423, 'w': 168.27, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is a particular kind of anal and rectal trauma (Figure 30.4). In the rarest cases, they may result from accidental ingestion, with the foreign body making its way through the whole digestive tract and impacting on the rectal or anal walls (e.g., a toothpick impacted in the anal canal, giving origin to bilateral anal abscesses). Most of them are inserted per anum and almost always by the patient attempting sexual gratification. By the way, do not assume this occurs only with flamboyantly gay people — in many cases, you will find middle-aged or even senior married men, who give the most incredible explanations for the unfortunate location of the foreign body. Self-inserted foreign bodies, whatever their shape and size, do not ordinarily cause rectal lesions that go deeper than the mucosa, but the same cannot be said when insertion is due to sexual assault, where perforation at the level of peritoneal reflection or even at the rectosigmoid junction is not exceptional.',\n", " 'md': 'This is a particular kind of anal and rectal trauma (Figure 30.4). In the rarest cases, they may result from accidental ingestion, with the foreign body making its way through the whole digestive tract and impacting on the rectal or anal walls (e.g., a toothpick impacted in the anal canal, giving origin to bilateral anal abscesses). Most of them are inserted per anum and almost always by the patient attempting sexual gratification. By the way, do not assume this occurs only with flamboyantly gay people — in many cases, you will find middle-aged or even senior married men, who give the most incredible explanations for the unfortunate location of the foreign body. Self-inserted foreign bodies, whatever their shape and size, do not ordinarily cause rectal lesions that go deeper than the mucosa, but the same cannot be said when insertion is due to sexual assault, where perforation at the level of peritoneal reflection or even at the rectosigmoid junction is not exceptional.',\n", " 'bBox': {'x': 72, 'y': 492, 'w': 467.86, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 30.4',\n", " 'md': '### Figure 30.4',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure illustrates a case of rectal foreign bodies, highlighting the types of injuries that can occur due to self-insertion or accidental ingestion. The image likely depicts the anatomical location of the foreign body and its potential impact on the rectal or anal walls.\\n- **Summary**: The figure serves to visually represent the trauma associated with rectal foreign bodies, emphasizing the risks involved in both self-insertion and accidental ingestion.\\n```',\n", " 'md': '- **Description**: This figure illustrates a case of rectal foreign bodies, highlighting the types of injuries that can occur due to self-insertion or accidental ingestion. The image likely depicts the anatomical location of the foreign body and its potential impact on the rectal or anal walls.\\n- **Summary**: The figure serves to visually represent the trauma associated with rectal foreign bodies, emphasizing the risks involved in both self-insertion and accidental ingestion.\\n```',\n", " 'bBox': {'x': 86, 'y': 423, 'w': 168.27, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'rarest cases, they may result from accidental ingestion, with the foreign'}]},\n", " {'page': 548,\n", " 'text': ' Figure 30.4. “Ouch.”\\n\\n When the patient gives a history of impalement injury (fact or fiction),\\nyou must carry out a careful abdominal examination and consider\\nabdominal imaging in order to confirm or rule out a visceral perforation,\\nwhich may necessitate a laparotomy. In all other cases, an initial attempt\\nto remove the foreign body through the anal canal is recommended,\\nunder local, regional or general anesthesia, which allows relaxation of the\\nanal sphincters and prevents muscular disruptions due to forceful\\nstretching.\\n\\n Many instruments and maneuvers for grasping the foreign body\\nhave been described, but if extraction is not easy, the risk of\\nlaceration of the rectal wall or the anal canal increases with time\\nand effort, and laparotomy should be considered, always with the\\npatient in the lithotomy position. In that case, you should try first to\\ndeliver the foreign body through the anus to the hands of the perineal\\noperator by manipulating it from outside the rectum, but sometimes\\nopening the rectum and removing the object from the top is,\\nparadoxically, the least invasive way of solving the problem. A post-',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Figure 30.4\\n**Caption:** “Ouch.”\\n\\nWhen the patient gives a history of impalement injury (fact or fiction), you must carry out a careful abdominal examination and consider abdominal imaging in order to confirm or rule out a visceral perforation, which may necessitate a laparotomy. In all other cases, an initial attempt to remove the foreign body through the anal canal is recommended, under local, regional or general anesthesia, which allows relaxation of the anal sphincters and prevents muscular disruptions due to forceful stretching.\\n\\nMany instruments and maneuvers for grasping the foreign body have been described, but if extraction is not easy, the risk of laceration of the rectal wall or the anal canal increases with time and effort, and laparotomy should be considered, always with the patient in the lithotomy position. In that case, you should try first to deliver the foreign body through the anus to the hands of the perineal operator by manipulating it from outside the rectum, but sometimes opening the rectum and removing the object from the top is, paradoxically, the least invasive way of solving the problem. A post-\\n```\\n\\n### Image Description\\n- **Figure 30.4**: The image likely depicts a scenario related to the medical context of impalement injuries, possibly illustrating the anatomy involved or the procedure for foreign body extraction. The caption \"Ouch.\" suggests a focus on the discomfort or urgency of the situation. The image may include graphical elements that represent the anatomy of the anal canal or the tools used for extraction, but specific details are not provided in the text.\\n\\n### Summary\\nThis page discusses the medical approach to handling impalement injuries, emphasizing the importance of careful examination and the potential need for surgical intervention. It outlines the procedures for foreign body extraction and the considerations for patient positioning and anesthesia.',\n", " 'images': [{'name': 'img_p547_1.png',\n", " 'height': 555,\n", " 'width': 358,\n", " 'x': 217.4400000000005,\n", " 'y': 82.80000000000001,\n", " 'original_width': 615,\n", " 'original_height': 952}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 30.4',\n", " 'md': '### Figure 30.4',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** “Ouch.”\\n\\nWhen the patient gives a history of impalement injury (fact or fiction), you must carry out a careful abdominal examination and consider abdominal imaging in order to confirm or rule out a visceral perforation, which may necessitate a laparotomy. In all other cases, an initial attempt to remove the foreign body through the anal canal is recommended, under local, regional or general anesthesia, which allows relaxation of the anal sphincters and prevents muscular disruptions due to forceful stretching.\\n\\nMany instruments and maneuvers for grasping the foreign body have been described, but if extraction is not easy, the risk of laceration of the rectal wall or the anal canal increases with time and effort, and laparotomy should be considered, always with the patient in the lithotomy position. In that case, you should try first to deliver the foreign body through the anus to the hands of the perineal operator by manipulating it from outside the rectum, but sometimes opening the rectum and removing the object from the top is, paradoxically, the least invasive way of solving the problem. A post-\\n```',\n", " 'md': '**Caption:** “Ouch.”\\n\\nWhen the patient gives a history of impalement injury (fact or fiction), you must carry out a careful abdominal examination and consider abdominal imaging in order to confirm or rule out a visceral perforation, which may necessitate a laparotomy. In all other cases, an initial attempt to remove the foreign body through the anal canal is recommended, under local, regional or general anesthesia, which allows relaxation of the anal sphincters and prevents muscular disruptions due to forceful stretching.\\n\\nMany instruments and maneuvers for grasping the foreign body have been described, but if extraction is not easy, the risk of laceration of the rectal wall or the anal canal increases with time and effort, and laparotomy should be considered, always with the patient in the lithotomy position. In that case, you should try first to deliver the foreign body through the anus to the hands of the perineal operator by manipulating it from outside the rectum, but sometimes opening the rectum and removing the object from the top is, paradoxically, the least invasive way of solving the problem. A post-\\n```',\n", " 'bBox': {'x': 72, 'y': 474, 'w': 467.68, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 30.4**: The image likely depicts a scenario related to the medical context of impalement injuries, possibly illustrating the anatomy involved or the procedure for foreign body extraction. The caption \"Ouch.\" suggests a focus on the discomfort or urgency of the situation. The image may include graphical elements that represent the anatomy of the anal canal or the tools used for extraction, but specific details are not provided in the text.',\n", " 'md': '- **Figure 30.4**: The image likely depicts a scenario related to the medical context of impalement injuries, possibly illustrating the anatomy involved or the procedure for foreign body extraction. The caption \"Ouch.\" suggests a focus on the discomfort or urgency of the situation. The image may include graphical elements that represent the anatomy of the anal canal or the tools used for extraction, but specific details are not provided in the text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the medical approach to handling impalement injuries, emphasizing the importance of careful examination and the potential need for surgical intervention. It outlines the procedures for foreign body extraction and the considerations for patient positioning and anesthesia.',\n", " 'md': 'This page discusses the medical approach to handling impalement injuries, emphasizing the importance of careful examination and the potential need for surgical intervention. It outlines the procedures for foreign body extraction and the considerations for patient positioning and anesthesia.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 549,\n", " 'text': 'extraction rectoscopy is mandatory to ensure the integrity of the rectal\\nwall.\\n\\n Necrotizing perineal infections (Fournier’s gangrene)\\n\\n Necrotizing perineal infections may be the consequence of neglected\\nanorectal infections but they also arise from trauma, skin infections and\\nurethral instrumentation. A urethral source implies Fournier’s gangrene —\\nan eponym that has been incorrectly extended to the whole spectrum of\\nthis entity. But more important than etiology is prompt diagnosis and\\ntreatment.\\n\\n These patients are commonly diabetic, very obese or\\nimmunosuppressed. The synergistic action of Gram-negative bacteria,\\nanaerobes and Streptococcus causes rapid dissemination of the infection\\nalong superficial fascial and subcutaneous planes, with secondary\\nischemic involvement of the skin. Pain may be the first symptom but it\\nmay be vague. Swelling of the perineum, crepitus, local tenderness\\nand erythema of the skin — followed by its necrosis — are the\\ntypical elements found on examination.\\n\\n There is no need for X-rays or CTs, unless one suspects extension to\\nfascial abdominal or retroperitoneal tissues. Only prompt treatment can\\nprevent a fatal evolution; it should include supportive care, high-\\ndose i.v. antibiotics to cover aerobic and anaerobic bacteria and\\nprompt surgical debridement — which is the mainstay of treatment.\\n\\n Necrotic skin must be resected, but as fascial and fat necrosis extend\\nmuch further, extensive skin incisions are usually necessary to allow\\nradical excision of fascia and fatty tissue until well-perfused and viable fat\\nis found. If the infection extends to the perineal muscles, they must be\\nsacrificed following the same criteria. Debride as much as necessary at\\nyour first operation but plan on taking the patient back to the\\noperating room the next day(s) until you are satisfied that the\\ninfection is under control. Concerns about future reconstruction should\\nbe left to the plastic surgeon, but if it is necessary to excise scrotal skin, it\\nis convenient to wrap the testicles, which are rarely compromised, in',\n", " 'md': '```markdown\\n# Necrotizing Perineal Infections (Fournier’s Gangrene)\\n\\n## Overview\\nNecrotizing perineal infections may be the consequence of neglected anorectal infections, but they also arise from trauma, skin infections, and urethral instrumentation. A urethral source implies Fournier’s gangrene — an eponym that has been incorrectly extended to the whole spectrum of this entity. However, more important than etiology is prompt diagnosis and treatment.\\n\\n## Patient Profile\\nThese patients are commonly:\\n- Diabetic\\n- Very obese\\n- Immunosuppressed\\n\\n## Pathophysiology\\nThe synergistic action of Gram-negative bacteria, anaerobes, and Streptococcus causes rapid dissemination of the infection along superficial fascial and subcutaneous planes, with secondary ischemic involvement of the skin.\\n\\n## Symptoms\\n- Pain (may be vague)\\n- Swelling of the perineum\\n- Crepitus\\n- Local tenderness\\n- Erythema of the skin, followed by necrosis\\n\\n## Diagnosis\\nThere is no need for X-rays or CTs unless one suspects extension to fascial abdominal or retroperitoneal tissues. Only prompt treatment can prevent a fatal evolution.\\n\\n## Treatment\\nTreatment should include:\\n- Supportive care\\n- High-dose intravenous antibiotics to cover aerobic and anaerobic bacteria\\n- Prompt surgical debridement, which is the mainstay of treatment.\\n\\nNecrotic skin must be resected, but as fascial and fat necrosis extend much further, extensive skin incisions are usually necessary to allow radical excision of fascia and fatty tissue until well-perfused and viable fat is found. If the infection extends to the perineal muscles, they must be sacrificed following the same criteria.\\n\\n## Surgical Considerations\\n- Debride as much as necessary at your first operation but plan on taking the patient back to the operating room the next day(s) until you are satisfied that the infection is under control.\\n- Concerns about future reconstruction should be left to the plastic surgeon.\\n- If it is necessary to excise scrotal skin, it is convenient to wrap the testicles, which are rarely compromised.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Necrotizing Perineal Infections (Fournier’s Gangrene)',\n", " 'md': '# Necrotizing Perineal Infections (Fournier’s Gangrene)',\n", " 'bBox': {'x': 86, 'y': 145, 'w': 416.51, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Overview',\n", " 'md': '## Overview',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Necrotizing perineal infections may be the consequence of neglected anorectal infections, but they also arise from trauma, skin infections, and urethral instrumentation. A urethral source implies Fournier’s gangrene — an eponym that has been incorrectly extended to the whole spectrum of this entity. However, more important than etiology is prompt diagnosis and treatment.',\n", " 'md': 'Necrotizing perineal infections may be the consequence of neglected anorectal infections, but they also arise from trauma, skin infections, and urethral instrumentation. A urethral source implies Fournier’s gangrene — an eponym that has been incorrectly extended to the whole spectrum of this entity. However, more important than etiology is prompt diagnosis and treatment.',\n", " 'bBox': {'x': 72, 'y': 214, 'w': 467.39, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Patient Profile',\n", " 'md': '## Patient Profile',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'These patients are commonly:\\n- Diabetic\\n- Very obese\\n- Immunosuppressed',\n", " 'md': 'These patients are commonly:\\n- Diabetic\\n- Very obese\\n- Immunosuppressed',\n", " 'bBox': {'x': 86, 'y': 299, 'w': 54.38, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Pathophysiology',\n", " 'md': '## Pathophysiology',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The synergistic action of Gram-negative bacteria, anaerobes, and Streptococcus causes rapid dissemination of the infection along superficial fascial and subcutaneous planes, with secondary ischemic involvement of the skin.',\n", " 'md': 'The synergistic action of Gram-negative bacteria, anaerobes, and Streptococcus causes rapid dissemination of the infection along superficial fascial and subcutaneous planes, with secondary ischemic involvement of the skin.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Symptoms',\n", " 'md': '## Symptoms',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Pain (may be vague)\\n- Swelling of the perineum\\n- Crepitus\\n- Local tenderness\\n- Erythema of the skin, followed by necrosis',\n", " 'md': '- Pain (may be vague)\\n- Swelling of the perineum\\n- Crepitus\\n- Local tenderness\\n- Erythema of the skin, followed by necrosis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnosis',\n", " 'md': '## Diagnosis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'There is no need for X-rays or CTs unless one suspects extension to fascial abdominal or retroperitoneal tissues. Only prompt treatment can prevent a fatal evolution.',\n", " 'md': 'There is no need for X-rays or CTs unless one suspects extension to fascial abdominal or retroperitoneal tissues. Only prompt treatment can prevent a fatal evolution.',\n", " 'bBox': {'x': 72, 'y': 299, 'w': 466.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Treatment',\n", " 'md': '## Treatment',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Treatment should include:\\n- Supportive care\\n- High-dose intravenous antibiotics to cover aerobic and anaerobic bacteria\\n- Prompt surgical debridement, which is the mainstay of treatment.\\n\\nNecrotic skin must be resected, but as fascial and fat necrosis extend much further, extensive skin incisions are usually necessary to allow radical excision of fascia and fatty tissue until well-perfused and viable fat is found. If the infection extends to the perineal muscles, they must be sacrificed following the same criteria.',\n", " 'md': 'Treatment should include:\\n- Supportive care\\n- High-dose intravenous antibiotics to cover aerobic and anaerobic bacteria\\n- Prompt surgical debridement, which is the mainstay of treatment.\\n\\nNecrotic skin must be resected, but as fascial and fat necrosis extend much further, extensive skin incisions are usually necessary to allow radical excision of fascia and fatty tissue until well-perfused and viable fat is found. If the infection extends to the perineal muscles, they must be sacrificed following the same criteria.',\n", " 'bBox': {'x': 72, 'y': 264, 'w': 467.59, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Considerations',\n", " 'md': '## Surgical Considerations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Debride as much as necessary at your first operation but plan on taking the patient back to the operating room the next day(s) until you are satisfied that the infection is under control.\\n- Concerns about future reconstruction should be left to the plastic surgeon.\\n- If it is necessary to excise scrotal skin, it is convenient to wrap the testicles, which are rarely compromised.\\n```',\n", " 'md': '- Debride as much as necessary at your first operation but plan on taking the patient back to the operating room the next day(s) until you are satisfied that the infection is under control.\\n- Concerns about future reconstruction should be left to the plastic surgeon.\\n- If it is necessary to excise scrotal skin, it is convenient to wrap the testicles, which are rarely compromised.\\n```',\n", " 'bBox': {'x': 217, 'y': 299, 'w': 24.79, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 550,\n", " 'text': 'healthy tissues in the abdominal wall or the thigh.\\n\\n So chop out everything that stinks, is dark, gray or dead — irrespective of how large\\n and horrendous the wound you create. And do it again and again — as many times as it\\n is necessary. Eventually it will all pink-up, granulate, contract and heal.\\n\\n Two controversial issues remain: the necessity of a colostomy\\nand the use of hyperbaric oxygen. Most authors think a diverting\\nstoma is generally not necessary even in the case of a free-floating anus.\\nNevertheless, when ongoing fecal contamination is not easily\\nmanageable (e.g. incontinent patient, poor nursing facilities), consider\\nproximal fecal diversion. The use of hyperbaric oxygen has been strongly\\nrecommended on the basis of the action of oxygen free radicals against\\nanaerobic bacteria, but it remains controversial, cumbersome and\\nexpensive and so cannot be considered a necessary component of the\\n‘standard’.\\n\\n “Your knife should be the instrument to provide oxygen\\n to the wound.”\\n\\n1 Luis A. Carriquiry authored this chapter in the previous edition.',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nHealthy tissues in the abdominal wall or the thigh.\\n\\nSo chop out everything that stinks, is dark, gray or dead — irrespective of how large and horrendous the wound you create. And do it again and again — as many times as it is necessary. Eventually, it will all pink-up, granulate, contract and heal.\\n\\nTwo controversial issues remain: the necessity of a colostomy and the use of hyperbaric oxygen. Most authors think a diverting stoma is generally not necessary even in the case of a free-floating anus. Nevertheless, when ongoing fecal contamination is not easily manageable (e.g. incontinent patient, poor nursing facilities), consider proximal fecal diversion. The use of hyperbaric oxygen has been strongly recommended on the basis of the action of oxygen free radicals against anaerobic bacteria, but it remains controversial, cumbersome and expensive and so cannot be considered a necessary component of the ‘standard’.\\n\\n“Your knife should be the instrument to provide oxygen to the wound.”\\n\\n1. Luis A. Carriquiry authored this chapter in the previous edition.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted while excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Healthy tissues in the abdominal wall or the thigh.\\n\\nSo chop out everything that stinks, is dark, gray or dead — irrespective of how large and horrendous the wound you create. And do it again and again — as many times as it is necessary. Eventually, it will all pink-up, granulate, contract and heal.\\n\\nTwo controversial issues remain: the necessity of a colostomy and the use of hyperbaric oxygen. Most authors think a diverting stoma is generally not necessary even in the case of a free-floating anus. Nevertheless, when ongoing fecal contamination is not easily manageable (e.g. incontinent patient, poor nursing facilities), consider proximal fecal diversion. The use of hyperbaric oxygen has been strongly recommended on the basis of the action of oxygen free radicals against anaerobic bacteria, but it remains controversial, cumbersome and expensive and so cannot be considered a necessary component of the ‘standard’.\\n\\n“Your knife should be the instrument to provide oxygen to the wound.”\\n\\n1. Luis A. Carriquiry authored this chapter in the previous edition.\\n```',\n", " 'md': 'Healthy tissues in the abdominal wall or the thigh.\\n\\nSo chop out everything that stinks, is dark, gray or dead — irrespective of how large and horrendous the wound you create. And do it again and again — as many times as it is necessary. Eventually, it will all pink-up, granulate, contract and heal.\\n\\nTwo controversial issues remain: the necessity of a colostomy and the use of hyperbaric oxygen. Most authors think a diverting stoma is generally not necessary even in the case of a free-floating anus. Nevertheless, when ongoing fecal contamination is not easily manageable (e.g. incontinent patient, poor nursing facilities), consider proximal fecal diversion. The use of hyperbaric oxygen has been strongly recommended on the basis of the action of oxygen free radicals against anaerobic bacteria, but it remains controversial, cumbersome and expensive and so cannot be considered a necessary component of the ‘standard’.\\n\\n“Your knife should be the instrument to provide oxygen to the wound.”\\n\\n1. Luis A. Carriquiry authored this chapter in the previous edition.\\n```',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.94, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted while excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been extracted while excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 442, 'y': 265, 'w': 14.4, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 551,\n", " 'text': 'Chapter 31\\nSurgical complications of endoscopy\\nAhmad Assalia and Anat Ilivitzki\\n\\n If you are too fond of new remedies, first you will not cure\\n your patients; secondly, you will have no patients to cure.\\n Astley Paston Cooper\\n\\n Complications of endoscopy may be defined as immediate, occurring\\nduring the procedure or before the patient leaves the endoscopic suite, or\\ndelayed, occurring up to 30 days after the procedure.\\n\\n Some basic points\\n\\n • In the real world, complications are much more frequent than is\\n suggested by the ‘beautiful’ figures quoted in the books!\\n • Complication rates vary with expertise and case volume; expect\\n more with less experienced endoscopists — those still climbing the\\n learning curve, or those who continue climbing forever.\\n • The risks associated with endoscopy are higher when the pathology\\n is more complex and in therapeutic as opposed to diagnostic\\n procedures.\\n • With complications of endoscopy it’s particularly important to\\n know when not to operate rather than when to operate; many\\n episodes of post-endoscopy bleeding and perforation are best\\n treated conservatively. It is unhelpful to carry out a laparotomy for\\n post-endoscopy complications and then be unable to identify the',\n", " 'md': '```markdown\\n# Chapter 31\\n## Surgical Complications of Endoscopy\\n### Ahmad Assalia and Anat Ilivitzki\\n\\n> \"If you are too fond of new remedies, first you will not cure your patients; secondly, you will have no patients to cure.\"\\n> — Astley Paston Cooper\\n\\nComplications of endoscopy may be defined as immediate, occurring during the procedure or before the patient leaves the endoscopic suite, or delayed, occurring up to 30 days after the procedure.\\n\\n### Some Basic Points\\n\\n- In the real world, complications are much more frequent than is suggested by the ‘beautiful’ figures quoted in the books!\\n- Complication rates vary with expertise and case volume; expect more with less experienced endoscopists — those still climbing the learning curve, or those who continue climbing forever.\\n- The risks associated with endoscopy are higher when the pathology is more complex and in therapeutic as opposed to diagnostic procedures.\\n- With complications of endoscopy, it’s particularly important to know when not to operate rather than when to operate; many episodes of post-endoscopy bleeding and perforation are best treated conservatively. It is unhelpful to carry out a laparotomy for post-endoscopy complications and then be unable to identify the cause.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 31',\n", " 'md': '# Chapter 31',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 148.79, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Complications of Endoscopy',\n", " 'md': '## Surgical Complications of Endoscopy',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 325.91, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Ahmad Assalia and Anat Ilivitzki',\n", " 'md': '### Ahmad Assalia and Anat Ilivitzki',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 203.9, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '> \"If you are too fond of new remedies, first you will not cure your patients; secondly, you will have no patients to cure.\"\\n> — Astley Paston Cooper\\n\\nComplications of endoscopy may be defined as immediate, occurring during the procedure or before the patient leaves the endoscopic suite, or delayed, occurring up to 30 days after the procedure.',\n", " 'md': '> \"If you are too fond of new remedies, first you will not cure your patients; secondly, you will have no patients to cure.\"\\n> — Astley Paston Cooper\\n\\nComplications of endoscopy may be defined as immediate, occurring during the procedure or before the patient leaves the endoscopic suite, or delayed, occurring up to 30 days after the procedure.',\n", " 'bBox': {'x': 72, 'y': 309, 'w': 467.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Some Basic Points',\n", " 'md': '### Some Basic Points',\n", " 'bBox': {'x': 86, 'y': 461, 'w': 146.21, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- In the real world, complications are much more frequent than is suggested by the ‘beautiful’ figures quoted in the books!\\n- Complication rates vary with expertise and case volume; expect more with less experienced endoscopists — those still climbing the learning curve, or those who continue climbing forever.\\n- The risks associated with endoscopy are higher when the pathology is more complex and in therapeutic as opposed to diagnostic procedures.\\n- With complications of endoscopy, it’s particularly important to know when not to operate rather than when to operate; many episodes of post-endoscopy bleeding and perforation are best treated conservatively. It is unhelpful to carry out a laparotomy for post-endoscopy complications and then be unable to identify the cause.\\n```',\n", " 'md': '- In the real world, complications are much more frequent than is suggested by the ‘beautiful’ figures quoted in the books!\\n- Complication rates vary with expertise and case volume; expect more with less experienced endoscopists — those still climbing the learning curve, or those who continue climbing forever.\\n- The risks associated with endoscopy are higher when the pathology is more complex and in therapeutic as opposed to diagnostic procedures.\\n- With complications of endoscopy, it’s particularly important to know when not to operate rather than when to operate; many episodes of post-endoscopy bleeding and perforation are best treated conservatively. It is unhelpful to carry out a laparotomy for post-endoscopy complications and then be unable to identify the cause.\\n```',\n", " 'bBox': {'x': 100, 'y': 515, 'w': 436.91, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 552,\n", " 'text': ' perforation or bleeding source.\\n\\n When called to see a ‘sick’ patient after an endoscopic procedure:\\n\\n Suspect catastrophe! And until proven otherwise, assume the patient has\\n the most dreadful surgical complications.\\n What’s common is common! Adverse events following immediately\\n after endoscopy are likely to be due to the procedure itself.\\n\\n Always transfer these ‘sick’ patients to the surgical\\n service regardless of the immediate need for surgical intervention. In the\\n interests of everyone, especially the patient, the best environment is the surgical\\n floor where patients can be monitored and treated appropriately.\\n\\n Recognition and early management of complications is\\n the key for a successful outcome. So… if you don’t think about it,\\n you won’t diagnose it.\\n\\n Regardless of the etiology, always treat shock\\n immediately and prepare the patient with obvious\\n peritonitis for urgent laparotomy.\\n Always READ carefully any admission and progress notes and the endoscopic\\n report; TALK to the patient, his doctor and directly contact the GI specialist who\\n performed the ‘uneventful’ procedure (many clues for the nature of the complication\\n are there) and VIEW, personally, all images taken at the endoscopy and\\n thereafter.\\n\\n Complications of upper gastrointestinal endoscopy\\n\\n Flexible esophagogastroduodenoscopy (EGD) is a relatively safe\\nprocedure with few complications. Almost half of the serious\\ncomplications that occur are cardiopulmonary, related to aspiration,\\nhypoxemia, vasovagal reflexes, and endocarditis. The surgical\\ncomplications are outlined below.',\n", " 'md': '```markdown\\n## Complications of Upper Gastrointestinal Endoscopy\\n\\nWhen called to see a ‘sick’ patient after an endoscopic procedure:\\n\\n- **Suspect catastrophe!** And until proven otherwise, assume the patient has the most dreadful surgical complications.\\n- What’s common is common! Adverse events following immediately after endoscopy are likely to be due to the procedure itself.\\n\\nAlways transfer these ‘sick’ patients to the surgical service regardless of the immediate need for surgical intervention. In the interests of everyone, especially the patient, the best environment is the surgical floor where patients can be monitored and treated appropriately.\\n\\nRecognition and early management of complications is the key for a successful outcome. So… if you don’t think about it, you won’t diagnose it.\\n\\nRegardless of the etiology, always treat shock immediately and prepare the patient with obvious peritonitis for urgent laparotomy. Always READ carefully any admission and progress notes and the endoscopic report; TALK to the patient, his doctor and directly contact the GI specialist who performed the ‘uneventful’ procedure (many clues for the nature of the complication are there) and VIEW, personally, all images taken at the endoscopy and thereafter.\\n\\n### Complications of Upper Gastrointestinal Endoscopy\\n\\nFlexible esophagogastroduodenoscopy (EGD) is a relatively safe procedure with few complications. Almost half of the serious complications that occur are cardiopulmonary, related to aspiration, hypoxemia, vasovagal reflexes, and endocarditis. The surgical complications are outlined below.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Complications of Upper Gastrointestinal Endoscopy',\n", " 'md': '## Complications of Upper Gastrointestinal Endoscopy',\n", " 'bBox': {'x': 86, 'y': 392, 'w': 404.58, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'When called to see a ‘sick’ patient after an endoscopic procedure:\\n\\n- **Suspect catastrophe!** And until proven otherwise, assume the patient has the most dreadful surgical complications.\\n- What’s common is common! Adverse events following immediately after endoscopy are likely to be due to the procedure itself.\\n\\nAlways transfer these ‘sick’ patients to the surgical service regardless of the immediate need for surgical intervention. In the interests of everyone, especially the patient, the best environment is the surgical floor where patients can be monitored and treated appropriately.\\n\\nRecognition and early management of complications is the key for a successful outcome. So… if you don’t think about it, you won’t diagnose it.\\n\\nRegardless of the etiology, always treat shock immediately and prepare the patient with obvious peritonitis for urgent laparotomy. Always READ carefully any admission and progress notes and the endoscopic report; TALK to the patient, his doctor and directly contact the GI specialist who performed the ‘uneventful’ procedure (many clues for the nature of the complication are there) and VIEW, personally, all images taken at the endoscopy and thereafter.',\n", " 'md': 'When called to see a ‘sick’ patient after an endoscopic procedure:\\n\\n- **Suspect catastrophe!** And until proven otherwise, assume the patient has the most dreadful surgical complications.\\n- What’s common is common! Adverse events following immediately after endoscopy are likely to be due to the procedure itself.\\n\\nAlways transfer these ‘sick’ patients to the surgical service regardless of the immediate need for surgical intervention. In the interests of everyone, especially the patient, the best environment is the surgical floor where patients can be monitored and treated appropriately.\\n\\nRecognition and early management of complications is the key for a successful outcome. So… if you don’t think about it, you won’t diagnose it.\\n\\nRegardless of the etiology, always treat shock immediately and prepare the patient with obvious peritonitis for urgent laparotomy. Always READ carefully any admission and progress notes and the endoscopic report; TALK to the patient, his doctor and directly contact the GI specialist who performed the ‘uneventful’ procedure (many clues for the nature of the complication are there) and VIEW, personally, all images taken at the endoscopy and thereafter.',\n", " 'bBox': {'x': 72, 'y': 134, 'w': 457.8, 'h': 16.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Complications of Upper Gastrointestinal Endoscopy',\n", " 'md': '### Complications of Upper Gastrointestinal Endoscopy',\n", " 'bBox': {'x': 86, 'y': 392, 'w': 404.58, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Flexible esophagogastroduodenoscopy (EGD) is a relatively safe procedure with few complications. Almost half of the serious complications that occur are cardiopulmonary, related to aspiration, hypoxemia, vasovagal reflexes, and endocarditis. The surgical complications are outlined below.\\n```',\n", " 'md': 'Flexible esophagogastroduodenoscopy (EGD) is a relatively safe procedure with few complications. Almost half of the serious complications that occur are cardiopulmonary, related to aspiration, hypoxemia, vasovagal reflexes, and endocarditis. The surgical complications are outlined below.\\n```',\n", " 'bBox': {'x': 72, 'y': 392, 'w': 211.1, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 553,\n", " 'text': ' Esophageal perforation\\n\\n The cervical esophagus is the area most at risk. Risk factors include\\nanterior cervical osteophytes, Zenker’s diverticulum, esophageal stricture\\nor web and a cervical rib. Most cervical esophageal perforations\\noccur during rigid endoscopy or with blind passage of a flexible\\nendoscope. Retching with an over-inflated stomach, and the endoscope\\noccluding the gastro-esophageal junction, can result in Mallory-Weiss\\ntears or transmural perforation. Cervical pain, crepitus and cellulitis\\nare all signs of high esophageal perforation. Halitosis develops\\nrapidly due to overgrowth of anaerobic bacteria. Distal perforations cause\\nchest pain. A cervical soft tissue X-ray and chest radiograph may be\\nhelpful in the initial stages for the detection of cervical air,\\npneumomediastinum and pneumothorax or pleural effusion. The\\ndiagnosis is confirmed with water-soluble esophagography or a CT\\nscan. Don’t waste time — get an urgent CT scan with an oral, water-\\nsoluble contrast medium — it will detect minimal perforations and\\nprovide additional valuable information as to the location and extent\\nof the inflammatory process. Esophagoscopy is accurate in\\nvisualizing clinically significant perforations. ħowever, it may miss tiny\\ntears hidden under a mucosal fold and could convert a mini-perforation\\ninto a larger one. Thus, endoscopy is not considered a primary diagnotic\\ntool but may be useful in the management, which is outlined in\\nChapter 15.\\n\\n Post-EGD upper gastrointestinal bleeding\\n\\n Post-EGD upper gastrointestinal bleeding (variceal and non-\\nvariceal) is approached and treated according to the principles presented\\nin Chapter 17.\\n\\n Other complications\\n\\n Following sclerotherapy, and less frequently after band ligation for\\nesophageal varices, up to half of the patients will experience one or more\\nof the following: chest pain, pleural effusion, pulmonary infiltrates and\\nbacteremia (without perforation). Bacteremia is especially common after',\n", " 'md': '```markdown\\n# Esophageal Perforation\\n\\nThe cervical esophagus is the area most at risk. Risk factors include anterior cervical osteophytes, Zenker’s diverticulum, esophageal stricture or web, and a cervical rib. Most cervical esophageal perforations occur during rigid endoscopy or with blind passage of a flexible endoscope. Retching with an over-inflated stomach, and the endoscope occluding the gastro-esophageal junction, can result in Mallory-Weiss tears or transmural perforation.\\n\\nCervical pain, crepitus, and cellulitis are all signs of high esophageal perforation. Halitosis develops rapidly due to overgrowth of anaerobic bacteria. Distal perforations cause chest pain. A cervical soft tissue X-ray and chest radiograph may be helpful in the initial stages for the detection of cervical air, pneumomediastinum, and pneumothorax or pleural effusion. The diagnosis is confirmed with water-soluble esophagography or a CT scan. Don’t waste time — get an urgent CT scan with an oral, water-soluble contrast medium — it will detect minimal perforations and provide additional valuable information as to the location and extent of the inflammatory process.\\n\\nEsophagoscopy is accurate in visualizing clinically significant perforations. However, it may miss tiny tears hidden under a mucosal fold and could convert a mini-perforation into a larger one. Thus, endoscopy is not considered a primary diagnostic tool but may be useful in the management, which is outlined in Chapter 15.\\n\\n## Post-EGD Upper Gastrointestinal Bleeding\\n\\nPost-EGD upper gastrointestinal bleeding (variceal and non-variceal) is approached and treated according to the principles presented in Chapter 17.\\n\\n## Other Complications\\n\\nFollowing sclerotherapy, and less frequently after band ligation for esophageal varices, up to half of the patients will experience one or more of the following: chest pain, pleural effusion, pulmonary infiltrates, and bacteremia (without perforation). Bacteremia is especially common after.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Esophageal Perforation',\n", " 'md': '# Esophageal Perforation',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 184.83, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The cervical esophagus is the area most at risk. Risk factors include anterior cervical osteophytes, Zenker’s diverticulum, esophageal stricture or web, and a cervical rib. Most cervical esophageal perforations occur during rigid endoscopy or with blind passage of a flexible endoscope. Retching with an over-inflated stomach, and the endoscope occluding the gastro-esophageal junction, can result in Mallory-Weiss tears or transmural perforation.\\n\\nCervical pain, crepitus, and cellulitis are all signs of high esophageal perforation. Halitosis develops rapidly due to overgrowth of anaerobic bacteria. Distal perforations cause chest pain. A cervical soft tissue X-ray and chest radiograph may be helpful in the initial stages for the detection of cervical air, pneumomediastinum, and pneumothorax or pleural effusion. The diagnosis is confirmed with water-soluble esophagography or a CT scan. Don’t waste time — get an urgent CT scan with an oral, water-soluble contrast medium — it will detect minimal perforations and provide additional valuable information as to the location and extent of the inflammatory process.\\n\\nEsophagoscopy is accurate in visualizing clinically significant perforations. However, it may miss tiny tears hidden under a mucosal fold and could convert a mini-perforation into a larger one. Thus, endoscopy is not considered a primary diagnostic tool but may be useful in the management, which is outlined in Chapter 15.',\n", " 'md': 'The cervical esophagus is the area most at risk. Risk factors include anterior cervical osteophytes, Zenker’s diverticulum, esophageal stricture or web, and a cervical rib. Most cervical esophageal perforations occur during rigid endoscopy or with blind passage of a flexible endoscope. Retching with an over-inflated stomach, and the endoscope occluding the gastro-esophageal junction, can result in Mallory-Weiss tears or transmural perforation.\\n\\nCervical pain, crepitus, and cellulitis are all signs of high esophageal perforation. Halitosis develops rapidly due to overgrowth of anaerobic bacteria. Distal perforations cause chest pain. A cervical soft tissue X-ray and chest radiograph may be helpful in the initial stages for the detection of cervical air, pneumomediastinum, and pneumothorax or pleural effusion. The diagnosis is confirmed with water-soluble esophagography or a CT scan. Don’t waste time — get an urgent CT scan with an oral, water-soluble contrast medium — it will detect minimal perforations and provide additional valuable information as to the location and extent of the inflammatory process.\\n\\nEsophagoscopy is accurate in visualizing clinically significant perforations. However, it may miss tiny tears hidden under a mucosal fold and could convert a mini-perforation into a larger one. Thus, endoscopy is not considered a primary diagnostic tool but may be useful in the management, which is outlined in Chapter 15.',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.7, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Post-EGD Upper Gastrointestinal Bleeding',\n", " 'md': '## Post-EGD Upper Gastrointestinal Bleeding',\n", " 'bBox': {'x': 86, 'y': 515, 'w': 328.25, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Post-EGD upper gastrointestinal bleeding (variceal and non-variceal) is approached and treated according to the principles presented in Chapter 17.',\n", " 'md': 'Post-EGD upper gastrointestinal bleeding (variceal and non-variceal) is approached and treated according to the principles presented in Chapter 17.',\n", " 'bBox': {'x': 72, 'y': 515, 'w': 467.47, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Other Complications',\n", " 'md': '## Other Complications',\n", " 'bBox': {'x': 86, 'y': 627, 'w': 159.99, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Following sclerotherapy, and less frequently after band ligation for esophageal varices, up to half of the patients will experience one or more of the following: chest pain, pleural effusion, pulmonary infiltrates, and bacteremia (without perforation). Bacteremia is especially common after.\\n```',\n", " 'md': 'Following sclerotherapy, and less frequently after band ligation for esophageal varices, up to half of the patients will experience one or more of the following: chest pain, pleural effusion, pulmonary infiltrates, and bacteremia (without perforation). Bacteremia is especially common after.\\n```',\n", " 'bBox': {'x': 72, 'y': 679, 'w': 467.52, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 15.'}, {'text': ''}]},\n", " {'page': 554,\n", " 'text': 'esophageal dilatation, so antibiotic prophylaxis should be considered in\\nan effort to prevent bacterial endocarditis in susceptible individuals.\\nEsophageal placement of stents for malignant strictures may cause\\nerosions, bleeding, migration, tumor ingrowth with recurrent obstruction,\\nfood impaction or (if they are inserted across the gastroesophageal\\njunction) reflux with aspiration. Remember — these patients have a\\nshort life expectancy; do no more than the minimum required for\\npalliation. This may include repeated endoscopies for ablation of the\\ntumor ingrowth or placement of a second stent.\\n\\n Complications of percutaneous endoscopic gastrostomy\\n (PEG)\\n DIB (death in bed) — a common early sequel of\\n tracheostomy and gastrostomy.\\n\\n PEG tubes are commonly used as a feeding route in elderly and\\ndebilitated patients. In some cultures and places it seems that patients\\nare not allowed to die without having a PEG tube inserted! (ħurrah! No\\nneed to spoon feed the poor old chap — more time for the modern nurse\\nto stare at the computer screen!) This is an invasive procedure and\\ncomplications after PEG insertion are not uncommon.\\n\\n Leakage\\n\\n This is by far the most important complication. It tends to present in the\\nfirst few days following the procedure. The clinical scenario ranges from\\nasymptomatic leakage around the gastrostomy tube to overwhelming\\nperitonitis and sepsis. The reason is inadequate fixation of the\\nstomach against the inner abdominal wall or the separation of the\\ntwo due to various factors, especially ischemia and necrosis of the\\ngastric wall due to excessive tightness of the fixing device — whatever\\nmethod is used.\\n\\n Clinical features\\n Clinical features depend on whether the leaking gastric juice or feeding',\n", " 'md': '```markdown\\n## Esophageal Dilatation and Stenting\\n\\nEsophageal dilatation, so antibiotic prophylaxis should be considered in an effort to prevent bacterial endocarditis in susceptible individuals. Esophageal placement of stents for malignant strictures may cause erosions, bleeding, migration, tumor ingrowth with recurrent obstruction, food impaction or (if they are inserted across the gastroesophageal junction) reflux with aspiration. Remember — these patients have a short life expectancy; do no more than the minimum required for palliation. This may include repeated endoscopies for ablation of the tumor ingrowth or placement of a second stent.\\n\\n### Complications of Percutaneous Endoscopic Gastrostomy (PEG)\\n\\n- **DIB (death in bed)** — a common early sequel of tracheostomy and gastrostomy.\\n\\nPEG tubes are commonly used as a feeding route in elderly and debilitated patients. In some cultures and places, it seems that patients are not allowed to die without having a PEG tube inserted! (ħurrah! No need to spoon feed the poor old chap — more time for the modern nurse to stare at the computer screen!) This is an invasive procedure and complications after PEG insertion are not uncommon.\\n\\n#### Leakage\\n\\nThis is by far the most important complication. It tends to present in the first few days following the procedure. The clinical scenario ranges from asymptomatic leakage around the gastrostomy tube to overwhelming peritonitis and sepsis. The reason is inadequate fixation of the stomach against the inner abdominal wall or the separation of the two due to various factors, especially ischemia and necrosis of the gastric wall due to excessive tightness of the fixing device — whatever method is used.\\n\\n### Clinical Features\\n\\nClinical features depend on whether the leaking gastric juice or feeding...\\n```\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the provided content. If there were any images or figures, they would be described and numbered accordingly.*',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Esophageal Dilatation and Stenting',\n", " 'md': '## Esophageal Dilatation and Stenting',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Esophageal dilatation, so antibiotic prophylaxis should be considered in an effort to prevent bacterial endocarditis in susceptible individuals. Esophageal placement of stents for malignant strictures may cause erosions, bleeding, migration, tumor ingrowth with recurrent obstruction, food impaction or (if they are inserted across the gastroesophageal junction) reflux with aspiration. Remember — these patients have a short life expectancy; do no more than the minimum required for palliation. This may include repeated endoscopies for ablation of the tumor ingrowth or placement of a second stent.',\n", " 'md': 'Esophageal dilatation, so antibiotic prophylaxis should be considered in an effort to prevent bacterial endocarditis in susceptible individuals. Esophageal placement of stents for malignant strictures may cause erosions, bleeding, migration, tumor ingrowth with recurrent obstruction, food impaction or (if they are inserted across the gastroesophageal junction) reflux with aspiration. Remember — these patients have a short life expectancy; do no more than the minimum required for palliation. This may include repeated endoscopies for ablation of the tumor ingrowth or placement of a second stent.',\n", " 'bBox': {'x': 72, 'y': 219, 'w': 299.84, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Complications of Percutaneous Endoscopic Gastrostomy (PEG)',\n", " 'md': '### Complications of Percutaneous Endoscopic Gastrostomy (PEG)',\n", " 'bBox': {'x': 86, 'y': 261, 'w': 452.87, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- **DIB (death in bed)** — a common early sequel of tracheostomy and gastrostomy.\\n\\nPEG tubes are commonly used as a feeding route in elderly and debilitated patients. In some cultures and places, it seems that patients are not allowed to die without having a PEG tube inserted! (ħurrah! No need to spoon feed the poor old chap — more time for the modern nurse to stare at the computer screen!) This is an invasive procedure and complications after PEG insertion are not uncommon.',\n", " 'md': '- **DIB (death in bed)** — a common early sequel of tracheostomy and gastrostomy.\\n\\nPEG tubes are commonly used as a feeding route in elderly and debilitated patients. In some cultures and places, it seems that patients are not allowed to die without having a PEG tube inserted! (ħurrah! No need to spoon feed the poor old chap — more time for the modern nurse to stare at the computer screen!) This is an invasive procedure and complications after PEG insertion are not uncommon.',\n", " 'bBox': {'x': 72, 'y': 329, 'w': 467.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Leakage',\n", " 'md': '#### Leakage',\n", " 'bBox': {'x': 86, 'y': 490, 'w': 66.24, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is by far the most important complication. It tends to present in the first few days following the procedure. The clinical scenario ranges from asymptomatic leakage around the gastrostomy tube to overwhelming peritonitis and sepsis. The reason is inadequate fixation of the stomach against the inner abdominal wall or the separation of the two due to various factors, especially ischemia and necrosis of the gastric wall due to excessive tightness of the fixing device — whatever method is used.',\n", " 'md': 'This is by far the most important complication. It tends to present in the first few days following the procedure. The clinical scenario ranges from asymptomatic leakage around the gastrostomy tube to overwhelming peritonitis and sepsis. The reason is inadequate fixation of the stomach against the inner abdominal wall or the separation of the two due to various factors, especially ischemia and necrosis of the gastric wall due to excessive tightness of the fixing device — whatever method is used.',\n", " 'bBox': {'x': 72, 'y': 490, 'w': 467.98, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Clinical Features',\n", " 'md': '### Clinical Features',\n", " 'bBox': {'x': 86, 'y': 681, 'w': 111.12, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Clinical features depend on whether the leaking gastric juice or feeding...\\n```\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the provided content. If there were any images or figures, they would be described and numbered accordingly.*',\n", " 'md': 'Clinical features depend on whether the leaking gastric juice or feeding...\\n```\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the provided content. If there were any images or figures, they would be described and numbered accordingly.*',\n", " 'bBox': {'x': 86, 'y': 681, 'w': 453.12, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 555,\n", " 'text': 'solution leaks only to the outside around the tube, or whether the leak is\\ninto the peritoneal cavity. If the latter is the case the clinical picture may\\nrange from mild pain and abdominal distension due to ileus to full-blown\\nperitonitis and ‘sepsis’.\\n\\n Diagnosis\\n The finding of free intraperitoneal air is not diagnostic because\\npneumoperitoneum may be present for weeks after uncomplicated PEG\\ninsertion. Intraperitoneal leak should be excluded by a contrast study —\\nwith contrast instilled through the PEG tube.\\n\\n Management\\n If a contrast study excludes intraperitoneal leakage, then the PEG tube\\nhas to be ‘rested’ — allowing the tissue around it to seal. Attach the PEG\\ntube to gravity drainage, administer i.v. fluids and antibiotics, and follow\\nthe patient closely. Wait a week and then repeat the contrast study before\\nattempting PEG feeding. This, with the addition of a nasogastric tube,\\nshould also be the approach when the PEG tube is pulled out\\ninadvertently less than 2 weeks after insertion, and there are no\\nsigns of peritonitis or sepsis and no evidence of intraperitoneal leak\\non contrast study. In cases with obvious leakage into the peritoneal\\ncavity, your management should be guided by the clinical scenario.\\nWhile minor and asymptomatic leaks can be treated conservatively,\\noperative treatment is mandatory with free intraperitoneal leaks and\\nsigns of infection.\\n\\n Operation\\n Early on, in the absence of significant tissue edema, place a purse-\\nstring suture around the PEG tube and (carefully and all around) refix the\\nstomach to the abdominal wall. But if the surrounding tissues and the\\nhole in the stomach look ‘bad’, then take out the tube and carefully suture\\nor staple off the hole. Based on the condition of the patient and the\\ndegree of peritonitis consider whether you wish to insert a gastrostomy\\n(or jejunostomy) tube in another, healthier location. Needless to say,\\nthorough ‘peritoneal toilet’ is mandatory ( Chapter 13). This procedure\\ncould be accomplished laparoscopically if you have enough skills or by a\\nmini-laparotomy in the upper midline.',\n", " 'md': '```markdown\\n## Diagnosis and Management of PEG Tube Complications\\n\\n### Diagnosis\\nThe finding of free intraperitoneal air is not diagnostic because pneumoperitoneum may be present for weeks after uncomplicated PEG insertion. Intraperitoneal leak should be excluded by a contrast study — with contrast instilled through the PEG tube.\\n\\n### Management\\nIf a contrast study excludes intraperitoneal leakage, then the PEG tube has to be ‘rested’ — allowing the tissue around it to seal. Attach the PEG tube to gravity drainage, administer intravenous (i.v.) fluids and antibiotics, and follow the patient closely. Wait a week and then repeat the contrast study before attempting PEG feeding. This, with the addition of a nasogastric tube, should also be the approach when the PEG tube is pulled out inadvertently less than 2 weeks after insertion, and there are no signs of peritonitis or sepsis and no evidence of intraperitoneal leak on contrast study. In cases with obvious leakage into the peritoneal cavity, your management should be guided by the clinical scenario. While minor and asymptomatic leaks can be treated conservatively, operative treatment is mandatory with free intraperitoneal leaks and signs of infection.\\n\\n### Operation\\nEarly on, in the absence of significant tissue edema, place a purse-string suture around the PEG tube and (carefully and all around) refix the stomach to the abdominal wall. But if the surrounding tissues and the hole in the stomach look ‘bad’, then take out the tube and carefully suture or staple off the hole. Based on the condition of the patient and the degree of peritonitis consider whether you wish to insert a gastrostomy (or jejunostomy) tube in another, healthier location. Thorough ‘peritoneal toilet’ is mandatory. This procedure could be accomplished laparoscopically if you have enough skills or by a mini-laparotomy in the upper midline.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnosis and Management of PEG Tube Complications',\n", " 'md': '## Diagnosis and Management of PEG Tube Complications',\n", " 'bBox': {'x': 86, 'y': 174, 'w': 87.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diagnosis',\n", " 'md': '### Diagnosis',\n", " 'bBox': {'x': 86, 'y': 174, 'w': 68.75, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The finding of free intraperitoneal air is not diagnostic because pneumoperitoneum may be present for weeks after uncomplicated PEG insertion. Intraperitoneal leak should be excluded by a contrast study — with contrast instilled through the PEG tube.',\n", " 'md': 'The finding of free intraperitoneal air is not diagnostic because pneumoperitoneum may be present for weeks after uncomplicated PEG insertion. Intraperitoneal leak should be excluded by a contrast study — with contrast instilled through the PEG tube.',\n", " 'bBox': {'x': 72, 'y': 211, 'w': 467.39, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management',\n", " 'md': '### Management',\n", " 'bBox': {'x': 86, 'y': 283, 'w': 87.94, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'If a contrast study excludes intraperitoneal leakage, then the PEG tube has to be ‘rested’ — allowing the tissue around it to seal. Attach the PEG tube to gravity drainage, administer intravenous (i.v.) fluids and antibiotics, and follow the patient closely. Wait a week and then repeat the contrast study before attempting PEG feeding. This, with the addition of a nasogastric tube, should also be the approach when the PEG tube is pulled out inadvertently less than 2 weeks after insertion, and there are no signs of peritonitis or sepsis and no evidence of intraperitoneal leak on contrast study. In cases with obvious leakage into the peritoneal cavity, your management should be guided by the clinical scenario. While minor and asymptomatic leaks can be treated conservatively, operative treatment is mandatory with free intraperitoneal leaks and signs of infection.',\n", " 'md': 'If a contrast study excludes intraperitoneal leakage, then the PEG tube has to be ‘rested’ — allowing the tissue around it to seal. Attach the PEG tube to gravity drainage, administer intravenous (i.v.) fluids and antibiotics, and follow the patient closely. Wait a week and then repeat the contrast study before attempting PEG feeding. This, with the addition of a nasogastric tube, should also be the approach when the PEG tube is pulled out inadvertently less than 2 weeks after insertion, and there are no signs of peritonitis or sepsis and no evidence of intraperitoneal leak on contrast study. In cases with obvious leakage into the peritoneal cavity, your management should be guided by the clinical scenario. While minor and asymptomatic leaks can be treated conservatively, operative treatment is mandatory with free intraperitoneal leaks and signs of infection.',\n", " 'bBox': {'x': 72, 'y': 283, 'w': 467.98, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Operation',\n", " 'md': '### Operation',\n", " 'bBox': {'x': 86, 'y': 542, 'w': 67.95, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Early on, in the absence of significant tissue edema, place a purse-string suture around the PEG tube and (carefully and all around) refix the stomach to the abdominal wall. But if the surrounding tissues and the hole in the stomach look ‘bad’, then take out the tube and carefully suture or staple off the hole. Based on the condition of the patient and the degree of peritonitis consider whether you wish to insert a gastrostomy (or jejunostomy) tube in another, healthier location. Thorough ‘peritoneal toilet’ is mandatory. This procedure could be accomplished laparoscopically if you have enough skills or by a mini-laparotomy in the upper midline.\\n```',\n", " 'md': 'Early on, in the absence of significant tissue edema, place a purse-string suture around the PEG tube and (carefully and all around) refix the stomach to the abdominal wall. But if the surrounding tissues and the hole in the stomach look ‘bad’, then take out the tube and carefully suture or staple off the hole. Based on the condition of the patient and the degree of peritonitis consider whether you wish to insert a gastrostomy (or jejunostomy) tube in another, healthier location. Thorough ‘peritoneal toilet’ is mandatory. This procedure could be accomplished laparoscopically if you have enough skills or by a mini-laparotomy in the upper midline.\\n```',\n", " 'bBox': {'x': 72, 'y': 579, 'w': 467.88, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'could be accomplished laparoscopically if you have enough skills or by a'}]},\n", " {'page': 556,\n", " 'text': ' Late leaks\\n Less frequently, leaks may occur long after PEG insertion, particularly\\nin patients with poor healing capabilities and occasionally also after\\ninadvertent or planned removal of the tube. Most often such late leaks\\nbehave like a controlled gastric fistula and will eventually seal\\nspontaneously with conservative measures. ħowever, an uncontrolled\\nleak into the peritoneal cavity may occur and should be managed\\naccording to the above principles.\\n\\n Perforation of a viscus\\n\\n Rarely, the colon or even small bowel can be ‘impaled’ by the PEG\\ntube during its placement. This could present early on with a free leak\\nand peritonitis or later with an abscess or colonic fistula (external and/or\\ncommunicating with the stomach). The management (conservative vs.\\noperative) depends on the acuteness of presentation, the anatomy of the\\ncomplication and the patient’s general condition. Free leaks must be\\ncontrolled; abscesses have to be drained while controlled fistulas are\\nmanaged conservatively. Cologastric-PEG fistulas usually subside\\nwhen the tube is pulled out!\\n\\n Complications of endoscopic retrograde cholangio-\\n pancreatography (ERCP)\\n\\n ERCP carries a relatively high incidence of complications. Were we not\\nconstrained by the Editors, who advised against the use of percentages\\nin this book, we would have told you that in decreasing order of\\nfrequency, the complications include: pancreatitis (2%-5%), bleeding\\n(2%), cholangitis (1%-2%) and perforation (0.5%-1.2%). The mortality\\nrate of the last mentioned complication may be as high as 15%.\\nTherefore, ERCP — especially therapeutic ERCP — should be viewed as\\na potentially risky endoscopic procedure that shouldn’t be embarked\\nupon lightly, like popping yet another can of that awful light American\\nbeer . We have seen disasters developing after unnecessary ERCP,\\nordered, for example, because of transient elevation of liver enzymes\\nafter laparoscopic cholecystectomy…',\n", " 'md': '```markdown\\n## Late Leaks\\n\\nLess frequently, leaks may occur long after PEG insertion, particularly in patients with poor healing capabilities and occasionally also after inadvertent or planned removal of the tube. Most often such late leaks behave like a controlled gastric fistula and will eventually seal spontaneously with conservative measures. However, an uncontrolled leak into the peritoneal cavity may occur and should be managed according to the above principles.\\n\\n## Perforation of a Viscus\\n\\nRarely, the colon or even small bowel can be ‘impaled’ by the PEG tube during its placement. This could present early on with a free leak and peritonitis or later with an abscess or colonic fistula (external and/or communicating with the stomach). The management (conservative vs. operative) depends on the acuteness of presentation, the anatomy of the complication, and the patient’s general condition. Free leaks must be controlled; abscesses have to be drained while controlled fistulas are managed conservatively. Cologastric-PEG fistulas usually subside when the tube is pulled out!\\n\\n## Complications of Endoscopic Retrograde Cholangio-Pancreatography (ERCP)\\n\\nERCP carries a relatively high incidence of complications. Were we not constrained by the Editors, who advised against the use of percentages in this book, we would have told you that in decreasing order of frequency, the complications include: pancreatitis (2%-5%), bleeding (2%), cholangitis (1%-2%) and perforation (0.5%-1.2%). The mortality rate of the last mentioned complication may be as high as 15%. Therefore, ERCP — especially therapeutic ERCP — should be viewed as a potentially risky endoscopic procedure that shouldn’t be embarked upon lightly, like popping yet another can of that awful light American beer. We have seen disasters developing after unnecessary ERCP, ordered, for example, because of transient elevation of liver enzymes after laparoscopic cholecystectomy…\\n```',\n", " 'images': [{'name': 'img_p555_1.png',\n", " 'height': 19,\n", " 'width': 17,\n", " 'x': 106.55999999999995,\n", " 'y': 654.48}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Late Leaks',\n", " 'md': '## Late Leaks',\n", " 'bBox': {'x': 86, 'y': 86, 'w': 69.57, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Less frequently, leaks may occur long after PEG insertion, particularly in patients with poor healing capabilities and occasionally also after inadvertent or planned removal of the tube. Most often such late leaks behave like a controlled gastric fistula and will eventually seal spontaneously with conservative measures. However, an uncontrolled leak into the peritoneal cavity may occur and should be managed according to the above principles.',\n", " 'md': 'Less frequently, leaks may occur long after PEG insertion, particularly in patients with poor healing capabilities and occasionally also after inadvertent or planned removal of the tube. Most often such late leaks behave like a controlled gastric fistula and will eventually seal spontaneously with conservative measures. However, an uncontrolled leak into the peritoneal cavity may occur and should be managed according to the above principles.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.49, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Perforation of a Viscus',\n", " 'md': '## Perforation of a Viscus',\n", " 'bBox': {'x': 86, 'y': 250, 'w': 178.38, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Rarely, the colon or even small bowel can be ‘impaled’ by the PEG tube during its placement. This could present early on with a free leak and peritonitis or later with an abscess or colonic fistula (external and/or communicating with the stomach). The management (conservative vs. operative) depends on the acuteness of presentation, the anatomy of the complication, and the patient’s general condition. Free leaks must be controlled; abscesses have to be drained while controlled fistulas are managed conservatively. Cologastric-PEG fistulas usually subside when the tube is pulled out!',\n", " 'md': 'Rarely, the colon or even small bowel can be ‘impaled’ by the PEG tube during its placement. This could present early on with a free leak and peritonitis or later with an abscess or colonic fistula (external and/or communicating with the stomach). The management (conservative vs. operative) depends on the acuteness of presentation, the anatomy of the complication, and the patient’s general condition. Free leaks must be controlled; abscesses have to be drained while controlled fistulas are managed conservatively. Cologastric-PEG fistulas usually subside when the tube is pulled out!',\n", " 'bBox': {'x': 72, 'y': 319, 'w': 467.34, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Complications of Endoscopic Retrograde Cholangio-Pancreatography (ERCP)',\n", " 'md': '## Complications of Endoscopic Retrograde Cholangio-Pancreatography (ERCP)',\n", " 'bBox': {'x': 86, 'y': 461, 'w': 195.89, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'ERCP carries a relatively high incidence of complications. Were we not constrained by the Editors, who advised against the use of percentages in this book, we would have told you that in decreasing order of frequency, the complications include: pancreatitis (2%-5%), bleeding (2%), cholangitis (1%-2%) and perforation (0.5%-1.2%). The mortality rate of the last mentioned complication may be as high as 15%. Therefore, ERCP — especially therapeutic ERCP — should be viewed as a potentially risky endoscopic procedure that shouldn’t be embarked upon lightly, like popping yet another can of that awful light American beer. We have seen disasters developing after unnecessary ERCP, ordered, for example, because of transient elevation of liver enzymes after laparoscopic cholecystectomy…\\n```',\n", " 'md': 'ERCP carries a relatively high incidence of complications. Were we not constrained by the Editors, who advised against the use of percentages in this book, we would have told you that in decreasing order of frequency, the complications include: pancreatitis (2%-5%), bleeding (2%), cholangitis (1%-2%) and perforation (0.5%-1.2%). The mortality rate of the last mentioned complication may be as high as 15%. Therefore, ERCP — especially therapeutic ERCP — should be viewed as a potentially risky endoscopic procedure that shouldn’t be embarked upon lightly, like popping yet another can of that awful light American beer. We have seen disasters developing after unnecessary ERCP, ordered, for example, because of transient elevation of liver enzymes after laparoscopic cholecystectomy…\\n```',\n", " 'bBox': {'x': 72, 'y': 461, 'w': 467.98, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 557,\n", " 'text': ' Pancreatitis\\n\\n While hyperamylasemia may be seen in up to two-thirds of patients,\\nclinical pancreatitis occurs rarely. The incidence is the same for both\\ndiagnostic and therapeutic procedures. The severity in the majority of\\ncases is usually mild to moderate and self-limiting. Unfortunately,\\nhowever, severe post-ERCP pancreatitis, and even fatalities, can\\noccur. Interestingly, pancreatitis is more common in younger patients\\nand has its highest incidence in patients having ERCP for suspected\\n‘sphincter of Oddi dysfunction’.\\n\\n One of those mystifying diagnoses seen only by those who write the articles… The Editors\\n\\n Diagnosis\\n Any significant upper abdominal pain coupled with\\nhyperamylasemia after ERCP should raise the suspicion of\\npancreatitis. Sometimes the diagnosis is difficult to make, since\\nperforation (see below) may give a similar clinical presentation. If\\ncannulation of the duct was easy and no ‘precut’ or therapeutic\\ninterventions were attempted, the likelihood of duodenal perforation is\\nlow. Even so, whenever you suspect a perforation order a\\nGastrografin® UGI study, or preferably and much better, a CT scan,\\nto exclude a perforation and to confirm the pancreatitis.\\n\\n Management\\n Intravenous fluids and NPO until the symptoms abate are usually all\\nthat is required. In a minority of patients, a more severe and protracted\\ncourse may follow. The management strategy in such cases is discussed\\nin Chapter 19. Obviously, impacted common bile duct stones may\\nprecipitate pancreatitis and prolong its course; if so — repeated ERCP or\\noperative common bile duct exploration may be indicated.\\n\\n Hemorrhage\\n\\n Clinically significant hemorrhage may occur after endoscopic',\n", " 'md': '```markdown\\n# Pancreatitis\\n\\nWhile hyperamylasemia may be seen in up to two-thirds of patients, clinical pancreatitis occurs rarely. The incidence is the same for both diagnostic and therapeutic procedures. The severity in the majority of cases is usually mild to moderate and self-limiting. Unfortunately, however, severe post-ERCP pancreatitis, and even fatalities, can occur. Interestingly, pancreatitis is more common in younger patients and has its highest incidence in patients having ERCP for suspected ‘sphincter of Oddi dysfunction’.\\n\\n> One of those mystifying diagnoses seen only by those who write the articles… The Editors\\n\\n## Diagnosis\\n\\nAny significant upper abdominal pain coupled with hyperamylasemia after ERCP should raise the suspicion of pancreatitis. Sometimes the diagnosis is difficult to make, since perforation (see below) may give a similar clinical presentation. If cannulation of the duct was easy and no ‘precut’ or therapeutic interventions were attempted, the likelihood of duodenal perforation is low. Even so, whenever you suspect a perforation order a Gastrografin® UGI study, or preferably and much better, a CT scan, to exclude a perforation and to confirm the pancreatitis.\\n\\n## Management\\n\\nIntravenous fluids and NPO until the symptoms abate are usually all that is required. In a minority of patients, a more severe and protracted course may follow. The management strategy in such cases is discussed in Chapter 19. Obviously, impacted common bile duct stones may precipitate pancreatitis and prolong its course; if so — repeated ERCP or operative common bile duct exploration may be indicated.\\n\\n## Hemorrhage\\n\\nClinically significant hemorrhage may occur after endoscopic\\n```\\n\\n### Notes:\\n- No figures or images were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.\\n- There are no formulas present in the text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Pancreatitis',\n", " 'md': '# Pancreatitis',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 93.81, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'While hyperamylasemia may be seen in up to two-thirds of patients, clinical pancreatitis occurs rarely. The incidence is the same for both diagnostic and therapeutic procedures. The severity in the majority of cases is usually mild to moderate and self-limiting. Unfortunately, however, severe post-ERCP pancreatitis, and even fatalities, can occur. Interestingly, pancreatitis is more common in younger patients and has its highest incidence in patients having ERCP for suspected ‘sphincter of Oddi dysfunction’.\\n\\n> One of those mystifying diagnoses seen only by those who write the articles… The Editors',\n", " 'md': 'While hyperamylasemia may be seen in up to two-thirds of patients, clinical pancreatitis occurs rarely. The incidence is the same for both diagnostic and therapeutic procedures. The severity in the majority of cases is usually mild to moderate and self-limiting. Unfortunately, however, severe post-ERCP pancreatitis, and even fatalities, can occur. Interestingly, pancreatitis is more common in younger patients and has its highest incidence in patients having ERCP for suspected ‘sphincter of Oddi dysfunction’.\\n\\n> One of those mystifying diagnoses seen only by those who write the articles… The Editors',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 454.13, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnosis',\n", " 'md': '## Diagnosis',\n", " 'bBox': {'x': 86, 'y': 327, 'w': 68.75, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Any significant upper abdominal pain coupled with hyperamylasemia after ERCP should raise the suspicion of pancreatitis. Sometimes the diagnosis is difficult to make, since perforation (see below) may give a similar clinical presentation. If cannulation of the duct was easy and no ‘precut’ or therapeutic interventions were attempted, the likelihood of duodenal perforation is low. Even so, whenever you suspect a perforation order a Gastrografin® UGI study, or preferably and much better, a CT scan, to exclude a perforation and to confirm the pancreatitis.',\n", " 'md': 'Any significant upper abdominal pain coupled with hyperamylasemia after ERCP should raise the suspicion of pancreatitis. Sometimes the diagnosis is difficult to make, since perforation (see below) may give a similar clinical presentation. If cannulation of the duct was easy and no ‘precut’ or therapeutic interventions were attempted, the likelihood of duodenal perforation is low. Even so, whenever you suspect a perforation order a Gastrografin® UGI study, or preferably and much better, a CT scan, to exclude a perforation and to confirm the pancreatitis.',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.35, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management',\n", " 'md': '## Management',\n", " 'bBox': {'x': 86, 'y': 522, 'w': 87.94, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Intravenous fluids and NPO until the symptoms abate are usually all that is required. In a minority of patients, a more severe and protracted course may follow. The management strategy in such cases is discussed in Chapter 19. Obviously, impacted common bile duct stones may precipitate pancreatitis and prolong its course; if so — repeated ERCP or operative common bile duct exploration may be indicated.',\n", " 'md': 'Intravenous fluids and NPO until the symptoms abate are usually all that is required. In a minority of patients, a more severe and protracted course may follow. The management strategy in such cases is discussed in Chapter 19. Obviously, impacted common bile duct stones may precipitate pancreatitis and prolong its course; if so — repeated ERCP or operative common bile duct exploration may be indicated.',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.8, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Hemorrhage',\n", " 'md': '## Hemorrhage',\n", " 'bBox': {'x': 86, 'y': 669, 'w': 97.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Clinically significant hemorrhage may occur after endoscopic\\n```',\n", " 'md': 'Clinically significant hemorrhage may occur after endoscopic\\n```',\n", " 'bBox': {'x': 86, 'y': 348, 'w': 124.92, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No figures or images were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.\\n- There are no formulas present in the text.',\n", " 'md': '- No figures or images were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.\\n- There are no formulas present in the text.',\n", " 'bBox': {'x': 72, 'y': 348, 'w': 45.18, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'precipitate pancreatitis and prolong its course; if so — repeated ERCP or'}]},\n", " {'page': 558,\n", " 'text': 'sphincterotomy (ES).\\n\\n Diagnosis\\n Bleeding may present as upper GI bleeding or mimic lower GI\\nbleeding; the patient may develop hemodynamic compromise before\\nhematemesis or melena appears. Admit the patient to the ICU or the\\nsurgical floor for close monitoring and apply all the principles of\\nmanagement of UGI bleeding ( Chapter 17).\\n\\n Management\\n Repeat endoscopy is indicated for accurate diagnosis and to\\nconfirm if the bleeding is in the form of oozing or brisk arterial\\n‘pumping’, and also to achieve hemostasis. If endoscopic hemostasis\\nfails and the patient’s condition is still stable, and an experienced\\ninterventional radiologist is available, then celiac angiography with\\nselective embolization of the gastroduodenal artery bleeding branch may\\nprevent operative intervention. ħowever, if this in turn fails or is\\nunavailable, and the bleeding continues or the patient is unstable, then\\noperative intervention must be undertaken. After full Kocherization of\\nthe duodenum, a longitudinal duodenotomy in the second part will allow\\naccess to the papilla of Vater. The bleeding is controlled by suture\\nligature, being careful not to stenose the opening of the papilla or the\\nsphincterotomy site (you may end up converting the sphincterotomy to\\nsphincteroplasty). In a ‘stable’ patient in whom ERCP and ES have failed,\\none can proceed with a definitive surgical correction of the problem for\\nwhich the ES had been attempted — e.g. common duct exploration for\\nimpacted stones. Otherwise, the minimum should be done that\\nallows drainage of the obstructed biliary system (e.g.\\ncholecystostomy or a T-tube).\\n\\n Perforation\\n\\n This is by far the most serious complication of ERCP and\\nendoscopy in general, with up to one-fifth of patients dying. The vast\\nmajority of perforations are into the retroperitoneum in the peri-ampullary\\narea. They are caused by ‘precut’ or ES. Less frequently, guidewire\\nperforations of the common bile duct and the pancreatic duct may occur.',\n", " 'md': '```markdown\\n## Diagnosis\\nBleeding may present as upper GI bleeding or mimic lower GI bleeding; the patient may develop hemodynamic compromise before hematemesis or melena appears. Admit the patient to the ICU or the surgical floor for close monitoring and apply all the principles of management of UGI bleeding (Chapter 17).\\n\\n## Management\\nRepeat endoscopy is indicated for accurate diagnosis and to confirm if the bleeding is in the form of oozing or brisk arterial ‘pumping’, and also to achieve hemostasis. If endoscopic hemostasis fails and the patient’s condition is still stable, and an experienced interventional radiologist is available, then celiac angiography with selective embolization of the gastroduodenal artery bleeding branch may prevent operative intervention. However, if this in turn fails or is unavailable, and the bleeding continues or the patient is unstable, then operative intervention must be undertaken. After full Kocherization of the duodenum, a longitudinal duodenotomy in the second part will allow access to the papilla of Vater. The bleeding is controlled by suture ligature, being careful not to stenose the opening of the papilla or the sphincterotomy site (you may end up converting the sphincterotomy to sphincteroplasty). In a ‘stable’ patient in whom ERCP and ES have failed, one can proceed with a definitive surgical correction of the problem for which the ES had been attempted — e.g. common duct exploration for impacted stones. Otherwise, the minimum should be done that allows drainage of the obstructed biliary system (e.g. cholecystostomy or a T-tube).\\n\\n## Perforation\\nThis is by far the most serious complication of ERCP and endoscopy in general, with up to one-fifth of patients dying. The vast majority of perforations are into the retroperitoneum in the peri-ampullary area. They are caused by ‘precut’ or ES. Less frequently, guidewire perforations of the common bile duct and the pancreatic duct may occur.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnosis',\n", " 'md': '## Diagnosis',\n", " 'bBox': {'x': 86, 'y': 124, 'w': 68.75, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Bleeding may present as upper GI bleeding or mimic lower GI bleeding; the patient may develop hemodynamic compromise before hematemesis or melena appears. Admit the patient to the ICU or the surgical floor for close monitoring and apply all the principles of management of UGI bleeding (Chapter 17).',\n", " 'md': 'Bleeding may present as upper GI bleeding or mimic lower GI bleeding; the patient may develop hemodynamic compromise before hematemesis or melena appears. Admit the patient to the ICU or the surgical floor for close monitoring and apply all the principles of management of UGI bleeding (Chapter 17).',\n", " 'bBox': {'x': 72, 'y': 211, 'w': 196.7, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management',\n", " 'md': '## Management',\n", " 'bBox': {'x': 86, 'y': 250, 'w': 87.94, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Repeat endoscopy is indicated for accurate diagnosis and to confirm if the bleeding is in the form of oozing or brisk arterial ‘pumping’, and also to achieve hemostasis. If endoscopic hemostasis fails and the patient’s condition is still stable, and an experienced interventional radiologist is available, then celiac angiography with selective embolization of the gastroduodenal artery bleeding branch may prevent operative intervention. However, if this in turn fails or is unavailable, and the bleeding continues or the patient is unstable, then operative intervention must be undertaken. After full Kocherization of the duodenum, a longitudinal duodenotomy in the second part will allow access to the papilla of Vater. The bleeding is controlled by suture ligature, being careful not to stenose the opening of the papilla or the sphincterotomy site (you may end up converting the sphincterotomy to sphincteroplasty). In a ‘stable’ patient in whom ERCP and ES have failed, one can proceed with a definitive surgical correction of the problem for which the ES had been attempted — e.g. common duct exploration for impacted stones. Otherwise, the minimum should be done that allows drainage of the obstructed biliary system (e.g. cholecystostomy or a T-tube).',\n", " 'md': 'Repeat endoscopy is indicated for accurate diagnosis and to confirm if the bleeding is in the form of oozing or brisk arterial ‘pumping’, and also to achieve hemostasis. If endoscopic hemostasis fails and the patient’s condition is still stable, and an experienced interventional radiologist is available, then celiac angiography with selective embolization of the gastroduodenal artery bleeding branch may prevent operative intervention. However, if this in turn fails or is unavailable, and the bleeding continues or the patient is unstable, then operative intervention must be undertaken. After full Kocherization of the duodenum, a longitudinal duodenotomy in the second part will allow access to the papilla of Vater. The bleeding is controlled by suture ligature, being careful not to stenose the opening of the papilla or the sphincterotomy site (you may end up converting the sphincterotomy to sphincteroplasty). In a ‘stable’ patient in whom ERCP and ES have failed, one can proceed with a definitive surgical correction of the problem for which the ES had been attempted — e.g. common duct exploration for impacted stones. Otherwise, the minimum should be done that allows drainage of the obstructed biliary system (e.g. cholecystostomy or a T-tube).',\n", " 'bBox': {'x': 72, 'y': 124, 'w': 467.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Perforation',\n", " 'md': '## Perforation',\n", " 'bBox': {'x': 86, 'y': 612, 'w': 88.27, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is by far the most serious complication of ERCP and endoscopy in general, with up to one-fifth of patients dying. The vast majority of perforations are into the retroperitoneum in the peri-ampullary area. They are caused by ‘precut’ or ES. Less frequently, guidewire perforations of the common bile duct and the pancreatic duct may occur.\\n```',\n", " 'md': 'This is by far the most serious complication of ERCP and endoscopy in general, with up to one-fifth of patients dying. The vast majority of perforations are into the retroperitoneum in the peri-ampullary area. They are caused by ‘precut’ or ES. Less frequently, guidewire perforations of the common bile duct and the pancreatic duct may occur.\\n```',\n", " 'bBox': {'x': 72, 'y': 553, 'w': 467.87, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 559,\n", " 'text': 'Only a tenth of perforations are intraperitoneal and are caused by\\nthe endoscope itself — usually in the anterior wall of the second\\npart of the duodenum. Risk factors for this include limited experience of\\nthe endoscopist, too generous precut or ES, therapeutic procedure,\\nintramural injection of contrast material, repeated ERCP, and patients\\nwith a Billroth II gastrectomy, in whom the access to the papilla is ‘in\\nreverse’, through the afferent loop.\\n\\n Diagnosis\\n This is often apparent during the procedure or at the conclusion of it\\nwhen the endoscopist suspects that something went awry. Abdominal\\nand back pain during or immediately after ERCP, together with the\\npresence of retroperitoneal air on plain X-ray, will confirm the\\ndiagnosis. If suspected already during the procedure, then injection of\\ncontrast medium by the endoscopist can demonstrate the leak. The\\npreferred single modality for the diagnosis is an abdominal CT scan\\ndetecting retroperitoneal or intraperitoneal air and contrast leakage.\\nThis prevents a mistaken diagnosis of pancreatitis, which could delay the\\nappropriate management. Even more importantly, what you see on\\nthe CT helps you to decide about how to manage the patient!\\n\\n Management\\n Patients with evidence of a free leak into the peritoneal cavity\\nshould undergo an emergency laparotomy (yes, of course after\\nadequate resuscitation and administration of antibiotics). Free leak\\nis usually a result of ‘rough’ endoscopy with the endoscope gashing the\\nduodedum. Clinically it manifests with peritonitis and a spectrum of SIRS.\\nWhen abdominal X-rays show a significant pneumoperitoneum you are\\nallowed to take the patient to the OR without a CT. But if the diagnosis\\nis not clear, CT would show intraperitoneal air and leaking contrast.\\n\\n At operation — ‘Kocherize’ and simply repair the duodenal rent. You\\ncan do it in one or two layers but try not to narrow its lumen. The majority\\nof such cases are operated upon within 24 hours — those who are\\nneglected longer tend not to survive — thus there is absolutely no need\\nto add any maneuvers (such as a ‘duodenal exclusion’ of the feeding\\njejunostomy) to the repair. This is, however, one of the rare',\n", " 'md': '```markdown\\n## Diagnosis and Management of Perforations\\n\\n### Perforations\\nOnly a tenth of perforations are intraperitoneal and are caused by the endoscope itself — usually in the anterior wall of the second part of the duodenum. Risk factors for this include limited experience of the endoscopist, too generous precut or ES, therapeutic procedure, intramural injection of contrast material, repeated ERCP, and patients with a Billroth II gastrectomy, in whom the access to the papilla is ‘in reverse’, through the afferent loop.\\n\\n### Diagnosis\\nThis is often apparent during the procedure or at the conclusion of it when the endoscopist suspects that something went awry. Abdominal and back pain during or immediately after ERCP, together with the presence of retroperitoneal air on plain X-ray, will confirm the diagnosis. If suspected already during the procedure, then injection of contrast medium by the endoscopist can demonstrate the leak. The preferred single modality for the diagnosis is an abdominal CT scan detecting retroperitoneal or intraperitoneal air and contrast leakage. This prevents a mistaken diagnosis of pancreatitis, which could delay the appropriate management. Even more importantly, what you see on the CT helps you to decide about how to manage the patient!\\n\\n### Management\\nPatients with evidence of a free leak into the peritoneal cavity should undergo an emergency laparotomy (yes, of course after adequate resuscitation and administration of antibiotics). Free leak is usually a result of ‘rough’ endoscopy with the endoscope gashing the duodenum. Clinically it manifests with peritonitis and a spectrum of SIRS. When abdominal X-rays show a significant pneumoperitoneum you are allowed to take the patient to the OR without a CT. But if the diagnosis is not clear, CT would show intraperitoneal air and leaking contrast.\\n\\nAt operation — ‘Kocherize’ and simply repair the duodenal rent. You can do it in one or two layers but try not to narrow its lumen. The majority of such cases are operated upon within 24 hours — those who are neglected longer tend not to survive — thus there is absolutely no need to add any maneuvers (such as a ‘duodenal exclusion’ of the feeding jejunostomy) to the repair. This is, however, one of the rare...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnosis and Management of Perforations',\n", " 'md': '## Diagnosis and Management of Perforations',\n", " 'bBox': {'x': 86, 'y': 224, 'w': 87.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Perforations',\n", " 'md': '### Perforations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Only a tenth of perforations are intraperitoneal and are caused by the endoscope itself — usually in the anterior wall of the second part of the duodenum. Risk factors for this include limited experience of the endoscopist, too generous precut or ES, therapeutic procedure, intramural injection of contrast material, repeated ERCP, and patients with a Billroth II gastrectomy, in whom the access to the papilla is ‘in reverse’, through the afferent loop.',\n", " 'md': 'Only a tenth of perforations are intraperitoneal and are caused by the endoscope itself — usually in the anterior wall of the second part of the duodenum. Risk factors for this include limited experience of the endoscopist, too generous precut or ES, therapeutic procedure, intramural injection of contrast material, repeated ERCP, and patients with a Billroth II gastrectomy, in whom the access to the papilla is ‘in reverse’, through the afferent loop.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.42, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diagnosis',\n", " 'md': '### Diagnosis',\n", " 'bBox': {'x': 86, 'y': 224, 'w': 68.75, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'This is often apparent during the procedure or at the conclusion of it when the endoscopist suspects that something went awry. Abdominal and back pain during or immediately after ERCP, together with the presence of retroperitoneal air on plain X-ray, will confirm the diagnosis. If suspected already during the procedure, then injection of contrast medium by the endoscopist can demonstrate the leak. The preferred single modality for the diagnosis is an abdominal CT scan detecting retroperitoneal or intraperitoneal air and contrast leakage. This prevents a mistaken diagnosis of pancreatitis, which could delay the appropriate management. Even more importantly, what you see on the CT helps you to decide about how to manage the patient!',\n", " 'md': 'This is often apparent during the procedure or at the conclusion of it when the endoscopist suspects that something went awry. Abdominal and back pain during or immediately after ERCP, together with the presence of retroperitoneal air on plain X-ray, will confirm the diagnosis. If suspected already during the procedure, then injection of contrast medium by the endoscopist can demonstrate the leak. The preferred single modality for the diagnosis is an abdominal CT scan detecting retroperitoneal or intraperitoneal air and contrast leakage. This prevents a mistaken diagnosis of pancreatitis, which could delay the appropriate management. Even more importantly, what you see on the CT helps you to decide about how to manage the patient!',\n", " 'bBox': {'x': 72, 'y': 224, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management',\n", " 'md': '### Management',\n", " 'bBox': {'x': 86, 'y': 449, 'w': 87.94, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Patients with evidence of a free leak into the peritoneal cavity should undergo an emergency laparotomy (yes, of course after adequate resuscitation and administration of antibiotics). Free leak is usually a result of ‘rough’ endoscopy with the endoscope gashing the duodenum. Clinically it manifests with peritonitis and a spectrum of SIRS. When abdominal X-rays show a significant pneumoperitoneum you are allowed to take the patient to the OR without a CT. But if the diagnosis is not clear, CT would show intraperitoneal air and leaking contrast.\\n\\nAt operation — ‘Kocherize’ and simply repair the duodenal rent. You can do it in one or two layers but try not to narrow its lumen. The majority of such cases are operated upon within 24 hours — those who are neglected longer tend not to survive — thus there is absolutely no need to add any maneuvers (such as a ‘duodenal exclusion’ of the feeding jejunostomy) to the repair. This is, however, one of the rare...\\n```',\n", " 'md': 'Patients with evidence of a free leak into the peritoneal cavity should undergo an emergency laparotomy (yes, of course after adequate resuscitation and administration of antibiotics). Free leak is usually a result of ‘rough’ endoscopy with the endoscope gashing the duodenum. Clinically it manifests with peritonitis and a spectrum of SIRS. When abdominal X-rays show a significant pneumoperitoneum you are allowed to take the patient to the OR without a CT. But if the diagnosis is not clear, CT would show intraperitoneal air and leaking contrast.\\n\\nAt operation — ‘Kocherize’ and simply repair the duodenal rent. You can do it in one or two layers but try not to narrow its lumen. The majority of such cases are operated upon within 24 hours — those who are neglected longer tend not to survive — thus there is absolutely no need to add any maneuvers (such as a ‘duodenal exclusion’ of the feeding jejunostomy) to the repair. This is, however, one of the rare...\\n```',\n", " 'bBox': {'x': 72, 'y': 224, 'w': 468, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 560,\n", " 'text': 'indications for leaving a drain behind.\\n\\n Most patients, however, experience mini-perforations into the\\nretroperitoneum at the site of the ‘precut’ or sphincterotomy. SIRS may\\nbe mild or moderate and abdominal tenderness confined to the upper\\nabdomen. X-rays and CT will show air only in the retroperitoneum (a few\\nbubbles of air leaking into the peritoneum cavity should not make you\\nrush to the OR…) and contrast won’t be seen leaking into the peritoneal\\ncavity.\\n\\n There is ample evidence that the majority of these patients can be successfully treated\\n non-operatively if the following conditions are met:\\n\\n Absence of clinical peritonitis and/or systemic\\n inflammation (hemodynamic compromise, high fever and leukocytosis).\\n Absence of large pneumoperitoneum.\\n Absence of free leakage of contrast.\\n\\n If such conditions are met, a nasogastric tube is inserted and broad-\\nspectrum antibiotics with adequate Gram-negative coverage are\\nadministered. Patients should be followed closely (by one observer —\\nYOU!) and improvement should be expected within 12-24 hours.\\nNormally, these patients recover within 7-10 days; any repeated\\nprocedures, if still indicated, should be postponed well after that time.\\n\\n The lack of significant clinical improvement, with the appearance\\nor worsening of peritoneal irritation or signs of ongoing sepsis\\nmandate an operation. After fully ‘Kocherizing’ the duodenum, the site\\nof perforation is usually revealed at its posterior aspect. Depending on\\nthe degree of induration and inflammation of the tissues, either primary\\nclosure or an omental patch repair are performed and a drain left in situ.\\n\\n The next step depends on the patient’s condition, underlying pathology,\\nfailure or success of the ‘index’ ERCP and the adequacy of the duodenal\\nclosure. The principles are: if the patient’s condition is stable and the',\n", " 'md': '```markdown\\n## Indications for Leaving a Drain Behind\\n\\nMost patients, however, experience mini-perforations into the retroperitoneum at the site of the ‘precut’ or sphincterotomy. SIRS may be mild or moderate and abdominal tenderness confined to the upper abdomen. X-rays and CT will show air only in the retroperitoneum (a few bubbles of air leaking into the peritoneum cavity should not make you rush to the OR…) and contrast won’t be seen leaking into the peritoneal cavity.\\n\\nThere is ample evidence that the majority of these patients can be successfully treated non-operatively if the following conditions are met:\\n\\n- Absence of clinical peritonitis and/or systemic inflammation (hemodynamic compromise, high fever, and leukocytosis).\\n- Absence of large pneumoperitoneum.\\n- Absence of free leakage of contrast.\\n\\nIf such conditions are met, a nasogastric tube is inserted and broad-spectrum antibiotics with adequate Gram-negative coverage are administered. Patients should be followed closely (by one observer — YOU!) and improvement should be expected within 12-24 hours. Normally, these patients recover within 7-10 days; any repeated procedures, if still indicated, should be postponed well after that time.\\n\\nThe lack of significant clinical improvement, with the appearance or worsening of peritoneal irritation or signs of ongoing sepsis mandate an operation. After fully ‘Kocherizing’ the duodenum, the site of perforation is usually revealed at its posterior aspect. Depending on the degree of induration and inflammation of the tissues, either primary closure or an omental patch repair are performed and a drain left in situ.\\n\\nThe next step depends on the patient’s condition, underlying pathology, failure or success of the ‘index’ ERCP and the adequacy of the duodenal closure. The principles are: if the patient’s condition is stable and the...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Indications for Leaving a Drain Behind',\n", " 'md': '## Indications for Leaving a Drain Behind',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Most patients, however, experience mini-perforations into the retroperitoneum at the site of the ‘precut’ or sphincterotomy. SIRS may be mild or moderate and abdominal tenderness confined to the upper abdomen. X-rays and CT will show air only in the retroperitoneum (a few bubbles of air leaking into the peritoneum cavity should not make you rush to the OR…) and contrast won’t be seen leaking into the peritoneal cavity.\\n\\nThere is ample evidence that the majority of these patients can be successfully treated non-operatively if the following conditions are met:\\n\\n- Absence of clinical peritonitis and/or systemic inflammation (hemodynamic compromise, high fever, and leukocytosis).\\n- Absence of large pneumoperitoneum.\\n- Absence of free leakage of contrast.\\n\\nIf such conditions are met, a nasogastric tube is inserted and broad-spectrum antibiotics with adequate Gram-negative coverage are administered. Patients should be followed closely (by one observer — YOU!) and improvement should be expected within 12-24 hours. Normally, these patients recover within 7-10 days; any repeated procedures, if still indicated, should be postponed well after that time.\\n\\nThe lack of significant clinical improvement, with the appearance or worsening of peritoneal irritation or signs of ongoing sepsis mandate an operation. After fully ‘Kocherizing’ the duodenum, the site of perforation is usually revealed at its posterior aspect. Depending on the degree of induration and inflammation of the tissues, either primary closure or an omental patch repair are performed and a drain left in situ.\\n\\nThe next step depends on the patient’s condition, underlying pathology, failure or success of the ‘index’ ERCP and the adequacy of the duodenal closure. The principles are: if the patient’s condition is stable and the...\\n```',\n", " 'md': 'Most patients, however, experience mini-perforations into the retroperitoneum at the site of the ‘precut’ or sphincterotomy. SIRS may be mild or moderate and abdominal tenderness confined to the upper abdomen. X-rays and CT will show air only in the retroperitoneum (a few bubbles of air leaking into the peritoneum cavity should not make you rush to the OR…) and contrast won’t be seen leaking into the peritoneal cavity.\\n\\nThere is ample evidence that the majority of these patients can be successfully treated non-operatively if the following conditions are met:\\n\\n- Absence of clinical peritonitis and/or systemic inflammation (hemodynamic compromise, high fever, and leukocytosis).\\n- Absence of large pneumoperitoneum.\\n- Absence of free leakage of contrast.\\n\\nIf such conditions are met, a nasogastric tube is inserted and broad-spectrum antibiotics with adequate Gram-negative coverage are administered. Patients should be followed closely (by one observer — YOU!) and improvement should be expected within 12-24 hours. Normally, these patients recover within 7-10 days; any repeated procedures, if still indicated, should be postponed well after that time.\\n\\nThe lack of significant clinical improvement, with the appearance or worsening of peritoneal irritation or signs of ongoing sepsis mandate an operation. After fully ‘Kocherizing’ the duodenum, the site of perforation is usually revealed at its posterior aspect. Depending on the degree of induration and inflammation of the tissues, either primary closure or an omental patch repair are performed and a drain left in situ.\\n\\nThe next step depends on the patient’s condition, underlying pathology, failure or success of the ‘index’ ERCP and the adequacy of the duodenal closure. The principles are: if the patient’s condition is stable and the...\\n```',\n", " 'bBox': {'x': 72, 'y': 137, 'w': 467.88, 'h': 16.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 561,\n", " 'text': 'repair looks adequate (this occurs with early perforations), there is no\\nneed for a pyloric exclusion procedure. An obstructed biliary system\\nshould be decompressed preferably by a T-tube (after cholecystectomy\\nand common bile duct exploration and clearance). If you are already\\nthere, please do not leave the patient at the mercy of the\\nendoscopist again! If you are worried about the duodenal repair, or its\\nlumen, do add a pyloric exclusion procedure. This is accomplished by\\nmaking a gastrotomy just proximal to the pylorus and closing the pylorus\\nfrom the inside with a non-absorbable (the absorbable gets absorbed too\\nquickly) suture — then forming a gastrojejunostomy. Finally, you may\\nwant to feed a narrow-bore nasogastric tube deep into the efferent loop\\nof the gastrojejunostomy to feed your patient distal to the anastomosis\\nand the duodenal repair. And leave a periduodenal drain!\\n\\n In highly specialized centers, a repeat ERCP with insertion of a stent,\\nto ‘seal’ the perforation, may be attempted, but most endoscopists are\\nunderstandably reluctant to have another go at these patients after\\nendoscopy has caused the problem in the first place.\\n\\n Yes, severe complications and deaths after ERCP are heartbreaking. But what is tragic\\n is that in many such cases it is clear in retrospect that the original procedure was not\\n really indicated (for example, MRCP could have excluded the suspected\\n choledocholithiasis). Make sure your requests for ERCP are solidly indicated.\\n\\n Complications of colonoscopy\\n\\n Colonoscopy is relatively a safe procedure, with the main\\ncomplications being perforation and hemorrhage. The complication rate\\nis very low for diagnostic procedures, and rises when the procedure is\\ntherapeutic — especially after polypectomy.\\n\\n Bleeding\\n\\n Bleeding might occur immediately after the procedure or may be\\nsecondary or delayed, from an ulcer developing at the site of the',\n", " 'md': '```markdown\\n# Complications of ERCP and Colonoscopy\\n\\n## Text\\n\\nRepair looks adequate (this occurs with early perforations), there is no need for a pyloric exclusion procedure. An obstructed biliary system should be decompressed preferably by a T-tube (after cholecystectomy and common bile duct exploration and clearance). If you are already there, please do not leave the patient at the mercy of the endoscopist again! If you are worried about the duodenal repair, or its lumen, do add a pyloric exclusion procedure. This is accomplished by making a gastrotomy just proximal to the pylorus and closing the pylorus from the inside with a non-absorbable (the absorbable gets absorbed too quickly) suture — then forming a gastrojejunostomy. Finally, you may want to feed a narrow-bore nasogastric tube deep into the efferent loop of the gastrojejunostomy to feed your patient distal to the anastomosis and the duodenal repair. And leave a periduodenal drain!\\n\\nIn highly specialized centers, a repeat ERCP with insertion of a stent, to ‘seal’ the perforation, may be attempted, but most endoscopists are understandably reluctant to have another go at these patients after endoscopy has caused the problem in the first place.\\n\\nYes, severe complications and deaths after ERCP are heartbreaking. But what is tragic is that in many such cases it is clear in retrospect that the original procedure was not really indicated (for example, MRCP could have excluded the suspected choledocholithiasis). Make sure your requests for ERCP are solidly indicated.\\n\\n## Complications of Colonoscopy\\n\\nColonoscopy is relatively a safe procedure, with the main complications being perforation and hemorrhage. The complication rate is very low for diagnostic procedures, and rises when the procedure is therapeutic — especially after polypectomy.\\n\\n### Bleeding\\n\\nBleeding might occur immediately after the procedure or may be secondary or delayed, from an ulcer developing at the site of the...\\n```\\n\\n### Image Identification and Description\\n- No images or figures were identified on this page.\\n\\n### Summary\\nThis page discusses the management of complications arising from ERCP and colonoscopy procedures, emphasizing the importance of proper indications for these interventions and detailing the potential complications, particularly focusing on bleeding and the need for careful postoperative management.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Complications of ERCP and Colonoscopy',\n", " 'md': '# Complications of ERCP and Colonoscopy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Repair looks adequate (this occurs with early perforations), there is no need for a pyloric exclusion procedure. An obstructed biliary system should be decompressed preferably by a T-tube (after cholecystectomy and common bile duct exploration and clearance). If you are already there, please do not leave the patient at the mercy of the endoscopist again! If you are worried about the duodenal repair, or its lumen, do add a pyloric exclusion procedure. This is accomplished by making a gastrotomy just proximal to the pylorus and closing the pylorus from the inside with a non-absorbable (the absorbable gets absorbed too quickly) suture — then forming a gastrojejunostomy. Finally, you may want to feed a narrow-bore nasogastric tube deep into the efferent loop of the gastrojejunostomy to feed your patient distal to the anastomosis and the duodenal repair. And leave a periduodenal drain!\\n\\nIn highly specialized centers, a repeat ERCP with insertion of a stent, to ‘seal’ the perforation, may be attempted, but most endoscopists are understandably reluctant to have another go at these patients after endoscopy has caused the problem in the first place.\\n\\nYes, severe complications and deaths after ERCP are heartbreaking. But what is tragic is that in many such cases it is clear in retrospect that the original procedure was not really indicated (for example, MRCP could have excluded the suspected choledocholithiasis). Make sure your requests for ERCP are solidly indicated.',\n", " 'md': 'Repair looks adequate (this occurs with early perforations), there is no need for a pyloric exclusion procedure. An obstructed biliary system should be decompressed preferably by a T-tube (after cholecystectomy and common bile duct exploration and clearance). If you are already there, please do not leave the patient at the mercy of the endoscopist again! If you are worried about the duodenal repair, or its lumen, do add a pyloric exclusion procedure. This is accomplished by making a gastrotomy just proximal to the pylorus and closing the pylorus from the inside with a non-absorbable (the absorbable gets absorbed too quickly) suture — then forming a gastrojejunostomy. Finally, you may want to feed a narrow-bore nasogastric tube deep into the efferent loop of the gastrojejunostomy to feed your patient distal to the anastomosis and the duodenal repair. And leave a periduodenal drain!\\n\\nIn highly specialized centers, a repeat ERCP with insertion of a stent, to ‘seal’ the perforation, may be attempted, but most endoscopists are understandably reluctant to have another go at these patients after endoscopy has caused the problem in the first place.\\n\\nYes, severe complications and deaths after ERCP are heartbreaking. But what is tragic is that in many such cases it is clear in retrospect that the original procedure was not really indicated (for example, MRCP could have excluded the suspected choledocholithiasis). Make sure your requests for ERCP are solidly indicated.',\n", " 'bBox': {'x': 72, 'y': 168, 'w': 467.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Complications of Colonoscopy',\n", " 'md': '## Complications of Colonoscopy',\n", " 'bBox': {'x': 86, 'y': 526, 'w': 240.91, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Colonoscopy is relatively a safe procedure, with the main complications being perforation and hemorrhage. The complication rate is very low for diagnostic procedures, and rises when the procedure is therapeutic — especially after polypectomy.',\n", " 'md': 'Colonoscopy is relatively a safe procedure, with the main complications being perforation and hemorrhage. The complication rate is very low for diagnostic procedures, and rises when the procedure is therapeutic — especially after polypectomy.',\n", " 'bBox': {'x': 72, 'y': 454, 'w': 394.19, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Bleeding',\n", " 'md': '### Bleeding',\n", " 'bBox': {'x': 86, 'y': 655, 'w': 69.89, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Bleeding might occur immediately after the procedure or may be secondary or delayed, from an ulcer developing at the site of the...\\n```',\n", " 'md': 'Bleeding might occur immediately after the procedure or may be secondary or delayed, from an ulcer developing at the site of the...\\n```',\n", " 'bBox': {'x': 86, 'y': 454, 'w': 387.99, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.',\n", " 'md': '- No images or figures were identified on this page.',\n", " 'bBox': {'x': 184, 'y': 562, 'w': 14.4, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the management of complications arising from ERCP and colonoscopy procedures, emphasizing the importance of proper indications for these interventions and detailing the potential complications, particularly focusing on bleeding and the need for careful postoperative management.',\n", " 'md': 'This page discusses the management of complications arising from ERCP and colonoscopy procedures, emphasizing the importance of proper indications for these interventions and detailing the potential complications, particularly focusing on bleeding and the need for careful postoperative management.',\n", " 'bBox': {'x': 86, 'y': 454, 'w': 380.19, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 562,\n", " 'text': 'polypectomy or biopsy. The risk is higher with resection of polyps larger\\nthan 15mm, recurrent or difficult procedures, or a bleeding tendency.\\nRarely, bleeding may occur due to mucosal injury caused by traumatic\\ninsertion and manipulation of the scope. Very rarely, vigorous\\nmanipulations in the region of the splenic flexure of the colon result in a\\nsplenic injury and intra-abdominal hemorrhage.\\n\\n Management\\n This includes resuscitation and correction of any coagulopathy followed\\nby an endoscopic attempt to treat the bleeding. If, after replacing fluids\\nand correcting coagulation deficits, the patient has clearly stopped\\nbleeding, one may elect not to repeat the colonoscopy so as to minimize\\nthe risk of a perforation at the biopsy site. In selected stable patients,\\nwhose pathology (diagosed during the colonoscopy) doesn’t require\\nresection, an angiographic selective distal embolization may be\\nattempted provided a highly skilled interventional radiologist is available.\\nJust remember the (low) possibility of bowel ischemia following such an\\nintervention!\\n\\n The persistence of bleeding after unsuccessful colonoscopic or\\nradiological management mandates an immediate abdominal exploration.\\nAlways have the endoscopist ready in the operating room to\\nperform an intra-operative colonoscopy (or even better — master the\\ntechnique yourself). Remember — finding the bleeding spot could be\\na difficult task: an intra-operative colonoscopy will minimize blood\\nloss and prevent unnecessary bowel resections. In most instances,\\nafter localizing the bleeding source, all you have to do is to place a\\ncolotomy and achieve hemostasis by oversewing the site of bleeding;\\nthen close the colotomy. If bleeding originates from a source that requires\\nresection (e.g. a large polyp or carcinoma) then an appropriate colectomy\\nshould be performed.\\n\\n Perforation\\n\\n The mechanism of perforation determines the size of the hole, which,\\noccasionally, can then be managed selectively by the smart surgeon —\\nnot the gastroenterologist.',\n", " 'md': '```markdown\\n## Management of Complications in Polypectomy and Biopsy\\n\\nThe risk of complications is higher with resection of polyps larger than 15mm, recurrent or difficult procedures, or in patients with a bleeding tendency. Rarely, bleeding may occur due to mucosal injury caused by traumatic insertion and manipulation of the scope. Very rarely, vigorous manipulations in the region of the splenic flexure of the colon can result in splenic injury and intra-abdominal hemorrhage.\\n\\n### Management\\n\\nThis includes resuscitation and correction of any coagulopathy followed by an endoscopic attempt to treat the bleeding. If, after replacing fluids and correcting coagulation deficits, the patient has clearly stopped bleeding, one may elect not to repeat the colonoscopy to minimize the risk of perforation at the biopsy site. In selected stable patients, whose pathology diagnosed during the colonoscopy doesn’t require resection, an angiographic selective distal embolization may be attempted provided a highly skilled interventional radiologist is available. Just remember the (low) possibility of bowel ischemia following such an intervention!\\n\\nThe persistence of bleeding after unsuccessful colonoscopic or radiological management mandates an immediate abdominal exploration. Always have the endoscopist ready in the operating room to perform an intra-operative colonoscopy (or even better — master the technique yourself). Remember — finding the bleeding spot could be a difficult task: an intra-operative colonoscopy will minimize blood loss and prevent unnecessary bowel resections. In most instances, after localizing the bleeding source, all you have to do is place a colotomy and achieve hemostasis by oversewing the site of bleeding; then close the colotomy. If bleeding originates from a source that requires resection (e.g., a large polyp or carcinoma), then an appropriate colectomy should be performed.\\n\\n### Perforation\\n\\nThe mechanism of perforation determines the size of the hole, which, occasionally, can then be managed selectively by the smart surgeon — not the gastroenterologist.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Complications in Polypectomy and Biopsy',\n", " 'md': '## Management of Complications in Polypectomy and Biopsy',\n", " 'bBox': {'x': 86, 'y': 207, 'w': 87.94, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The risk of complications is higher with resection of polyps larger than 15mm, recurrent or difficult procedures, or in patients with a bleeding tendency. Rarely, bleeding may occur due to mucosal injury caused by traumatic insertion and manipulation of the scope. Very rarely, vigorous manipulations in the region of the splenic flexure of the colon can result in splenic injury and intra-abdominal hemorrhage.',\n", " 'md': 'The risk of complications is higher with resection of polyps larger than 15mm, recurrent or difficult procedures, or in patients with a bleeding tendency. Rarely, bleeding may occur due to mucosal injury caused by traumatic insertion and manipulation of the scope. Very rarely, vigorous manipulations in the region of the splenic flexure of the colon can result in splenic injury and intra-abdominal hemorrhage.',\n", " 'bBox': {'x': 72, 'y': 169, 'w': 299.7, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management',\n", " 'md': '### Management',\n", " 'bBox': {'x': 86, 'y': 207, 'w': 87.94, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'This includes resuscitation and correction of any coagulopathy followed by an endoscopic attempt to treat the bleeding. If, after replacing fluids and correcting coagulation deficits, the patient has clearly stopped bleeding, one may elect not to repeat the colonoscopy to minimize the risk of perforation at the biopsy site. In selected stable patients, whose pathology diagnosed during the colonoscopy doesn’t require resection, an angiographic selective distal embolization may be attempted provided a highly skilled interventional radiologist is available. Just remember the (low) possibility of bowel ischemia following such an intervention!\\n\\nThe persistence of bleeding after unsuccessful colonoscopic or radiological management mandates an immediate abdominal exploration. Always have the endoscopist ready in the operating room to perform an intra-operative colonoscopy (or even better — master the technique yourself). Remember — finding the bleeding spot could be a difficult task: an intra-operative colonoscopy will minimize blood loss and prevent unnecessary bowel resections. In most instances, after localizing the bleeding source, all you have to do is place a colotomy and achieve hemostasis by oversewing the site of bleeding; then close the colotomy. If bleeding originates from a source that requires resection (e.g., a large polyp or carcinoma), then an appropriate colectomy should be performed.',\n", " 'md': 'This includes resuscitation and correction of any coagulopathy followed by an endoscopic attempt to treat the bleeding. If, after replacing fluids and correcting coagulation deficits, the patient has clearly stopped bleeding, one may elect not to repeat the colonoscopy to minimize the risk of perforation at the biopsy site. In selected stable patients, whose pathology diagnosed during the colonoscopy doesn’t require resection, an angiographic selective distal embolization may be attempted provided a highly skilled interventional radiologist is available. Just remember the (low) possibility of bowel ischemia following such an intervention!\\n\\nThe persistence of bleeding after unsuccessful colonoscopic or radiological management mandates an immediate abdominal exploration. Always have the endoscopist ready in the operating room to perform an intra-operative colonoscopy (or even better — master the technique yourself). Remember — finding the bleeding spot could be a difficult task: an intra-operative colonoscopy will minimize blood loss and prevent unnecessary bowel resections. In most instances, after localizing the bleeding source, all you have to do is place a colotomy and achieve hemostasis by oversewing the site of bleeding; then close the colotomy. If bleeding originates from a source that requires resection (e.g., a large polyp or carcinoma), then an appropriate colectomy should be performed.',\n", " 'bBox': {'x': 72, 'y': 207, 'w': 467.84, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Perforation',\n", " 'md': '### Perforation',\n", " 'bBox': {'x': 86, 'y': 638, 'w': 88.27, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The mechanism of perforation determines the size of the hole, which, occasionally, can then be managed selectively by the smart surgeon — not the gastroenterologist.\\n```',\n", " 'md': 'The mechanism of perforation determines the size of the hole, which, occasionally, can then be managed selectively by the smart surgeon — not the gastroenterologist.\\n```',\n", " 'bBox': {'x': 72, 'y': 638, 'w': 467.44, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 563,\n", " 'text': ' Difficult, traumatic, and therapeutic colonoscopies are associated\\nwith an increased risk of perforation of the colon. Barotrauma from\\nexcessive insufflation of air, ‘looping’ the scope, excessive use of cautery,\\nor overzealous dilatation of strictures are common causative factors. In\\naddition, prior surgery, diverticulitis, or pre-existing intra-abdominal\\nadhesions and a poorly prepared bowel may increase the difficulty of the\\nprocedure and the possibility of perforation.\\n\\n When a colonic perforation occurs, the spectrum of consequences is\\nwide and unpredictable. The mechanism of perforation matters —\\nperforations that follow therapeutic colonoscopy (at a biopsy or\\npolypectomy site) are usually small and more amenable to non-\\noperative treatment. On the other hand, perforations following\\ndiagnostic colonoscopy often result in sizeable rents in the colonic\\nwall — and thus require prompt surgical treatment.\\n\\n Diagnosis\\n The key to diagnosis is to suspect it. Think about the possibility\\nof perforation in any patient who develops abdominal discomfort or\\npain at any time after colonoscopy. We have seen patients dying from\\nneglected intra-abdominal infection — having their ‘non-specific’\\ncomplaints attributed to ‘gas pain’ by their super-busy and ultra-confident\\ngastroenterologists.\\n\\n Presentation is wide-ranging: abdominal complaints and signs may\\ndevelop immediately after the colonoscopy when there is a large colonic\\ntear. On the other hand, patients may present a few days later with\\ngradually increasing local and systemic manifestations of infection. Such\\ndelayed presentation is typical of perforations that are initially contained\\nwithin the retroperitoneum or the mesenteric leaves, and gradually leak\\nor rupture into the free peritoneal cavity. Polypectomy with cautery\\nnecrosis of the bowel wall may also result in delayed perforation.\\n\\n The abdominal-peritoneal signs and systemic repercussions of colonic\\nperforation are well known to you. But remember that loops of bowel —\\npumped up with air during colonoscopy — may still be tender many hours\\nafter the procedure.',\n", " 'md': '```markdown\\n# Colonoscopy and Colonic Perforation\\n\\nDifficult, traumatic, and therapeutic colonoscopies are associated with an increased risk of perforation of the colon. Barotrauma from excessive insufflation of air, ‘looping’ the scope, excessive use of cautery, or overzealous dilatation of strictures are common causative factors. In addition, prior surgery, diverticulitis, or pre-existing intra-abdominal adhesions and a poorly prepared bowel may increase the difficulty of the procedure and the possibility of perforation.\\n\\nWhen a colonic perforation occurs, the spectrum of consequences is wide and unpredictable. The mechanism of perforation matters — perforations that follow therapeutic colonoscopy (at a biopsy or polypectomy site) are usually small and more amenable to non-operative treatment. On the other hand, perforations following diagnostic colonoscopy often result in sizeable rents in the colonic wall — and thus require prompt surgical treatment.\\n\\n## Diagnosis\\n\\nThe key to diagnosis is to suspect it. Think about the possibility of perforation in any patient who develops abdominal discomfort or pain at any time after colonoscopy. We have seen patients dying from neglected intra-abdominal infection — having their ‘non-specific’ complaints attributed to ‘gas pain’ by their super-busy and ultra-confident gastroenterologists.\\n\\nPresentation is wide-ranging: abdominal complaints and signs may develop immediately after the colonoscopy when there is a large colonic tear. On the other hand, patients may present a few days later with gradually increasing local and systemic manifestations of infection. Such delayed presentation is typical of perforations that are initially contained within the retroperitoneum or the mesenteric leaves, and gradually leak or rupture into the free peritoneal cavity. Polypectomy with cautery necrosis of the bowel wall may also result in delayed perforation.\\n\\nThe abdominal-peritoneal signs and systemic repercussions of colonic perforation are well known to you. But remember that loops of bowel — pumped up with air during colonoscopy — may still be tender many hours after the procedure.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Colonoscopy and Colonic Perforation',\n", " 'md': '# Colonoscopy and Colonic Perforation',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Difficult, traumatic, and therapeutic colonoscopies are associated with an increased risk of perforation of the colon. Barotrauma from excessive insufflation of air, ‘looping’ the scope, excessive use of cautery, or overzealous dilatation of strictures are common causative factors. In addition, prior surgery, diverticulitis, or pre-existing intra-abdominal adhesions and a poorly prepared bowel may increase the difficulty of the procedure and the possibility of perforation.\\n\\nWhen a colonic perforation occurs, the spectrum of consequences is wide and unpredictable. The mechanism of perforation matters — perforations that follow therapeutic colonoscopy (at a biopsy or polypectomy site) are usually small and more amenable to non-operative treatment. On the other hand, perforations following diagnostic colonoscopy often result in sizeable rents in the colonic wall — and thus require prompt surgical treatment.',\n", " 'md': 'Difficult, traumatic, and therapeutic colonoscopies are associated with an increased risk of perforation of the colon. Barotrauma from excessive insufflation of air, ‘looping’ the scope, excessive use of cautery, or overzealous dilatation of strictures are common causative factors. In addition, prior surgery, diverticulitis, or pre-existing intra-abdominal adhesions and a poorly prepared bowel may increase the difficulty of the procedure and the possibility of perforation.\\n\\nWhen a colonic perforation occurs, the spectrum of consequences is wide and unpredictable. The mechanism of perforation matters — perforations that follow therapeutic colonoscopy (at a biopsy or polypectomy site) are usually small and more amenable to non-operative treatment. On the other hand, perforations following diagnostic colonoscopy often result in sizeable rents in the colonic wall — and thus require prompt surgical treatment.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.59, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnosis',\n", " 'md': '## Diagnosis',\n", " 'bBox': {'x': 86, 'y': 358, 'w': 68.75, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The key to diagnosis is to suspect it. Think about the possibility of perforation in any patient who develops abdominal discomfort or pain at any time after colonoscopy. We have seen patients dying from neglected intra-abdominal infection — having their ‘non-specific’ complaints attributed to ‘gas pain’ by their super-busy and ultra-confident gastroenterologists.\\n\\nPresentation is wide-ranging: abdominal complaints and signs may develop immediately after the colonoscopy when there is a large colonic tear. On the other hand, patients may present a few days later with gradually increasing local and systemic manifestations of infection. Such delayed presentation is typical of perforations that are initially contained within the retroperitoneum or the mesenteric leaves, and gradually leak or rupture into the free peritoneal cavity. Polypectomy with cautery necrosis of the bowel wall may also result in delayed perforation.\\n\\nThe abdominal-peritoneal signs and systemic repercussions of colonic perforation are well known to you. But remember that loops of bowel — pumped up with air during colonoscopy — may still be tender many hours after the procedure.\\n```',\n", " 'md': 'The key to diagnosis is to suspect it. Think about the possibility of perforation in any patient who develops abdominal discomfort or pain at any time after colonoscopy. We have seen patients dying from neglected intra-abdominal infection — having their ‘non-specific’ complaints attributed to ‘gas pain’ by their super-busy and ultra-confident gastroenterologists.\\n\\nPresentation is wide-ranging: abdominal complaints and signs may develop immediately after the colonoscopy when there is a large colonic tear. On the other hand, patients may present a few days later with gradually increasing local and systemic manifestations of infection. Such delayed presentation is typical of perforations that are initially contained within the retroperitoneum or the mesenteric leaves, and gradually leak or rupture into the free peritoneal cavity. Polypectomy with cautery necrosis of the bowel wall may also result in delayed perforation.\\n\\nThe abdominal-peritoneal signs and systemic repercussions of colonic perforation are well known to you. But remember that loops of bowel — pumped up with air during colonoscopy — may still be tender many hours after the procedure.\\n```',\n", " 'bBox': {'x': 72, 'y': 358, 'w': 467.92, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 564,\n", " 'text': ' Start with a plain upright chest X-ray or left lateral decubitus films\\nof the abdomen and look for free air. The findings of free intra-\\nabdominal air together with a clinical picture of local or generalized\\nperitonitis are diagnostic of perforation. Pneumoperitoneum may be seen\\nafter colonoscopy with minimal or no clinical evidence suggesting\\nperforation (‘benign’ post-colonoscopic pneumoperitoneum). Conversely,\\nfree air may be missing when the perforation is initially contained or\\nretroperitoneal. Basing decision-making on the absence or presence\\nof free air reflects naivety common to non-surgeons (e.g.\\ngastroenterologists) attempting to treat abdominal surgical\\nemergencies.\\n\\n Obviously, clinical signs of perforation and free air on abdominal X-ray\\nare diagnostic of perforation. In the absence of free air insist on\\nobtaining a CT scan (or a Gastrografin® enema if CT is not\\navailable). Not only is CT able to show free air not visualized by plain X-\\nrays but it may also show other details suggestive of injury such as\\ncolonic wall hematoma or air in the colonic wall, the mesentery or the\\nretroperitoneum. When combined with rectal contrast, CT usually\\ndemonstrates the site and size of the leak and whether it is contained or\\nnot. Free fluid may reflect spillage of bowel contents or developing\\nperitonitis.\\n\\n Remember — the chief cause of death following colonoscopic\\nperforation is delay in diagnosis and consequent delay in treatment.\\nThis hold-up usually results from the failure of the responsible clinician (it\\nis usually the colonoscopist himself to whom the patient presents with the\\ncomplication) to consider such a diagnosis. Remember the ‘surgical\\nostrich’ who can’t diagnose his own complications? Well,\\ngastroenterologists are no different ( Figure 31.1) We have to help them\\npull their head out of the sand.',\n", " 'md': '```markdown\\n## Page Content\\n\\nStart with a plain upright chest X-ray or left lateral decubitus films of the abdomen and look for free air. The findings of free intra-abdominal air together with a clinical picture of local or generalized peritonitis are diagnostic of perforation. Pneumoperitoneum may be seen after colonoscopy with minimal or no clinical evidence suggesting perforation (‘benign’ post-colonoscopic pneumoperitoneum). Conversely, free air may be missing when the perforation is initially contained or retroperitoneal. Basing decision-making on the absence or presence of free air reflects naivety common to non-surgeons (e.g. gastroenterologists) attempting to treat abdominal surgical emergencies.\\n\\nObviously, clinical signs of perforation and free air on abdominal X-ray are diagnostic of perforation. In the absence of free air insist on obtaining a CT scan (or a Gastrografin® enema if CT is not available). Not only is CT able to show free air not visualized by plain X-rays but it may also show other details suggestive of injury such as colonic wall hematoma or air in the colonic wall, the mesentery or the retroperitoneum. When combined with rectal contrast, CT usually demonstrates the site and size of the leak and whether it is contained or not. Free fluid may reflect spillage of bowel contents or developing peritonitis.\\n\\nRemember — the chief cause of death following colonoscopic perforation is delay in diagnosis and consequent delay in treatment. This hold-up usually results from the failure of the responsible clinician (it is usually the colonoscopist himself to whom the patient presents with the complication) to consider such a diagnosis. Remember the ‘surgical ostrich’ who can’t diagnose his own complications? Well, gastroenterologists are no different (Figure 31.1). We have to help them pull their head out of the sand.\\n\\n## Figures\\n\\n### Figure 31.1\\n- **Description**: This figure likely illustrates a humorous or critical depiction of gastroenterologists in relation to their ability to diagnose complications from colonoscopy. The exact content of the image is not provided, but it serves to emphasize the point made in the text about the need for awareness in diagnosing complications.\\n- **Summary**: The figure serves as a metaphorical representation of the challenges faced by gastroenterologists in recognizing their own procedural complications, reinforcing the message of the text.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Start with a plain upright chest X-ray or left lateral decubitus films of the abdomen and look for free air. The findings of free intra-abdominal air together with a clinical picture of local or generalized peritonitis are diagnostic of perforation. Pneumoperitoneum may be seen after colonoscopy with minimal or no clinical evidence suggesting perforation (‘benign’ post-colonoscopic pneumoperitoneum). Conversely, free air may be missing when the perforation is initially contained or retroperitoneal. Basing decision-making on the absence or presence of free air reflects naivety common to non-surgeons (e.g. gastroenterologists) attempting to treat abdominal surgical emergencies.\\n\\nObviously, clinical signs of perforation and free air on abdominal X-ray are diagnostic of perforation. In the absence of free air insist on obtaining a CT scan (or a Gastrografin® enema if CT is not available). Not only is CT able to show free air not visualized by plain X-rays but it may also show other details suggestive of injury such as colonic wall hematoma or air in the colonic wall, the mesentery or the retroperitoneum. When combined with rectal contrast, CT usually demonstrates the site and size of the leak and whether it is contained or not. Free fluid may reflect spillage of bowel contents or developing peritonitis.\\n\\nRemember — the chief cause of death following colonoscopic perforation is delay in diagnosis and consequent delay in treatment. This hold-up usually results from the failure of the responsible clinician (it is usually the colonoscopist himself to whom the patient presents with the complication) to consider such a diagnosis. Remember the ‘surgical ostrich’ who can’t diagnose his own complications? Well, gastroenterologists are no different (Figure 31.1). We have to help them pull their head out of the sand.',\n", " 'md': 'Start with a plain upright chest X-ray or left lateral decubitus films of the abdomen and look for free air. The findings of free intra-abdominal air together with a clinical picture of local or generalized peritonitis are diagnostic of perforation. Pneumoperitoneum may be seen after colonoscopy with minimal or no clinical evidence suggesting perforation (‘benign’ post-colonoscopic pneumoperitoneum). Conversely, free air may be missing when the perforation is initially contained or retroperitoneal. Basing decision-making on the absence or presence of free air reflects naivety common to non-surgeons (e.g. gastroenterologists) attempting to treat abdominal surgical emergencies.\\n\\nObviously, clinical signs of perforation and free air on abdominal X-ray are diagnostic of perforation. In the absence of free air insist on obtaining a CT scan (or a Gastrografin® enema if CT is not available). Not only is CT able to show free air not visualized by plain X-rays but it may also show other details suggestive of injury such as colonic wall hematoma or air in the colonic wall, the mesentery or the retroperitoneum. When combined with rectal contrast, CT usually demonstrates the site and size of the leak and whether it is contained or not. Free fluid may reflect spillage of bowel contents or developing peritonitis.\\n\\nRemember — the chief cause of death following colonoscopic perforation is delay in diagnosis and consequent delay in treatment. This hold-up usually results from the failure of the responsible clinician (it is usually the colonoscopist himself to whom the patient presents with the complication) to consider such a diagnosis. Remember the ‘surgical ostrich’ who can’t diagnose his own complications? Well, gastroenterologists are no different (Figure 31.1). We have to help them pull their head out of the sand.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures',\n", " 'md': '## Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 31.1',\n", " 'md': '### Figure 31.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure likely illustrates a humorous or critical depiction of gastroenterologists in relation to their ability to diagnose complications from colonoscopy. The exact content of the image is not provided, but it serves to emphasize the point made in the text about the need for awareness in diagnosing complications.\\n- **Summary**: The figure serves as a metaphorical representation of the challenges faced by gastroenterologists in recognizing their own procedural complications, reinforcing the message of the text.\\n```',\n", " 'md': '- **Description**: This figure likely illustrates a humorous or critical depiction of gastroenterologists in relation to their ability to diagnose complications from colonoscopy. The exact content of the image is not provided, but it serves to emphasize the point made in the text about the need for awareness in diagnosing complications.\\n- **Summary**: The figure serves as a metaphorical representation of the challenges faced by gastroenterologists in recognizing their own procedural complications, reinforcing the message of the text.\\n```',\n", " 'bBox': {'x': 232, 'y': 234, 'w': 102.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 565,\n", " 'text': ' PERYA2014\\nFigure 31.1. “Nurse, is that the omentum?”\\n\\n Non-operative management\\n Not all patients with colonoscopic bowel injury need a\\nlaparotomy. Patients who are minimally symptomatic, without fever or\\ntachycardia, and in whom the abdominal exam is benign (i.e. no features\\nof peritonitis), can be managed non-operatively with nil-per-mouth and\\nbroad-spectrum antibiotics (as you would manage acute diverticulitis —\\n Chapter 28). Patients who respond to conservative treatment typically\\nhave no, or minimal pneumoperitoneum and no, or minimal leak of\\ncontrast on CT.\\n\\n As stated above, perforation at the site of a polypectomy is more\\namenable to a trial of non-operative management. Such an approach is\\noften successful because these patients have had bowel preparation\\nprior to colonoscopy and therefore the potential for abdominal\\ncontamination is reduced. All such patients should be closely monitored\\nfor local and systemic progression of the process or failure to improve.\\nDeterioration should prompt an urgent surgical intervention. If the',\n", " 'md': \"```markdown\\n# Page Content\\n\\n## Non-operative management\\n\\nNot all patients with colonoscopic bowel injury need a laparotomy. Patients who are minimally symptomatic, without fever or tachycardia, and in whom the abdominal exam is benign (i.e. no features of peritonitis), can be managed non-operatively with nil-per-mouth and broad-spectrum antibiotics (as you would manage acute diverticulitis — Chapter 28). Patients who respond to conservative treatment typically have no, or minimal pneumoperitoneum and no, or minimal leak of contrast on CT.\\n\\nAs stated above, perforation at the site of a polypectomy is more amenable to a trial of non-operative management. Such an approach is often successful because these patients have had bowel preparation prior to colonoscopy and therefore the potential for abdominal contamination is reduced. All such patients should be closely monitored for local and systemic progression of the process or failure to improve. Deterioration should prompt an urgent surgical intervention.\\n\\n## Figure Description\\n\\n**Figure 31.1**: “Nurse, is that the omentum?”\\nThis figure likely depicts a clinical scenario or illustration related to the discussion of non-operative management of bowel injuries. The context suggests it may involve a nurse's inquiry regarding anatomical structures during a medical procedure.\\n\\n### Summary\\nThe figure serves to highlight the importance of understanding anatomical landmarks in the context of non-operative management of bowel injuries, particularly in relation to polypectomy complications.\\n```\",\n", " 'images': [{'name': 'img_p564_1.png',\n", " 'height': 578,\n", " 'width': 764,\n", " 'x': 117.35999999999967,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1312,\n", " 'original_height': 992}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 531, 'y': 460, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 531, 'y': 460, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Non-operative management',\n", " 'md': '## Non-operative management',\n", " 'bBox': {'x': 86, 'y': 439, 'w': 189.46, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Not all patients with colonoscopic bowel injury need a laparotomy. Patients who are minimally symptomatic, without fever or tachycardia, and in whom the abdominal exam is benign (i.e. no features of peritonitis), can be managed non-operatively with nil-per-mouth and broad-spectrum antibiotics (as you would manage acute diverticulitis — Chapter 28). Patients who respond to conservative treatment typically have no, or minimal pneumoperitoneum and no, or minimal leak of contrast on CT.\\n\\nAs stated above, perforation at the site of a polypectomy is more amenable to a trial of non-operative management. Such an approach is often successful because these patients have had bowel preparation prior to colonoscopy and therefore the potential for abdominal contamination is reduced. All such patients should be closely monitored for local and systemic progression of the process or failure to improve. Deterioration should prompt an urgent surgical intervention.',\n", " 'md': 'Not all patients with colonoscopic bowel injury need a laparotomy. Patients who are minimally symptomatic, without fever or tachycardia, and in whom the abdominal exam is benign (i.e. no features of peritonitis), can be managed non-operatively with nil-per-mouth and broad-spectrum antibiotics (as you would manage acute diverticulitis — Chapter 28). Patients who respond to conservative treatment typically have no, or minimal pneumoperitoneum and no, or minimal leak of contrast on CT.\\n\\nAs stated above, perforation at the site of a polypectomy is more amenable to a trial of non-operative management. Such an approach is often successful because these patients have had bowel preparation prior to colonoscopy and therefore the potential for abdominal contamination is reduced. All such patients should be closely monitored for local and systemic progression of the process or failure to improve. Deterioration should prompt an urgent surgical intervention.',\n", " 'bBox': {'x': 72, 'y': 439, 'w': 467.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure Description',\n", " 'md': '## Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"**Figure 31.1**: “Nurse, is that the omentum?”\\nThis figure likely depicts a clinical scenario or illustration related to the discussion of non-operative management of bowel injuries. The context suggests it may involve a nurse's inquiry regarding anatomical structures during a medical procedure.\",\n", " 'md': \"**Figure 31.1**: “Nurse, is that the omentum?”\\nThis figure likely depicts a clinical scenario or illustration related to the discussion of non-operative management of bowel injuries. The context suggests it may involve a nurse's inquiry regarding anatomical structures during a medical procedure.\",\n", " 'bBox': {'x': 86, 'y': 439, 'w': 189.46, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 531, 'y': 460, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The figure serves to highlight the importance of understanding anatomical landmarks in the context of non-operative management of bowel injuries, particularly in relation to polypectomy complications.\\n```',\n", " 'md': 'The figure serves to highlight the importance of understanding anatomical landmarks in the context of non-operative management of bowel injuries, particularly in relation to polypectomy complications.\\n```',\n", " 'bBox': {'x': 86, 'y': 439, 'w': 189.46, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'have no, or minimal pneumoperitoneum and no, or minimal leak of'}]},\n", " {'page': 566,\n", " 'text': 'perforation is at the site of pathology for which a colectomy will be\\nrecommended anyway, what’s the point of sweating through\\nconservative management? Go ahead and do the definitive surgery\\nright away. However, this is true only as long as the local conditions\\nallow you to complete an oncologic dissection and a safe\\nanastomosis. Otherwise — what’s the hurry?\\n\\n Operative management\\n Patients who look sick, complain of localized or spreading pain, with\\nsystemic sepsis and localized or generalized peritonitis — associated\\nwith the aforementioned radiological features — should receive\\nantibiotics and undergo an emergency laparotomy. In most patients\\nundergoing early exploration the findings are those of peritoneal\\ncontamination rather than established infection; all that is required is\\n‘peritoneal toilet’ ( Chapter 13) and primary suture of the perforation as\\nyou would do with any traumatic colonic injury, unless you have to resect\\nthe associated polyp or cancer. The absence of feces in the colon helps\\nto minimize the severity of contamination/infection. A diverting or\\nexteriorizing colostomy may be indicated in selected patients, e.g. with\\nneglected established peritonitis or severe debilitating comorbidities such\\nas malnutrition or steroid dependence.\\n\\n Endoscopic or laparoscopic management\\n With modern endoscopic equipment, and advanced laparoscopic\\ncapabilities, less traumatic options exist for a significant portion of\\ncolonoscopic perforations. When a perforation is diagnosed at the\\ntime of the procedure, the endoscopist may try and approximate the\\nedges of the tear using endoscopic clips. The interest in ‘natural\\norifice transluminal surgery’ (NOTES) led to the development of even\\nmore advanced solutions for endoscopic suturing and other forms of\\ntissue approximation but the availability of these investigational devices is\\nstill limited.\\n\\n When operation is mandatory, most injuries can be approached\\nlaparoscopically provided an experienced surgeon and appropriate\\ninstruments are available. Colonic perforations can be sutured or\\nstapled, if local conditions allow for a primary repair. Alternatively,',\n", " 'md': '```markdown\\n## Operative Management\\n\\nPatients who look sick, complain of localized or spreading pain, with systemic sepsis and localized or generalized peritonitis — associated with the aforementioned radiological features — should receive antibiotics and undergo an emergency laparotomy. In most patients undergoing early exploration, the findings are those of peritoneal contamination rather than established infection; all that is required is ‘peritoneal toilet’ (Chapter 13) and primary suture of the perforation as you would do with any traumatic colonic injury, unless you have to resect the associated polyp or cancer. The absence of feces in the colon helps to minimize the severity of contamination/infection. A diverting or exteriorizing colostomy may be indicated in selected patients, e.g. with neglected established peritonitis or severe debilitating comorbidities such as malnutrition or steroid dependence.\\n\\n## Endoscopic or Laparoscopic Management\\n\\nWith modern endoscopic equipment, and advanced laparoscopic capabilities, less traumatic options exist for a significant portion of colonoscopic perforations. When a perforation is diagnosed at the time of the procedure, the endoscopist may try and approximate the edges of the tear using endoscopic clips. The interest in ‘natural orifice transluminal surgery’ (NOTES) led to the development of even more advanced solutions for endoscopic suturing and other forms of tissue approximation but the availability of these investigational devices is still limited.\\n\\nWhen operation is mandatory, most injuries can be approached laparoscopically provided an experienced surgeon and appropriate instruments are available. Colonic perforations can be sutured or stapled, if local conditions allow for a primary repair. Alternatively,\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Operative Management',\n", " 'md': '## Operative Management',\n", " 'bBox': {'x': 86, 'y': 207, 'w': 159.11, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Patients who look sick, complain of localized or spreading pain, with systemic sepsis and localized or generalized peritonitis — associated with the aforementioned radiological features — should receive antibiotics and undergo an emergency laparotomy. In most patients undergoing early exploration, the findings are those of peritoneal contamination rather than established infection; all that is required is ‘peritoneal toilet’ (Chapter 13) and primary suture of the perforation as you would do with any traumatic colonic injury, unless you have to resect the associated polyp or cancer. The absence of feces in the colon helps to minimize the severity of contamination/infection. A diverting or exteriorizing colostomy may be indicated in selected patients, e.g. with neglected established peritonitis or severe debilitating comorbidities such as malnutrition or steroid dependence.',\n", " 'md': 'Patients who look sick, complain of localized or spreading pain, with systemic sepsis and localized or generalized peritonitis — associated with the aforementioned radiological features — should receive antibiotics and undergo an emergency laparotomy. In most patients undergoing early exploration, the findings are those of peritoneal contamination rather than established infection; all that is required is ‘peritoneal toilet’ (Chapter 13) and primary suture of the perforation as you would do with any traumatic colonic injury, unless you have to resect the associated polyp or cancer. The absence of feces in the colon helps to minimize the severity of contamination/infection. A diverting or exteriorizing colostomy may be indicated in selected patients, e.g. with neglected established peritonitis or severe debilitating comorbidities such as malnutrition or steroid dependence.',\n", " 'bBox': {'x': 72, 'y': 327, 'w': 467.67, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Endoscopic or Laparoscopic Management',\n", " 'md': '## Endoscopic or Laparoscopic Management',\n", " 'bBox': {'x': 86, 'y': 466, 'w': 285.37, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'With modern endoscopic equipment, and advanced laparoscopic capabilities, less traumatic options exist for a significant portion of colonoscopic perforations. When a perforation is diagnosed at the time of the procedure, the endoscopist may try and approximate the edges of the tear using endoscopic clips. The interest in ‘natural orifice transluminal surgery’ (NOTES) led to the development of even more advanced solutions for endoscopic suturing and other forms of tissue approximation but the availability of these investigational devices is still limited.\\n\\nWhen operation is mandatory, most injuries can be approached laparoscopically provided an experienced surgeon and appropriate instruments are available. Colonic perforations can be sutured or stapled, if local conditions allow for a primary repair. Alternatively,\\n```',\n", " 'md': 'With modern endoscopic equipment, and advanced laparoscopic capabilities, less traumatic options exist for a significant portion of colonoscopic perforations. When a perforation is diagnosed at the time of the procedure, the endoscopist may try and approximate the edges of the tear using endoscopic clips. The interest in ‘natural orifice transluminal surgery’ (NOTES) led to the development of even more advanced solutions for endoscopic suturing and other forms of tissue approximation but the availability of these investigational devices is still limited.\\n\\nWhen operation is mandatory, most injuries can be approached laparoscopically provided an experienced surgeon and appropriate instruments are available. Colonic perforations can be sutured or stapled, if local conditions allow for a primary repair. Alternatively,\\n```',\n", " 'bBox': {'x': 72, 'y': 536, 'w': 467.76, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'you would do with any traumatic colonic injury, unless you have to resect'}]},\n", " {'page': 567,\n", " 'text': 'laparoscopic exteriorization and stoma construction for late, neglected\\ncases, is a valid option.\\n\\n To re-cap\\n\\n The management of endoscopic injury to any hollow\\n gastrointestinal viscus, from the esophagus down to the rectum,\\n can be summed up as follows:\\n\\n Always suspect disasters.\\n Image for diagnosis.\\n Those who are missed and neglected tend to die.\\n Some can be managed conservatively.\\n Some need an immediate operation.\\n Some who are managed conservatively may eventually need an operation.\\n\\n To achieve optimal results — be selective, alert and\\n always ready to change your mind. You are not a\\n politician — you can be proud to be a flipflopper!\\n\\n “A fool with a tool is still a fool.”',\n", " 'md': '```markdown\\n# Management of Endoscopic Injury to Hollow Gastrointestinal Viscus\\n\\nLaparoscopic exteriorization and stoma construction for late, neglected cases is a valid option.\\n\\n## Summary of Management Steps\\n\\nThe management of endoscopic injury to any hollow gastrointestinal viscus, from the esophagus down to the rectum, can be summed up as follows:\\n\\n1. Always suspect disasters.\\n2. Image for diagnosis.\\n3. Those who are missed and neglected tend to die.\\n4. Some can be managed conservatively.\\n5. Some need an immediate operation.\\n6. Some who are managed conservatively may eventually need an operation.\\n\\nTo achieve optimal results — be selective, alert, and always ready to change your mind. You are not a politician — you can be proud to be a flipflopper!\\n\\n> “A fool with a tool is still a fool.”\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management of Endoscopic Injury to Hollow Gastrointestinal Viscus',\n", " 'md': '# Management of Endoscopic Injury to Hollow Gastrointestinal Viscus',\n", " 'bBox': {'x': 122, 'y': 193, 'w': 88.75, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Laparoscopic exteriorization and stoma construction for late, neglected cases is a valid option.',\n", " 'md': 'Laparoscopic exteriorization and stoma construction for late, neglected cases is a valid option.',\n", " 'bBox': {'x': 413, 'y': 193, 'w': 13.59, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary of Management Steps',\n", " 'md': '## Summary of Management Steps',\n", " 'bBox': {'x': 122, 'y': 193, 'w': 88.75, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The management of endoscopic injury to any hollow gastrointestinal viscus, from the esophagus down to the rectum, can be summed up as follows:\\n\\n1. Always suspect disasters.\\n2. Image for diagnosis.\\n3. Those who are missed and neglected tend to die.\\n4. Some can be managed conservatively.\\n5. Some need an immediate operation.\\n6. Some who are managed conservatively may eventually need an operation.\\n\\nTo achieve optimal results — be selective, alert, and always ready to change your mind. You are not a politician — you can be proud to be a flipflopper!\\n\\n> “A fool with a tool is still a fool.”\\n```',\n", " 'md': 'The management of endoscopic injury to any hollow gastrointestinal viscus, from the esophagus down to the rectum, can be summed up as follows:\\n\\n1. Always suspect disasters.\\n2. Image for diagnosis.\\n3. Those who are missed and neglected tend to die.\\n4. Some can be managed conservatively.\\n5. Some need an immediate operation.\\n6. Some who are managed conservatively may eventually need an operation.\\n\\nTo achieve optimal results — be selective, alert, and always ready to change your mind. You are not a politician — you can be proud to be a flipflopper!\\n\\n> “A fool with a tool is still a fool.”\\n```',\n", " 'bBox': {'x': 79, 'y': 193, 'w': 453.52, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 568,\n", " 'text': 'Chapter 32\\nAbdominal trauma\\nRoger Saadia\\n\\n This chapter has been subdivided into the following three\\n sections:\\n\\n 1. Penetrating abdominal trauma\\n 2. Blunt abdominal trauma.\\n 3. Operative management of individual organ injuries.\\n\\n 1 Penetrating abdominal trauma\\n For a more detailed discussion of the general management of trauma and its complications we\\n recommend that you look at Ari’s chapter in our other book 1. The Editors\\n It is absolutely necessary for a surgeon to search the\\n wounds himself, which are not drest by him at first, in order\\n to discover their nature and know their extent.\\n A. Belloste\\n\\n General principles',\n", " 'md': '```markdown\\n# Chapter 32: Abdominal Trauma\\n**Author:** Roger Saadia\\n\\nThis chapter has been subdivided into the following three sections:\\n\\n1. Penetrating abdominal trauma\\n2. Blunt abdominal trauma\\n3. Operative management of individual organ injuries\\n\\n## 1. Penetrating Abdominal Trauma\\nFor a more detailed discussion of the general management of trauma and its complications, we recommend that you look at Ari’s chapter in our other book [1. The Editors](#).\\n\\n> \"It is absolutely necessary for a surgeon to search the wounds himself, which are not dressed by him at first, in order to discover their nature and know their extent.\"\\n> — A. Belloste\\n\\n### General Principles\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 32: Abdominal Trauma',\n", " 'md': '# Chapter 32: Abdominal Trauma',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 163.5, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Roger Saadia\\n\\nThis chapter has been subdivided into the following three sections:\\n\\n1. Penetrating abdominal trauma\\n2. Blunt abdominal trauma\\n3. Operative management of individual organ injuries',\n", " 'md': '**Author:** Roger Saadia\\n\\nThis chapter has been subdivided into the following three sections:\\n\\n1. Penetrating abdominal trauma\\n2. Blunt abdominal trauma\\n3. Operative management of individual organ injuries',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 453.27, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': '1. Penetrating Abdominal Trauma',\n", " 'md': '## 1. Penetrating Abdominal Trauma',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 212.71, 'h': 20.16}},\n", " {'type': 'text',\n", " 'value': 'For a more detailed discussion of the general management of trauma and its complications, we recommend that you look at Ari’s chapter in our other book [1. The Editors](#).\\n\\n> \"It is absolutely necessary for a surgeon to search the wounds himself, which are not dressed by him at first, in order to discover their nature and know their extent.\"\\n> — A. Belloste',\n", " 'md': 'For a more detailed discussion of the general management of trauma and its complications, we recommend that you look at Ari’s chapter in our other book [1. The Editors](#).\\n\\n> \"It is absolutely necessary for a surgeon to search the wounds himself, which are not dressed by him at first, in order to discover their nature and know their extent.\"\\n> — A. Belloste',\n", " 'bBox': {'x': 77, 'y': 562, 'w': 372.13, 'h': 18.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'General Principles',\n", " 'md': '### General Principles',\n", " 'bBox': {'x': 86, 'y': 705, 'w': 144.36, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'recommend that you look at Ari’s chapter in our other book 1'}]},\n", " {'page': 569,\n", " 'text': ' The crucial decision faced by the surgeon managing abdominal trauma\\nis whether an exploratory laparotomy is indicated. The decision to\\noperate rests solely on the high likelihood that a significant injury is\\npresent; it does not require a precise inventory of all the possible intra-\\nabdominal visceral injuries. In penetrating trauma, the role of clinical\\nevaluation is primordial. Depending on the circumstances, it needs to\\nbe complemented sometimes by adjunctive diagnostic measures.\\n\\n The surgeon’s initial objective is to identify the patient requiring\\n surgery while avoiding unnecessary laparotomies. These are termed\\n ‘negative’ when no injuries are present and ‘non-therapeutic’ when the identified injuries would\\n have healed spontaneously if left alone (for example, a minor hepatic laceration associated\\n with a small hemoperitoneum but no active bleeding).\\n\\n In order to fulfill this ideal requirement of timely necessary surgery with\\na zero rate of unnecessary laparotomies, numerous algorithms, some\\nvery complicated, have been devised incorporating various diagnostic\\ntests. Not a single one is fool-proof or has gained universal acceptance.\\nIn fact, even the most experienced trauma surgeon, from time to\\ntime, does perform an unnecessary laparotomy. While such surgery\\nis attended by some morbidity, this is a fair price to pay for not\\nmissing a significant intra-abdominal injury, provided that the\\nfrequency of such laparotomies is not unreasonably high.\\n\\n In civilian practice, there are two main mechanisms of penetrating\\nabdominal trauma: stab wounds and gunshot injuries. Owing to\\nsurgical tradition, these two categories have been treated differently, with\\nmandatory surgery being advocated for gunshot wounds. More recently,\\nthere has been a tendency to apply the same management principles\\nirrespective of the injury mechanism.\\n\\n After penetrating abdominal trauma, two possible clinical pictures\\ncan be found, in isolation or in combination: hypovolemic shock\\nand peritonitis. The former is the result of bleeding from an injured solid\\norgan (e.g. spleen, liver) or a sizable vessel. The latter is the\\nconsequence of soiling of the peritoneal cavity caused usually by an',\n", " 'md': '```markdown\\n# Abdominal Trauma Management\\n\\nThe crucial decision faced by the surgeon managing abdominal trauma is whether an exploratory laparotomy is indicated. The decision to operate rests solely on the high likelihood that a significant injury is present; it does not require a precise inventory of all the possible intra-abdominal visceral injuries. In penetrating trauma, the role of clinical evaluation is primordial. Depending on the circumstances, it needs to be complemented sometimes by adjunctive diagnostic measures.\\n\\nThe surgeon’s initial objective is to identify the patient requiring surgery while avoiding unnecessary laparotomies. These are termed ‘negative’ when no injuries are present and ‘non-therapeutic’ when the identified injuries would have healed spontaneously if left alone (for example, a minor hepatic laceration associated with a small hemoperitoneum but no active bleeding).\\n\\nIn order to fulfill this ideal requirement of timely necessary surgery with a zero rate of unnecessary laparotomies, numerous algorithms, some very complicated, have been devised incorporating various diagnostic tests. Not a single one is fool-proof or has gained universal acceptance. In fact, even the most experienced trauma surgeon, from time to time, does perform an unnecessary laparotomy. While such surgery is attended by some morbidity, this is a fair price to pay for not missing a significant intra-abdominal injury, provided that the frequency of such laparotomies is not unreasonably high.\\n\\nIn civilian practice, there are two main mechanisms of penetrating abdominal trauma: stab wounds and gunshot injuries. Owing to surgical tradition, these two categories have been treated differently, with mandatory surgery being advocated for gunshot wounds. More recently, there has been a tendency to apply the same management principles irrespective of the injury mechanism.\\n\\nAfter penetrating abdominal trauma, two possible clinical pictures can be found, in isolation or in combination: hypovolemic shock and peritonitis. The former is the result of bleeding from an injured solid organ (e.g. spleen, liver) or a sizable vessel. The latter is the consequence of soiling of the peritoneal cavity caused usually by an .\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Abdominal Trauma Management',\n", " 'md': '# Abdominal Trauma Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The crucial decision faced by the surgeon managing abdominal trauma is whether an exploratory laparotomy is indicated. The decision to operate rests solely on the high likelihood that a significant injury is present; it does not require a precise inventory of all the possible intra-abdominal visceral injuries. In penetrating trauma, the role of clinical evaluation is primordial. Depending on the circumstances, it needs to be complemented sometimes by adjunctive diagnostic measures.\\n\\nThe surgeon’s initial objective is to identify the patient requiring surgery while avoiding unnecessary laparotomies. These are termed ‘negative’ when no injuries are present and ‘non-therapeutic’ when the identified injuries would have healed spontaneously if left alone (for example, a minor hepatic laceration associated with a small hemoperitoneum but no active bleeding).\\n\\nIn order to fulfill this ideal requirement of timely necessary surgery with a zero rate of unnecessary laparotomies, numerous algorithms, some very complicated, have been devised incorporating various diagnostic tests. Not a single one is fool-proof or has gained universal acceptance. In fact, even the most experienced trauma surgeon, from time to time, does perform an unnecessary laparotomy. While such surgery is attended by some morbidity, this is a fair price to pay for not missing a significant intra-abdominal injury, provided that the frequency of such laparotomies is not unreasonably high.\\n\\nIn civilian practice, there are two main mechanisms of penetrating abdominal trauma: stab wounds and gunshot injuries. Owing to surgical tradition, these two categories have been treated differently, with mandatory surgery being advocated for gunshot wounds. More recently, there has been a tendency to apply the same management principles irrespective of the injury mechanism.\\n\\nAfter penetrating abdominal trauma, two possible clinical pictures can be found, in isolation or in combination: hypovolemic shock and peritonitis. The former is the result of bleeding from an injured solid organ (e.g. spleen, liver) or a sizable vessel. The latter is the consequence of soiling of the peritoneal cavity caused usually by an .\\n```',\n", " 'md': 'The crucial decision faced by the surgeon managing abdominal trauma is whether an exploratory laparotomy is indicated. The decision to operate rests solely on the high likelihood that a significant injury is present; it does not require a precise inventory of all the possible intra-abdominal visceral injuries. In penetrating trauma, the role of clinical evaluation is primordial. Depending on the circumstances, it needs to be complemented sometimes by adjunctive diagnostic measures.\\n\\nThe surgeon’s initial objective is to identify the patient requiring surgery while avoiding unnecessary laparotomies. These are termed ‘negative’ when no injuries are present and ‘non-therapeutic’ when the identified injuries would have healed spontaneously if left alone (for example, a minor hepatic laceration associated with a small hemoperitoneum but no active bleeding).\\n\\nIn order to fulfill this ideal requirement of timely necessary surgery with a zero rate of unnecessary laparotomies, numerous algorithms, some very complicated, have been devised incorporating various diagnostic tests. Not a single one is fool-proof or has gained universal acceptance. In fact, even the most experienced trauma surgeon, from time to time, does perform an unnecessary laparotomy. While such surgery is attended by some morbidity, this is a fair price to pay for not missing a significant intra-abdominal injury, provided that the frequency of such laparotomies is not unreasonably high.\\n\\nIn civilian practice, there are two main mechanisms of penetrating abdominal trauma: stab wounds and gunshot injuries. Owing to surgical tradition, these two categories have been treated differently, with mandatory surgery being advocated for gunshot wounds. More recently, there has been a tendency to apply the same management principles irrespective of the injury mechanism.\\n\\nAfter penetrating abdominal trauma, two possible clinical pictures can be found, in isolation or in combination: hypovolemic shock and peritonitis. The former is the result of bleeding from an injured solid organ (e.g. spleen, liver) or a sizable vessel. The latter is the consequence of soiling of the peritoneal cavity caused usually by an .\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.93, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 570,\n", " 'text': 'injured hollow viscus (gut, biliary system, urinary bladder).\\n\\n Abdominal stab wounds\\n Though shock may be temporarily alleviated by transfusion,\\n it cannot be arrested or overcome; resuscitation divorced\\n from surgery is folly.\\n William Heneage Ogilvie\\n\\n The diagnosis of a stabbed abdomen is straightforward in the majority\\nof cases: there is a visible wound on the abdominal wall and the patient\\nor witnesses usually confirm the circumstances of the assault. Don’t be\\ntaken in by fishermen’s tales about how long the steak knife was but\\nremember instead the adage: “Treat the patient not the weapon.”\\n\\n It bears repeating that clinical evaluation of the patient\\n(supplemented by an upright chest X-ray) is the most important step\\nin the diagnostic work-up. There are scenarios mandating an\\nexploratory laparotomy without the need for additional confirmatory\\ndiagnostic procedures. The only required tests are those in preparation\\nfor a laparotomy (basic blood work, blood group and match, and when\\nnecessary EKG, βħCG…).\\n\\n The following are indications for immediate surgery:\\n\\n Hemodynamic instability in the absence of an associated extra-\\n abdominal injury that could, by itself, account for shock. Fluid resuscitation must be\\n started immediately. However, remember that the patient is not\\n bleeding Ringer’s lactate! Blood and its components should be started\\n as soon as available to reduce crystalloid loading or ‘salt-water drowning’.\\n ‘Permissive hypotension’ should be maintained until surgical hemostasis has been\\n achieved. (Patients in extremis should be transferred expeditiously to the operating\\n room since emergency room thoracotomy is not a useful maneuver in this context;\\n as for emergency room laparotomy, it is extremely efficient in transferring the\\n patient’s total blood volume from the abdomen to the floor…).',\n", " 'md': '```markdown\\n## Abdominal Stab Wounds\\n\\nThough shock may be temporarily alleviated by transfusion, it cannot be arrested or overcome; resuscitation divorced from surgery is folly.\\n— William Heneage Ogilvie\\n\\nThe diagnosis of a stabbed abdomen is straightforward in the majority of cases: there is a visible wound on the abdominal wall and the patient or witnesses usually confirm the circumstances of the assault. Don’t be taken in by fishermen’s tales about how long the steak knife was but remember instead the adage: “Treat the patient not the weapon.”\\n\\nIt bears repeating that clinical evaluation of the patient (supplemented by an upright chest X-ray) is the most important step in the diagnostic work-up. There are scenarios mandating an exploratory laparotomy without the need for additional confirmatory diagnostic procedures. The only required tests are those in preparation for a laparotomy (basic blood work, blood group and match, and when necessary EKG, βħCG…).\\n\\n### Indications for Immediate Surgery\\n\\n- Hemodynamic instability in the absence of an associated extra-abdominal injury that could, by itself, account for shock. Fluid resuscitation must be started immediately. However, remember that the patient is not bleeding Ringer’s lactate! Blood and its components should be started as soon as available to reduce crystalloid loading or ‘salt-water drowning’. ‘Permissive hypotension’ should be maintained until surgical hemostasis has been achieved. (Patients in extremis should be transferred expeditiously to the operating room since emergency room thoracotomy is not a useful maneuver in this context; as for emergency room laparotomy, it is extremely efficient in transferring the patient’s total blood volume from the abdomen to the floor…).\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Stab Wounds',\n", " 'md': '## Abdominal Stab Wounds',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 191.25, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Though shock may be temporarily alleviated by transfusion, it cannot be arrested or overcome; resuscitation divorced from surgery is folly.\\n— William Heneage Ogilvie\\n\\nThe diagnosis of a stabbed abdomen is straightforward in the majority of cases: there is a visible wound on the abdominal wall and the patient or witnesses usually confirm the circumstances of the assault. Don’t be taken in by fishermen’s tales about how long the steak knife was but remember instead the adage: “Treat the patient not the weapon.”\\n\\nIt bears repeating that clinical evaluation of the patient (supplemented by an upright chest X-ray) is the most important step in the diagnostic work-up. There are scenarios mandating an exploratory laparotomy without the need for additional confirmatory diagnostic procedures. The only required tests are those in preparation for a laparotomy (basic blood work, blood group and match, and when necessary EKG, βħCG…).',\n", " 'md': 'Though shock may be temporarily alleviated by transfusion, it cannot be arrested or overcome; resuscitation divorced from surgery is folly.\\n— William Heneage Ogilvie\\n\\nThe diagnosis of a stabbed abdomen is straightforward in the majority of cases: there is a visible wound on the abdominal wall and the patient or witnesses usually confirm the circumstances of the assault. Don’t be taken in by fishermen’s tales about how long the steak knife was but remember instead the adage: “Treat the patient not the weapon.”\\n\\nIt bears repeating that clinical evaluation of the patient (supplemented by an upright chest X-ray) is the most important step in the diagnostic work-up. There are scenarios mandating an exploratory laparotomy without the need for additional confirmatory diagnostic procedures. The only required tests are those in preparation for a laparotomy (basic blood work, blood group and match, and when necessary EKG, βħCG…).',\n", " 'bBox': {'x': 72, 'y': 160, 'w': 467.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Indications for Immediate Surgery',\n", " 'md': '### Indications for Immediate Surgery',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Hemodynamic instability in the absence of an associated extra-abdominal injury that could, by itself, account for shock. Fluid resuscitation must be started immediately. However, remember that the patient is not bleeding Ringer’s lactate! Blood and its components should be started as soon as available to reduce crystalloid loading or ‘salt-water drowning’. ‘Permissive hypotension’ should be maintained until surgical hemostasis has been achieved. (Patients in extremis should be transferred expeditiously to the operating room since emergency room thoracotomy is not a useful maneuver in this context; as for emergency room laparotomy, it is extremely efficient in transferring the patient’s total blood volume from the abdomen to the floor…).\\n```',\n", " 'md': '- Hemodynamic instability in the absence of an associated extra-abdominal injury that could, by itself, account for shock. Fluid resuscitation must be started immediately. However, remember that the patient is not bleeding Ringer’s lactate! Blood and its components should be started as soon as available to reduce crystalloid loading or ‘salt-water drowning’. ‘Permissive hypotension’ should be maintained until surgical hemostasis has been achieved. (Patients in extremis should be transferred expeditiously to the operating room since emergency room thoracotomy is not a useful maneuver in this context; as for emergency room laparotomy, it is extremely efficient in transferring the patient’s total blood volume from the abdomen to the floor…).\\n```',\n", " 'bBox': {'x': 86, 'y': 354, 'w': 398.15, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 571,\n", " 'text': ' Peritonitis is frequent and there is little diagnostic value in eliciting tenderness\\n and even guarding on abdominal palpation in the immediate vicinity of the\\n laceration. Signs of peritonitis need to be found at a distance\\n from the wound in order to confidently establish the\\n diagnosis. Always ensure that the bladder is empty before you prod for\\n abdominal tenderness (these patients often arrive to the emergency room with a\\n bladder ready to burst, courtesy of over-enthusiastic paramedics).\\n The demonstration of free intraperitoneal air on the upright chest X-ray.\\n Abdominal X-rays are unnecessary in stabbed abdomens except for the lateral\\n decubitus film in a patient that cannot sit up for a chest X-ray.\\n Omental or intestinal evisceration. A laparotomy is advisable\\n because of the high likelihood of visceral injury. Even if the laparotomy turns out to\\n be negative, it would have served the double purpose of safely reducing the\\n herniated viscera and allowing for a meticulous closure of the lacerated abdominal\\n wall, preventing hernia formation.\\n A retained stabbing instrument. This could be tamponading a sizable\\n blood vessel and therefore should be removed in the operating room.\\n\\n Abdominal stab wounds: when to observe? How to\\n investigate?\\n\\n Reading the standard textbooks, one gets a little confused about\\nhow to manage the asymptomatic patient with, typically, an anterior\\nabdominal wall laceration. In about one-third of these, the wound\\ndoes not extend into the peritoneal cavity and in another third it\\ndoes but there are no significant visceral injuries. Exploring all\\nthese patients would not be a good idea.\\n\\n Diagnostic procedures are sometimes advocated. Diagnostic\\nperitoneal lavage is cumbersome and lacks accuracy; it is attended by a\\nhigh rate of non-therapeutic laparotomies. Exploration of the wound\\nunder local anesthesia aims at identifying a breach of the parietal\\nperitoneum. It is often difficult though to determine with certainty the\\nextension of the track — try it in an obese or combative patient in the',\n", " 'md': '```markdown\\n## Abdominal Stab Wounds: When to Observe? How to Investigate?\\n\\nPeritonitis is frequent and there is little diagnostic value in eliciting tenderness and even guarding on abdominal palpation in the immediate vicinity of the laceration. Signs of peritonitis need to be found at a distance from the wound in order to confidently establish the diagnosis. Always ensure that the bladder is empty before you prod for abdominal tenderness (these patients often arrive to the emergency room with a bladder ready to burst, courtesy of over-enthusiastic paramedics).\\n\\nThe demonstration of free intraperitoneal air on the upright chest X-ray. Abdominal X-rays are unnecessary in stabbed abdomens except for the lateral decubitus film in a patient that cannot sit up for a chest X-ray.\\n\\n- Omental or intestinal evisceration. A laparotomy is advisable because of the high likelihood of visceral injury. Even if the laparotomy turns out to be negative, it would have served the double purpose of safely reducing the herniated viscera and allowing for a meticulous closure of the lacerated abdominal wall, preventing hernia formation.\\n- A retained stabbing instrument. This could be tamponading a sizable blood vessel and therefore should be removed in the operating room.\\n\\nReading the standard textbooks, one gets a little confused about how to manage the asymptomatic patient with, typically, an anterior abdominal wall laceration. In about one-third of these, the wound does not extend into the peritoneal cavity and in another third it does but there are no significant visceral injuries. Exploring all these patients would not be a good idea.\\n\\nDiagnostic procedures are sometimes advocated. Diagnostic peritoneal lavage is cumbersome and lacks accuracy; it is attended by a high rate of non-therapeutic laparotomies. Exploration of the wound under local anesthesia aims at identifying a breach of the parietal peritoneum. It is often difficult though to determine with certainty the extension of the track — try it in an obese or combative patient in the .\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Stab Wounds: When to Observe? How to Investigate?',\n", " 'md': '## Abdominal Stab Wounds: When to Observe? How to Investigate?',\n", " 'bBox': {'x': 86, 'y': 457, 'w': 96.56, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Peritonitis is frequent and there is little diagnostic value in eliciting tenderness and even guarding on abdominal palpation in the immediate vicinity of the laceration. Signs of peritonitis need to be found at a distance from the wound in order to confidently establish the diagnosis. Always ensure that the bladder is empty before you prod for abdominal tenderness (these patients often arrive to the emergency room with a bladder ready to burst, courtesy of over-enthusiastic paramedics).\\n\\nThe demonstration of free intraperitoneal air on the upright chest X-ray. Abdominal X-rays are unnecessary in stabbed abdomens except for the lateral decubitus film in a patient that cannot sit up for a chest X-ray.\\n\\n- Omental or intestinal evisceration. A laparotomy is advisable because of the high likelihood of visceral injury. Even if the laparotomy turns out to be negative, it would have served the double purpose of safely reducing the herniated viscera and allowing for a meticulous closure of the lacerated abdominal wall, preventing hernia formation.\\n- A retained stabbing instrument. This could be tamponading a sizable blood vessel and therefore should be removed in the operating room.\\n\\nReading the standard textbooks, one gets a little confused about how to manage the asymptomatic patient with, typically, an anterior abdominal wall laceration. In about one-third of these, the wound does not extend into the peritoneal cavity and in another third it does but there are no significant visceral injuries. Exploring all these patients would not be a good idea.\\n\\nDiagnostic procedures are sometimes advocated. Diagnostic peritoneal lavage is cumbersome and lacks accuracy; it is attended by a high rate of non-therapeutic laparotomies. Exploration of the wound under local anesthesia aims at identifying a breach of the parietal peritoneum. It is often difficult though to determine with certainty the extension of the track — try it in an obese or combative patient in the .\\n```',\n", " 'md': 'Peritonitis is frequent and there is little diagnostic value in eliciting tenderness and even guarding on abdominal palpation in the immediate vicinity of the laceration. Signs of peritonitis need to be found at a distance from the wound in order to confidently establish the diagnosis. Always ensure that the bladder is empty before you prod for abdominal tenderness (these patients often arrive to the emergency room with a bladder ready to burst, courtesy of over-enthusiastic paramedics).\\n\\nThe demonstration of free intraperitoneal air on the upright chest X-ray. Abdominal X-rays are unnecessary in stabbed abdomens except for the lateral decubitus film in a patient that cannot sit up for a chest X-ray.\\n\\n- Omental or intestinal evisceration. A laparotomy is advisable because of the high likelihood of visceral injury. Even if the laparotomy turns out to be negative, it would have served the double purpose of safely reducing the herniated viscera and allowing for a meticulous closure of the lacerated abdominal wall, preventing hernia formation.\\n- A retained stabbing instrument. This could be tamponading a sizable blood vessel and therefore should be removed in the operating room.\\n\\nReading the standard textbooks, one gets a little confused about how to manage the asymptomatic patient with, typically, an anterior abdominal wall laceration. In about one-third of these, the wound does not extend into the peritoneal cavity and in another third it does but there are no significant visceral injuries. Exploring all these patients would not be a good idea.\\n\\nDiagnostic procedures are sometimes advocated. Diagnostic peritoneal lavage is cumbersome and lacks accuracy; it is attended by a high rate of non-therapeutic laparotomies. Exploration of the wound under local anesthesia aims at identifying a breach of the parietal peritoneum. It is often difficult though to determine with certainty the extension of the track — try it in an obese or combative patient in the .\\n```',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.54, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 572,\n", " 'text': 'rough-and-tumble atmosphere of a busy emergency department!\\nLaparoscopy is a logistically demanding test since it requires general\\nanesthesia. ħere, its main value is to ascertain intraperitoneal\\npenetration. Don’t be fooled by overconfident minimally invasive\\nsurgeons; a negative laparoscopic assessment of the peritoneal cavity\\ncannot exclude a small intestinal laceration with minimal spillage, nor can\\nit assess the retroperitoneum. In addition, post-procedure clinical or\\nradiological abdominal assessments are made unreliable. About the\\nselective role of laparoscopy for a suspected diaphragmatic injury see\\nbelow.\\n\\n There remain two (we believe, complementary) approaches to the\\nasymptomatic patient with an anterior abdominal stab wound,\\nnamely clinical reassessment and helical computed tomography\\n(CT) scanning.\\n\\n Serial clinical reassessment of the patient\\n\\n This policy has been dubbed ‘selective conservatism’, and has proved\\nits worth in many centers. The patient is admitted, kept nil per os and\\ngiven an i.v. infusion. The vital signs and urine output are closely\\nmonitored. The abdomen is re-examined at frequent intervals\\nchecking for the development of peritonitis; the initial area of\\ntenderness around the wound can be circumscribed with a marker\\nand spreading tenderness is watched for over the observation\\nperiod. Analgesia, antibiotics or nasogastric decompression are not\\nrequired. If, after an observation period of 18-24 hours, no signs of\\nhypovolemia or peritonitis are elicited, it is highly unlikely that a significant\\nintra-abdominal injury is present. A very good indicator of this is a\\npatient angrily demanding a meal tray. In applying this policy, keep an\\nopen mind at all times and do not persevere stubbornly with non-\\noperative management in the face of even subtle deterioration. Having\\nto operate in a delayed fashion in a well-monitored patient is not a\\nsign of personal failure but a tribute to your clinical acumen. An\\noccasional unnecessary laparotomy will be performed: this is nothing to\\nbe ashamed of and when in doubt it is safer to err on the side of surgical\\nexploration.',\n", " 'md': '```markdown\\n# Laparoscopy and Management of Abdominal Stab Wounds\\n\\nLaparoscopy is a logistically demanding test since it requires general anesthesia. Here, its main value is to ascertain intraperitoneal penetration. Don’t be fooled by overconfident minimally invasive surgeons; a negative laparoscopic assessment of the peritoneal cavity cannot exclude a small intestinal laceration with minimal spillage, nor can it assess the retroperitoneum. In addition, post-procedure clinical or radiological abdominal assessments are made unreliable. About the selective role of laparoscopy for a suspected diaphragmatic injury see below.\\n\\nThere remain two (we believe, complementary) approaches to the asymptomatic patient with an anterior abdominal stab wound, namely clinical reassessment and helical computed tomography (CT) scanning.\\n\\n## Serial Clinical Reassessment of the Patient\\n\\nThis policy has been dubbed ‘selective conservatism’, and has proved its worth in many centers. The patient is admitted, kept nil per os and given an i.v. infusion. The vital signs and urine output are closely monitored. The abdomen is re-examined at frequent intervals checking for the development of peritonitis; the initial area of tenderness around the wound can be circumscribed with a marker and spreading tenderness is watched for over the observation period. Analgesia, antibiotics or nasogastric decompression are not required. If, after an observation period of 18-24 hours, no signs of hypovolemia or peritonitis are elicited, it is highly unlikely that a significant intra-abdominal injury is present. A very good indicator of this is a patient angrily demanding a meal tray. In applying this policy, keep an open mind at all times and do not persevere stubbornly with non-operative management in the face of even subtle deterioration. Having to operate in a delayed fashion in a well-monitored patient is not a sign of personal failure but a tribute to your clinical acumen. An occasional unnecessary laparotomy will be performed: this is nothing to be ashamed of and when in doubt it is safer to err on the side of surgical exploration.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Laparoscopy and Management of Abdominal Stab Wounds',\n", " 'md': '# Laparoscopy and Management of Abdominal Stab Wounds',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Laparoscopy is a logistically demanding test since it requires general anesthesia. Here, its main value is to ascertain intraperitoneal penetration. Don’t be fooled by overconfident minimally invasive surgeons; a negative laparoscopic assessment of the peritoneal cavity cannot exclude a small intestinal laceration with minimal spillage, nor can it assess the retroperitoneum. In addition, post-procedure clinical or radiological abdominal assessments are made unreliable. About the selective role of laparoscopy for a suspected diaphragmatic injury see below.\\n\\nThere remain two (we believe, complementary) approaches to the asymptomatic patient with an anterior abdominal stab wound, namely clinical reassessment and helical computed tomography (CT) scanning.',\n", " 'md': 'Laparoscopy is a logistically demanding test since it requires general anesthesia. Here, its main value is to ascertain intraperitoneal penetration. Don’t be fooled by overconfident minimally invasive surgeons; a negative laparoscopic assessment of the peritoneal cavity cannot exclude a small intestinal laceration with minimal spillage, nor can it assess the retroperitoneum. In addition, post-procedure clinical or radiological abdominal assessments are made unreliable. About the selective role of laparoscopy for a suspected diaphragmatic injury see below.\\n\\nThere remain two (we believe, complementary) approaches to the asymptomatic patient with an anterior abdominal stab wound, namely clinical reassessment and helical computed tomography (CT) scanning.',\n", " 'bBox': {'x': 72, 'y': 169, 'w': 467.5, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Serial Clinical Reassessment of the Patient',\n", " 'md': '## Serial Clinical Reassessment of the Patient',\n", " 'bBox': {'x': 86, 'y': 363, 'w': 329.19, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This policy has been dubbed ‘selective conservatism’, and has proved its worth in many centers. The patient is admitted, kept nil per os and given an i.v. infusion. The vital signs and urine output are closely monitored. The abdomen is re-examined at frequent intervals checking for the development of peritonitis; the initial area of tenderness around the wound can be circumscribed with a marker and spreading tenderness is watched for over the observation period. Analgesia, antibiotics or nasogastric decompression are not required. If, after an observation period of 18-24 hours, no signs of hypovolemia or peritonitis are elicited, it is highly unlikely that a significant intra-abdominal injury is present. A very good indicator of this is a patient angrily demanding a meal tray. In applying this policy, keep an open mind at all times and do not persevere stubbornly with non-operative management in the face of even subtle deterioration. Having to operate in a delayed fashion in a well-monitored patient is not a sign of personal failure but a tribute to your clinical acumen. An occasional unnecessary laparotomy will be performed: this is nothing to be ashamed of and when in doubt it is safer to err on the side of surgical exploration.\\n```',\n", " 'md': 'This policy has been dubbed ‘selective conservatism’, and has proved its worth in many centers. The patient is admitted, kept nil per os and given an i.v. infusion. The vital signs and urine output are closely monitored. The abdomen is re-examined at frequent intervals checking for the development of peritonitis; the initial area of tenderness around the wound can be circumscribed with a marker and spreading tenderness is watched for over the observation period. Analgesia, antibiotics or nasogastric decompression are not required. If, after an observation period of 18-24 hours, no signs of hypovolemia or peritonitis are elicited, it is highly unlikely that a significant intra-abdominal injury is present. A very good indicator of this is a patient angrily demanding a meal tray. In applying this policy, keep an open mind at all times and do not persevere stubbornly with non-operative management in the face of even subtle deterioration. Having to operate in a delayed fashion in a well-monitored patient is not a sign of personal failure but a tribute to your clinical acumen. An occasional unnecessary laparotomy will be performed: this is nothing to be ashamed of and when in doubt it is safer to err on the side of surgical exploration.\\n```',\n", " 'bBox': {'x': 72, 'y': 399, 'w': 467.73, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 573,\n", " 'text': ' Abdominal CT scan\\n\\n In recent years, both the access to CT scanning and the quality of the\\nimages have improved dramatically. In many centers, the asymptomatic\\nstabbed patient is often sent to the scanner by the emergency physician\\nbefore the surgeon is even consulted. Whatever seasoned trauma\\nsurgeons may think of this practice, the train has long since left the\\nstation...\\n\\n Undoubtedly, this investigation is often valuable, even though its\\nshortcomings in early intestinal perforation are well known. Some\\npatients are shown to have only a superficial wound with greater ease\\nand accuracy than by local tract exploration. They can be safely\\ndischarged from the emergency department. A small minority of\\nasymptomatic patients are diagnosed with a significant visceral injury\\n(that would have eventually declared itself under observation). Their trip\\nto the operating room is thereby expedited. The remaining majority of the\\npatients with a negative or equivocal CT scan need to be admitted and\\nobserved as described above.\\n\\n The primacy of clinical evaluation is unquestioned. ħowever, as in the\\nmanagement of acute appendicitis, its interplay with the judicious use of\\nthe CT scanner can refine one’s decision-making a little further.\\n\\n Abdominal gunshot wounds — dogma versus modern\\n imaging\\n It is highly desirable that anyone engaged in war surgery\\n should keep his idea fluid and so be ready to abandon\\n methods which prove unsatisfactory in favour of others\\n which, at first, may appear revolutionary and even not free\\n from inherent danger.\\n H. H. Sampson\\n\\n Traditional wisdom inherited from war experience has held that an\\nexploratory laparotomy is always indicated in these patients irrespective\\nof their clinical condition. This policy has been predicated on the higher',\n", " 'md': '```markdown\\n# Abdominal CT Scan\\n\\nIn recent years, both the access to CT scanning and the quality of the images have improved dramatically. In many centers, the asymptomatic stabbed patient is often sent to the scanner by the emergency physician before the surgeon is even consulted. Whatever seasoned trauma surgeons may think of this practice, the train has long since left the station...\\n\\nUndoubtedly, this investigation is often valuable, even though its shortcomings in early intestinal perforation are well known. Some patients are shown to have only a superficial wound with greater ease and accuracy than by local tract exploration. They can be safely discharged from the emergency department. A small minority of asymptomatic patients are diagnosed with a significant visceral injury (that would have eventually declared itself under observation). Their trip to the operating room is thereby expedited. The remaining majority of the patients with a negative or equivocal CT scan need to be admitted and observed as described above.\\n\\nThe primacy of clinical evaluation is unquestioned. However, as in the management of acute appendicitis, its interplay with the judicious use of the CT scanner can refine one’s decision-making a little further.\\n\\n## Abdominal Gunshot Wounds — Dogma Versus Modern Imaging\\n\\n> It is highly desirable that anyone engaged in war surgery should keep his idea fluid and so be ready to abandon methods which prove unsatisfactory in favour of others which, at first, may appear revolutionary and even not free from inherent danger.\\n> — H. H. Sampson\\n\\nTraditional wisdom inherited from war experience has held that an exploratory laparotomy is always indicated in these patients irrespective of their clinical condition. This policy has been predicated on the higher...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- The quote from H. H. Sampson has been formatted as a block quote for clarity.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Abdominal CT Scan',\n", " 'md': '# Abdominal CT Scan',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 154.49, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In recent years, both the access to CT scanning and the quality of the images have improved dramatically. In many centers, the asymptomatic stabbed patient is often sent to the scanner by the emergency physician before the surgeon is even consulted. Whatever seasoned trauma surgeons may think of this practice, the train has long since left the station...\\n\\nUndoubtedly, this investigation is often valuable, even though its shortcomings in early intestinal perforation are well known. Some patients are shown to have only a superficial wound with greater ease and accuracy than by local tract exploration. They can be safely discharged from the emergency department. A small minority of asymptomatic patients are diagnosed with a significant visceral injury (that would have eventually declared itself under observation). Their trip to the operating room is thereby expedited. The remaining majority of the patients with a negative or equivocal CT scan need to be admitted and observed as described above.\\n\\nThe primacy of clinical evaluation is unquestioned. However, as in the management of acute appendicitis, its interplay with the judicious use of the CT scanner can refine one’s decision-making a little further.',\n", " 'md': 'In recent years, both the access to CT scanning and the quality of the images have improved dramatically. In many centers, the asymptomatic stabbed patient is often sent to the scanner by the emergency physician before the surgeon is even consulted. Whatever seasoned trauma surgeons may think of this practice, the train has long since left the station...\\n\\nUndoubtedly, this investigation is often valuable, even though its shortcomings in early intestinal perforation are well known. Some patients are shown to have only a superficial wound with greater ease and accuracy than by local tract exploration. They can be safely discharged from the emergency department. A small minority of asymptomatic patients are diagnosed with a significant visceral injury (that would have eventually declared itself under observation). Their trip to the operating room is thereby expedited. The remaining majority of the patients with a negative or equivocal CT scan need to be admitted and observed as described above.\\n\\nThe primacy of clinical evaluation is unquestioned. However, as in the management of acute appendicitis, its interplay with the judicious use of the CT scanner can refine one’s decision-making a little further.',\n", " 'bBox': {'x': 72, 'y': 124, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Gunshot Wounds — Dogma Versus Modern Imaging',\n", " 'md': '## Abdominal Gunshot Wounds — Dogma Versus Modern Imaging',\n", " 'bBox': {'x': 86, 'y': 502, 'w': 452.38, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '> It is highly desirable that anyone engaged in war surgery should keep his idea fluid and so be ready to abandon methods which prove unsatisfactory in favour of others which, at first, may appear revolutionary and even not free from inherent danger.\\n> — H. H. Sampson\\n\\nTraditional wisdom inherited from war experience has held that an exploratory laparotomy is always indicated in these patients irrespective of their clinical condition. This policy has been predicated on the higher...\\n```',\n", " 'md': '> It is highly desirable that anyone engaged in war surgery should keep his idea fluid and so be ready to abandon methods which prove unsatisfactory in favour of others which, at first, may appear revolutionary and even not free from inherent danger.\\n> — H. H. Sampson\\n\\nTraditional wisdom inherited from war experience has held that an exploratory laparotomy is always indicated in these patients irrespective of their clinical condition. This policy has been predicated on the higher...\\n```',\n", " 'bBox': {'x': 72, 'y': 603, 'w': 467.38, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- The quote from H. H. Sampson has been formatted as a block quote for clarity.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- The quote from H. H. Sampson has been formatted as a block quote for clarity.',\n", " 'bBox': {'x': 388, 'y': 643, 'w': 101.53, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 574,\n", " 'text': 'likelihood of significant intra-abdominal injuries in gunshot than in stab\\nwounds. This premise, if true, implies merely that shock and peritonitis\\nare more frequently associated with the former than with the latter.\\nDecision-making is then easy. But what about the benign-looking\\nabdomen with a gunshot wound that is encountered nowadays not\\nthat infrequently in many large urban trauma centers?\\n\\n There is accumulating evidence to suggest that initially asymptomatic\\ngunshot victims can be managed safely along the same broad lines as\\nstabbed patients. While the role of initial and serial clinical\\nreassessments is here again very important, we contend that an early\\nCT scan of both the abdomen and chest is mandatory, not only in\\nasymptomatic patients but in all gunshot victims who are stable\\nenough to go to the scanner. Bullets tend to travel longer distances\\nthan the length of a knifeblade. Imaging of the whole torso is essential to\\ndocument the trajectory of the bullet(s), which could extend beyond the\\nconfines of the abdominal cavity. A missing bullet should prompt the\\nsearch for an extra-abdominal location or a hidden exit wound.\\nFurthermore, a bullet entering the abdomen can significantly damage\\nbony structures (thoracolumbar spine, pelvis, hip, etc.). The information\\ngleaned from these images is often invaluable despite the occasional\\n‘scatter’ caused by a retained metal fragment. Sometimes, it will be\\nseen that the missile’s trajectory is tangential, missing the\\nperitoneal cavity: a laparotomy can be avoided, but semi-elective\\ndebridement of the abdominal wall may prove necessary in some of\\nthese cases.\\n\\n So, if you have an immediate access to the scanner and the\\npatient is not exsanguinating, then use it! The findings can modify\\nyour operative approach and even help you to avoid an operation\\naltogether.\\n\\n Difficult scenarios: the CT scan reigns supreme\\n\\n Stab wounds to the lower chest, the flank or the perineum pose the\\nproblem of possible but clinically occult injury to intra-abdominal viscera:',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nThe likelihood of significant intra-abdominal injuries in gunshot than in stab wounds. This premise, if true, implies merely that shock and peritonitis are more frequently associated with the former than with the latter. Decision-making is then easy. But what about the benign-looking abdomen with a gunshot wound that is encountered nowadays not that infrequently in many large urban trauma centers?\\n\\nThere is accumulating evidence to suggest that initially asymptomatic gunshot victims can be managed safely along the same broad lines as stabbed patients. While the role of initial and serial clinical reassessments is here again very important, we contend that an early CT scan of both the abdomen and chest is mandatory, not only in asymptomatic patients but in all gunshot victims who are stable enough to go to the scanner. Bullets tend to travel longer distances than the length of a knifeblade. Imaging of the whole torso is essential to document the trajectory of the bullet(s), which could extend beyond the confines of the abdominal cavity. A missing bullet should prompt the search for an extra-abdominal location or a hidden exit wound. Furthermore, a bullet entering the abdomen can significantly damage bony structures (thoracolumbar spine, pelvis, hip, etc.). The information gleaned from these images is often invaluable despite the occasional ‘scatter’ caused by a retained metal fragment. Sometimes, it will be seen that the missile’s trajectory is tangential, missing the peritoneal cavity: a laparotomy can be avoided, but semi-elective debridement of the abdominal wall may prove necessary in some of these cases.\\n\\nSo, if you have immediate access to the scanner and the patient is not exsanguinating, then use it! The findings can modify your operative approach and even help you to avoid an operation altogether.\\n\\nDifficult scenarios: the CT scan reigns supreme\\n\\nStab wounds to the lower chest, the flank or the perineum pose the problem of possible but clinically occult injury to intra-abdominal viscera:\\n```\\n\\n## Image Identification and Description\\n\\n*No images or figures were identified on this page.*',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The likelihood of significant intra-abdominal injuries in gunshot than in stab wounds. This premise, if true, implies merely that shock and peritonitis are more frequently associated with the former than with the latter. Decision-making is then easy. But what about the benign-looking abdomen with a gunshot wound that is encountered nowadays not that infrequently in many large urban trauma centers?\\n\\nThere is accumulating evidence to suggest that initially asymptomatic gunshot victims can be managed safely along the same broad lines as stabbed patients. While the role of initial and serial clinical reassessments is here again very important, we contend that an early CT scan of both the abdomen and chest is mandatory, not only in asymptomatic patients but in all gunshot victims who are stable enough to go to the scanner. Bullets tend to travel longer distances than the length of a knifeblade. Imaging of the whole torso is essential to document the trajectory of the bullet(s), which could extend beyond the confines of the abdominal cavity. A missing bullet should prompt the search for an extra-abdominal location or a hidden exit wound. Furthermore, a bullet entering the abdomen can significantly damage bony structures (thoracolumbar spine, pelvis, hip, etc.). The information gleaned from these images is often invaluable despite the occasional ‘scatter’ caused by a retained metal fragment. Sometimes, it will be seen that the missile’s trajectory is tangential, missing the peritoneal cavity: a laparotomy can be avoided, but semi-elective debridement of the abdominal wall may prove necessary in some of these cases.\\n\\nSo, if you have immediate access to the scanner and the patient is not exsanguinating, then use it! The findings can modify your operative approach and even help you to avoid an operation altogether.\\n\\nDifficult scenarios: the CT scan reigns supreme\\n\\nStab wounds to the lower chest, the flank or the perineum pose the problem of possible but clinically occult injury to intra-abdominal viscera:\\n```',\n", " 'md': 'The likelihood of significant intra-abdominal injuries in gunshot than in stab wounds. This premise, if true, implies merely that shock and peritonitis are more frequently associated with the former than with the latter. Decision-making is then easy. But what about the benign-looking abdomen with a gunshot wound that is encountered nowadays not that infrequently in many large urban trauma centers?\\n\\nThere is accumulating evidence to suggest that initially asymptomatic gunshot victims can be managed safely along the same broad lines as stabbed patients. While the role of initial and serial clinical reassessments is here again very important, we contend that an early CT scan of both the abdomen and chest is mandatory, not only in asymptomatic patients but in all gunshot victims who are stable enough to go to the scanner. Bullets tend to travel longer distances than the length of a knifeblade. Imaging of the whole torso is essential to document the trajectory of the bullet(s), which could extend beyond the confines of the abdominal cavity. A missing bullet should prompt the search for an extra-abdominal location or a hidden exit wound. Furthermore, a bullet entering the abdomen can significantly damage bony structures (thoracolumbar spine, pelvis, hip, etc.). The information gleaned from these images is often invaluable despite the occasional ‘scatter’ caused by a retained metal fragment. Sometimes, it will be seen that the missile’s trajectory is tangential, missing the peritoneal cavity: a laparotomy can be avoided, but semi-elective debridement of the abdominal wall may prove necessary in some of these cases.\\n\\nSo, if you have immediate access to the scanner and the patient is not exsanguinating, then use it! The findings can modify your operative approach and even help you to avoid an operation altogether.\\n\\nDifficult scenarios: the CT scan reigns supreme\\n\\nStab wounds to the lower chest, the flank or the perineum pose the problem of possible but clinically occult injury to intra-abdominal viscera:\\n```',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.82, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 408, 'y': 237, 'w': 28, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*',\n", " 'md': '*No images or figures were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 575,\n", " 'text': '• The diaphragm. An isolated diaphragmatic laceration is often at first\\n clinically silent but is sometimes complicated by a secondary\\n diaphragmatic hernia. This complication is more likely to occur on\\n the left than on the right side which is relatively shielded by the bulk\\n of the liver. Little is known about the natural history of diaphragmatic\\n wounds but very small ones are probably often missed with\\n impunity. It is, however, the standard of care to look for them\\n whenever a stab wound is located in the lower chest or upper\\n abdomen (especially on the left side). In this scenario, if there\\n are no other clinical reasons to operate, then a thoracoscopy or\\n a laparoscopy should be performed during the patient’s\\n hospital stay to check the integrity of the diaphragm; if a\\n laceration is identified, it should be repaired at laparotomy (or\\n laparoscopically if you are able to do it). Reconstructed coronal CT\\n scan views of the diaphragmatic domes can also be very helpful\\n and, if available, are already supplanting laparoscopy.\\n• The flank. A stab wound to the flank can involve the retroperitoneal\\n portion of the duodenum or colon and the kidney. Peritoneal signs\\n are present only at a late stage (sometimes too late, associated with\\n advanced retroperitoneal infection). Therefore, a CT scan must\\n always be obtained early (there is no longer any need for a\\n combined contrast enema). An injury to the kidney is often benign\\n and is usually associated with frank hematuria. The possibility of a\\n ureteric injury is more serious and must be entertained in the\\n presence of microscopic hematuria. Nowadays, the CT scan has\\n supplanted the intravenous pyelogram (IVP) as the screening\\n investigation of choice in suspected injuries to the urinary tract.\\n• The perineum. Abdominal penetration must always be suspected. A\\n digital rectal exam looking for rectal bleeding is a mandatory\\n component of the clinical examination. A CT scan is helpful and\\n may need to be supplemented by rectosigmoidoscopy.\\n• Patients with multiple stab or gunshot wounds to both the\\n chest and abdomen may constitute a dilemma in the choice or\\n sequencing of the operations if both the chest and abdomen are\\n possible candidates for the source of severe hemorrhage; this is\\n particularly the case if they are unstable and unfit for transfer to the\\n CT scanner. Alternatively, one can come across a patient with a high\\n epigastric stab wound and hypotension in whom the possibility of a',\n", " 'md': '```markdown\\n# Diaphragmatic and Abdominal Injuries\\n\\n## The Diaphragm\\nAn isolated diaphragmatic laceration is often clinically silent at first but can be complicated by a secondary diaphragmatic hernia. This complication is more likely to occur on the left side than on the right, which is relatively shielded by the bulk of the liver. Little is known about the natural history of diaphragmatic wounds, but very small ones are probably often missed with impunity. It is, however, the standard of care to look for them whenever a stab wound is located in the lower chest or upper abdomen (especially on the left side). In this scenario, if there are no other clinical reasons to operate, then a thoracoscopy or a laparoscopy should be performed during the patient’s hospital stay to check the integrity of the diaphragm; if a laceration is identified, it should be repaired at laparotomy (or laparoscopically if you are able to do it). Reconstructed coronal CT scan views of the diaphragmatic domes can also be very helpful and, if available, are already supplanting laparoscopy.\\n\\n## The Flank\\nA stab wound to the flank can involve the retroperitoneal portion of the duodenum or colon and the kidney. Peritoneal signs are present only at a late stage (sometimes too late, associated with advanced retroperitoneal infection). Therefore, a CT scan must always be obtained early (there is no longer any need for a combined contrast enema). An injury to the kidney is often benign and is usually associated with frank hematuria. The possibility of a ureteric injury is more serious and must be entertained in the presence of microscopic hematuria. Nowadays, the CT scan has supplanted the intravenous pyelogram (IVP) as the screening investigation of choice in suspected injuries to the urinary tract.\\n\\n## The Perineum\\nAbdominal penetration must always be suspected. A digital rectal exam looking for rectal bleeding is a mandatory component of the clinical examination. A CT scan is helpful and may need to be supplemented by rectosigmoidoscopy.\\n\\n## Multiple Injuries\\nPatients with multiple stab or gunshot wounds to both the chest and abdomen may constitute a dilemma in the choice or sequencing of the operations if both the chest and abdomen are possible candidates for the source of severe hemorrhage; this is particularly the case if they are unstable and unfit for transfer to the CT scanner. Alternatively, one can come across a patient with a high epigastric stab wound and hypotension in whom the possibility of a...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Diaphragmatic and Abdominal Injuries',\n", " 'md': '# Diaphragmatic and Abdominal Injuries',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Diaphragm',\n", " 'md': '## The Diaphragm',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'An isolated diaphragmatic laceration is often clinically silent at first but can be complicated by a secondary diaphragmatic hernia. This complication is more likely to occur on the left side than on the right, which is relatively shielded by the bulk of the liver. Little is known about the natural history of diaphragmatic wounds, but very small ones are probably often missed with impunity. It is, however, the standard of care to look for them whenever a stab wound is located in the lower chest or upper abdomen (especially on the left side). In this scenario, if there are no other clinical reasons to operate, then a thoracoscopy or a laparoscopy should be performed during the patient’s hospital stay to check the integrity of the diaphragm; if a laceration is identified, it should be repaired at laparotomy (or laparoscopically if you are able to do it). Reconstructed coronal CT scan views of the diaphragmatic domes can also be very helpful and, if available, are already supplanting laparoscopy.',\n", " 'md': 'An isolated diaphragmatic laceration is often clinically silent at first but can be complicated by a secondary diaphragmatic hernia. This complication is more likely to occur on the left side than on the right, which is relatively shielded by the bulk of the liver. Little is known about the natural history of diaphragmatic wounds, but very small ones are probably often missed with impunity. It is, however, the standard of care to look for them whenever a stab wound is located in the lower chest or upper abdomen (especially on the left side). In this scenario, if there are no other clinical reasons to operate, then a thoracoscopy or a laparoscopy should be performed during the patient’s hospital stay to check the integrity of the diaphragm; if a laceration is identified, it should be repaired at laparotomy (or laparoscopically if you are able to do it). Reconstructed coronal CT scan views of the diaphragmatic domes can also be very helpful and, if available, are already supplanting laparoscopy.',\n", " 'bBox': {'x': 100, 'y': 152, 'w': 436.85, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Flank',\n", " 'md': '## The Flank',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A stab wound to the flank can involve the retroperitoneal portion of the duodenum or colon and the kidney. Peritoneal signs are present only at a late stage (sometimes too late, associated with advanced retroperitoneal infection). Therefore, a CT scan must always be obtained early (there is no longer any need for a combined contrast enema). An injury to the kidney is often benign and is usually associated with frank hematuria. The possibility of a ureteric injury is more serious and must be entertained in the presence of microscopic hematuria. Nowadays, the CT scan has supplanted the intravenous pyelogram (IVP) as the screening investigation of choice in suspected injuries to the urinary tract.',\n", " 'md': 'A stab wound to the flank can involve the retroperitoneal portion of the duodenum or colon and the kidney. Peritoneal signs are present only at a late stage (sometimes too late, associated with advanced retroperitoneal infection). Therefore, a CT scan must always be obtained early (there is no longer any need for a combined contrast enema). An injury to the kidney is often benign and is usually associated with frank hematuria. The possibility of a ureteric injury is more serious and must be entertained in the presence of microscopic hematuria. Nowadays, the CT scan has supplanted the intravenous pyelogram (IVP) as the screening investigation of choice in suspected injuries to the urinary tract.',\n", " 'bBox': {'x': 100, 'y': 386, 'w': 436.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Perineum',\n", " 'md': '## The Perineum',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Abdominal penetration must always be suspected. A digital rectal exam looking for rectal bleeding is a mandatory component of the clinical examination. A CT scan is helpful and may need to be supplemented by rectosigmoidoscopy.',\n", " 'md': 'Abdominal penetration must always be suspected. A digital rectal exam looking for rectal bleeding is a mandatory component of the clinical examination. A CT scan is helpful and may need to be supplemented by rectosigmoidoscopy.',\n", " 'bBox': {'x': 100, 'y': 571, 'w': 437.05, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Multiple Injuries',\n", " 'md': '## Multiple Injuries',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Patients with multiple stab or gunshot wounds to both the chest and abdomen may constitute a dilemma in the choice or sequencing of the operations if both the chest and abdomen are possible candidates for the source of severe hemorrhage; this is particularly the case if they are unstable and unfit for transfer to the CT scanner. Alternatively, one can come across a patient with a high epigastric stab wound and hypotension in whom the possibility of a...\\n```',\n", " 'md': 'Patients with multiple stab or gunshot wounds to both the chest and abdomen may constitute a dilemma in the choice or sequencing of the operations if both the chest and abdomen are possible candidates for the source of severe hemorrhage; this is particularly the case if they are unstable and unfit for transfer to the CT scanner. Alternatively, one can come across a patient with a high epigastric stab wound and hypotension in whom the possibility of a...\\n```',\n", " 'bBox': {'x': 100, 'y': 674, 'w': 436.95, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 576,\n", " 'text': ' cardiac tamponade should be entertained. In these cases, an\\n ultrasound scan in the emergency room (focused assessment\\n with sonography in trauma [FAST]) may help to formulate a\\n logical management plan. FAST is used more frequently in blunt\\n trauma and will be discussed in the next section.\\n\\n What to do when CT scanning is not available?\\n\\n Some of you readers from developing countries may not have\\nunrestricted access to emergency CT scans. The great majority of\\npenetrating trauma victims can be managed by the combination of\\nthree diagnostic modalities: clinical examination, an upright chest\\nX-ray and, yes, exploratory laparotomy, the latter being resorted to\\nmore liberally whenever in doubt. Keep the threshold for intervention low.\\nThe acceptable price to pay, in this context, is a higher rate of\\nunnecessary laparotomies rather than missed injuries. In patients with a\\nflank injury or hematuria, a one-shot IVP in the emergency room is easy\\nto perform and very useful (especially in confirming the presence of a\\nfunctioning kidney on the uninjured side).\\n\\n To recap…\\n\\n Clinical evaluation (including vital signs assessment and abdominal\\nexamination) retains to this day its primacy in the management of\\npenetrating abdominal trauma. There are clear-cut clinical scenarios\\nrequiring immediate laparotomy. In other situations, clinical observation\\nremains extremely valuable. In recent years, abdominal CT scanning has\\nestablished itself as the best diagnostic adjunct. Know when to operate\\nand when not to ( Figure 32.1)!',\n", " 'md': '```markdown\\n## Management of Penetrating Abdominal Trauma\\n\\nCardiac tamponade should be entertained. In these cases, an ultrasound scan in the emergency room (focused assessment with sonography in trauma [FAST]) may help to formulate a logical management plan. FAST is used more frequently in blunt trauma and will be discussed in the next section.\\n\\n### What to do when CT scanning is not available?\\n\\nSome of you readers from developing countries may not have unrestricted access to emergency CT scans. The great majority of penetrating trauma victims can be managed by the combination of three diagnostic modalities: clinical examination, an upright chest X-ray, and, yes, exploratory laparotomy, the latter being resorted to more liberally whenever in doubt. Keep the threshold for intervention low. The acceptable price to pay, in this context, is a higher rate of unnecessary laparotomies rather than missed injuries. In patients with a flank injury or hematuria, a one-shot IVP in the emergency room is easy to perform and very useful (especially in confirming the presence of a functioning kidney on the uninjured side).\\n\\n### To recap…\\n\\nClinical evaluation (including vital signs assessment and abdominal examination) retains to this day its primacy in the management of penetrating abdominal trauma. There are clear-cut clinical scenarios requiring immediate laparotomy. In other situations, clinical observation remains extremely valuable. In recent years, abdominal CT scanning has established itself as the best diagnostic adjunct. Know when to operate and when not to (Figure 32.1)!\\n\\n### Figure 32.1\\n*Description*: This figure likely illustrates a clinical decision-making process or flowchart related to the management of penetrating abdominal trauma, emphasizing the importance of clinical evaluation and the use of diagnostic modalities. The specific content of the figure is not provided in the text.\\n\\n*Summary*: The figure serves as a visual aid to reinforce the key points discussed regarding the management of penetrating abdominal trauma, particularly in the context of when to operate and when to observe.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Penetrating Abdominal Trauma',\n", " 'md': '## Management of Penetrating Abdominal Trauma',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Cardiac tamponade should be entertained. In these cases, an ultrasound scan in the emergency room (focused assessment with sonography in trauma [FAST]) may help to formulate a logical management plan. FAST is used more frequently in blunt trauma and will be discussed in the next section.',\n", " 'md': 'Cardiac tamponade should be entertained. In these cases, an ultrasound scan in the emergency room (focused assessment with sonography in trauma [FAST]) may help to formulate a logical management plan. FAST is used more frequently in blunt trauma and will be discussed in the next section.',\n", " 'bBox': {'x': 100, 'y': 152, 'w': 308.65, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'What to do when CT scanning is not available?',\n", " 'md': '### What to do when CT scanning is not available?',\n", " 'bBox': {'x': 86, 'y': 197, 'w': 369.6, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Some of you readers from developing countries may not have unrestricted access to emergency CT scans. The great majority of penetrating trauma victims can be managed by the combination of three diagnostic modalities: clinical examination, an upright chest X-ray, and, yes, exploratory laparotomy, the latter being resorted to more liberally whenever in doubt. Keep the threshold for intervention low. The acceptable price to pay, in this context, is a higher rate of unnecessary laparotomies rather than missed injuries. In patients with a flank injury or hematuria, a one-shot IVP in the emergency room is easy to perform and very useful (especially in confirming the presence of a functioning kidney on the uninjured side).',\n", " 'md': 'Some of you readers from developing countries may not have unrestricted access to emergency CT scans. The great majority of penetrating trauma victims can be managed by the combination of three diagnostic modalities: clinical examination, an upright chest X-ray, and, yes, exploratory laparotomy, the latter being resorted to more liberally whenever in doubt. Keep the threshold for intervention low. The acceptable price to pay, in this context, is a higher rate of unnecessary laparotomies rather than missed injuries. In patients with a flank injury or hematuria, a one-shot IVP in the emergency room is easy to perform and very useful (especially in confirming the presence of a functioning kidney on the uninjured side).',\n", " 'bBox': {'x': 72, 'y': 316, 'w': 467.8, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'To recap…',\n", " 'md': '### To recap…',\n", " 'bBox': {'x': 86, 'y': 441, 'w': 84.31, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Clinical evaluation (including vital signs assessment and abdominal examination) retains to this day its primacy in the management of penetrating abdominal trauma. There are clear-cut clinical scenarios requiring immediate laparotomy. In other situations, clinical observation remains extremely valuable. In recent years, abdominal CT scanning has established itself as the best diagnostic adjunct. Know when to operate and when not to (Figure 32.1)!',\n", " 'md': 'Clinical evaluation (including vital signs assessment and abdominal examination) retains to this day its primacy in the management of penetrating abdominal trauma. There are clear-cut clinical scenarios requiring immediate laparotomy. In other situations, clinical observation remains extremely valuable. In recent years, abdominal CT scanning has established itself as the best diagnostic adjunct. Know when to operate and when not to (Figure 32.1)!',\n", " 'bBox': {'x': 72, 'y': 543, 'w': 467.9, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 32.1',\n", " 'md': '### Figure 32.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*Description*: This figure likely illustrates a clinical decision-making process or flowchart related to the management of penetrating abdominal trauma, emphasizing the importance of clinical evaluation and the use of diagnostic modalities. The specific content of the figure is not provided in the text.\\n\\n*Summary*: The figure serves as a visual aid to reinforce the key points discussed regarding the management of penetrating abdominal trauma, particularly in the context of when to operate and when to observe.\\n```',\n", " 'md': '*Description*: This figure likely illustrates a clinical decision-making process or flowchart related to the management of penetrating abdominal trauma, emphasizing the importance of clinical evaluation and the use of diagnostic modalities. The specific content of the figure is not provided in the text.\\n\\n*Summary*: The figure serves as a visual aid to reinforce the key points discussed regarding the management of penetrating abdominal trauma, particularly in the context of when to operate and when to observe.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 577,\n", " 'text': ' PERYA2s 14\\nFigure 32.1. “Let’s be conservative!”\\n\\n Failure to promptly recognize and treat simple life-\\n threatening injuries is the tragedy of trauma, not the inability\\n to handle the catastrophic or complicated injury.\\n F. William Blaisdell\\n\\n Editorial comment: Ari\\n I would like to mention here three ‘special forms’ of penetrating trauma which may need a\\n different approach: impalement injury, shotgun and pellet gun injuries.\\n\\n Impalement injuries\\n Impalement injuries are caused by penetration of the body by an object that usually is retained\\n in situ. It can be a steel rod ( Figure 32.2), piece of wood, or even an AK-47 ( Figure 32.3).\\n The most common causes are accidental falls or collisions, violence or sexually perverted acts\\n — did you ever hear about Vlad the Impaler? Typically, they cause complex and multiple organ\\n injuries, and require some special attention during transport and at treatment in the hospital.',\n", " 'md': '```markdown\\n# Page 14\\n\\n**Figure 32.1**: “Let’s be conservative!”\\n\\n> Failure to promptly recognize and treat simple life-threatening injuries is the tragedy of trauma, not the inability to handle the catastrophic or complicated injury.\\n> — F. William Blaisdell\\n\\n**Editorial comment**: Ari\\nI would like to mention here three ‘special forms’ of penetrating trauma which may need a different approach: impalement injury, shotgun, and pellet gun injuries.\\n\\n## Impalement Injuries\\nImpalement injuries are caused by penetration of the body by an object that usually is retained in situ. It can be a steel rod (Figure 32.2), piece of wood, or even an AK-47 (Figure 32.3). The most common causes are accidental falls or collisions, violence, or sexually perverted acts — did you ever hear about Vlad the Impaler? Typically, they cause complex and multiple organ injuries and require some special attention during transport and at treatment in the hospital.\\n```\\n\\n### Image Descriptions\\n- **Figure 32.2**: Description of an impalement injury involving a steel rod. The image likely illustrates the injury and its context.\\n- **Figure 32.3**: Description of an impalement injury involving an AK-47. The image likely illustrates the injury and its context.',\n", " 'images': [{'name': 'img_p576_1.png',\n", " 'height': 526,\n", " 'width': 796,\n", " 'x': 109.4399999999996,\n", " 'y': 82.79999999999995,\n", " 'original_width': 1368,\n", " 'original_height': 904}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page 14',\n", " 'md': '# Page 14',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 32.1**: “Let’s be conservative!”\\n\\n> Failure to promptly recognize and treat simple life-threatening injuries is the tragedy of trauma, not the inability to handle the catastrophic or complicated injury.\\n> — F. William Blaisdell\\n\\n**Editorial comment**: Ari\\nI would like to mention here three ‘special forms’ of penetrating trauma which may need a different approach: impalement injury, shotgun, and pellet gun injuries.',\n", " 'md': '**Figure 32.1**: “Let’s be conservative!”\\n\\n> Failure to promptly recognize and treat simple life-threatening injuries is the tragedy of trauma, not the inability to handle the catastrophic or complicated injury.\\n> — F. William Blaisdell\\n\\n**Editorial comment**: Ari\\nI would like to mention here three ‘special forms’ of penetrating trauma which may need a different approach: impalement injury, shotgun, and pellet gun injuries.',\n", " 'bBox': {'x': 108, 'y': 405, 'w': 381.29, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Impalement Injuries',\n", " 'md': '## Impalement Injuries',\n", " 'bBox': {'x': 77, 'y': 584, 'w': 135.11, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Impalement injuries are caused by penetration of the body by an object that usually is retained in situ. It can be a steel rod (Figure 32.2), piece of wood, or even an AK-47 (Figure 32.3). The most common causes are accidental falls or collisions, violence, or sexually perverted acts — did you ever hear about Vlad the Impaler? Typically, they cause complex and multiple organ injuries and require some special attention during transport and at treatment in the hospital.\\n```',\n", " 'md': 'Impalement injuries are caused by penetration of the body by an object that usually is retained in situ. It can be a steel rod (Figure 32.2), piece of wood, or even an AK-47 (Figure 32.3). The most common causes are accidental falls or collisions, violence, or sexually perverted acts — did you ever hear about Vlad the Impaler? Typically, they cause complex and multiple organ injuries and require some special attention during transport and at treatment in the hospital.\\n```',\n", " 'bBox': {'x': 77, 'y': 405, 'w': 457.58, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Descriptions',\n", " 'md': '### Image Descriptions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 32.2**: Description of an impalement injury involving a steel rod. The image likely illustrates the injury and its context.\\n- **Figure 32.3**: Description of an impalement injury involving an AK-47. The image likely illustrates the injury and its context.',\n", " 'md': '- **Figure 32.2**: Description of an impalement injury involving a steel rod. The image likely illustrates the injury and its context.\\n- **Figure 32.3**: Description of an impalement injury involving an AK-47. The image likely illustrates the injury and its context.',\n", " 'bBox': {'x': 332, 'y': 405, 'w': 28, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 578,\n", " 'text': 'The basic rule is that the impaled object should not be\\nmanipulated or removed during transport or at the ER, but it is\\nimportant that it is stabilized securely. If possible and needed, it can be\\nshortened. Because they are always contaminated, antibiotic and tetanus prophylaxis should be\\nadministered.\\n\\nVirtually all patients require surgery; those in shock need to go the\\nOR immediately. The positioning of the patient may require special supports and\\nmodifications of the standard techniques. The object must remain secured and\\nin place until everything is ready; premature removal of the object\\nmay cause the release of a tamponade from a major vascular\\nstructure! Use unconventional incisions if needed. Once the object has been removed, the\\nstandard routine for exploration and repair of all injuries is performed like for any other trauma.\\n\\nFigure 32.2. Impalement injury: steel rod.',\n", " 'md': '```markdown\\n## Page Content\\n\\nThe basic rule is that the impaled object should not be manipulated or removed during transport or at the ER, but it is important that it is stabilized securely. If possible and needed, it can be shortened. Because they are always contaminated, antibiotic and tetanus prophylaxis should be administered.\\n\\nVirtually all patients require surgery; those in shock need to go to the OR immediately. The positioning of the patient may require special supports and modifications of the standard techniques. The object must remain secured and in place until everything is ready; premature removal of the object may cause the release of a tamponade from a major vascular structure! Use unconventional incisions if needed. Once the object has been removed, the standard routine for exploration and repair of all injuries is performed like for any other trauma.\\n\\n### Figure 32.2\\n**Description:** Impalement injury: steel rod. This figure likely illustrates a medical scenario involving a steel rod impaled in a patient, emphasizing the importance of stabilization and surgical intervention.\\n\\n**Summary:** The image depicts a clinical case of an impalement injury, highlighting the critical nature of handling such injuries in emergency situations.\\n```',\n", " 'images': [{'name': 'img_p577_1.png',\n", " 'height': 434,\n", " 'width': 402,\n", " 'x': 206.63999999999942,\n", " 'y': 334.8,\n", " 'original_width': 920,\n", " 'original_height': 992}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The basic rule is that the impaled object should not be manipulated or removed during transport or at the ER, but it is important that it is stabilized securely. If possible and needed, it can be shortened. Because they are always contaminated, antibiotic and tetanus prophylaxis should be administered.\\n\\nVirtually all patients require surgery; those in shock need to go to the OR immediately. The positioning of the patient may require special supports and modifications of the standard techniques. The object must remain secured and in place until everything is ready; premature removal of the object may cause the release of a tamponade from a major vascular structure! Use unconventional incisions if needed. Once the object has been removed, the standard routine for exploration and repair of all injuries is performed like for any other trauma.',\n", " 'md': 'The basic rule is that the impaled object should not be manipulated or removed during transport or at the ER, but it is important that it is stabilized securely. If possible and needed, it can be shortened. Because they are always contaminated, antibiotic and tetanus prophylaxis should be administered.\\n\\nVirtually all patients require surgery; those in shock need to go to the OR immediately. The positioning of the patient may require special supports and modifications of the standard techniques. The object must remain secured and in place until everything is ready; premature removal of the object may cause the release of a tamponade from a major vascular structure! Use unconventional incisions if needed. Once the object has been removed, the standard routine for exploration and repair of all injuries is performed like for any other trauma.',\n", " 'bBox': {'x': 77, 'y': 87, 'w': 457.76, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 32.2',\n", " 'md': '### Figure 32.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** Impalement injury: steel rod. This figure likely illustrates a medical scenario involving a steel rod impaled in a patient, emphasizing the importance of stabilization and surgical intervention.\\n\\n**Summary:** The image depicts a clinical case of an impalement injury, highlighting the critical nature of handling such injuries in emergency situations.\\n```',\n", " 'md': '**Description:** Impalement injury: steel rod. This figure likely illustrates a medical scenario involving a steel rod impaled in a patient, emphasizing the importance of stabilization and surgical intervention.\\n\\n**Summary:** The image depicts a clinical case of an impalement injury, highlighting the critical nature of handling such injuries in emergency situations.\\n```',\n", " 'bBox': {'x': 77, 'y': 87, 'w': 54.37, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 579,\n", " 'text': 'Figure 32.3. Impalement injury: AK-47.\\n\\nShotgun injuries\\nShotgun injuries form a special type of penetrating injury because of the unique ballistic\\nproperties resulting in a wide range of injuries from trivial to the most severe ones. Although\\nthere are many things that affect the severity, the range is the most\\nimportant. The point-blank or close-range shotgun injuries (less than 3 yards… a yard\\nbeing almost a meter) cause massive tissue destruction in a fairly tight pattern and are often\\nfatal, if hitting vital structures. Surgery, even only for debridement, is\\nmandatory. Often it also involves removal of the embedded foreign material such as the\\nvictim’s clothing.\\n\\nInjuries from close to middle range (3 to 7 yards) will usually\\npenetrate the abdominal wall and cause injuries to the internal\\norgans. Laparotomy is nearly always the safest option. Shotgun injuries\\nfrom 7 to 20 yards usually produce a scattered wound and are capable of penetrating the skin\\nand fascia. These patients need close observation, whereas asymptomatic patients with long-\\nrange shotgun injuries (more than 20 yards) seldom need treatment other than managing the',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Shotgun Injuries\\n\\nShotgun injuries form a special type of penetrating injury because of the unique ballistic properties resulting in a wide range of injuries from trivial to the most severe ones. Although there are many things that affect the severity, the range is the most important.\\n\\n- **Point-Blank or Close-Range Injuries**:\\n- Less than 3 yards (a yard being almost a meter) cause massive tissue destruction in a fairly tight pattern and are often fatal if hitting vital structures.\\n- Surgery, even only for debridement, is mandatory. Often it also involves removal of the embedded foreign material such as the victim’s clothing.\\n\\n- **Close to Middle Range Injuries**:\\n- 3 to 7 yards usually penetrate the abdominal wall and cause injuries to the internal organs.\\n- Laparotomy is nearly always the safest option.\\n\\n- **Wounds from 7 to 20 Yards**:\\n- Usually produce a scattered wound and are capable of penetrating the skin and fascia.\\n- These patients need close observation.\\n\\n- **Long-Range Shotgun Injuries**:\\n- More than 20 yards seldom need treatment other than managing the .\\n\\n## Figures\\n\\n### Figure 32.3\\n- **Description**: Impalement injury caused by an AK-47.\\n- **Summary**: This figure illustrates the nature of impalement injuries, specifically those resulting from gunshot wounds, highlighting the severity and implications of such injuries.\\n```',\n", " 'images': [{'name': 'img_p578_1.png',\n", " 'height': 510,\n", " 'width': 672,\n", " 'x': 139.67999999999938,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1155,\n", " 'original_height': 874}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Shotgun Injuries',\n", " 'md': '## Shotgun Injuries',\n", " 'bBox': {'x': 77, 'y': 408, 'w': 113.48, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Shotgun injuries form a special type of penetrating injury because of the unique ballistic properties resulting in a wide range of injuries from trivial to the most severe ones. Although there are many things that affect the severity, the range is the most important.\\n\\n- **Point-Blank or Close-Range Injuries**:\\n- Less than 3 yards (a yard being almost a meter) cause massive tissue destruction in a fairly tight pattern and are often fatal if hitting vital structures.\\n- Surgery, even only for debridement, is mandatory. Often it also involves removal of the embedded foreign material such as the victim’s clothing.\\n\\n- **Close to Middle Range Injuries**:\\n- 3 to 7 yards usually penetrate the abdominal wall and cause injuries to the internal organs.\\n- Laparotomy is nearly always the safest option.\\n\\n- **Wounds from 7 to 20 Yards**:\\n- Usually produce a scattered wound and are capable of penetrating the skin and fascia.\\n- These patients need close observation.\\n\\n- **Long-Range Shotgun Injuries**:\\n- More than 20 yards seldom need treatment other than managing the .',\n", " 'md': 'Shotgun injuries form a special type of penetrating injury because of the unique ballistic properties resulting in a wide range of injuries from trivial to the most severe ones. Although there are many things that affect the severity, the range is the most important.\\n\\n- **Point-Blank or Close-Range Injuries**:\\n- Less than 3 yards (a yard being almost a meter) cause massive tissue destruction in a fairly tight pattern and are often fatal if hitting vital structures.\\n- Surgery, even only for debridement, is mandatory. Often it also involves removal of the embedded foreign material such as the victim’s clothing.\\n\\n- **Close to Middle Range Injuries**:\\n- 3 to 7 yards usually penetrate the abdominal wall and cause injuries to the internal organs.\\n- Laparotomy is nearly always the safest option.\\n\\n- **Wounds from 7 to 20 Yards**:\\n- Usually produce a scattered wound and are capable of penetrating the skin and fascia.\\n- These patients need close observation.\\n\\n- **Long-Range Shotgun Injuries**:\\n- More than 20 yards seldom need treatment other than managing the .',\n", " 'bBox': {'x': 77, 'y': 408, 'w': 457.77, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures',\n", " 'md': '## Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 32.3',\n", " 'md': '### Figure 32.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: Impalement injury caused by an AK-47.\\n- **Summary**: This figure illustrates the nature of impalement injuries, specifically those resulting from gunshot wounds, highlighting the severity and implications of such injuries.\\n```',\n", " 'md': '- **Description**: Impalement injury caused by an AK-47.\\n- **Summary**: This figure illustrates the nature of impalement injuries, specifically those resulting from gunshot wounds, highlighting the severity and implications of such injuries.\\n```',\n", " 'bBox': {'x': 522, 'y': 537, 'w': 12, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 580,\n", " 'text': 'superficial wounds.\\n\\nIn patients needing urgent surgery (close-range injuries, usually lateral in those surviving to the\\nhospital) and where evisceration is often present, a transverse incision is preferred to facilitate\\nlater abdominal closure, because of the extensive debridement required. In middle-range\\ninjuries a formal midline laparotomy can be performed, the abdomen explored and injuries\\nrepaired like in other penetrating gunshot wounds. Special care must be taken to\\nrun the whole small bowel completely and repair all perforations,\\nbecause small pellets can travel between the leaves of the\\nmesentery and cause small perforations that are difficult to see.\\n\\nAir gun pellet injuries\\nAir and paintball gun activities have become very popular among the Rambo-generation\\nadolescents and like-minded grown-ups, and more than 30,000 air gun injuries occur annually\\nin the United States — where in some states killing innocent squirrels seems a national hobby.\\nThese non-powder guns employ the power of compressed air to launch a projectile, mostly of a\\nlow velocity. Although deemed harmless, there are many reports of\\nserious morbidity or even deaths after air weapon injuries.\\nWhile the injuries were seldom dangerous in the past unless hitting the eye or other poorly\\nprotected areas in the head, modern air guns have the capability of\\ncausing penetrating abdominal injuries with hollow organ\\nperforations.\\nPatients with one or multiple pellet injury signs over the abdomen must undergo a thorough\\nclinical examination. It is useful to know the type of gun used as well as the distance from where\\nthe shots came. The longer the distance, the less likely there will be a penetrating injury\\nbecause pellets, due to their ballistic properties, rapidly lose their velocity. Any signs of severe\\n(intra-abdominal) bleeding or generalized tenderness should alert to the possibility of a\\npenetrating vascular or hollow organ injury best treated with early laparotomy. Other (stable)\\npatients should undergo radiological imaging like regular penetrating trauma patients.\\n\\nObvious subcutaneous pellets can be removed. Patients with suspected or verified intra-\\nabdominal pellets should be admitted for observation unless urgent surgery is indicated for',\n", " 'md': '```markdown\\n## Superficial Wounds\\n\\nIn patients needing urgent surgery (close-range injuries, usually lateral in those surviving to the hospital) and where evisceration is often present, a transverse incision is preferred to facilitate later abdominal closure, because of the extensive debridement required. In middle-range injuries, a formal midline laparotomy can be performed, the abdomen explored, and injuries repaired like in other penetrating gunshot wounds. Special care must be taken to run the whole small bowel completely and repair all perforations, because small pellets can travel between the leaves of the mesentery and cause small perforations that are difficult to see.\\n\\n### Air Gun Pellet Injuries\\n\\nAir and paintball gun activities have become very popular among the Rambo-generation adolescents and like-minded grown-ups, and more than 30,000 air gun injuries occur annually in the United States — where in some states killing innocent squirrels seems a national hobby. These non-powder guns employ the power of compressed air to launch a projectile, mostly of a low velocity. Although deemed harmless, there are many reports of serious morbidity or even deaths after air weapon injuries. While the injuries were seldom dangerous in the past unless hitting the eye or other poorly protected areas in the head, modern air guns have the capability of causing penetrating abdominal injuries with hollow organ perforations.\\n\\nPatients with one or multiple pellet injury signs over the abdomen must undergo a thorough clinical examination. It is useful to know the type of gun used as well as the distance from where the shots came. The longer the distance, the less likely there will be a penetrating injury because pellets, due to their ballistic properties, rapidly lose their velocity. Any signs of severe (intra-abdominal) bleeding or generalized tenderness should alert to the possibility of a penetrating vascular or hollow organ injury best treated with early laparotomy. Other (stable) patients should undergo radiological imaging like regular penetrating trauma patients.\\n\\nObvious subcutaneous pellets can be removed. Patients with suspected or verified intra-abdominal pellets should be admitted for observation unless urgent surgery is indicated.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Superficial Wounds',\n", " 'md': '## Superficial Wounds',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In patients needing urgent surgery (close-range injuries, usually lateral in those surviving to the hospital) and where evisceration is often present, a transverse incision is preferred to facilitate later abdominal closure, because of the extensive debridement required. In middle-range injuries, a formal midline laparotomy can be performed, the abdomen explored, and injuries repaired like in other penetrating gunshot wounds. Special care must be taken to run the whole small bowel completely and repair all perforations, because small pellets can travel between the leaves of the mesentery and cause small perforations that are difficult to see.',\n", " 'md': 'In patients needing urgent surgery (close-range injuries, usually lateral in those surviving to the hospital) and where evisceration is often present, a transverse incision is preferred to facilitate later abdominal closure, because of the extensive debridement required. In middle-range injuries, a formal midline laparotomy can be performed, the abdomen explored, and injuries repaired like in other penetrating gunshot wounds. Special care must be taken to run the whole small bowel completely and repair all perforations, because small pellets can travel between the leaves of the mesentery and cause small perforations that are difficult to see.',\n", " 'bBox': {'x': 77, 'y': 116, 'w': 457.8, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Air Gun Pellet Injuries',\n", " 'md': '### Air Gun Pellet Injuries',\n", " 'bBox': {'x': 77, 'y': 285, 'w': 147.06, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Air and paintball gun activities have become very popular among the Rambo-generation adolescents and like-minded grown-ups, and more than 30,000 air gun injuries occur annually in the United States — where in some states killing innocent squirrels seems a national hobby. These non-powder guns employ the power of compressed air to launch a projectile, mostly of a low velocity. Although deemed harmless, there are many reports of serious morbidity or even deaths after air weapon injuries. While the injuries were seldom dangerous in the past unless hitting the eye or other poorly protected areas in the head, modern air guns have the capability of causing penetrating abdominal injuries with hollow organ perforations.\\n\\nPatients with one or multiple pellet injury signs over the abdomen must undergo a thorough clinical examination. It is useful to know the type of gun used as well as the distance from where the shots came. The longer the distance, the less likely there will be a penetrating injury because pellets, due to their ballistic properties, rapidly lose their velocity. Any signs of severe (intra-abdominal) bleeding or generalized tenderness should alert to the possibility of a penetrating vascular or hollow organ injury best treated with early laparotomy. Other (stable) patients should undergo radiological imaging like regular penetrating trauma patients.\\n\\nObvious subcutaneous pellets can be removed. Patients with suspected or verified intra-abdominal pellets should be admitted for observation unless urgent surgery is indicated.\\n```',\n", " 'md': 'Air and paintball gun activities have become very popular among the Rambo-generation adolescents and like-minded grown-ups, and more than 30,000 air gun injuries occur annually in the United States — where in some states killing innocent squirrels seems a national hobby. These non-powder guns employ the power of compressed air to launch a projectile, mostly of a low velocity. Although deemed harmless, there are many reports of serious morbidity or even deaths after air weapon injuries. While the injuries were seldom dangerous in the past unless hitting the eye or other poorly protected areas in the head, modern air guns have the capability of causing penetrating abdominal injuries with hollow organ perforations.\\n\\nPatients with one or multiple pellet injury signs over the abdomen must undergo a thorough clinical examination. It is useful to know the type of gun used as well as the distance from where the shots came. The longer the distance, the less likely there will be a penetrating injury because pellets, due to their ballistic properties, rapidly lose their velocity. Any signs of severe (intra-abdominal) bleeding or generalized tenderness should alert to the possibility of a penetrating vascular or hollow organ injury best treated with early laparotomy. Other (stable) patients should undergo radiological imaging like regular penetrating trauma patients.\\n\\nObvious subcutaneous pellets can be removed. Patients with suspected or verified intra-abdominal pellets should be admitted for observation unless urgent surgery is indicated.\\n```',\n", " 'bBox': {'x': 77, 'y': 234, 'w': 457.76, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 581,\n", " 'text': 'shock or peritonitis. Although there are reports of successful ‘expectant observation’ of\\nasymptomatic patients with pellets penetrating the colon and passing per rectum 12 hours later,\\nthe post-traumatic phase after pellet injuries can be subtle with signs of infection appearing later\\nthan with more powerful gunshot wounds of the abdomen. Most surgeons do not\\nwant to wait and take the risk, but prefer early laparotomy to\\nexplore and repair the injuries. Ari\\n\\n 2 Blunt abdominal trauma\\n Definition of a heavy trauma: somebody who arrives at the\\n hospital in more than one ambulance.\\n John Edwards\\n\\n He should have a special love for the wounded persons as\\n for his own body.\\n Hans von Gersdorff\\n\\n Differences between blunt and penetrating trauma\\n\\n There are several differences between these two types of injury:\\n\\n • Penetrating abdominal trauma is made obvious by the\\n presence of a wound. Blunt abdominal trauma is sometimes\\n unequivocally identifiable by the presence of a visible contusion of\\n the abdominal wall (e.g. seat belt sign) but, more frequently, it is\\n only suspected from the mechanism of injury.\\n • Penetrating abdominal trauma is usually confined to the\\n abdomen. Common mechanisms of blunt trauma (vehicle\\n accidents, falls, beatings…) often result in polytrauma, the\\n abdominal component being associated with other cavity or system\\n injuries (head, chest, pelvis, vertebral column, long bones).\\n • The patterns of intra-abdominal visceral injuries are different.\\n ħollow viscera injuries are common in penetrating trauma. They\\n are very rare in blunt trauma where solid organ injuries (to the liver,',\n", " 'md': '```markdown\\n# Blunt Abdominal Trauma\\n\\n## Definition of Heavy Trauma\\n- **Definition**: A heavy trauma is defined as someone who arrives at the hospital in more than one ambulance.\\n- **Quote**: \"He should have a special love for the wounded persons as for his own body.\" - Hans von Gersdorff\\n\\n## Differences Between Blunt and Penetrating Trauma\\nThere are several differences between these two types of injury:\\n\\n- **Visibility of Injury**:\\n- Penetrating abdominal trauma is made obvious by the presence of a wound.\\n- Blunt abdominal trauma is sometimes unequivocally identifiable by the presence of a visible contusion of the abdominal wall (e.g., seat belt sign), but more frequently, it is only suspected from the mechanism of injury.\\n\\n- **Location of Injury**:\\n- Penetrating abdominal trauma is usually confined to the abdomen.\\n- Common mechanisms of blunt trauma (vehicle accidents, falls, beatings, etc.) often result in polytrauma, with the abdominal component being associated with other cavity or system injuries (head, chest, pelvis, vertebral column, long bones).\\n\\n- **Patterns of Intra-abdominal Visceral Injuries**:\\n- Hollow viscera injuries are common in penetrating trauma.\\n- They are very rare in blunt trauma, where solid organ injuries (to the liver, etc.) are more prevalent.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Blunt Abdominal Trauma',\n", " 'md': '# Blunt Abdominal Trauma',\n", " 'bBox': {'x': 383, 'y': 611, 'w': 35.19, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Definition of Heavy Trauma',\n", " 'md': '## Definition of Heavy Trauma',\n", " 'bBox': {'x': 357, 'y': 611, 'w': 16, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Definition**: A heavy trauma is defined as someone who arrives at the hospital in more than one ambulance.\\n- **Quote**: \"He should have a special love for the wounded persons as for his own body.\" - Hans von Gersdorff',\n", " 'md': '- **Definition**: A heavy trauma is defined as someone who arrives at the hospital in more than one ambulance.\\n- **Quote**: \"He should have a special love for the wounded persons as for his own body.\" - Hans von Gersdorff',\n", " 'bBox': {'x': 108, 'y': 299, 'w': 381.29, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Differences Between Blunt and Penetrating Trauma',\n", " 'md': '## Differences Between Blunt and Penetrating Trauma',\n", " 'bBox': {'x': 86, 'y': 437, 'w': 394.47, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'There are several differences between these two types of injury:\\n\\n- **Visibility of Injury**:\\n- Penetrating abdominal trauma is made obvious by the presence of a wound.\\n- Blunt abdominal trauma is sometimes unequivocally identifiable by the presence of a visible contusion of the abdominal wall (e.g., seat belt sign), but more frequently, it is only suspected from the mechanism of injury.\\n\\n- **Location of Injury**:\\n- Penetrating abdominal trauma is usually confined to the abdomen.\\n- Common mechanisms of blunt trauma (vehicle accidents, falls, beatings, etc.) often result in polytrauma, with the abdominal component being associated with other cavity or system injuries (head, chest, pelvis, vertebral column, long bones).\\n\\n- **Patterns of Intra-abdominal Visceral Injuries**:\\n- Hollow viscera injuries are common in penetrating trauma.\\n- They are very rare in blunt trauma, where solid organ injuries (to the liver, etc.) are more prevalent.\\n```',\n", " 'md': 'There are several differences between these two types of injury:\\n\\n- **Visibility of Injury**:\\n- Penetrating abdominal trauma is made obvious by the presence of a wound.\\n- Blunt abdominal trauma is sometimes unequivocally identifiable by the presence of a visible contusion of the abdominal wall (e.g., seat belt sign), but more frequently, it is only suspected from the mechanism of injury.\\n\\n- **Location of Injury**:\\n- Penetrating abdominal trauma is usually confined to the abdomen.\\n- Common mechanisms of blunt trauma (vehicle accidents, falls, beatings, etc.) often result in polytrauma, with the abdominal component being associated with other cavity or system injuries (head, chest, pelvis, vertebral column, long bones).\\n\\n- **Patterns of Intra-abdominal Visceral Injuries**:\\n- Hollow viscera injuries are common in penetrating trauma.\\n- They are very rare in blunt trauma, where solid organ injuries (to the liver, etc.) are more prevalent.\\n```',\n", " 'bBox': {'x': 86, 'y': 473, 'w': 429.17, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 582,\n", " 'text': ' spleen, and pancreas) predominate.\\n • Clinical evaluation is unreliable in blunt trauma. This is due to\\n several factors:\\n the frequent presence of a head injury with decreased level of\\n consciousness;\\n the nature of multi-system trauma results in ‘distracting’\\n injuries whereby the pain experienced at other sites (chest,\\n long bones, pelvic fracture…) masks or distorts the patient’s\\n perception of abdominal pain and tenderness;\\n while hypotension is frequently caused by an injured intra-\\n abdominal solid organ, it is as frequently due to an associated\\n long bone or pelvic fracture or a hemothorax. It may not even\\n be the result of hypovolemic shock but represent a sign of\\n cardiogenic (due to cardiac contusion, pericardial tamponade,\\n tension pneumothorax) or spinal shock;\\n tenderness on palpation may be the result of bruising of the\\n abdominal wall rather than reflect a more severe intra-\\n abdominal injury.\\n PZRYAHY\\nFigure 32.4. “So what’s wrong inside your black box?”\\n\\n In blunt abdominal trauma, unlike in penetrating injuries, the\\n reliance on a clinical picture of shock or peritonitis cannot',\n", " 'md': '```markdown\\n## Page Content\\n\\n- Spleen, and pancreas predominate.\\n- Clinical evaluation is unreliable in blunt trauma. This is due to several factors:\\n- The frequent presence of a head injury with decreased level of consciousness.\\n- The nature of multi-system trauma results in ‘distracting’ injuries whereby the pain experienced at other sites (chest, long bones, pelvic fracture…) masks or distorts the patient’s perception of abdominal pain and tenderness.\\n- While hypotension is frequently caused by an injured intra-abdominal solid organ, it is as frequently due to an associated long bone or pelvic fracture or a hemothorax. It may not even be the result of hypovolemic shock but represent a sign of cardiogenic (due to cardiac contusion, pericardial tamponade, tension pneumothorax) or spinal shock.\\n- Tenderness on palpation may be the result of bruising of the abdominal wall rather than reflect a more severe intra-abdominal injury.\\n\\n### Figure 32.4\\n**Caption:** “So what’s wrong inside your black box?”\\n\\nIn blunt abdominal trauma, unlike in penetrating injuries, the reliance on a clinical picture of shock or peritonitis cannot be solely depended upon.\\n```',\n", " 'images': [{'name': 'img_p581_1.png',\n", " 'height': 8,\n", " 'width': 8,\n", " 'x': 110.15999999999985,\n", " 'y': 128.88},\n", " {'name': 'img_p581_1.png',\n", " 'height': 8,\n", " 'width': 8,\n", " 'x': 110.15999999999985,\n", " 'y': 164.88},\n", " {'name': 'img_p581_1.png',\n", " 'height': 8,\n", " 'width': 8,\n", " 'x': 110.15999999999985,\n", " 'y': 234},\n", " {'name': 'img_p581_1.png',\n", " 'height': 8,\n", " 'width': 8,\n", " 'x': 110.15999999999985,\n", " 'y': 336.24},\n", " {'name': 'img_p581_2.png',\n", " 'height': 430,\n", " 'width': 800,\n", " 'x': 108,\n", " 'y': 398.88,\n", " 'original_width': 1374,\n", " 'original_height': 736}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Spleen, and pancreas predominate.\\n- Clinical evaluation is unreliable in blunt trauma. This is due to several factors:\\n- The frequent presence of a head injury with decreased level of consciousness.\\n- The nature of multi-system trauma results in ‘distracting’ injuries whereby the pain experienced at other sites (chest, long bones, pelvic fracture…) masks or distorts the patient’s perception of abdominal pain and tenderness.\\n- While hypotension is frequently caused by an injured intra-abdominal solid organ, it is as frequently due to an associated long bone or pelvic fracture or a hemothorax. It may not even be the result of hypovolemic shock but represent a sign of cardiogenic (due to cardiac contusion, pericardial tamponade, tension pneumothorax) or spinal shock.\\n- Tenderness on palpation may be the result of bruising of the abdominal wall rather than reflect a more severe intra-abdominal injury.',\n", " 'md': '- Spleen, and pancreas predominate.\\n- Clinical evaluation is unreliable in blunt trauma. This is due to several factors:\\n- The frequent presence of a head injury with decreased level of consciousness.\\n- The nature of multi-system trauma results in ‘distracting’ injuries whereby the pain experienced at other sites (chest, long bones, pelvic fracture…) masks or distorts the patient’s perception of abdominal pain and tenderness.\\n- While hypotension is frequently caused by an injured intra-abdominal solid organ, it is as frequently due to an associated long bone or pelvic fracture or a hemothorax. It may not even be the result of hypovolemic shock but represent a sign of cardiogenic (due to cardiac contusion, pericardial tamponade, tension pneumothorax) or spinal shock.\\n- Tenderness on palpation may be the result of bruising of the abdominal wall rather than reflect a more severe intra-abdominal injury.',\n", " 'bBox': {'x': 108, 'y': 105, 'w': 429.3, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 32.4',\n", " 'md': '### Figure 32.4',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** “So what’s wrong inside your black box?”\\n\\nIn blunt abdominal trauma, unlike in penetrating injuries, the reliance on a clinical picture of shock or peritonitis cannot be solely depended upon.\\n```',\n", " 'md': '**Caption:** “So what’s wrong inside your black box?”\\n\\nIn blunt abdominal trauma, unlike in penetrating injuries, the reliance on a clinical picture of shock or peritonitis cannot be solely depended upon.\\n```',\n", " 'bBox': {'x': 79, 'y': 690, 'w': 453.59, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 583,\n", " 'text': ' constitute the sole justification for a laparotomy. The abdomen in blunt\\n trauma has come to be seen as a ‘black box’ ( Figure 32.4), in other words, an uncertain\\n source for the patient’s current instability or subsequent deterioration. It is, therefore,\\n imperative to resort to additional diagnostic tests. The aims of these investigations are not\\n only to confirm the presence of abdominal trauma, but also, whenever possible, to\\n document as precisely as possible the nature of the visceral injuries since their\\n treatment is not invariably surgical.\\n\\n Adjunctive diagnostic tests\\n\\n There are three main diagnostic tests used in blunt trauma: helical\\ncomputed tomography (CT) scan, ultrasound scan (referred to as FAST\\n— focused abdominal sonography for trauma) and diagnostic peritoneal\\nlavage (DPL). In modern, well-equipped centers, an abdominal CT\\nscan is the investigation of choice in the stable patient, while FAST\\nor DPL (if FAST not available) are more frequently employed when\\nthe patient is hemodynamically unstable. The latter two tests could\\nalso be used more liberally in facilities that cannot offer unrestricted\\naccess to CT scanning.\\n\\n Diagnostic peritoneal lavage\\n\\n Both a nasogastric tube and a Foley catheter are first inserted in\\npreparation for the DPL (it would be a pity to puncture the stomach or the\\nbladder!). The technique entails the placement, under local anesthesia, of\\na catheter into the peritoneal cavity. One liter of warmed saline is thereby\\ninfused, given a moment to mix with the intraperitoneal contents and\\nrecovered by laying the bag on the floor.\\n\\n The DPL is deemed positive in cases of:\\n\\n • Aspiration of blood from the catheter on insertion (grossly positive\\n DPL).\\n • Presence of more than 100,000 red blood cells per mm3 in the\\n effluent (microscopically positive DPL).',\n", " 'md': \"```markdown\\n## Diagnostic Tests in Blunt Abdominal Trauma\\n\\nThe abdomen in blunt trauma has come to be seen as a ‘black box’ (Figure 32.4), in other words, an uncertain source for the patient’s current instability or subsequent deterioration. It is, therefore, imperative to resort to additional diagnostic tests. The aims of these investigations are not only to confirm the presence of abdominal trauma but also, whenever possible, to document as precisely as possible the nature of the visceral injuries since their treatment is not invariably surgical.\\n\\n### Adjunctive Diagnostic Tests\\n\\nThere are three main diagnostic tests used in blunt trauma: helical computed tomography (CT) scan, ultrasound scan (referred to as FAST — focused abdominal sonography for trauma), and diagnostic peritoneal lavage (DPL). In modern, well-equipped centers, an abdominal CT scan is the investigation of choice in the stable patient, while FAST or DPL (if FAST not available) are more frequently employed when the patient is hemodynamically unstable. The latter two tests could also be used more liberally in facilities that cannot offer unrestricted access to CT scanning.\\n\\n### Diagnostic Peritoneal Lavage\\n\\nBoth a nasogastric tube and a Foley catheter are first inserted in preparation for the DPL (it would be a pity to puncture the stomach or the bladder!). The technique entails the placement, under local anesthesia, of a catheter into the peritoneal cavity. One liter of warmed saline is thereby infused, given a moment to mix with the intraperitoneal contents, and recovered by laying the bag on the floor.\\n\\nThe DPL is deemed positive in cases of:\\n\\n- Aspiration of blood from the catheter on insertion (grossly positive DPL).\\n- Presence of more than 100,000 red blood cells per mm³ in the effluent (microscopically positive DPL).\\n```\\n\\n### Figure Description\\n- **Figure 32.4**: This figure likely illustrates the concept of the abdomen as a 'black box' in the context of blunt trauma, emphasizing the uncertainty surrounding the diagnosis and treatment of visceral injuries. The specific content of the figure is not provided in the text, but it serves to visually represent the challenges faced in diagnosing abdominal trauma.\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnostic Tests in Blunt Abdominal Trauma',\n", " 'md': '## Diagnostic Tests in Blunt Abdominal Trauma',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The abdomen in blunt trauma has come to be seen as a ‘black box’ (Figure 32.4), in other words, an uncertain source for the patient’s current instability or subsequent deterioration. It is, therefore, imperative to resort to additional diagnostic tests. The aims of these investigations are not only to confirm the presence of abdominal trauma but also, whenever possible, to document as precisely as possible the nature of the visceral injuries since their treatment is not invariably surgical.',\n", " 'md': 'The abdomen in blunt trauma has come to be seen as a ‘black box’ (Figure 32.4), in other words, an uncertain source for the patient’s current instability or subsequent deterioration. It is, therefore, imperative to resort to additional diagnostic tests. The aims of these investigations are not only to confirm the presence of abdominal trauma but also, whenever possible, to document as precisely as possible the nature of the visceral injuries since their treatment is not invariably surgical.',\n", " 'bBox': {'x': 79, 'y': 145, 'w': 452.59, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Adjunctive Diagnostic Tests',\n", " 'md': '### Adjunctive Diagnostic Tests',\n", " 'bBox': {'x': 86, 'y': 256, 'w': 215.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'There are three main diagnostic tests used in blunt trauma: helical computed tomography (CT) scan, ultrasound scan (referred to as FAST — focused abdominal sonography for trauma), and diagnostic peritoneal lavage (DPL). In modern, well-equipped centers, an abdominal CT scan is the investigation of choice in the stable patient, while FAST or DPL (if FAST not available) are more frequently employed when the patient is hemodynamically unstable. The latter two tests could also be used more liberally in facilities that cannot offer unrestricted access to CT scanning.',\n", " 'md': 'There are three main diagnostic tests used in blunt trauma: helical computed tomography (CT) scan, ultrasound scan (referred to as FAST — focused abdominal sonography for trauma), and diagnostic peritoneal lavage (DPL). In modern, well-equipped centers, an abdominal CT scan is the investigation of choice in the stable patient, while FAST or DPL (if FAST not available) are more frequently employed when the patient is hemodynamically unstable. The latter two tests could also be used more liberally in facilities that cannot offer unrestricted access to CT scanning.',\n", " 'bBox': {'x': 72, 'y': 358, 'w': 467.3, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diagnostic Peritoneal Lavage',\n", " 'md': '### Diagnostic Peritoneal Lavage',\n", " 'bBox': {'x': 86, 'y': 468, 'w': 224.37, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Both a nasogastric tube and a Foley catheter are first inserted in preparation for the DPL (it would be a pity to puncture the stomach or the bladder!). The technique entails the placement, under local anesthesia, of a catheter into the peritoneal cavity. One liter of warmed saline is thereby infused, given a moment to mix with the intraperitoneal contents, and recovered by laying the bag on the floor.\\n\\nThe DPL is deemed positive in cases of:\\n\\n- Aspiration of blood from the catheter on insertion (grossly positive DPL).\\n- Presence of more than 100,000 red blood cells per mm³ in the effluent (microscopically positive DPL).\\n```',\n", " 'md': 'Both a nasogastric tube and a Foley catheter are first inserted in preparation for the DPL (it would be a pity to puncture the stomach or the bladder!). The technique entails the placement, under local anesthesia, of a catheter into the peritoneal cavity. One liter of warmed saline is thereby infused, given a moment to mix with the intraperitoneal contents, and recovered by laying the bag on the floor.\\n\\nThe DPL is deemed positive in cases of:\\n\\n- Aspiration of blood from the catheter on insertion (grossly positive DPL).\\n- Presence of more than 100,000 red blood cells per mm³ in the effluent (microscopically positive DPL).\\n```',\n", " 'bBox': {'x': 72, 'y': 520, 'w': 467.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Description',\n", " 'md': '### Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- **Figure 32.4**: This figure likely illustrates the concept of the abdomen as a 'black box' in the context of blunt trauma, emphasizing the uncertainty surrounding the diagnosis and treatment of visceral injuries. The specific content of the figure is not provided in the text, but it serves to visually represent the challenges faced in diagnosing abdominal trauma.\",\n", " 'md': \"- **Figure 32.4**: This figure likely illustrates the concept of the abdomen as a 'black box' in the context of blunt trauma, emphasizing the uncertainty surrounding the diagnosis and treatment of visceral injuries. The specific content of the figure is not provided in the text, but it serves to visually represent the challenges faced in diagnosing abdominal trauma.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 584,\n", " 'text': ' • Presence of bile, intestinal contents or urine in the effluent.\\n • Presence of more than 500 white blood cells per mm3 in the effluent\\n (this is controversial).\\n • Flow of the DPL fluid through the urinary catheter or the chest tube,\\n indicating a bladder or diaphragmatic injury, respectively (these\\n scenarios are rare).\\n\\n Historically, DPL was the diagnostic gold standard for blunt\\nabdominal trauma but, in recent times, it has lost its shine for the\\nfollowing reasons:\\n\\n • It is cumbersome and difficult to perform in a combative or obese\\n patient.\\n • It has absolute or relative contraindications: previous surgery,\\n pregnancy.\\n • It is invasive and attended by a small complication rate (e.g. bowel\\n perforation).\\n • Most importantly, if laparotomies were to be performed for all\\n instances of microscopically or even grossly positive DPL, the\\n rate of non-therapeutic laparotomies would be unacceptably\\n high because, in most cases, the source of bleeding could have\\n been treated non-operatively. Of course, an unnecessary\\n laparotomy carries a significant morbidity in the context of\\n multi-system trauma.\\n\\n In modern centers, DPL is used only in the very unstable patient\\nto confirm, pre-operatively, the presence of a large\\nhemoperitoneum. But if your hospital lacks access to the more\\nsophisticated investigations, do remember that a negative DPL is a\\ncrucial piece of information in ruling out the abdominal ‘black box’\\nas a source for concern in a severe, multi-system trauma patient.\\n\\n Focused assessment with sonography in trauma\\n\\n The aim of FAST is to detect the presence of free fluid in the following\\nareas:',\n", " 'md': '```markdown\\n## Text Extraction\\n\\n- Presence of bile, intestinal contents or urine in the effluent.\\n- Presence of more than 500 white blood cells per mm³ in the effluent (this is controversial).\\n- Flow of the DPL fluid through the urinary catheter or the chest tube, indicating a bladder or diaphragmatic injury, respectively (these scenarios are rare).\\n\\nHistorically, DPL was the diagnostic gold standard for blunt abdominal trauma but, in recent times, it has lost its shine for the following reasons:\\n\\n- It is cumbersome and difficult to perform in a combative or obese patient.\\n- It has absolute or relative contraindications: previous surgery, pregnancy.\\n- It is invasive and attended by a small complication rate (e.g. bowel perforation).\\n- Most importantly, if laparotomies were to be performed for all instances of microscopically or even grossly positive DPL, the rate of non-therapeutic laparotomies would be unacceptably high because, in most cases, the source of bleeding could have been treated non-operatively. Of course, an unnecessary laparotomy carries a significant morbidity in the context of multi-system trauma.\\n\\nIn modern centers, DPL is used only in the very unstable patient to confirm, pre-operatively, the presence of a large hemoperitoneum. But if your hospital lacks access to the more sophisticated investigations, do remember that a negative DPL is a crucial piece of information in ruling out the abdominal ‘black box’ as a source for concern in a severe, multi-system trauma patient.\\n\\n### Focused Assessment with Sonography in Trauma\\n\\nThe aim of FAST is to detect the presence of free fluid in the following areas:\\n```\\n\\n## Image Identification and Description\\n\\n- No images, graphs, or tables were identified on this page.\\n\\n## Summary\\n\\nThis page discusses the diagnostic criteria and historical context of Diagnostic Peritoneal Lavage (DPL) in blunt abdominal trauma, highlighting its limitations and current usage in modern medical practice. It also introduces the Focused Assessment with Sonography in Trauma (FAST) as a method to detect free fluid in trauma patients.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Presence of bile, intestinal contents or urine in the effluent.\\n- Presence of more than 500 white blood cells per mm³ in the effluent (this is controversial).\\n- Flow of the DPL fluid through the urinary catheter or the chest tube, indicating a bladder or diaphragmatic injury, respectively (these scenarios are rare).\\n\\nHistorically, DPL was the diagnostic gold standard for blunt abdominal trauma but, in recent times, it has lost its shine for the following reasons:\\n\\n- It is cumbersome and difficult to perform in a combative or obese patient.\\n- It has absolute or relative contraindications: previous surgery, pregnancy.\\n- It is invasive and attended by a small complication rate (e.g. bowel perforation).\\n- Most importantly, if laparotomies were to be performed for all instances of microscopically or even grossly positive DPL, the rate of non-therapeutic laparotomies would be unacceptably high because, in most cases, the source of bleeding could have been treated non-operatively. Of course, an unnecessary laparotomy carries a significant morbidity in the context of multi-system trauma.\\n\\nIn modern centers, DPL is used only in the very unstable patient to confirm, pre-operatively, the presence of a large hemoperitoneum. But if your hospital lacks access to the more sophisticated investigations, do remember that a negative DPL is a crucial piece of information in ruling out the abdominal ‘black box’ as a source for concern in a severe, multi-system trauma patient.',\n", " 'md': '- Presence of bile, intestinal contents or urine in the effluent.\\n- Presence of more than 500 white blood cells per mm³ in the effluent (this is controversial).\\n- Flow of the DPL fluid through the urinary catheter or the chest tube, indicating a bladder or diaphragmatic injury, respectively (these scenarios are rare).\\n\\nHistorically, DPL was the diagnostic gold standard for blunt abdominal trauma but, in recent times, it has lost its shine for the following reasons:\\n\\n- It is cumbersome and difficult to perform in a combative or obese patient.\\n- It has absolute or relative contraindications: previous surgery, pregnancy.\\n- It is invasive and attended by a small complication rate (e.g. bowel perforation).\\n- Most importantly, if laparotomies were to be performed for all instances of microscopically or even grossly positive DPL, the rate of non-therapeutic laparotomies would be unacceptably high because, in most cases, the source of bleeding could have been treated non-operatively. Of course, an unnecessary laparotomy carries a significant morbidity in the context of multi-system trauma.\\n\\nIn modern centers, DPL is used only in the very unstable patient to confirm, pre-operatively, the presence of a large hemoperitoneum. But if your hospital lacks access to the more sophisticated investigations, do remember that a negative DPL is a crucial piece of information in ruling out the abdominal ‘black box’ as a source for concern in a severe, multi-system trauma patient.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Focused Assessment with Sonography in Trauma',\n", " 'md': '### Focused Assessment with Sonography in Trauma',\n", " 'bBox': {'x': 86, 'y': 661, 'w': 383.47, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The aim of FAST is to detect the presence of free fluid in the following areas:\\n```',\n", " 'md': 'The aim of FAST is to detect the presence of free fluid in the following areas:\\n```',\n", " 'bBox': {'x': 72, 'y': 552, 'w': 453.45, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.',\n", " 'md': '- No images, graphs, or tables were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the diagnostic criteria and historical context of Diagnostic Peritoneal Lavage (DPL) in blunt abdominal trauma, highlighting its limitations and current usage in modern medical practice. It also introduces the Focused Assessment with Sonography in Trauma (FAST) as a method to detect free fluid in trauma patients.',\n", " 'md': 'This page discusses the diagnostic criteria and historical context of Diagnostic Peritoneal Lavage (DPL) in blunt abdominal trauma, highlighting its limitations and current usage in modern medical practice. It also introduces the Focused Assessment with Sonography in Trauma (FAST) as a method to detect free fluid in trauma patients.',\n", " 'bBox': {'x': 72, 'y': 552, 'w': 383.47, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 585,\n", " 'text': ' • The pericardial sac.\\n • Morrison’s (hepatorenal) pouch in the right upper abdominal\\n quadrant.\\n • The splenorenal recess in the left upper abdominal quadrant.\\n • The pelvis.\\n FAST can assist in the diagnosis of pericardial tamponade (a rather\\nrare finding in blunt trauma). In the evaluation of the abdomen, it\\nduplicates somewhat the role of DPL with the advantages of being\\nrelatively cheap, totally non-invasive and applicable at the patient’s\\nbedside. FAST is reliable only in the hands of personnel specially trained\\nin the technique (surgeons, emergency room physicians, radiologists)\\nand in centers with a high case-volume. In modern centers, FAST plays\\nan important role in the assessment of the unstable trauma patient\\n— a laparotomy is usually indicated in a hypotensive patient found\\nto have a large amount of free intraperitoneal fluid. It is also\\ncommonly used in stable patients, but more as a practice exercise rather\\nthan a test allowing for definitive decision-making. The use of FAST as a\\nscreening tool for abdominal CT scanning is more controversial.\\n\\n Computed tomography\\n\\n CT scanning has become an essential part of modern\\nmanagement of the stable, blunt, multi-trauma patient. It is very\\ncommon nowadays to dispense with the cervical spine X-rays, the\\nthoracolumbar spine X-rays, the pelvic X-ray and even sometimes with\\nthe chest X-ray: the patient is taken instead to a radiology suite adjacent\\nto the resuscitation room and a quadruple scan of the head, neck, chest\\nand abdomen (including the vertebral column and the pelvis) is obtained\\nin a few minutes.\\n\\n The abdominal component of this diagnostic work-up is extremely\\nvaluable because:\\n\\n • Both the peritoneal cavity and the retroperitoneum can be assessed.',\n", " 'md': '```markdown\\n# Page Content\\n\\n- The pericardial sac.\\n- Morrison’s (hepatorenal) pouch in the right upper abdominal quadrant.\\n- The splenorenal recess in the left upper abdominal quadrant.\\n- The pelvis.\\n\\nFAST can assist in the diagnosis of pericardial tamponade (a rather rare finding in blunt trauma). In the evaluation of the abdomen, it duplicates somewhat the role of DPL with the advantages of being relatively cheap, totally non-invasive and applicable at the patient’s bedside. FAST is reliable only in the hands of personnel specially trained in the technique (surgeons, emergency room physicians, radiologists) and in centers with a high case-volume. In modern centers, FAST plays an important role in the assessment of the unstable trauma patient — a laparotomy is usually indicated in a hypotensive patient found to have a large amount of free intraperitoneal fluid. It is also commonly used in stable patients, but more as a practice exercise rather than a test allowing for definitive decision-making. The use of FAST as a screening tool for abdominal CT scanning is more controversial.\\n\\n## Computed Tomography\\n\\nCT scanning has become an essential part of modern management of the stable, blunt, multi-trauma patient. It is very common nowadays to dispense with the cervical spine X-rays, the thoracolumbar spine X-rays, the pelvic X-ray and even sometimes with the chest X-ray: the patient is taken instead to a radiology suite adjacent to the resuscitation room and a quadruple scan of the head, neck, chest and abdomen (including the vertebral column and the pelvis) is obtained in a few minutes.\\n\\nThe abdominal component of this diagnostic work-up is extremely valuable because:\\n\\n- Both the peritoneal cavity and the retroperitoneum can be assessed.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The pericardial sac.\\n- Morrison’s (hepatorenal) pouch in the right upper abdominal quadrant.\\n- The splenorenal recess in the left upper abdominal quadrant.\\n- The pelvis.\\n\\nFAST can assist in the diagnosis of pericardial tamponade (a rather rare finding in blunt trauma). In the evaluation of the abdomen, it duplicates somewhat the role of DPL with the advantages of being relatively cheap, totally non-invasive and applicable at the patient’s bedside. FAST is reliable only in the hands of personnel specially trained in the technique (surgeons, emergency room physicians, radiologists) and in centers with a high case-volume. In modern centers, FAST plays an important role in the assessment of the unstable trauma patient — a laparotomy is usually indicated in a hypotensive patient found to have a large amount of free intraperitoneal fluid. It is also commonly used in stable patients, but more as a practice exercise rather than a test allowing for definitive decision-making. The use of FAST as a screening tool for abdominal CT scanning is more controversial.',\n", " 'md': '- The pericardial sac.\\n- Morrison’s (hepatorenal) pouch in the right upper abdominal quadrant.\\n- The splenorenal recess in the left upper abdominal quadrant.\\n- The pelvis.\\n\\nFAST can assist in the diagnosis of pericardial tamponade (a rather rare finding in blunt trauma). In the evaluation of the abdomen, it duplicates somewhat the role of DPL with the advantages of being relatively cheap, totally non-invasive and applicable at the patient’s bedside. FAST is reliable only in the hands of personnel specially trained in the technique (surgeons, emergency room physicians, radiologists) and in centers with a high case-volume. In modern centers, FAST plays an important role in the assessment of the unstable trauma patient — a laparotomy is usually indicated in a hypotensive patient found to have a large amount of free intraperitoneal fluid. It is also commonly used in stable patients, but more as a practice exercise rather than a test allowing for definitive decision-making. The use of FAST as a screening tool for abdominal CT scanning is more controversial.',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.92, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Computed Tomography',\n", " 'md': '## Computed Tomography',\n", " 'bBox': {'x': 86, 'y': 468, 'w': 182.07, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'CT scanning has become an essential part of modern management of the stable, blunt, multi-trauma patient. It is very common nowadays to dispense with the cervical spine X-rays, the thoracolumbar spine X-rays, the pelvic X-ray and even sometimes with the chest X-ray: the patient is taken instead to a radiology suite adjacent to the resuscitation room and a quadruple scan of the head, neck, chest and abdomen (including the vertebral column and the pelvis) is obtained in a few minutes.\\n\\nThe abdominal component of this diagnostic work-up is extremely valuable because:\\n\\n- Both the peritoneal cavity and the retroperitoneum can be assessed.\\n```',\n", " 'md': 'CT scanning has become an essential part of modern management of the stable, blunt, multi-trauma patient. It is very common nowadays to dispense with the cervical spine X-rays, the thoracolumbar spine X-rays, the pelvic X-ray and even sometimes with the chest X-ray: the patient is taken instead to a radiology suite adjacent to the resuscitation room and a quadruple scan of the head, neck, chest and abdomen (including the vertebral column and the pelvis) is obtained in a few minutes.\\n\\nThe abdominal component of this diagnostic work-up is extremely valuable because:\\n\\n- Both the peritoneal cavity and the retroperitoneum can be assessed.\\n```',\n", " 'bBox': {'x': 72, 'y': 504, 'w': 467.63, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'bBox': {'x': 198, 'y': 504, 'w': 28.79, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 586,\n", " 'text': ' • The integrity of bony structures (lumbar spine, pelvis) can be\\n ascertained.\\n • A precise inventory of injuries to solid intraperitoneal (liver, spleen)\\n and retroperitoneal (pancreas, kidneys) organs can be made; these\\n injuries can be accurately graded.\\n • The new generation scanners are able to detect intestinal injuries\\n (suggested by mesenteric stranding, bowel thickening or\\n extraluminal air).\\n • Free fluid (with radiological blood density) in the absence of solid\\n organ injury can be detected suggesting the presence of a\\n significant mesenteric injury.\\n\\n In equivocal CT scan findings, clinical judgment is essential; a\\nrepeat CT scan 24 hours later, clinical observation or immediate\\nlaparotomy are the main options to be weighed.\\n\\n The recourse to ‘total body scanning’ has become so unregulated\\nin some ‘high-tech’ centers that a note of caution needs to be\\nsounded:\\n\\n • Cost aside, liberal trauma ‘scannograms’ deliver a very high dose of\\n radiation; this, combined with the recurrent need for CT scanning\\n through an entire life-time carries a significant long-term cancer risk.\\n Always ask yourself when sending a trauma patient to the scanner\\n whether a quadruple test is essential in this particular patient. Could\\n not, for example, the chest CT be replaced by a simple chest X-ray?\\n An easy way to keep in mind this danger is to remember the\\n acronym, VOMIT (Victims of Modern Imaging Technology),\\n coined by R. Hayward (BMJ, 2003).\\n\\n Only stable or well-resuscitated patients can be put through the\\n scanner. Borderline patients can decompensate catastrophically\\n in the radiology suite.\\n\\n The statement in the above box is controversial in real-life practice. We prefer to use the term',\n", " 'md': '```markdown\\n## Page Content\\n\\n- The integrity of bony structures (lumbar spine, pelvis) can be ascertained.\\n- A precise inventory of injuries to solid intraperitoneal (liver, spleen) and retroperitoneal (pancreas, kidneys) organs can be made; these injuries can be accurately graded.\\n- The new generation scanners are able to detect intestinal injuries (suggested by mesenteric stranding, bowel thickening or extraluminal air).\\n- Free fluid (with radiological blood density) in the absence of solid organ injury can be detected suggesting the presence of a significant mesenteric injury.\\n\\nIn equivocal CT scan findings, clinical judgment is essential; a repeat CT scan 24 hours later, clinical observation or immediate laparotomy are the main options to be weighed.\\n\\nThe recourse to ‘total body scanning’ has become so unregulated in some ‘high-tech’ centers that a note of caution needs to be sounded:\\n\\n- Cost aside, liberal trauma ‘scannograms’ deliver a very high dose of radiation; this, combined with the recurrent need for CT scanning through an entire life-time carries a significant long-term cancer risk. Always ask yourself when sending a trauma patient to the scanner whether a quadruple test is essential in this particular patient. Could not, for example, the chest CT be replaced by a simple chest X-ray? An easy way to keep in mind this danger is to remember the acronym, VOMIT (Victims of Modern Imaging Technology), coined by R. Hayward (BMJ, 2003).\\n\\nOnly stable or well-resuscitated patients can be put through the scanner. Borderline patients can decompensate catastrophically in the radiology suite.\\n\\nThe statement in the above box is controversial in real-life practice. We prefer to use the term\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the guidelines, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The integrity of bony structures (lumbar spine, pelvis) can be ascertained.\\n- A precise inventory of injuries to solid intraperitoneal (liver, spleen) and retroperitoneal (pancreas, kidneys) organs can be made; these injuries can be accurately graded.\\n- The new generation scanners are able to detect intestinal injuries (suggested by mesenteric stranding, bowel thickening or extraluminal air).\\n- Free fluid (with radiological blood density) in the absence of solid organ injury can be detected suggesting the presence of a significant mesenteric injury.\\n\\nIn equivocal CT scan findings, clinical judgment is essential; a repeat CT scan 24 hours later, clinical observation or immediate laparotomy are the main options to be weighed.\\n\\nThe recourse to ‘total body scanning’ has become so unregulated in some ‘high-tech’ centers that a note of caution needs to be sounded:\\n\\n- Cost aside, liberal trauma ‘scannograms’ deliver a very high dose of radiation; this, combined with the recurrent need for CT scanning through an entire life-time carries a significant long-term cancer risk. Always ask yourself when sending a trauma patient to the scanner whether a quadruple test is essential in this particular patient. Could not, for example, the chest CT be replaced by a simple chest X-ray? An easy way to keep in mind this danger is to remember the acronym, VOMIT (Victims of Modern Imaging Technology), coined by R. Hayward (BMJ, 2003).\\n\\nOnly stable or well-resuscitated patients can be put through the scanner. Borderline patients can decompensate catastrophically in the radiology suite.\\n\\nThe statement in the above box is controversial in real-life practice. We prefer to use the term\\n```',\n", " 'md': '- The integrity of bony structures (lumbar spine, pelvis) can be ascertained.\\n- A precise inventory of injuries to solid intraperitoneal (liver, spleen) and retroperitoneal (pancreas, kidneys) organs can be made; these injuries can be accurately graded.\\n- The new generation scanners are able to detect intestinal injuries (suggested by mesenteric stranding, bowel thickening or extraluminal air).\\n- Free fluid (with radiological blood density) in the absence of solid organ injury can be detected suggesting the presence of a significant mesenteric injury.\\n\\nIn equivocal CT scan findings, clinical judgment is essential; a repeat CT scan 24 hours later, clinical observation or immediate laparotomy are the main options to be weighed.\\n\\nThe recourse to ‘total body scanning’ has become so unregulated in some ‘high-tech’ centers that a note of caution needs to be sounded:\\n\\n- Cost aside, liberal trauma ‘scannograms’ deliver a very high dose of radiation; this, combined with the recurrent need for CT scanning through an entire life-time carries a significant long-term cancer risk. Always ask yourself when sending a trauma patient to the scanner whether a quadruple test is essential in this particular patient. Could not, for example, the chest CT be replaced by a simple chest X-ray? An easy way to keep in mind this danger is to remember the acronym, VOMIT (Victims of Modern Imaging Technology), coined by R. Hayward (BMJ, 2003).\\n\\nOnly stable or well-resuscitated patients can be put through the scanner. Borderline patients can decompensate catastrophically in the radiology suite.\\n\\nThe statement in the above box is controversial in real-life practice. We prefer to use the term\\n```',\n", " 'bBox': {'x': 72, 'y': 104, 'w': 464.53, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the guidelines, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the guidelines, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 524, 'y': 193, 'w': 12.79, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 587,\n", " 'text': ' ‘hemodynamically normal’ rather than ‘stable’. And unless the patient needs to be rushed\\n immediately to the OR, many of the relevant cases are borderline. A quick CT, just across the\\n trauma room, in a young tachycardic patient is something we practice daily and rarely see the\\n dreaded crash, known from times when CT was across the hospital and took 30 minutes to\\n complete. A useful term for the ‘borderline’ cases is ‘responders’ — those who remain\\n normotensive after moderate fluid resuscitation or blood transfusion. Danny & Ari\\n\\n • CT images are as good as their interpreter. In the middle of the\\n night, expert radiologists are rarely available. Always keep your\\n clinical judgment on high alert, especially when there is discordance\\n between the clinical picture and CT images. Remember BARF\\n (Brainless Application of Radiological Findings) and reach for\\n an anti-emetic.\\n\\n Non-operative management of solid organ injuries in\\n blunt trauma\\n\\n The majority of patients with blunt splenic or hepatic injury (and\\nalmost all patients with an isolated blunt renal injury) can be treated\\nconservatively. Once such an injury has been identified on CT scan,\\nand provided there is no clinical or radiological evidence of an associated\\nhollow viscus injury, non-operative management can be attempted. The\\nhemodynamic status rather than the radiological grade of the injury\\nconstitutes the basis for therapeutic decision-making — treat the\\npatient and not the images — the grade of injury has merely predictive\\nvalue in the success of conservative management. The patient is\\nadmitted for the first 24 hours to a high-care unit for close observation.\\nContinuous vital signs and urine output monitoring, serial abdominal\\nexamination and repeated hemoglobin evaluation are conducted. Then,\\nwith every passing day on the ward with no sign of ongoing bleeding, the\\nsuccess of the conservative approach becomes more likely. Repeat CT\\nscans are not required routinely on this admission but only if\\ncomplications occur. On discharge, the patient is cautioned to avoid\\nputting the injured organ at risk of a secondary rupture (e.g. contact\\nsports, bar-room brawls) until a CT scan 8-12 weeks later documents\\ncomplete healing. More subtle differences between splenic and',\n", " 'md': '```markdown\\n## Non-operative Management of Solid Organ Injuries in Blunt Trauma\\n\\nThe majority of patients with blunt splenic or hepatic injury (and almost all patients with an isolated blunt renal injury) can be treated conservatively. Once such an injury has been identified on CT scan, and provided there is no clinical or radiological evidence of an associated hollow viscus injury, non-operative management can be attempted.\\n\\nThe hemodynamic status rather than the radiological grade of the injury constitutes the basis for therapeutic decision-making — treat the patient and not the images — the grade of injury has merely predictive value in the success of conservative management.\\n\\nThe patient is admitted for the first 24 hours to a high-care unit for close observation. Continuous vital signs and urine output monitoring, serial abdominal examination, and repeated hemoglobin evaluation are conducted. Then, with every passing day on the ward with no sign of ongoing bleeding, the success of the conservative approach becomes more likely.\\n\\nRepeat CT scans are not required routinely on this admission but only if complications occur. On discharge, the patient is cautioned to avoid putting the injured organ at risk of a secondary rupture (e.g., contact sports, bar-room brawls) until a CT scan 8-12 weeks later documents complete healing.\\n\\nMore subtle differences between splenic and hepatic injuries may be noted, but further details are not provided in this section.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Non-operative Management of Solid Organ Injuries in Blunt Trauma',\n", " 'md': '## Non-operative Management of Solid Organ Injuries in Blunt Trauma',\n", " 'bBox': {'x': 86, 'y': 355, 'w': 111.28, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The majority of patients with blunt splenic or hepatic injury (and almost all patients with an isolated blunt renal injury) can be treated conservatively. Once such an injury has been identified on CT scan, and provided there is no clinical or radiological evidence of an associated hollow viscus injury, non-operative management can be attempted.\\n\\nThe hemodynamic status rather than the radiological grade of the injury constitutes the basis for therapeutic decision-making — treat the patient and not the images — the grade of injury has merely predictive value in the success of conservative management.\\n\\nThe patient is admitted for the first 24 hours to a high-care unit for close observation. Continuous vital signs and urine output monitoring, serial abdominal examination, and repeated hemoglobin evaluation are conducted. Then, with every passing day on the ward with no sign of ongoing bleeding, the success of the conservative approach becomes more likely.\\n\\nRepeat CT scans are not required routinely on this admission but only if complications occur. On discharge, the patient is cautioned to avoid putting the injured organ at risk of a secondary rupture (e.g., contact sports, bar-room brawls) until a CT scan 8-12 weeks later documents complete healing.\\n\\nMore subtle differences between splenic and hepatic injuries may be noted, but further details are not provided in this section.\\n```',\n", " 'md': 'The majority of patients with blunt splenic or hepatic injury (and almost all patients with an isolated blunt renal injury) can be treated conservatively. Once such an injury has been identified on CT scan, and provided there is no clinical or radiological evidence of an associated hollow viscus injury, non-operative management can be attempted.\\n\\nThe hemodynamic status rather than the radiological grade of the injury constitutes the basis for therapeutic decision-making — treat the patient and not the images — the grade of injury has merely predictive value in the success of conservative management.\\n\\nThe patient is admitted for the first 24 hours to a high-care unit for close observation. Continuous vital signs and urine output monitoring, serial abdominal examination, and repeated hemoglobin evaluation are conducted. Then, with every passing day on the ward with no sign of ongoing bleeding, the success of the conservative approach becomes more likely.\\n\\nRepeat CT scans are not required routinely on this admission but only if complications occur. On discharge, the patient is cautioned to avoid putting the injured organ at risk of a secondary rupture (e.g., contact sports, bar-room brawls) until a CT scan 8-12 weeks later documents complete healing.\\n\\nMore subtle differences between splenic and hepatic injuries may be noted, but further details are not provided in this section.\\n```',\n", " 'bBox': {'x': 72, 'y': 355, 'w': 467.97, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 588,\n", " 'text': 'hepatic injuries should now be pointed out.\\n\\n Spleen\\n\\n Non-operative management of a splenic injury should not be\\nstubbornly continued in the face of an increased requirement for\\nblood transfusion. When there are episodes of hypotension\\n(unexplained by extra-abdominal injuries) or a sustained drop in\\nhemoglobin (not accounted for by hemodilution), there should be a low\\nthreshold for splenectomy especially in an adult. It is a real tragedy to\\nlose a patient from splenic hemorrhage when definitive control of the\\nbleeding can be achieved by a simple surgical procedure, namely a\\nsplenectomy (acrobatic splenic salvage procedures belong to the\\npast). The very small risk of post-splenectomy sepsis in adults can be\\nfurther minimized by patient education and vaccination (anti-\\nPneumococcus, anti-Meningococcus and anti-Haemophilus influenzae).\\n\\n There is a range of opinions with regard to the trigger for\\nabandoning conservative management. Some believe that untreated\\nhypotension alone (from a presumed splenic source) justifies\\nintervention; others are prepared to transfuse up to a maximum of 2 units\\nof blood before changing course. The message is clear: do not\\npersevere with multiple blood transfusions to treat ongoing splenic\\nbleeding. The initial CT scan may reveal a contrast ‘blush’ in the splenic\\nparenchyma pointing to active bleeding; there is evidence to suggest that\\nroutine angioembolization of these bleeding vessels, in the stable\\npatient, increases the success rate of non-operative management.\\n\\n Liver\\n\\n The intra-operative control of hepatic bleeding is difficult. The loss of\\nthe tamponade effect at laparotomy followed by mobilization of the liver\\ncan result in renewed hemorrhage, sometimes torrential. In tackling a\\nbleeding liver, there is no equivalent simple procedure like a\\nsplenectomy. Therefore, more diligence is called for in the pursuit of\\nconservative management, as well as a greater reliance on aggressive\\ntransfusions of blood products and factors. There has been increasing',\n", " 'md': '```markdown\\n# Spleen and Liver Management\\n\\n## Spleen\\n\\nNon-operative management of a splenic injury should not be stubbornly continued in the face of an increased requirement for blood transfusion. When there are episodes of hypotension (unexplained by extra-abdominal injuries) or a sustained drop in hemoglobin (not accounted for by hemodilution), there should be a low threshold for splenectomy, especially in an adult. It is a real tragedy to lose a patient from splenic hemorrhage when definitive control of the bleeding can be achieved by a simple surgical procedure, namely a splenectomy (acrobatic splenic salvage procedures belong to the past). The very small risk of post-splenectomy sepsis in adults can be further minimized by patient education and vaccination (anti-Pneumococcus, anti-Meningococcus, and anti-Haemophilus influenzae).\\n\\nThere is a range of opinions with regard to the trigger for abandoning conservative management. Some believe that untreated hypotension alone (from a presumed splenic source) justifies intervention; others are prepared to transfuse up to a maximum of 2 units of blood before changing course. The message is clear: do not persevere with multiple blood transfusions to treat ongoing splenic bleeding. The initial CT scan may reveal a contrast ‘blush’ in the splenic parenchyma pointing to active bleeding; there is evidence to suggest that routine angioembolization of these bleeding vessels, in the stable patient, increases the success rate of non-operative management.\\n\\n## Liver\\n\\nThe intra-operative control of hepatic bleeding is difficult. The loss of the tamponade effect at laparotomy followed by mobilization of the liver can result in renewed hemorrhage, sometimes torrential. In tackling a bleeding liver, there is no equivalent simple procedure like a splenectomy. Therefore, more diligence is called for in the pursuit of conservative management, as well as a greater reliance on aggressive transfusions of blood products and factors. There has been increasing...\\n```\\n\\n### Notes:\\n- The text has been extracted and structured into markdown format.\\n- No images or figures were identified on the page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been organized under appropriate headings for clarity.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Spleen and Liver Management',\n", " 'md': '# Spleen and Liver Management',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 54.26, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Spleen',\n", " 'md': '## Spleen',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 54.26, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Non-operative management of a splenic injury should not be stubbornly continued in the face of an increased requirement for blood transfusion. When there are episodes of hypotension (unexplained by extra-abdominal injuries) or a sustained drop in hemoglobin (not accounted for by hemodilution), there should be a low threshold for splenectomy, especially in an adult. It is a real tragedy to lose a patient from splenic hemorrhage when definitive control of the bleeding can be achieved by a simple surgical procedure, namely a splenectomy (acrobatic splenic salvage procedures belong to the past). The very small risk of post-splenectomy sepsis in adults can be further minimized by patient education and vaccination (anti-Pneumococcus, anti-Meningococcus, and anti-Haemophilus influenzae).\\n\\nThere is a range of opinions with regard to the trigger for abandoning conservative management. Some believe that untreated hypotension alone (from a presumed splenic source) justifies intervention; others are prepared to transfuse up to a maximum of 2 units of blood before changing course. The message is clear: do not persevere with multiple blood transfusions to treat ongoing splenic bleeding. The initial CT scan may reveal a contrast ‘blush’ in the splenic parenchyma pointing to active bleeding; there is evidence to suggest that routine angioembolization of these bleeding vessels, in the stable patient, increases the success rate of non-operative management.',\n", " 'md': 'Non-operative management of a splenic injury should not be stubbornly continued in the face of an increased requirement for blood transfusion. When there are episodes of hypotension (unexplained by extra-abdominal injuries) or a sustained drop in hemoglobin (not accounted for by hemodilution), there should be a low threshold for splenectomy, especially in an adult. It is a real tragedy to lose a patient from splenic hemorrhage when definitive control of the bleeding can be achieved by a simple surgical procedure, namely a splenectomy (acrobatic splenic salvage procedures belong to the past). The very small risk of post-splenectomy sepsis in adults can be further minimized by patient education and vaccination (anti-Pneumococcus, anti-Meningococcus, and anti-Haemophilus influenzae).\\n\\nThere is a range of opinions with regard to the trigger for abandoning conservative management. Some believe that untreated hypotension alone (from a presumed splenic source) justifies intervention; others are prepared to transfuse up to a maximum of 2 units of blood before changing course. The message is clear: do not persevere with multiple blood transfusions to treat ongoing splenic bleeding. The initial CT scan may reveal a contrast ‘blush’ in the splenic parenchyma pointing to active bleeding; there is evidence to suggest that routine angioembolization of these bleeding vessels, in the stable patient, increases the success rate of non-operative management.',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.55, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Liver',\n", " 'md': '## Liver',\n", " 'bBox': {'x': 86, 'y': 574, 'w': 39.55, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The intra-operative control of hepatic bleeding is difficult. The loss of the tamponade effect at laparotomy followed by mobilization of the liver can result in renewed hemorrhage, sometimes torrential. In tackling a bleeding liver, there is no equivalent simple procedure like a splenectomy. Therefore, more diligence is called for in the pursuit of conservative management, as well as a greater reliance on aggressive transfusions of blood products and factors. There has been increasing...\\n```',\n", " 'md': 'The intra-operative control of hepatic bleeding is difficult. The loss of the tamponade effect at laparotomy followed by mobilization of the liver can result in renewed hemorrhage, sometimes torrential. In tackling a bleeding liver, there is no equivalent simple procedure like a splenectomy. Therefore, more diligence is called for in the pursuit of conservative management, as well as a greater reliance on aggressive transfusions of blood products and factors. There has been increasing...\\n```',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 43.14, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text has been extracted and structured into markdown format.\\n- No images or figures were identified on the page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been organized under appropriate headings for clarity.',\n", " 'md': '- The text has been extracted and structured into markdown format.\\n- No images or figures were identified on the page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been organized under appropriate headings for clarity.',\n", " 'bBox': {'x': 378, 'y': 330, 'w': 28, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 589,\n", " 'text': 'recourse to angioembolization in attempts (often successful) to avoid\\nsurgery. With hepatic injuries treated non-operatively, there is a\\nhigher complication rate than with splenic injuries. Increasing right\\nupper quadrant pain, jaundice, melena or sepsis should prompt\\nspecialized investigations (repeat CT scan, endoscopic retrograde\\ncholangiopancreatography [ERCP], angiography). Most of these\\ncomplications can be treated by interventional radiology (see also\\nChapter 25).\\n\\n When to operate in blunt trauma?\\n\\n The most common indications for surgery in blunt trauma are:\\n\\n • The hemodynamically unstable patient with a significant\\n hemoperitoneum preferably demonstrated by DPL or FAST; these\\n investigations may be omitted when other extra-abdominal injuries\\n are confidently ruled out in a hypotensive patient with a tense,\\n distended abdomen.\\n • The patient with an acute post-traumatic diaphragmatic hernia\\n demonstrated on chest X-ray or CT scan.\\n • The patient with or without peritoneal signs but with free\\n intraperitoneal air demonstrated on an upright chest X-ray or\\n abdominal CT scan.\\n • The patient with a hollow viscus injury (bowel, gallbladder,\\n intraperitoneal urinary bladder) demonstrated clinically or on CT\\n scan.\\n • The patient with CT evidence of a significant pancreatic injury.\\n • The patient with a significant hemoperitoneum in the absence, on\\n CT scan, of solid organ injury; think of a severe mesenteric injury\\n with a potential for bowel ischemia.\\n • The patient with signs of sepsis or a persistently tender\\n abdomen in the presence of equivocal CT images.\\n • The patient in whom conservative management of a hepatic or\\n splenic injury (identified initially by CT scan) has failed.\\n\\n (For the operative management of these specific injuries see the next',\n", " 'md': '```markdown\\n## Current Page Content\\n\\nRecourse to angioembolization in attempts (often successful) to avoid surgery. With hepatic injuries treated non-operatively, there is a higher complication rate than with splenic injuries. Increasing right upper quadrant pain, jaundice, melena, or sepsis should prompt specialized investigations (repeat CT scan, endoscopic retrograde cholangiopancreatography [ERCP], angiography). Most of these complications can be treated by interventional radiology (see also Chapter 25).\\n\\n### When to operate in blunt trauma?\\n\\nThe most common indications for surgery in blunt trauma are:\\n\\n- The hemodynamically unstable patient with a significant hemoperitoneum preferably demonstrated by DPL or FAST; these investigations may be omitted when other extra-abdominal injuries are confidently ruled out in a hypotensive patient with a tense, distended abdomen.\\n- The patient with an acute post-traumatic diaphragmatic hernia demonstrated on chest X-ray or CT scan.\\n- The patient with or without peritoneal signs but with free intraperitoneal air demonstrated on an upright chest X-ray or abdominal CT scan.\\n- The patient with a hollow viscus injury (bowel, gallbladder, intraperitoneal urinary bladder) demonstrated clinically or on CT scan.\\n- The patient with CT evidence of a significant pancreatic injury.\\n- The patient with a significant hemoperitoneum in the absence, on CT scan, of solid organ injury; think of a severe mesenteric injury with a potential for bowel ischemia.\\n- The patient with signs of sepsis or a persistently tender abdomen in the presence of equivocal CT images.\\n- The patient in whom conservative management of a hepatic or splenic injury (identified initially by CT scan) has failed.\\n\\n(For the operative management of these specific injuries see the next)\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Recourse to angioembolization in attempts (often successful) to avoid surgery. With hepatic injuries treated non-operatively, there is a higher complication rate than with splenic injuries. Increasing right upper quadrant pain, jaundice, melena, or sepsis should prompt specialized investigations (repeat CT scan, endoscopic retrograde cholangiopancreatography [ERCP], angiography). Most of these complications can be treated by interventional radiology (see also Chapter 25).',\n", " 'md': 'Recourse to angioembolization in attempts (often successful) to avoid surgery. With hepatic injuries treated non-operatively, there is a higher complication rate than with splenic injuries. Increasing right upper quadrant pain, jaundice, melena, or sepsis should prompt specialized investigations (repeat CT scan, endoscopic retrograde cholangiopancreatography [ERCP], angiography). Most of these complications can be treated by interventional radiology (see also Chapter 25).',\n", " 'bBox': {'x': 72, 'y': 169, 'w': 173.55, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'When to operate in blunt trauma?',\n", " 'md': '### When to operate in blunt trauma?',\n", " 'bBox': {'x': 86, 'y': 245, 'w': 263.86, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The most common indications for surgery in blunt trauma are:\\n\\n- The hemodynamically unstable patient with a significant hemoperitoneum preferably demonstrated by DPL or FAST; these investigations may be omitted when other extra-abdominal injuries are confidently ruled out in a hypotensive patient with a tense, distended abdomen.\\n- The patient with an acute post-traumatic diaphragmatic hernia demonstrated on chest X-ray or CT scan.\\n- The patient with or without peritoneal signs but with free intraperitoneal air demonstrated on an upright chest X-ray or abdominal CT scan.\\n- The patient with a hollow viscus injury (bowel, gallbladder, intraperitoneal urinary bladder) demonstrated clinically or on CT scan.\\n- The patient with CT evidence of a significant pancreatic injury.\\n- The patient with a significant hemoperitoneum in the absence, on CT scan, of solid organ injury; think of a severe mesenteric injury with a potential for bowel ischemia.\\n- The patient with signs of sepsis or a persistently tender abdomen in the presence of equivocal CT images.\\n- The patient in whom conservative management of a hepatic or splenic injury (identified initially by CT scan) has failed.\\n\\n(For the operative management of these specific injuries see the next)\\n```',\n", " 'md': 'The most common indications for surgery in blunt trauma are:\\n\\n- The hemodynamically unstable patient with a significant hemoperitoneum preferably demonstrated by DPL or FAST; these investigations may be omitted when other extra-abdominal injuries are confidently ruled out in a hypotensive patient with a tense, distended abdomen.\\n- The patient with an acute post-traumatic diaphragmatic hernia demonstrated on chest X-ray or CT scan.\\n- The patient with or without peritoneal signs but with free intraperitoneal air demonstrated on an upright chest X-ray or abdominal CT scan.\\n- The patient with a hollow viscus injury (bowel, gallbladder, intraperitoneal urinary bladder) demonstrated clinically or on CT scan.\\n- The patient with CT evidence of a significant pancreatic injury.\\n- The patient with a significant hemoperitoneum in the absence, on CT scan, of solid organ injury; think of a severe mesenteric injury with a potential for bowel ischemia.\\n- The patient with signs of sepsis or a persistently tender abdomen in the presence of equivocal CT images.\\n- The patient in whom conservative management of a hepatic or splenic injury (identified initially by CT scan) has failed.\\n\\n(For the operative management of these specific injuries see the next)\\n```',\n", " 'bBox': {'x': 86, 'y': 169, 'w': 453.52, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 25).'}]},\n", " {'page': 590,\n", " 'text': 'section.)\\n\\n To summarize\\n\\n Clinical evaluation is often unreliable in the management of blunt\\nabdominal trauma. Great reliance is placed on the abdominal CT scan in\\nstable patients, and on DPL or FAST in hypotensive patients. The results\\nof these investigations always need interpretation in the overall clinical\\ncontext.\\n\\n Things have changed since it was stated more than 100 years ago:\\n\\n Exploratory laparotomy offers, in our judgment, the quickest\\n and the safest method of positive diagnosis. The\\n emergency warrants a decisive step.\\n Albert Miles\\n\\n 3 Operative management of individual organ injuries\\n It is judgment not genital insufficiency driving a surgeon to\\n pack his patient’s abdomen.\\n David J. Richardson\\n\\n You have decided to perform a laparotomy. Nowadays, this is more\\nlikely for penetrating than for blunt trauma. Most solid visceral injuries\\nin blunt trauma can be managed conservatively: often doing ‘less’ is\\n‘better’, with limited blood loss and the avoidance of unnecessary\\ntissue injury. The incision and assessment of the damage are described\\nelsewhere in this book ( Chapters 10 and 11).\\n\\n Diaphragm\\n\\n A through-and-through diaphragmatic laceration requires suture-repair\\nwith interrupted (or running) ®) suture material. Lacerations withheavy (0 or 2-0 non-absorbable\\nmonofilament such as Prolene',\n", " 'md': '```markdown\\n## Summary of Clinical Evaluation in Blunt Abdominal Trauma\\n\\nClinical evaluation is often unreliable in the management of blunt abdominal trauma. Great reliance is placed on the abdominal CT scan in stable patients, and on DPL or FAST in hypotensive patients. The results of these investigations always need interpretation in the overall clinical context.\\n\\n### Historical Perspective\\n\\nThings have changed since it was stated more than 100 years ago:\\n\\n> \"Exploratory laparotomy offers, in our judgment, the quickest and the safest method of positive diagnosis. The emergency warrants a decisive step.\"\\n> — Albert Miles\\n\\n> \"It is judgment not genital insufficiency driving a surgeon to pack his patient’s abdomen.\"\\n> — David J. Richardson\\n\\n### Operative Management of Individual Organ Injuries\\n\\nYou have decided to perform a laparotomy. Nowadays, this is more likely for penetrating than for blunt trauma. Most solid visceral injuries in blunt trauma can be managed conservatively: often doing ‘less’ is ‘better’, with limited blood loss and the avoidance of unnecessary tissue injury. The incision and assessment of the damage are described elsewhere in this book (Chapters 10 and 11).\\n\\n### Diaphragm\\n\\nA through-and-through diaphragmatic laceration requires suture-repair with interrupted (or running) suture material. Lacerations with heavy (0 or 2-0) non-absorbable monofilament such as Prolene.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary of Clinical Evaluation in Blunt Abdominal Trauma',\n", " 'md': '## Summary of Clinical Evaluation in Blunt Abdominal Trauma',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Clinical evaluation is often unreliable in the management of blunt abdominal trauma. Great reliance is placed on the abdominal CT scan in stable patients, and on DPL or FAST in hypotensive patients. The results of these investigations always need interpretation in the overall clinical context.',\n", " 'md': 'Clinical evaluation is often unreliable in the management of blunt abdominal trauma. Great reliance is placed on the abdominal CT scan in stable patients, and on DPL or FAST in hypotensive patients. The results of these investigations always need interpretation in the overall clinical context.',\n", " 'bBox': {'x': 72, 'y': 181, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Historical Perspective',\n", " 'md': '### Historical Perspective',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Things have changed since it was stated more than 100 years ago:\\n\\n> \"Exploratory laparotomy offers, in our judgment, the quickest and the safest method of positive diagnosis. The emergency warrants a decisive step.\"\\n> — Albert Miles\\n\\n> \"It is judgment not genital insufficiency driving a surgeon to pack his patient’s abdomen.\"\\n> — David J. Richardson',\n", " 'md': 'Things have changed since it was stated more than 100 years ago:\\n\\n> \"Exploratory laparotomy offers, in our judgment, the quickest and the safest method of positive diagnosis. The emergency warrants a decisive step.\"\\n> — Albert Miles\\n\\n> \"It is judgment not genital insufficiency driving a surgeon to pack his patient’s abdomen.\"\\n> — David J. Richardson',\n", " 'bBox': {'x': 86, 'y': 266, 'w': 427.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Operative Management of Individual Organ Injuries',\n", " 'md': '### Operative Management of Individual Organ Injuries',\n", " 'bBox': {'x': 114, 'y': 394, 'w': 346.9, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'You have decided to perform a laparotomy. Nowadays, this is more likely for penetrating than for blunt trauma. Most solid visceral injuries in blunt trauma can be managed conservatively: often doing ‘less’ is ‘better’, with limited blood loss and the avoidance of unnecessary tissue injury. The incision and assessment of the damage are described elsewhere in this book (Chapters 10 and 11).',\n", " 'md': 'You have decided to perform a laparotomy. Nowadays, this is more likely for penetrating than for blunt trauma. Most solid visceral injuries in blunt trauma can be managed conservatively: often doing ‘less’ is ‘better’, with limited blood loss and the avoidance of unnecessary tissue injury. The incision and assessment of the damage are described elsewhere in this book (Chapters 10 and 11).',\n", " 'bBox': {'x': 72, 'y': 536, 'w': 467.49, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diaphragm',\n", " 'md': '### Diaphragm',\n", " 'bBox': {'x': 86, 'y': 646, 'w': 86.45, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A through-and-through diaphragmatic laceration requires suture-repair with interrupted (or running) suture material. Lacerations with heavy (0 or 2-0) non-absorbable monofilament such as Prolene.\\n```',\n", " 'md': 'A through-and-through diaphragmatic laceration requires suture-repair with interrupted (or running) suture material. Lacerations with heavy (0 or 2-0) non-absorbable monofilament such as Prolene.\\n```',\n", " 'bBox': {'x': 72, 'y': 646, 'w': 467.37, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 591,\n", " 'text': 'substantial tissue loss are very rare and need repair with a synthetic\\nmesh. A prosthesis may not be necessary when the tissue loss is at the\\nperiphery; instead, the diaphragm can be reimplanted to the ribs more\\ncephalad. This is of particular benefit in the presence of extensive\\ncontamination. Remember that even in the absence of a pre-operative\\npneumothorax, an ipsilateral chest tube must be inserted at some\\nstage of the procedure. It is often said that minor diaphragmatic tears\\ncan be ignored on the right side because the bulk of the liver prevents\\nfuture bowel herniation. ħowever, large right-sided lacerations (seen\\nusually in blunt trauma) must be repaired because the liver itself can, in\\ntime, be ‘sucked up’ into the chest.\\n\\n Liver and biliary tree (see also Chapter 25)\\n\\n An irreverent classification of hepatic injuries is shown in Table 32.1.\\n Table 32.1. Classification of hepatic injuries.\\n Grade I: Nothing should be done (treat conservatively)\\n Grade Il: Something should be done (local hemostasis)\\n Grade III: Too much should not be done (packing only)\\n Grade IV: Only God can do something (heroic measures):\\n The following are some practical management principles:\\n\\n • Bleeding from small, superficial capsular tears can be controlled by\\n cautery, individual vessel ligation or clipping, or by atraumatic\\n suture-repair of the fragile hepatic capsule.\\n • More severe bleeding from a deep or craggy hepatic laceration\\n constitutes a surgical challenge requiring a stepwise approach. After\\n a quick glance, bimanual compression of the hepatic parenchyma\\n will control the bleeding temporarily, allowing the anesthetist to catch\\n up with the blood loss. This must be followed by rapid\\n mobilization of the liver by division of the falciform, left and\\n right triangular ligaments — the liver can be literally dislocated\\n into the abdominal incision. Additional exposure via a median',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nSubstantial tissue loss are very rare and need repair with a synthetic mesh. A prosthesis may not be necessary when the tissue loss is at the periphery; instead, the diaphragm can be reimplanted to the ribs more cephalad. This is of particular benefit in the presence of extensive contamination. Remember that even in the absence of a pre-operative pneumothorax, an ipsilateral chest tube must be inserted at some stage of the procedure. It is often said that minor diaphragmatic tears can be ignored on the right side because the bulk of the liver prevents future bowel herniation. However, large right-sided lacerations (seen usually in blunt trauma) must be repaired because the liver itself can, in time, be ‘sucked up’ into the chest.\\n\\nLiver and biliary tree (see also Chapter 25)\\n\\nAn irreverent classification of hepatic injuries is shown in Table 32.1.\\n\\n### Table 32.1. Classification of hepatic injuries\\n\\n| Grade | Description |\\n|---------|--------------------------------------------------|\\n| Grade I | Nothing should be done (treat conservatively) |\\n| Grade II| Something should be done (local hemostasis) |\\n| Grade III| Too much should not be done (packing only) |\\n| Grade IV| Only God can do something (heroic measures) |\\n\\nThe following are some practical management principles:\\n\\n- Bleeding from small, superficial capsular tears can be controlled by cautery, individual vessel ligation or clipping, or by atraumatic suture-repair of the fragile hepatic capsule.\\n- More severe bleeding from a deep or craggy hepatic laceration constitutes a surgical challenge requiring a stepwise approach. After a quick glance, bimanual compression of the hepatic parenchyma will control the bleeding temporarily, allowing the anesthetist to catch up with the blood loss. This must be followed by rapid mobilization of the liver by division of the falciform, left and right triangular ligaments — the liver can be literally dislocated into the abdominal incision.\\n\\n## Image Identification and Description\\n\\n- **Figure 1**: No images or graphs were identified on this page.\\n\\n## Summary\\n\\nThis page discusses the management of substantial tissue loss, particularly in relation to diaphragmatic tears and hepatic injuries. It includes a classification of hepatic injuries and practical management principles for dealing with bleeding from liver injuries.\\n```',\n", " 'images': [{'name': 'img_p590_1.png',\n", " 'height': 272,\n", " 'width': 811,\n", " 'x': 105.84000000000015,\n", " 'y': 344.15999999999997,\n", " 'original_width': 1392,\n", " 'original_height': 468}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Substantial tissue loss are very rare and need repair with a synthetic mesh. A prosthesis may not be necessary when the tissue loss is at the periphery; instead, the diaphragm can be reimplanted to the ribs more cephalad. This is of particular benefit in the presence of extensive contamination. Remember that even in the absence of a pre-operative pneumothorax, an ipsilateral chest tube must be inserted at some stage of the procedure. It is often said that minor diaphragmatic tears can be ignored on the right side because the bulk of the liver prevents future bowel herniation. However, large right-sided lacerations (seen usually in blunt trauma) must be repaired because the liver itself can, in time, be ‘sucked up’ into the chest.\\n\\nLiver and biliary tree (see also Chapter 25)\\n\\nAn irreverent classification of hepatic injuries is shown in Table 32.1.',\n", " 'md': 'Substantial tissue loss are very rare and need repair with a synthetic mesh. A prosthesis may not be necessary when the tissue loss is at the periphery; instead, the diaphragm can be reimplanted to the ribs more cephalad. This is of particular benefit in the presence of extensive contamination. Remember that even in the absence of a pre-operative pneumothorax, an ipsilateral chest tube must be inserted at some stage of the procedure. It is often said that minor diaphragmatic tears can be ignored on the right side because the bulk of the liver prevents future bowel herniation. However, large right-sided lacerations (seen usually in blunt trauma) must be repaired because the liver itself can, in time, be ‘sucked up’ into the chest.\\n\\nLiver and biliary tree (see also Chapter 25)\\n\\nAn irreverent classification of hepatic injuries is shown in Table 32.1.',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.87, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 32.1. Classification of hepatic injuries',\n", " 'md': '### Table 32.1. Classification of hepatic injuries',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Grade', 'Description'],\n", " ['Grade I', 'Nothing should be done (treat conservatively)'],\n", " ['Grade II', 'Something should be done (local hemostasis)'],\n", " ['Grade III', 'Too much should not be done (packing only)'],\n", " ['Grade IV', 'Only God can do something (heroic measures)']],\n", " 'md': '| Grade | Description |\\n|---------|--------------------------------------------------|\\n| Grade I | Nothing should be done (treat conservatively) |\\n| Grade II| Something should be done (local hemostasis) |\\n| Grade III| Too much should not be done (packing only) |\\n| Grade IV| Only God can do something (heroic measures) |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Grade\",\"Description\"\\n\"Grade I\",\"Nothing should be done (treat conservatively)\"\\n\"Grade II\",\"Something should be done (local hemostasis)\"\\n\"Grade III\",\"Too much should not be done (packing only)\"\\n\"Grade IV\",\"Only God can do something (heroic measures)\"',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The following are some practical management principles:\\n\\n- Bleeding from small, superficial capsular tears can be controlled by cautery, individual vessel ligation or clipping, or by atraumatic suture-repair of the fragile hepatic capsule.\\n- More severe bleeding from a deep or craggy hepatic laceration constitutes a surgical challenge requiring a stepwise approach. After a quick glance, bimanual compression of the hepatic parenchyma will control the bleeding temporarily, allowing the anesthetist to catch up with the blood loss. This must be followed by rapid mobilization of the liver by division of the falciform, left and right triangular ligaments — the liver can be literally dislocated into the abdominal incision.',\n", " 'md': 'The following are some practical management principles:\\n\\n- Bleeding from small, superficial capsular tears can be controlled by cautery, individual vessel ligation or clipping, or by atraumatic suture-repair of the fragile hepatic capsule.\\n- More severe bleeding from a deep or craggy hepatic laceration constitutes a surgical challenge requiring a stepwise approach. After a quick glance, bimanual compression of the hepatic parenchyma will control the bleeding temporarily, allowing the anesthetist to catch up with the blood loss. This must be followed by rapid mobilization of the liver by division of the falciform, left and right triangular ligaments — the liver can be literally dislocated into the abdominal incision.',\n", " 'bBox': {'x': 86, 'y': 511, 'w': 436.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: No images or graphs were identified on this page.',\n", " 'md': '- **Figure 1**: No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the management of substantial tissue loss, particularly in relation to diaphragmatic tears and hepatic injuries. It includes a classification of hepatic injuries and practical management principles for dealing with bleeding from liver injuries.\\n```',\n", " 'md': 'This page discusses the management of substantial tissue loss, particularly in relation to diaphragmatic tears and hepatic injuries. It includes a classification of hepatic injuries and practical management principles for dealing with bleeding from liver injuries.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 592,\n", " 'text': ' sternotomy or right thoracotomy is rarely indicated. The Pringle\\n maneuver (inflow occlusion of the undissected triad of the portal\\n vein, hepatic artery and common bile duct) is sometimes useful and\\n safe for up to 60 minutes (or even longer, provided you intermittently\\n resume the flow every 15-20 minutes). Deep parenchymal bleeding\\n is controlled as well as possible by clipping visible bleeding vessels\\n and by conservative resectional debridement. This rarely controls\\n the hemorrhage completely — supplementary packing is\\n necessary. Packs must be judiciously placed around (not into) the\\n liver. The aim is to close the laceration by tight packing and thereby\\n tamponade the bleeding. Excessive packing must be avoided\\n because it can result in inferior vena cava compression or\\n abdominal compartment syndrome with aggravation of the\\n hypotension. And always leave the abdomen open after packing.\\n A return to the OR will be necessary in 36-72 hours for pack\\n removal. There is always a danger of losing sight of time and\\n the amount of blood loss that is incurred while trying to\\n achieve an elusive ‘perfect’ result. More bleeding will require\\n more transfusions and aggravate the coagulopathy in a well-\\n known vicious cycle. We strongly advise you to look at the\\n clock before you tackle a nasty liver laceration: you should\\n achieve both vessel control and packing, ideally within 45\\n minutes.\\n• Retrohepatic caval injuries are characterized by exsanguinating\\n hemorrhage despite inflow occlusion. There are probably more\\n techniques described for immediate hemostasis than there are\\n survivors. It is perhaps best to resort to damage control with packing\\n and come back to fight another day.\\n• Injuries to the porta hepatis require a wide Kocher maneuver for\\n exposure. The injured portal vein should be repaired, or ligated as a\\n last resort. ħepatic artery ligation is better tolerated than portal vein\\n ligation. Suture-repair or Roux-en-Y biliary enteric anastomoses are\\n the treatment options for an injured common bile duct; the latter can\\n be performed either at the initial operation or at the reconstruction\\n phase of a damage control strategy. Unilateral lobar bile duct injuries\\n should be managed by ligation.\\n• An injured gallbladder should be resected.',\n", " 'md': '```markdown\\n# Surgical Management of Liver Injuries\\n\\n## Key Points\\n\\n- **Sternotomy or Right Thoracotomy**: Rarely indicated.\\n- **Pringle Maneuver**: Inflow occlusion of the undissected triad of the portal vein, hepatic artery, and common bile duct. Useful and safe for up to 60 minutes (or longer with intermittent flow resumption every 15-20 minutes).\\n- **Deep Parenchymal Bleeding Control**:\\n- Clipping visible bleeding vessels.\\n- Conservative resectional debridement.\\n- Supplementary packing may be necessary.\\n- Packs should be placed around (not into) the liver to achieve tamponade.\\n- Avoid excessive packing to prevent inferior vena cava compression or abdominal compartment syndrome, which can worsen hypotension.\\n- Leave the abdomen open after packing.\\n- A return to the operating room (OR) is necessary in 36-72 hours for pack removal.\\n\\n- **Timing and Blood Loss**:\\n- Be mindful of time and blood loss during liver laceration management.\\n- Aim for vessel control and packing ideally within 45 minutes to avoid a vicious cycle of bleeding and transfusions.\\n\\n- **Retrohepatic Caval Injuries**:\\n- Characterized by exsanguinating hemorrhage despite inflow occlusion.\\n- Damage control with packing is often the best approach.\\n\\n- **Injuries to the Porta Hepatis**:\\n- Require a wide Kocher maneuver for exposure.\\n- Repair or ligation of the injured portal vein as a last resort.\\n- Hepatic artery ligation is better tolerated than portal vein ligation.\\n- Treatment options for an injured common bile duct include suture-repair or Roux-en-Y biliary enteric anastomoses, which can be performed during the initial operation or reconstruction phase.\\n- Unilateral lobar bile duct injuries should be managed by ligation.\\n\\n- **Injured Gallbladder**: Should be resected.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Surgical Management of Liver Injuries',\n", " 'md': '# Surgical Management of Liver Injuries',\n", " 'bBox': {'x': 490, 'y': 284, 'w': 16, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Key Points',\n", " 'md': '## Key Points',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Sternotomy or Right Thoracotomy**: Rarely indicated.\\n- **Pringle Maneuver**: Inflow occlusion of the undissected triad of the portal vein, hepatic artery, and common bile duct. Useful and safe for up to 60 minutes (or longer with intermittent flow resumption every 15-20 minutes).\\n- **Deep Parenchymal Bleeding Control**:\\n- Clipping visible bleeding vessels.\\n- Conservative resectional debridement.\\n- Supplementary packing may be necessary.\\n- Packs should be placed around (not into) the liver to achieve tamponade.\\n- Avoid excessive packing to prevent inferior vena cava compression or abdominal compartment syndrome, which can worsen hypotension.\\n- Leave the abdomen open after packing.\\n- A return to the operating room (OR) is necessary in 36-72 hours for pack removal.\\n\\n- **Timing and Blood Loss**:\\n- Be mindful of time and blood loss during liver laceration management.\\n- Aim for vessel control and packing ideally within 45 minutes to avoid a vicious cycle of bleeding and transfusions.\\n\\n- **Retrohepatic Caval Injuries**:\\n- Characterized by exsanguinating hemorrhage despite inflow occlusion.\\n- Damage control with packing is often the best approach.\\n\\n- **Injuries to the Porta Hepatis**:\\n- Require a wide Kocher maneuver for exposure.\\n- Repair or ligation of the injured portal vein as a last resort.\\n- Hepatic artery ligation is better tolerated than portal vein ligation.\\n- Treatment options for an injured common bile duct include suture-repair or Roux-en-Y biliary enteric anastomoses, which can be performed during the initial operation or reconstruction phase.\\n- Unilateral lobar bile duct injuries should be managed by ligation.\\n\\n- **Injured Gallbladder**: Should be resected.\\n```',\n", " 'md': '- **Sternotomy or Right Thoracotomy**: Rarely indicated.\\n- **Pringle Maneuver**: Inflow occlusion of the undissected triad of the portal vein, hepatic artery, and common bile duct. Useful and safe for up to 60 minutes (or longer with intermittent flow resumption every 15-20 minutes).\\n- **Deep Parenchymal Bleeding Control**:\\n- Clipping visible bleeding vessels.\\n- Conservative resectional debridement.\\n- Supplementary packing may be necessary.\\n- Packs should be placed around (not into) the liver to achieve tamponade.\\n- Avoid excessive packing to prevent inferior vena cava compression or abdominal compartment syndrome, which can worsen hypotension.\\n- Leave the abdomen open after packing.\\n- A return to the operating room (OR) is necessary in 36-72 hours for pack removal.\\n\\n- **Timing and Blood Loss**:\\n- Be mindful of time and blood loss during liver laceration management.\\n- Aim for vessel control and packing ideally within 45 minutes to avoid a vicious cycle of bleeding and transfusions.\\n\\n- **Retrohepatic Caval Injuries**:\\n- Characterized by exsanguinating hemorrhage despite inflow occlusion.\\n- Damage control with packing is often the best approach.\\n\\n- **Injuries to the Porta Hepatis**:\\n- Require a wide Kocher maneuver for exposure.\\n- Repair or ligation of the injured portal vein as a last resort.\\n- Hepatic artery ligation is better tolerated than portal vein ligation.\\n- Treatment options for an injured common bile duct include suture-repair or Roux-en-Y biliary enteric anastomoses, which can be performed during the initial operation or reconstruction phase.\\n- Unilateral lobar bile duct injuries should be managed by ligation.\\n\\n- **Injured Gallbladder**: Should be resected.\\n```',\n", " 'bBox': {'x': 100, 'y': 201, 'w': 199.12, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 593,\n", " 'text': ' Spleen\\n\\n The treatment at laparotomy of an actively bleeding spleen in the adult\\nis splenectomy. Again: acrobatic surgical splenic conservation\\nprocedures belong to expensive surgical textbooks; they have no\\nplace in the OR. The risk of post-splenectomy sepsis is small and can\\nbe further minimized by vaccination, vigilance and appropriate\\nprophylaxis, as discussed in the previous section.\\n\\n Pancreas\\n\\n The state of the main pancreatic duct and the site of the\\npresumed injury (proximal versus distal) are crucial determinants of\\nthe operative strategy in the injured pancreas. In blunt trauma,\\nfracture of the pancreatic parenchyma opposite the vertebral column is\\ntypically seen on the pre-operative CT scan. It usually involves disruption\\nof the main duct. Confirmation in the stable patient may require\\nendoscopic (ERCP) or magnetic resonance\\ncholangiopancreatography (MRCP) if these investigations can be\\ncarried out immediately. In penetrating trauma, the question of duct\\nintegrity is often posed during the trauma laparotomy. The anterior aspect\\nof the pancreas is exposed through the lesser sac by division of the\\ngastrocolic omentum; the posterior aspect of the head is exposed by a\\nKocher maneuver, while the posterior aspect of the tail is achieved by\\nsplenic mobilization. Intra-operative pancreatography (through a\\nduodenotomy and cannulation of the ampulla of Vater) is described, but it\\nis rarely performed in practice. In superficial pancreatic wounds, the\\nmain duct may be presumed to be intact and drainage alone is sufficient.\\nIn deeper parenchymal wounds of the body or tail, ductal transection is\\nlikely and a distal pancreatectomy (with splenectomy) is warranted. For\\ndeeper injuries of the head, wide drainage is indicated; the management\\nof the inevitable pancreatic fistula in a stable patient is simpler than\\ntreating a leaking anastomosis after Roux-en-Y pancreaticojejunostomy.\\nThe Whipple procedure is reserved for massive injuries of the pancreatic\\nhead, with biliary ductal and duodenal disruption. This procedure is\\nattended by a high mortality; it should be preferably ‘staged’, with the\\ndefinitive reconstruction performed only after the patient has been\\nstabilized.',\n", " 'md': '```markdown\\n# Spleen\\n\\nThe treatment at laparotomy of an actively bleeding spleen in the adult is splenectomy. Again, acrobatic surgical splenic conservation procedures belong to expensive surgical textbooks; they have no place in the OR. The risk of post-splenectomy sepsis is small and can be further minimized by vaccination, vigilance, and appropriate prophylaxis, as discussed in the previous section.\\n\\n# Pancreas\\n\\nThe state of the main pancreatic duct and the site of the presumed injury (proximal versus distal) are crucial determinants of the operative strategy in the injured pancreas. In blunt trauma, fracture of the pancreatic parenchyma opposite the vertebral column is typically seen on the pre-operative CT scan. It usually involves disruption of the main duct. Confirmation in the stable patient may require endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) if these investigations can be carried out immediately.\\n\\nIn penetrating trauma, the question of duct integrity is often posed during the trauma laparotomy. The anterior aspect of the pancreas is exposed through the lesser sac by division of the gastrocolic omentum; the posterior aspect of the head is exposed by a Kocher maneuver, while the posterior aspect of the tail is achieved by splenic mobilization. Intra-operative pancreatography (through a duodenotomy and cannulation of the ampulla of Vater) is described, but it is rarely performed in practice.\\n\\nIn superficial pancreatic wounds, the main duct may be presumed to be intact and drainage alone is sufficient. In deeper parenchymal wounds of the body or tail, ductal transection is likely and a distal pancreatectomy (with splenectomy) is warranted. For deeper injuries of the head, wide drainage is indicated; the management of the inevitable pancreatic fistula in a stable patient is simpler than treating a leaking anastomosis after Roux-en-Y pancreaticojejunostomy.\\n\\nThe Whipple procedure is reserved for massive injuries of the pancreatic head, with biliary ductal and duodenal disruption. This procedure is attended by a high mortality; it should be preferably ‘staged’, with the definitive reconstruction performed only after the patient has been stabilized.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Spleen',\n", " 'md': '# Spleen',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 54.26, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The treatment at laparotomy of an actively bleeding spleen in the adult is splenectomy. Again, acrobatic surgical splenic conservation procedures belong to expensive surgical textbooks; they have no place in the OR. The risk of post-splenectomy sepsis is small and can be further minimized by vaccination, vigilance, and appropriate prophylaxis, as discussed in the previous section.',\n", " 'md': 'The treatment at laparotomy of an actively bleeding spleen in the adult is splenectomy. Again, acrobatic surgical splenic conservation procedures belong to expensive surgical textbooks; they have no place in the OR. The risk of post-splenectomy sepsis is small and can be further minimized by vaccination, vigilance, and appropriate prophylaxis, as discussed in the previous section.',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.52, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Pancreas',\n", " 'md': '# Pancreas',\n", " 'bBox': {'x': 86, 'y': 250, 'w': 73.6, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The state of the main pancreatic duct and the site of the presumed injury (proximal versus distal) are crucial determinants of the operative strategy in the injured pancreas. In blunt trauma, fracture of the pancreatic parenchyma opposite the vertebral column is typically seen on the pre-operative CT scan. It usually involves disruption of the main duct. Confirmation in the stable patient may require endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) if these investigations can be carried out immediately.\\n\\nIn penetrating trauma, the question of duct integrity is often posed during the trauma laparotomy. The anterior aspect of the pancreas is exposed through the lesser sac by division of the gastrocolic omentum; the posterior aspect of the head is exposed by a Kocher maneuver, while the posterior aspect of the tail is achieved by splenic mobilization. Intra-operative pancreatography (through a duodenotomy and cannulation of the ampulla of Vater) is described, but it is rarely performed in practice.\\n\\nIn superficial pancreatic wounds, the main duct may be presumed to be intact and drainage alone is sufficient. In deeper parenchymal wounds of the body or tail, ductal transection is likely and a distal pancreatectomy (with splenectomy) is warranted. For deeper injuries of the head, wide drainage is indicated; the management of the inevitable pancreatic fistula in a stable patient is simpler than treating a leaking anastomosis after Roux-en-Y pancreaticojejunostomy.\\n\\nThe Whipple procedure is reserved for massive injuries of the pancreatic head, with biliary ductal and duodenal disruption. This procedure is attended by a high mortality; it should be preferably ‘staged’, with the definitive reconstruction performed only after the patient has been stabilized.\\n```',\n", " 'md': 'The state of the main pancreatic duct and the site of the presumed injury (proximal versus distal) are crucial determinants of the operative strategy in the injured pancreas. In blunt trauma, fracture of the pancreatic parenchyma opposite the vertebral column is typically seen on the pre-operative CT scan. It usually involves disruption of the main duct. Confirmation in the stable patient may require endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) if these investigations can be carried out immediately.\\n\\nIn penetrating trauma, the question of duct integrity is often posed during the trauma laparotomy. The anterior aspect of the pancreas is exposed through the lesser sac by division of the gastrocolic omentum; the posterior aspect of the head is exposed by a Kocher maneuver, while the posterior aspect of the tail is achieved by splenic mobilization. Intra-operative pancreatography (through a duodenotomy and cannulation of the ampulla of Vater) is described, but it is rarely performed in practice.\\n\\nIn superficial pancreatic wounds, the main duct may be presumed to be intact and drainage alone is sufficient. In deeper parenchymal wounds of the body or tail, ductal transection is likely and a distal pancreatectomy (with splenectomy) is warranted. For deeper injuries of the head, wide drainage is indicated; the management of the inevitable pancreatic fistula in a stable patient is simpler than treating a leaking anastomosis after Roux-en-Y pancreaticojejunostomy.\\n\\nThe Whipple procedure is reserved for massive injuries of the pancreatic head, with biliary ductal and duodenal disruption. This procedure is attended by a high mortality; it should be preferably ‘staged’, with the definitive reconstruction performed only after the patient has been stabilized.\\n```',\n", " 'bBox': {'x': 72, 'y': 190, 'w': 467.98, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 594,\n", " 'text': ' The following aphorism captures very graphically the\\nmanagement of this injury:\\n\\n For pancreatic trauma, treat the pancreas like a\\n crawfish: suck the head, eat the tail.\\n Timothy Fabian\\n\\n Kidney, ureter and bladder (see also Chapter 37)\\n\\n The intra-operative discovery of a perinephric hematoma is usually\\nindicative of renal injury. A large proportion of these are self-limiting.\\nRenal exploration is indicated in the presence of an expanding or\\npulsatile hematoma, or when a hilar injury is suspected. Moderate\\nseverity injuries can be controlled usually by cortical renorrhaphy and\\ndrainage; occasionally, a polar nephrectomy may be indicated. A\\nshattered kidney or a vascular hilar injury are treated by nephrectomy;\\npreliminary control of the renal artery and vein should not be\\nattempted in the presence of hemodynamic instability. Attempts at\\nsaving a kidney, in these situations, are not warranted, unless the patient\\nhas a single kidney.\\n\\n Lacerations of the renal pelvis are repaired with fine absorbable\\nsutures. An injured ureter should be carefully exposed, avoiding ischemic\\ndamage by over-enthusiastic skeletonization. Primary repair with\\nabsorbable material over a stent is the rule. Very proximal or very distal\\nureteric injuries may require an expert urologic opinion.\\n\\n An intraperitoneal bladder injury requires repair with absorbable\\nsutures and catheter drainage. In an extraperitoneal rupture from\\nblunt trauma, catheter drainage alone is sufficient. A urethral Foley\\ncatheter is adequate in most cases. In severe, complex bladder injuries\\nor significant bleeding, suprapubic drainage may be added to allow for\\nefficient, postoperative bladder irrigation.\\n\\n Stomach\\n\\n Most gastric injuries are caused by penetrating trauma and are treated',\n", " 'md': '```markdown\\n# Page Content\\n\\nThe following aphorism captures very graphically the management of this injury:\\n\\n> For pancreatic trauma, treat the pancreas like a crawfish: suck the head, eat the tail.\\n> — Timothy Fabian\\n\\n## Kidney, Ureter, and Bladder (see also Chapter 37)\\n\\nThe intra-operative discovery of a perinephric hematoma is usually indicative of renal injury. A large proportion of these are self-limiting. Renal exploration is indicated in the presence of an expanding or pulsatile hematoma, or when a hilar injury is suspected. Moderate severity injuries can be controlled usually by cortical renorrhaphy and drainage; occasionally, a polar nephrectomy may be indicated. A shattered kidney or a vascular hilar injury are treated by nephrectomy; preliminary control of the renal artery and vein should not be attempted in the presence of hemodynamic instability. Attempts at saving a kidney, in these situations, are not warranted, unless the patient has a single kidney.\\n\\nLacerations of the renal pelvis are repaired with fine absorbable sutures. An injured ureter should be carefully exposed, avoiding ischemic damage by over-enthusiastic skeletonization. Primary repair with absorbable material over a stent is the rule. Very proximal or very distal ureteric injuries may require an expert urologic opinion.\\n\\nAn intraperitoneal bladder injury requires repair with absorbable sutures and catheter drainage. In an extraperitoneal rupture from blunt trauma, catheter drainage alone is sufficient. A urethral Foley catheter is adequate in most cases. In severe, complex bladder injuries or significant bleeding, suprapubic drainage may be added to allow for efficient, postoperative bladder irrigation.\\n\\n## Stomach\\n\\nMost gastric injuries are caused by penetrating trauma and are treated\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The following aphorism captures very graphically the management of this injury:\\n\\n> For pancreatic trauma, treat the pancreas like a crawfish: suck the head, eat the tail.\\n> — Timothy Fabian',\n", " 'md': 'The following aphorism captures very graphically the management of this injury:\\n\\n> For pancreatic trauma, treat the pancreas like a crawfish: suck the head, eat the tail.\\n> — Timothy Fabian',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 246.19, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Kidney, Ureter, and Bladder (see also Chapter 37)',\n", " 'md': '## Kidney, Ureter, and Bladder (see also Chapter 37)',\n", " 'bBox': {'x': 392, 'y': 216, 'w': 91.05, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The intra-operative discovery of a perinephric hematoma is usually indicative of renal injury. A large proportion of these are self-limiting. Renal exploration is indicated in the presence of an expanding or pulsatile hematoma, or when a hilar injury is suspected. Moderate severity injuries can be controlled usually by cortical renorrhaphy and drainage; occasionally, a polar nephrectomy may be indicated. A shattered kidney or a vascular hilar injury are treated by nephrectomy; preliminary control of the renal artery and vein should not be attempted in the presence of hemodynamic instability. Attempts at saving a kidney, in these situations, are not warranted, unless the patient has a single kidney.\\n\\nLacerations of the renal pelvis are repaired with fine absorbable sutures. An injured ureter should be carefully exposed, avoiding ischemic damage by over-enthusiastic skeletonization. Primary repair with absorbable material over a stent is the rule. Very proximal or very distal ureteric injuries may require an expert urologic opinion.\\n\\nAn intraperitoneal bladder injury requires repair with absorbable sutures and catheter drainage. In an extraperitoneal rupture from blunt trauma, catheter drainage alone is sufficient. A urethral Foley catheter is adequate in most cases. In severe, complex bladder injuries or significant bleeding, suprapubic drainage may be added to allow for efficient, postoperative bladder irrigation.',\n", " 'md': 'The intra-operative discovery of a perinephric hematoma is usually indicative of renal injury. A large proportion of these are self-limiting. Renal exploration is indicated in the presence of an expanding or pulsatile hematoma, or when a hilar injury is suspected. Moderate severity injuries can be controlled usually by cortical renorrhaphy and drainage; occasionally, a polar nephrectomy may be indicated. A shattered kidney or a vascular hilar injury are treated by nephrectomy; preliminary control of the renal artery and vein should not be attempted in the presence of hemodynamic instability. Attempts at saving a kidney, in these situations, are not warranted, unless the patient has a single kidney.\\n\\nLacerations of the renal pelvis are repaired with fine absorbable sutures. An injured ureter should be carefully exposed, avoiding ischemic damage by over-enthusiastic skeletonization. Primary repair with absorbable material over a stent is the rule. Very proximal or very distal ureteric injuries may require an expert urologic opinion.\\n\\nAn intraperitoneal bladder injury requires repair with absorbable sutures and catheter drainage. In an extraperitoneal rupture from blunt trauma, catheter drainage alone is sufficient. A urethral Foley catheter is adequate in most cases. In severe, complex bladder injuries or significant bleeding, suprapubic drainage may be added to allow for efficient, postoperative bladder irrigation.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.73, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Stomach',\n", " 'md': '## Stomach',\n", " 'bBox': {'x': 86, 'y': 681, 'w': 69.9, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Most gastric injuries are caused by penetrating trauma and are treated\\n```',\n", " 'md': 'Most gastric injuries are caused by penetrating trauma and are treated\\n```',\n", " 'bBox': {'x': 86, 'y': 717, 'w': 453.52, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 86, 'y': 85, 'w': 29.57, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 595,\n", " 'text': 'by simple, one-layer suture-repair. The posterior gastric wall should\\nalways be checked by opening the lesser sac. In penetrating trauma\\nof the upper abdomen, a bloody nasogastric tube aspirate is often\\nindicative of a gastric injury: search for it diligently and remember that\\nsome areas of the stomach are difficult to assess: the gastroesophageal\\njunction, the fundus and the uppermost parts of the lesser curve and\\nposterior wall. Blunt injuries are rare and gastric resection is required only\\nin exceptional cases.\\n\\n Duodenum\\n\\n Intramural duodenal hematomas do not require evacuation;\\nnasogastric decompression, fluid replacement and adequate nutrition\\n(usually parenteral) need to be instituted for up to 3-4 weeks.\\n\\n Small, clean-cut lacerations can be safely repaired primarily. Extensive\\nlacerations, the presence of significant tissue contusion (usually inflicted\\nby blunt trauma), the involvement of the common bile duct or high-\\nvelocity gunshot injuries should be treated by duodenal repair and\\npyloric exclusion. This procedure consists of closure of the pylorus (by\\nstapling or suture from inside the stomach) and re-establishment of\\ngastrointestinal continuity by a gastrojejunostomy; the addition of a\\ntruncal vagotomy is not warranted. A feeding jejunostomy is a useful\\nadjunct for the provision of enteral feeding.\\n\\n However, there is currently a feeling that this procedure (i.e.\\n‘exclusion’) is overused. Instead, we often prefer primary repair\\nsupplemented by tube duodenostomy. A Foley catheter is inserted\\nthrough the corner of the duodenal suture line and suction drainage to\\npick up the leakage around the repair is provided. The aim is to\\ndecompress the duodenal lumen through a controlled fistula. We do not\\nadvise a duodenostomy through an intact duodenal wall.\\n\\n The Whipple operation is reserved for massive, combined\\npancreaticoduodenal disruptions. In an unstable patient, you should\\nstage it: resect and divert first, and return another day to fight the\\nreconstruction battle.',\n", " 'md': '```markdown\\n# Surgical Management of Gastric and Duodenal Injuries\\n\\n## Gastric Injuries\\n- Simple, one-layer suture-repair is recommended.\\n- Always check the posterior gastric wall by opening the lesser sac.\\n- In cases of penetrating trauma to the upper abdomen, a bloody nasogastric tube aspirate often indicates a gastric injury. It is crucial to search for it diligently.\\n- Some areas of the stomach are difficult to assess, including:\\n- Gastroesophageal junction\\n- Fundus\\n- Uppermost parts of the lesser curve\\n- Posterior wall\\n- Blunt injuries are rare, and gastric resection is required only in exceptional cases.\\n\\n## Duodenal Injuries\\n- Intramural duodenal hematomas do not require evacuation; instead, nasogastric decompression, fluid replacement, and adequate nutrition (usually parenteral) should be instituted for up to 3-4 weeks.\\n- Small, clean-cut lacerations can be safely repaired primarily.\\n- Extensive lacerations, significant tissue contusion (usually from blunt trauma), involvement of the common bile duct, or high-velocity gunshot injuries should be treated by:\\n- Duodenal repair and pyloric exclusion.\\n- This procedure involves closure of the pylorus (by stapling or suture from inside the stomach) and re-establishment of gastrointestinal continuity by a gastrojejunostomy.\\n- The addition of a truncal vagotomy is not warranted.\\n- A feeding jejunostomy is a useful adjunct for enteral feeding.\\n\\n- There is a current sentiment that the exclusion procedure is overused. Instead, primary repair supplemented by tube duodenostomy is often preferred.\\n- A Foley catheter is inserted through the corner of the duodenal suture line, and suction drainage is provided to manage leakage around the repair. The aim is to decompress the duodenal lumen through a controlled fistula.\\n- A duodenostomy through an intact duodenal wall is not advised.\\n\\n## Whipple Operation\\n- The Whipple operation is reserved for massive, combined pancreaticoduodenal disruptions.\\n- In unstable patients, it is advisable to stage the procedure: resect and divert first, and return another day for reconstruction.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Surgical Management of Gastric and Duodenal Injuries',\n", " 'md': '# Surgical Management of Gastric and Duodenal Injuries',\n", " 'bBox': {'x': 167, 'y': 281, 'w': 63.19, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Gastric Injuries',\n", " 'md': '## Gastric Injuries',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Simple, one-layer suture-repair is recommended.\\n- Always check the posterior gastric wall by opening the lesser sac.\\n- In cases of penetrating trauma to the upper abdomen, a bloody nasogastric tube aspirate often indicates a gastric injury. It is crucial to search for it diligently.\\n- Some areas of the stomach are difficult to assess, including:\\n- Gastroesophageal junction\\n- Fundus\\n- Uppermost parts of the lesser curve\\n- Posterior wall\\n- Blunt injuries are rare, and gastric resection is required only in exceptional cases.',\n", " 'md': '- Simple, one-layer suture-repair is recommended.\\n- Always check the posterior gastric wall by opening the lesser sac.\\n- In cases of penetrating trauma to the upper abdomen, a bloody nasogastric tube aspirate often indicates a gastric injury. It is crucial to search for it diligently.\\n- Some areas of the stomach are difficult to assess, including:\\n- Gastroesophageal junction\\n- Fundus\\n- Uppermost parts of the lesser curve\\n- Posterior wall\\n- Blunt injuries are rare, and gastric resection is required only in exceptional cases.',\n", " 'bBox': {'x': 72, 'y': 202, 'w': 133.56, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Duodenal Injuries',\n", " 'md': '## Duodenal Injuries',\n", " 'bBox': {'x': 167, 'y': 281, 'w': 63.19, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- Intramural duodenal hematomas do not require evacuation; instead, nasogastric decompression, fluid replacement, and adequate nutrition (usually parenteral) should be instituted for up to 3-4 weeks.\\n- Small, clean-cut lacerations can be safely repaired primarily.\\n- Extensive lacerations, significant tissue contusion (usually from blunt trauma), involvement of the common bile duct, or high-velocity gunshot injuries should be treated by:\\n- Duodenal repair and pyloric exclusion.\\n- This procedure involves closure of the pylorus (by stapling or suture from inside the stomach) and re-establishment of gastrointestinal continuity by a gastrojejunostomy.\\n- The addition of a truncal vagotomy is not warranted.\\n- A feeding jejunostomy is a useful adjunct for enteral feeding.\\n\\n- There is a current sentiment that the exclusion procedure is overused. Instead, primary repair supplemented by tube duodenostomy is often preferred.\\n- A Foley catheter is inserted through the corner of the duodenal suture line, and suction drainage is provided to manage leakage around the repair. The aim is to decompress the duodenal lumen through a controlled fistula.\\n- A duodenostomy through an intact duodenal wall is not advised.',\n", " 'md': '- Intramural duodenal hematomas do not require evacuation; instead, nasogastric decompression, fluid replacement, and adequate nutrition (usually parenteral) should be instituted for up to 3-4 weeks.\\n- Small, clean-cut lacerations can be safely repaired primarily.\\n- Extensive lacerations, significant tissue contusion (usually from blunt trauma), involvement of the common bile duct, or high-velocity gunshot injuries should be treated by:\\n- Duodenal repair and pyloric exclusion.\\n- This procedure involves closure of the pylorus (by stapling or suture from inside the stomach) and re-establishment of gastrointestinal continuity by a gastrojejunostomy.\\n- The addition of a truncal vagotomy is not warranted.\\n- A feeding jejunostomy is a useful adjunct for enteral feeding.\\n\\n- There is a current sentiment that the exclusion procedure is overused. Instead, primary repair supplemented by tube duodenostomy is often preferred.\\n- A Foley catheter is inserted through the corner of the duodenal suture line, and suction drainage is provided to manage leakage around the repair. The aim is to decompress the duodenal lumen through a controlled fistula.\\n- A duodenostomy through an intact duodenal wall is not advised.',\n", " 'bBox': {'x': 86, 'y': 281, 'w': 79.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Whipple Operation',\n", " 'md': '## Whipple Operation',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The Whipple operation is reserved for massive, combined pancreaticoduodenal disruptions.\\n- In unstable patients, it is advisable to stage the procedure: resect and divert first, and return another day for reconstruction.\\n```',\n", " 'md': '- The Whipple operation is reserved for massive, combined pancreaticoduodenal disruptions.\\n- In unstable patients, it is advisable to stage the procedure: resect and divert first, and return another day for reconstruction.\\n```',\n", " 'bBox': {'x': 167, 'y': 281, 'w': 63.19, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 596,\n", " 'text': ' Small bowel\\n\\n Most lacerations can be treated with one-layer suture-repair.\\nOccasionally a segmental resection may be required in injuries involving\\nthe mesenteric side of the intestine or for the treatment of multiple\\nlacerations in close proximity. Neglected, longstanding lacerations\\n(more than 24 hours) with an established peritonitis may require the\\nfashioning of a temporary stoma rather than primary repair. Rarely,\\nan extensive mesenteric laceration may endanger a very large segment\\nof bowel which, if resected, would result in a short-gut syndrome; at least\\n100cm of small bowel in the absence of the ileocecal valve (or 75cm with\\npreservation of the ileocecal junction) are deemed necessary for\\nadequate enteral nutrition.\\n\\n Colon\\n\\n Right- or left-sided simple colonic lacerations can be safely\\ntreated by suture-repair in most cases. If the severity of the laceration\\nwarrants a resection, an ileocolic anastomosis (after a right\\nhemicolectomy) is usually safe. A colocolic anastomosis (after a more\\ndistal resection) may not be as safe. In any case, a colostomy rather\\nthan repair is recommended in the presence of massive peritoneal\\ncontamination, severe associated injuries or gross hemodynamic\\ninstability. In borderline cases, we advise you to err on the side of\\nperforming a colostomy; the stubborn resort to primary repair may turn\\nout to be a costly act of surgical bravado: more trauma patients die\\nfrom a leaking primary anastomosis than from a subsequent\\nclosure of a colostomy gone wrong. Large mesocolic hematomas are\\nbest treated by segmental colectomy. Extensive deserosalization (typical\\nin seat-belt injuries of the cecum or sigmoid colon) should be treated by\\nserosal repair rather than resection.\\n\\n Rectum\\n\\n In the absence of gross fecal contamination, minor lacerations can be\\ntreated by simple suture-repair. In all other cases, a proximal diverting\\ncolostomy must be added; a loop sigmoid colostomy is usually',\n", " 'md': '```markdown\\n# Small Bowel\\n\\nMost lacerations can be treated with one-layer suture-repair. Occasionally, a segmental resection may be required in injuries involving the mesenteric side of the intestine or for the treatment of multiple lacerations in close proximity. Neglected, longstanding lacerations (more than 24 hours) with an established peritonitis may require the fashioning of a temporary stoma rather than primary repair. Rarely, an extensive mesenteric laceration may endanger a very large segment of bowel which, if resected, would result in a short-gut syndrome; at least \\\\(100 \\\\, \\\\text{cm}\\\\) of small bowel in the absence of the ileocecal valve (or \\\\(75 \\\\, \\\\text{cm}\\\\) with preservation of the ileocecal junction) are deemed necessary for adequate enteral nutrition.\\n\\n# Colon\\n\\nRight- or left-sided simple colonic lacerations can be safely treated by suture-repair in most cases. If the severity of the laceration warrants a resection, an ileocolic anastomosis (after a right hemicolectomy) is usually safe. A colocolic anastomosis (after a more distal resection) may not be as safe. In any case, a colostomy rather than repair is recommended in the presence of massive peritoneal contamination, severe associated injuries, or gross hemodynamic instability. In borderline cases, we advise you to err on the side of performing a colostomy; the stubborn resort to primary repair may turn out to be a costly act of surgical bravado: more trauma patients die from a leaking primary anastomosis than from a subsequent closure of a colostomy gone wrong. Large mesocolic hematomas are best treated by segmental colectomy. Extensive deserosalization (typical in seat-belt injuries of the cecum or sigmoid colon) should be treated by serosal repair rather than resection.\\n\\n# Rectum\\n\\nIn the absence of gross fecal contamination, minor lacerations can be treated by simple suture-repair. In all other cases, a proximal diverting colostomy must be added; a loop sigmoid colostomy is usually required.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Small Bowel',\n", " 'md': '# Small Bowel',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 95.63, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Most lacerations can be treated with one-layer suture-repair. Occasionally, a segmental resection may be required in injuries involving the mesenteric side of the intestine or for the treatment of multiple lacerations in close proximity. Neglected, longstanding lacerations (more than 24 hours) with an established peritonitis may require the fashioning of a temporary stoma rather than primary repair. Rarely, an extensive mesenteric laceration may endanger a very large segment of bowel which, if resected, would result in a short-gut syndrome; at least \\\\(100 \\\\, \\\\text{cm}\\\\) of small bowel in the absence of the ileocecal valve (or \\\\(75 \\\\, \\\\text{cm}\\\\) with preservation of the ileocecal junction) are deemed necessary for adequate enteral nutrition.',\n", " 'md': 'Most lacerations can be treated with one-layer suture-repair. Occasionally, a segmental resection may be required in injuries involving the mesenteric side of the intestine or for the treatment of multiple lacerations in close proximity. Neglected, longstanding lacerations (more than 24 hours) with an established peritonitis may require the fashioning of a temporary stoma rather than primary repair. Rarely, an extensive mesenteric laceration may endanger a very large segment of bowel which, if resected, would result in a short-gut syndrome; at least \\\\(100 \\\\, \\\\text{cm}\\\\) of small bowel in the absence of the ileocecal valve (or \\\\(75 \\\\, \\\\text{cm}\\\\) with preservation of the ileocecal junction) are deemed necessary for adequate enteral nutrition.',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 468, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Colon',\n", " 'md': '# Colon',\n", " 'bBox': {'x': 86, 'y': 332, 'w': 46.89, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Right- or left-sided simple colonic lacerations can be safely treated by suture-repair in most cases. If the severity of the laceration warrants a resection, an ileocolic anastomosis (after a right hemicolectomy) is usually safe. A colocolic anastomosis (after a more distal resection) may not be as safe. In any case, a colostomy rather than repair is recommended in the presence of massive peritoneal contamination, severe associated injuries, or gross hemodynamic instability. In borderline cases, we advise you to err on the side of performing a colostomy; the stubborn resort to primary repair may turn out to be a costly act of surgical bravado: more trauma patients die from a leaking primary anastomosis than from a subsequent closure of a colostomy gone wrong. Large mesocolic hematomas are best treated by segmental colectomy. Extensive deserosalization (typical in seat-belt injuries of the cecum or sigmoid colon) should be treated by serosal repair rather than resection.',\n", " 'md': 'Right- or left-sided simple colonic lacerations can be safely treated by suture-repair in most cases. If the severity of the laceration warrants a resection, an ileocolic anastomosis (after a right hemicolectomy) is usually safe. A colocolic anastomosis (after a more distal resection) may not be as safe. In any case, a colostomy rather than repair is recommended in the presence of massive peritoneal contamination, severe associated injuries, or gross hemodynamic instability. In borderline cases, we advise you to err on the side of performing a colostomy; the stubborn resort to primary repair may turn out to be a costly act of surgical bravado: more trauma patients die from a leaking primary anastomosis than from a subsequent closure of a colostomy gone wrong. Large mesocolic hematomas are best treated by segmental colectomy. Extensive deserosalization (typical in seat-belt injuries of the cecum or sigmoid colon) should be treated by serosal repair rather than resection.',\n", " 'bBox': {'x': 72, 'y': 332, 'w': 467.82, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Rectum',\n", " 'md': '# Rectum',\n", " 'bBox': {'x': 86, 'y': 643, 'w': 60.71, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In the absence of gross fecal contamination, minor lacerations can be treated by simple suture-repair. In all other cases, a proximal diverting colostomy must be added; a loop sigmoid colostomy is usually required.\\n```',\n", " 'md': 'In the absence of gross fecal contamination, minor lacerations can be treated by simple suture-repair. In all other cases, a proximal diverting colostomy must be added; a loop sigmoid colostomy is usually required.\\n```',\n", " 'bBox': {'x': 72, 'y': 402, 'w': 467.27, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 597,\n", " 'text': 'adequate. Small lacerations of the infraperitoneal rectal segment require\\nneither extensive mobilization of the rectum nor suture-repair; a diverting\\ncolostomy alone is sufficient. Wash-out of the distal rectal stump and\\npresacral drainage are unnecessary except in very extensive\\ninjuries with wide dissection and soiling of the perirectal spaces.\\n\\n Intra-abdominal vascular injuries\\n\\n • Aorta. A most important step in the management of aortic injuries is\\n exposure in order to achieve proximal and distal control. Depending\\n on the level, this ‘medial visceral rotation’ maneuver begins either\\n lateral to the spleen or, lower down, by incising the white line of Toldt\\n lateral to the left colon. The viscera, including the spleen, pancreatic\\n tail, left colon and, if necessary, the left kidney, are gradually\\n mobilized medially. The suprarenal aorta can be approached\\n through the gastrohepatic omentum (via the lesser sac) with\\n retraction of the stomach and esophagus to the left. For injuries of\\n the supraceliac aorta, a left thoracotomy may be required. Aortic\\n injuries are repaired with 3-0 or 4-0 sutures of polypropylene\\n monofilament.\\n • Infrahepatic vena cava. The exposure is achieved by incision of\\n the white line of Toldt lateral to the right colon with medial reflection\\n of the right colon, duodenum and, if necessary, the right kidney. The\\n bleeding site must be occluded by direct finger or sponge-stick\\n pressure; vascular clamps may be used but no attempt should be\\n made to encircle the vessel. Venorrhaphy can be achieved with 4-0\\n or 5-0 monofilament vascular sutures. The presence of a posterior\\n laceration should be checked for: if present, it can be repaired by\\n gentle rotation of the vena cava or from inside the lumen. In massive\\n disruptions, a synthetic graft may be used, but more commonly the\\n inferior vena cava is ligated. Ligation above the renal veins is not\\n well tolerated.\\n • Common or external iliac artery. Suture-repair or, if necessary,\\n use a graft. A synthetic graft may be used even in the presence of\\n peritoneal soiling. In this case, polytetrafluoroethylene (PTFE) is the\\n preferred material. If gross contamination is present, consideration\\n should be given to arterial ligation and restoration of the circulation',\n", " 'md': '```markdown\\n# Intra-abdominal Vascular Injuries\\n\\n## Text\\n\\n- **Aorta**: A most important step in the management of aortic injuries is exposure in order to achieve proximal and distal control. Depending on the level, this ‘medial visceral rotation’ maneuver begins either lateral to the spleen or, lower down, by incising the white line of Toldt lateral to the left colon. The viscera, including the spleen, pancreatic tail, left colon and, if necessary, the left kidney, are gradually mobilized medially. The suprarenal aorta can be approached through the gastrohepatic omentum (via the lesser sac) with retraction of the stomach and esophagus to the left. For injuries of the supraceliac aorta, a left thoracotomy may be required. Aortic injuries are repaired with \\\\(3-0\\\\) or \\\\(4-0\\\\) sutures of polypropylene monofilament.\\n\\n- **Infrahepatic vena cava**: The exposure is achieved by incision of the white line of Toldt lateral to the right colon with medial reflection of the right colon, duodenum and, if necessary, the right kidney. The bleeding site must be occluded by direct finger or sponge-stick pressure; vascular clamps may be used but no attempt should be made to encircle the vessel. Venorrhaphy can be achieved with \\\\(4-0\\\\) or \\\\(5-0\\\\) monofilament vascular sutures. The presence of a posterior laceration should be checked for: if present, it can be repaired by gentle rotation of the vena cava or from inside the lumen. In massive disruptions, a synthetic graft may be used, but more commonly the inferior vena cava is ligated. Ligation above the renal veins is not well tolerated.\\n\\n- **Common or external iliac artery**: Suture-repair or, if necessary, use a graft. A synthetic graft may be used even in the presence of peritoneal soiling. In this case, polytetrafluoroethylene (PTFE) is the preferred material. If gross contamination is present, consideration should be given to arterial ligation and restoration of the circulation.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Intra-abdominal Vascular Injuries',\n", " 'md': '# Intra-abdominal Vascular Injuries',\n", " 'bBox': {'x': 86, 'y': 195, 'w': 259.29, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Aorta**: A most important step in the management of aortic injuries is exposure in order to achieve proximal and distal control. Depending on the level, this ‘medial visceral rotation’ maneuver begins either lateral to the spleen or, lower down, by incising the white line of Toldt lateral to the left colon. The viscera, including the spleen, pancreatic tail, left colon and, if necessary, the left kidney, are gradually mobilized medially. The suprarenal aorta can be approached through the gastrohepatic omentum (via the lesser sac) with retraction of the stomach and esophagus to the left. For injuries of the supraceliac aorta, a left thoracotomy may be required. Aortic injuries are repaired with \\\\(3-0\\\\) or \\\\(4-0\\\\) sutures of polypropylene monofilament.\\n\\n- **Infrahepatic vena cava**: The exposure is achieved by incision of the white line of Toldt lateral to the right colon with medial reflection of the right colon, duodenum and, if necessary, the right kidney. The bleeding site must be occluded by direct finger or sponge-stick pressure; vascular clamps may be used but no attempt should be made to encircle the vessel. Venorrhaphy can be achieved with \\\\(4-0\\\\) or \\\\(5-0\\\\) monofilament vascular sutures. The presence of a posterior laceration should be checked for: if present, it can be repaired by gentle rotation of the vena cava or from inside the lumen. In massive disruptions, a synthetic graft may be used, but more commonly the inferior vena cava is ligated. Ligation above the renal veins is not well tolerated.\\n\\n- **Common or external iliac artery**: Suture-repair or, if necessary, use a graft. A synthetic graft may be used even in the presence of peritoneal soiling. In this case, polytetrafluoroethylene (PTFE) is the preferred material. If gross contamination is present, consideration should be given to arterial ligation and restoration of the circulation.\\n```',\n", " 'md': '- **Aorta**: A most important step in the management of aortic injuries is exposure in order to achieve proximal and distal control. Depending on the level, this ‘medial visceral rotation’ maneuver begins either lateral to the spleen or, lower down, by incising the white line of Toldt lateral to the left colon. The viscera, including the spleen, pancreatic tail, left colon and, if necessary, the left kidney, are gradually mobilized medially. The suprarenal aorta can be approached through the gastrohepatic omentum (via the lesser sac) with retraction of the stomach and esophagus to the left. For injuries of the supraceliac aorta, a left thoracotomy may be required. Aortic injuries are repaired with \\\\(3-0\\\\) or \\\\(4-0\\\\) sutures of polypropylene monofilament.\\n\\n- **Infrahepatic vena cava**: The exposure is achieved by incision of the white line of Toldt lateral to the right colon with medial reflection of the right colon, duodenum and, if necessary, the right kidney. The bleeding site must be occluded by direct finger or sponge-stick pressure; vascular clamps may be used but no attempt should be made to encircle the vessel. Venorrhaphy can be achieved with \\\\(4-0\\\\) or \\\\(5-0\\\\) monofilament vascular sutures. The presence of a posterior laceration should be checked for: if present, it can be repaired by gentle rotation of the vena cava or from inside the lumen. In massive disruptions, a synthetic graft may be used, but more commonly the inferior vena cava is ligated. Ligation above the renal veins is not well tolerated.\\n\\n- **Common or external iliac artery**: Suture-repair or, if necessary, use a graft. A synthetic graft may be used even in the presence of peritoneal soiling. In this case, polytetrafluoroethylene (PTFE) is the preferred material. If gross contamination is present, consideration should be given to arterial ligation and restoration of the circulation.\\n```',\n", " 'bBox': {'x': 100, 'y': 248, 'w': 437.15, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 598,\n", " 'text': ' by means of an extra-anatomical femorofemoral bypass. The\\n internal iliac artery may be ligated with impunity.\\n • The exposure of the iliac veins is notoriously difficult and may\\n require the division of the ipsilateral internal iliac artery or even a\\n temporary transection of the common iliac artery. Iliac veins may be\\n ligated with acceptable morbidity; compression stockings and limb\\n elevation are indicated postoperatively.\\n • The celiac artery and the inferior mesenteric artery (IMA) may be\\n ligated. In desperate situations, to control life-threatening bleeding,\\n the proximal (retropancreatic) superior mesenteric artery (SMA) can\\n be ligated as well (with preservation of blood flow through\\n collaterals); but in general, repair or shunting is the preferred\\n strategy.\\n • The infrapancreatic portion of the SMA should be repaired. The\\n superior mesenteric vein should be repaired if possible, since its\\n ligation may cause bowel infarction, severe postoperative intestinal\\n congestion and intestinal varices. The inferior mesenteric vein\\n may be ligated without risk.\\n • ħeroic attempts at restoring flow by repairing a vessel in a patient in\\n extremis are to be avoided. At times, ligation with later\\n revascularization may be possible. A better approach is a temporary\\n shunt across the injury with definitive grafting over the subsequent\\n 24 hours.\\n\\n Retroperitoneal hematomas\\n\\n The main issue is whether to explore such a hematoma discovered in\\nthe course of a trauma laparotomy.\\n\\n As a general rule, all retroperitoneal hematomas in penetrating trauma should be explored,\\n irrespective of size or location. In blunt trauma a more selective policy can be applied\\n depending mainly on the location of the hematoma — as follows.\\n\\n • A central abdominal location (Zone I) including the main\\n abdominal vessels and the duodenopancreatic complex always',\n", " 'md': '```markdown\\n## Current Page Content\\n\\n- By means of an extra-anatomical femorofemoral bypass, the internal iliac artery may be ligated with impunity.\\n- The exposure of the iliac veins is notoriously difficult and may require the division of the ipsilateral internal iliac artery or even a temporary transection of the common iliac artery. Iliac veins may be ligated with acceptable morbidity; compression stockings and limb elevation are indicated postoperatively.\\n- The celiac artery and the inferior mesenteric artery (IMA) may be ligated. In desperate situations, to control life-threatening bleeding, the proximal (retropancreatic) superior mesenteric artery (SMA) can be ligated as well (with preservation of blood flow through collaterals); but in general, repair or shunting is the preferred strategy.\\n- The infrapancreatic portion of the SMA should be repaired. The superior mesenteric vein should be repaired if possible, since its ligation may cause bowel infarction, severe postoperative intestinal congestion, and intestinal varices. The inferior mesenteric vein may be ligated without risk.\\n- Heroic attempts at restoring flow by repairing a vessel in a patient in extremis are to be avoided. At times, ligation with later revascularization may be possible. A better approach is a temporary shunt across the injury with definitive grafting over the subsequent 24 hours.\\n\\n### Retroperitoneal Hematomas\\n\\nThe main issue is whether to explore such a hematoma discovered in the course of a trauma laparotomy.\\n\\nAs a general rule, all retroperitoneal hematomas in penetrating trauma should be explored, irrespective of size or location. In blunt trauma, a more selective policy can be applied depending mainly on the location of the hematoma — as follows.\\n\\n- A central abdominal location (Zone I) including the main abdominal vessels and the duodenopancreatic complex always...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- By means of an extra-anatomical femorofemoral bypass, the internal iliac artery may be ligated with impunity.\\n- The exposure of the iliac veins is notoriously difficult and may require the division of the ipsilateral internal iliac artery or even a temporary transection of the common iliac artery. Iliac veins may be ligated with acceptable morbidity; compression stockings and limb elevation are indicated postoperatively.\\n- The celiac artery and the inferior mesenteric artery (IMA) may be ligated. In desperate situations, to control life-threatening bleeding, the proximal (retropancreatic) superior mesenteric artery (SMA) can be ligated as well (with preservation of blood flow through collaterals); but in general, repair or shunting is the preferred strategy.\\n- The infrapancreatic portion of the SMA should be repaired. The superior mesenteric vein should be repaired if possible, since its ligation may cause bowel infarction, severe postoperative intestinal congestion, and intestinal varices. The inferior mesenteric vein may be ligated without risk.\\n- Heroic attempts at restoring flow by repairing a vessel in a patient in extremis are to be avoided. At times, ligation with later revascularization may be possible. A better approach is a temporary shunt across the injury with definitive grafting over the subsequent 24 hours.',\n", " 'md': '- By means of an extra-anatomical femorofemoral bypass, the internal iliac artery may be ligated with impunity.\\n- The exposure of the iliac veins is notoriously difficult and may require the division of the ipsilateral internal iliac artery or even a temporary transection of the common iliac artery. Iliac veins may be ligated with acceptable morbidity; compression stockings and limb elevation are indicated postoperatively.\\n- The celiac artery and the inferior mesenteric artery (IMA) may be ligated. In desperate situations, to control life-threatening bleeding, the proximal (retropancreatic) superior mesenteric artery (SMA) can be ligated as well (with preservation of blood flow through collaterals); but in general, repair or shunting is the preferred strategy.\\n- The infrapancreatic portion of the SMA should be repaired. The superior mesenteric vein should be repaired if possible, since its ligation may cause bowel infarction, severe postoperative intestinal congestion, and intestinal varices. The inferior mesenteric vein may be ligated without risk.\\n- Heroic attempts at restoring flow by repairing a vessel in a patient in extremis are to be avoided. At times, ligation with later revascularization may be possible. A better approach is a temporary shunt across the injury with definitive grafting over the subsequent 24 hours.',\n", " 'bBox': {'x': 100, 'y': 102, 'w': 437.62, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Retroperitoneal Hematomas',\n", " 'md': '### Retroperitoneal Hematomas',\n", " 'bBox': {'x': 86, 'y': 507, 'w': 218.87, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The main issue is whether to explore such a hematoma discovered in the course of a trauma laparotomy.\\n\\nAs a general rule, all retroperitoneal hematomas in penetrating trauma should be explored, irrespective of size or location. In blunt trauma, a more selective policy can be applied depending mainly on the location of the hematoma — as follows.\\n\\n- A central abdominal location (Zone I) including the main abdominal vessels and the duodenopancreatic complex always...\\n```',\n", " 'md': 'The main issue is whether to explore such a hematoma discovered in the course of a trauma laparotomy.\\n\\nAs a general rule, all retroperitoneal hematomas in penetrating trauma should be explored, irrespective of size or location. In blunt trauma, a more selective policy can be applied depending mainly on the location of the hematoma — as follows.\\n\\n- A central abdominal location (Zone I) including the main abdominal vessels and the duodenopancreatic complex always...\\n```',\n", " 'bBox': {'x': 72, 'y': 412, 'w': 466.91, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 599,\n", " 'text': ' warrants exploration.\\n • Lateral hematomas (Zone II) including the kidneys and\\n retroperitoneal colonic wall can be left alone unless they are very\\n large, are pulsating or expanding.\\n • Blunt (unlike penetrating) traumatic pelvic hematomas (Zone III)\\n should not be explored. Breaching the intact retroperitoneum may\\n result in a loss of the tamponade effect with catastrophic\\n intraperitoneal hemorrhage (see Table 32.2).\\n Table 32.2. Approach to traumatic retroperitoneal hematoma:\\n Type of hematoma Penetrating injury Blunt injury\\n Central (Zone I) Explore Explore\\n Lateral (Zone Il) Usually explore Usually do not explore\\n Pelvic (Zone III) Explore Do not explore\\n Management of blunt traumatic pelvic hematomas\\n\\n With the exception of isolated fractures of the iliac crest, fractures\\ninvolving the pelvic or obturator rings and/or sacrum have the potential\\nfor significant bleeding leading to shock and death. The pelvis is always\\nimaged in severe blunt trauma, either by CT scanning (in stable patients)\\nor by a simple anteroposterior radiograph (in unstable patients). Bleeding\\nfrom a pelvic fracture arises from disrupted pelvic veins, from lacerated\\nbranches of the internal iliac arteries and from cancellous bone, in\\nvarious combinations.\\n\\n In an unstable patient with a significant pelvic fracture who does not\\nrespond or responds partially to resuscitation, one must assume that the\\nsource of bleeding is pelvic in origin, once an extra-abdominal source of\\nhemorrhage has been ruled out. The first step is then to minimize the\\npelvic blood loss by increasing the tamponade effect of the pelvic',\n", " 'md': '```markdown\\n## Management of Blunt Traumatic Pelvic Hematomas\\n\\n- Lateral hematomas (Zone II) including the kidneys and retroperitoneal colonic wall can be left alone unless they are very large, are pulsating, or expanding.\\n- Blunt (unlike penetrating) traumatic pelvic hematomas (Zone III) should not be explored. Breaching the intact retroperitoneum may result in a loss of the tamponade effect with catastrophic intraperitoneal hemorrhage (see Table 32.2).\\n\\n### Table 32.2. Approach to Traumatic Retroperitoneal Hematoma:\\n\\n| Type of Hematoma | Penetrating Injury | Blunt Injury |\\n|--------------------------|--------------------|----------------------|\\n| Central (Zone I) | Explore | Explore |\\n| Lateral (Zone II) | Usually explore | Usually do not explore|\\n| Pelvic (Zone III) | Explore | Do not explore |\\n\\nWith the exception of isolated fractures of the iliac crest, fractures involving the pelvic or obturator rings and/or sacrum have the potential for significant bleeding leading to shock and death. The pelvis is always imaged in severe blunt trauma, either by CT scanning (in stable patients) or by a simple anteroposterior radiograph (in unstable patients). Bleeding from a pelvic fracture arises from disrupted pelvic veins, from lacerated branches of the internal iliac arteries, and from cancellous bone, in various combinations.\\n\\nIn an unstable patient with a significant pelvic fracture who does not respond or responds partially to resuscitation, one must assume that the source of bleeding is pelvic in origin, once an extra-abdominal source of hemorrhage has been ruled out. The first step is then to minimize the pelvic blood loss by increasing the tamponade effect of the pelvic.\\n```',\n", " 'images': [{'name': 'img_p598_1.png',\n", " 'height': 382,\n", " 'width': 812,\n", " 'x': 105.11999999999898,\n", " 'y': 230.39999999999998,\n", " 'original_width': 1396,\n", " 'original_height': 656}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Blunt Traumatic Pelvic Hematomas',\n", " 'md': '## Management of Blunt Traumatic Pelvic Hematomas',\n", " 'bBox': {'x': 86, 'y': 458, 'w': 393.56, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Lateral hematomas (Zone II) including the kidneys and retroperitoneal colonic wall can be left alone unless they are very large, are pulsating, or expanding.\\n- Blunt (unlike penetrating) traumatic pelvic hematomas (Zone III) should not be explored. Breaching the intact retroperitoneum may result in a loss of the tamponade effect with catastrophic intraperitoneal hemorrhage (see Table 32.2).',\n", " 'md': '- Lateral hematomas (Zone II) including the kidneys and retroperitoneal colonic wall can be left alone unless they are very large, are pulsating, or expanding.\\n- Blunt (unlike penetrating) traumatic pelvic hematomas (Zone III) should not be explored. Breaching the intact retroperitoneum may result in a loss of the tamponade effect with catastrophic intraperitoneal hemorrhage (see Table 32.2).',\n", " 'bBox': {'x': 100, 'y': 106, 'w': 436.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 32.2. Approach to Traumatic Retroperitoneal Hematoma:',\n", " 'md': '### Table 32.2. Approach to Traumatic Retroperitoneal Hematoma:',\n", " 'bBox': {'x': 109.57, 'y': 233.36, 'w': 379, 'h': 19.75}},\n", " {'type': 'table',\n", " 'rows': [['Type of Hematoma', 'Penetrating Injury', 'Blunt Injury'],\n", " ['Central (Zone I)', 'Explore', 'Explore'],\n", " ['Lateral (Zone II)', 'Usually explore', 'Usually do not explore'],\n", " ['Pelvic (Zone III)', 'Explore', 'Do not explore']],\n", " 'md': '| Type of Hematoma | Penetrating Injury | Blunt Injury |\\n|--------------------------|--------------------|----------------------|\\n| Central (Zone I) | Explore | Explore |\\n| Lateral (Zone II) | Usually explore | Usually do not explore|\\n| Pelvic (Zone III) | Explore | Do not explore |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Type of Hematoma\",\"Penetrating Injury\",\"Blunt Injury\"\\n\"Central (Zone I)\",\"Explore\",\"Explore\"\\n\"Lateral (Zone II)\",\"Usually explore\",\"Usually do not explore\"\\n\"Pelvic (Zone III)\",\"Explore\",\"Do not explore\"',\n", " 'bBox': {'x': 100, 'y': 106, 'w': 115.46, 'h': 185.14}},\n", " {'type': 'text',\n", " 'value': 'With the exception of isolated fractures of the iliac crest, fractures involving the pelvic or obturator rings and/or sacrum have the potential for significant bleeding leading to shock and death. The pelvis is always imaged in severe blunt trauma, either by CT scanning (in stable patients) or by a simple anteroposterior radiograph (in unstable patients). Bleeding from a pelvic fracture arises from disrupted pelvic veins, from lacerated branches of the internal iliac arteries, and from cancellous bone, in various combinations.\\n\\nIn an unstable patient with a significant pelvic fracture who does not respond or responds partially to resuscitation, one must assume that the source of bleeding is pelvic in origin, once an extra-abdominal source of hemorrhage has been ruled out. The first step is then to minimize the pelvic blood loss by increasing the tamponade effect of the pelvic.\\n```',\n", " 'md': 'With the exception of isolated fractures of the iliac crest, fractures involving the pelvic or obturator rings and/or sacrum have the potential for significant bleeding leading to shock and death. The pelvis is always imaged in severe blunt trauma, either by CT scanning (in stable patients) or by a simple anteroposterior radiograph (in unstable patients). Bleeding from a pelvic fracture arises from disrupted pelvic veins, from lacerated branches of the internal iliac arteries, and from cancellous bone, in various combinations.\\n\\nIn an unstable patient with a significant pelvic fracture who does not respond or responds partially to resuscitation, one must assume that the source of bleeding is pelvic in origin, once an extra-abdominal source of hemorrhage has been ruled out. The first step is then to minimize the pelvic blood loss by increasing the tamponade effect of the pelvic.\\n```',\n", " 'bBox': {'x': 72, 'y': 106, 'w': 467.92, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 600,\n", " 'text': 'retroperitoneum: this is best achieved by the application of a\\nspecially designed pelvic sling or binder (every emergency\\ndepartment should have one); otherwise a sheet should be tightly\\nwrapped around the iliac crests, criss-crossed anteriorly and tied\\ndown.\\n\\n This temporary stabilization of the pelvic bony fragments may result in\\nhemodynamic improvement; if this succeeds, an abdominal CT scan may\\nbe obtained and will enable one to differentiate definitively between\\nabdominal visceral bleeding and pelvic bleeding. The former warrants an\\nemergency laparotomy. If the latter is present alone, a laparotomy\\nshould be avoided because it may increase the bleeding by loss of\\nthe tamponade effect. In that scenario, transfer of the patient to the\\nangiography suite for attempts at angioembolization of pelvic\\narterial bleeding is the best strategy; throughout the procedure,\\nresuscitation must be pursued by the trauma team (the radiology\\nstaff, while excellent at what they do, have difficulty in spelling the\\nword ‘resuscitation’ — if any radiologist is reading this we are just\\njoking of course!). If angiography facilities are not available, the\\napplication of an external pelvic fixator by the orthopedic team may be\\nbeneficial (it works best when the bleeding arises from a venous or bony\\nsource but may fail to make a difference in arterial bleeding).\\n\\n A grossly unstable patient, unresponsive to resuscitation, is fit\\nonly for transfer to the OR. In order to control pelvic bleeding, a low\\nvertical midline incision can be used to both evacuate the pelvic\\nhematoma (which has displaced the intraperitoneal viscera upwards) and\\npack this extraperitoneal space. If access is required for a concomitant\\nintraperitoneal hemorrhage from another source, it is advisable to enter\\nthe abdominal cavity through a transverse incision higher up. Mortality\\nremains extremely high in that scenario.\\n\\n The abbreviated trauma laparotomy (damage control)\\n When physiology is severely compromised, attempts at\\n restoring anatomy are counterproductive.\\n\\n In a small minority of patients, time-consuming organ repair cannot be',\n", " 'md': '```markdown\\n## Current Page Content\\n\\n### Text\\nRetroperitoneum: This is best achieved by the application of a specially designed pelvic sling or binder (every emergency department should have one); otherwise, a sheet should be tightly wrapped around the iliac crests, criss-crossed anteriorly and tied down.\\n\\nThis temporary stabilization of the pelvic bony fragments may result in hemodynamic improvement; if this succeeds, an abdominal CT scan may be obtained and will enable one to differentiate definitively between abdominal visceral bleeding and pelvic bleeding. The former warrants an emergency laparotomy. If the latter is present alone, a laparotomy should be avoided because it may increase the bleeding by loss of the tamponade effect. In that scenario, transfer of the patient to the angiography suite for attempts at angioembolization of pelvic arterial bleeding is the best strategy; throughout the procedure, resuscitation must be pursued by the trauma team (the radiology staff, while excellent at what they do, have difficulty in spelling the word ‘resuscitation’ — if any radiologist is reading this we are just joking of course!). If angiography facilities are not available, the application of an external pelvic fixator by the orthopedic team may be beneficial (it works best when the bleeding arises from a venous or bony source but may fail to make a difference in arterial bleeding).\\n\\nA grossly unstable patient, unresponsive to resuscitation, is fit only for transfer to the OR. In order to control pelvic bleeding, a low vertical midline incision can be used to both evacuate the pelvic hematoma (which has displaced the intraperitoneal viscera upwards) and pack this extraperitoneal space. If access is required for a concomitant intraperitoneal hemorrhage from another source, it is advisable to enter the abdominal cavity through a transverse incision higher up. Mortality remains extremely high in that scenario.\\n\\n### Abbreviated Trauma Laparotomy (Damage Control)\\nWhen physiology is severely compromised, attempts at restoring anatomy are counterproductive.\\n\\nIn a small minority of patients, time-consuming organ repair cannot be...\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured without any headers or footers.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Retroperitoneum: This is best achieved by the application of a specially designed pelvic sling or binder (every emergency department should have one); otherwise, a sheet should be tightly wrapped around the iliac crests, criss-crossed anteriorly and tied down.\\n\\nThis temporary stabilization of the pelvic bony fragments may result in hemodynamic improvement; if this succeeds, an abdominal CT scan may be obtained and will enable one to differentiate definitively between abdominal visceral bleeding and pelvic bleeding. The former warrants an emergency laparotomy. If the latter is present alone, a laparotomy should be avoided because it may increase the bleeding by loss of the tamponade effect. In that scenario, transfer of the patient to the angiography suite for attempts at angioembolization of pelvic arterial bleeding is the best strategy; throughout the procedure, resuscitation must be pursued by the trauma team (the radiology staff, while excellent at what they do, have difficulty in spelling the word ‘resuscitation’ — if any radiologist is reading this we are just joking of course!). If angiography facilities are not available, the application of an external pelvic fixator by the orthopedic team may be beneficial (it works best when the bleeding arises from a venous or bony source but may fail to make a difference in arterial bleeding).\\n\\nA grossly unstable patient, unresponsive to resuscitation, is fit only for transfer to the OR. In order to control pelvic bleeding, a low vertical midline incision can be used to both evacuate the pelvic hematoma (which has displaced the intraperitoneal viscera upwards) and pack this extraperitoneal space. If access is required for a concomitant intraperitoneal hemorrhage from another source, it is advisable to enter the abdominal cavity through a transverse incision higher up. Mortality remains extremely high in that scenario.',\n", " 'md': 'Retroperitoneum: This is best achieved by the application of a specially designed pelvic sling or binder (every emergency department should have one); otherwise, a sheet should be tightly wrapped around the iliac crests, criss-crossed anteriorly and tied down.\\n\\nThis temporary stabilization of the pelvic bony fragments may result in hemodynamic improvement; if this succeeds, an abdominal CT scan may be obtained and will enable one to differentiate definitively between abdominal visceral bleeding and pelvic bleeding. The former warrants an emergency laparotomy. If the latter is present alone, a laparotomy should be avoided because it may increase the bleeding by loss of the tamponade effect. In that scenario, transfer of the patient to the angiography suite for attempts at angioembolization of pelvic arterial bleeding is the best strategy; throughout the procedure, resuscitation must be pursued by the trauma team (the radiology staff, while excellent at what they do, have difficulty in spelling the word ‘resuscitation’ — if any radiologist is reading this we are just joking of course!). If angiography facilities are not available, the application of an external pelvic fixator by the orthopedic team may be beneficial (it works best when the bleeding arises from a venous or bony source but may fail to make a difference in arterial bleeding).\\n\\nA grossly unstable patient, unresponsive to resuscitation, is fit only for transfer to the OR. In order to control pelvic bleeding, a low vertical midline incision can be used to both evacuate the pelvic hematoma (which has displaced the intraperitoneal viscera upwards) and pack this extraperitoneal space. If access is required for a concomitant intraperitoneal hemorrhage from another source, it is advisable to enter the abdominal cavity through a transverse incision higher up. Mortality remains extremely high in that scenario.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Abbreviated Trauma Laparotomy (Damage Control)',\n", " 'md': '### Abbreviated Trauma Laparotomy (Damage Control)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'When physiology is severely compromised, attempts at restoring anatomy are counterproductive.\\n\\nIn a small minority of patients, time-consuming organ repair cannot be...\\n```',\n", " 'md': 'When physiology is severely compromised, attempts at restoring anatomy are counterproductive.\\n\\nIn a small minority of patients, time-consuming organ repair cannot be...\\n```',\n", " 'bBox': {'x': 86, 'y': 678, 'w': 453.19, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured without any headers or footers.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured without any headers or footers.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 601,\n", " 'text': 'undertaken safely when the physiological status is critically impaired. A\\nbailout procedure consisting of the temporary control of bleeding and\\ncontamination is the only viable option. These cases can be recognized\\neither by a set of physiological criteria or by an anatomical pattern\\nof injuries. In the former model, the presence of coagulopathy,\\nhypothermia and acidosis are indicators of impending physiological\\nexhaustion. Each one of these amplifies the other two in a vicious cycle\\nthat is aptly referred to as the ‘triad of death’. In that scenario, a dogged\\ndetermination to spend the time it takes to achieve definitive organ repair\\nmay result in the patient’s demise. If the latter model is applied, the\\nsurgeon takes the decision for a bailout procedure by a flash assessment\\nof the injury pattern. For example, an injury to a major intra-abdominal\\nvessel associated with a severe duodenopancreatic disruption is\\nrecognized immediately as a potential for massive blood loss should a\\nprolonged, definitive, reconstructive procedure be undertaken. In these\\ncircumstances, there is only a place for a combination of packing,\\nvessel shunting, tube drainage and the simplest means of\\npreventing peritoneal contamination (by stapling or tying off injured\\nintestine with tapes). Abdominal closure consists of expeditious\\ncutaneous approximation or is better avoided altogether — preventing\\nthe commonly associated abdominal compartment syndrome ( Chapter\\n33). The patient is then treated in the surgical intensive care unit where\\nsecondary stabilization is conducted over the next 24-48 hours. Delayed\\ndefinitive organ repair (or resection) and abdominal closure are\\nundertaken only in a patient who is hemodynamically more stable,\\nrewarmed and who has an improved clotting profile.\\n\\n To sum up…\\n\\n Injured organs must be surgically repaired or resected as soon as\\npossible. This being said, the surgeon should be able to recognize the\\npotential for spontaneous healing of even severe visceral injuries (as in\\nsome cases of blunt trauma). Furthermore, he should know to temper\\nhis enthusiasm for immediately restoring the anatomy in the face of\\nseverely impaired physiology.\\n\\n Now, we hope, you know what to do. If not Google it up ( Figure 32.5)!',\n", " 'md': '```markdown\\n## Summary of Surgical Management in Critically Impaired Patients\\n\\nWhen the physiological status is critically impaired, a bailout procedure involving temporary control of bleeding and contamination is the only viable option. Cases can be recognized by physiological criteria or anatomical patterns of injuries.\\n\\n### Physiological Criteria\\n- Indicators of impending physiological exhaustion include:\\n- Coagulopathy\\n- Hypothermia\\n- Acidosis\\n\\nThese factors amplify each other in a vicious cycle known as the \"triad of death.\" A determination to achieve definitive organ repair may lead to the patient\\'s demise.\\n\\n### Anatomical Patterns\\nSurgeons may decide on a bailout procedure based on a quick assessment of the injury pattern. For instance, an injury to a major intra-abdominal vessel with severe duodenopancreatic disruption indicates a risk of massive blood loss if a prolonged reconstructive procedure is attempted.\\n\\n### Recommended Actions\\nIn such cases, the following actions are recommended:\\n- Packing\\n- Vessel shunting\\n- Tube drainage\\n- Preventing peritoneal contamination (e.g., stapling or tying off injured intestine)\\n\\nAbdominal closure should be done expeditiously or avoided to prevent abdominal compartment syndrome. Patients are then treated in the surgical intensive care unit for secondary stabilization over the next 24-48 hours. Delayed definitive organ repair and abdominal closure are only performed when the patient is hemodynamically stable, rewarmed, and has an improved clotting profile.\\n\\n### Conclusion\\nInjured organs must be surgically repaired or resected as soon as possible. Surgeons should recognize the potential for spontaneous healing of severe visceral injuries and temper their enthusiasm for immediate anatomical restoration in cases of severely impaired physiology.\\n\\n### Reference\\nIf further information is needed, please refer to the source: [Google it up](https://www.google.com) (Figure 32.5).\\n```\\n\\n### Figure Description\\n- **Figure 32.5**: This figure likely contains a visual representation related to the surgical management of critically impaired patients, but the specific content of the figure is not provided in the text. Please refer to the original document for details.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary of Surgical Management in Critically Impaired Patients',\n", " 'md': '## Summary of Surgical Management in Critically Impaired Patients',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'When the physiological status is critically impaired, a bailout procedure involving temporary control of bleeding and contamination is the only viable option. Cases can be recognized by physiological criteria or anatomical patterns of injuries.',\n", " 'md': 'When the physiological status is critically impaired, a bailout procedure involving temporary control of bleeding and contamination is the only viable option. Cases can be recognized by physiological criteria or anatomical patterns of injuries.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Physiological Criteria',\n", " 'md': '### Physiological Criteria',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Indicators of impending physiological exhaustion include:\\n- Coagulopathy\\n- Hypothermia\\n- Acidosis\\n\\nThese factors amplify each other in a vicious cycle known as the \"triad of death.\" A determination to achieve definitive organ repair may lead to the patient\\'s demise.',\n", " 'md': '- Indicators of impending physiological exhaustion include:\\n- Coagulopathy\\n- Hypothermia\\n- Acidosis\\n\\nThese factors amplify each other in a vicious cycle known as the \"triad of death.\" A determination to achieve definitive organ repair may lead to the patient\\'s demise.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Anatomical Patterns',\n", " 'md': '### Anatomical Patterns',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Surgeons may decide on a bailout procedure based on a quick assessment of the injury pattern. For instance, an injury to a major intra-abdominal vessel with severe duodenopancreatic disruption indicates a risk of massive blood loss if a prolonged reconstructive procedure is attempted.',\n", " 'md': 'Surgeons may decide on a bailout procedure based on a quick assessment of the injury pattern. For instance, an injury to a major intra-abdominal vessel with severe duodenopancreatic disruption indicates a risk of massive blood loss if a prolonged reconstructive procedure is attempted.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Recommended Actions',\n", " 'md': '### Recommended Actions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In such cases, the following actions are recommended:\\n- Packing\\n- Vessel shunting\\n- Tube drainage\\n- Preventing peritoneal contamination (e.g., stapling or tying off injured intestine)\\n\\nAbdominal closure should be done expeditiously or avoided to prevent abdominal compartment syndrome. Patients are then treated in the surgical intensive care unit for secondary stabilization over the next 24-48 hours. Delayed definitive organ repair and abdominal closure are only performed when the patient is hemodynamically stable, rewarmed, and has an improved clotting profile.',\n", " 'md': 'In such cases, the following actions are recommended:\\n- Packing\\n- Vessel shunting\\n- Tube drainage\\n- Preventing peritoneal contamination (e.g., stapling or tying off injured intestine)\\n\\nAbdominal closure should be done expeditiously or avoided to prevent abdominal compartment syndrome. Patients are then treated in the surgical intensive care unit for secondary stabilization over the next 24-48 hours. Delayed definitive organ repair and abdominal closure are only performed when the patient is hemodynamically stable, rewarmed, and has an improved clotting profile.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Conclusion',\n", " 'md': '### Conclusion',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Injured organs must be surgically repaired or resected as soon as possible. Surgeons should recognize the potential for spontaneous healing of severe visceral injuries and temper their enthusiasm for immediate anatomical restoration in cases of severely impaired physiology.',\n", " 'md': 'Injured organs must be surgically repaired or resected as soon as possible. Surgeons should recognize the potential for spontaneous healing of severe visceral injuries and temper their enthusiasm for immediate anatomical restoration in cases of severely impaired physiology.',\n", " 'bBox': {'x': 72, 'y': 661, 'w': 205, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Reference',\n", " 'md': '### Reference',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'If further information is needed, please refer to the source: [Google it up](https://www.google.com) (Figure 32.5).\\n```',\n", " 'md': 'If further information is needed, please refer to the source: [Google it up](https://www.google.com) (Figure 32.5).\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Description',\n", " 'md': '### Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 32.5**: This figure likely contains a visual representation related to the surgical management of critically impaired patients, but the specific content of the figure is not provided in the text. Please refer to the original document for details.',\n", " 'md': '- **Figure 32.5**: This figure likely contains a visual representation related to the surgical management of critically impaired patients, but the specific content of the figure is not provided in the text. Please refer to the original document for details.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'the commonly associated abdominal compartment syndrome ( Chapter 33). The patient is then treated in the surgical intensive care unit where secondary stabilization is conducted over the next 24-48 hours. Delayed'},\n", " {'text': ''}]},\n", " {'page': 602,\n", " 'text': ' SpLeen Gle\\n {\\n $\\n Figure 32.5. The surgeon: “What should we fix first?” Assistant: “Google it up!”\\n\\n1 Schein’s Common Sense Prevention and Management of Surgical Complications.\\n Shrewsbury, UK: tfm publishing, 2013: Chapter 24.',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\nFigure 32.5. The surgeon: “What should we fix first?” Assistant: “Google it up!”\\n\\n1. Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013: Chapter 24.\\n\\n## Images\\n**Figure 32.5**: This image depicts a humorous exchange between a surgeon and an assistant regarding the management of surgical complications. The surgeon is asking what should be prioritized for fixing, to which the assistant suggests looking it up on Google. The image likely conveys a light-hearted take on the reliance on technology in modern medical practice.\\n\\n### Summary\\nThe image illustrates a conversation that highlights the intersection of traditional medical practices and modern technology, emphasizing the role of digital resources in decision-making processes in surgery.\\n```',\n", " 'images': [{'name': 'img_p601_1.png',\n", " 'height': 438,\n", " 'width': 608,\n", " 'x': 155.51999999999862,\n", " 'y': 82.79999999999998,\n", " 'original_width': 1395,\n", " 'original_height': 1003}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 32.5. The surgeon: “What should we fix first?” Assistant: “Google it up!”\\n\\n1. Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013: Chapter 24.',\n", " 'md': 'Figure 32.5. The surgeon: “What should we fix first?” Assistant: “Google it up!”\\n\\n1. Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013: Chapter 24.',\n", " 'bBox': {'x': 73, 'y': 127.83, 'w': 410.07, 'h': 18.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 32.5**: This image depicts a humorous exchange between a surgeon and an assistant regarding the management of surgical complications. The surgeon is asking what should be prioritized for fixing, to which the assistant suggests looking it up on Google. The image likely conveys a light-hearted take on the reliance on technology in modern medical practice.',\n", " 'md': '**Figure 32.5**: This image depicts a humorous exchange between a surgeon and an assistant regarding the management of surgical complications. The surgeon is asking what should be prioritized for fixing, to which the assistant suggests looking it up on Google. The image likely conveys a light-hearted take on the reliance on technology in modern medical practice.',\n", " 'bBox': {'x': 404.5, 'y': 127.83, 'w': 27.72, 'h': 18.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The image illustrates a conversation that highlights the intersection of traditional medical practices and modern technology, emphasizing the role of digital resources in decision-making processes in surgery.\\n```',\n", " 'md': 'The image illustrates a conversation that highlights the intersection of traditional medical practices and modern technology, emphasizing the role of digital resources in decision-making processes in surgery.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}, {'text': ''}]},\n", " {'page': 603,\n", " 'text': 'Chapter 33\\nThe abdominal compartment syndrome\\nAri Leppäniemi and Moshe Schein\\n\\n Abdominal compartment syndrome is a whole body\\n disease.\\n Thomas Scalea\\n\\n The abdominal cavity is a contained space with clear boundaries,\\nalthough not as rigid as the intracranial, intrathoracic or extremity fascial\\nspaces. And as in all confined spaces with rigid or semirigid boundaries\\n— any attempt to increase the volume contained in such spaces will\\ninevitably lead to a rise in intracavity pressure (remember Boyle’s law\\nfrom high school?). Such increases in pressure are never healthy for the\\nphysiology!\\n\\n There are many causes of increased intra-abdominal ‘volume’ and the\\nrelationship with intra-abdominal pressure is not quite straightforward but\\nlet’s first look at some of the definitions:\\n\\n • IAP — intra-abdominal pressure is the steady-state pressure\\n concealed within the abdominal cavity, expressed in mmħg and is\\n normally about 0-5mmħg. If you sneeze or try to defecate, it may\\n temporarily be much higher but don’t worry, that is not ACS…\\n • IAH — intra-abdominal hypertension is a sustained or repeated\\n pathological elevation of the IAP ≥12mmħg.\\n • ACS — abdominal compartment syndrome is defined as\\n sustained IAP >20mmHg that is associated with new organ',\n", " 'md': '```markdown\\n# Chapter 33: The Abdominal Compartment Syndrome\\n**Authors:** Ari Leppäniemi and Moshe Schein\\n\\n> \"Abdominal compartment syndrome is a whole body disease.\"\\n> — Thomas Scalea\\n\\nThe abdominal cavity is a contained space with clear boundaries, although not as rigid as the intracranial, intrathoracic, or extremity fascial spaces. As in all confined spaces with rigid or semirigid boundaries, any attempt to increase the volume contained in such spaces will inevitably lead to a rise in intracavity pressure (remember Boyle’s law from high school?). Such increases in pressure are never healthy for the physiology!\\n\\nThere are many causes of increased intra-abdominal ‘volume’ and the relationship with intra-abdominal pressure is not quite straightforward, but let’s first look at some of the definitions:\\n\\n- **IAP** — intra-abdominal pressure is the steady-state pressure concealed within the abdominal cavity, expressed in mmHg and is normally about 0-5 mmHg. If you sneeze or try to defecate, it may temporarily be much higher but don’t worry, that is not ACS…\\n- **IAH** — intra-abdominal hypertension is a sustained or repeated pathological elevation of the IAP ≥ 12 mmHg.\\n- **ACS** — abdominal compartment syndrome is defined as sustained IAP > 20 mmHg that is associated with new organ dysfunction.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 33: The Abdominal Compartment Syndrome',\n", " 'md': '# Chapter 33: The Abdominal Compartment Syndrome',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 350.5, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Ari Leppäniemi and Moshe Schein\\n\\n> \"Abdominal compartment syndrome is a whole body disease.\"\\n> — Thomas Scalea\\n\\nThe abdominal cavity is a contained space with clear boundaries, although not as rigid as the intracranial, intrathoracic, or extremity fascial spaces. As in all confined spaces with rigid or semirigid boundaries, any attempt to increase the volume contained in such spaces will inevitably lead to a rise in intracavity pressure (remember Boyle’s law from high school?). Such increases in pressure are never healthy for the physiology!\\n\\nThere are many causes of increased intra-abdominal ‘volume’ and the relationship with intra-abdominal pressure is not quite straightforward, but let’s first look at some of the definitions:\\n\\n- **IAP** — intra-abdominal pressure is the steady-state pressure concealed within the abdominal cavity, expressed in mmHg and is normally about 0-5 mmHg. If you sneeze or try to defecate, it may temporarily be much higher but don’t worry, that is not ACS…\\n- **IAH** — intra-abdominal hypertension is a sustained or repeated pathological elevation of the IAP ≥ 12 mmHg.\\n- **ACS** — abdominal compartment syndrome is defined as sustained IAP > 20 mmHg that is associated with new organ dysfunction.\\n\\n```',\n", " 'md': '**Authors:** Ari Leppäniemi and Moshe Schein\\n\\n> \"Abdominal compartment syndrome is a whole body disease.\"\\n> — Thomas Scalea\\n\\nThe abdominal cavity is a contained space with clear boundaries, although not as rigid as the intracranial, intrathoracic, or extremity fascial spaces. As in all confined spaces with rigid or semirigid boundaries, any attempt to increase the volume contained in such spaces will inevitably lead to a rise in intracavity pressure (remember Boyle’s law from high school?). Such increases in pressure are never healthy for the physiology!\\n\\nThere are many causes of increased intra-abdominal ‘volume’ and the relationship with intra-abdominal pressure is not quite straightforward, but let’s first look at some of the definitions:\\n\\n- **IAP** — intra-abdominal pressure is the steady-state pressure concealed within the abdominal cavity, expressed in mmHg and is normally about 0-5 mmHg. If you sneeze or try to defecate, it may temporarily be much higher but don’t worry, that is not ACS…\\n- **IAH** — intra-abdominal hypertension is a sustained or repeated pathological elevation of the IAP ≥ 12 mmHg.\\n- **ACS** — abdominal compartment syndrome is defined as sustained IAP > 20 mmHg that is associated with new organ dysfunction.\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 467.69, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 604,\n", " 'text': ' dysfunction or failure. Remember: IAH — whatever is the IAP\\n — is not ACS unless the patient also has the typical\\n manifestations of the syndrome:\\n increased airway pressure (respiratory distress, difficult to\\n mechanically ventilate);\\n decreased cardiac output (hypotension despite adequate\\n volume status);\\n decreased urinary output (renal dysfunction despite optimal\\n hydration);\\n abdominal distension.\\n\\n So, while IAħ refers to a continuous variable (like arterial\\nhypertension), ACS is like pregnancy, either you are or you are not\\npregnant!\\n\\n Risk factors for IAH and ACS\\n\\n There are many conditions that can lead to IAħ such as, for example,\\nabdominal trauma (especially ‘damage control’ surgery), severe acute\\npancreatitis or ruptured abdominal aortic aneurysm. In order to better\\ncharacterize the risk factors it is useful to group them according to\\nthe main pathophysiological problem. Some of the people who put\\nthis list together are intensivists, so have some patience…:',\n", " 'md': '```markdown\\n## Text Extraction\\n\\n- Dysfunction or failure. Remember: IAH — whatever is the IAP — is not ACS unless the patient also has the typical manifestations of the syndrome:\\n- Increased airway pressure (respiratory distress, difficult to mechanically ventilate);\\n- Decreased cardiac output (hypotension despite adequate volume status);\\n- Decreased urinary output (renal dysfunction despite optimal hydration);\\n- Abdominal distension.\\n\\n- So, while IAH refers to a continuous variable (like arterial hypertension), ACS is like pregnancy, either you are or you are not pregnant!\\n\\n### Risk Factors for IAH and ACS\\n\\n- There are many conditions that can lead to IAH such as, for example, abdominal trauma (especially ‘damage control’ surgery), severe acute pancreatitis or ruptured abdominal aortic aneurysm. In order to better characterize the risk factors it is useful to group them according to the main pathophysiological problem. Some of the people who put this list together are intensivists, so have some patience…:\\n```\\n\\n### Notes\\n- No formulas or images were identified on this page.\\n- The text has been extracted and structured according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Dysfunction or failure. Remember: IAH — whatever is the IAP — is not ACS unless the patient also has the typical manifestations of the syndrome:\\n- Increased airway pressure (respiratory distress, difficult to mechanically ventilate);\\n- Decreased cardiac output (hypotension despite adequate volume status);\\n- Decreased urinary output (renal dysfunction despite optimal hydration);\\n- Abdominal distension.\\n\\n- So, while IAH refers to a continuous variable (like arterial hypertension), ACS is like pregnancy, either you are or you are not pregnant!',\n", " 'md': '- Dysfunction or failure. Remember: IAH — whatever is the IAP — is not ACS unless the patient also has the typical manifestations of the syndrome:\\n- Increased airway pressure (respiratory distress, difficult to mechanically ventilate);\\n- Decreased cardiac output (hypotension despite adequate volume status);\\n- Decreased urinary output (renal dysfunction despite optimal hydration);\\n- Abdominal distension.\\n\\n- So, while IAH refers to a continuous variable (like arterial hypertension), ACS is like pregnancy, either you are or you are not pregnant!',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 464.9, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Risk Factors for IAH and ACS',\n", " 'md': '### Risk Factors for IAH and ACS',\n", " 'bBox': {'x': 86, 'y': 361, 'w': 228.05, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- There are many conditions that can lead to IAH such as, for example, abdominal trauma (especially ‘damage control’ surgery), severe acute pancreatitis or ruptured abdominal aortic aneurysm. In order to better characterize the risk factors it is useful to group them according to the main pathophysiological problem. Some of the people who put this list together are intensivists, so have some patience…:\\n```',\n", " 'md': '- There are many conditions that can lead to IAH such as, for example, abdominal trauma (especially ‘damage control’ surgery), severe acute pancreatitis or ruptured abdominal aortic aneurysm. In order to better characterize the risk factors it is useful to group them according to the main pathophysiological problem. Some of the people who put this list together are intensivists, so have some patience…:\\n```',\n", " 'bBox': {'x': 72, 'y': 447, 'w': 468.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No formulas or images were identified on this page.\\n- The text has been extracted and structured according to the requirements.',\n", " 'md': '- No formulas or images were identified on this page.\\n- The text has been extracted and structured according to the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 605,\n", " 'text': 'Figure 33.1. Abdominal X-ray showing a massively dilated rectosigmoid — causing IAH\\nand ACS — and the corresponding findings at operation.\\n\\n• Increased intra-abdominal contents: hemoperitoneum or pneumo-\\n peritoneum or intraperitoneal fluid collections or abscesses, liver\\n dysfunction with tense ascites, peritoneal dialysis, intraperitoneal or\\n retroperitoneal tumors, acute pancreatitis, laparoscopy with\\n excessive insufflation pressures. Note that even normal pregnancy\\n causes sustained IAħ!\\n• Increased intraluminal contents: gastric dilatation, ileus, colonic\\n pseudo-obstruction ( Figure 33.1), volvulus.\\n• Diminished abdominal wall compliance: major burns, major\\n trauma, abdominal surgery, prone positioning (this is why you can\\n kill a fat man by placing him in a forced prone position. Watch this\\n clip: https://www.youtube.com/watch?v=pvATEjsf41g).\\n• Capillary leak/fluid resuscitation: acidosis, damage control\\n laparotomy, hypothermia, massive fluid resuscitation,\\n polytransfusion, increased APACħE II — or SOFA — score\\n (remember what it means from Chapter 19?) 1.\\n• Others: coagulopathy, bacteremia, massive ventral hernia repair,\\n obesity or increased body mass index, peritonitis, pneumonia,',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Figure 33.1\\n**Description:** Abdominal X-ray showing a massively dilated rectosigmoid, which is causing intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). The figure illustrates the corresponding findings observed during the operation.\\n\\n### Key Points\\n- **Increased intra-abdominal contents:**\\n- Conditions such as hemoperitoneum, pneumoperitoneum, intraperitoneal fluid collections, abscesses, liver dysfunction with tense ascites, peritoneal dialysis, intraperitoneal or retroperitoneal tumors, acute pancreatitis, and laparoscopy with excessive insufflation pressures can lead to increased intra-abdominal pressure.\\n- Note that even normal pregnancy can cause sustained IAH.\\n\\n- **Increased intraluminal contents:**\\n- Conditions like gastric dilatation, ileus, colonic pseudo-obstruction (referenced in Figure 33.1), and volvulus can contribute to increased pressure.\\n\\n- **Diminished abdominal wall compliance:**\\n- Factors such as major burns, major trauma, abdominal surgery, and prone positioning can reduce abdominal wall compliance.\\n- It is noted that placing an individual with obesity in a forced prone position can be dangerous.\\n\\n- **Capillary leak/fluid resuscitation:**\\n- Conditions such as acidosis, damage control laparotomy, hypothermia, massive fluid resuscitation, polytransfusion, and increased APACHE II or SOFA scores can lead to increased intra-abdominal pressure.\\n\\n- **Others:**\\n- Additional factors include coagulopathy, bacteremia, massive ventral hernia repair, obesity or increased body mass index, peritonitis, and pneumonia.\\n\\n### Hyperlink\\n- Watch this clip: [YouTube Video](https://www.youtube.com/watch?v=pvATEjsf41g)\\n```',\n", " 'images': [{'name': 'img_p604_1.png',\n", " 'height': 510,\n", " 'width': 707,\n", " 'x': 131.03999999999996,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1215,\n", " 'original_height': 874}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 33.1',\n", " 'md': '### Figure 33.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** Abdominal X-ray showing a massively dilated rectosigmoid, which is causing intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). The figure illustrates the corresponding findings observed during the operation.',\n", " 'md': '**Description:** Abdominal X-ray showing a massively dilated rectosigmoid, which is causing intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). The figure illustrates the corresponding findings observed during the operation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key Points',\n", " 'md': '### Key Points',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Increased intra-abdominal contents:**\\n- Conditions such as hemoperitoneum, pneumoperitoneum, intraperitoneal fluid collections, abscesses, liver dysfunction with tense ascites, peritoneal dialysis, intraperitoneal or retroperitoneal tumors, acute pancreatitis, and laparoscopy with excessive insufflation pressures can lead to increased intra-abdominal pressure.\\n- Note that even normal pregnancy can cause sustained IAH.\\n\\n- **Increased intraluminal contents:**\\n- Conditions like gastric dilatation, ileus, colonic pseudo-obstruction (referenced in Figure 33.1), and volvulus can contribute to increased pressure.\\n\\n- **Diminished abdominal wall compliance:**\\n- Factors such as major burns, major trauma, abdominal surgery, and prone positioning can reduce abdominal wall compliance.\\n- It is noted that placing an individual with obesity in a forced prone position can be dangerous.\\n\\n- **Capillary leak/fluid resuscitation:**\\n- Conditions such as acidosis, damage control laparotomy, hypothermia, massive fluid resuscitation, polytransfusion, and increased APACHE II or SOFA scores can lead to increased intra-abdominal pressure.\\n\\n- **Others:**\\n- Additional factors include coagulopathy, bacteremia, massive ventral hernia repair, obesity or increased body mass index, peritonitis, and pneumonia.',\n", " 'md': '- **Increased intra-abdominal contents:**\\n- Conditions such as hemoperitoneum, pneumoperitoneum, intraperitoneal fluid collections, abscesses, liver dysfunction with tense ascites, peritoneal dialysis, intraperitoneal or retroperitoneal tumors, acute pancreatitis, and laparoscopy with excessive insufflation pressures can lead to increased intra-abdominal pressure.\\n- Note that even normal pregnancy can cause sustained IAH.\\n\\n- **Increased intraluminal contents:**\\n- Conditions like gastric dilatation, ileus, colonic pseudo-obstruction (referenced in Figure 33.1), and volvulus can contribute to increased pressure.\\n\\n- **Diminished abdominal wall compliance:**\\n- Factors such as major burns, major trauma, abdominal surgery, and prone positioning can reduce abdominal wall compliance.\\n- It is noted that placing an individual with obesity in a forced prone position can be dangerous.\\n\\n- **Capillary leak/fluid resuscitation:**\\n- Conditions such as acidosis, damage control laparotomy, hypothermia, massive fluid resuscitation, polytransfusion, and increased APACHE II or SOFA scores can lead to increased intra-abdominal pressure.\\n\\n- **Others:**\\n- Additional factors include coagulopathy, bacteremia, massive ventral hernia repair, obesity or increased body mass index, peritonitis, and pneumonia.',\n", " 'bBox': {'x': 100, 'y': 448, 'w': 436.49, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Hyperlink',\n", " 'md': '### Hyperlink',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Watch this clip: [YouTube Video](https://www.youtube.com/watch?v=pvATEjsf41g)\\n```',\n", " 'md': '- Watch this clip: [YouTube Video](https://www.youtube.com/watch?v=pvATEjsf41g)\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'url': 'http://https//www.youtube.com/watch?v=pvATEjsf41g', 'text': ''},\n", " {'text': ''},\n", " {'text': ' Chapter 19?) 1'}]},\n", " {'page': 606,\n", " 'text': ' sepsis, shock or hypotension, mechanical ventilation, positive end-\\n expiratory pressure (PEEP) >10mmħg.\\n\\n As you can see from the list above, almost all of your patients —\\nincluding those who did not undergo any abdominal operation — or\\neven those who do not suffer from any intra-abdominal pathology\\n(e.g. burns) — can develop IAH! So, for example, if you are morbidly\\nobese the huge omentum nestling within your abdomen produces IAħ —\\nwhich makes you susceptible to ACS…\\n\\n Pathophysiology of IAH and ACS\\n\\n Almost all organ systems are affected by IAH. The most easily\\ndetected signs are renal and respiratory but do not overlook the effects\\non cardiovascular, gastrointestinal, or neurological systems ( Figure\\n33.2).\\n\\n Table 33.1 summarizes the physiological consequences of intra-\\nabdominal hypertension. For those of you who are not intensivists, here\\nis a list of the consequences of IAħ that surgeons understand:',\n", " 'md': '```markdown\\n## Page Content\\n\\nSepsis, shock or hypotension, mechanical ventilation, positive end-expiratory pressure (PEEP) >10 mmHg.\\n\\nAs you can see from the list above, almost all of your patients — including those who did not undergo any abdominal operation — or even those who do not suffer from any intra-abdominal pathology (e.g. burns) — can develop IAH! So, for example, if you are morbidly obese the huge omentum nestling within your abdomen produces IAH — which makes you susceptible to ACS…\\n\\n### Pathophysiology of IAH and ACS\\n\\nAlmost all organ systems are affected by IAH. The most easily detected signs are renal and respiratory but do not overlook the effects on cardiovascular, gastrointestinal, or neurological systems (Figure 33.2).\\n\\nTable 33.1 summarizes the physiological consequences of intra-abdominal hypertension. For those of you who are not intensivists, here is a list of the consequences of IAH that surgeons understand:\\n\\n### Table 33.1: Physiological Consequences of Intra-Abdominal Hypertension\\n\\n| Consequence | Description |\\n|--------------------------|-----------------------------------------------|\\n| Renal Effects | |\\n| Respiratory Effects | |\\n| Cardiovascular Effects | |\\n| Gastrointestinal Effects | |\\n| Neurological Effects | |\\n\\n### Figures\\n\\n- **Figure 33.2**: This figure illustrates the effects of intra-abdominal hypertension on various organ systems. The specific content of the figure is not extractable, but it is noted that it highlights the impact on renal, respiratory, cardiovascular, gastrointestinal, and neurological systems.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Sepsis, shock or hypotension, mechanical ventilation, positive end-expiratory pressure (PEEP) >10 mmHg.\\n\\nAs you can see from the list above, almost all of your patients — including those who did not undergo any abdominal operation — or even those who do not suffer from any intra-abdominal pathology (e.g. burns) — can develop IAH! So, for example, if you are morbidly obese the huge omentum nestling within your abdomen produces IAH — which makes you susceptible to ACS…',\n", " 'md': 'Sepsis, shock or hypotension, mechanical ventilation, positive end-expiratory pressure (PEEP) >10 mmHg.\\n\\nAs you can see from the list above, almost all of your patients — including those who did not undergo any abdominal operation — or even those who do not suffer from any intra-abdominal pathology (e.g. burns) — can develop IAH! So, for example, if you are morbidly obese the huge omentum nestling within your abdomen produces IAH — which makes you susceptible to ACS…',\n", " 'bBox': {'x': 72, 'y': 139, 'w': 467.8, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Pathophysiology of IAH and ACS',\n", " 'md': '### Pathophysiology of IAH and ACS',\n", " 'bBox': {'x': 86, 'y': 265, 'w': 260.22, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Almost all organ systems are affected by IAH. The most easily detected signs are renal and respiratory but do not overlook the effects on cardiovascular, gastrointestinal, or neurological systems (Figure 33.2).\\n\\nTable 33.1 summarizes the physiological consequences of intra-abdominal hypertension. For those of you who are not intensivists, here is a list of the consequences of IAH that surgeons understand:',\n", " 'md': 'Almost all organ systems are affected by IAH. The most easily detected signs are renal and respiratory but do not overlook the effects on cardiovascular, gastrointestinal, or neurological systems (Figure 33.2).\\n\\nTable 33.1 summarizes the physiological consequences of intra-abdominal hypertension. For those of you who are not intensivists, here is a list of the consequences of IAH that surgeons understand:',\n", " 'bBox': {'x': 72, 'y': 351, 'w': 467.92, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 33.1: Physiological Consequences of Intra-Abdominal Hypertension',\n", " 'md': '### Table 33.1: Physiological Consequences of Intra-Abdominal Hypertension',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Consequence', 'Description'],\n", " ['Renal Effects', ''],\n", " ['Respiratory Effects', ''],\n", " ['Cardiovascular Effects', ''],\n", " ['Gastrointestinal Effects', ''],\n", " ['Neurological Effects', '']],\n", " 'md': '| Consequence | Description |\\n|--------------------------|-----------------------------------------------|\\n| Renal Effects | |\\n| Respiratory Effects | |\\n| Cardiovascular Effects | |\\n| Gastrointestinal Effects | |\\n| Neurological Effects | |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Consequence\",\"Description\"\\n\"Renal Effects\",\"\"\\n\"Respiratory Effects\",\"\"\\n\"Cardiovascular Effects\",\"\"\\n\"Gastrointestinal Effects\",\"\"\\n\"Neurological Effects\",\"\"',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 33.2**: This figure illustrates the effects of intra-abdominal hypertension on various organ systems. The specific content of the figure is not extractable, but it is noted that it highlights the impact on renal, respiratory, cardiovascular, gastrointestinal, and neurological systems.\\n```',\n", " 'md': '- **Figure 33.2**: This figure illustrates the effects of intra-abdominal hypertension on various organ systems. The specific content of the figure is not extractable, but it is noted that it highlights the impact on renal, respiratory, cardiovascular, gastrointestinal, and neurological systems.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'on cardiovascular, gastrointestinal, or neurological systems ( Figure 33.2).'},\n", " {'text': 'abdominal hypertension. For those of you who are not intensivists, here'}]},\n", " {'page': 607,\n", " 'text': ' CVP + wedge pressure Craniospinal pressure\\n Thoracic airway\\n pressures Cardiac output\\n Respiratory failure Urinary output\\n Venous return\\n Venous stasis\\nFigure 33.2. The abdominal compartment syndrome.\\n\\n • Increased airway pressure.\\n • Decreased cardiac output.\\n • Decreased urinary output.\\n • Decreased intestinal mucosal blood flow.\\n • Increased intracerebral pressure.\\n • Decreased blood flow to the abdominal wall.',\n", " 'md': '```markdown\\n## Page Content\\n\\n- CVP + wedge pressure\\n- Craniospinal pressure\\n- Thoracic airway pressures\\n- Cardiac output\\n- Respiratory failure\\n- Urinary output\\n- Venous return\\n- Venous stasis\\n\\n### Figure 33.2\\n**Description:** This figure illustrates the abdominal compartment syndrome, highlighting various physiological changes associated with the condition.\\n\\n**Key Points:**\\n- Increased airway pressure.\\n- Decreased cardiac output.\\n- Decreased urinary output.\\n- Decreased intestinal mucosal blood flow.\\n- Increased intracerebral pressure.\\n- Decreased blood flow to the abdominal wall.\\n```',\n", " 'images': [{'name': 'img_p606_1.png',\n", " 'height': 832,\n", " 'width': 847,\n", " 'x': 96.48000000000002,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1456,\n", " 'original_height': 1432}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- CVP + wedge pressure\\n- Craniospinal pressure\\n- Thoracic airway pressures\\n- Cardiac output\\n- Respiratory failure\\n- Urinary output\\n- Venous return\\n- Venous stasis',\n", " 'md': '- CVP + wedge pressure\\n- Craniospinal pressure\\n- Thoracic airway pressures\\n- Cardiac output\\n- Respiratory failure\\n- Urinary output\\n- Venous return\\n- Venous stasis',\n", " 'bBox': {'x': 100.93, 'y': 110.03, 'w': 387.38, 'h': 17.82}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 33.2',\n", " 'md': '### Figure 33.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure illustrates the abdominal compartment syndrome, highlighting various physiological changes associated with the condition.\\n\\n**Key Points:**\\n- Increased airway pressure.\\n- Decreased cardiac output.\\n- Decreased urinary output.\\n- Decreased intestinal mucosal blood flow.\\n- Increased intracerebral pressure.\\n- Decreased blood flow to the abdominal wall.\\n```',\n", " 'md': '**Description:** This figure illustrates the abdominal compartment syndrome, highlighting various physiological changes associated with the condition.\\n\\n**Key Points:**\\n- Increased airway pressure.\\n- Decreased cardiac output.\\n- Decreased urinary output.\\n- Decreased intestinal mucosal blood flow.\\n- Increased intracerebral pressure.\\n- Decreased blood flow to the abdominal wall.\\n```',\n", " 'bBox': {'x': 100, 'y': 157.05, 'w': 281.46, 'h': 17.82}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 608,\n", " 'text': \" Table 33.1. Physiological consequences of intra-abdominal\\n hypertension:_\\n Increased Decreased No change\\n Mean blood pressure\\n Heart rate\\n Peak airway pressure\\n Thoracic/pleural pressure\\n Central venous pressure\\n Pulmonary capillary wedge pressure '\\n Inferior vena cava pressure\\n Renal vein pressure\\n Systemic vascular resistance\\n Cardiac output\\n Venous return\\n Visceral blood flow\\n Gastric mucosal pH\\n Renal blood flow\\n Glomerular filtration rate\\n Cerebrospinal fluid pressure\\n Abdominal wall compliance\\n These abnormalities are often present despite apparently normal\\ncardiac filling pressures because transmission of increased IAP to\\nthe thorax elevates central venous pressure (CVP), right atrial\\npressure and pulmonary capillary wedge pressure. Cardiovascular,\\nrespiratory and renal dysfunction become progressively difficult to\\nmanage unless IAP is reduced. Rarer consequences of ACS have\\nbeen described, such as intestinal ischemia following laparoscopic\\ncholecystectomy or spinal cord infarction in the setting of IAħ following\\nperforation of a gastric ulcer.\\n\\n It is easy to understand why the effects of IAħ are not limited to the\\nabdominal cavity but also affect the chest cavity and even the intracranial\\nspace (through diminished venous outflow leading to increased\\nintracranial pressure). When two or more anatomical compartments\",\n", " 'md': '```markdown\\n## Table 33.1: Physiological Consequences of Intra-abdominal Hypertension\\n\\n| Parameter | Increased | Decreased | No Change |\\n|---------------------------------------------|-----------|-----------|-----------|\\n| Mean blood pressure | | | |\\n| Heart rate | | | |\\n| Peak airway pressure | | | |\\n| Thoracic/pleural pressure | | | |\\n| Central venous pressure | | | |\\n| Pulmonary capillary wedge pressure | | | |\\n| Inferior vena cava pressure | | | |\\n| Renal vein pressure | | | |\\n| Systemic vascular resistance | | | |\\n| Cardiac output | | | |\\n| Venous return | | | |\\n| Visceral blood flow | | | |\\n| Gastric mucosal pH | | | |\\n| Renal blood flow | | | |\\n| Glomerular filtration rate | | | |\\n| Cerebrospinal fluid pressure | | | |\\n| Abdominal wall compliance | | | |\\n\\nThese abnormalities are often present despite apparently normal cardiac filling pressures because transmission of increased intra-abdominal pressure (IAP) to the thorax elevates central venous pressure (CVP), right atrial pressure, and pulmonary capillary wedge pressure. Cardiovascular, respiratory, and renal dysfunction become progressively difficult to manage unless IAP is reduced. Rarer consequences of abdominal compartment syndrome (ACS) have been described, such as intestinal ischemia following laparoscopic cholecystectomy or spinal cord infarction in the setting of IAP following perforation of a gastric ulcer.\\n\\nIt is easy to understand why the effects of IAP are not limited to the abdominal cavity but also affect the chest cavity and even the intracranial space (through diminished venous outflow leading to increased intracranial pressure). When two or more anatomical compartments are affected, the consequences can be severe.\\n```',\n", " 'images': [{'name': 'img_p607_1.png',\n", " 'height': 768,\n", " 'width': 818,\n", " 'x': 103.67999999999984,\n", " 'y': 72,\n", " 'original_width': 1404,\n", " 'original_height': 1318}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 33.1: Physiological Consequences of Intra-abdominal Hypertension',\n", " 'md': '## Table 33.1: Physiological Consequences of Intra-abdominal Hypertension',\n", " 'bBox': {'x': 109.62, 'y': 73.98, 'w': 261.19, 'h': 20.79}},\n", " {'type': 'table',\n", " 'rows': [['Parameter', 'Increased', 'Decreased', 'No Change'],\n", " ['Mean blood pressure', '', '', ''],\n", " ['Heart rate', '', '', ''],\n", " ['Peak airway pressure', '', '', ''],\n", " ['Thoracic/pleural pressure', '', '', ''],\n", " ['Central venous pressure', '', '', ''],\n", " ['Pulmonary capillary wedge pressure', '', '', ''],\n", " ['Inferior vena cava pressure', '', '', ''],\n", " ['Renal vein pressure', '', '', ''],\n", " ['Systemic vascular resistance', '', '', ''],\n", " ['Cardiac output', '', '', ''],\n", " ['Venous return', '', '', ''],\n", " ['Visceral blood flow', '', '', ''],\n", " ['Gastric mucosal pH', '', '', ''],\n", " ['Renal blood flow', '', '', ''],\n", " ['Glomerular filtration rate', '', '', ''],\n", " ['Cerebrospinal fluid pressure', '', '', ''],\n", " ['Abdominal wall compliance', '', '', '']],\n", " 'md': '| Parameter | Increased | Decreased | No Change |\\n|---------------------------------------------|-----------|-----------|-----------|\\n| Mean blood pressure | | | |\\n| Heart rate | | | |\\n| Peak airway pressure | | | |\\n| Thoracic/pleural pressure | | | |\\n| Central venous pressure | | | |\\n| Pulmonary capillary wedge pressure | | | |\\n| Inferior vena cava pressure | | | |\\n| Renal vein pressure | | | |\\n| Systemic vascular resistance | | | |\\n| Cardiac output | | | |\\n| Venous return | | | |\\n| Visceral blood flow | | | |\\n| Gastric mucosal pH | | | |\\n| Renal blood flow | | | |\\n| Glomerular filtration rate | | | |\\n| Cerebrospinal fluid pressure | | | |\\n| Abdominal wall compliance | | | |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Parameter\",\"Increased\",\"Decreased\",\"No Change\"\\n\"Mean blood pressure\",\"\",\"\",\"\"\\n\"Heart rate\",\"\",\"\",\"\"\\n\"Peak airway pressure\",\"\",\"\",\"\"\\n\"Thoracic/pleural pressure\",\"\",\"\",\"\"\\n\"Central venous pressure\",\"\",\"\",\"\"\\n\"Pulmonary capillary wedge pressure\",\"\",\"\",\"\"\\n\"Inferior vena cava pressure\",\"\",\"\",\"\"\\n\"Renal vein pressure\",\"\",\"\",\"\"\\n\"Systemic vascular resistance\",\"\",\"\",\"\"\\n\"Cardiac output\",\"\",\"\",\"\"\\n\"Venous return\",\"\",\"\",\"\"\\n\"Visceral blood flow\",\"\",\"\",\"\"\\n\"Gastric mucosal pH\",\"\",\"\",\"\"\\n\"Renal blood flow\",\"\",\"\",\"\"\\n\"Glomerular filtration rate\",\"\",\"\",\"\"\\n\"Cerebrospinal fluid pressure\",\"\",\"\",\"\"\\n\"Abdominal wall compliance\",\"\",\"\",\"\"',\n", " 'bBox': {'x': 108.13, 'y': 114.57, 'w': 240.41, 'h': 16.33}},\n", " {'type': 'text',\n", " 'value': 'These abnormalities are often present despite apparently normal cardiac filling pressures because transmission of increased intra-abdominal pressure (IAP) to the thorax elevates central venous pressure (CVP), right atrial pressure, and pulmonary capillary wedge pressure. Cardiovascular, respiratory, and renal dysfunction become progressively difficult to manage unless IAP is reduced. Rarer consequences of abdominal compartment syndrome (ACS) have been described, such as intestinal ischemia following laparoscopic cholecystectomy or spinal cord infarction in the setting of IAP following perforation of a gastric ulcer.\\n\\nIt is easy to understand why the effects of IAP are not limited to the abdominal cavity but also affect the chest cavity and even the intracranial space (through diminished venous outflow leading to increased intracranial pressure). When two or more anatomical compartments are affected, the consequences can be severe.\\n```',\n", " 'md': 'These abnormalities are often present despite apparently normal cardiac filling pressures because transmission of increased intra-abdominal pressure (IAP) to the thorax elevates central venous pressure (CVP), right atrial pressure, and pulmonary capillary wedge pressure. Cardiovascular, respiratory, and renal dysfunction become progressively difficult to manage unless IAP is reduced. Rarer consequences of abdominal compartment syndrome (ACS) have been described, such as intestinal ischemia following laparoscopic cholecystectomy or spinal cord infarction in the setting of IAP following perforation of a gastric ulcer.\\n\\nIt is easy to understand why the effects of IAP are not limited to the abdominal cavity but also affect the chest cavity and even the intracranial space (through diminished venous outflow leading to increased intracranial pressure). When two or more anatomical compartments are affected, the consequences can be severe.\\n```',\n", " 'bBox': {'x': 72, 'y': 115.56, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 609,\n", " 'text': 'have elevated compartmental pressures, it is called a\\npolycompartment syndrome.\\n\\n When to suspect IAH?\\n 8\\n PERTA 2014\\n Figure 33.3. “What? Abdominal compartment syndrome? Never heard of it!”\\n\\n Seeing a patient with a hugely distended abdomen might be a hint (\\nFigure 33.3) but after reading of a study showing that physical\\nexamination (palpation) is highly inaccurate in determining IAP, we\\nstopped using that as a criterion, especially since measuring IAP is so\\nsimple that even surgeons can do it ( Figure 33.4). So, all you need to\\ndo is to suspect and measure IAP, especially when the patient has:\\n\\n • A tense, distended abdomen.\\n • Respiratory failure.\\n • Diminished cardiac output.\\n • Labile blood pressure.',\n", " 'md': '```markdown\\n## Abdominal Compartment Syndrome\\n\\nWhen to suspect Intra-Abdominal Hypertension (IAH)?\\n\\nSeeing a patient with a hugely distended abdomen might be a hint (Figure 33.3) but after reading of a study showing that physical examination (palpation) is highly inaccurate in determining Intra-Abdominal Pressure (IAP), we stopped using that as a criterion, especially since measuring IAP is so simple that even surgeons can do it (Figure 33.4). So, all you need to do is to suspect and measure IAP, especially when the patient has:\\n\\n- A tense, distended abdomen.\\n- Respiratory failure.\\n- Diminished cardiac output.\\n- Labile blood pressure.\\n\\n### Figures\\n\\n**Figure 33.3**: “What? Abdominal compartment syndrome? Never heard of it!”\\n*Description*: This figure likely depicts a patient with a distended abdomen, illustrating a potential sign of abdominal compartment syndrome. The context suggests that visual examination alone is not a reliable method for diagnosing IAH.\\n\\n**Figure 33.4**: **\\n*Description*: This figure is referenced in the context of measuring IAP, indicating that it may contain information or a method related to the measurement of intra-abdominal pressure.\\n```',\n", " 'images': [{'name': 'img_p608_1.png',\n", " 'height': 547,\n", " 'width': 806,\n", " 'x': 106.55999999999995,\n", " 'y': 159.84000000000003,\n", " 'original_width': 1386,\n", " 'original_height': 940}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 531, 'y': 85, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Compartment Syndrome',\n", " 'md': '## Abdominal Compartment Syndrome',\n", " 'bBox': {'x': 531, 'y': 85, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'When to suspect Intra-Abdominal Hypertension (IAH)?\\n\\nSeeing a patient with a hugely distended abdomen might be a hint (Figure 33.3) but after reading of a study showing that physical examination (palpation) is highly inaccurate in determining Intra-Abdominal Pressure (IAP), we stopped using that as a criterion, especially since measuring IAP is so simple that even surgeons can do it (Figure 33.4). So, all you need to do is to suspect and measure IAP, especially when the patient has:\\n\\n- A tense, distended abdomen.\\n- Respiratory failure.\\n- Diminished cardiac output.\\n- Labile blood pressure.',\n", " 'md': 'When to suspect Intra-Abdominal Hypertension (IAH)?\\n\\nSeeing a patient with a hugely distended abdomen might be a hint (Figure 33.3) but after reading of a study showing that physical examination (palpation) is highly inaccurate in determining Intra-Abdominal Pressure (IAP), we stopped using that as a criterion, especially since measuring IAP is so simple that even surgeons can do it (Figure 33.4). So, all you need to do is to suspect and measure IAP, especially when the patient has:\\n\\n- A tense, distended abdomen.\\n- Respiratory failure.\\n- Diminished cardiac output.\\n- Labile blood pressure.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 459.21, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 33.3**: “What? Abdominal compartment syndrome? Never heard of it!”\\n*Description*: This figure likely depicts a patient with a distended abdomen, illustrating a potential sign of abdominal compartment syndrome. The context suggests that visual examination alone is not a reliable method for diagnosing IAH.\\n\\n**Figure 33.4**: **\\n*Description*: This figure is referenced in the context of measuring IAP, indicating that it may contain information or a method related to the measurement of intra-abdominal pressure.\\n```',\n", " 'md': '**Figure 33.3**: “What? Abdominal compartment syndrome? Never heard of it!”\\n*Description*: This figure likely depicts a patient with a distended abdomen, illustrating a potential sign of abdominal compartment syndrome. The context suggests that visual examination alone is not a reliable method for diagnosing IAH.\\n\\n**Figure 33.4**: **\\n*Description*: This figure is referenced in the context of measuring IAP, indicating that it may contain information or a method related to the measurement of intra-abdominal pressure.\\n```',\n", " 'bBox': {'x': 413, 'y': 85, 'w': 16, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Figure 33.3) but after reading of a study showing that physical examination (palpation) is highly inaccurate in determining IAP, we'},\n", " {'text': 'do is to suspect and measure IAP, especially when the patient has'}]},\n", " {'page': 610,\n", " 'text': ' • Oliguria non-responsive to conventional management.\\n • Acidosis.\\n\\n Figure 33.4. Ari measuring IAP.\\n\\n Diagnosis of IAH\\n If you don’t take a temperature, you can’t find a fever.\\n\\n Why guess? Just measure the IAP! You don’t need fancy equipment,\\njust a Foley catheter and a tube system that costs a few dollars.\\nħowever, you need to be aware of the principles of IAP measurement as\\nstated by the 2013 consensus definition of the World Society of the\\nAbdominal Compartment Syndrome.\\n\\n 2013 consensus definition of the World Society of the\\n Abdominal Compartment Syndrome: “The reference standard for\\n intermittent IAP measurements is via the urinary bladder with a maximal instillation volume of\\n 25ml of sterile saline. IAP should be expressed in mmHg and measured at end-expiration in',\n", " 'md': '```markdown\\n## Page Content\\n\\n- Oliguria non-responsive to conventional management.\\n- Acidosis.\\n\\n### Figure 33.4\\n**Description**: This figure depicts Ari measuring Intra-Abdominal Pressure (IAP). The image likely shows a clinical setting where a healthcare professional is using a Foley catheter and a tube system to measure IAP, emphasizing the simplicity and cost-effectiveness of the method.\\n\\n### Diagnosis of IAH\\n\"If you don’t take a temperature, you can’t find a fever.\"\\n\\n**Key Point**:\\n- Why guess? Just measure the IAP! You don’t need fancy equipment, just a Foley catheter and a tube system that costs a few dollars. However, you need to be aware of the principles of IAP measurement as stated by the 2013 consensus definition of the World Society of the Abdominal Compartment Syndrome.\\n\\n### 2013 Consensus Definition\\nThe reference standard for intermittent IAP measurements is via the urinary bladder with a maximal instillation volume of 25 ml of sterile saline. IAP should be expressed in mmHg and measured at end-expiration.\\n```',\n", " 'images': [{'name': 'img_p609_1.png',\n", " 'height': 475,\n", " 'width': 678,\n", " 'x': 138.23999999999978,\n", " 'y': 154.08,\n", " 'original_width': 1166,\n", " 'original_height': 816}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Oliguria non-responsive to conventional management.\\n- Acidosis.',\n", " 'md': '- Oliguria non-responsive to conventional management.\\n- Acidosis.',\n", " 'bBox': {'x': 100, 'y': 86, 'w': 344.65, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 33.4',\n", " 'md': '### Figure 33.4',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description**: This figure depicts Ari measuring Intra-Abdominal Pressure (IAP). The image likely shows a clinical setting where a healthcare professional is using a Foley catheter and a tube system to measure IAP, emphasizing the simplicity and cost-effectiveness of the method.',\n", " 'md': '**Description**: This figure depicts Ari measuring Intra-Abdominal Pressure (IAP). The image likely shows a clinical setting where a healthcare professional is using a Foley catheter and a tube system to measure IAP, emphasizing the simplicity and cost-effectiveness of the method.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diagnosis of IAH',\n", " 'md': '### Diagnosis of IAH',\n", " 'bBox': {'x': 86, 'y': 463, 'w': 132.4, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '\"If you don’t take a temperature, you can’t find a fever.\"\\n\\n**Key Point**:\\n- Why guess? Just measure the IAP! You don’t need fancy equipment, just a Foley catheter and a tube system that costs a few dollars. However, you need to be aware of the principles of IAP measurement as stated by the 2013 consensus definition of the World Society of the Abdominal Compartment Syndrome.',\n", " 'md': '\"If you don’t take a temperature, you can’t find a fever.\"\\n\\n**Key Point**:\\n- Why guess? Just measure the IAP! You don’t need fancy equipment, just a Foley catheter and a tube system that costs a few dollars. However, you need to be aware of the principles of IAP measurement as stated by the 2013 consensus definition of the World Society of the Abdominal Compartment Syndrome.',\n", " 'bBox': {'x': 72, 'y': 495, 'w': 453.2, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': '2013 Consensus Definition',\n", " 'md': '### 2013 Consensus Definition',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The reference standard for intermittent IAP measurements is via the urinary bladder with a maximal instillation volume of 25 ml of sterile saline. IAP should be expressed in mmHg and measured at end-expiration.\\n```',\n", " 'md': 'The reference standard for intermittent IAP measurements is via the urinary bladder with a maximal instillation volume of 25 ml of sterile saline. IAP should be expressed in mmHg and measured at end-expiration.\\n```',\n", " 'bBox': {'x': 79, 'y': 683, 'w': 453.53, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 611,\n", " 'text': ' the supine position after ensuring that abdominal muscle contractions are absent and with the\\n transducer zeroed at the level of the mid-axillary line.”\\n\\n So basically, all you need to measure IAP is a Foley catheter:\\ndisconnect it from the urine bag; instill 25ml saline into the bladder and\\nelevate the disconnected catheter perpendicular to the supine patient and\\nhis bed. If you don’t have a transducer in your allegedly ‘cutting edge’\\ninstitution — the height of the water-urine column in the catheter is the\\nIAP in cmħ2O (1cm ħ2O=0.735mmħg). The level will fluctuate with the\\npatient’s respiratory cycle — up during inspiration, down during expiration\\n— following the movements of the diaphragm. A neurogenic or small\\ncontracted bladder may render the measurements invalid. Errors can\\nalso occur if the catheter is blocked or if a pelvic hematoma selectively\\ncompresses the bladder. Because the Trendelenburg position (or its\\nreverse) may affect intra-bladder pressure, accurate measurements are\\nbest achieved in the supine position.\\n\\n More definitions\\n\\n Like all good things in life, categorizing and grading a phenomenon\\nmakes it more reliable and ‘scientific’. And those of you who still use\\ncmħ2O (you shouldn’t), remember that 1mmħg = 1.36cmħ2O.\\n\\n IAħ is graded as shown in Table 33.2 below.\\n Table 33.2. Grading of intra-abdominal hypertension (IAH):\\n Grade I: IAP 12-15mmHg:\\n Grade Il: IAP 16-2OmmHg\\n Grade III: IAP 21-25mmHg:\\n Grade IV= IAP >2SmmHg:\\n A few more definitions (as you know — academics spend their time\\ninventing definitions and classifications and then revising them...):',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nThe supine position after ensuring that abdominal muscle contractions are absent and with the transducer zeroed at the level of the mid-axillary line.\\n\\nSo basically, all you need to measure IAP is a Foley catheter: disconnect it from the urine bag; instill 25ml saline into the bladder and elevate the disconnected catheter perpendicular to the supine patient and his bed. If you don’t have a transducer in your allegedly ‘cutting edge’ institution — the height of the water-urine column in the catheter is the IAP in cm\\\\(\\\\text{H}_2\\\\text{O}\\\\) (1 cm \\\\(\\\\text{H}_2\\\\text{O}\\\\) = 0.735 mm\\\\(\\\\text{Hg}\\\\)). The level will fluctuate with the patient’s respiratory cycle — up during inspiration, down during expiration — following the movements of the diaphragm. A neurogenic or small contracted bladder may render the measurements invalid. Errors can also occur if the catheter is blocked or if a pelvic hematoma selectively compresses the bladder. Because the Trendelenburg position (or its reverse) may affect intra-bladder pressure, accurate measurements are best achieved in the supine position.\\n\\nMore definitions\\n\\nLike all good things in life, categorizing and grading a phenomenon makes it more reliable and ‘scientific’. And those of you who still use cm\\\\(\\\\text{H}_2\\\\text{O}\\\\) (you shouldn’t), remember that 1 mm\\\\(\\\\text{Hg}\\\\) = 1.36 cm\\\\(\\\\text{H}_2\\\\text{O}\\\\).\\n\\nIAH is graded as shown in Table 33.2 below.\\n\\n## Table Extraction\\n\\n### Table 33.2. Grading of intra-abdominal hypertension (IAH):\\n\\n| Grade | IAP Range |\\n|---------|-------------------|\\n| Grade I | 12-15 mmHg |\\n| Grade II| 16-20 mmHg |\\n| Grade III| 21-25 mmHg |\\n| Grade IV| >25 mmHg |\\n\\nA few more definitions (as you know — academics spend their time inventing definitions and classifications and then revising them...).\\n```',\n", " 'images': [{'name': 'img_p610_1.png',\n", " 'height': 256,\n", " 'width': 812,\n", " 'x': 105.11999999999989,\n", " 'y': 516.2399999999999,\n", " 'original_width': 1396,\n", " 'original_height': 440}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The supine position after ensuring that abdominal muscle contractions are absent and with the transducer zeroed at the level of the mid-axillary line.\\n\\nSo basically, all you need to measure IAP is a Foley catheter: disconnect it from the urine bag; instill 25ml saline into the bladder and elevate the disconnected catheter perpendicular to the supine patient and his bed. If you don’t have a transducer in your allegedly ‘cutting edge’ institution — the height of the water-urine column in the catheter is the IAP in cm\\\\(\\\\text{H}_2\\\\text{O}\\\\) (1 cm \\\\(\\\\text{H}_2\\\\text{O}\\\\) = 0.735 mm\\\\(\\\\text{Hg}\\\\)). The level will fluctuate with the patient’s respiratory cycle — up during inspiration, down during expiration — following the movements of the diaphragm. A neurogenic or small contracted bladder may render the measurements invalid. Errors can also occur if the catheter is blocked or if a pelvic hematoma selectively compresses the bladder. Because the Trendelenburg position (or its reverse) may affect intra-bladder pressure, accurate measurements are best achieved in the supine position.\\n\\nMore definitions\\n\\nLike all good things in life, categorizing and grading a phenomenon makes it more reliable and ‘scientific’. And those of you who still use cm\\\\(\\\\text{H}_2\\\\text{O}\\\\) (you shouldn’t), remember that 1 mm\\\\(\\\\text{Hg}\\\\) = 1.36 cm\\\\(\\\\text{H}_2\\\\text{O}\\\\).\\n\\nIAH is graded as shown in Table 33.2 below.',\n", " 'md': 'The supine position after ensuring that abdominal muscle contractions are absent and with the transducer zeroed at the level of the mid-axillary line.\\n\\nSo basically, all you need to measure IAP is a Foley catheter: disconnect it from the urine bag; instill 25ml saline into the bladder and elevate the disconnected catheter perpendicular to the supine patient and his bed. If you don’t have a transducer in your allegedly ‘cutting edge’ institution — the height of the water-urine column in the catheter is the IAP in cm\\\\(\\\\text{H}_2\\\\text{O}\\\\) (1 cm \\\\(\\\\text{H}_2\\\\text{O}\\\\) = 0.735 mm\\\\(\\\\text{Hg}\\\\)). The level will fluctuate with the patient’s respiratory cycle — up during inspiration, down during expiration — following the movements of the diaphragm. A neurogenic or small contracted bladder may render the measurements invalid. Errors can also occur if the catheter is blocked or if a pelvic hematoma selectively compresses the bladder. Because the Trendelenburg position (or its reverse) may affect intra-bladder pressure, accurate measurements are best achieved in the supine position.\\n\\nMore definitions\\n\\nLike all good things in life, categorizing and grading a phenomenon makes it more reliable and ‘scientific’. And those of you who still use cm\\\\(\\\\text{H}_2\\\\text{O}\\\\) (you shouldn’t), remember that 1 mm\\\\(\\\\text{Hg}\\\\) = 1.36 cm\\\\(\\\\text{H}_2\\\\text{O}\\\\).\\n\\nIAH is graded as shown in Table 33.2 below.',\n", " 'bBox': {'x': 72, 'y': 87, 'w': 467.79, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table Extraction',\n", " 'md': '## Table Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 33.2. Grading of intra-abdominal hypertension (IAH):',\n", " 'md': '### Table 33.2. Grading of intra-abdominal hypertension (IAH):',\n", " 'bBox': {'x': 110.56, 'y': 518.71, 'w': 356.24, 'h': 19.8}},\n", " {'type': 'table',\n", " 'rows': [['Grade', 'IAP Range'],\n", " ['Grade I', '12-15 mmHg'],\n", " ['Grade II', '16-20 mmHg'],\n", " ['Grade III', '21-25 mmHg'],\n", " ['Grade IV', '>25 mmHg']],\n", " 'md': '| Grade | IAP Range |\\n|---------|-------------------|\\n| Grade I | 12-15 mmHg |\\n| Grade II| 16-20 mmHg |\\n| Grade III| 21-25 mmHg |\\n| Grade IV| >25 mmHg |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Grade\",\"IAP Range\"\\n\"Grade I\",\"12-15 mmHg\"\\n\"Grade II\",\"16-20 mmHg\"\\n\"Grade III\",\"21-25 mmHg\"\\n\"Grade IV\",\">25 mmHg\"',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A few more definitions (as you know — academics spend their time inventing definitions and classifications and then revising them...).\\n```',\n", " 'md': 'A few more definitions (as you know — academics spend their time inventing definitions and classifications and then revising them...).\\n```',\n", " 'bBox': {'x': 86, 'y': 395, 'w': 452.64, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 612,\n", " 'text': ' • Primary IAH or ACS: if the condition associated with injury or\\n illness is in the abdominopelvic region, it is called primary IAH or\\n ACS. Think about abdominal trauma, pelvic fracture, ruptured\\n abdominal aortic aneurysm. These conditions usually require early\\n surgical or interventional radiological intervention.\\n • Secondary ICS or IAH: refers to conditions that do not originate in\\n the abdominopelvic region and are often associated with massive\\n fluid resuscitation, such as in sepsis or major burns.\\n • Recurrent IAH or ACS: IAħ or ACS developing following previous\\n surgical or medical treatment of primary or secondary IAħ or ACS (it\\n was called tertiary in the past but recurrent makes more sense).\\n\\n And, finally, if your patient is very sick and in the ICU, and the\\nintensivists probably will (or they should) try to keep the abdominal\\nperfusion pressure (APP) above 60mmħg, you can show your expertise\\nby knowing that:\\n\\n APP = MAP — IAP (the meaning of MAP is intuitive...)\\n\\n How common is IAH?\\n\\n We can still remember the time when patients with severe acute\\npancreatitis developed ‘early multiple organ failure’ and then just died in\\nspite of ‘adequate’ fluid resuscitation. Some of them probably had\\nunrecognized and untreated ACS. Some 15 years ago, when we\\nstarted routinely measuring the IAP of all pancreatitis patients in the ICU\\nin ħelsinki, we found that about 40% of them had IAħ and about 10%\\ndeveloped ACS. Of course, since that time we have got smarter and\\nbetter in avoiding excessive fluid resuscitation leading to IAħ!\\n\\n In a general ICU with mixed medical and surgical patients, the\\nincidence of IAħ used to be about 50% and ACS about 10%. However,\\nwith increasing awareness, and better prevention and treatment of\\nIAH, the incidence of full-blown ACS has decreased dramatically.\\nLeaving the abdomen open after damage control surgery for trauma\\nor other surgical emergencies (see below) has also had a major',\n", " 'md': '```markdown\\n## Abdominal Compartment Syndrome (ACS) and Intra-Abdominal Hypertension (IAH)\\n\\n- **Primary IAH or ACS**: If the condition associated with injury or illness is in the abdominopelvic region, it is called primary IAH or ACS. Think about abdominal trauma, pelvic fracture, ruptured abdominal aortic aneurysm. These conditions usually require early surgical or interventional radiological intervention.\\n\\n- **Secondary ICS or IAH**: Refers to conditions that do not originate in the abdominopelvic region and are often associated with massive fluid resuscitation, such as in sepsis or major burns.\\n\\n- **Recurrent IAH or ACS**: IAH or ACS developing following previous surgical or medical treatment of primary or secondary IAH or ACS (it was called tertiary in the past but recurrent makes more sense).\\n\\nAnd, finally, if your patient is very sick and in the ICU, and the intensivists probably will (or they should) try to keep the abdominal perfusion pressure (APP) above 60 mmHg, you can show your expertise by knowing that:\\n\\n\\\\[\\n\\\\text{APP} = \\\\text{MAP} - \\\\text{IAP}\\n\\\\]\\n\\n(The meaning of MAP is intuitive...)\\n\\n### How common is IAH?\\n\\nWe can still remember the time when patients with severe acute pancreatitis developed ‘early multiple organ failure’ and then just died in spite of ‘adequate’ fluid resuscitation. Some of them probably had unrecognized and untreated ACS. Some 15 years ago, when we started routinely measuring the IAP of all pancreatitis patients in the ICU in Helsinki, we found that about 40% of them had IAH and about 10% developed ACS. Of course, since that time we have got smarter and better in avoiding excessive fluid resuscitation leading to IAH!\\n\\nIn a general ICU with mixed medical and surgical patients, the incidence of IAH used to be about 50% and ACS about 10%. However, with increasing awareness, and better prevention and treatment of IAH, the incidence of full-blown ACS has decreased dramatically. Leaving the abdomen open after damage control surgery for trauma or other surgical emergencies (see below) has also had a major impact.\\n```',\n", " 'images': [{'name': 'img_p611_1.png',\n", " 'height': 51,\n", " 'width': 41,\n", " 'x': 168.47999999999956,\n", " 'y': 280.8,\n", " 'original_width': 28,\n", " 'original_height': 35}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Compartment Syndrome (ACS) and Intra-Abdominal Hypertension (IAH)',\n", " 'md': '## Abdominal Compartment Syndrome (ACS) and Intra-Abdominal Hypertension (IAH)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Primary IAH or ACS**: If the condition associated with injury or illness is in the abdominopelvic region, it is called primary IAH or ACS. Think about abdominal trauma, pelvic fracture, ruptured abdominal aortic aneurysm. These conditions usually require early surgical or interventional radiological intervention.\\n\\n- **Secondary ICS or IAH**: Refers to conditions that do not originate in the abdominopelvic region and are often associated with massive fluid resuscitation, such as in sepsis or major burns.\\n\\n- **Recurrent IAH or ACS**: IAH or ACS developing following previous surgical or medical treatment of primary or secondary IAH or ACS (it was called tertiary in the past but recurrent makes more sense).\\n\\nAnd, finally, if your patient is very sick and in the ICU, and the intensivists probably will (or they should) try to keep the abdominal perfusion pressure (APP) above 60 mmHg, you can show your expertise by knowing that:\\n\\n\\\\[\\n\\\\text{APP} = \\\\text{MAP} - \\\\text{IAP}\\n\\\\]\\n\\n(The meaning of MAP is intuitive...)',\n", " 'md': '- **Primary IAH or ACS**: If the condition associated with injury or illness is in the abdominopelvic region, it is called primary IAH or ACS. Think about abdominal trauma, pelvic fracture, ruptured abdominal aortic aneurysm. These conditions usually require early surgical or interventional radiological intervention.\\n\\n- **Secondary ICS or IAH**: Refers to conditions that do not originate in the abdominopelvic region and are often associated with massive fluid resuscitation, such as in sepsis or major burns.\\n\\n- **Recurrent IAH or ACS**: IAH or ACS developing following previous surgical or medical treatment of primary or secondary IAH or ACS (it was called tertiary in the past but recurrent makes more sense).\\n\\nAnd, finally, if your patient is very sick and in the ICU, and the intensivists probably will (or they should) try to keep the abdominal perfusion pressure (APP) above 60 mmHg, you can show your expertise by knowing that:\\n\\n\\\\[\\n\\\\text{APP} = \\\\text{MAP} - \\\\text{IAP}\\n\\\\]\\n\\n(The meaning of MAP is intuitive...)',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 433.25, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'How common is IAH?',\n", " 'md': '### How common is IAH?',\n", " 'bBox': {'x': 86, 'y': 431, 'w': 170.1, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'We can still remember the time when patients with severe acute pancreatitis developed ‘early multiple organ failure’ and then just died in spite of ‘adequate’ fluid resuscitation. Some of them probably had unrecognized and untreated ACS. Some 15 years ago, when we started routinely measuring the IAP of all pancreatitis patients in the ICU in Helsinki, we found that about 40% of them had IAH and about 10% developed ACS. Of course, since that time we have got smarter and better in avoiding excessive fluid resuscitation leading to IAH!\\n\\nIn a general ICU with mixed medical and surgical patients, the incidence of IAH used to be about 50% and ACS about 10%. However, with increasing awareness, and better prevention and treatment of IAH, the incidence of full-blown ACS has decreased dramatically. Leaving the abdomen open after damage control surgery for trauma or other surgical emergencies (see below) has also had a major impact.\\n```',\n", " 'md': 'We can still remember the time when patients with severe acute pancreatitis developed ‘early multiple organ failure’ and then just died in spite of ‘adequate’ fluid resuscitation. Some of them probably had unrecognized and untreated ACS. Some 15 years ago, when we started routinely measuring the IAP of all pancreatitis patients in the ICU in Helsinki, we found that about 40% of them had IAH and about 10% developed ACS. Of course, since that time we have got smarter and better in avoiding excessive fluid resuscitation leading to IAH!\\n\\nIn a general ICU with mixed medical and surgical patients, the incidence of IAH used to be about 50% and ACS about 10%. However, with increasing awareness, and better prevention and treatment of IAH, the incidence of full-blown ACS has decreased dramatically. Leaving the abdomen open after damage control surgery for trauma or other surgical emergencies (see below) has also had a major impact.\\n```',\n", " 'bBox': {'x': 72, 'y': 484, 'w': 467.47, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 613,\n", " 'text': 'effect in reducing this often iatrogenic disease.\\n\\n Prevention\\n\\n It is always better to prevent than treat and here are some simple\\nrules for surgeons on how to avoid ACS:\\n\\n Consider leaving the abdomen open:\\n\\n • After damage control surgery — not only after trauma.\\n • If massive visceral edema is present.\\n • After prolonged operations — usually for abdominal catastrophes.\\n • If massive transfusion has been given.\\n Decrease the risk of ACS by avoiding:\\n\\n • Massive crystalloid resuscitation.\\n • Too tight abdominal closure.\\n\\n Consider avoiding closure of the abdomen in high-risk situations. How to do it — using\\n a TAC (temporary abdominal closure) device or closing the skin only — is described in\\n Chapters 40 and 48.\\n\\n Treatment\\n\\n Non-operative management\\n\\n Unless the patient is trying to die on you, try non-operative\\nmanagement first. In principle you should attempt to reduce the intra-\\nabdominal volume and improve abdominal wall compliance.',\n", " 'md': '```markdown\\n## Prevention\\n\\nIt is always better to prevent than treat and here are some simple rules for surgeons on how to avoid ACS:\\n\\n- **Consider leaving the abdomen open:**\\n- After damage control surgery — not only after trauma.\\n- If massive visceral edema is present.\\n- After prolonged operations — usually for abdominal catastrophes.\\n- If massive transfusion has been given.\\n\\n- **Decrease the risk of ACS by avoiding:**\\n- Massive crystalloid resuscitation.\\n- Too tight abdominal closure.\\n\\nConsider avoiding closure of the abdomen in high-risk situations. How to do it — using a TAC (temporary abdominal closure) device or closing the skin only — is described in Chapters 40 and 48.\\n\\n## Treatment\\n\\n### Non-operative management\\n\\nUnless the patient is trying to die on you, try non-operative management first. In principle, you should attempt to reduce the intra-abdominal volume and improve abdominal wall compliance.\\n```',\n", " 'images': [{'name': 'img_p612_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 79.19999999999982,\n", " 'y': 532.8}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Prevention',\n", " 'md': '## Prevention',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 85.53, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'It is always better to prevent than treat and here are some simple rules for surgeons on how to avoid ACS:\\n\\n- **Consider leaving the abdomen open:**\\n- After damage control surgery — not only after trauma.\\n- If massive visceral edema is present.\\n- After prolonged operations — usually for abdominal catastrophes.\\n- If massive transfusion has been given.\\n\\n- **Decrease the risk of ACS by avoiding:**\\n- Massive crystalloid resuscitation.\\n- Too tight abdominal closure.\\n\\nConsider avoiding closure of the abdomen in high-risk situations. How to do it — using a TAC (temporary abdominal closure) device or closing the skin only — is described in Chapters 40 and 48.',\n", " 'md': 'It is always better to prevent than treat and here are some simple rules for surgeons on how to avoid ACS:\\n\\n- **Consider leaving the abdomen open:**\\n- After damage control surgery — not only after trauma.\\n- If massive visceral edema is present.\\n- After prolonged operations — usually for abdominal catastrophes.\\n- If massive transfusion has been given.\\n\\n- **Decrease the risk of ACS by avoiding:**\\n- Massive crystalloid resuscitation.\\n- Too tight abdominal closure.\\n\\nConsider avoiding closure of the abdomen in high-risk situations. How to do it — using a TAC (temporary abdominal closure) device or closing the skin only — is described in Chapters 40 and 48.',\n", " 'bBox': {'x': 72, 'y': 165, 'w': 467.03, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Treatment',\n", " 'md': '## Treatment',\n", " 'bBox': {'x': 86, 'y': 595, 'w': 79.1, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Non-operative management',\n", " 'md': '### Non-operative management',\n", " 'bBox': {'x': 86, 'y': 638, 'w': 217.96, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Unless the patient is trying to die on you, try non-operative management first. In principle, you should attempt to reduce the intra-abdominal volume and improve abdominal wall compliance.\\n```',\n", " 'md': 'Unless the patient is trying to die on you, try non-operative management first. In principle, you should attempt to reduce the intra-abdominal volume and improve abdominal wall compliance.\\n```',\n", " 'bBox': {'x': 86, 'y': 638, 'w': 217.96, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 614,\n", " 'text': 'Inserting nasogastric and rectal tubes, reducing the volume of enteral\\nnutrition, using gastro- and colo-prokinetic agents and performing\\ncolonoscopic decompression will reduce the volume of gastrointestinal\\ncontent and consequently IAP. Utilizing percutaneous drainage of ascites\\nor large localized fluid collections is also helpful, at least temporarily.\\n\\n What often happens is that when a sick patient (who does not need\\nimmediate surgery) with elevated IAP is transferred to the ICU, after\\nadequate sedation, pain management and hemodynamic optimization,\\nIAP decreases significantly. In addition, avoiding the prone position, not\\nelevating the head of the bed above 30°, and removing constricting\\nbandages (check that the abdominal binder is not applied too tight!)\\nimproves abdominal compliance and decreases IAP.\\n\\n Using neuromuscular blockade is controversial but we have used it\\nsometimes for short periods. More significant results can be achieved\\nby aiming for a negative fluid balance by increasing diuresis. The\\nlast resort (before surgery) is hemodialysis-ultrafiltration to remove\\nexcess fluids and thus alleviate tissue swelling.\\n\\n Surgical management\\n\\n If medical management fails, surgery usually doesn’t (or so we hope,\\nsometimes justifiably, sometimes not…). Obviously, a patient with full-\\nblown, life-threatening ACS needs surgical decompression — even in the\\nICU in the most urgent cases. The dramatic improvement of ventilation\\nand urine output will convince even the most hardline skeptic that ACS is\\nfor real (we’ve seen this ‘conversion’ many times). The decision to\\nperform decompressive laparostomy is much harder in patients with IAħ.\\n\\n However, again, the decision to decompress the abdomen should\\nnot be taken based on isolated measurements of IAP without taking\\ninto account the whole clinical picture. A good guideline is the\\nabdominal perfusion pressure (remember APP = MAP — IAP). If APP\\nis >60mmHg, and there are no signs of significant organ\\ndysfunction (check urine output, lactate, liver function,\\ncardiovascular and respiratory parameters), it is usually safe to',\n", " 'md': '```markdown\\n## Management of Elevated Intra-Abdominal Pressure (IAP)\\n\\nInserting nasogastric and rectal tubes, reducing the volume of enteral nutrition, using gastro- and colo-prokinetic agents, and performing colonoscopic decompression will reduce the volume of gastrointestinal content and consequently IAP. Utilizing percutaneous drainage of ascites or large localized fluid collections is also helpful, at least temporarily.\\n\\nWhat often happens is that when a sick patient (who does not need immediate surgery) with elevated IAP is transferred to the ICU, after adequate sedation, pain management, and hemodynamic optimization, IAP decreases significantly. In addition, avoiding the prone position, not elevating the head of the bed above 30°, and removing constricting bandages (check that the abdominal binder is not applied too tight!) improves abdominal compliance and decreases IAP.\\n\\nUsing neuromuscular blockade is controversial, but we have used it sometimes for short periods. More significant results can be achieved by aiming for a negative fluid balance by increasing diuresis. The last resort (before surgery) is hemodialysis-ultrafiltration to remove excess fluids and thus alleviate tissue swelling.\\n\\n### Surgical Management\\n\\nIf medical management fails, surgery usually doesn’t (or so we hope, sometimes justifiably, sometimes not…). Obviously, a patient with full-blown, life-threatening ACS needs surgical decompression — even in the ICU in the most urgent cases. The dramatic improvement of ventilation and urine output will convince even the most hardline skeptic that ACS is for real (we’ve seen this ‘conversion’ many times). The decision to perform decompressive laparostomy is much harder in patients with IAħ.\\n\\nHowever, again, the decision to decompress the abdomen should not be taken based on isolated measurements of IAP without taking into account the whole clinical picture. A good guideline is the abdominal perfusion pressure (remember APP = MAP — IAP). If APP is >60 mmHg, and there are no signs of significant organ dysfunction (check urine output, lactate, liver function, cardiovascular and respiratory parameters), it is usually safe to proceed.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Elevated Intra-Abdominal Pressure (IAP)',\n", " 'md': '## Management of Elevated Intra-Abdominal Pressure (IAP)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Inserting nasogastric and rectal tubes, reducing the volume of enteral nutrition, using gastro- and colo-prokinetic agents, and performing colonoscopic decompression will reduce the volume of gastrointestinal content and consequently IAP. Utilizing percutaneous drainage of ascites or large localized fluid collections is also helpful, at least temporarily.\\n\\nWhat often happens is that when a sick patient (who does not need immediate surgery) with elevated IAP is transferred to the ICU, after adequate sedation, pain management, and hemodynamic optimization, IAP decreases significantly. In addition, avoiding the prone position, not elevating the head of the bed above 30°, and removing constricting bandages (check that the abdominal binder is not applied too tight!) improves abdominal compliance and decreases IAP.\\n\\nUsing neuromuscular blockade is controversial, but we have used it sometimes for short periods. More significant results can be achieved by aiming for a negative fluid balance by increasing diuresis. The last resort (before surgery) is hemodialysis-ultrafiltration to remove excess fluids and thus alleviate tissue swelling.',\n", " 'md': 'Inserting nasogastric and rectal tubes, reducing the volume of enteral nutrition, using gastro- and colo-prokinetic agents, and performing colonoscopic decompression will reduce the volume of gastrointestinal content and consequently IAP. Utilizing percutaneous drainage of ascites or large localized fluid collections is also helpful, at least temporarily.\\n\\nWhat often happens is that when a sick patient (who does not need immediate surgery) with elevated IAP is transferred to the ICU, after adequate sedation, pain management, and hemodynamic optimization, IAP decreases significantly. In addition, avoiding the prone position, not elevating the head of the bed above 30°, and removing constricting bandages (check that the abdominal binder is not applied too tight!) improves abdominal compliance and decreases IAP.\\n\\nUsing neuromuscular blockade is controversial, but we have used it sometimes for short periods. More significant results can be achieved by aiming for a negative fluid balance by increasing diuresis. The last resort (before surgery) is hemodialysis-ultrafiltration to remove excess fluids and thus alleviate tissue swelling.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.85, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Surgical Management',\n", " 'md': '### Surgical Management',\n", " 'bBox': {'x': 86, 'y': 431, 'w': 171.97, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'If medical management fails, surgery usually doesn’t (or so we hope, sometimes justifiably, sometimes not…). Obviously, a patient with full-blown, life-threatening ACS needs surgical decompression — even in the ICU in the most urgent cases. The dramatic improvement of ventilation and urine output will convince even the most hardline skeptic that ACS is for real (we’ve seen this ‘conversion’ many times). The decision to perform decompressive laparostomy is much harder in patients with IAħ.\\n\\nHowever, again, the decision to decompress the abdomen should not be taken based on isolated measurements of IAP without taking into account the whole clinical picture. A good guideline is the abdominal perfusion pressure (remember APP = MAP — IAP). If APP is >60 mmHg, and there are no signs of significant organ dysfunction (check urine output, lactate, liver function, cardiovascular and respiratory parameters), it is usually safe to proceed.\\n```',\n", " 'md': 'If medical management fails, surgery usually doesn’t (or so we hope, sometimes justifiably, sometimes not…). Obviously, a patient with full-blown, life-threatening ACS needs surgical decompression — even in the ICU in the most urgent cases. The dramatic improvement of ventilation and urine output will convince even the most hardline skeptic that ACS is for real (we’ve seen this ‘conversion’ many times). The decision to perform decompressive laparostomy is much harder in patients with IAħ.\\n\\nHowever, again, the decision to decompress the abdomen should not be taken based on isolated measurements of IAP without taking into account the whole clinical picture. A good guideline is the abdominal perfusion pressure (remember APP = MAP — IAP). If APP is >60 mmHg, and there are no signs of significant organ dysfunction (check urine output, lactate, liver function, cardiovascular and respiratory parameters), it is usually safe to proceed.\\n```',\n", " 'bBox': {'x': 72, 'y': 500, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 615,\n", " 'text': 'continue with non-operative management.\\n\\n On the other hand, established ACS with signs of progressive organ\\ndysfunction or failure mandates an emergency decompressive\\nlaparotomy, which, when performed in the well-resuscitated patient,\\nshould promptly restore normal physiology.\\n\\n To prevent hemodynamic decompensation during the laparotomy, intravascular volume\\n should be restored, oxygen delivery maximized, and hypothermia and coagulation\\n defects corrected. Following decompression, the abdominal skin and fascial edges are\\n left open using one of the temporary abdominal closure (TAC) methods described in\\n Chapter 48.\\n\\n Technique of surgical decompression\\n A full-length (OK, leave a couple of cm of fascia on both ends to\\nfacilitate later closure) midline abdominal incision is the standard\\napproach for abdominal decompression. There are other techniques such\\nas a transverse bilateral subcostal incision (sometimes used in patients\\nwith severe pancreatitis who might need necrosectomy later) or less\\naggressive methods such as the subcutaneous linea alba fasciotomy that\\nleaves the skin (except three short transverse skin incisions to do the\\nfasciotomy) and peritoneum intact.\\n\\n This ‘non-invasive fasciotomy’ can be used for borderline cases; it\\navoids the morbidity of an open abdomen and can easily be extended to\\na full-thickness laparostomy if necessary. The downside is the\\nunavoidable hernia that can be fixed later on with the component\\nseparation technique. One of us (Ari) has once performed (but never\\npublished…) a minimal access component separation through two small\\nlateral transverse skin incisions ( Figure 33.5) just to reduce IAP. In this\\ncase it worked but the level of evidence for the usefulness of this\\ntechnique is about level 5… .\\n\\n So…',\n", " 'md': '```markdown\\n## Non-Operative Management and Surgical Decompression\\n\\nContinue with non-operative management.\\n\\nOn the other hand, established ACS with signs of progressive organ dysfunction or failure mandates an emergency decompressive laparotomy, which, when performed in the well-resuscitated patient, should promptly restore normal physiology.\\n\\nTo prevent hemodynamic decompensation during the laparotomy, intravascular volume should be restored, oxygen delivery maximized, and hypothermia and coagulation defects corrected. Following decompression, the abdominal skin and fascial edges are left open using one of the temporary abdominal closure (TAC) methods described in Chapter 48.\\n\\n### Technique of Surgical Decompression\\n\\nA full-length (OK, leave a couple of cm of fascia on both ends to facilitate later closure) midline abdominal incision is the standard approach for abdominal decompression. There are other techniques such as a transverse bilateral subcostal incision (sometimes used in patients with severe pancreatitis who might need necrosectomy later) or less aggressive methods such as the subcutaneous linea alba fasciotomy that leaves the skin (except three short transverse skin incisions to do the fasciotomy) and peritoneum intact.\\n\\nThis ‘non-invasive fasciotomy’ can be used for borderline cases; it avoids the morbidity of an open abdomen and can easily be extended to a full-thickness laparostomy if necessary. The downside is the unavoidable hernia that can be fixed later on with the component separation technique. One of us (Ari) has once performed (but never published…) a minimal access component separation through two small lateral transverse skin incisions (Figure 33.5) just to reduce IAP. In this case, it worked but the level of evidence for the usefulness of this technique is about level 5.\\n```\\n\\n### Figure Description\\n- **Figure 33.5**: This figure likely illustrates the minimal access component separation technique mentioned in the text. The description suggests that it involves two small lateral transverse skin incisions aimed at reducing intra-abdominal pressure (IAP). The figure may provide a visual representation of the surgical approach and its application in managing abdominal compartment syndrome (ACS).',\n", " 'images': [{'name': 'img_p614_2.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 248.39999999999964,\n", " 'y': 636.4799999999999}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Non-Operative Management and Surgical Decompression',\n", " 'md': '## Non-Operative Management and Surgical Decompression',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Continue with non-operative management.\\n\\nOn the other hand, established ACS with signs of progressive organ dysfunction or failure mandates an emergency decompressive laparotomy, which, when performed in the well-resuscitated patient, should promptly restore normal physiology.\\n\\nTo prevent hemodynamic decompensation during the laparotomy, intravascular volume should be restored, oxygen delivery maximized, and hypothermia and coagulation defects corrected. Following decompression, the abdominal skin and fascial edges are left open using one of the temporary abdominal closure (TAC) methods described in Chapter 48.',\n", " 'md': 'Continue with non-operative management.\\n\\nOn the other hand, established ACS with signs of progressive organ dysfunction or failure mandates an emergency decompressive laparotomy, which, when performed in the well-resuscitated patient, should promptly restore normal physiology.\\n\\nTo prevent hemodynamic decompensation during the laparotomy, intravascular volume should be restored, oxygen delivery maximized, and hypothermia and coagulation defects corrected. Following decompression, the abdominal skin and fascial edges are left open using one of the temporary abdominal closure (TAC) methods described in Chapter 48.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 453.55, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Technique of Surgical Decompression',\n", " 'md': '### Technique of Surgical Decompression',\n", " 'bBox': {'x': 86, 'y': 342, 'w': 258.45, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'A full-length (OK, leave a couple of cm of fascia on both ends to facilitate later closure) midline abdominal incision is the standard approach for abdominal decompression. There are other techniques such as a transverse bilateral subcostal incision (sometimes used in patients with severe pancreatitis who might need necrosectomy later) or less aggressive methods such as the subcutaneous linea alba fasciotomy that leaves the skin (except three short transverse skin incisions to do the fasciotomy) and peritoneum intact.\\n\\nThis ‘non-invasive fasciotomy’ can be used for borderline cases; it avoids the morbidity of an open abdomen and can easily be extended to a full-thickness laparostomy if necessary. The downside is the unavoidable hernia that can be fixed later on with the component separation technique. One of us (Ari) has once performed (but never published…) a minimal access component separation through two small lateral transverse skin incisions (Figure 33.5) just to reduce IAP. In this case, it worked but the level of evidence for the usefulness of this technique is about level 5.\\n```',\n", " 'md': 'A full-length (OK, leave a couple of cm of fascia on both ends to facilitate later closure) midline abdominal incision is the standard approach for abdominal decompression. There are other techniques such as a transverse bilateral subcostal incision (sometimes used in patients with severe pancreatitis who might need necrosectomy later) or less aggressive methods such as the subcutaneous linea alba fasciotomy that leaves the skin (except three short transverse skin incisions to do the fasciotomy) and peritoneum intact.\\n\\nThis ‘non-invasive fasciotomy’ can be used for borderline cases; it avoids the morbidity of an open abdomen and can easily be extended to a full-thickness laparostomy if necessary. The downside is the unavoidable hernia that can be fixed later on with the component separation technique. One of us (Ari) has once performed (but never published…) a minimal access component separation through two small lateral transverse skin incisions (Figure 33.5) just to reduce IAP. In this case, it worked but the level of evidence for the usefulness of this technique is about level 5.\\n```',\n", " 'bBox': {'x': 72, 'y': 137, 'w': 467.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Description',\n", " 'md': '### Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 33.5**: This figure likely illustrates the minimal access component separation technique mentioned in the text. The description suggests that it involves two small lateral transverse skin incisions aimed at reducing intra-abdominal pressure (IAP). The figure may provide a visual representation of the surgical approach and its application in managing abdominal compartment syndrome (ACS).',\n", " 'md': '- **Figure 33.5**: This figure likely illustrates the minimal access component separation technique mentioned in the text. The description suggests that it involves two small lateral transverse skin incisions aimed at reducing intra-abdominal pressure (IAP). The figure may provide a visual representation of the surgical approach and its application in managing abdominal compartment syndrome (ACS).',\n", " 'bBox': {'x': 261, 'y': 647, 'w': 4, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 48.'},\n", " {'text': 'case it worked but the level of evidence for the usefulness of this'}]},\n", " {'page': 616,\n", " 'text': 'IAH is yet another factor to consider in the overall management of\\nthe emergency abdominal patient. It may be obvious — ‘crying’ for\\nabdominal decompression. More commonly, however, it is relatively silent but\\ncontributing to your patient’s SIRS, organ dysfunction and death. Be as aware of intra-\\nabdominal hypertension as you are of arterial hypertension. It is much more common and\\nclinically relevant than you have suspected hitherto.',\n", " 'md': '```markdown\\n# Page Content\\n\\nIAH is yet another factor to consider in the overall management of the emergency abdominal patient. It may be obvious — ‘crying’ for abdominal decompression. More commonly, however, it is relatively silent but contributing to your patient’s SIRS, organ dysfunction and death. Be as aware of intra-abdominal hypertension as you are of arterial hypertension. It is much more common and clinically relevant than you have suspected hitherto.\\n```',\n", " 'images': [{'name': 'img_p615_1.png',\n", " 'height': 402,\n", " 'width': 539,\n", " 'x': 172.80000000000018,\n", " 'y': 214.55999999999997,\n", " 'original_width': 1085,\n", " 'original_height': 808}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'IAH is yet another factor to consider in the overall management of the emergency abdominal patient. It may be obvious — ‘crying’ for abdominal decompression. More commonly, however, it is relatively silent but contributing to your patient’s SIRS, organ dysfunction and death. Be as aware of intra-abdominal hypertension as you are of arterial hypertension. It is much more common and clinically relevant than you have suspected hitherto.\\n```',\n", " 'md': 'IAH is yet another factor to consider in the overall management of the emergency abdominal patient. It may be obvious — ‘crying’ for abdominal decompression. More commonly, however, it is relatively silent but contributing to your patient’s SIRS, organ dysfunction and death. Be as aware of intra-abdominal hypertension as you are of arterial hypertension. It is much more common and clinically relevant than you have suspected hitherto.\\n```',\n", " 'bBox': {'x': 79, 'y': 94, 'w': 452.97, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 617,\n", " 'text': 'Figure 33.5. ‘Minimally invasive’ component separation for abdominal decompression.\\nMeasure IAP. Place the transverse lateral skin incision (big enough to admit your hand)\\njust above the umbilical level on the anticipated place where the lateral margin of the\\nrectus sheet is. Make a small vertical opening on the external oblique muscle 2-3cm\\nlateral to the rectus sheath to check that you are in the right place. If so, then continue\\ndividing the aponeurotic part of the external oblique muscle 2cm lateral to the rectus\\nmuscle extending it cranially to the costal margin and caudally aiming to the level of the\\narcuate line (linea semicircularis). Complete the procedure by separating the external and\\ninternal oblique muscles from each other (in the avascular plane) as far dorsally as you\\ncan. Close the skin. Do the same on the other side. Measure IAP again and record it.\\n\\n And now, enough yakking — we are going fishing ( Figure 33.6).',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Figure 33.5\\n**Title:** ‘Minimally invasive’ component separation for abdominal decompression.\\n\\n**Description:** This figure illustrates the surgical technique for performing a minimally invasive component separation aimed at abdominal decompression. The procedure begins with measuring intra-abdominal pressure (IAP). A transverse lateral skin incision is made just above the umbilical level, large enough to admit a hand, at the anticipated location of the lateral margin of the rectus sheath. A small vertical opening is created in the external oblique muscle, 2-3 cm lateral to the rectus sheath, to confirm the correct position. If confirmed, the aponeurotic part of the external oblique muscle is divided 2 cm lateral to the rectus muscle, extending cranially to the costal margin and caudally to the level of the arcuate line (linea semicircularis). The procedure is completed by separating the external and internal oblique muscles in the avascular plane as far dorsally as possible, followed by closing the skin. The same steps are repeated on the opposite side, and IAP is measured and recorded again.\\n\\n----\\n\\n### Figure 33.6\\n**Description:** The text indicates a transition to a new topic with the phrase \"And now, enough yakking — we are going fishing.\" However, no further details or images are provided for this figure in the current text.\\n\\n```',\n", " 'images': [{'name': 'img_p616_1.png',\n", " 'height': 380,\n", " 'width': 539,\n", " 'x': 172.80000000000018,\n", " 'y': 82.79999999999998,\n", " 'original_width': 1085,\n", " 'original_height': 765}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 33.5',\n", " 'md': '### Figure 33.5',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Title:** ‘Minimally invasive’ component separation for abdominal decompression.\\n\\n**Description:** This figure illustrates the surgical technique for performing a minimally invasive component separation aimed at abdominal decompression. The procedure begins with measuring intra-abdominal pressure (IAP). A transverse lateral skin incision is made just above the umbilical level, large enough to admit a hand, at the anticipated location of the lateral margin of the rectus sheath. A small vertical opening is created in the external oblique muscle, 2-3 cm lateral to the rectus sheath, to confirm the correct position. If confirmed, the aponeurotic part of the external oblique muscle is divided 2 cm lateral to the rectus muscle, extending cranially to the costal margin and caudally to the level of the arcuate line (linea semicircularis). The procedure is completed by separating the external and internal oblique muscles in the avascular plane as far dorsally as possible, followed by closing the skin. The same steps are repeated on the opposite side, and IAP is measured and recorded again.\\n\\n----',\n", " 'md': '**Title:** ‘Minimally invasive’ component separation for abdominal decompression.\\n\\n**Description:** This figure illustrates the surgical technique for performing a minimally invasive component separation aimed at abdominal decompression. The procedure begins with measuring intra-abdominal pressure (IAP). A transverse lateral skin incision is made just above the umbilical level, large enough to admit a hand, at the anticipated location of the lateral margin of the rectus sheath. A small vertical opening is created in the external oblique muscle, 2-3 cm lateral to the rectus sheath, to confirm the correct position. If confirmed, the aponeurotic part of the external oblique muscle is divided 2 cm lateral to the rectus muscle, extending cranially to the costal margin and caudally to the level of the arcuate line (linea semicircularis). The procedure is completed by separating the external and internal oblique muscles in the avascular plane as far dorsally as possible, followed by closing the skin. The same steps are repeated on the opposite side, and IAP is measured and recorded again.\\n\\n----',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 33.6',\n", " 'md': '### Figure 33.6',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** The text indicates a transition to a new topic with the phrase \"And now, enough yakking — we are going fishing.\" However, no further details or images are provided for this figure in the current text.\\n\\n```',\n", " 'md': '**Description:** The text indicates a transition to a new topic with the phrase \"And now, enough yakking — we are going fishing.\" However, no further details or images are provided for this figure in the current text.\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 618,\n", " 'text': ' Figure 33.6. Ari (the one who always smiles) and Moshe, fishing the Chippewa River, near\\n Ladysmith, Northern Wisconsin.\\n\\n1 Acute Physiology and Chronic Health Evaluation (APACHE II).\\n Sequential Organ Failure Assessment (SOFA) — severity of illness score for hospital\\n mortality. Calculator: http://clincalc.com/IcuMortality/SOFA.aspx.',\n", " 'md': '```markdown\\n# Page Content\\n\\n**Figure 33.6**: Ari (the one who always smiles) and Moshe, fishing the Chippewa River, near Ladysmith, Northern Wisconsin.\\n\\n1. **Acute Physiology and Chronic Health Evaluation (APACHE II)**.\\n2. **Sequential Organ Failure Assessment (SOFA)** — severity of illness score for hospital mortality.\\n- Calculator: [SOFA Calculator](http://clincalc.com/IcuMortality/SOFA.aspx).\\n```\\n\\n### Image Description\\n- **Figure 33.6**: This image depicts two individuals, Ari and Moshe, engaged in fishing at the Chippewa River in Northern Wisconsin. The scene captures a serene outdoor environment, highlighting the natural beauty of the river and surrounding landscape.\\n\\n### Summary\\nThe page includes a description of an image featuring two people fishing, along with references to two medical scoring systems (APACHE II and SOFA) and a hyperlink to a calculator for the SOFA score.',\n", " 'images': [{'name': 'img_p617_1.png',\n", " 'height': 504,\n", " 'width': 699,\n", " 'x': 133.19999999999982,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1200,\n", " 'original_height': 864}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 33.6**: Ari (the one who always smiles) and Moshe, fishing the Chippewa River, near Ladysmith, Northern Wisconsin.\\n\\n1. **Acute Physiology and Chronic Health Evaluation (APACHE II)**.\\n2. **Sequential Organ Failure Assessment (SOFA)** — severity of illness score for hospital mortality.\\n- Calculator: [SOFA Calculator](http://clincalc.com/IcuMortality/SOFA.aspx).\\n```',\n", " 'md': '**Figure 33.6**: Ari (the one who always smiles) and Moshe, fishing the Chippewa River, near Ladysmith, Northern Wisconsin.\\n\\n1. **Acute Physiology and Chronic Health Evaluation (APACHE II)**.\\n2. **Sequential Organ Failure Assessment (SOFA)** — severity of illness score for hospital mortality.\\n- Calculator: [SOFA Calculator](http://clincalc.com/IcuMortality/SOFA.aspx).\\n```',\n", " 'bBox': {'x': 73, 'y': 364, 'w': 167.33, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 33.6**: This image depicts two individuals, Ari and Moshe, engaged in fishing at the Chippewa River in Northern Wisconsin. The scene captures a serene outdoor environment, highlighting the natural beauty of the river and surrounding landscape.',\n", " 'md': '- **Figure 33.6**: This image depicts two individuals, Ari and Moshe, engaged in fishing at the Chippewa River in Northern Wisconsin. The scene captures a serene outdoor environment, highlighting the natural beauty of the river and surrounding landscape.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The page includes a description of an image featuring two people fishing, along with references to two medical scoring systems (APACHE II and SOFA) and a hyperlink to a calculator for the SOFA score.',\n", " 'md': 'The page includes a description of an image featuring two people fishing, along with references to two medical scoring systems (APACHE II and SOFA) and a hyperlink to a calculator for the SOFA score.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'},\n", " {'url': 'http://clincalc.com/IcuMortality/SOFA.aspx', 'text': ''}]},\n", " {'page': 619,\n", " 'text': 'Chapter 34\\nAbdominal aortic emergencies\\nPaul N. Rogers\\n\\n Abdominal/back pain and hypotension = a ruptured AAA,\\n unless proven otherwise.\\n\\n Urological and orthopedic wards are a cemetery for\\n ruptured AAA cases.\\n\\n Presentation\\n\\n It is usually easy to make the diagnosis of a leaking abdominal aortic\\naneurysm (AAA). Typically the patient presents with a sudden onset of\\nacute lumbar backache, abdominal pain and collapse associated with\\nhypotension. On examination the presence of a pulsatile abdominal mass\\nconfirms the diagnosis. In this situation the patient proceeds directly to\\nthe operating room with a delay only to allow cross-matched blood to\\nbecome available if the patient is stable.\\n\\n Atypical presentation\\n\\n Not infrequently, however, the diagnosis can be problematic. There\\nmay be no history of collapse and the patient may be normotensive on\\nadmission. The only clue may be non-specific back or abdominal pain. A\\npulsatile mass may not be palpable. Ruptured AAA patients are\\nfrequently obese; thinner patients tend to notice their AAA and present\\nearly for an elective repair. A leaking AAA may be mislabeled as ‘ureteric',\n", " 'md': '```markdown\\n# Chapter 34: Abdominal Aortic Emergencies\\n**Author:** Paul N. Rogers\\n\\n## Key Points\\n- Abdominal/back pain and hypotension = a ruptured AAA, unless proven otherwise.\\n- Urological and orthopedic wards are a cemetery for ruptured AAA cases.\\n\\n## Presentation\\nIt is usually easy to make the diagnosis of a leaking abdominal aortic aneurysm (AAA). Typically, the patient presents with a sudden onset of acute lumbar backache, abdominal pain, and collapse associated with hypotension. On examination, the presence of a pulsatile abdominal mass confirms the diagnosis. In this situation, the patient proceeds directly to the operating room with a delay only to allow cross-matched blood to become available if the patient is stable.\\n\\n## Atypical Presentation\\nNot infrequently, however, the diagnosis can be problematic. There may be no history of collapse, and the patient may be normotensive on admission. The only clue may be non-specific back or abdominal pain. A pulsatile mass may not be palpable. Ruptured AAA patients are frequently obese; thinner patients tend to notice their AAA and present early for an elective repair. A leaking AAA may be mislabeled as ‘ureteric ’.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 34: Abdominal Aortic Emergencies',\n", " 'md': '# Chapter 34: Abdominal Aortic Emergencies',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 271.01, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Paul N. Rogers',\n", " 'md': '**Author:** Paul N. Rogers',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 97.55, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Key Points',\n", " 'md': '## Key Points',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Abdominal/back pain and hypotension = a ruptured AAA, unless proven otherwise.\\n- Urological and orthopedic wards are a cemetery for ruptured AAA cases.',\n", " 'md': '- Abdominal/back pain and hypotension = a ruptured AAA, unless proven otherwise.\\n- Urological and orthopedic wards are a cemetery for ruptured AAA cases.',\n", " 'bBox': {'x': 108, 'y': 326, 'w': 159.14, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Presentation',\n", " 'md': '## Presentation',\n", " 'bBox': {'x': 86, 'y': 417, 'w': 100.24, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'It is usually easy to make the diagnosis of a leaking abdominal aortic aneurysm (AAA). Typically, the patient presents with a sudden onset of acute lumbar backache, abdominal pain, and collapse associated with hypotension. On examination, the presence of a pulsatile abdominal mass confirms the diagnosis. In this situation, the patient proceeds directly to the operating room with a delay only to allow cross-matched blood to become available if the patient is stable.',\n", " 'md': 'It is usually easy to make the diagnosis of a leaking abdominal aortic aneurysm (AAA). Typically, the patient presents with a sudden onset of acute lumbar backache, abdominal pain, and collapse associated with hypotension. On examination, the presence of a pulsatile abdominal mass confirms the diagnosis. In this situation, the patient proceeds directly to the operating room with a delay only to allow cross-matched blood to become available if the patient is stable.',\n", " 'bBox': {'x': 72, 'y': 453, 'w': 467.13, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Atypical Presentation',\n", " 'md': '## Atypical Presentation',\n", " 'bBox': {'x': 86, 'y': 417, 'w': 168.28, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Not infrequently, however, the diagnosis can be problematic. There may be no history of collapse, and the patient may be normotensive on admission. The only clue may be non-specific back or abdominal pain. A pulsatile mass may not be palpable. Ruptured AAA patients are frequently obese; thinner patients tend to notice their AAA and present early for an elective repair. A leaking AAA may be mislabeled as ‘ureteric ’.\\n```',\n", " 'md': 'Not infrequently, however, the diagnosis can be problematic. There may be no history of collapse, and the patient may be normotensive on admission. The only clue may be non-specific back or abdominal pain. A pulsatile mass may not be palpable. Ruptured AAA patients are frequently obese; thinner patients tend to notice their AAA and present early for an elective repair. A leaking AAA may be mislabeled as ‘ureteric ’.\\n```',\n", " 'bBox': {'x': 72, 'y': 664, 'w': 467.82, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 620,\n", " 'text': 'colic’ but the absence of microscopic hematuria should alert one to the\\npossibility that a leaking aneurysm is responsible for the symptoms.\\nSimilarly, we have seen patients present with acute scrotal pain,\\ndiagnosed as epididymo-orchitis and then cured by insertion of an aortic\\ntube graft. Always keep the diagnosis of a leaking AAA in your mind,\\notherwise you may overlook it! In appropriate individuals, particularly\\nmen in late-middle and old age, if significant and unexplained abdominal\\nor back pain causes the patient to present acutely, abdominal aneurysms\\nshould be excluded by means of ultrasound or CT.\\n\\n The diagnostic dilemma\\n\\n A different diagnostic problem occurs in the patient who is known\\nto have an aneurysm and who presents with abdominal or back\\npain, which may or may not be related to the aneurysm. The difficulty\\nhere is that a small, contained, ‘herald’ leak from an aneurysm might\\nproduce pain without any hemodynamic instability. Examination in these\\npatients may be unhelpful in that the aneurysm may not be tender. These\\npatients are at high risk of a further bleed from the aneurysm and this\\ncould be sudden and catastrophic. For this reason it is important that they\\nare identified appropriately and have an operation before a major,\\npossibly fatal, hemorrhage occurs. The difficulty of course is that such a\\npatient might easily have another cause for the symptoms, mechanical\\nbackache for example, which is unrelated to the aneurysm. ħere, an\\noperation is clearly not in the patient’s best interests, particularly if his or\\nher general health is poor. This dilemma, of operating without delay in\\npatients who require it yet avoiding operation in those in whom it is\\nnot necessary, is a difficult one, sometimes even for experienced\\nclinicians, to resolve. An emergency CT scan (with i.v. contrast) is\\nindicated in this situation to delineate the AAA and the presence of any\\nassociated leak — usually into the retroperitoneum. In general, however,\\nin this situation it is safer to err on the side of operating on too many\\nrather than too few patients.\\n\\n Who should have an operation?\\n\\n A useful rule of thumb is that the chances of survival in a patient',\n", " 'md': \"```markdown\\n## Diagnostic Considerations for Aneurysms\\n\\nColic may present without microscopic hematuria, which should raise suspicion for a leaking aneurysm as the underlying cause of symptoms. There have been cases where patients presented with acute scrotal pain, initially diagnosed as epididymo-orchitis, but were ultimately treated successfully with the insertion of an aortic tube graft. It is crucial to keep the possibility of a leaking abdominal aortic aneurysm (AAA) in mind, especially in appropriate individuals such as men in late-middle and old age. If significant and unexplained abdominal or back pain leads to an acute presentation, abdominal aneurysms should be ruled out using ultrasound or CT imaging.\\n\\n### The Diagnostic Dilemma\\n\\nA different diagnostic challenge arises when a patient with a known aneurysm presents with abdominal or back pain, which may or may not be related to the aneurysm itself. A small, contained, 'herald' leak from an aneurysm can cause pain without any hemodynamic instability. Physical examination may not be helpful, as the aneurysm may not exhibit tenderness. These patients are at high risk for further bleeding from the aneurysm, which could be sudden and catastrophic. Therefore, it is essential to identify these patients accurately and consider surgical intervention before a major, potentially fatal hemorrhage occurs.\\n\\nHowever, the challenge lies in the fact that such patients may have alternative causes for their symptoms, such as mechanical backache, which are unrelated to the aneurysm. In these cases, surgery may not be in the patient's best interest, particularly if their overall health is compromised. This dilemma—deciding when to operate without delay for those who need it while avoiding unnecessary surgery for others—is a complex issue, even for experienced clinicians. An emergency CT scan (with intravenous contrast) is recommended in this scenario to delineate the AAA and check for any associated leaks, typically into the retroperitoneum. Generally, it is safer to err on the side of operating on too many patients rather than too few.\\n\\n### Who Should Have an Operation?\\n\\nA useful rule of thumb is that the chances of survival in a patient...\\n```\\n\\n*Note: The text extraction has been completed, but the content appears to be cut off at the end. If there are any figures, tables, or images on the page, please provide that information for further extraction and description.*\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnostic Considerations for Aneurysms',\n", " 'md': '## Diagnostic Considerations for Aneurysms',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Colic may present without microscopic hematuria, which should raise suspicion for a leaking aneurysm as the underlying cause of symptoms. There have been cases where patients presented with acute scrotal pain, initially diagnosed as epididymo-orchitis, but were ultimately treated successfully with the insertion of an aortic tube graft. It is crucial to keep the possibility of a leaking abdominal aortic aneurysm (AAA) in mind, especially in appropriate individuals such as men in late-middle and old age. If significant and unexplained abdominal or back pain leads to an acute presentation, abdominal aneurysms should be ruled out using ultrasound or CT imaging.',\n", " 'md': 'Colic may present without microscopic hematuria, which should raise suspicion for a leaking aneurysm as the underlying cause of symptoms. There have been cases where patients presented with acute scrotal pain, initially diagnosed as epididymo-orchitis, but were ultimately treated successfully with the insertion of an aortic tube graft. It is crucial to keep the possibility of a leaking abdominal aortic aneurysm (AAA) in mind, especially in appropriate individuals such as men in late-middle and old age. If significant and unexplained abdominal or back pain leads to an acute presentation, abdominal aneurysms should be ruled out using ultrasound or CT imaging.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Diagnostic Dilemma',\n", " 'md': '### The Diagnostic Dilemma',\n", " 'bBox': {'x': 86, 'y': 261, 'w': 188.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': \"A different diagnostic challenge arises when a patient with a known aneurysm presents with abdominal or back pain, which may or may not be related to the aneurysm itself. A small, contained, 'herald' leak from an aneurysm can cause pain without any hemodynamic instability. Physical examination may not be helpful, as the aneurysm may not exhibit tenderness. These patients are at high risk for further bleeding from the aneurysm, which could be sudden and catastrophic. Therefore, it is essential to identify these patients accurately and consider surgical intervention before a major, potentially fatal hemorrhage occurs.\\n\\nHowever, the challenge lies in the fact that such patients may have alternative causes for their symptoms, such as mechanical backache, which are unrelated to the aneurysm. In these cases, surgery may not be in the patient's best interest, particularly if their overall health is compromised. This dilemma—deciding when to operate without delay for those who need it while avoiding unnecessary surgery for others—is a complex issue, even for experienced clinicians. An emergency CT scan (with intravenous contrast) is recommended in this scenario to delineate the AAA and check for any associated leaks, typically into the retroperitoneum. Generally, it is safer to err on the side of operating on too many patients rather than too few.\",\n", " 'md': \"A different diagnostic challenge arises when a patient with a known aneurysm presents with abdominal or back pain, which may or may not be related to the aneurysm itself. A small, contained, 'herald' leak from an aneurysm can cause pain without any hemodynamic instability. Physical examination may not be helpful, as the aneurysm may not exhibit tenderness. These patients are at high risk for further bleeding from the aneurysm, which could be sudden and catastrophic. Therefore, it is essential to identify these patients accurately and consider surgical intervention before a major, potentially fatal hemorrhage occurs.\\n\\nHowever, the challenge lies in the fact that such patients may have alternative causes for their symptoms, such as mechanical backache, which are unrelated to the aneurysm. In these cases, surgery may not be in the patient's best interest, particularly if their overall health is compromised. This dilemma—deciding when to operate without delay for those who need it while avoiding unnecessary surgery for others—is a complex issue, even for experienced clinicians. An emergency CT scan (with intravenous contrast) is recommended in this scenario to delineate the AAA and check for any associated leaks, typically into the retroperitoneum. Generally, it is safer to err on the side of operating on too many patients rather than too few.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Who Should Have an Operation?',\n", " 'md': '### Who Should Have an Operation?',\n", " 'bBox': {'x': 86, 'y': 672, 'w': 251.01, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A useful rule of thumb is that the chances of survival in a patient...\\n```\\n\\n*Note: The text extraction has been completed, but the content appears to be cut off at the end. If there are any figures, tables, or images on the page, please provide that information for further extraction and description.*',\n", " 'md': 'A useful rule of thumb is that the chances of survival in a patient...\\n```\\n\\n*Note: The text extraction has been completed, but the content appears to be cut off at the end. If there are any figures, tables, or images on the page, please provide that information for further extraction and description.*',\n", " 'bBox': {'x': 86, 'y': 708, 'w': 452.96, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 621,\n", " 'text': 'with a ruptured AAA are directly proportional to the blood pressure\\non admission. Profoundly shocked patients rarely survive; sure, they\\nmay survive the operation but usually do not leave the hospital through\\nthe front door. Consequently, it has been proposed that operating on\\nshocked ruptured AAA patients is futile and a waste of resources.\\nAnother view is that you should proceed with the operation unless the\\npatient is clearly ‘agonal’ or known to suffer from an incurable disease.\\nYou may be able to save the occasional patient and gain additional\\nexperience, which may help you to save the next rupture patient. These\\nissues of philosophy of care are for the individual surgeon to resolve with\\nhis God, his patients and their families. A scoring system has been\\ndevised that aims to help with this decision-making. The so-called\\n‘ħardman criteria’ relate the presence of several easily determined\\nvariables to the likelihood of survival after surgery for a ruptured\\naneurysm.\\n\\n The Hardman criteria 1 ( Table 34.1)\\n\\n Perhaps not surprisingly since these criteria were published other\\nstudies have demonstrated that it is possible to operate on patients with\\nthree ħardman criteria successfully (confirming the rule of “never say\\nnever”). The waters have been further muddied by reports from several\\nseries of endovascular repair showing that the peri-operative mortality for\\nall categories of patients is lower than for open repair. Nevertheless, the\\ncriteria are a useful adjunct to the decision-making process in these\\npatients.',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nWith a ruptured AAA are directly proportional to the blood pressure on admission. Profoundly shocked patients rarely survive; sure, they may survive the operation but usually do not leave the hospital through the front door. Consequently, it has been proposed that operating on shocked ruptured AAA patients is futile and a waste of resources. Another view is that you should proceed with the operation unless the patient is clearly ‘agonal’ or known to suffer from an incurable disease. You may be able to save the occasional patient and gain additional experience, which may help you to save the next rupture patient. These issues of philosophy of care are for the individual surgeon to resolve with his God, his patients, and their families. A scoring system has been devised that aims to help with this decision-making. The so-called ‘Hardman criteria’ relate the presence of several easily determined variables to the likelihood of survival after surgery for a ruptured aneurysm.\\n\\n### The Hardman Criteria 1 (Table 34.1)\\n\\nPerhaps not surprisingly since these criteria were published, other studies have demonstrated that it is possible to operate on patients with three Hardman criteria successfully (confirming the rule of “never say never”). The waters have been further muddied by reports from several series of endovascular repair showing that the peri-operative mortality for all categories of patients is lower than for open repair. Nevertheless, the criteria are a useful adjunct to the decision-making process in these patients.\\n\\n## Table Extraction\\n\\n| Criteria | Description |\\n|----------|-------------|\\n| 1 | |\\n| 2 | |\\n| 3 | |\\n| ... | ... |\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'With a ruptured AAA are directly proportional to the blood pressure on admission. Profoundly shocked patients rarely survive; sure, they may survive the operation but usually do not leave the hospital through the front door. Consequently, it has been proposed that operating on shocked ruptured AAA patients is futile and a waste of resources. Another view is that you should proceed with the operation unless the patient is clearly ‘agonal’ or known to suffer from an incurable disease. You may be able to save the occasional patient and gain additional experience, which may help you to save the next rupture patient. These issues of philosophy of care are for the individual surgeon to resolve with his God, his patients, and their families. A scoring system has been devised that aims to help with this decision-making. The so-called ‘Hardman criteria’ relate the presence of several easily determined variables to the likelihood of survival after surgery for a ruptured aneurysm.',\n", " 'md': 'With a ruptured AAA are directly proportional to the blood pressure on admission. Profoundly shocked patients rarely survive; sure, they may survive the operation but usually do not leave the hospital through the front door. Consequently, it has been proposed that operating on shocked ruptured AAA patients is futile and a waste of resources. Another view is that you should proceed with the operation unless the patient is clearly ‘agonal’ or known to suffer from an incurable disease. You may be able to save the occasional patient and gain additional experience, which may help you to save the next rupture patient. These issues of philosophy of care are for the individual surgeon to resolve with his God, his patients, and their families. A scoring system has been devised that aims to help with this decision-making. The so-called ‘Hardman criteria’ relate the presence of several easily determined variables to the likelihood of survival after surgery for a ruptured aneurysm.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Hardman Criteria 1 (Table 34.1)',\n", " 'md': '### The Hardman Criteria 1 (Table 34.1)',\n", " 'bBox': {'x': 86, 'y': 355, 'w': 186.51, 'h': 22.56}},\n", " {'type': 'text',\n", " 'value': 'Perhaps not surprisingly since these criteria were published, other studies have demonstrated that it is possible to operate on patients with three Hardman criteria successfully (confirming the rule of “never say never”). The waters have been further muddied by reports from several series of endovascular repair showing that the peri-operative mortality for all categories of patients is lower than for open repair. Nevertheless, the criteria are a useful adjunct to the decision-making process in these patients.',\n", " 'md': 'Perhaps not surprisingly since these criteria were published, other studies have demonstrated that it is possible to operate on patients with three Hardman criteria successfully (confirming the rule of “never say never”). The waters have been further muddied by reports from several series of endovascular repair showing that the peri-operative mortality for all categories of patients is lower than for open repair. Nevertheless, the criteria are a useful adjunct to the decision-making process in these patients.',\n", " 'bBox': {'x': 72, 'y': 414, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table Extraction',\n", " 'md': '## Table Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Criteria', 'Description'],\n", " ['1', ''],\n", " ['2', ''],\n", " ['3', ''],\n", " ['...', '...']],\n", " 'md': '| Criteria | Description |\\n|----------|-------------|\\n| 1 | |\\n| 2 | |\\n| 3 | |\\n| ... | ... |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Criteria\",\"Description\"\\n\"1\",\"\"\\n\"2\",\"\"\\n\"3\",\"\"\\n\"...\",\"...\"',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 622,\n", " 'text': ' Table 34.1. The Hardman criteria 1\\n Age >76.\\n History of unconsciousness_\\n Hemoglobin <9.Og/dL:\\n Creatinine >2.lmg% (190umol/L)\\n ECG evidence of ischemia.\\n If three or more criteria are present the mortality is 100%\\n If two are present the mortality is 72%\\n If one, 37%\\n The operation\\n\\n Once the diagnosis of aortic rupture has been established, or strongly\\nsuspected, the patient should be rushed to the operating theater without\\ndelay. Do not even bother with additional lines and intravenous fluids as\\nwhat you pour in will pour out, and increasing the blood pressure will only\\nincrease the bleeding. Aim for stable hypotension in resuscitation —\\nthe so-called ‘permissive hypotension’.\\n\\n Preparation\\n\\n ‘Prep and drape’ (including the groins in case aortofemoral bypass is\\nnecessary) for surgery while the anesthetic team establishes the\\nappropriate monitoring lines. Do not allow them, however, to waste time\\nby inserting unnecessary gimmicks such as the pulmonary arterial\\ncatheter. Administer prophylactic antibiotics. Anesthesia should not be\\ninduced until you are ready to make the skin incision; not infrequently the\\nadministration of muscle relaxants at induction, and the subsequent\\nrelaxation of the abdominal wall, is sufficient to permit a further bleed\\nfrom the aneurysm with an immediate hemodynamic collapse.\\nRemember: your clamp on the aorta proximal to the aneurysm is\\nmore important that anything else.',\n", " 'md': '```markdown\\n## Table 34.1. The Hardman Criteria\\n\\n| Criteria | Value |\\n|--------------------------------------------|------------------------|\\n| Age | > 76 |\\n| History of unconsciousness | Yes |\\n| Hemoglobin | < 9.0 g/dL |\\n| Creatinine | > 2.1 mg% (190 µmol/L) |\\n| ECG evidence of ischemia | Yes |\\n\\n- If three or more criteria are present, the mortality is 100%.\\n- If two are present, the mortality is 72%.\\n- If one is present, the mortality is 37%.\\n\\n----\\n\\n## The Operation\\n\\nOnce the diagnosis of aortic rupture has been established, or strongly suspected, the patient should be rushed to the operating theater without delay. Do not even bother with additional lines and intravenous fluids as what you pour in will pour out, and increasing the blood pressure will only increase the bleeding. Aim for stable hypotension in resuscitation — the so-called ‘permissive hypotension’.\\n\\n----\\n\\n## Preparation\\n\\n‘Prep and drape’ (including the groins in case aortofemoral bypass is necessary) for surgery while the anesthetic team establishes the appropriate monitoring lines. Do not allow them, however, to waste time by inserting unnecessary gimmicks such as the pulmonary arterial catheter. Administer prophylactic antibiotics. Anesthesia should not be induced until you are ready to make the skin incision; not infrequently the administration of muscle relaxants at induction, and the subsequent relaxation of the abdominal wall, is sufficient to permit a further bleed from the aneurysm with an immediate hemodynamic collapse. Remember: your clamp on the aorta proximal to the aneurysm is more important than anything else.\\n```',\n", " 'images': [{'name': 'img_p621_1.png',\n", " 'height': 434,\n", " 'width': 812,\n", " 'x': 105.11999999999989,\n", " 'y': 72,\n", " 'original_width': 1394,\n", " 'original_height': 744}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 34.1. The Hardman Criteria',\n", " 'md': '## Table 34.1. The Hardman Criteria',\n", " 'bBox': {'x': 115, 'y': 657, 'w': 23.99, 'h': 14.4}},\n", " {'type': 'table',\n", " 'rows': [['Criteria', 'Value'],\n", " ['Age', '> 76'],\n", " ['History of unconsciousness', 'Yes'],\n", " ['Hemoglobin', '< 9.0 g/dL'],\n", " ['Creatinine', '> 2.1 mg% (190 µmol/L)'],\n", " ['ECG evidence of ischemia', 'Yes']],\n", " 'md': '| Criteria | Value |\\n|--------------------------------------------|------------------------|\\n| Age | > 76 |\\n| History of unconsciousness | Yes |\\n| Hemoglobin | < 9.0 g/dL |\\n| Creatinine | > 2.1 mg% (190 µmol/L) |\\n| ECG evidence of ischemia | Yes |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Criteria\",\"Value\"\\n\"Age\",\"> 76\"\\n\"History of unconsciousness\",\"Yes\"\\n\"Hemoglobin\",\"< 9.0 g/dL\"\\n\"Creatinine\",\"> 2.1 mg% (190 µmol/L)\"\\n\"ECG evidence of ischemia\",\"Yes\"',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- If three or more criteria are present, the mortality is 100%.\\n- If two are present, the mortality is 72%.\\n- If one is present, the mortality is 37%.\\n\\n----',\n", " 'md': '- If three or more criteria are present, the mortality is 100%.\\n- If two are present, the mortality is 72%.\\n- If one is present, the mortality is 37%.\\n\\n----',\n", " 'bBox': {'x': 115, 'y': 657, 'w': 23.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Operation',\n", " 'md': '## The Operation',\n", " 'bBox': {'x': 86, 'y': 327, 'w': 109.42, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Once the diagnosis of aortic rupture has been established, or strongly suspected, the patient should be rushed to the operating theater without delay. Do not even bother with additional lines and intravenous fluids as what you pour in will pour out, and increasing the blood pressure will only increase the bleeding. Aim for stable hypotension in resuscitation — the so-called ‘permissive hypotension’.\\n\\n----',\n", " 'md': 'Once the diagnosis of aortic rupture has been established, or strongly suspected, the patient should be rushed to the operating theater without delay. Do not even bother with additional lines and intravenous fluids as what you pour in will pour out, and increasing the blood pressure will only increase the bleeding. Aim for stable hypotension in resuscitation — the so-called ‘permissive hypotension’.\\n\\n----',\n", " 'bBox': {'x': 72, 'y': 363, 'w': 467.74, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Preparation',\n", " 'md': '## Preparation',\n", " 'bBox': {'x': 86, 'y': 489, 'w': 91.96, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '‘Prep and drape’ (including the groins in case aortofemoral bypass is necessary) for surgery while the anesthetic team establishes the appropriate monitoring lines. Do not allow them, however, to waste time by inserting unnecessary gimmicks such as the pulmonary arterial catheter. Administer prophylactic antibiotics. Anesthesia should not be induced until you are ready to make the skin incision; not infrequently the administration of muscle relaxants at induction, and the subsequent relaxation of the abdominal wall, is sufficient to permit a further bleed from the aneurysm with an immediate hemodynamic collapse. Remember: your clamp on the aorta proximal to the aneurysm is more important than anything else.\\n```',\n", " 'md': '‘Prep and drape’ (including the groins in case aortofemoral bypass is necessary) for surgery while the anesthetic team establishes the appropriate monitoring lines. Do not allow them, however, to waste time by inserting unnecessary gimmicks such as the pulmonary arterial catheter. Administer prophylactic antibiotics. Anesthesia should not be induced until you are ready to make the skin incision; not infrequently the administration of muscle relaxants at induction, and the subsequent relaxation of the abdominal wall, is sufficient to permit a further bleed from the aneurysm with an immediate hemodynamic collapse. Remember: your clamp on the aorta proximal to the aneurysm is more important than anything else.\\n```',\n", " 'bBox': {'x': 72, 'y': 558, 'w': 467.88, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 623,\n", " 'text': ' Incision\\n\\n Open the abdomen through a long mid-line incision extending from the\\nxiphisternum to a point mid way between the umbilicus and the\\nsymphysis pubis. Occasionally, if the distal iliac arteries are to be\\napproached, the incision must be extended. In most cases, however, for\\nthe insertion of a simple aortic tube graft, an incision as described is\\nadequate.\\n\\n Proximal control\\n\\n Upon entering the peritoneal cavity, the diagnosis is immediately\\nconfirmed by the presence of a large retroperitoneal hematoma. The first\\npriority is to obtain control of the aorta proximal to the aneurysm. In the\\nmajority of patients who are stable at this stage (with a contained\\nretroperitoneal leak), there is time to approach the aorta above the\\naneurysm and just below the level of the renal arteries. In patients who\\nare unstable, rapid control of aortic bleeding may be obtained by\\napproaching the aorta just under the diaphragm and temporarily\\napplying a clamp there until the infrarenal aorta can be dissected.\\nOther approaches to unstable patients, or those who become unstable\\nduring dissection, include blunt compression of the proximal aorta by ‘a\\nswab on a stick’ (gauze held in a Rampley’s forceps) and insertion of a\\nlarge Foley catheter through the aortic defect if this is encountered during\\ndissection of the AAA neck; balloon occlusion of the aorta may then allow\\nyou a few extra minutes to gain control:\\n\\n • Subdiaphragmatic aortic control: Remember how you do truncal\\n vagotomy? Of course you don’t! So pay attention. Incise the\\n phrenoesophageal ligament overlying the esophagus (feel the\\n nasogastric tube underneath). With your index finger bluntly mobilize\\n the esophagus to the right; forget about hemostasis at this stage.\\n Now feel the aorta pulsating to the left of the esophagus, dissect\\n with your index finger on both sides of the aorta until you feel the\\n spine. Apply a straight aortic clamp, pushing it ‘onto’ the spine.\\n Leave a few packs to provide hemostasis and proceed as below. An\\n alternative approach is to go through the lesser sac, elevate the',\n", " 'md': '```markdown\\n# Incision\\n\\nOpen the abdomen through a long mid-line incision extending from the xiphisternum to a point midway between the umbilicus and the symphysis pubis. Occasionally, if the distal iliac arteries are to be approached, the incision must be extended. In most cases, however, for the insertion of a simple aortic tube graft, an incision as described is adequate.\\n\\n## Proximal Control\\n\\nUpon entering the peritoneal cavity, the diagnosis is immediately confirmed by the presence of a large retroperitoneal hematoma. The first priority is to obtain control of the aorta proximal to the aneurysm. In the majority of patients who are stable at this stage (with a contained retroperitoneal leak), there is time to approach the aorta above the aneurysm and just below the level of the renal arteries. In patients who are unstable, rapid control of aortic bleeding may be obtained by approaching the aorta just under the diaphragm and temporarily applying a clamp there until the infrarenal aorta can be dissected. Other approaches to unstable patients, or those who become unstable during dissection, include blunt compression of the proximal aorta by ‘a swab on a stick’ (gauze held in a Rampley’s forceps) and insertion of a large Foley catheter through the aortic defect if this is encountered during dissection of the AAA neck; balloon occlusion of the aorta may then allow you a few extra minutes to gain control.\\n\\n- **Subdiaphragmatic aortic control**: Remember how you do truncal vagotomy? Of course you don’t! So pay attention. Incise the phrenoesophageal ligament overlying the esophagus (feel the nasogastric tube underneath). With your index finger bluntly mobilize the esophagus to the right; forget about hemostasis at this stage. Now feel the aorta pulsating to the left of the esophagus, dissect with your index finger on both sides of the aorta until you feel the spine. Apply a straight aortic clamp, pushing it ‘onto’ the spine. Leave a few packs to provide hemostasis and proceed as below. An alternative approach is to go through the lesser sac, elevate the...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Incision',\n", " 'md': '# Incision',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 62.52, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Open the abdomen through a long mid-line incision extending from the xiphisternum to a point midway between the umbilicus and the symphysis pubis. Occasionally, if the distal iliac arteries are to be approached, the incision must be extended. In most cases, however, for the insertion of a simple aortic tube graft, an incision as described is adequate.',\n", " 'md': 'Open the abdomen through a long mid-line incision extending from the xiphisternum to a point midway between the umbilicus and the symphysis pubis. Occasionally, if the distal iliac arteries are to be approached, the incision must be extended. In most cases, however, for the insertion of a simple aortic tube graft, an incision as described is adequate.',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.46, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Proximal Control',\n", " 'md': '## Proximal Control',\n", " 'bBox': {'x': 86, 'y': 250, 'w': 130.57, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Upon entering the peritoneal cavity, the diagnosis is immediately confirmed by the presence of a large retroperitoneal hematoma. The first priority is to obtain control of the aorta proximal to the aneurysm. In the majority of patients who are stable at this stage (with a contained retroperitoneal leak), there is time to approach the aorta above the aneurysm and just below the level of the renal arteries. In patients who are unstable, rapid control of aortic bleeding may be obtained by approaching the aorta just under the diaphragm and temporarily applying a clamp there until the infrarenal aorta can be dissected. Other approaches to unstable patients, or those who become unstable during dissection, include blunt compression of the proximal aorta by ‘a swab on a stick’ (gauze held in a Rampley’s forceps) and insertion of a large Foley catheter through the aortic defect if this is encountered during dissection of the AAA neck; balloon occlusion of the aorta may then allow you a few extra minutes to gain control.\\n\\n- **Subdiaphragmatic aortic control**: Remember how you do truncal vagotomy? Of course you don’t! So pay attention. Incise the phrenoesophageal ligament overlying the esophagus (feel the nasogastric tube underneath). With your index finger bluntly mobilize the esophagus to the right; forget about hemostasis at this stage. Now feel the aorta pulsating to the left of the esophagus, dissect with your index finger on both sides of the aorta until you feel the spine. Apply a straight aortic clamp, pushing it ‘onto’ the spine. Leave a few packs to provide hemostasis and proceed as below. An alternative approach is to go through the lesser sac, elevate the...\\n```',\n", " 'md': 'Upon entering the peritoneal cavity, the diagnosis is immediately confirmed by the presence of a large retroperitoneal hematoma. The first priority is to obtain control of the aorta proximal to the aneurysm. In the majority of patients who are stable at this stage (with a contained retroperitoneal leak), there is time to approach the aorta above the aneurysm and just below the level of the renal arteries. In patients who are unstable, rapid control of aortic bleeding may be obtained by approaching the aorta just under the diaphragm and temporarily applying a clamp there until the infrarenal aorta can be dissected. Other approaches to unstable patients, or those who become unstable during dissection, include blunt compression of the proximal aorta by ‘a swab on a stick’ (gauze held in a Rampley’s forceps) and insertion of a large Foley catheter through the aortic defect if this is encountered during dissection of the AAA neck; balloon occlusion of the aorta may then allow you a few extra minutes to gain control.\\n\\n- **Subdiaphragmatic aortic control**: Remember how you do truncal vagotomy? Of course you don’t! So pay attention. Incise the phrenoesophageal ligament overlying the esophagus (feel the nasogastric tube underneath). With your index finger bluntly mobilize the esophagus to the right; forget about hemostasis at this stage. Now feel the aorta pulsating to the left of the esophagus, dissect with your index finger on both sides of the aorta until you feel the spine. Apply a straight aortic clamp, pushing it ‘onto’ the spine. Leave a few packs to provide hemostasis and proceed as below. An alternative approach is to go through the lesser sac, elevate the...\\n```',\n", " 'bBox': {'x': 72, 'y': 302, 'w': 467.89, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 624,\n", " 'text': ' stomach and apply a clamp on the aorta immediately above the\\n pancreas.\\n• Infrarenal aortic control: Returning to the matter of isolation of the\\n aortic neck, note that the main principle to be observed is to avoid\\n disturbing the retroperitoneal hematoma while gaining control of the\\n proximal aorta. Once you enter the retroperitoneum at the neck’s\\n level, dissect bluntly using your finger or the tip of the suction\\n apparatus, to identify and isolate the neck of the aneurysm. Once\\n the neck is identified carry on backwards on either side of the aorta\\n until the vertebral bodies are reached. Do not attempt to encircle\\n the aorta with a tape. Apply a straight aortic clamp in an\\n anteroposterior direction with the tips of the jaws of the clamp\\n resting against the vertebral bodies. Placement of this clamp is\\n facilitated by placing the index and middle fingers of your non-\\n dominant hand on either side of the aorta so that the vertebral\\n bodies can be palpated. The jaws of the open clamp are then slid\\n along the backs of the fingers until the clamp lies in the appropriate\\n position. During this maneuver an ‘extra’ length of aorta can often be\\n isolated by retracting the aneurysm gently downwards with your\\n hand. Now you can remove the subdiaphragmatic clamp.\\n• Juxtarenal neck: Occasionally the aneurysm extends close to the\\n origin of the renal arteries. If this is the case then the neck of the\\n aneurysm will be obscured by the left renal vein, which may be\\n stretched anteriorly. Care must be taken that the vein is not\\n damaged. It may be divided to facilitate access to the aneurysm\\n neck. This is done by very gently mobilizing the vein from the\\n underlying aorta. It should be ligated securely as close to the vena\\n cava as prudence permits. If this is done then the vein may be\\n ligated with impunity and the kidney will not be endangered,\\n because collateral venous drainage will take place via the adrenal\\n and gonadal anastomoses. How do you know that effective\\n proximal control has been achieved? Simple — the\\n retroperitoneal hematoma stops pulsating. If it pulsates your\\n clamp is not properly placed. Reapply it!\\n\\n Distal control',\n", " 'md': '```markdown\\n## Stomach and Aortic Control\\n\\n- Apply a clamp on the aorta immediately above the pancreas.\\n\\n### Infrarenal Aortic Control\\nReturning to the matter of isolation of the aortic neck, note that the main principle to be observed is to avoid disturbing the retroperitoneal hematoma while gaining control of the proximal aorta. Once you enter the retroperitoneum at the neck’s level, dissect bluntly using your finger or the tip of the suction apparatus, to identify and isolate the neck of the aneurysm. Once the neck is identified, carry on backwards on either side of the aorta until the vertebral bodies are reached. Do not attempt to encircle the aorta with a tape. Apply a straight aortic clamp in an anteroposterior direction with the tips of the jaws of the clamp resting against the vertebral bodies. Placement of this clamp is facilitated by placing the index and middle fingers of your non-dominant hand on either side of the aorta so that the vertebral bodies can be palpated. The jaws of the open clamp are then slid along the backs of the fingers until the clamp lies in the appropriate position. During this maneuver, an ‘extra’ length of aorta can often be isolated by retracting the aneurysm gently downwards with your hand. Now you can remove the subdiaphragmatic clamp.\\n\\n### Juxtarenal Neck\\nOccasionally the aneurysm extends close to the origin of the renal arteries. If this is the case, then the neck of the aneurysm will be obscured by the left renal vein, which may be stretched anteriorly. Care must be taken that the vein is not damaged. It may be divided to facilitate access to the aneurysm neck. This is done by very gently mobilizing the vein from the underlying aorta. It should be ligated securely as close to the vena cava as prudence permits. If this is done, then the vein may be ligated with impunity and the kidney will not be endangered, because collateral venous drainage will take place via the adrenal and gonadal anastomoses.\\n\\nHow do you know that effective proximal control has been achieved? Simple — the retroperitoneal hematoma stops pulsating. If it pulsates, your clamp is not properly placed. Reapply it!\\n\\n### Distal Control\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Stomach and Aortic Control',\n", " 'md': '## Stomach and Aortic Control',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Apply a clamp on the aorta immediately above the pancreas.',\n", " 'md': '- Apply a clamp on the aorta immediately above the pancreas.',\n", " 'bBox': {'x': 100, 'y': 102, 'w': 63.19, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Infrarenal Aortic Control',\n", " 'md': '### Infrarenal Aortic Control',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Returning to the matter of isolation of the aortic neck, note that the main principle to be observed is to avoid disturbing the retroperitoneal hematoma while gaining control of the proximal aorta. Once you enter the retroperitoneum at the neck’s level, dissect bluntly using your finger or the tip of the suction apparatus, to identify and isolate the neck of the aneurysm. Once the neck is identified, carry on backwards on either side of the aorta until the vertebral bodies are reached. Do not attempt to encircle the aorta with a tape. Apply a straight aortic clamp in an anteroposterior direction with the tips of the jaws of the clamp resting against the vertebral bodies. Placement of this clamp is facilitated by placing the index and middle fingers of your non-dominant hand on either side of the aorta so that the vertebral bodies can be palpated. The jaws of the open clamp are then slid along the backs of the fingers until the clamp lies in the appropriate position. During this maneuver, an ‘extra’ length of aorta can often be isolated by retracting the aneurysm gently downwards with your hand. Now you can remove the subdiaphragmatic clamp.',\n", " 'md': 'Returning to the matter of isolation of the aortic neck, note that the main principle to be observed is to avoid disturbing the retroperitoneal hematoma while gaining control of the proximal aorta. Once you enter the retroperitoneum at the neck’s level, dissect bluntly using your finger or the tip of the suction apparatus, to identify and isolate the neck of the aneurysm. Once the neck is identified, carry on backwards on either side of the aorta until the vertebral bodies are reached. Do not attempt to encircle the aorta with a tape. Apply a straight aortic clamp in an anteroposterior direction with the tips of the jaws of the clamp resting against the vertebral bodies. Placement of this clamp is facilitated by placing the index and middle fingers of your non-dominant hand on either side of the aorta so that the vertebral bodies can be palpated. The jaws of the open clamp are then slid along the backs of the fingers until the clamp lies in the appropriate position. During this maneuver, an ‘extra’ length of aorta can often be isolated by retracting the aneurysm gently downwards with your hand. Now you can remove the subdiaphragmatic clamp.',\n", " 'bBox': {'x': 100, 'y': 155, 'w': 437.2, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Juxtarenal Neck',\n", " 'md': '### Juxtarenal Neck',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Occasionally the aneurysm extends close to the origin of the renal arteries. If this is the case, then the neck of the aneurysm will be obscured by the left renal vein, which may be stretched anteriorly. Care must be taken that the vein is not damaged. It may be divided to facilitate access to the aneurysm neck. This is done by very gently mobilizing the vein from the underlying aorta. It should be ligated securely as close to the vena cava as prudence permits. If this is done, then the vein may be ligated with impunity and the kidney will not be endangered, because collateral venous drainage will take place via the adrenal and gonadal anastomoses.\\n\\nHow do you know that effective proximal control has been achieved? Simple — the retroperitoneal hematoma stops pulsating. If it pulsates, your clamp is not properly placed. Reapply it!',\n", " 'md': 'Occasionally the aneurysm extends close to the origin of the renal arteries. If this is the case, then the neck of the aneurysm will be obscured by the left renal vein, which may be stretched anteriorly. Care must be taken that the vein is not damaged. It may be divided to facilitate access to the aneurysm neck. This is done by very gently mobilizing the vein from the underlying aorta. It should be ligated securely as close to the vena cava as prudence permits. If this is done, then the vein may be ligated with impunity and the kidney will not be endangered, because collateral venous drainage will take place via the adrenal and gonadal anastomoses.\\n\\nHow do you know that effective proximal control has been achieved? Simple — the retroperitoneal hematoma stops pulsating. If it pulsates, your clamp is not properly placed. Reapply it!',\n", " 'bBox': {'x': 100, 'y': 522, 'w': 436.52, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Distal Control',\n", " 'md': '### Distal Control',\n", " 'bBox': {'x': 86, 'y': 683, 'w': 105.74, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 625,\n", " 'text': ' The next part of the dissection, to identify the common iliac arteries, is\\noften more difficult. Under normal circumstances, the pelvis is the site of\\naccumulation of much of the retroperitoneal hematoma and the iliac\\narteries are buried within this. The arteries are difficult to locate not only\\nbecause they are buried in hematoma but because with the aorta\\nclamped proximally, there is no pulsation to guide the operator. In most\\npatients, however, the presence of atheroma in the vessels makes\\npalpation in the depths of the hematoma possible. Again, the use of the\\nsuction apparatus facilitates isolation of the iliac vessels. Otherwise, dig\\nwith your fingers within the hematoma and ‘fish’ the iliacs out. As with\\nthe aorta, no attempt should be made to encircle the iliac vessels\\nwith tapes. This invariably produces damage to the iliac veins,\\nwhich is a disaster. It is sufficient to clear the anterior and lateral\\naspects of the iliac vessels and apply clamps in an anteroposterior\\nmanner as before.\\n\\n An alternative is balloon control: after proximal control has been\\nachieved, and when the iliacs are immersed within a huge hematoma,\\nyou may also rapidly open the aneurysm sac and shove a Foley or large\\nFogarty catheter into each iliac artery, inflating the balloons to produce\\ntemporary distal control. Surely you haven’t forgotten to occlude the\\nlumen of the Foley...\\n\\n Aortic replacement\\n\\n Once the proximal and distal arterial tree is controlled, incise the\\naneurysm sac in a longitudinal fashion; stay slightly to the right of the\\nmidline to avoid the origin of the inferior mesenteric artery. Evacuate the\\nclot and control back bleeding from any patent lumbar arteries and the\\ninferior mesenteric artery with sutures within the aneurysm sac. This can\\nbe done in a controlled way by firstly packing the upper and lower ends of\\nthe lumen with gauze swabs and then tackling each part of the aneurysm\\nin turn. A small self-retaining retractor placed within the aneurysm sac to\\nretract its cut edges facilitates this and the next few stages of the\\nprocedure; a hinged laminectomy retractor is best.\\n\\n The proportion of patients in whom aortic replacement with a simple\\ntube graft can be achieved varies widely from surgeon to surgeon and',\n", " 'md': '```markdown\\n## Aortic Surgery Techniques\\n\\nThe next part of the dissection, to identify the common iliac arteries, is often more difficult. Under normal circumstances, the pelvis is the site of accumulation of much of the retroperitoneal hematoma and the iliac arteries are buried within this. The arteries are difficult to locate not only because they are buried in hematoma but because with the aorta clamped proximally, there is no pulsation to guide the operator. In most patients, however, the presence of atheroma in the vessels makes palpation in the depths of the hematoma possible. Again, the use of the suction apparatus facilitates isolation of the iliac vessels. Otherwise, dig with your fingers within the hematoma and ‘fish’ the iliacs out. As with the aorta, no attempt should be made to encircle the iliac vessels with tapes. This invariably produces damage to the iliac veins, which is a disaster. It is sufficient to clear the anterior and lateral aspects of the iliac vessels and apply clamps in an anteroposterior manner as before.\\n\\nAn alternative is balloon control: after proximal control has been achieved, and when the iliacs are immersed within a huge hematoma, you may also rapidly open the aneurysm sac and shove a Foley or large Fogarty catheter into each iliac artery, inflating the balloons to produce temporary distal control. Surely you haven’t forgotten to occlude the lumen of the Foley...\\n\\n### Aortic Replacement\\n\\nOnce the proximal and distal arterial tree is controlled, incise the aneurysm sac in a longitudinal fashion; stay slightly to the right of the midline to avoid the origin of the inferior mesenteric artery. Evacuate the clot and control back bleeding from any patent lumbar arteries and the inferior mesenteric artery with sutures within the aneurysm sac. This can be done in a controlled way by firstly packing the upper and lower ends of the lumen with gauze swabs and then tackling each part of the aneurysm in turn. A small self-retaining retractor placed within the aneurysm sac to retract its cut edges facilitates this and the next few stages of the procedure; a hinged laminectomy retractor is best.\\n\\nThe proportion of patients in whom aortic replacement with a simple tube graft can be achieved varies widely from surgeon to surgeon.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Aortic Surgery Techniques',\n", " 'md': '## Aortic Surgery Techniques',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The next part of the dissection, to identify the common iliac arteries, is often more difficult. Under normal circumstances, the pelvis is the site of accumulation of much of the retroperitoneal hematoma and the iliac arteries are buried within this. The arteries are difficult to locate not only because they are buried in hematoma but because with the aorta clamped proximally, there is no pulsation to guide the operator. In most patients, however, the presence of atheroma in the vessels makes palpation in the depths of the hematoma possible. Again, the use of the suction apparatus facilitates isolation of the iliac vessels. Otherwise, dig with your fingers within the hematoma and ‘fish’ the iliacs out. As with the aorta, no attempt should be made to encircle the iliac vessels with tapes. This invariably produces damage to the iliac veins, which is a disaster. It is sufficient to clear the anterior and lateral aspects of the iliac vessels and apply clamps in an anteroposterior manner as before.\\n\\nAn alternative is balloon control: after proximal control has been achieved, and when the iliacs are immersed within a huge hematoma, you may also rapidly open the aneurysm sac and shove a Foley or large Fogarty catheter into each iliac artery, inflating the balloons to produce temporary distal control. Surely you haven’t forgotten to occlude the lumen of the Foley...',\n", " 'md': 'The next part of the dissection, to identify the common iliac arteries, is often more difficult. Under normal circumstances, the pelvis is the site of accumulation of much of the retroperitoneal hematoma and the iliac arteries are buried within this. The arteries are difficult to locate not only because they are buried in hematoma but because with the aorta clamped proximally, there is no pulsation to guide the operator. In most patients, however, the presence of atheroma in the vessels makes palpation in the depths of the hematoma possible. Again, the use of the suction apparatus facilitates isolation of the iliac vessels. Otherwise, dig with your fingers within the hematoma and ‘fish’ the iliacs out. As with the aorta, no attempt should be made to encircle the iliac vessels with tapes. This invariably produces damage to the iliac veins, which is a disaster. It is sufficient to clear the anterior and lateral aspects of the iliac vessels and apply clamps in an anteroposterior manner as before.\\n\\nAn alternative is balloon control: after proximal control has been achieved, and when the iliacs are immersed within a huge hematoma, you may also rapidly open the aneurysm sac and shove a Foley or large Fogarty catheter into each iliac artery, inflating the balloons to produce temporary distal control. Surely you haven’t forgotten to occlude the lumen of the Foley...',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Aortic Replacement',\n", " 'md': '### Aortic Replacement',\n", " 'bBox': {'x': 86, 'y': 479, 'w': 149.9, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Once the proximal and distal arterial tree is controlled, incise the aneurysm sac in a longitudinal fashion; stay slightly to the right of the midline to avoid the origin of the inferior mesenteric artery. Evacuate the clot and control back bleeding from any patent lumbar arteries and the inferior mesenteric artery with sutures within the aneurysm sac. This can be done in a controlled way by firstly packing the upper and lower ends of the lumen with gauze swabs and then tackling each part of the aneurysm in turn. A small self-retaining retractor placed within the aneurysm sac to retract its cut edges facilitates this and the next few stages of the procedure; a hinged laminectomy retractor is best.\\n\\nThe proportion of patients in whom aortic replacement with a simple tube graft can be achieved varies widely from surgeon to surgeon.\\n```',\n", " 'md': 'Once the proximal and distal arterial tree is controlled, incise the aneurysm sac in a longitudinal fashion; stay slightly to the right of the midline to avoid the origin of the inferior mesenteric artery. Evacuate the clot and control back bleeding from any patent lumbar arteries and the inferior mesenteric artery with sutures within the aneurysm sac. This can be done in a controlled way by firstly packing the upper and lower ends of the lumen with gauze swabs and then tackling each part of the aneurysm in turn. A small self-retaining retractor placed within the aneurysm sac to retract its cut edges facilitates this and the next few stages of the procedure; a hinged laminectomy retractor is best.\\n\\nThe proportion of patients in whom aortic replacement with a simple tube graft can be achieved varies widely from surgeon to surgeon.\\n```',\n", " 'bBox': {'x': 72, 'y': 479, 'w': 467.86, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 626,\n", " 'text': 'center to center. We believe that in the majority of patients insertion\\nof a tube graft can be achieved quite satisfactorily. The advantages\\nof this are that limitation of dissection in the pelvis minimizes the risk of\\ndamage to the iliac veins and to the autonomic nerves in the pelvis.\\nFurthermore, there seems little point in extending the length of what is\\nalready a difficult operation by inserting a bifurcation graft unnecessarily.\\nObviously there are circumstances when a tube graft is not acceptable —\\nnamely when the patient has occlusive aorto-iliac disease, when the iliac\\narteries are also significantly aneurysmal, or in some situations when the\\nbifurcation is widely splayed so that the orifices of the common iliac\\narteries are far apart. In the latter two situations it may be possible to\\ninsert a bifurcated prosthesis and still remain inside the abdomen by\\nanastomosing to the origins of the common or external iliac arteries. The\\navoidance of groin incisions, which are notoriously prone to infection, is a\\ngood thing.\\n\\n Take care when fashioning the aorta to receive the graft. The\\nlongitudinal incision in the aortic sac should be terminated at both ends\\nby a transverse incision so that the incision becomes T-shaped at each\\nend. The limbs of the ‘T’ at either end should not extend more than 50%\\nof the circumference of the normal aorta.\\n\\n Suture the graft in place using monofilament material so that a\\nparachute technique can be used. This allows you to visualize clearly\\nthe placement of the individual posterior sutures. Large bites of the\\nposterior aortic wall should be taken because the tissues in this situation\\nare often very poor. Furthermore, leaks that occur after completion of the\\nanastomosis are notoriously difficult to repair if they are situated at the\\nback wall. Once the upper anastomosis has been completed, a clamp is\\napplied to the graft just below the anastomosis and the clamp on the\\naorta then released. Assuming there are no significant leaks at the upper\\nend, attention is turned to the distal anastomosis. This is completed in a\\nsimilar fashion to the proximal anastomosis. Back-bleeding from the iliac\\nvessels should be checked before the distal anastomosis is completed.\\nLikewise, the graft should be flushed with saline and one or two ‘strokes’\\nof the patient’s own cardiac output to clear it of thrombotic junk. If there is\\nno back-bleeding it may be necessary to pass balloon embolectomy\\ncatheters into the iliac systems to check that there has been no',\n", " 'md': '```markdown\\n## Surgical Technique for Graft Insertion\\n\\nWe believe that in the majority of patients, insertion of a tube graft can be achieved quite satisfactorily. The advantages of this are that limitation of dissection in the pelvis minimizes the risk of damage to the iliac veins and to the autonomic nerves in the pelvis. Furthermore, there seems little point in extending the length of what is already a difficult operation by inserting a bifurcation graft unnecessarily.\\n\\nObviously, there are circumstances when a tube graft is not acceptable — namely when the patient has occlusive aorto-iliac disease, when the iliac arteries are also significantly aneurysmal, or in some situations when the bifurcation is widely splayed so that the orifices of the common iliac arteries are far apart. In the latter two situations, it may be possible to insert a bifurcated prosthesis and still remain inside the abdomen by anastomosing to the origins of the common or external iliac arteries. The avoidance of groin incisions, which are notoriously prone to infection, is a good thing.\\n\\nTake care when fashioning the aorta to receive the graft. The longitudinal incision in the aortic sac should be terminated at both ends by a transverse incision so that the incision becomes T-shaped at each end. The limbs of the ‘T’ at either end should not extend more than 50% of the circumference of the normal aorta.\\n\\nSuture the graft in place using monofilament material so that a parachute technique can be used. This allows you to visualize clearly the placement of the individual posterior sutures. Large bites of the posterior aortic wall should be taken because the tissues in this situation are often very poor. Furthermore, leaks that occur after completion of the anastomosis are notoriously difficult to repair if they are situated at the back wall.\\n\\nOnce the upper anastomosis has been completed, a clamp is applied to the graft just below the anastomosis and the clamp on the aorta then released. Assuming there are no significant leaks at the upper end, attention is turned to the distal anastomosis. This is completed in a similar fashion to the proximal anastomosis. Back-bleeding from the iliac vessels should be checked before the distal anastomosis is completed. Likewise, the graft should be flushed with saline and one or two ‘strokes’ of the patient’s own cardiac output to clear it of thrombotic junk. If there is no back-bleeding, it may be necessary to pass balloon embolectomy catheters into the iliac systems to check that there has been no...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Technique for Graft Insertion',\n", " 'md': '## Surgical Technique for Graft Insertion',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'We believe that in the majority of patients, insertion of a tube graft can be achieved quite satisfactorily. The advantages of this are that limitation of dissection in the pelvis minimizes the risk of damage to the iliac veins and to the autonomic nerves in the pelvis. Furthermore, there seems little point in extending the length of what is already a difficult operation by inserting a bifurcation graft unnecessarily.\\n\\nObviously, there are circumstances when a tube graft is not acceptable — namely when the patient has occlusive aorto-iliac disease, when the iliac arteries are also significantly aneurysmal, or in some situations when the bifurcation is widely splayed so that the orifices of the common iliac arteries are far apart. In the latter two situations, it may be possible to insert a bifurcated prosthesis and still remain inside the abdomen by anastomosing to the origins of the common or external iliac arteries. The avoidance of groin incisions, which are notoriously prone to infection, is a good thing.\\n\\nTake care when fashioning the aorta to receive the graft. The longitudinal incision in the aortic sac should be terminated at both ends by a transverse incision so that the incision becomes T-shaped at each end. The limbs of the ‘T’ at either end should not extend more than 50% of the circumference of the normal aorta.\\n\\nSuture the graft in place using monofilament material so that a parachute technique can be used. This allows you to visualize clearly the placement of the individual posterior sutures. Large bites of the posterior aortic wall should be taken because the tissues in this situation are often very poor. Furthermore, leaks that occur after completion of the anastomosis are notoriously difficult to repair if they are situated at the back wall.\\n\\nOnce the upper anastomosis has been completed, a clamp is applied to the graft just below the anastomosis and the clamp on the aorta then released. Assuming there are no significant leaks at the upper end, attention is turned to the distal anastomosis. This is completed in a similar fashion to the proximal anastomosis. Back-bleeding from the iliac vessels should be checked before the distal anastomosis is completed. Likewise, the graft should be flushed with saline and one or two ‘strokes’ of the patient’s own cardiac output to clear it of thrombotic junk. If there is no back-bleeding, it may be necessary to pass balloon embolectomy catheters into the iliac systems to check that there has been no...\\n```',\n", " 'md': 'We believe that in the majority of patients, insertion of a tube graft can be achieved quite satisfactorily. The advantages of this are that limitation of dissection in the pelvis minimizes the risk of damage to the iliac veins and to the autonomic nerves in the pelvis. Furthermore, there seems little point in extending the length of what is already a difficult operation by inserting a bifurcation graft unnecessarily.\\n\\nObviously, there are circumstances when a tube graft is not acceptable — namely when the patient has occlusive aorto-iliac disease, when the iliac arteries are also significantly aneurysmal, or in some situations when the bifurcation is widely splayed so that the orifices of the common iliac arteries are far apart. In the latter two situations, it may be possible to insert a bifurcated prosthesis and still remain inside the abdomen by anastomosing to the origins of the common or external iliac arteries. The avoidance of groin incisions, which are notoriously prone to infection, is a good thing.\\n\\nTake care when fashioning the aorta to receive the graft. The longitudinal incision in the aortic sac should be terminated at both ends by a transverse incision so that the incision becomes T-shaped at each end. The limbs of the ‘T’ at either end should not extend more than 50% of the circumference of the normal aorta.\\n\\nSuture the graft in place using monofilament material so that a parachute technique can be used. This allows you to visualize clearly the placement of the individual posterior sutures. Large bites of the posterior aortic wall should be taken because the tissues in this situation are often very poor. Furthermore, leaks that occur after completion of the anastomosis are notoriously difficult to repair if they are situated at the back wall.\\n\\nOnce the upper anastomosis has been completed, a clamp is applied to the graft just below the anastomosis and the clamp on the aorta then released. Assuming there are no significant leaks at the upper end, attention is turned to the distal anastomosis. This is completed in a similar fashion to the proximal anastomosis. Back-bleeding from the iliac vessels should be checked before the distal anastomosis is completed. Likewise, the graft should be flushed with saline and one or two ‘strokes’ of the patient’s own cardiac output to clear it of thrombotic junk. If there is no back-bleeding, it may be necessary to pass balloon embolectomy catheters into the iliac systems to check that there has been no...\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 627,\n", " 'text': 'intravascular thrombus formation. Once the distal anastomosis has been\\ncompleted and found to be secure, the iliac clamps should be released\\nindividually allowing time for any hypotension to recover before the\\nsecond clamp is removed. The anesthesia team will appreciate a warning\\nfrom you that the time is approaching for removal of the clamps, allowing\\nthem to be well ahead with fluid replacement. Inadequate fluid\\nreplacement at this stage will result in significant hypotension when the\\niliac clamps are released.\\n\\n A word about heparin\\n\\n It is clearly not sensible to administer systemic heparin prior to cross-\\nclamping in patients who are bleeding to death from an aortic rupture. In\\npatients in whom surgery has been carried out for suspected rupture,\\nhowever, and in whom no rupture is found at operation, systemic\\nheparinization according to the surgeon’s normal practice should be\\ncarried out. It is permissible, however, to heparinize locally the iliac\\nvessels once the aneurysm sac has been opened and back-bleeding\\nfrom the small vessels has been controlled. ħeparinized saline may be\\nflushed down each of the iliac vessels in turn before reapplying the iliac\\ncross-clamps. No consensus on the need for this practice has been\\nreached and in the vast majority of patients it appears to be unnecessary.\\n\\n Abdominal closure\\n\\n The large retroperitoneal hematoma and visceral swelling resulting\\nfrom shock, resuscitation, reperfusion and exposure, commonly produce\\nsevere intra-abdominal hypertension, which becomes manifest after\\nclosure of the abdomen. Rather than closing under excessive tension,\\nuse temporary abdominal closure as discussed in Chapter 33, and\\ncome back to close the abdomen later.\\n\\n The avoidance of abdominal compartment syndrome is crucial in these physiologically\\n compromised patients in whom any further derangement may be the straw that breaks\\n the camel’s back.',\n", " 'md': '```markdown\\n# Intravascular Thrombus Formation\\n\\nOnce the distal anastomosis has been completed and found to be secure, the iliac clamps should be released individually allowing time for any hypotension to recover before the second clamp is removed. The anesthesia team will appreciate a warning from you that the time is approaching for removal of the clamps, allowing them to be well ahead with fluid replacement. Inadequate fluid replacement at this stage will result in significant hypotension when the iliac clamps are released.\\n\\n## A Word About Heparin\\n\\nIt is clearly not sensible to administer systemic heparin prior to cross-clamping in patients who are bleeding to death from an aortic rupture. In patients in whom surgery has been carried out for suspected rupture, however, and in whom no rupture is found at operation, systemic heparinization according to the surgeon’s normal practice should be carried out. It is permissible, however, to heparinize locally the iliac vessels once the aneurysm sac has been opened and back-bleeding from the small vessels has been controlled. Heparinized saline may be flushed down each of the iliac vessels in turn before reapplying the iliac cross-clamps. No consensus on the need for this practice has been reached and in the vast majority of patients it appears to be unnecessary.\\n\\n## Abdominal Closure\\n\\nThe large retroperitoneal hematoma and visceral swelling resulting from shock, resuscitation, reperfusion, and exposure, commonly produce severe intra-abdominal hypertension, which becomes manifest after closure of the abdomen. Rather than closing under excessive tension, use temporary abdominal closure as discussed in Chapter 33, and come back to close the abdomen later.\\n\\nThe avoidance of abdominal compartment syndrome is crucial in these physiologically compromised patients in whom any further derangement may be the straw that breaks the camel’s back.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Intravascular Thrombus Formation',\n", " 'md': '# Intravascular Thrombus Formation',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Once the distal anastomosis has been completed and found to be secure, the iliac clamps should be released individually allowing time for any hypotension to recover before the second clamp is removed. The anesthesia team will appreciate a warning from you that the time is approaching for removal of the clamps, allowing them to be well ahead with fluid replacement. Inadequate fluid replacement at this stage will result in significant hypotension when the iliac clamps are released.',\n", " 'md': 'Once the distal anastomosis has been completed and found to be secure, the iliac clamps should be released individually allowing time for any hypotension to recover before the second clamp is removed. The anesthesia team will appreciate a warning from you that the time is approaching for removal of the clamps, allowing them to be well ahead with fluid replacement. Inadequate fluid replacement at this stage will result in significant hypotension when the iliac clamps are released.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'A Word About Heparin',\n", " 'md': '## A Word About Heparin',\n", " 'bBox': {'x': 86, 'y': 245, 'w': 169.47, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'It is clearly not sensible to administer systemic heparin prior to cross-clamping in patients who are bleeding to death from an aortic rupture. In patients in whom surgery has been carried out for suspected rupture, however, and in whom no rupture is found at operation, systemic heparinization according to the surgeon’s normal practice should be carried out. It is permissible, however, to heparinize locally the iliac vessels once the aneurysm sac has been opened and back-bleeding from the small vessels has been controlled. Heparinized saline may be flushed down each of the iliac vessels in turn before reapplying the iliac cross-clamps. No consensus on the need for this practice has been reached and in the vast majority of patients it appears to be unnecessary.',\n", " 'md': 'It is clearly not sensible to administer systemic heparin prior to cross-clamping in patients who are bleeding to death from an aortic rupture. In patients in whom surgery has been carried out for suspected rupture, however, and in whom no rupture is found at operation, systemic heparinization according to the surgeon’s normal practice should be carried out. It is permissible, however, to heparinize locally the iliac vessels once the aneurysm sac has been opened and back-bleeding from the small vessels has been controlled. Heparinized saline may be flushed down each of the iliac vessels in turn before reapplying the iliac cross-clamps. No consensus on the need for this practice has been reached and in the vast majority of patients it appears to be unnecessary.',\n", " 'bBox': {'x': 72, 'y': 281, 'w': 467.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Closure',\n", " 'md': '## Abdominal Closure',\n", " 'bBox': {'x': 86, 'y': 489, 'w': 148.97, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The large retroperitoneal hematoma and visceral swelling resulting from shock, resuscitation, reperfusion, and exposure, commonly produce severe intra-abdominal hypertension, which becomes manifest after closure of the abdomen. Rather than closing under excessive tension, use temporary abdominal closure as discussed in Chapter 33, and come back to close the abdomen later.\\n\\nThe avoidance of abdominal compartment syndrome is crucial in these physiologically compromised patients in whom any further derangement may be the straw that breaks the camel’s back.\\n```',\n", " 'md': 'The large retroperitoneal hematoma and visceral swelling resulting from shock, resuscitation, reperfusion, and exposure, commonly produce severe intra-abdominal hypertension, which becomes manifest after closure of the abdomen. Rather than closing under excessive tension, use temporary abdominal closure as discussed in Chapter 33, and come back to close the abdomen later.\\n\\nThe avoidance of abdominal compartment syndrome is crucial in these physiologically compromised patients in whom any further derangement may be the straw that breaks the camel’s back.\\n```',\n", " 'bBox': {'x': 72, 'y': 489, 'w': 467.34, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 628,\n", " 'text': ' Many patients who reach the operating table will survive the operation\\nonly to die in its aftermath, usually from associated medical illnesses\\nsuch as myocardial infarction. A successful outcome therefore requires\\nexcellent postoperative ICU care as well as competent surgery. The\\noperation is only half the battle.\\n\\n In ruptured AAA, the operation is commonly the beginning of the end\\n— the end arriving postoperatively ( Figure 34.1).\\n HERE\\n haveWE\\n aoRtic\\n (RuptuREd\\n AneyRysm |\\n FZRYAT4\\n Figure 34.1. Ruptured AAA: common outcome…\\n\\n Endovascular repair\\n\\n As aortic stent-grafting has become an established treatment for AAA\\nin the elective patient, interest has developed in the use of the same\\ntechniques in ruptured AAA patients in the hope of reducing the operative\\nmortality from the current 40-50%. Emergency endovascular aneurysm\\nrepair (eEVAR) is now confined to a few major centers but is\\nbecoming more commonplace as familiarity with the necessary\\narrangements increases. The limitations of this treatment are the need',\n", " 'md': '```markdown\\n## Page Content\\n\\nMany patients who reach the operating table will survive the operation only to die in its aftermath, usually from associated medical illnesses such as myocardial infarction. A successful outcome therefore requires excellent postoperative ICU care as well as competent surgery. The operation is only half the battle.\\n\\nIn ruptured AAA, the operation is commonly the beginning of the end — the end arriving postoperatively (Figure 34.1).\\n\\n### Figure 34.1\\n**Description:** This figure illustrates the common outcomes associated with ruptured abdominal aortic aneurysms (AAA). The image likely depicts a clinical scenario or a flowchart related to the postoperative care of patients who have undergone surgery for ruptured AAA.\\n\\n**Caption:** Ruptured AAA: common outcome…\\n\\n----\\n\\n### Endovascular Repair\\n\\nAs aortic stent-grafting has become an established treatment for AAA in the elective patient, interest has developed in the use of the same techniques in ruptured AAA patients in the hope of reducing the operative mortality from the current 40-50%. Emergency endovascular aneurysm repair (eEVAR) is now confined to a few major centers but is becoming more commonplace as familiarity with the necessary arrangements increases. The limitations of this treatment are the need...\\n```',\n", " 'images': [{'name': 'img_p627_1.png',\n", " 'height': 581,\n", " 'width': 798,\n", " 'x': 108.72000000000025,\n", " 'y': 217.44,\n", " 'original_width': 1371,\n", " 'original_height': 997}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Many patients who reach the operating table will survive the operation only to die in its aftermath, usually from associated medical illnesses such as myocardial infarction. A successful outcome therefore requires excellent postoperative ICU care as well as competent surgery. The operation is only half the battle.\\n\\nIn ruptured AAA, the operation is commonly the beginning of the end — the end arriving postoperatively (Figure 34.1).',\n", " 'md': 'Many patients who reach the operating table will survive the operation only to die in its aftermath, usually from associated medical illnesses such as myocardial infarction. A successful outcome therefore requires excellent postoperative ICU care as well as competent surgery. The operation is only half the battle.\\n\\nIn ruptured AAA, the operation is commonly the beginning of the end — the end arriving postoperatively (Figure 34.1).',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.21, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 34.1',\n", " 'md': '### Figure 34.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure illustrates the common outcomes associated with ruptured abdominal aortic aneurysms (AAA). The image likely depicts a clinical scenario or a flowchart related to the postoperative care of patients who have undergone surgery for ruptured AAA.\\n\\n**Caption:** Ruptured AAA: common outcome…\\n\\n----',\n", " 'md': '**Description:** This figure illustrates the common outcomes associated with ruptured abdominal aortic aneurysms (AAA). The image likely depicts a clinical scenario or a flowchart related to the postoperative care of patients who have undergone surgery for ruptured AAA.\\n\\n**Caption:** Ruptured AAA: common outcome…\\n\\n----',\n", " 'bBox': {'x': 313.42, 'y': 299.52, 'w': 45.49, 'h': 14.83}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Endovascular Repair',\n", " 'md': '### Endovascular Repair',\n", " 'bBox': {'x': 86, 'y': 579, 'w': 159.1, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As aortic stent-grafting has become an established treatment for AAA in the elective patient, interest has developed in the use of the same techniques in ruptured AAA patients in the hope of reducing the operative mortality from the current 40-50%. Emergency endovascular aneurysm repair (eEVAR) is now confined to a few major centers but is becoming more commonplace as familiarity with the necessary arrangements increases. The limitations of this treatment are the need...\\n```',\n", " 'md': 'As aortic stent-grafting has become an established treatment for AAA in the elective patient, interest has developed in the use of the same techniques in ruptured AAA patients in the hope of reducing the operative mortality from the current 40-50%. Emergency endovascular aneurysm repair (eEVAR) is now confined to a few major centers but is becoming more commonplace as familiarity with the necessary arrangements increases. The limitations of this treatment are the need...\\n```',\n", " 'bBox': {'x': 72, 'y': 326.22, 'w': 467.61, 'h': 14.83}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 629,\n", " 'text': 'for pre-op CT, an expensive stock of modular prostheses and immediate\\navailability of appropriately skilled surgeons and radiologists. The patient\\nneeds to be stable enough to cope with the delay to obtain CT images\\nthat are required to obtain the measurements for the stent-graft. This\\nprocedure is appropriate for only a minority of patients at present\\nbut it is expected that more will be suitable in future as techniques\\nimprove.\\n\\n Free intraperitoneal hemorrhage (see Table 11.1)\\n\\n Most AAA patients with a free intraperitoneal rupture will not reach\\nsurgery. In the few who do, rapid proximal control is even more crucial.\\nOther causes of non-traumatic intraperitoneal bleeding are rare and\\ninclude ruptured visceral artery aneurysms. If this is encountered then\\nthe common sense principle of first stopping the bleeding by suture\\nligation or packing is followed by an assessment of the need for\\nrevascularization. Splenic artery aneurysms are the commonest of these\\nlesions; they occur most often in women and rupture is a disaster\\nparticularly associated with pregnancy. When exposure and thus\\nproximal and distal control are difficult, do not forget the option of\\nendoaneurysmorrhaphy: open the sac of the aneurysm, control the\\nbleeding with finger pressure and/or balloon catheters, and suture the\\nproximal and distal openings from within. Currently, more and more of\\nsuch aneurysms are diagnosed on CT and managed angiographically by\\nthe radiologist — in stable patients of course.\\n\\n Aortic occlusion\\n\\n This emergency is characterized by acute ischemia of the legs with\\nmottling of the skin of the lower trunk. It occurs for three reasons:\\n\\n • Saddle embolus. A large clot originating from the heart occludes\\n the aortic bifurcation. The patient most likely will have signs of atrial\\n fibrillation or a recent history of acute myocardial infarction.\\n • Aortic thrombosis. The patient probably has a history of pre-\\n existing arterial disease suggestive of aorto-iliac involvement.\\n Occasionally this disaster will occur unannounced in a patient who is',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nFor pre-op CT, an expensive stock of modular prostheses and immediate availability of appropriately skilled surgeons and radiologists. The patient needs to be stable enough to cope with the delay to obtain CT images that are required to obtain the measurements for the stent-graft. This procedure is appropriate for only a minority of patients at present but it is expected that more will be suitable in future as techniques improve.\\n\\nFree intraperitoneal hemorrhage (see Table 11.1)\\n\\nMost AAA patients with a free intraperitoneal rupture will not reach surgery. In the few who do, rapid proximal control is even more crucial. Other causes of non-traumatic intraperitoneal bleeding are rare and include ruptured visceral artery aneurysms. If this is encountered then the common sense principle of first stopping the bleeding by suture ligation or packing is followed by an assessment of the need for revascularization. Splenic artery aneurysms are the commonest of these lesions; they occur most often in women and rupture is a disaster particularly associated with pregnancy. When exposure and thus proximal and distal control are difficult, do not forget the option of endoaneurysmorrhaphy: open the sac of the aneurysm, control the bleeding with finger pressure and/or balloon catheters, and suture the proximal and distal openings from within. Currently, more and more of such aneurysms are diagnosed on CT and managed angiographically by the radiologist — in stable patients of course.\\n\\n### Aortic Occlusion\\n\\nThis emergency is characterized by acute ischemia of the legs with mottling of the skin of the lower trunk. It occurs for three reasons:\\n\\n- **Saddle embolus**: A large clot originating from the heart occludes the aortic bifurcation. The patient most likely will have signs of atrial fibrillation or a recent history of acute myocardial infarction.\\n- **Aortic thrombosis**: The patient probably has a history of pre-existing arterial disease suggestive of aorto-iliac involvement. Occasionally this disaster will occur unannounced in a patient who is...\\n\\n## Table Extraction\\n\\n| Table Number | Description |\\n|--------------|-------------|\\n| 11.1 | Free intraperitoneal hemorrhage |\\n\\n## Image Identification and Description\\n\\n- **Figure 1**: \\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'For pre-op CT, an expensive stock of modular prostheses and immediate availability of appropriately skilled surgeons and radiologists. The patient needs to be stable enough to cope with the delay to obtain CT images that are required to obtain the measurements for the stent-graft. This procedure is appropriate for only a minority of patients at present but it is expected that more will be suitable in future as techniques improve.\\n\\nFree intraperitoneal hemorrhage (see Table 11.1)\\n\\nMost AAA patients with a free intraperitoneal rupture will not reach surgery. In the few who do, rapid proximal control is even more crucial. Other causes of non-traumatic intraperitoneal bleeding are rare and include ruptured visceral artery aneurysms. If this is encountered then the common sense principle of first stopping the bleeding by suture ligation or packing is followed by an assessment of the need for revascularization. Splenic artery aneurysms are the commonest of these lesions; they occur most often in women and rupture is a disaster particularly associated with pregnancy. When exposure and thus proximal and distal control are difficult, do not forget the option of endoaneurysmorrhaphy: open the sac of the aneurysm, control the bleeding with finger pressure and/or balloon catheters, and suture the proximal and distal openings from within. Currently, more and more of such aneurysms are diagnosed on CT and managed angiographically by the radiologist — in stable patients of course.',\n", " 'md': 'For pre-op CT, an expensive stock of modular prostheses and immediate availability of appropriately skilled surgeons and radiologists. The patient needs to be stable enough to cope with the delay to obtain CT images that are required to obtain the measurements for the stent-graft. This procedure is appropriate for only a minority of patients at present but it is expected that more will be suitable in future as techniques improve.\\n\\nFree intraperitoneal hemorrhage (see Table 11.1)\\n\\nMost AAA patients with a free intraperitoneal rupture will not reach surgery. In the few who do, rapid proximal control is even more crucial. Other causes of non-traumatic intraperitoneal bleeding are rare and include ruptured visceral artery aneurysms. If this is encountered then the common sense principle of first stopping the bleeding by suture ligation or packing is followed by an assessment of the need for revascularization. Splenic artery aneurysms are the commonest of these lesions; they occur most often in women and rupture is a disaster particularly associated with pregnancy. When exposure and thus proximal and distal control are difficult, do not forget the option of endoaneurysmorrhaphy: open the sac of the aneurysm, control the bleeding with finger pressure and/or balloon catheters, and suture the proximal and distal openings from within. Currently, more and more of such aneurysms are diagnosed on CT and managed angiographically by the radiologist — in stable patients of course.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.84, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Aortic Occlusion',\n", " 'md': '### Aortic Occlusion',\n", " 'bBox': {'x': 86, 'y': 539, 'w': 129.65, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This emergency is characterized by acute ischemia of the legs with mottling of the skin of the lower trunk. It occurs for three reasons:\\n\\n- **Saddle embolus**: A large clot originating from the heart occludes the aortic bifurcation. The patient most likely will have signs of atrial fibrillation or a recent history of acute myocardial infarction.\\n- **Aortic thrombosis**: The patient probably has a history of pre-existing arterial disease suggestive of aorto-iliac involvement. Occasionally this disaster will occur unannounced in a patient who is...',\n", " 'md': 'This emergency is characterized by acute ischemia of the legs with mottling of the skin of the lower trunk. It occurs for three reasons:\\n\\n- **Saddle embolus**: A large clot originating from the heart occludes the aortic bifurcation. The patient most likely will have signs of atrial fibrillation or a recent history of acute myocardial infarction.\\n- **Aortic thrombosis**: The patient probably has a history of pre-existing arterial disease suggestive of aorto-iliac involvement. Occasionally this disaster will occur unannounced in a patient who is...',\n", " 'bBox': {'x': 72, 'y': 592, 'w': 436.51, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table Extraction',\n", " 'md': '## Table Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Table Number', 'Description'],\n", " ['11.1', 'Free intraperitoneal hemorrhage']],\n", " 'md': '| Table Number | Description |\\n|--------------|-------------|\\n| 11.1 | Free intraperitoneal hemorrhage |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Table Number\",\"Description\"\\n\"11.1\",\"Free intraperitoneal hemorrhage\"',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: \\n```',\n", " 'md': '- **Figure 1**: \\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 630,\n", " 'text': ' desperately ill for some other reason. Extreme dehydration, for\\n example, may cause ‘sludging’ of major vessels if there has been\\n some pre-existing atheroma. Malignancy may produce intra-arterial\\n thrombosis.\\n • Aortic dissection. Suspect this if there is a history of interscapular\\n pain associated with obvious hypertension. Look for evidence of\\n other pulse deficits or signs of visceral ischemia suggesting\\n involvement of other aortic branches.\\n\\n Management\\n\\n This depends on the etiology and the presence of any relevant\\nunderlying pathology. Embolism may often be dealt with easily by\\nbilateral transfemoral embolectomy under local anesthetic. Thrombosis\\non pre-existing atheroma is a more difficult problem. Catheter\\nthrombectomy is unlikely to be successful either in the short or long term.\\nIf the patient is very fit (unlikely), aortofemoral bypass may be indicated.\\nMore likely, an extra-anatomic bypass (axillofemoral) may be feasible,\\nalways assuming that any underlying illness is not likely to cause the\\npatient’s demise in the immediate future. Often these patients are not fit\\nfor any intervention and the aortic thrombosis is an indication that the end\\nis near.\\n\\n Aortic dissection is a complex illness and its management is variable.\\nThe mainstay is control of hypertension and relief of major vessel\\nocclusion by endovascular ‘fenestration’ of the dissection. The details of\\nthis therapy are beyond the scope of this little book.\\n\\n In emergency aortic operations, simplicity of the operation is a key for survival: rapid and\\n atraumatic control, avoidance of injury to large veins, a tube graft, minimal blood loss, and\\n rapid surgery.\\n\\n Finally, Figure 34.2 depicts my own method of choice to prevent\\natherosclerosis and abdominal vascular disease.',\n", " 'md': '```markdown\\n## Management of Aortic Conditions\\n\\n### Text\\nDesperately ill for some other reason. Extreme dehydration, for example, may cause ‘sludging’ of major vessels if there has been some pre-existing atheroma. Malignancy may produce intra-arterial thrombosis.\\n\\n- **Aortic dissection**: Suspect this if there is a history of interscapular pain associated with obvious hypertension. Look for evidence of other pulse deficits or signs of visceral ischemia suggesting involvement of other aortic branches.\\n\\n### Management\\nThis depends on the etiology and the presence of any relevant underlying pathology. Embolism may often be dealt with easily by bilateral transfemoral embolectomy under local anesthetic. Thrombosis on pre-existing atheroma is a more difficult problem. Catheter thrombectomy is unlikely to be successful either in the short or long term. If the patient is very fit (unlikely), aortofemoral bypass may be indicated. More likely, an extra-anatomic bypass (axillofemoral) may be feasible, always assuming that any underlying illness is not likely to cause the patient’s demise in the immediate future. Often these patients are not fit for any intervention and the aortic thrombosis is an indication that the end is near.\\n\\nAortic dissection is a complex illness and its management is variable. The mainstay is control of hypertension and relief of major vessel occlusion by endovascular ‘fenestration’ of the dissection. The details of this therapy are beyond the scope of this little book.\\n\\nIn emergency aortic operations, simplicity of the operation is a key for survival: rapid and atraumatic control, avoidance of injury to large veins, a tube graft, minimal blood loss, and rapid surgery.\\n\\nFinally, **Figure 34.2** depicts my own method of choice to prevent atherosclerosis and abdominal vascular disease.\\n\\n### Images\\n- **Figure 34.2**: This figure illustrates a method to prevent atherosclerosis and abdominal vascular disease. The specific details of the image are not provided in the text, but it is noted as a personal method of choice by the author.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Aortic Conditions',\n", " 'md': '## Management of Aortic Conditions',\n", " 'bBox': {'x': 86, 'y': 250, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Desperately ill for some other reason. Extreme dehydration, for example, may cause ‘sludging’ of major vessels if there has been some pre-existing atheroma. Malignancy may produce intra-arterial thrombosis.\\n\\n- **Aortic dissection**: Suspect this if there is a history of interscapular pain associated with obvious hypertension. Look for evidence of other pulse deficits or signs of visceral ischemia suggesting involvement of other aortic branches.',\n", " 'md': 'Desperately ill for some other reason. Extreme dehydration, for example, may cause ‘sludging’ of major vessels if there has been some pre-existing atheroma. Malignancy may produce intra-arterial thrombosis.\\n\\n- **Aortic dissection**: Suspect this if there is a history of interscapular pain associated with obvious hypertension. Look for evidence of other pulse deficits or signs of visceral ischemia suggesting involvement of other aortic branches.',\n", " 'bBox': {'x': 100, 'y': 136, 'w': 235.89, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management',\n", " 'md': '### Management',\n", " 'bBox': {'x': 86, 'y': 250, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This depends on the etiology and the presence of any relevant underlying pathology. Embolism may often be dealt with easily by bilateral transfemoral embolectomy under local anesthetic. Thrombosis on pre-existing atheroma is a more difficult problem. Catheter thrombectomy is unlikely to be successful either in the short or long term. If the patient is very fit (unlikely), aortofemoral bypass may be indicated. More likely, an extra-anatomic bypass (axillofemoral) may be feasible, always assuming that any underlying illness is not likely to cause the patient’s demise in the immediate future. Often these patients are not fit for any intervention and the aortic thrombosis is an indication that the end is near.\\n\\nAortic dissection is a complex illness and its management is variable. The mainstay is control of hypertension and relief of major vessel occlusion by endovascular ‘fenestration’ of the dissection. The details of this therapy are beyond the scope of this little book.\\n\\nIn emergency aortic operations, simplicity of the operation is a key for survival: rapid and atraumatic control, avoidance of injury to large veins, a tube graft, minimal blood loss, and rapid surgery.\\n\\nFinally, **Figure 34.2** depicts my own method of choice to prevent atherosclerosis and abdominal vascular disease.',\n", " 'md': 'This depends on the etiology and the presence of any relevant underlying pathology. Embolism may often be dealt with easily by bilateral transfemoral embolectomy under local anesthetic. Thrombosis on pre-existing atheroma is a more difficult problem. Catheter thrombectomy is unlikely to be successful either in the short or long term. If the patient is very fit (unlikely), aortofemoral bypass may be indicated. More likely, an extra-anatomic bypass (axillofemoral) may be feasible, always assuming that any underlying illness is not likely to cause the patient’s demise in the immediate future. Often these patients are not fit for any intervention and the aortic thrombosis is an indication that the end is near.\\n\\nAortic dissection is a complex illness and its management is variable. The mainstay is control of hypertension and relief of major vessel occlusion by endovascular ‘fenestration’ of the dissection. The details of this therapy are beyond the scope of this little book.\\n\\nIn emergency aortic operations, simplicity of the operation is a key for survival: rapid and atraumatic control, avoidance of injury to large veins, a tube graft, minimal blood loss, and rapid surgery.\\n\\nFinally, **Figure 34.2** depicts my own method of choice to prevent atherosclerosis and abdominal vascular disease.',\n", " 'bBox': {'x': 72, 'y': 250, 'w': 467.66, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Images',\n", " 'md': '### Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 34.2**: This figure illustrates a method to prevent atherosclerosis and abdominal vascular disease. The specific details of the image are not provided in the text, but it is noted as a personal method of choice by the author.\\n```',\n", " 'md': '- **Figure 34.2**: This figure illustrates a method to prevent atherosclerosis and abdominal vascular disease. The specific details of the image are not provided in the text, but it is noted as a personal method of choice by the author.\\n```',\n", " 'bBox': {'x': 72, 'y': 335, 'w': 310.28, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'atherosclerosis and abdominal vascular disease.'}]},\n", " {'page': 631,\n", " 'text': 'Figure 34.2. The author with a bottle of Pol Roger — Winston Churchill’s favorite\\nchampagne. (We wonder how a Scottish surgeon employed by the NHS can afford it .\\nCo-editors.)\\n\\n1 Hardman DT, Fisher CM, Patel MI, et al. Ruptured abdominal aortic aneurysms: who should\\n be offered surgery? J Vasc Surg 1996; 23: 123-9.',\n", " 'md': '```markdown\\n# Page Content\\n\\n**Figure 34.2**: The author with a bottle of Pol Roger — Winston Churchill’s favorite champagne. (We wonder how a Scottish surgeon employed by the NHS can afford it. Co-editors.)\\n\\n1. Hardman DT, Fisher CM, Patel MI, et al. Ruptured abdominal aortic aneurysms: who should be offered surgery? *J Vasc Surg* 1996; 23: 123-9.\\n```\\n\\n### Image Description\\n- **Figure 34.2**: This image features the author holding a bottle of Pol Roger champagne, which is noted as Winston Churchill’s favorite. The context suggests a light-hearted commentary on the affordability of such luxury by a Scottish surgeon working for the NHS.\\n\\n### References\\n- The reference provided is a citation for a medical journal article discussing the criteria for offering surgery to patients with ruptured abdominal aortic aneurysms.',\n", " 'images': [{'name': 'img_p630_1.png',\n", " 'height': 348,\n", " 'width': 323,\n", " 'x': 226.07999999999993,\n", " 'y': 82.80000000000001,\n", " 'original_width': 743,\n", " 'original_height': 800},\n", " {'name': 'img_p630_2.png',\n", " 'height': 14,\n", " 'width': 14,\n", " 'x': 523.4399999999996,\n", " 'y': 277.92}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 34.2**: The author with a bottle of Pol Roger — Winston Churchill’s favorite champagne. (We wonder how a Scottish surgeon employed by the NHS can afford it. Co-editors.)\\n\\n1. Hardman DT, Fisher CM, Patel MI, et al. Ruptured abdominal aortic aneurysms: who should be offered surgery? *J Vasc Surg* 1996; 23: 123-9.\\n```',\n", " 'md': '**Figure 34.2**: The author with a bottle of Pol Roger — Winston Churchill’s favorite champagne. (We wonder how a Scottish surgeon employed by the NHS can afford it. Co-editors.)\\n\\n1. Hardman DT, Fisher CM, Patel MI, et al. Ruptured abdominal aortic aneurysms: who should be offered surgery? *J Vasc Surg* 1996; 23: 123-9.\\n```',\n", " 'bBox': {'x': 73, 'y': 287, 'w': 463, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 34.2**: This image features the author holding a bottle of Pol Roger champagne, which is noted as Winston Churchill’s favorite. The context suggests a light-hearted commentary on the affordability of such luxury by a Scottish surgeon working for the NHS.',\n", " 'md': '- **Figure 34.2**: This image features the author holding a bottle of Pol Roger champagne, which is noted as Winston Churchill’s favorite. The context suggests a light-hearted commentary on the affordability of such luxury by a Scottish surgeon working for the NHS.',\n", " 'bBox': {'x': 533, 'y': 287, 'w': 3, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'References',\n", " 'md': '### References',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The reference provided is a citation for a medical journal article discussing the criteria for offering surgery to patients with ruptured abdominal aortic aneurysms.',\n", " 'md': '- The reference provided is a citation for a medical journal article discussing the criteria for offering surgery to patients with ruptured abdominal aortic aneurysms.',\n", " 'bBox': {'x': 533, 'y': 287, 'w': 3, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 632,\n", " 'text': 'Chapter 35\\nGynecological emergencies\\nMoshe Schein\\n\\n Have you ever seen a surgeon who is convinced that the\\n ‘pelvic acute abdomen’ in a woman is surgical and not due\\n to a gynecological affliction?\\n B. Cristalli\\n\\n We note the quotation above but have you ever seen a gynecologist who is convinced that the\\n ‘acute abdomen’ is gynecological in origin, and not due to acute appendicitis? The Editors\\n\\n In most locales, general surgeons are not expected to undertake\\npractical obstetrics, but it is certain you’ll face a gynecological emergency\\nat some stage. This could involve evaluation of low abdominal pain in a\\nwoman, a common and often difficult situation, or unexpected\\ngynaecological pathology in the OR. You should know how to handle\\nthese eventualities. Acute abdominal pain is common in women during\\ntheir reproductive years. Such pain is as likely to be gynecological as it is\\nto be surgical. Your gynecological colleagues, talented as they are, often\\npossess a vision limited by the boundaries of the bony pelvis ( Figure\\n35.1). Consequently, they are often reluctant to diagnose any acute\\ncondition as ‘gynecological’ unless you have ruled out acute\\nappendicitis. On the other hand, occasionally you operate for what you\\nthink is acute appendicitis, and the findings are gynecological. Another\\nsituation which provides you with the opportunity of interacting with\\ngynecologists/obstetricians, is the pregnant patient. As you know,',\n", " 'md': '```markdown\\n# Chapter 35: Gynecological Emergencies\\n**Author:** Moshe Schein\\n\\nHave you ever seen a surgeon who is convinced that the ‘pelvic acute abdomen’ in a woman is surgical and not due to a gynecological affliction?\\n**- B. Cristalli**\\n\\nWe note the quotation above but have you ever seen a gynecologist who is convinced that the ‘acute abdomen’ is gynecological in origin, and not due to acute appendicitis?\\n**- The Editors**\\n\\nIn most locales, general surgeons are not expected to undertake practical obstetrics, but it is certain you’ll face a gynecological emergency at some stage. This could involve evaluation of low abdominal pain in a woman, a common and often difficult situation, or unexpected gynecological pathology in the OR. You should know how to handle these eventualities. Acute abdominal pain is common in women during their reproductive years. Such pain is as likely to be gynecological as it is to be surgical. Your gynecological colleagues, talented as they are, often possess a vision limited by the boundaries of the bony pelvis (Figure 35.1). Consequently, they are often reluctant to diagnose any acute condition as ‘gynecological’ unless you have ruled out acute appendicitis. On the other hand, occasionally you operate for what you think is acute appendicitis, and the findings are gynecological. Another situation which provides you with the opportunity of interacting with gynecologists/obstetricians, is the pregnant patient. As you know,\\n\\n## Figure 35.1\\n*Description:* This figure likely illustrates the anatomical boundaries of the bony pelvis, which may limit the diagnostic perspective of gynecologists. The figure emphasizes the importance of considering both surgical and gynecological causes of acute abdominal pain in women.\\n\\n*Summary:* The figure serves to highlight the challenges faced by gynecologists in diagnosing acute conditions due to anatomical constraints, reinforcing the need for collaboration between surgical and gynecological specialties.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 35: Gynecological Emergencies',\n", " 'md': '# Chapter 35: Gynecological Emergencies',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 247.52, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Moshe Schein\\n\\nHave you ever seen a surgeon who is convinced that the ‘pelvic acute abdomen’ in a woman is surgical and not due to a gynecological affliction?\\n**- B. Cristalli**\\n\\nWe note the quotation above but have you ever seen a gynecologist who is convinced that the ‘acute abdomen’ is gynecological in origin, and not due to acute appendicitis?\\n**- The Editors**\\n\\nIn most locales, general surgeons are not expected to undertake practical obstetrics, but it is certain you’ll face a gynecological emergency at some stage. This could involve evaluation of low abdominal pain in a woman, a common and often difficult situation, or unexpected gynecological pathology in the OR. You should know how to handle these eventualities. Acute abdominal pain is common in women during their reproductive years. Such pain is as likely to be gynecological as it is to be surgical. Your gynecological colleagues, talented as they are, often possess a vision limited by the boundaries of the bony pelvis (Figure 35.1). Consequently, they are often reluctant to diagnose any acute condition as ‘gynecological’ unless you have ruled out acute appendicitis. On the other hand, occasionally you operate for what you think is acute appendicitis, and the findings are gynecological. Another situation which provides you with the opportunity of interacting with gynecologists/obstetricians, is the pregnant patient. As you know,',\n", " 'md': '**Author:** Moshe Schein\\n\\nHave you ever seen a surgeon who is convinced that the ‘pelvic acute abdomen’ in a woman is surgical and not due to a gynecological affliction?\\n**- B. Cristalli**\\n\\nWe note the quotation above but have you ever seen a gynecologist who is convinced that the ‘acute abdomen’ is gynecological in origin, and not due to acute appendicitis?\\n**- The Editors**\\n\\nIn most locales, general surgeons are not expected to undertake practical obstetrics, but it is certain you’ll face a gynecological emergency at some stage. This could involve evaluation of low abdominal pain in a woman, a common and often difficult situation, or unexpected gynecological pathology in the OR. You should know how to handle these eventualities. Acute abdominal pain is common in women during their reproductive years. Such pain is as likely to be gynecological as it is to be surgical. Your gynecological colleagues, talented as they are, often possess a vision limited by the boundaries of the bony pelvis (Figure 35.1). Consequently, they are often reluctant to diagnose any acute condition as ‘gynecological’ unless you have ruled out acute appendicitis. On the other hand, occasionally you operate for what you think is acute appendicitis, and the findings are gynecological. Another situation which provides you with the opportunity of interacting with gynecologists/obstetricians, is the pregnant patient. As you know,',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 467.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 35.1',\n", " 'md': '## Figure 35.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*Description:* This figure likely illustrates the anatomical boundaries of the bony pelvis, which may limit the diagnostic perspective of gynecologists. The figure emphasizes the importance of considering both surgical and gynecological causes of acute abdominal pain in women.\\n\\n*Summary:* The figure serves to highlight the challenges faced by gynecologists in diagnosing acute conditions due to anatomical constraints, reinforcing the need for collaboration between surgical and gynecological specialties.\\n```',\n", " 'md': '*Description:* This figure likely illustrates the anatomical boundaries of the bony pelvis, which may limit the diagnostic perspective of gynecologists. The figure emphasizes the importance of considering both surgical and gynecological causes of acute abdominal pain in women.\\n\\n*Summary:* The figure serves to highlight the challenges faced by gynecologists in diagnosing acute conditions due to anatomical constraints, reinforcing the need for collaboration between surgical and gynecological specialties.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'possess a vision limited by the boundaries of the bony pelvis ( Figure 35.1). Consequently, they are often reluctant to diagnose any acute condition as ‘gynecological’ unless you have ruled out acute'}]},\n", " {'page': 633,\n", " 'text': 'complications of pregnancy itself may be the cause of abdominal pain\\nwhile in addition it may modify the presentation of common surgical\\ndisorders, making diagnosis difficult. It can also present real problems in\\nthe injured patient.\\n SuRgCRY\\n PERYA24+\\n Figure 35.1. “Call the general surgeon.”\\n\\n Acute pelvic emergencies are common and both surgeon and\\ngynecologist must be able to understand what’s going on and\\ndecide whether it’s the former or the latter who is to be in charge. If\\nyou happen to be on call and see women, whether referred directly or via\\nyour local gynecologist, you’ll encounter mainly two kinds of\\nsyndromes: pain and bleeding. These two conditions may present\\nalone or be associated with other symptoms such as fever, vaginal\\ndischarge, etc. We’re not going to address painless bleeding, which is the\\nbread and butter of gynecological practice.\\n\\n The age of the patient is an important consideration since the\\ngynecological pathology you are likely to encounter differs markedly\\namong the following groups: premenstrual, menstrual-fertile, pregnant,\\nmenopausal — each group having its own disease profile and\\nassociated, different, clinical approach. This chapter deals with problems',\n", " 'md': \"```markdown\\n# Page Content\\n\\nComplications of pregnancy itself may be the cause of abdominal pain while in addition it may modify the presentation of common surgical disorders, making diagnosis difficult. It can also present real problems in the injured patient.\\n\\n**Figure 35.1.** “Call the general surgeon.”\\n\\nAcute pelvic emergencies are common and both surgeon and gynecologist must be able to understand what’s going on and decide whether it’s the former or the latter who is to be in charge. If you happen to be on call and see women, whether referred directly or via your local gynecologist, you’ll encounter mainly two kinds of syndromes: pain and bleeding. These two conditions may present alone or be associated with other symptoms such as fever, vaginal discharge, etc. We’re not going to address painless bleeding, which is the bread and butter of gynecological practice.\\n\\nThe age of the patient is an important consideration since the gynecological pathology you are likely to encounter differs markedly among the following groups: premenstrual, menstrual-fertile, pregnant, menopausal — each group having its own disease profile and associated, different, clinical approach. This chapter deals with problems.\\n```\\n\\n### Image Description\\n\\n**Figure 35.1**: This figure is titled “Call the general surgeon.” It likely depicts a scenario or a flowchart related to the decision-making process in acute pelvic emergencies, emphasizing the need for surgical intervention. The exact content of the image is not provided, but it serves as a visual aid to highlight the importance of recognizing when to involve a general surgeon in gynecological emergencies.\\n\\n### Summary\\n\\nThe text discusses the complexities of diagnosing abdominal pain in pregnant patients and the importance of understanding the different gynecological pathologies based on the patient's age and condition. It emphasizes the need for collaboration between surgeons and gynecologists in managing acute pelvic emergencies.\",\n", " 'images': [{'name': 'img_p632_1.png',\n", " 'height': 540,\n", " 'width': 802,\n", " 'x': 108,\n", " 'y': 149.03999999999996,\n", " 'original_width': 1377,\n", " 'original_height': 928}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Complications of pregnancy itself may be the cause of abdominal pain while in addition it may modify the presentation of common surgical disorders, making diagnosis difficult. It can also present real problems in the injured patient.\\n\\n**Figure 35.1.** “Call the general surgeon.”\\n\\nAcute pelvic emergencies are common and both surgeon and gynecologist must be able to understand what’s going on and decide whether it’s the former or the latter who is to be in charge. If you happen to be on call and see women, whether referred directly or via your local gynecologist, you’ll encounter mainly two kinds of syndromes: pain and bleeding. These two conditions may present alone or be associated with other symptoms such as fever, vaginal discharge, etc. We’re not going to address painless bleeding, which is the bread and butter of gynecological practice.\\n\\nThe age of the patient is an important consideration since the gynecological pathology you are likely to encounter differs markedly among the following groups: premenstrual, menstrual-fertile, pregnant, menopausal — each group having its own disease profile and associated, different, clinical approach. This chapter deals with problems.\\n```',\n", " 'md': 'Complications of pregnancy itself may be the cause of abdominal pain while in addition it may modify the presentation of common surgical disorders, making diagnosis difficult. It can also present real problems in the injured patient.\\n\\n**Figure 35.1.** “Call the general surgeon.”\\n\\nAcute pelvic emergencies are common and both surgeon and gynecologist must be able to understand what’s going on and decide whether it’s the former or the latter who is to be in charge. If you happen to be on call and see women, whether referred directly or via your local gynecologist, you’ll encounter mainly two kinds of syndromes: pain and bleeding. These two conditions may present alone or be associated with other symptoms such as fever, vaginal discharge, etc. We’re not going to address painless bleeding, which is the bread and butter of gynecological practice.\\n\\nThe age of the patient is an important consideration since the gynecological pathology you are likely to encounter differs markedly among the following groups: premenstrual, menstrual-fertile, pregnant, menopausal — each group having its own disease profile and associated, different, clinical approach. This chapter deals with problems.\\n```',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.65, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 35.1**: This figure is titled “Call the general surgeon.” It likely depicts a scenario or a flowchart related to the decision-making process in acute pelvic emergencies, emphasizing the need for surgical intervention. The exact content of the image is not provided, but it serves as a visual aid to highlight the importance of recognizing when to involve a general surgeon in gynecological emergencies.',\n", " 'md': '**Figure 35.1**: This figure is titled “Call the general surgeon.” It likely depicts a scenario or a flowchart related to the decision-making process in acute pelvic emergencies, emphasizing the need for surgical intervention. The exact content of the image is not provided, but it serves as a visual aid to highlight the importance of recognizing when to involve a general surgeon in gynecological emergencies.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"The text discusses the complexities of diagnosing abdominal pain in pregnant patients and the importance of understanding the different gynecological pathologies based on the patient's age and condition. It emphasizes the need for collaboration between surgeons and gynecologists in managing acute pelvic emergencies.\",\n", " 'md': \"The text discusses the complexities of diagnosing abdominal pain in pregnant patients and the importance of understanding the different gynecological pathologies based on the patient's age and condition. It emphasizes the need for collaboration between surgeons and gynecologists in managing acute pelvic emergencies.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 634,\n", " 'text': 'encountered in women of child-bearing potential and those who are\\nalready pregnant since these are the two groups that most frequently\\nproduce dilemmas.\\n\\n Acute abdominal pain in the fertile woman\\n\\n Assessment\\n\\n As a sweeping generalization, all women should be considered\\nfertile (and potentially pregnant) until proven otherwise. In these\\ndays of ovum donation IVF, pregnancy in women in their late fifties\\nis no longer a great rarity!\\n\\n We do not have to remind you to take a history concerning\\nmenstruation, sexual activity and contraception. Pregnancy, whether\\nuterine or ectopic, should always be ruled out; this is done in most\\nhospitals with a rapid pregnancy test. Any history of pain which occurs\\nduring the first days of the menstrual period, hints at underlying\\nendometriosis. Acute pain developing mid-cycle (mittelschmerz) may be\\ndue to rupture of the Graafian follicle at ovulation. Pain referred to the\\nshoulder raises the possibility of free intraperitoneal blood irritating\\nthe diaphragm, with a likely source of bleeding being a ruptured\\novarian cyst or an ectopic pregnancy.\\n\\n We do not want to talk to you about physical examination. You\\nsurely know that the conditions to be discussed below can produce signs\\nof peritoneal irritation, often indistinguishable from those of acute\\nappendicitis. ħowever, the site of pain and local findings on\\nexamination are helpful in narrowing the differential diagnosis. When\\nbilateral, consider pelvic inflammatory disease (PID); when on the right\\nthink about acute appendicitis; when on the left, in an older lady, consider\\nacute diverticulitis ( Chapters 3 and 28). Bimanual vaginal examination\\nperformed by your gynecological colleague (or by you) is an essential\\npart of the assessment of these patients. You are palpating for masses or\\nfullness in the cul-de-sac (pouch of Douglas) and looking for excitation\\ntenderness — when moving the cervix produces a lot of pain (PID,\\nectopic pregnancy).',\n", " 'md': '```markdown\\n# Acute Abdominal Pain in the Fertile Woman\\n\\n## Assessment\\n\\nAs a sweeping generalization, all women should be considered fertile (and potentially pregnant) until proven otherwise. In these days of ovum donation IVF, pregnancy in women in their late fifties is no longer a great rarity!\\n\\nWe do not have to remind you to take a history concerning menstruation, sexual activity, and contraception. Pregnancy, whether uterine or ectopic, should always be ruled out; this is done in most hospitals with a rapid pregnancy test. Any history of pain which occurs during the first days of the menstrual period hints at underlying endometriosis. Acute pain developing mid-cycle (mittelschmerz) may be due to rupture of the Graafian follicle at ovulation. Pain referred to the shoulder raises the possibility of free intraperitoneal blood irritating the diaphragm, with a likely source of bleeding being a ruptured ovarian cyst or an ectopic pregnancy.\\n\\nWe do not want to talk to you about physical examination. You surely know that the conditions to be discussed below can produce signs of peritoneal irritation, often indistinguishable from those of acute appendicitis. However, the site of pain and local findings on examination are helpful in narrowing the differential diagnosis. When bilateral, consider pelvic inflammatory disease (PID); when on the right think about acute appendicitis; when on the left, in an older lady, consider acute diverticulitis (Chapters 3 and 28). Bimanual vaginal examination performed by your gynecological colleague (or by you) is an essential part of the assessment of these patients. You are palpating for masses or fullness in the cul-de-sac (pouch of Douglas) and looking for excitation tenderness — when moving the cervix produces a lot of pain (PID, ectopic pregnancy).\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Acute Abdominal Pain in the Fertile Woman',\n", " 'md': '# Acute Abdominal Pain in the Fertile Woman',\n", " 'bBox': {'x': 86, 'y': 162, 'w': 331.9, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Assessment',\n", " 'md': '## Assessment',\n", " 'bBox': {'x': 86, 'y': 206, 'w': 97.52, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As a sweeping generalization, all women should be considered fertile (and potentially pregnant) until proven otherwise. In these days of ovum donation IVF, pregnancy in women in their late fifties is no longer a great rarity!\\n\\nWe do not have to remind you to take a history concerning menstruation, sexual activity, and contraception. Pregnancy, whether uterine or ectopic, should always be ruled out; this is done in most hospitals with a rapid pregnancy test. Any history of pain which occurs during the first days of the menstrual period hints at underlying endometriosis. Acute pain developing mid-cycle (mittelschmerz) may be due to rupture of the Graafian follicle at ovulation. Pain referred to the shoulder raises the possibility of free intraperitoneal blood irritating the diaphragm, with a likely source of bleeding being a ruptured ovarian cyst or an ectopic pregnancy.\\n\\nWe do not want to talk to you about physical examination. You surely know that the conditions to be discussed below can produce signs of peritoneal irritation, often indistinguishable from those of acute appendicitis. However, the site of pain and local findings on examination are helpful in narrowing the differential diagnosis. When bilateral, consider pelvic inflammatory disease (PID); when on the right think about acute appendicitis; when on the left, in an older lady, consider acute diverticulitis (Chapters 3 and 28). Bimanual vaginal examination performed by your gynecological colleague (or by you) is an essential part of the assessment of these patients. You are palpating for masses or fullness in the cul-de-sac (pouch of Douglas) and looking for excitation tenderness — when moving the cervix produces a lot of pain (PID, ectopic pregnancy).\\n```',\n", " 'md': 'As a sweeping generalization, all women should be considered fertile (and potentially pregnant) until proven otherwise. In these days of ovum donation IVF, pregnancy in women in their late fifties is no longer a great rarity!\\n\\nWe do not have to remind you to take a history concerning menstruation, sexual activity, and contraception. Pregnancy, whether uterine or ectopic, should always be ruled out; this is done in most hospitals with a rapid pregnancy test. Any history of pain which occurs during the first days of the menstrual period hints at underlying endometriosis. Acute pain developing mid-cycle (mittelschmerz) may be due to rupture of the Graafian follicle at ovulation. Pain referred to the shoulder raises the possibility of free intraperitoneal blood irritating the diaphragm, with a likely source of bleeding being a ruptured ovarian cyst or an ectopic pregnancy.\\n\\nWe do not want to talk to you about physical examination. You surely know that the conditions to be discussed below can produce signs of peritoneal irritation, often indistinguishable from those of acute appendicitis. However, the site of pain and local findings on examination are helpful in narrowing the differential diagnosis. When bilateral, consider pelvic inflammatory disease (PID); when on the right think about acute appendicitis; when on the left, in an older lady, consider acute diverticulitis (Chapters 3 and 28). Bimanual vaginal examination performed by your gynecological colleague (or by you) is an essential part of the assessment of these patients. You are palpating for masses or fullness in the cul-de-sac (pouch of Douglas) and looking for excitation tenderness — when moving the cervix produces a lot of pain (PID, ectopic pregnancy).\\n```',\n", " 'bBox': {'x': 72, 'y': 206, 'w': 467.94, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'performed by your gynecological colleague (or by you) is an essential'},\n", " {'text': 'performed by your gynecological colleague (or by you) is an essential'}]},\n", " {'page': 635,\n", " 'text': ' Ultrasound (we hope your gynecologist friend is armed with a\\ntransvaginal ultrasound) is the key investigation, allowing visualization\\nof any free fluid, the uterus and adnexae.\\n\\n Many acutely painful gynecological conditions can be treated\\n non-operatively. With all the above information at hand, your job, together with the\\n gynecologist, is to classify the patient into one of the following groups:\\n\\n ‘Benign’ abdominal examination — most probably a gynecological condition. Treat\\n conservatively.\\n ‘Impressive’ abdominal examination with no apparent gynecological pathology. Get\\n a CT. For some this perhaps is the best indication for diagnostic/therapeutic\\n laparoscopy.\\n ‘Not sure’. Get a CT +/- admit and observe.\\n\\n Ectopic pregnancy\\n\\n The great French surgeon ħenri Mondor said: “When faced with an\\nacute abdomen, consider ectopic pregnancy, think always about it,\\nalways. Just thinking about it again is not enough, keep thinking\\nabout it.”\\n\\n Ectopic means that the fertilized ovum has implanted somewhere\\noutside the usual location (i.e. the body of the uterus). The most\\ncommon site for an ectopic is the tubes, but implantation may occur in\\nthe ovary, cervix and peritoneal cavity. The latter (abdominal ectopic\\npregnancy) is rare and associated with a higher maternal mortality rate\\nthan ectopic pregnancies in general. Unlike ectopic pregnancy at other\\nsites it very rarely leads to delivery of a viable infant. Heterotopic\\npregnancy (intra-uterine and ectopic pregnancy at the same time) is so\\nrare that if a normal pregnancy is seen on ultrasound, an ectopic can be\\nruled out.\\n\\n Although the presentation of these patients varies tremendously,\\ntypically they have abdominal pain and vaginal bleeding. Many women',\n", " 'md': '```markdown\\n## Ultrasound in Gynecological Conditions\\n\\nUltrasound (we hope your gynecologist friend is armed with a transvaginal ultrasound) is the key investigation, allowing visualization of any free fluid, the uterus, and adnexae.\\n\\nMany acutely painful gynecological conditions can be treated non-operatively. With all the above information at hand, your job, together with the gynecologist, is to classify the patient into one of the following groups:\\n\\n- **‘Benign’ abdominal examination** — most probably a gynecological condition. Treat conservatively.\\n- **‘Impressive’ abdominal examination** with no apparent gynecological pathology. Get a CT. For some, this perhaps is the best indication for diagnostic/therapeutic laparoscopy.\\n- **‘Not sure’**. Get a CT +/- admit and observe.\\n\\n### Ectopic Pregnancy\\n\\nThe great French surgeon Henri Mondor said: “When faced with an acute abdomen, consider ectopic pregnancy, think always about it, always. Just thinking about it again is not enough, keep thinking about it.”\\n\\nEctopic means that the fertilized ovum has implanted somewhere outside the usual location (i.e., the body of the uterus). The most common site for an ectopic is the tubes, but implantation may occur in the ovary, cervix, and peritoneal cavity. The latter (abdominal ectopic pregnancy) is rare and associated with a higher maternal mortality rate than ectopic pregnancies in general. Unlike ectopic pregnancy at other sites, it very rarely leads to delivery of a viable infant. Heterotopic pregnancy (intra-uterine and ectopic pregnancy at the same time) is so rare that if a normal pregnancy is seen on ultrasound, an ectopic can be ruled out.\\n\\nAlthough the presentation of these patients varies tremendously, typically they have abdominal pain and vaginal bleeding. Many women...\\n```',\n", " 'images': [{'name': 'img_p634_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 226.07999999999998},\n", " {'name': 'img_p634_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 266.4},\n", " {'name': 'img_p634_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 325.44}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Ultrasound in Gynecological Conditions',\n", " 'md': '## Ultrasound in Gynecological Conditions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Ultrasound (we hope your gynecologist friend is armed with a transvaginal ultrasound) is the key investigation, allowing visualization of any free fluid, the uterus, and adnexae.\\n\\nMany acutely painful gynecological conditions can be treated non-operatively. With all the above information at hand, your job, together with the gynecologist, is to classify the patient into one of the following groups:\\n\\n- **‘Benign’ abdominal examination** — most probably a gynecological condition. Treat conservatively.\\n- **‘Impressive’ abdominal examination** with no apparent gynecological pathology. Get a CT. For some, this perhaps is the best indication for diagnostic/therapeutic laparoscopy.\\n- **‘Not sure’**. Get a CT +/- admit and observe.',\n", " 'md': 'Ultrasound (we hope your gynecologist friend is armed with a transvaginal ultrasound) is the key investigation, allowing visualization of any free fluid, the uterus, and adnexae.\\n\\nMany acutely painful gynecological conditions can be treated non-operatively. With all the above information at hand, your job, together with the gynecologist, is to classify the patient into one of the following groups:\\n\\n- **‘Benign’ abdominal examination** — most probably a gynecological condition. Treat conservatively.\\n- **‘Impressive’ abdominal examination** with no apparent gynecological pathology. Get a CT. For some, this perhaps is the best indication for diagnostic/therapeutic laparoscopy.\\n- **‘Not sure’**. Get a CT +/- admit and observe.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 466.77, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Ectopic Pregnancy',\n", " 'md': '### Ectopic Pregnancy',\n", " 'bBox': {'x': 86, 'y': 392, 'w': 148.07, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The great French surgeon Henri Mondor said: “When faced with an acute abdomen, consider ectopic pregnancy, think always about it, always. Just thinking about it again is not enough, keep thinking about it.”\\n\\nEctopic means that the fertilized ovum has implanted somewhere outside the usual location (i.e., the body of the uterus). The most common site for an ectopic is the tubes, but implantation may occur in the ovary, cervix, and peritoneal cavity. The latter (abdominal ectopic pregnancy) is rare and associated with a higher maternal mortality rate than ectopic pregnancies in general. Unlike ectopic pregnancy at other sites, it very rarely leads to delivery of a viable infant. Heterotopic pregnancy (intra-uterine and ectopic pregnancy at the same time) is so rare that if a normal pregnancy is seen on ultrasound, an ectopic can be ruled out.\\n\\nAlthough the presentation of these patients varies tremendously, typically they have abdominal pain and vaginal bleeding. Many women...\\n```',\n", " 'md': 'The great French surgeon Henri Mondor said: “When faced with an acute abdomen, consider ectopic pregnancy, think always about it, always. Just thinking about it again is not enough, keep thinking about it.”\\n\\nEctopic means that the fertilized ovum has implanted somewhere outside the usual location (i.e., the body of the uterus). The most common site for an ectopic is the tubes, but implantation may occur in the ovary, cervix, and peritoneal cavity. The latter (abdominal ectopic pregnancy) is rare and associated with a higher maternal mortality rate than ectopic pregnancies in general. Unlike ectopic pregnancy at other sites, it very rarely leads to delivery of a viable infant. Heterotopic pregnancy (intra-uterine and ectopic pregnancy at the same time) is so rare that if a normal pregnancy is seen on ultrasound, an ectopic can be ruled out.\\n\\nAlthough the presentation of these patients varies tremendously, typically they have abdominal pain and vaginal bleeding. Many women...\\n```',\n", " 'bBox': {'x': 72, 'y': 392, 'w': 467.72, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 636,\n", " 'text': 'do not even know about the pregnancy, ignoring associated symptoms of\\npregnancy such as a missed menstrual period. Some elements of history\\nmay be considered risk factors: previous history of ectopic pregnancy,\\nPID, endometriosis and tubal surgery — including previous tubal ligation!\\nContraception with an intra-uterine device (IUD) is not a risk factor in\\nitself but an early pregnancy with an IUD in situ has to be considered\\nectopic until proven otherwise. An IUD prevents intra-uterine\\npregnancies, but not ectopics! IVF is a risk factor.\\n\\n The diagnosis rests on a tripod of pregnancy, pain and bleeding.\\nTypically the patient arrives with a sharp and sudden unilateral pelvic\\npain, mild brownish bleeding and pregnancy (positive pregnancy test)\\nwith an empty uterus at ultrasound. The diagnosis comes easily when the\\nwoman knows she’s pregnant and has vaginal bleeding. It can be a lot\\nmore difficult when pain is the only sign and the pregnancy is yet to be\\ndiscovered. Cataclysmic hemorrhage is very rare nowadays, but any\\ninternal hemorrhage syndrome in a woman is a ruptured ectopic\\npregnancy until proven otherwise.\\n\\n Physical findings include signs of hypovolemic shock and peritoneal\\nirritation that are proportional to the amount of blood loss. On pelvic\\nexamination you may find a para-uterine painful mass or at least a ‘little\\nsomething’ next to the uterus. The pouch of Douglas is tender and may\\ncontain a boggy mass (hematocele).\\n\\n Ultrasound is the imaging of choice to show the ectopic gestational\\nsac and free intraperitoneal bleeding.\\n\\n Management\\n\\n Although some ectopic pregnancies may resolve and absorb\\nspontaneously over time, the standard of care is an operative approach\\nin all cases. As a general surgeon you are most likely to be involved with\\nthe more dramatic scenario of a ruptured tubal ectopic (usually affecting\\nthe distal segment of the tube) which may occur as early as the 4th week\\nof gestation.',\n", " 'md': '```markdown\\n## Ectopic Pregnancy Overview\\n\\nEctopic pregnancy can often go unnoticed, with individuals sometimes unaware of their pregnancy and ignoring associated symptoms such as a missed menstrual period. Certain historical factors may be considered as risks, including:\\n\\n- Previous history of ectopic pregnancy\\n- Pelvic Inflammatory Disease (PID)\\n- Endometriosis\\n- Tubal surgery, including previous tubal ligation\\n\\nWhile contraception with an intra-uterine device (IUD) is not a risk factor by itself, an early pregnancy with an IUD in place must be considered ectopic until proven otherwise. An IUD prevents intra-uterine pregnancies but does not prevent ectopic pregnancies. Additionally, in vitro fertilization (IVF) is recognized as a risk factor.\\n\\n### Diagnosis\\n\\nThe diagnosis of ectopic pregnancy relies on three key elements: pregnancy, pain, and bleeding. Typically, patients present with:\\n\\n- Sharp and sudden unilateral pelvic pain\\n- Mild brownish bleeding\\n- A positive pregnancy test with an empty uterus observed on ultrasound\\n\\nThe diagnosis is straightforward when the patient is aware of their pregnancy and experiences vaginal bleeding. However, it becomes more challenging when pain is the only symptom and the pregnancy has not yet been identified. Although cataclysmic hemorrhage is rare today, any internal hemorrhage syndrome in a woman is considered a ruptured ectopic pregnancy until proven otherwise.\\n\\n### Physical Findings\\n\\nPhysical examination may reveal:\\n\\n- Signs of hypovolemic shock\\n- Peritoneal irritation, proportional to the amount of blood loss\\n- On pelvic examination, a para-uterine painful mass or a vague mass next to the uterus\\n- Tenderness in the pouch of Douglas, which may contain a boggy mass (hematocele)\\n\\n### Imaging\\n\\nUltrasound is the preferred imaging technique to identify the ectopic gestational sac and any free intraperitoneal bleeding.\\n\\n### Management\\n\\nWhile some ectopic pregnancies may resolve and absorb spontaneously over time, the standard of care is an operative approach in all cases. As a general surgeon, you are likely to encounter the more dramatic scenario of a ruptured tubal ectopic, which can occur as early as the 4th week of gestation.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Ectopic Pregnancy Overview',\n", " 'md': '## Ectopic Pregnancy Overview',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Ectopic pregnancy can often go unnoticed, with individuals sometimes unaware of their pregnancy and ignoring associated symptoms such as a missed menstrual period. Certain historical factors may be considered as risks, including:\\n\\n- Previous history of ectopic pregnancy\\n- Pelvic Inflammatory Disease (PID)\\n- Endometriosis\\n- Tubal surgery, including previous tubal ligation\\n\\nWhile contraception with an intra-uterine device (IUD) is not a risk factor by itself, an early pregnancy with an IUD in place must be considered ectopic until proven otherwise. An IUD prevents intra-uterine pregnancies but does not prevent ectopic pregnancies. Additionally, in vitro fertilization (IVF) is recognized as a risk factor.',\n", " 'md': 'Ectopic pregnancy can often go unnoticed, with individuals sometimes unaware of their pregnancy and ignoring associated symptoms such as a missed menstrual period. Certain historical factors may be considered as risks, including:\\n\\n- Previous history of ectopic pregnancy\\n- Pelvic Inflammatory Disease (PID)\\n- Endometriosis\\n- Tubal surgery, including previous tubal ligation\\n\\nWhile contraception with an intra-uterine device (IUD) is not a risk factor by itself, an early pregnancy with an IUD in place must be considered ectopic until proven otherwise. An IUD prevents intra-uterine pregnancies but does not prevent ectopic pregnancies. Additionally, in vitro fertilization (IVF) is recognized as a risk factor.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diagnosis',\n", " 'md': '### Diagnosis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The diagnosis of ectopic pregnancy relies on three key elements: pregnancy, pain, and bleeding. Typically, patients present with:\\n\\n- Sharp and sudden unilateral pelvic pain\\n- Mild brownish bleeding\\n- A positive pregnancy test with an empty uterus observed on ultrasound\\n\\nThe diagnosis is straightforward when the patient is aware of their pregnancy and experiences vaginal bleeding. However, it becomes more challenging when pain is the only symptom and the pregnancy has not yet been identified. Although cataclysmic hemorrhage is rare today, any internal hemorrhage syndrome in a woman is considered a ruptured ectopic pregnancy until proven otherwise.',\n", " 'md': 'The diagnosis of ectopic pregnancy relies on three key elements: pregnancy, pain, and bleeding. Typically, patients present with:\\n\\n- Sharp and sudden unilateral pelvic pain\\n- Mild brownish bleeding\\n- A positive pregnancy test with an empty uterus observed on ultrasound\\n\\nThe diagnosis is straightforward when the patient is aware of their pregnancy and experiences vaginal bleeding. However, it becomes more challenging when pain is the only symptom and the pregnancy has not yet been identified. Although cataclysmic hemorrhage is rare today, any internal hemorrhage syndrome in a woman is considered a ruptured ectopic pregnancy until proven otherwise.',\n", " 'bBox': {'x': 72, 'y': 369, 'w': 234, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Physical Findings',\n", " 'md': '### Physical Findings',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Physical examination may reveal:\\n\\n- Signs of hypovolemic shock\\n- Peritoneal irritation, proportional to the amount of blood loss\\n- On pelvic examination, a para-uterine painful mass or a vague mass next to the uterus\\n- Tenderness in the pouch of Douglas, which may contain a boggy mass (hematocele)',\n", " 'md': 'Physical examination may reveal:\\n\\n- Signs of hypovolemic shock\\n- Peritoneal irritation, proportional to the amount of blood loss\\n- On pelvic examination, a para-uterine painful mass or a vague mass next to the uterus\\n- Tenderness in the pouch of Douglas, which may contain a boggy mass (hematocele)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Imaging',\n", " 'md': '### Imaging',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Ultrasound is the preferred imaging technique to identify the ectopic gestational sac and any free intraperitoneal bleeding.',\n", " 'md': 'Ultrasound is the preferred imaging technique to identify the ectopic gestational sac and any free intraperitoneal bleeding.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management',\n", " 'md': '### Management',\n", " 'bBox': {'x': 86, 'y': 566, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'While some ectopic pregnancies may resolve and absorb spontaneously over time, the standard of care is an operative approach in all cases. As a general surgeon, you are likely to encounter the more dramatic scenario of a ruptured tubal ectopic, which can occur as early as the 4th week of gestation.\\n```',\n", " 'md': 'While some ectopic pregnancies may resolve and absorb spontaneously over time, the standard of care is an operative approach in all cases. As a general surgeon, you are likely to encounter the more dramatic scenario of a ruptured tubal ectopic, which can occur as early as the 4th week of gestation.\\n```',\n", " 'bBox': {'x': 72, 'y': 618, 'w': 467.79, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 637,\n", " 'text': ' The sudden development of acute peritonitis and hypovolemic\\nshock will force you to rush to the operating room without the\\ngynecologist and perform a laparotomy. Whether to enter the\\nabdomen through a midline incision or a Pfannenstiel incision depends\\non the urgency of the situation and the build of the patient.\\nSalpingectomy is usually the safest option. Control the bleeding sites with\\nsuture-ligatures and preserve the ovary. If the patient is not ‘bleeding\\nto death’ (rare!) then the procedure should be preferably performed\\n— by you, or in partnership with the gynecologist — through the\\nlaparoscope. In early cases, the uterus is normal or mildly enlarged and\\nthe ectopic pregnancy can be seen as a tube swollen by a blue ‘tumor’\\nand there is a small to moderate amount of black blood in the pouch of\\nDouglas. Note that in most ectopics at operation the bleeding has already\\nstopped; when it is active it may necessitate a simple salpingectomy.\\nWhen the ovaries are left intact the patient can still undergo in vitro\\nfertilization even after bilateral salpingectomies.\\n\\n Ovarian cysts\\n\\n Ovarian cysts are common in young women — they are usually\\n‘functional’ cysts (follicular or corpus luteum) and mostly asymptomatic.\\nħowever, when cysts develop in postmenopausal women, ovarian cancer\\nhas to be suspected and excluded. Only complicated ovarian cysts,\\nregardless of etiology, present as surgical emergencies.\\n\\n Acute pain develops when a cyst bleeds or undergoes torsion or\\nrupture. The intensity of pain and abdominal signs of peritoneal irritation\\nare proportional to the amount of bleeding. Pain is severe in the case of\\ntorsion. In women of childbearing age complications of ovarian cyst\\nmay mimic acute appendicitis, so to prevent an unnecessary\\noperation you have to image the abdomen ( Chapter 23).\\n\\n Imaging\\n\\n Typically, functional cysts are solitary, simple and small (<8cm). Free\\nfluid in the pouch of Douglas suggests rupture and bleeding. Larger and\\nmore complex cysts suggest pathology such as a dermoid cyst. Absence',\n", " 'md': '```markdown\\n# Page Content\\n\\nThe sudden development of acute peritonitis and hypovolemic shock will force you to rush to the operating room without the gynecologist and perform a laparotomy. Whether to enter the abdomen through a midline incision or a Pfannenstiel incision depends on the urgency of the situation and the build of the patient. Salpingectomy is usually the safest option. Control the bleeding sites with suture-ligatures and preserve the ovary. If the patient is not ‘bleeding to death’ (rare!) then the procedure should be preferably performed — by you, or in partnership with the gynecologist — through the laparoscope. In early cases, the uterus is normal or mildly enlarged and the ectopic pregnancy can be seen as a tube swollen by a blue ‘tumor’ and there is a small to moderate amount of black blood in the pouch of Douglas. Note that in most ectopics at operation the bleeding has already stopped; when it is active it may necessitate a simple salpingectomy. When the ovaries are left intact the patient can still undergo in vitro fertilization even after bilateral salpingectomies.\\n\\n## Ovarian Cysts\\n\\nOvarian cysts are common in young women — they are usually ‘functional’ cysts (follicular or corpus luteum) and mostly asymptomatic. However, when cysts develop in postmenopausal women, ovarian cancer has to be suspected and excluded. Only complicated ovarian cysts, regardless of etiology, present as surgical emergencies.\\n\\nAcute pain develops when a cyst bleeds or undergoes torsion or rupture. The intensity of pain and abdominal signs of peritoneal irritation are proportional to the amount of bleeding. Pain is severe in the case of torsion. In women of childbearing age, complications of ovarian cysts may mimic acute appendicitis, so to prevent an unnecessary operation you have to image the abdomen (Chapter 23).\\n\\n## Imaging\\n\\nTypically, functional cysts are solitary, simple and small (<8cm). Free fluid in the pouch of Douglas suggests rupture and bleeding. Larger and more complex cysts suggest pathology such as a dermoid cyst. Absence\\n```\\n\\n### Notes:\\n- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The sudden development of acute peritonitis and hypovolemic shock will force you to rush to the operating room without the gynecologist and perform a laparotomy. Whether to enter the abdomen through a midline incision or a Pfannenstiel incision depends on the urgency of the situation and the build of the patient. Salpingectomy is usually the safest option. Control the bleeding sites with suture-ligatures and preserve the ovary. If the patient is not ‘bleeding to death’ (rare!) then the procedure should be preferably performed — by you, or in partnership with the gynecologist — through the laparoscope. In early cases, the uterus is normal or mildly enlarged and the ectopic pregnancy can be seen as a tube swollen by a blue ‘tumor’ and there is a small to moderate amount of black blood in the pouch of Douglas. Note that in most ectopics at operation the bleeding has already stopped; when it is active it may necessitate a simple salpingectomy. When the ovaries are left intact the patient can still undergo in vitro fertilization even after bilateral salpingectomies.',\n", " 'md': 'The sudden development of acute peritonitis and hypovolemic shock will force you to rush to the operating room without the gynecologist and perform a laparotomy. Whether to enter the abdomen through a midline incision or a Pfannenstiel incision depends on the urgency of the situation and the build of the patient. Salpingectomy is usually the safest option. Control the bleeding sites with suture-ligatures and preserve the ovary. If the patient is not ‘bleeding to death’ (rare!) then the procedure should be preferably performed — by you, or in partnership with the gynecologist — through the laparoscope. In early cases, the uterus is normal or mildly enlarged and the ectopic pregnancy can be seen as a tube swollen by a blue ‘tumor’ and there is a small to moderate amount of black blood in the pouch of Douglas. Note that in most ectopics at operation the bleeding has already stopped; when it is active it may necessitate a simple salpingectomy. When the ovaries are left intact the patient can still undergo in vitro fertilization even after bilateral salpingectomies.',\n", " 'bBox': {'x': 72, 'y': 168, 'w': 468.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Ovarian Cysts',\n", " 'md': '## Ovarian Cysts',\n", " 'bBox': {'x': 86, 'y': 377, 'w': 108.53, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Ovarian cysts are common in young women — they are usually ‘functional’ cysts (follicular or corpus luteum) and mostly asymptomatic. However, when cysts develop in postmenopausal women, ovarian cancer has to be suspected and excluded. Only complicated ovarian cysts, regardless of etiology, present as surgical emergencies.\\n\\nAcute pain develops when a cyst bleeds or undergoes torsion or rupture. The intensity of pain and abdominal signs of peritoneal irritation are proportional to the amount of bleeding. Pain is severe in the case of torsion. In women of childbearing age, complications of ovarian cysts may mimic acute appendicitis, so to prevent an unnecessary operation you have to image the abdomen (Chapter 23).',\n", " 'md': 'Ovarian cysts are common in young women — they are usually ‘functional’ cysts (follicular or corpus luteum) and mostly asymptomatic. However, when cysts develop in postmenopausal women, ovarian cancer has to be suspected and excluded. Only complicated ovarian cysts, regardless of etiology, present as surgical emergencies.\\n\\nAcute pain develops when a cyst bleeds or undergoes torsion or rupture. The intensity of pain and abdominal signs of peritoneal irritation are proportional to the amount of bleeding. Pain is severe in the case of torsion. In women of childbearing age, complications of ovarian cysts may mimic acute appendicitis, so to prevent an unnecessary operation you have to image the abdomen (Chapter 23).',\n", " 'bBox': {'x': 72, 'y': 377, 'w': 467.92, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Imaging',\n", " 'md': '## Imaging',\n", " 'bBox': {'x': 86, 'y': 641, 'w': 63.44, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Typically, functional cysts are solitary, simple and small (<8cm). Free fluid in the pouch of Douglas suggests rupture and bleeding. Larger and more complex cysts suggest pathology such as a dermoid cyst. Absence\\n```',\n", " 'md': 'Typically, functional cysts are solitary, simple and small (<8cm). Free fluid in the pouch of Douglas suggests rupture and bleeding. Larger and more complex cysts suggest pathology such as a dermoid cyst. Absence\\n```',\n", " 'bBox': {'x': 72, 'y': 693, 'w': 467.39, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images or figures were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 638,\n", " 'text': 'of blood flow on ultrasound strongly indicates torsion. Most such\\npatients initially undergo a CT examination to exclude acute appendicitis,\\nwhich in addition to showing a normal appendix may document the free\\npelvic fluid and the ovarian pathology. If this is the case we would follow\\nup with a transvaginal ultrasound which is more accurate in delineating\\nthe pelvic pathology.\\n\\n Management\\n\\n Small (<8cm) simple ruptured cysts with minimal local and\\nsystemic findings should be treated conservatively. If, however, the\\nrupture results in significant intraperitoneal hemorrhage and when\\nanother pathology cannot be ruled out (e.g. larger or complex cysts),\\nsurgical intervention is indicated. Laparoscopy is preferable for\\nsmaller cysts and when malignancy is not suspected, but for very\\nlarge cysts (>10cm) laparotomy allows removal of the intact ovarian\\nmass without disrupting it. Whether you can do this through a\\nPfannenstiel incision depends on the build of the patient.\\n\\n Torsion is usually associated with more severe and persistent\\npain and more dramatic abdominal findings together with systemic\\nmanifestations; it is an indication for urgent operation. At operation if\\nthere is active bleeding from the cyst, obtain local hemostasis by\\nwhichever means. There is no need to aspirate or resect the cyst and\\nplease, do not even think of removing the ovary. If viable, the tube\\nand ovary can be detorted and conserved; only if clearly non-viable is the\\novary resected. Dermoid cysts are resected. Ovarian malignancies are\\nbeyond the scope of this compact book.\\n\\n Pelvic inflammatory disease (PID)\\n\\n Pelvic inflammatory disease is seldom a surgical emergency\\nnowadays, but it remains a frequent reason to visit the emergency room.\\nIt is an infective syndrome which involves, to a greater or lesser extent,\\nthe endometrium, tubes and ovaries. The patient is commonly young and\\nsexually active. The clinical spectrum of infection is wide, ranging from\\nminimal pain, dyspareunia, fever, and vaginal discharge, associated with',\n", " 'md': '```markdown\\n## Management\\n\\nSmall (<8cm) simple ruptured cysts with minimal local and systemic findings should be treated conservatively. If, however, the rupture results in significant intraperitoneal hemorrhage and when another pathology cannot be ruled out (e.g. larger or complex cysts), surgical intervention is indicated. Laparoscopy is preferable for smaller cysts and when malignancy is not suspected, but for very large cysts (>10cm) laparotomy allows removal of the intact ovarian mass without disrupting it. Whether you can do this through a Pfannenstiel incision depends on the build of the patient.\\n\\nTorsion is usually associated with more severe and persistent pain and more dramatic abdominal findings together with systemic manifestations; it is an indication for urgent operation. At operation if there is active bleeding from the cyst, obtain local hemostasis by whichever means. There is no need to aspirate or resect the cyst and please, do not even think of removing the ovary. If viable, the tube and ovary can be detorted and conserved; only if clearly non-viable is the ovary resected. Dermoid cysts are resected. Ovarian malignancies are beyond the scope of this compact book.\\n\\n## Pelvic Inflammatory Disease (PID)\\n\\nPelvic inflammatory disease is seldom a surgical emergency nowadays, but it remains a frequent reason to visit the emergency room. It is an infective syndrome which involves, to a greater or lesser extent, the endometrium, tubes and ovaries. The patient is commonly young and sexually active. The clinical spectrum of infection is wide, ranging from minimal pain, dyspareunia, fever, and vaginal discharge, associated with\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management',\n", " 'md': '## Management',\n", " 'bBox': {'x': 86, 'y': 211, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Small (<8cm) simple ruptured cysts with minimal local and systemic findings should be treated conservatively. If, however, the rupture results in significant intraperitoneal hemorrhage and when another pathology cannot be ruled out (e.g. larger or complex cysts), surgical intervention is indicated. Laparoscopy is preferable for smaller cysts and when malignancy is not suspected, but for very large cysts (>10cm) laparotomy allows removal of the intact ovarian mass without disrupting it. Whether you can do this through a Pfannenstiel incision depends on the build of the patient.\\n\\nTorsion is usually associated with more severe and persistent pain and more dramatic abdominal findings together with systemic manifestations; it is an indication for urgent operation. At operation if there is active bleeding from the cyst, obtain local hemostasis by whichever means. There is no need to aspirate or resect the cyst and please, do not even think of removing the ovary. If viable, the tube and ovary can be detorted and conserved; only if clearly non-viable is the ovary resected. Dermoid cysts are resected. Ovarian malignancies are beyond the scope of this compact book.',\n", " 'md': 'Small (<8cm) simple ruptured cysts with minimal local and systemic findings should be treated conservatively. If, however, the rupture results in significant intraperitoneal hemorrhage and when another pathology cannot be ruled out (e.g. larger or complex cysts), surgical intervention is indicated. Laparoscopy is preferable for smaller cysts and when malignancy is not suspected, but for very large cysts (>10cm) laparotomy allows removal of the intact ovarian mass without disrupting it. Whether you can do this through a Pfannenstiel incision depends on the build of the patient.\\n\\nTorsion is usually associated with more severe and persistent pain and more dramatic abdominal findings together with systemic manifestations; it is an indication for urgent operation. At operation if there is active bleeding from the cyst, obtain local hemostasis by whichever means. There is no need to aspirate or resect the cyst and please, do not even think of removing the ovary. If viable, the tube and ovary can be detorted and conserved; only if clearly non-viable is the ovary resected. Dermoid cysts are resected. Ovarian malignancies are beyond the scope of this compact book.',\n", " 'bBox': {'x': 72, 'y': 347, 'w': 467.61, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Pelvic Inflammatory Disease (PID)',\n", " 'md': '## Pelvic Inflammatory Disease (PID)',\n", " 'bBox': {'x': 86, 'y': 591, 'w': 264.83, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Pelvic inflammatory disease is seldom a surgical emergency nowadays, but it remains a frequent reason to visit the emergency room. It is an infective syndrome which involves, to a greater or lesser extent, the endometrium, tubes and ovaries. The patient is commonly young and sexually active. The clinical spectrum of infection is wide, ranging from minimal pain, dyspareunia, fever, and vaginal discharge, associated with\\n```',\n", " 'md': 'Pelvic inflammatory disease is seldom a surgical emergency nowadays, but it remains a frequent reason to visit the emergency room. It is an infective syndrome which involves, to a greater or lesser extent, the endometrium, tubes and ovaries. The patient is commonly young and sexually active. The clinical spectrum of infection is wide, ranging from minimal pain, dyspareunia, fever, and vaginal discharge, associated with\\n```',\n", " 'bBox': {'x': 72, 'y': 643, 'w': 467.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 639,\n", " 'text': 'mild endometritis/salpingitis, to severe peritonitis and septic shock due to\\na ruptured tubo-ovarian abscess. Likewise, physical findings depend on\\nthe disease process and vary from localized abdominal tenderness to\\ngeneralized tenderness and rebound. Note that the pain and tenderness\\nare commonly bilateral. Pelvic examination reveals a purulent discharge\\nwith cervical motion tenderness. Ovarian or pelvic abscesses may be\\npalpated or seen on ultrasound or CT.\\n\\n Treatment\\n\\n Without treatment the infection may develop into a tubal abscess and\\nthen spread intrapelvically and result in a true peritonitis. The late risk is\\ntubal obstruction and pelvic adhesions leading to infertility and chronic\\npelvic pain. The majority of mild cases should be treated with\\nantibiotics. Outpatient treatment is appropriate for patients who can\\ntolerate oral diet. Patients with severe abdominal and systemic\\nmanifestations should be admitted for intravenous antibiotic therapy.\\nAntibiotic treatment is empiric, targeting the common causative\\norganisms which are, in isolation or combination, Chlamydia trachomatis,\\nNeisseria gonorrhoeae, Escherichia coli and Haemophilus influenzae.\\nMany oral and i.v. agents are available for you to choose from (e.g.\\ndoxycycline orally, ampicillin/sulbactam or cefoxitin intravenously).\\n\\n Patients who do not respond to the above regimen or in whom the\\ndiagnosis is uncertain are subjected to laparoscopy. This should be left to\\nthe gynecologist. The typical case you will be involved with is the\\nruptured tubo-ovarian abscess, causing severe pelvic or diffuse\\nperitonitis. During laparotomy or laparoscopy you’ll find pus; you can\\nread how to deal with peritonitis in Chapter 13. The abscess should be\\ndrained; whether to remove the uterus and ovaries depends on the age\\nof the patient, the operative findings and your gynecologist.\\n\\n When talking about PID, textbooks usually mention the Fitz-Hugh-\\nCurtis syndrome or ‘perihepatitis’ as a late sequel — ascending from the\\npelvis. Although originally associated with gonococcal infection, nearly all\\npresent-day cases are associated with C. trachomatis infection. It may\\nproduce non-specific abdominal complaints and has been reported to\\nmimic acute cholecystitis, but in our experience it has never represented',\n", " 'md': '```markdown\\n## Page Content\\n\\nMild endometritis/salpingitis can progress to severe peritonitis and septic shock due to a ruptured tubo-ovarian abscess. Physical findings depend on the disease process and vary from localized abdominal tenderness to generalized tenderness and rebound. Note that the pain and tenderness are commonly bilateral. Pelvic examination reveals a purulent discharge with cervical motion tenderness. Ovarian or pelvic abscesses may be palpated or seen on ultrasound or CT.\\n\\n### Treatment\\n\\nWithout treatment, the infection may develop into a tubal abscess and then spread intrapelvically, resulting in true peritonitis. The late risk includes tubal obstruction and pelvic adhesions leading to infertility and chronic pelvic pain. The majority of mild cases should be treated with antibiotics. Outpatient treatment is appropriate for patients who can tolerate an oral diet. Patients with severe abdominal and systemic manifestations should be admitted for intravenous antibiotic therapy. Antibiotic treatment is empiric, targeting the common causative organisms which are, in isolation or combination, Chlamydia trachomatis, Neisseria gonorrhoeae, Escherichia coli, and Haemophilus influenzae. Many oral and intravenous agents are available for selection (e.g., doxycycline orally, ampicillin/sulbactam, or cefoxitin intravenously).\\n\\nPatients who do not respond to the above regimen or in whom the diagnosis is uncertain are subjected to laparoscopy. This should be left to the gynecologist. The typical case you will be involved with is the ruptured tubo-ovarian abscess, causing severe pelvic or diffuse peritonitis. During laparotomy or laparoscopy, pus will be found; you can read how to deal with peritonitis in Chapter 13. The abscess should be drained; whether to remove the uterus and ovaries depends on the age of the patient, the operative findings, and your gynecologist.\\n\\nWhen discussing PID, textbooks usually mention the Fitz-Hugh-Curtis syndrome or ‘perihepatitis’ as a late sequel — ascending from the pelvis. Although originally associated with gonococcal infection, nearly all present-day cases are associated with C. trachomatis infection. It may produce non-specific abdominal complaints and has been reported to mimic acute cholecystitis, but in our experience, it has never represented.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Mild endometritis/salpingitis can progress to severe peritonitis and septic shock due to a ruptured tubo-ovarian abscess. Physical findings depend on the disease process and vary from localized abdominal tenderness to generalized tenderness and rebound. Note that the pain and tenderness are commonly bilateral. Pelvic examination reveals a purulent discharge with cervical motion tenderness. Ovarian or pelvic abscesses may be palpated or seen on ultrasound or CT.',\n", " 'md': 'Mild endometritis/salpingitis can progress to severe peritonitis and septic shock due to a ruptured tubo-ovarian abscess. Physical findings depend on the disease process and vary from localized abdominal tenderness to generalized tenderness and rebound. Note that the pain and tenderness are commonly bilateral. Pelvic examination reveals a purulent discharge with cervical motion tenderness. Ovarian or pelvic abscesses may be palpated or seen on ultrasound or CT.',\n", " 'bBox': {'x': 72, 'y': 136, 'w': 467.64, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Treatment',\n", " 'md': '### Treatment',\n", " 'bBox': {'x': 86, 'y': 228, 'w': 79.1, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Without treatment, the infection may develop into a tubal abscess and then spread intrapelvically, resulting in true peritonitis. The late risk includes tubal obstruction and pelvic adhesions leading to infertility and chronic pelvic pain. The majority of mild cases should be treated with antibiotics. Outpatient treatment is appropriate for patients who can tolerate an oral diet. Patients with severe abdominal and systemic manifestations should be admitted for intravenous antibiotic therapy. Antibiotic treatment is empiric, targeting the common causative organisms which are, in isolation or combination, Chlamydia trachomatis, Neisseria gonorrhoeae, Escherichia coli, and Haemophilus influenzae. Many oral and intravenous agents are available for selection (e.g., doxycycline orally, ampicillin/sulbactam, or cefoxitin intravenously).\\n\\nPatients who do not respond to the above regimen or in whom the diagnosis is uncertain are subjected to laparoscopy. This should be left to the gynecologist. The typical case you will be involved with is the ruptured tubo-ovarian abscess, causing severe pelvic or diffuse peritonitis. During laparotomy or laparoscopy, pus will be found; you can read how to deal with peritonitis in Chapter 13. The abscess should be drained; whether to remove the uterus and ovaries depends on the age of the patient, the operative findings, and your gynecologist.\\n\\nWhen discussing PID, textbooks usually mention the Fitz-Hugh-Curtis syndrome or ‘perihepatitis’ as a late sequel — ascending from the pelvis. Although originally associated with gonococcal infection, nearly all present-day cases are associated with C. trachomatis infection. It may produce non-specific abdominal complaints and has been reported to mimic acute cholecystitis, but in our experience, it has never represented.\\n\\n```',\n", " 'md': 'Without treatment, the infection may develop into a tubal abscess and then spread intrapelvically, resulting in true peritonitis. The late risk includes tubal obstruction and pelvic adhesions leading to infertility and chronic pelvic pain. The majority of mild cases should be treated with antibiotics. Outpatient treatment is appropriate for patients who can tolerate an oral diet. Patients with severe abdominal and systemic manifestations should be admitted for intravenous antibiotic therapy. Antibiotic treatment is empiric, targeting the common causative organisms which are, in isolation or combination, Chlamydia trachomatis, Neisseria gonorrhoeae, Escherichia coli, and Haemophilus influenzae. Many oral and intravenous agents are available for selection (e.g., doxycycline orally, ampicillin/sulbactam, or cefoxitin intravenously).\\n\\nPatients who do not respond to the above regimen or in whom the diagnosis is uncertain are subjected to laparoscopy. This should be left to the gynecologist. The typical case you will be involved with is the ruptured tubo-ovarian abscess, causing severe pelvic or diffuse peritonitis. During laparotomy or laparoscopy, pus will be found; you can read how to deal with peritonitis in Chapter 13. The abscess should be drained; whether to remove the uterus and ovaries depends on the age of the patient, the operative findings, and your gynecologist.\\n\\nWhen discussing PID, textbooks usually mention the Fitz-Hugh-Curtis syndrome or ‘perihepatitis’ as a late sequel — ascending from the pelvis. Although originally associated with gonococcal infection, nearly all present-day cases are associated with C. trachomatis infection. It may produce non-specific abdominal complaints and has been reported to mimic acute cholecystitis, but in our experience, it has never represented.\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 228, 'w': 467.71, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'drained; whether to remove the uterus and ovaries depends on the age'}]},\n", " {'page': 640,\n", " 'text': 'a specific entity warranting operative measures. We have seen it,\\nhowever, as an incidental finding of perihepatic ‘piano-string’ adhesions\\nat laparoscopy or laparotomy for other conditions.\\n\\n Vaginal tears\\n\\n Vaginal tears are rare but may cause severe hemorrhage representing\\na true gynecological emergency. A vaginal tear can occur in young\\nfemales at their first intercourse — the ‘bloody defloration’. It can affect\\nwomen of any age who experience violent or peculiar sexual relations,\\nalone or with a partner. Always suspect that rape may have been a\\ncausative factor. Clinically, the bleeding is obvious. Diagnosis is by\\nspeculum examination: there is a lateral laceration, beginning at the\\nhymen and extending upwards and the edges are rather neat. In some\\ncases the tear is transmural and involves the cul-de-sac. Treatment\\nconsists of hemorrhage control and repair of the laceration with an\\nabsorbable continuous stitch in the lithotomy position; whether to do it\\nunder local or general anesthesia depends on the extent of the laceration\\nand the individual patient.\\n\\n Acute abdominal pain in the pregnant women\\n In men nine out of ten abdominal tumors are malignant; in\\n women nine out of ten abdominal swellings are the\\n pregnant uterus.\\n Rutherford Morrison\\n\\n General considerations\\n\\n A consultation about abdominal pain in a pregnant or immediately\\npostpartum woman is frequently an anxiety-provoking experience for the\\ngeneral surgeon. We think that the following few paragraphs will help you\\nto approach these difficult problems with a new understanding and\\nconfidence based on some simple concepts.\\n\\n Abdominal emergencies in pregnant women pose a great',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Vaginal Tears\\n\\nVaginal tears are rare but may cause severe hemorrhage representing a true gynecological emergency. A vaginal tear can occur in young females at their first intercourse — the ‘bloody defloration’. It can affect women of any age who experience violent or peculiar sexual relations, alone or with a partner. Always suspect that rape may have been a causative factor. Clinically, the bleeding is obvious. Diagnosis is by speculum examination: there is a lateral laceration, beginning at the hymen and extending upwards and the edges are rather neat. In some cases, the tear is transmural and involves the cul-de-sac. Treatment consists of hemorrhage control and repair of the laceration with an absorbable continuous stitch in the lithotomy position; whether to do it under local or general anesthesia depends on the extent of the laceration and the individual patient.\\n\\n## Acute Abdominal Pain in Pregnant Women\\n\\n> \"In men nine out of ten abdominal tumors are malignant; in women nine out of ten abdominal swellings are the pregnant uterus.\"\\n> — Rutherford Morrison\\n\\n### General Considerations\\n\\nA consultation about abdominal pain in a pregnant or immediately postpartum woman is frequently an anxiety-provoking experience for the general surgeon. We think that the following few paragraphs will help you to approach these difficult problems with a new understanding and confidence based on some simple concepts.\\n\\nAbdominal emergencies in pregnant women pose a great...\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- The text has been structured and formatted according to the markdown guidelines.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Vaginal Tears',\n", " 'md': '## Vaginal Tears',\n", " 'bBox': {'x': 86, 'y': 162, 'w': 102.09, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Vaginal tears are rare but may cause severe hemorrhage representing a true gynecological emergency. A vaginal tear can occur in young females at their first intercourse — the ‘bloody defloration’. It can affect women of any age who experience violent or peculiar sexual relations, alone or with a partner. Always suspect that rape may have been a causative factor. Clinically, the bleeding is obvious. Diagnosis is by speculum examination: there is a lateral laceration, beginning at the hymen and extending upwards and the edges are rather neat. In some cases, the tear is transmural and involves the cul-de-sac. Treatment consists of hemorrhage control and repair of the laceration with an absorbable continuous stitch in the lithotomy position; whether to do it under local or general anesthesia depends on the extent of the laceration and the individual patient.',\n", " 'md': 'Vaginal tears are rare but may cause severe hemorrhage representing a true gynecological emergency. A vaginal tear can occur in young females at their first intercourse — the ‘bloody defloration’. It can affect women of any age who experience violent or peculiar sexual relations, alone or with a partner. Always suspect that rape may have been a causative factor. Clinically, the bleeding is obvious. Diagnosis is by speculum examination: there is a lateral laceration, beginning at the hymen and extending upwards and the edges are rather neat. In some cases, the tear is transmural and involves the cul-de-sac. Treatment consists of hemorrhage control and repair of the laceration with an absorbable continuous stitch in the lithotomy position; whether to do it under local or general anesthesia depends on the extent of the laceration and the individual patient.',\n", " 'bBox': {'x': 72, 'y': 162, 'w': 467.55, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Acute Abdominal Pain in Pregnant Women',\n", " 'md': '## Acute Abdominal Pain in Pregnant Women',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '> \"In men nine out of ten abdominal tumors are malignant; in women nine out of ten abdominal swellings are the pregnant uterus.\"\\n> — Rutherford Morrison',\n", " 'md': '> \"In men nine out of ten abdominal tumors are malignant; in women nine out of ten abdominal swellings are the pregnant uterus.\"\\n> — Rutherford Morrison',\n", " 'bBox': {'x': 108, 'y': 471, 'w': 381.47, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'General Considerations',\n", " 'md': '### General Considerations',\n", " 'bBox': {'x': 86, 'y': 571, 'w': 183.92, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A consultation about abdominal pain in a pregnant or immediately postpartum woman is frequently an anxiety-provoking experience for the general surgeon. We think that the following few paragraphs will help you to approach these difficult problems with a new understanding and confidence based on some simple concepts.\\n\\nAbdominal emergencies in pregnant women pose a great...\\n```',\n", " 'md': 'A consultation about abdominal pain in a pregnant or immediately postpartum woman is frequently an anxiety-provoking experience for the general surgeon. We think that the following few paragraphs will help you to approach these difficult problems with a new understanding and confidence based on some simple concepts.\\n\\nAbdominal emergencies in pregnant women pose a great...\\n```',\n", " 'bBox': {'x': 72, 'y': 623, 'w': 467.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been structured and formatted according to the markdown guidelines.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been structured and formatted according to the markdown guidelines.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 641,\n", " 'text': 'challenge for the following reasons:\\n\\n • The growing uterus gradually distorts the normal abdominal\\n anatomy, displacing organs and thus changing the typical clinical\\n scenario.\\n • Physiologically, the pregnant woman is different; nausea and\\n vomiting are not uncommon during the first trimester, thereafter,\\n tachycardia, mild elevation of temperature and leukocytosis (and\\n even C-reactive protein [CRP]) are considered ‘normal’.\\n • To a certain degree, abdominal ‘aches and pains’ are common\\n during pregnancy.\\n • When dealing with a sick pregnant woman you automatically have\\n two patients — the life and well-being of the fetus must also be\\n considered.\\n\\n When it comes to treatment, there may be a conflict of interest\\nbetween the mother and fetus. Early in pregnancy, the risk is of\\nmiscarriage, while at the end it’s premature labor, and in both cases\\nit is hard to determine which is more risky — surgery or non-\\noperative management.\\n\\n Generally speaking, acute abdominal conditions during pregnancy are\\neither ‘because’ or ‘in spite’ of pregnancy.\\n\\n Abdominal emergencies specific to pregnancy are either:\\n\\n • Obstetric — such as ectopic pregnancy (see above), abortion and\\n septic abortion (a septic uterus may present with an impressive\\n ‘acute abdomen’), ‘red degeneration’ of a fibroid, placental\\n abruption, rupture of uterus, and pre-eclampsia. These conditions\\n won’t be further discussed. ħey, we didn’t promise you a manual of\\n obstetrics.\\n • General — such as acute pyelonephritis, which is more common in\\n pregnant women, or rupture of a visceral aneurysm (e.g. splenic\\n artery), which is rare but ‘typically’ occurs during pregnancy. Another\\n condition, which may be associated with pregnancy, is\\n spontaneous hematoma of the rectus abdominis muscle (this',\n", " 'md': '```markdown\\n# Challenges in Managing Abdominal Emergencies During Pregnancy\\n\\nThe management of abdominal emergencies during pregnancy presents unique challenges for the following reasons:\\n\\n- The growing uterus gradually distorts the normal abdominal anatomy, displacing organs and thus changing the typical clinical scenario.\\n- Physiologically, the pregnant woman is different; nausea and vomiting are not uncommon during the first trimester. Thereafter, tachycardia, mild elevation of temperature, and leukocytosis (and even C-reactive protein [CRP]) are considered ‘normal’.\\n- To a certain degree, abdominal ‘aches and pains’ are common during pregnancy.\\n- When dealing with a sick pregnant woman, you automatically have two patients — the life and well-being of the fetus must also be considered.\\n\\nWhen it comes to treatment, there may be a conflict of interest between the mother and fetus. Early in pregnancy, the risk is of miscarriage, while at the end it’s premature labor, and in both cases, it is hard to determine which is more risky — surgery or non-operative management.\\n\\nGenerally speaking, acute abdominal conditions during pregnancy are either ‘because’ or ‘in spite’ of pregnancy.\\n\\n## Abdominal Emergencies Specific to Pregnancy\\n\\nAbdominal emergencies specific to pregnancy are either:\\n\\n- **Obstetric** — such as ectopic pregnancy, abortion, and septic abortion (a septic uterus may present with an impressive ‘acute abdomen’), ‘red degeneration’ of a fibroid, placental abruption, rupture of the uterus, and pre-eclampsia. These conditions won’t be further discussed.\\n- **General** — such as acute pyelonephritis, which is more common in pregnant women, or rupture of a visceral aneurysm (e.g., splenic artery), which is rare but ‘typically’ occurs during pregnancy. Another condition, which may be associated with pregnancy, is spontaneous hematoma of the rectus abdominis muscle.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Challenges in Managing Abdominal Emergencies During Pregnancy',\n", " 'md': '# Challenges in Managing Abdominal Emergencies During Pregnancy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The management of abdominal emergencies during pregnancy presents unique challenges for the following reasons:\\n\\n- The growing uterus gradually distorts the normal abdominal anatomy, displacing organs and thus changing the typical clinical scenario.\\n- Physiologically, the pregnant woman is different; nausea and vomiting are not uncommon during the first trimester. Thereafter, tachycardia, mild elevation of temperature, and leukocytosis (and even C-reactive protein [CRP]) are considered ‘normal’.\\n- To a certain degree, abdominal ‘aches and pains’ are common during pregnancy.\\n- When dealing with a sick pregnant woman, you automatically have two patients — the life and well-being of the fetus must also be considered.\\n\\nWhen it comes to treatment, there may be a conflict of interest between the mother and fetus. Early in pregnancy, the risk is of miscarriage, while at the end it’s premature labor, and in both cases, it is hard to determine which is more risky — surgery or non-operative management.\\n\\nGenerally speaking, acute abdominal conditions during pregnancy are either ‘because’ or ‘in spite’ of pregnancy.',\n", " 'md': 'The management of abdominal emergencies during pregnancy presents unique challenges for the following reasons:\\n\\n- The growing uterus gradually distorts the normal abdominal anatomy, displacing organs and thus changing the typical clinical scenario.\\n- Physiologically, the pregnant woman is different; nausea and vomiting are not uncommon during the first trimester. Thereafter, tachycardia, mild elevation of temperature, and leukocytosis (and even C-reactive protein [CRP]) are considered ‘normal’.\\n- To a certain degree, abdominal ‘aches and pains’ are common during pregnancy.\\n- When dealing with a sick pregnant woman, you automatically have two patients — the life and well-being of the fetus must also be considered.\\n\\nWhen it comes to treatment, there may be a conflict of interest between the mother and fetus. Early in pregnancy, the risk is of miscarriage, while at the end it’s premature labor, and in both cases, it is hard to determine which is more risky — surgery or non-operative management.\\n\\nGenerally speaking, acute abdominal conditions during pregnancy are either ‘because’ or ‘in spite’ of pregnancy.',\n", " 'bBox': {'x': 72, 'y': 155, 'w': 467.41, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Emergencies Specific to Pregnancy',\n", " 'md': '## Abdominal Emergencies Specific to Pregnancy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Abdominal emergencies specific to pregnancy are either:\\n\\n- **Obstetric** — such as ectopic pregnancy, abortion, and septic abortion (a septic uterus may present with an impressive ‘acute abdomen’), ‘red degeneration’ of a fibroid, placental abruption, rupture of the uterus, and pre-eclampsia. These conditions won’t be further discussed.\\n- **General** — such as acute pyelonephritis, which is more common in pregnant women, or rupture of a visceral aneurysm (e.g., splenic artery), which is rare but ‘typically’ occurs during pregnancy. Another condition, which may be associated with pregnancy, is spontaneous hematoma of the rectus abdominis muscle.\\n```',\n", " 'md': 'Abdominal emergencies specific to pregnancy are either:\\n\\n- **Obstetric** — such as ectopic pregnancy, abortion, and septic abortion (a septic uterus may present with an impressive ‘acute abdomen’), ‘red degeneration’ of a fibroid, placental abruption, rupture of the uterus, and pre-eclampsia. These conditions won’t be further discussed.\\n- **General** — such as acute pyelonephritis, which is more common in pregnant women, or rupture of a visceral aneurysm (e.g., splenic artery), which is rare but ‘typically’ occurs during pregnancy. Another condition, which may be associated with pregnancy, is spontaneous hematoma of the rectus abdominis muscle.\\n```',\n", " 'bBox': {'x': 86, 'y': 260, 'w': 437.04, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 642,\n", " 'text': ' condition may also develop in non-pregnant men and women,\\n particularly in anticoagulated patients). The hematoma originates\\n from a ruptured branch of the inferior epigastric artery and develops\\n deep to the muscle. On examination a tender abdominal wall mass\\n is often felt; it won’t disappear when the patient tenses his or her\\n abdominal wall (Fothergill’s sign). Ultrasound can confirm the\\n diagnosis. Treatment is conservative.\\n\\n Abdominal emergencies randomly developing during\\n pregnancy\\n\\n Any abdominal emergency may occur during pregnancy. ħere are a\\nfew basic considerations:\\n\\n • ‘Think in trimesters’: during the first trimester the fetus is most\\n susceptible to the potentially damaging effects of drugs and X-rays.\\n Abdominal operations at this stage may precipitate an abortion.\\n Operations during the third trimester are more likely to induce\\n premature labor, posing additional risk to the mother and fetus.\\n Thus, surgery is best tolerated during the second trimester — if\\n you have the luxury of choice.\\n • The well-being of the mother overrides that of the fetus. If\\n maternal and fetal distress are present simultaneously on\\n presentation, all therapeutic efforts should be for the benefit of the\\n mother. A Cesarean section is considered only if the fetus is more\\n than 24 weeks old and in persistent distress in spite of maximal\\n therapy to the mother.\\n • Pregnant women suffer from a chronic abdominal compartment\\n syndrome ( Chapter 33). The abdominal emergency (e.g.\\n perforated appendicitis or intestinal obstruction) will further increase\\n the intra-abdominal pressure, reducing venous return and cardiac\\n output. Place such patients in a left lateral decubitus position in\\n order to shift the gravid uterus away from the compressed inferior\\n vena cava.\\n\\n You should be aware of acute appendicitis, acute cholecystitis\\nand intestinal obstruction.',\n", " 'md': '```markdown\\n## Abdominal Emergencies During Pregnancy\\n\\n### Key Considerations\\n\\n- **Condition Development**: Abdominal emergencies may also develop in non-pregnant men and women, particularly in anticoagulated patients. The hematoma originates from a ruptured branch of the inferior epigastric artery and develops deep to the muscle. On examination, a tender abdominal wall mass is often felt; it won’t disappear when the patient tenses his or her abdominal wall (Fothergill’s sign). Ultrasound can confirm the diagnosis. Treatment is conservative.\\n\\n- **Trimesters**:\\n- Think in trimesters: during the first trimester, the fetus is most susceptible to the potentially damaging effects of drugs and X-rays. Abdominal operations at this stage may precipitate an abortion. Operations during the third trimester are more likely to induce premature labor, posing additional risk to the mother and fetus. Thus, surgery is best tolerated during the second trimester — if you have the luxury of choice.\\n\\n- **Maternal Well-being**: The well-being of the mother overrides that of the fetus. If maternal and fetal distress are present simultaneously on presentation, all therapeutic efforts should be for the benefit of the mother. A Cesarean section is considered only if the fetus is more than 24 weeks old and in persistent distress in spite of maximal therapy to the mother.\\n\\n- **Chronic Abdominal Compartment Syndrome**: Pregnant women suffer from a chronic abdominal compartment syndrome (Chapter 33). The abdominal emergency (e.g., perforated appendicitis or intestinal obstruction) will further increase the intra-abdominal pressure, reducing venous return and cardiac output. Place such patients in a left lateral decubitus position in order to shift the gravid uterus away from the compressed inferior vena cava.\\n\\n### Common Conditions to be Aware of:\\n- Acute appendicitis\\n- Acute cholecystitis\\n- Intestinal obstruction\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Emergencies During Pregnancy',\n", " 'md': '## Abdominal Emergencies During Pregnancy',\n", " 'bBox': {'x': 86, 'y': 230, 'w': 101.19, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key Considerations',\n", " 'md': '### Key Considerations',\n", " 'bBox': {'x': 521, 'y': 474, 'w': 16.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Condition Development**: Abdominal emergencies may also develop in non-pregnant men and women, particularly in anticoagulated patients. The hematoma originates from a ruptured branch of the inferior epigastric artery and develops deep to the muscle. On examination, a tender abdominal wall mass is often felt; it won’t disappear when the patient tenses his or her abdominal wall (Fothergill’s sign). Ultrasound can confirm the diagnosis. Treatment is conservative.\\n\\n- **Trimesters**:\\n- Think in trimesters: during the first trimester, the fetus is most susceptible to the potentially damaging effects of drugs and X-rays. Abdominal operations at this stage may precipitate an abortion. Operations during the third trimester are more likely to induce premature labor, posing additional risk to the mother and fetus. Thus, surgery is best tolerated during the second trimester — if you have the luxury of choice.\\n\\n- **Maternal Well-being**: The well-being of the mother overrides that of the fetus. If maternal and fetal distress are present simultaneously on presentation, all therapeutic efforts should be for the benefit of the mother. A Cesarean section is considered only if the fetus is more than 24 weeks old and in persistent distress in spite of maximal therapy to the mother.\\n\\n- **Chronic Abdominal Compartment Syndrome**: Pregnant women suffer from a chronic abdominal compartment syndrome (Chapter 33). The abdominal emergency (e.g., perforated appendicitis or intestinal obstruction) will further increase the intra-abdominal pressure, reducing venous return and cardiac output. Place such patients in a left lateral decubitus position in order to shift the gravid uterus away from the compressed inferior vena cava.',\n", " 'md': '- **Condition Development**: Abdominal emergencies may also develop in non-pregnant men and women, particularly in anticoagulated patients. The hematoma originates from a ruptured branch of the inferior epigastric artery and develops deep to the muscle. On examination, a tender abdominal wall mass is often felt; it won’t disappear when the patient tenses his or her abdominal wall (Fothergill’s sign). Ultrasound can confirm the diagnosis. Treatment is conservative.\\n\\n- **Trimesters**:\\n- Think in trimesters: during the first trimester, the fetus is most susceptible to the potentially damaging effects of drugs and X-rays. Abdominal operations at this stage may precipitate an abortion. Operations during the third trimester are more likely to induce premature labor, posing additional risk to the mother and fetus. Thus, surgery is best tolerated during the second trimester — if you have the luxury of choice.\\n\\n- **Maternal Well-being**: The well-being of the mother overrides that of the fetus. If maternal and fetal distress are present simultaneously on presentation, all therapeutic efforts should be for the benefit of the mother. A Cesarean section is considered only if the fetus is more than 24 weeks old and in persistent distress in spite of maximal therapy to the mother.\\n\\n- **Chronic Abdominal Compartment Syndrome**: Pregnant women suffer from a chronic abdominal compartment syndrome (Chapter 33). The abdominal emergency (e.g., perforated appendicitis or intestinal obstruction) will further increase the intra-abdominal pressure, reducing venous return and cardiac output. Place such patients in a left lateral decubitus position in order to shift the gravid uterus away from the compressed inferior vena cava.',\n", " 'bBox': {'x': 86, 'y': 119, 'w': 450.64, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Common Conditions to be Aware of:',\n", " 'md': '### Common Conditions to be Aware of:',\n", " 'bBox': {'x': 314, 'y': 474, 'w': 24.79, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- Acute appendicitis\\n- Acute cholecystitis\\n- Intestinal obstruction\\n```',\n", " 'md': '- Acute appendicitis\\n- Acute cholecystitis\\n- Intestinal obstruction\\n```',\n", " 'bBox': {'x': 521, 'y': 474, 'w': 16.01, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'perforated appendicitis or intestinal obstruction) will further increase'}]},\n", " {'page': 643,\n", " 'text': ' Acute appendicitis\\n You are commonly called to ‘exclude acute appendicitis’ in a pregnant\\nwoman. Address the problem as discussed in Chapter 23. Remember\\nthat although the cecum is usually fixed in place it may be displaced by\\nthe gravid uterus. Similarly, the omentum is ‘lifted’ away and thus may not\\nprovide ‘walling-off’ protection to the perforated appendix — making free\\nperforation more likely. An ultrasound may help in excluding acute\\ncholecystitis and ovarian or uterine causes of pain and may document an\\nenlarged appendix. CT is not advisable because of the risks of irradiation\\nof the fetus. However, MRI has emerged as a reasonable diagnostic\\nalternative — use it if available as it may help to avoid an\\nunnecessary operation.\\n\\n Diagnostic laparoscopy and/or laparoscopic appendectomy during\\npregnancy have been reported as safe to both mother and fetus, but still\\nremain somewhat controversial — particularly in late pregnancy. And, as\\nin acute appendicitis in general, nothing is wrong with open\\nappendectomy — in that case place a muscle-splitting incision directly\\nover the point of maximal tenderness, wherever it is (it may be higher\\nthan usual). And of course do not forget to tilt the table to the left. Also\\nremember: the ‘best’ treatment of acute appendicitis occurring early\\nin pregnancy may be non-operative — with antibiotics. We don’t\\nhesitate to offer this to the patient!\\n\\n Acute cholecystitis\\n This is easily recognized clinically and ultrasonographically ( Chapter\\n20) during pregnancy. During the first trimester try conservative\\nmanagement, delaying the operation until the second trimester. If it\\noccurs during the third trimester try to postpone the operation, if\\npossible, until after delivery.\\n\\n Laparoscopic cholecystectomy appears to be safe during pregnancy.\\nInflate the abdomen with the lowest pressure possible and rotate the\\ntable well to the left to decrease compression of the IVC by the uterus.\\nWhen cholecystectomy is required late in pregnancy (when the uterus\\nfills the entire abdominal cavity) we prefer an open approach through a\\nsmall subcostal incision.',\n", " 'md': '```markdown\\n# Acute Appendicitis\\n\\nYou are commonly called to ‘exclude acute appendicitis’ in a pregnant woman. Address the problem as discussed in Chapter 23. Remember that although the cecum is usually fixed in place it may be displaced by the gravid uterus. Similarly, the omentum is ‘lifted’ away and thus may not provide ‘walling-off’ protection to the perforated appendix — making free perforation more likely. An ultrasound may help in excluding acute cholecystitis and ovarian or uterine causes of pain and may document an enlarged appendix. CT is not advisable because of the risks of irradiation of the fetus. However, MRI has emerged as a reasonable diagnostic alternative — use it if available as it may help to avoid an unnecessary operation.\\n\\nDiagnostic laparoscopy and/or laparoscopic appendectomy during pregnancy have been reported as safe to both mother and fetus, but still remain somewhat controversial — particularly in late pregnancy. And, as in acute appendicitis in general, nothing is wrong with open appendectomy — in that case place a muscle-splitting incision directly over the point of maximal tenderness, wherever it is (it may be higher than usual). And of course do not forget to tilt the table to the left. Also remember: the ‘best’ treatment of acute appendicitis occurring early in pregnancy may be non-operative — with antibiotics. We don’t hesitate to offer this to the patient!\\n\\n# Acute Cholecystitis\\n\\nThis is easily recognized clinically and ultrasonographically (Chapter 20) during pregnancy. During the first trimester try conservative management, delaying the operation until the second trimester. If it occurs during the third trimester try to postpone the operation, if possible, until after delivery.\\n\\nLaparoscopic cholecystectomy appears to be safe during pregnancy. Inflate the abdomen with the lowest pressure possible and rotate the table well to the left to decrease compression of the IVC by the uterus. When cholecystectomy is required late in pregnancy (when the uterus fills the entire abdominal cavity) we prefer an open approach through a small subcostal incision.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Acute Appendicitis',\n", " 'md': '# Acute Appendicitis',\n", " 'bBox': {'x': 86, 'y': 86, 'w': 127.89, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'You are commonly called to ‘exclude acute appendicitis’ in a pregnant woman. Address the problem as discussed in Chapter 23. Remember that although the cecum is usually fixed in place it may be displaced by the gravid uterus. Similarly, the omentum is ‘lifted’ away and thus may not provide ‘walling-off’ protection to the perforated appendix — making free perforation more likely. An ultrasound may help in excluding acute cholecystitis and ovarian or uterine causes of pain and may document an enlarged appendix. CT is not advisable because of the risks of irradiation of the fetus. However, MRI has emerged as a reasonable diagnostic alternative — use it if available as it may help to avoid an unnecessary operation.\\n\\nDiagnostic laparoscopy and/or laparoscopic appendectomy during pregnancy have been reported as safe to both mother and fetus, but still remain somewhat controversial — particularly in late pregnancy. And, as in acute appendicitis in general, nothing is wrong with open appendectomy — in that case place a muscle-splitting incision directly over the point of maximal tenderness, wherever it is (it may be higher than usual). And of course do not forget to tilt the table to the left. Also remember: the ‘best’ treatment of acute appendicitis occurring early in pregnancy may be non-operative — with antibiotics. We don’t hesitate to offer this to the patient!',\n", " 'md': 'You are commonly called to ‘exclude acute appendicitis’ in a pregnant woman. Address the problem as discussed in Chapter 23. Remember that although the cecum is usually fixed in place it may be displaced by the gravid uterus. Similarly, the omentum is ‘lifted’ away and thus may not provide ‘walling-off’ protection to the perforated appendix — making free perforation more likely. An ultrasound may help in excluding acute cholecystitis and ovarian or uterine causes of pain and may document an enlarged appendix. CT is not advisable because of the risks of irradiation of the fetus. However, MRI has emerged as a reasonable diagnostic alternative — use it if available as it may help to avoid an unnecessary operation.\\n\\nDiagnostic laparoscopy and/or laparoscopic appendectomy during pregnancy have been reported as safe to both mother and fetus, but still remain somewhat controversial — particularly in late pregnancy. And, as in acute appendicitis in general, nothing is wrong with open appendectomy — in that case place a muscle-splitting incision directly over the point of maximal tenderness, wherever it is (it may be higher than usual). And of course do not forget to tilt the table to the left. Also remember: the ‘best’ treatment of acute appendicitis occurring early in pregnancy may be non-operative — with antibiotics. We don’t hesitate to offer this to the patient!',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Acute Cholecystitis',\n", " 'md': '# Acute Cholecystitis',\n", " 'bBox': {'x': 86, 'y': 496, 'w': 131.1, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'This is easily recognized clinically and ultrasonographically (Chapter 20) during pregnancy. During the first trimester try conservative management, delaying the operation until the second trimester. If it occurs during the third trimester try to postpone the operation, if possible, until after delivery.\\n\\nLaparoscopic cholecystectomy appears to be safe during pregnancy. Inflate the abdomen with the lowest pressure possible and rotate the table well to the left to decrease compression of the IVC by the uterus. When cholecystectomy is required late in pregnancy (when the uterus fills the entire abdominal cavity) we prefer an open approach through a small subcostal incision.\\n```',\n", " 'md': 'This is easily recognized clinically and ultrasonographically (Chapter 20) during pregnancy. During the first trimester try conservative management, delaying the operation until the second trimester. If it occurs during the third trimester try to postpone the operation, if possible, until after delivery.\\n\\nLaparoscopic cholecystectomy appears to be safe during pregnancy. Inflate the abdomen with the lowest pressure possible and rotate the table well to the left to decrease compression of the IVC by the uterus. When cholecystectomy is required late in pregnancy (when the uterus fills the entire abdominal cavity) we prefer an open approach through a small subcostal incision.\\n```',\n", " 'bBox': {'x': 72, 'y': 517, 'w': 467.41, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'that although the cecum is usually fixed in place it may be displaced by'},\n", " {'text': 'This is easily recognized clinically and ultrasonographically ( Chapter 20) during pregnancy. During the first trimester try conservative management, delaying the operation until the second trimester. If it'}]},\n", " {'page': 644,\n", " 'text': ' This is perhaps the place to mention the HELLP syndrome\\n(ħemolysis, Elevated Liver enzymes, and Low Platelet count). It is a\\nrelatively rare syndrome, which may develop in a pre-eclamptic, pre-term\\npatient and be confused with acute biliary disease (even a ‘mild’ ħELLP\\nmay stretch the liver capsule producing severe RUQ pain). Liver\\nhemorrhage and hematoma and even liver rupture are serious\\ncomplications of the ħELLP syndrome and represent a surgical\\nemergency; the child should be promptly delivered and the liver managed\\nbased on trauma principles. In the unstable, coagulopathic patient the\\nliver should be packed. Think about HELLP: a misguided\\ncholecystectomy may kill the mother and baby.\\n\\n Intestinal obstruction\\n Sigmoid or cecal volvulus is more common during late pregnancy. The\\ndisplacement of abdominal structures during pregnancy may also shift\\nlongstanding adhesions, producing small bowel obstruction or volvulus.\\nPregnancy tends to cloud presenting features and impedes early\\ndiagnosis. Note that a few plain abdominal X-rays, with or without\\nGastrografin®, are entirely safe even in early pregnancy. So if you\\nsuspect a large or small bowel obstruction, do not hesitate. Remember\\nthat intestinal strangulation threatens the life of the mother and her\\nchild. This is no time for timidity.\\n\\n Trauma in pregnancy\\n\\n The management of abdominal trauma in pregnancy is identical to the\\nmanagement in the non-pregnant woman ( Chapter 32), except that in\\npregnancy there is concern for two patients — the mother and the fetus.\\nRemember that the pregnant woman has a marked increase in blood\\nvolume, a fact which tends to mask or delay clinical features of\\nhypovolemic shock. Assessment of the fetal status either by Doppler or\\nby continuous cardiotocography is mandatory when the clinical\\ncircumstances permit.\\n\\n The major specific clinical concerns in the injured pregnant female are\\nuterine rupture and abruptio placentae. The former condition is\\nsuggested by abdominal tenderness and signs of peritoneal irritation,',\n", " 'md': '```markdown\\n# HELLP Syndrome and Related Conditions\\n\\n## HELLP Syndrome\\nThis is perhaps the place to mention the HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count). It is a relatively rare syndrome, which may develop in a pre-eclamptic, pre-term patient and be confused with acute biliary disease (even a ‘mild’ HELLP may stretch the liver capsule producing severe RUQ pain). Liver hemorrhage and hematoma and even liver rupture are serious complications of the HELLP syndrome and represent a surgical emergency; the child should be promptly delivered and the liver managed based on trauma principles. In the unstable, coagulopathic patient the liver should be packed. Think about HELLP: a misguided cholecystectomy may kill the mother and baby.\\n\\n## Intestinal Obstruction\\nSigmoid or cecal volvulus is more common during late pregnancy. The displacement of abdominal structures during pregnancy may also shift longstanding adhesions, producing small bowel obstruction or volvulus. Pregnancy tends to cloud presenting features and impedes early diagnosis. Note that a few plain abdominal X-rays, with or without Gastrografin®, are entirely safe even in early pregnancy. So if you suspect a large or small bowel obstruction, do not hesitate. Remember that intestinal strangulation threatens the life of the mother and her child. This is no time for timidity.\\n\\n## Trauma in Pregnancy\\nThe management of abdominal trauma in pregnancy is identical to the management in the non-pregnant woman (Chapter 32), except that in pregnancy there is concern for two patients — the mother and the fetus. Remember that the pregnant woman has a marked increase in blood volume, a fact which tends to mask or delay clinical features of hypovolemic shock. Assessment of the fetal status either by Doppler or by continuous cardiotocography is mandatory when the clinical circumstances permit.\\n\\nThe major specific clinical concerns in the injured pregnant female are uterine rupture and abruptio placentae. The former condition is suggested by abdominal tenderness and signs of peritoneal irritation.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'HELLP Syndrome and Related Conditions',\n", " 'md': '# HELLP Syndrome and Related Conditions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'HELLP Syndrome',\n", " 'md': '## HELLP Syndrome',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This is perhaps the place to mention the HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count). It is a relatively rare syndrome, which may develop in a pre-eclamptic, pre-term patient and be confused with acute biliary disease (even a ‘mild’ HELLP may stretch the liver capsule producing severe RUQ pain). Liver hemorrhage and hematoma and even liver rupture are serious complications of the HELLP syndrome and represent a surgical emergency; the child should be promptly delivered and the liver managed based on trauma principles. In the unstable, coagulopathic patient the liver should be packed. Think about HELLP: a misguided cholecystectomy may kill the mother and baby.',\n", " 'md': 'This is perhaps the place to mention the HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count). It is a relatively rare syndrome, which may develop in a pre-eclamptic, pre-term patient and be confused with acute biliary disease (even a ‘mild’ HELLP may stretch the liver capsule producing severe RUQ pain). Liver hemorrhage and hematoma and even liver rupture are serious complications of the HELLP syndrome and represent a surgical emergency; the child should be promptly delivered and the liver managed based on trauma principles. In the unstable, coagulopathic patient the liver should be packed. Think about HELLP: a misguided cholecystectomy may kill the mother and baby.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.7, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Intestinal Obstruction',\n", " 'md': '## Intestinal Obstruction',\n", " 'bBox': {'x': 86, 'y': 290, 'w': 146.25, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Sigmoid or cecal volvulus is more common during late pregnancy. The displacement of abdominal structures during pregnancy may also shift longstanding adhesions, producing small bowel obstruction or volvulus. Pregnancy tends to cloud presenting features and impedes early diagnosis. Note that a few plain abdominal X-rays, with or without Gastrografin®, are entirely safe even in early pregnancy. So if you suspect a large or small bowel obstruction, do not hesitate. Remember that intestinal strangulation threatens the life of the mother and her child. This is no time for timidity.',\n", " 'md': 'Sigmoid or cecal volvulus is more common during late pregnancy. The displacement of abdominal structures during pregnancy may also shift longstanding adhesions, producing small bowel obstruction or volvulus. Pregnancy tends to cloud presenting features and impedes early diagnosis. Note that a few plain abdominal X-rays, with or without Gastrografin®, are entirely safe even in early pregnancy. So if you suspect a large or small bowel obstruction, do not hesitate. Remember that intestinal strangulation threatens the life of the mother and her child. This is no time for timidity.',\n", " 'bBox': {'x': 72, 'y': 234, 'w': 467.46, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Trauma in Pregnancy',\n", " 'md': '## Trauma in Pregnancy',\n", " 'bBox': {'x': 86, 'y': 234, 'w': 370, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The management of abdominal trauma in pregnancy is identical to the management in the non-pregnant woman (Chapter 32), except that in pregnancy there is concern for two patients — the mother and the fetus. Remember that the pregnant woman has a marked increase in blood volume, a fact which tends to mask or delay clinical features of hypovolemic shock. Assessment of the fetal status either by Doppler or by continuous cardiotocography is mandatory when the clinical circumstances permit.\\n\\nThe major specific clinical concerns in the injured pregnant female are uterine rupture and abruptio placentae. The former condition is suggested by abdominal tenderness and signs of peritoneal irritation.\\n```',\n", " 'md': 'The management of abdominal trauma in pregnancy is identical to the management in the non-pregnant woman (Chapter 32), except that in pregnancy there is concern for two patients — the mother and the fetus. Remember that the pregnant woman has a marked increase in blood volume, a fact which tends to mask or delay clinical features of hypovolemic shock. Assessment of the fetal status either by Doppler or by continuous cardiotocography is mandatory when the clinical circumstances permit.\\n\\nThe major specific clinical concerns in the injured pregnant female are uterine rupture and abruptio placentae. The former condition is suggested by abdominal tenderness and signs of peritoneal irritation.\\n```',\n", " 'bBox': {'x': 72, 'y': 234, 'w': 467.65, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'pregnancy there is concern for two patients — the mother and the fetus.'}]},\n", " {'page': 645,\n", " 'text': 'sometimes in conjunction with palpable fetal parts or inability to palpate\\nthe fundus. The latter is suggested by vaginal bleeding and uterine\\ncontractions. When the fetus is in jeopardy, a rapid Cesarean section\\nis usually in the best interests of both the mother and fetus.\\n\\n The ‘postpartum’ period\\n\\n Abdominal emergencies are notoriously difficult to diagnose\\nduring the early postpartum or post-Cesarean section period.\\nAbdominal pain and gastrointestinal symptoms are commonly attributed\\nto ‘after pain’, and fever or systemic malaise to ‘residual endometritis’. In\\naddition, at this stage the abdominal wall is maximally stretched out and\\nredundant, such that guarding and other peritoneal signs may be\\nmissing. ‘Things move around’ the abdomen during delivery and a loop of\\nbowel may be twisted or caught. We have treated perforated acute\\nappendicitis, perforated peptic ulcer and acute cholecystitis during the\\nearly postpartum days.\\n\\n I even did a splenectomy for spontaneous rupture of the spleen following an uneventful vaginal\\n delivery! Danny\\n\\n Diagnosis is usually delayed and so is the treatment. Be aware,\\nsuspect and use imaging liberally!\\n\\n “A male gynecologist is like an auto mechanic who has\\n never owned a car.”\\n Carry P. Snow',\n", " 'md': '```markdown\\n## Postpartum Complications\\n\\nSometimes in conjunction with palpable fetal parts or inability to palpate the fundus. The latter is suggested by vaginal bleeding and uterine contractions. When the fetus is in jeopardy, a rapid Cesarean section is usually in the best interests of both the mother and fetus.\\n\\n### The ‘Postpartum’ Period\\n\\nAbdominal emergencies are notoriously difficult to diagnose during the early postpartum or post-Cesarean section period. Abdominal pain and gastrointestinal symptoms are commonly attributed to ‘after pain’, and fever or systemic malaise to ‘residual endometritis’. In addition, at this stage the abdominal wall is maximally stretched out and redundant, such that guarding and other peritoneal signs may be missing. ‘Things move around’ the abdomen during delivery and a loop of bowel may be twisted or caught. We have treated perforated acute appendicitis, perforated peptic ulcer, and acute cholecystitis during the early postpartum days.\\n\\nI even did a splenectomy for spontaneous rupture of the spleen following an uneventful vaginal delivery! Danny\\n\\nDiagnosis is usually delayed and so is the treatment. Be aware, suspect and use imaging liberally!\\n\\n> “A male gynecologist is like an auto mechanic who has never owned a car.”\\n> — Carry P. Snow\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Postpartum Complications',\n", " 'md': '## Postpartum Complications',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Sometimes in conjunction with palpable fetal parts or inability to palpate the fundus. The latter is suggested by vaginal bleeding and uterine contractions. When the fetus is in jeopardy, a rapid Cesarean section is usually in the best interests of both the mother and fetus.',\n", " 'md': 'Sometimes in conjunction with palpable fetal parts or inability to palpate the fundus. The latter is suggested by vaginal bleeding and uterine contractions. When the fetus is in jeopardy, a rapid Cesarean section is usually in the best interests of both the mother and fetus.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.04, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The ‘Postpartum’ Period',\n", " 'md': '### The ‘Postpartum’ Period',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 188.49, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Abdominal emergencies are notoriously difficult to diagnose during the early postpartum or post-Cesarean section period. Abdominal pain and gastrointestinal symptoms are commonly attributed to ‘after pain’, and fever or systemic malaise to ‘residual endometritis’. In addition, at this stage the abdominal wall is maximally stretched out and redundant, such that guarding and other peritoneal signs may be missing. ‘Things move around’ the abdomen during delivery and a loop of bowel may be twisted or caught. We have treated perforated acute appendicitis, perforated peptic ulcer, and acute cholecystitis during the early postpartum days.\\n\\nI even did a splenectomy for spontaneous rupture of the spleen following an uneventful vaginal delivery! Danny\\n\\nDiagnosis is usually delayed and so is the treatment. Be aware, suspect and use imaging liberally!\\n\\n> “A male gynecologist is like an auto mechanic who has never owned a car.”\\n> — Carry P. Snow\\n```',\n", " 'md': 'Abdominal emergencies are notoriously difficult to diagnose during the early postpartum or post-Cesarean section period. Abdominal pain and gastrointestinal symptoms are commonly attributed to ‘after pain’, and fever or systemic malaise to ‘residual endometritis’. In addition, at this stage the abdominal wall is maximally stretched out and redundant, such that guarding and other peritoneal signs may be missing. ‘Things move around’ the abdomen during delivery and a loop of bowel may be twisted or caught. We have treated perforated acute appendicitis, perforated peptic ulcer, and acute cholecystitis during the early postpartum days.\\n\\nI even did a splenectomy for spontaneous rupture of the spleen following an uneventful vaginal delivery! Danny\\n\\nDiagnosis is usually delayed and so is the treatment. Be aware, suspect and use imaging liberally!\\n\\n> “A male gynecologist is like an auto mechanic who has never owned a car.”\\n> — Carry P. Snow\\n```',\n", " 'bBox': {'x': 72, 'y': 264, 'w': 467.89, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 646,\n", " 'text': 'Chapter 36\\nAbdominal emergencies in infancy and childhood\\nWojciech J. Górecki\\n\\n Children are not small adults.\\n\\n The well-known phrase that children are not small adults is eminently\\napplicable to pediatric abdominal emergencies, not only because of\\ndifferences in physiology and metabolism, but also because of a different\\nclinical spectrum of abdominal emergencies, their presentation and\\nmanagement. This chapter focuses on abdominal surgical emergencies\\nin infants and small children. Neonatal emergencies are omitted, as you\\nare unlikely to encounter them unless you are a specialist pediatric\\nsurgeon.\\n\\n The first principle to remember is that you are less likely to\\ncommit an error if you consider an atypical presentation of a\\ncommon condition than a typical presentation of a rare condition. In\\nother words, a pediatric acute abdomen is intussusception in\\ninfancy or appendicitis in childhood — until proven otherwise.\\nAnother principle is that, much like with adults, watchful waiting is a\\nprudent strategy in children.\\n\\n General approach to pediatric abdominal pain\\n\\n The philosophy of classifying the multiple etiologies of the acute\\nabdomen into several well-defined clinical patterns, presented in\\nChapter 3, works for children as well. The major pitfalls in assessing the',\n", " 'md': '```markdown\\n# Chapter 36\\n## Abdominal Emergencies in Infancy and Childhood\\n**Wojciech J. Górecki**\\n\\nChildren are not small adults.\\n\\nThe well-known phrase that children are not small adults is eminently applicable to pediatric abdominal emergencies, not only because of differences in physiology and metabolism, but also because of a different clinical spectrum of abdominal emergencies, their presentation, and management. This chapter focuses on abdominal surgical emergencies in infants and small children. Neonatal emergencies are omitted, as you are unlikely to encounter them unless you are a specialist pediatric surgeon.\\n\\nThe first principle to remember is that you are less likely to commit an error if you consider an atypical presentation of a common condition than a typical presentation of a rare condition. In other words, a pediatric acute abdomen is intussusception in infancy or appendicitis in childhood — until proven otherwise. Another principle is that, much like with adults, watchful waiting is a prudent strategy in children.\\n\\n### General Approach to Pediatric Abdominal Pain\\n\\nThe philosophy of classifying the multiple etiologies of the acute abdomen into several well-defined clinical patterns, presented in Chapter 3, works for children as well. The major pitfalls in assessing the\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 36',\n", " 'md': '# Chapter 36',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 148.79, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Emergencies in Infancy and Childhood',\n", " 'md': '## Abdominal Emergencies in Infancy and Childhood',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 437.93, 'h': 20.16}},\n", " {'type': 'text',\n", " 'value': '**Wojciech J. Górecki**\\n\\nChildren are not small adults.\\n\\nThe well-known phrase that children are not small adults is eminently applicable to pediatric abdominal emergencies, not only because of differences in physiology and metabolism, but also because of a different clinical spectrum of abdominal emergencies, their presentation, and management. This chapter focuses on abdominal surgical emergencies in infants and small children. Neonatal emergencies are omitted, as you are unlikely to encounter them unless you are a specialist pediatric surgeon.\\n\\nThe first principle to remember is that you are less likely to commit an error if you consider an atypical presentation of a common condition than a typical presentation of a rare condition. In other words, a pediatric acute abdomen is intussusception in infancy or appendicitis in childhood — until proven otherwise. Another principle is that, much like with adults, watchful waiting is a prudent strategy in children.',\n", " 'md': '**Wojciech J. Górecki**\\n\\nChildren are not small adults.\\n\\nThe well-known phrase that children are not small adults is eminently applicable to pediatric abdominal emergencies, not only because of differences in physiology and metabolism, but also because of a different clinical spectrum of abdominal emergencies, their presentation, and management. This chapter focuses on abdominal surgical emergencies in infants and small children. Neonatal emergencies are omitted, as you are unlikely to encounter them unless you are a specialist pediatric surgeon.\\n\\nThe first principle to remember is that you are less likely to commit an error if you consider an atypical presentation of a common condition than a typical presentation of a rare condition. In other words, a pediatric acute abdomen is intussusception in infancy or appendicitis in childhood — until proven otherwise. Another principle is that, much like with adults, watchful waiting is a prudent strategy in children.',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 468.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'General Approach to Pediatric Abdominal Pain',\n", " 'md': '### General Approach to Pediatric Abdominal Pain',\n", " 'bBox': {'x': 86, 'y': 638, 'w': 360.43, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The philosophy of classifying the multiple etiologies of the acute abdomen into several well-defined clinical patterns, presented in Chapter 3, works for children as well. The major pitfalls in assessing the\\n```',\n", " 'md': 'The philosophy of classifying the multiple etiologies of the acute abdomen into several well-defined clinical patterns, presented in Chapter 3, works for children as well. The major pitfalls in assessing the\\n```',\n", " 'bBox': {'x': 72, 'y': 708, 'w': 467.33, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 3, works for children as well. The major pitfalls in assessing the'}]},\n", " {'page': 647,\n", " 'text': 'pediatric acute abdomen are timing, history and abdominal palpation.\\n\\n Let’s start with some basics:\\n\\n • Children with abdominal pain present to the emergency room at\\n varying stages of disease because the timing of presentation\\n depends on the parents. Some parents delay, while others rush their\\n darlings to the ER at the slightest sign of trouble. Parents’ attitudes\\n to emergencies could be described like this: when their first child\\n swallows a coin they rush to the ER; when that happens to the\\n second child, they search for the coin in the child’s feces; the third\\n child has the coin deducted from his pocket money. As a general\\n rule — as originally stated by Sir Zachary Cope — consider any\\n abdominal pain lasting more than 6 hours as a potential\\n surgical problem.\\n • Younger children do not give you a history, but listen to the\\n parents because they know their kids so well. A classic example is\\n intussusception, where a description of the child’s behavior and a\\n glance at the stool (see below) can point you to the diagnosis even\\n before the physical examination.\\n • The importance of gentleness during abdominal palpation\\n cannot be over-emphasized. The majority of children with a sore\\n tummy object to abdominal palpation. Sometimes a toy provides a\\n temporary distraction that will allow you to examine the abdomen,\\n but it is pointless to persist if the child is antagonized. Instead of the\\n usual ‘head-to-toe’ sequence of the physical exam in adults, take\\n advantage of a spell of sleep or inattention to sneak a warm gentle\\n hand underneath the blanket to palpate the abdomen. Gentle\\n abdominal percussion or bed shaking with your knees while\\n watching the child’s face, will get you the sense of peritoneal\\n irritation without provoking an intentional pain.\\n • An infant who will not allow a gentle attempt even when held in his\\n mother’s lap should be sedated, because sedation does not affect\\n muscle guarding. Our preference is intranasal midazolam 0.1-\\n 0.2mg/kg.\\n • Examination of the scrotum is essential for two reasons. First, an\\n acute condition in the testicles, such as torsion, can present with\\n pain in the groin and iliac fossa. Secondly, perforated appendicitis',\n", " 'md': '```markdown\\n# Pediatric Acute Abdomen\\n\\n## Key Points\\n\\n- **Timing, History, and Abdominal Palpation**: These are crucial factors in assessing pediatric acute abdomen.\\n\\n### Basics of Pediatric Abdominal Pain\\n\\n- Children with abdominal pain present to the emergency room at varying stages of disease because the timing of presentation depends on the parents. Some parents delay, while others rush their children to the ER at the slightest sign of trouble. Parents’ attitudes to emergencies could be described like this: when their first child swallows a coin, they rush to the ER; when that happens to the second child, they search for the coin in the child’s feces; the third child has the coin deducted from his pocket money. As a general rule — as originally stated by Sir Zachary Cope — consider any abdominal pain lasting more than 6 hours as a potential surgical problem.\\n\\n- Younger children do not give you a history, but listen to the parents because they know their kids so well. A classic example is intussusception, where a description of the child’s behavior and a glance at the stool can point you to the diagnosis even before the physical examination.\\n\\n- The importance of gentleness during abdominal palpation cannot be over-emphasized. The majority of children with a sore tummy object to abdominal palpation. Sometimes a toy provides a temporary distraction that will allow you to examine the abdomen, but it is pointless to persist if the child is antagonized. Instead of the usual ‘head-to-toe’ sequence of the physical exam in adults, take advantage of a spell of sleep or inattention to sneak a warm gentle hand underneath the blanket to palpate the abdomen. Gentle abdominal percussion or bed shaking with your knees while watching the child’s face will get you the sense of peritoneal irritation without provoking an intentional pain.\\n\\n- An infant who will not allow a gentle attempt even when held in his mother’s lap should be sedated, because sedation does not affect muscle guarding. Our preference is intranasal midazolam 0.1-0.2 mg/kg.\\n\\n- Examination of the scrotum is essential for two reasons. First, an acute condition in the testicles, such as torsion, can present with pain in the groin and iliac fossa. Secondly, perforated appendicitis may also present similarly.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Pediatric Acute Abdomen',\n", " 'md': '# Pediatric Acute Abdomen',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Key Points',\n", " 'md': '## Key Points',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Timing, History, and Abdominal Palpation**: These are crucial factors in assessing pediatric acute abdomen.',\n", " 'md': '- **Timing, History, and Abdominal Palpation**: These are crucial factors in assessing pediatric acute abdomen.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Basics of Pediatric Abdominal Pain',\n", " 'md': '### Basics of Pediatric Abdominal Pain',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Children with abdominal pain present to the emergency room at varying stages of disease because the timing of presentation depends on the parents. Some parents delay, while others rush their children to the ER at the slightest sign of trouble. Parents’ attitudes to emergencies could be described like this: when their first child swallows a coin, they rush to the ER; when that happens to the second child, they search for the coin in the child’s feces; the third child has the coin deducted from his pocket money. As a general rule — as originally stated by Sir Zachary Cope — consider any abdominal pain lasting more than 6 hours as a potential surgical problem.\\n\\n- Younger children do not give you a history, but listen to the parents because they know their kids so well. A classic example is intussusception, where a description of the child’s behavior and a glance at the stool can point you to the diagnosis even before the physical examination.\\n\\n- The importance of gentleness during abdominal palpation cannot be over-emphasized. The majority of children with a sore tummy object to abdominal palpation. Sometimes a toy provides a temporary distraction that will allow you to examine the abdomen, but it is pointless to persist if the child is antagonized. Instead of the usual ‘head-to-toe’ sequence of the physical exam in adults, take advantage of a spell of sleep or inattention to sneak a warm gentle hand underneath the blanket to palpate the abdomen. Gentle abdominal percussion or bed shaking with your knees while watching the child’s face will get you the sense of peritoneal irritation without provoking an intentional pain.\\n\\n- An infant who will not allow a gentle attempt even when held in his mother’s lap should be sedated, because sedation does not affect muscle guarding. Our preference is intranasal midazolam 0.1-0.2 mg/kg.\\n\\n- Examination of the scrotum is essential for two reasons. First, an acute condition in the testicles, such as torsion, can present with pain in the groin and iliac fossa. Secondly, perforated appendicitis may also present similarly.\\n\\n```',\n", " 'md': '- Children with abdominal pain present to the emergency room at varying stages of disease because the timing of presentation depends on the parents. Some parents delay, while others rush their children to the ER at the slightest sign of trouble. Parents’ attitudes to emergencies could be described like this: when their first child swallows a coin, they rush to the ER; when that happens to the second child, they search for the coin in the child’s feces; the third child has the coin deducted from his pocket money. As a general rule — as originally stated by Sir Zachary Cope — consider any abdominal pain lasting more than 6 hours as a potential surgical problem.\\n\\n- Younger children do not give you a history, but listen to the parents because they know their kids so well. A classic example is intussusception, where a description of the child’s behavior and a glance at the stool can point you to the diagnosis even before the physical examination.\\n\\n- The importance of gentleness during abdominal palpation cannot be over-emphasized. The majority of children with a sore tummy object to abdominal palpation. Sometimes a toy provides a temporary distraction that will allow you to examine the abdomen, but it is pointless to persist if the child is antagonized. Instead of the usual ‘head-to-toe’ sequence of the physical exam in adults, take advantage of a spell of sleep or inattention to sneak a warm gentle hand underneath the blanket to palpate the abdomen. Gentle abdominal percussion or bed shaking with your knees while watching the child’s face will get you the sense of peritoneal irritation without provoking an intentional pain.\\n\\n- An infant who will not allow a gentle attempt even when held in his mother’s lap should be sedated, because sedation does not affect muscle guarding. Our preference is intranasal midazolam 0.1-0.2 mg/kg.\\n\\n- Examination of the scrotum is essential for two reasons. First, an acute condition in the testicles, such as torsion, can present with pain in the groin and iliac fossa. Secondly, perforated appendicitis may also present similarly.\\n\\n```',\n", " 'bBox': {'x': 100, 'y': 190, 'w': 437.65, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 648,\n", " 'text': ' occasionally presents with a painful scrotal swelling, because pus\\n enters the patent processus vaginalis, causing acute funiculitis.\\n• Rectal examination is best left to the end of the physical\\n examination, after looking at the throat and ears, and is not needed\\n if there is a clear indication for surgery.\\n\\n Clinical patterns of the acute abdomen in children (see\\n also Chapter 3)\\n\\n ħere are a few key points:\\n\\n• The combination of acute abdominal pain and shock is rare in\\n children, and should make you think of occult abdominal trauma\\n with rupture of an enlarged solid organ or intra-abdominal\\n malignancy. Ruptured ectopic pregnancy is possible in an\\n adolescent girl.\\n• Generalized peritonitis in children is most commonly due to\\n appendicitis. Do not try to elicit rebound tenderness, as you will\\n lose the confidence and cooperation of your patient. (This applies to\\n adults too!).\\n• Localized peritonitis in the left lower quadrant can be due to acute\\n constipation, whereas right or left upper quadrant tenderness is\\n commonly due to acute enlargement of the liver or spleen,\\n respectively. Please be informed that constipation is the second\\n most frequent diagnosis found on emergency discharge\\n records for missed pediatric abdominal catastrophes in court\\n cases.\\n• Intestinal obstruction in a virgin abdomen is caused by\\n intussusception or appendicitis. One of ten children with\\n complicated rotational anomalies of the midgut presents after the\\n neonatal period. The critical concern with malrotation is midgut\\n volvulus with acute extensive bowel ischemia. This life-threatening\\n condition carries the risk of rapid transmural intestinal necrosis. Your\\n surgical intervention should be prompt because simple counter-\\n clockwise detorsion of the bowel may save it. Don’t put the baby at\\n risk of a miserable life with a short bowel, yielding to the anesthetist\\n “because the blood is not ready”.',\n", " 'md': '```markdown\\n# Clinical Patterns of the Acute Abdomen in Children\\n\\nHere are a few key points:\\n\\n- The combination of acute abdominal pain and shock is rare in children, and should make you think of occult abdominal trauma with rupture of an enlarged solid organ or intra-abdominal malignancy. Ruptured ectopic pregnancy is possible in an adolescent girl.\\n- Generalized peritonitis in children is most commonly due to appendicitis. Do not try to elicit rebound tenderness, as you will lose the confidence and cooperation of your patient. (This applies to adults too!).\\n- Localized peritonitis in the left lower quadrant can be due to acute constipation, whereas right or left upper quadrant tenderness is commonly due to acute enlargement of the liver or spleen, respectively. Please be informed that constipation is the second most frequent diagnosis found on emergency discharge records for missed pediatric abdominal catastrophes in court cases.\\n- Intestinal obstruction in a virgin abdomen is caused by intussusception or appendicitis. One of ten children with complicated rotational anomalies of the midgut presents after the neonatal period. The critical concern with malrotation is midgut volvulus with acute extensive bowel ischemia. This life-threatening condition carries the risk of rapid transmural intestinal necrosis. Your surgical intervention should be prompt because simple counter-clockwise detorsion of the bowel may save it. Don’t put the baby at risk of a miserable life with a short bowel, yielding to the anesthetist “because the blood is not ready”.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Clinical Patterns of the Acute Abdomen in Children',\n", " 'md': '# Clinical Patterns of the Acute Abdomen in Children',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Here are a few key points:\\n\\n- The combination of acute abdominal pain and shock is rare in children, and should make you think of occult abdominal trauma with rupture of an enlarged solid organ or intra-abdominal malignancy. Ruptured ectopic pregnancy is possible in an adolescent girl.\\n- Generalized peritonitis in children is most commonly due to appendicitis. Do not try to elicit rebound tenderness, as you will lose the confidence and cooperation of your patient. (This applies to adults too!).\\n- Localized peritonitis in the left lower quadrant can be due to acute constipation, whereas right or left upper quadrant tenderness is commonly due to acute enlargement of the liver or spleen, respectively. Please be informed that constipation is the second most frequent diagnosis found on emergency discharge records for missed pediatric abdominal catastrophes in court cases.\\n- Intestinal obstruction in a virgin abdomen is caused by intussusception or appendicitis. One of ten children with complicated rotational anomalies of the midgut presents after the neonatal period. The critical concern with malrotation is midgut volvulus with acute extensive bowel ischemia. This life-threatening condition carries the risk of rapid transmural intestinal necrosis. Your surgical intervention should be prompt because simple counter-clockwise detorsion of the bowel may save it. Don’t put the baby at risk of a miserable life with a short bowel, yielding to the anesthetist “because the blood is not ready”.\\n```',\n", " 'md': 'Here are a few key points:\\n\\n- The combination of acute abdominal pain and shock is rare in children, and should make you think of occult abdominal trauma with rupture of an enlarged solid organ or intra-abdominal malignancy. Ruptured ectopic pregnancy is possible in an adolescent girl.\\n- Generalized peritonitis in children is most commonly due to appendicitis. Do not try to elicit rebound tenderness, as you will lose the confidence and cooperation of your patient. (This applies to adults too!).\\n- Localized peritonitis in the left lower quadrant can be due to acute constipation, whereas right or left upper quadrant tenderness is commonly due to acute enlargement of the liver or spleen, respectively. Please be informed that constipation is the second most frequent diagnosis found on emergency discharge records for missed pediatric abdominal catastrophes in court cases.\\n- Intestinal obstruction in a virgin abdomen is caused by intussusception or appendicitis. One of ten children with complicated rotational anomalies of the midgut presents after the neonatal period. The critical concern with malrotation is midgut volvulus with acute extensive bowel ischemia. This life-threatening condition carries the risk of rapid transmural intestinal necrosis. Your surgical intervention should be prompt because simple counter-clockwise detorsion of the bowel may save it. Don’t put the baby at risk of a miserable life with a short bowel, yielding to the anesthetist “because the blood is not ready”.\\n```',\n", " 'bBox': {'x': 100, 'y': 291, 'w': 437.43, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 649,\n", " 'text': ' • A surgical scar signifies adhesion-related small bowel obstruction\\n until proven otherwise. In doubtful cases, the Gastrografin®\\n challenge test (pediatric dose is 2ml/kg up to 100ml) described in\\n Chapter 21 is safe and effective in children.\\n • A word of caution for 21st century surgeons relating to the\\n scarless abdomen. Natural orifice transluminal endoscopic surgery\\n (NOTES) in children is against common sense, thus, should not be\\n mentioned in this book. ħowever, sutureless plastic closure of\\n gastroschisis and trans-endorectal pull-through for ħirschsprung’s\\n disease may present you with patients after major intra-abdominal\\n manipulations but with absolutely no scars.\\n • The two major pitfalls in pediatric small bowel obstruction are:\\n missing an incarcerated inguinal hernia and waiting too long with\\n conservative management before surgery.\\n\\n A wide spectrum of non-surgical conditions may mimic abdominal\\n emergencies. Particularly in infants, any acute systemic disease may present with apathy,\\n vomiting and stool abnormalities. The converse is also true. A child with an acute abdomen\\n may present with a wide array of seemingly unrelated symptoms suggesting early meningitis, a\\n neurological disorder or poisoning. Although gastroenteritis is common in children and\\n typically presents with acute abdominal complaints, for a surgeon it should only be a\\n diagnosis of exclusion. Remember, it is the first common erroneous diagnosis in court\\n cases.\\n\\n Specific pediatric emergencies\\n\\n The relative incidence of various conditions in different age groups is\\ndepicted in Figure 36.1.',\n", " 'md': '```markdown\\n# Page Content\\n\\n- A surgical scar signifies adhesion-related small bowel obstruction until proven otherwise. In doubtful cases, the Gastrografin® challenge test (pediatric dose is 2ml/kg up to 100ml) described in Chapter 21 is safe and effective in children.\\n- A word of caution for 21st century surgeons relating to the scarless abdomen. Natural orifice transluminal endoscopic surgery (NOTES) in children is against common sense, thus, should not be mentioned in this book. However, sutureless plastic closure of gastroschisis and trans-endorectal pull-through for Hirschsprung’s disease may present you with patients after major intra-abdominal manipulations but with absolutely no scars.\\n- The two major pitfalls in pediatric small bowel obstruction are: missing an incarcerated inguinal hernia and waiting too long with conservative management before surgery.\\n\\nA wide spectrum of non-surgical conditions may mimic abdominal emergencies. Particularly in infants, any acute systemic disease may present with apathy, vomiting, and stool abnormalities. The converse is also true. A child with an acute abdomen may present with a wide array of seemingly unrelated symptoms suggesting early meningitis, a neurological disorder, or poisoning. Although gastroenteritis is common in children and typically presents with acute abdominal complaints, for a surgeon it should only be a diagnosis of exclusion. Remember, it is the first common erroneous diagnosis in court cases.\\n\\n## Specific Pediatric Emergencies\\n\\nThe relative incidence of various conditions in different age groups is depicted in **Figure 36.1**.\\n```\\n\\n### Image Identification and Description\\n\\n- **Figure 36.1**: This figure illustrates the relative incidence of various pediatric conditions across different age groups. The graphical representation likely includes a bar chart or a line graph that categorizes conditions by age, providing a visual comparison of how frequently certain conditions occur in infants, toddlers, and older children. The specific details of the graph are not extractable from the text provided.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- A surgical scar signifies adhesion-related small bowel obstruction until proven otherwise. In doubtful cases, the Gastrografin® challenge test (pediatric dose is 2ml/kg up to 100ml) described in Chapter 21 is safe and effective in children.\\n- A word of caution for 21st century surgeons relating to the scarless abdomen. Natural orifice transluminal endoscopic surgery (NOTES) in children is against common sense, thus, should not be mentioned in this book. However, sutureless plastic closure of gastroschisis and trans-endorectal pull-through for Hirschsprung’s disease may present you with patients after major intra-abdominal manipulations but with absolutely no scars.\\n- The two major pitfalls in pediatric small bowel obstruction are: missing an incarcerated inguinal hernia and waiting too long with conservative management before surgery.\\n\\nA wide spectrum of non-surgical conditions may mimic abdominal emergencies. Particularly in infants, any acute systemic disease may present with apathy, vomiting, and stool abnormalities. The converse is also true. A child with an acute abdomen may present with a wide array of seemingly unrelated symptoms suggesting early meningitis, a neurological disorder, or poisoning. Although gastroenteritis is common in children and typically presents with acute abdominal complaints, for a surgeon it should only be a diagnosis of exclusion. Remember, it is the first common erroneous diagnosis in court cases.',\n", " 'md': '- A surgical scar signifies adhesion-related small bowel obstruction until proven otherwise. In doubtful cases, the Gastrografin® challenge test (pediatric dose is 2ml/kg up to 100ml) described in Chapter 21 is safe and effective in children.\\n- A word of caution for 21st century surgeons relating to the scarless abdomen. Natural orifice transluminal endoscopic surgery (NOTES) in children is against common sense, thus, should not be mentioned in this book. However, sutureless plastic closure of gastroschisis and trans-endorectal pull-through for Hirschsprung’s disease may present you with patients after major intra-abdominal manipulations but with absolutely no scars.\\n- The two major pitfalls in pediatric small bowel obstruction are: missing an incarcerated inguinal hernia and waiting too long with conservative management before surgery.\\n\\nA wide spectrum of non-surgical conditions may mimic abdominal emergencies. Particularly in infants, any acute systemic disease may present with apathy, vomiting, and stool abnormalities. The converse is also true. A child with an acute abdomen may present with a wide array of seemingly unrelated symptoms suggesting early meningitis, a neurological disorder, or poisoning. Although gastroenteritis is common in children and typically presents with acute abdominal complaints, for a surgeon it should only be a diagnosis of exclusion. Remember, it is the first common erroneous diagnosis in court cases.',\n", " 'bBox': {'x': 79, 'y': 121, 'w': 458.64, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Specific Pediatric Emergencies',\n", " 'md': '## Specific Pediatric Emergencies',\n", " 'bBox': {'x': 86, 'y': 546, 'w': 242.78, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The relative incidence of various conditions in different age groups is depicted in **Figure 36.1**.\\n```',\n", " 'md': 'The relative incidence of various conditions in different age groups is depicted in **Figure 36.1**.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 36.1**: This figure illustrates the relative incidence of various pediatric conditions across different age groups. The graphical representation likely includes a bar chart or a line graph that categorizes conditions by age, providing a visual comparison of how frequently certain conditions occur in infants, toddlers, and older children. The specific details of the graph are not extractable from the text provided.',\n", " 'md': '- **Figure 36.1**: This figure illustrates the relative incidence of various pediatric conditions across different age groups. The graphical representation likely includes a bar chart or a line graph that categorizes conditions by age, providing a visual comparison of how frequently certain conditions occur in infants, toddlers, and older children. The specific details of the graph are not extractable from the text provided.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 650,\n", " 'text': ' 30\\n 1 25\\n 20 Intussusception\\n 1 1015 incarceraled hemia\\n Appendicitis\\n Meckel\\n Testicular torsion\\n 0.5 1.5 10 11 12 13 14 15 16 17 18\\n 2 Age in years\\n Figure 36.1. Pediatric abdominal emergencies.\\n\\n Acute appendicitis (AA) (see also Chapter 23)\\n\\n AA is rare during the first year of life and is uncommon during the\\nsecond. Thereafter, the incidence rises and peaks between the age\\nof 12 and 20. AA in infancy typically presents as generalized\\nperitonitis due to perforation. The infant looks unwell, with fever,\\ntachycardia and tachypnea. The abdomen is distended and generally\\ntender with guarding. Diarrhea is more common than constipation. Pay\\nattention to the useful ‘hunger sign’; it’s rare to see a hungry child who\\nturns out to have AA. Consider AA in the second place on your list of\\ndifferential diagnoses for an infant with an acute abdomen, and in\\nthe first three places in a child. The white cell count is normal in many\\ncases of pediatric AA, but neutrophilia is more specific. Admitting children\\nwith equivocal signs for observation is a safe option, as the chance of\\nrupture under observation in a pediatric surgical ward is less than 1%\\n(oops — the Editors asked for no percentages…).\\n\\n A limited helical CT with rectal contrast is highly accurate in\\ndiagnosing AA in children, but clinical examination by an experienced\\npediatric surgeon is just as good. Even if the CT scan is positive,\\nappendectomy is not indicated if the child improves clinically. Moreover,\\nin our and many other institutions, children with early appendicitis receive\\nantibiotics and undergo appendectomy with a preference for performance\\nof the procedure during daytime hours. Evidence suggests that\\nperforation and complication rates, as well as operating time, are not',\n", " 'md': \"```markdown\\n# Page Content\\n\\n## Figure 36.1. Pediatric abdominal emergencies\\n\\n![Figure 36.1]()\\n\\n### Description\\nThis figure illustrates the incidence of various pediatric abdominal emergencies, including Intussusception, incarcerated hernia, Appendicitis, Meckel's diverticulum, and Testicular torsion, plotted against age in years. The graph shows a rise in the incidence of acute appendicitis (AA) as children age, peaking between 12 and 20 years. The x-axis represents age in years, while the y-axis indicates the incidence rate.\\n\\n### Text Content\\nAcute appendicitis (AA) (see also Chapter 23)\\n\\nAA is rare during the first year of life and is uncommon during the second. Thereafter, the incidence rises and peaks between the age of 12 and 20. AA in infancy typically presents as generalized peritonitis due to perforation. The infant looks unwell, with fever, tachycardia, and tachypnea. The abdomen is distended and generally tender with guarding. Diarrhea is more common than constipation. Pay attention to the useful ‘hunger sign’; it’s rare to see a hungry child who turns out to have AA. Consider AA in the second place on your list of differential diagnoses for an infant with an acute abdomen, and in the first three places in a child. The white cell count is normal in many cases of pediatric AA, but neutrophilia is more specific. Admitting children with equivocal signs for observation is a safe option, as the chance of rupture under observation in a pediatric surgical ward is less than 1% (oops — the Editors asked for no percentages…).\\n\\nA limited helical CT with rectal contrast is highly accurate in diagnosing AA in children, but clinical examination by an experienced pediatric surgeon is just as good. Even if the CT scan is positive, appendectomy is not indicated if the child improves clinically. Moreover, in our and many other institutions, children with early appendicitis receive antibiotics and undergo appendectomy with a preference for performance of the procedure during daytime hours. Evidence suggests that perforation and complication rates, as well as operating time, are not significantly affected by the timing of the surgery.\\n```\",\n", " 'images': [{'name': 'img_p649_1.png',\n", " 'height': 303,\n", " 'width': 907,\n", " 'x': 82.07999999999993,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1557,\n", " 'original_height': 520}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 36.1. Pediatric abdominal emergencies',\n", " 'md': '## Figure 36.1. Pediatric abdominal emergencies',\n", " 'bBox': {'x': 89.5, 'y': 98.12, 'w': 8.9, 'h': 74.14}},\n", " {'type': 'text',\n", " 'value': '![Figure 36.1]()',\n", " 'md': '![Figure 36.1]()',\n", " 'bBox': {'x': 89.5, 'y': 98.12, 'w': 8.9, 'h': 74.14}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Description',\n", " 'md': '### Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"This figure illustrates the incidence of various pediatric abdominal emergencies, including Intussusception, incarcerated hernia, Appendicitis, Meckel's diverticulum, and Testicular torsion, plotted against age in years. The graph shows a rise in the incidence of acute appendicitis (AA) as children age, peaking between 12 and 20 years. The x-axis represents age in years, while the y-axis indicates the incidence rate.\",\n", " 'md': \"This figure illustrates the incidence of various pediatric abdominal emergencies, including Intussusception, incarcerated hernia, Appendicitis, Meckel's diverticulum, and Testicular torsion, plotted against age in years. The graph shows a rise in the incidence of acute appendicitis (AA) as children age, peaking between 12 and 20 years. The x-axis represents age in years, while the y-axis indicates the incidence rate.\",\n", " 'bBox': {'x': 89.5, 'y': 98.12, 'w': 57.37, 'h': 74.14}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text Content',\n", " 'md': '### Text Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Acute appendicitis (AA) (see also Chapter 23)\\n\\nAA is rare during the first year of life and is uncommon during the second. Thereafter, the incidence rises and peaks between the age of 12 and 20. AA in infancy typically presents as generalized peritonitis due to perforation. The infant looks unwell, with fever, tachycardia, and tachypnea. The abdomen is distended and generally tender with guarding. Diarrhea is more common than constipation. Pay attention to the useful ‘hunger sign’; it’s rare to see a hungry child who turns out to have AA. Consider AA in the second place on your list of differential diagnoses for an infant with an acute abdomen, and in the first three places in a child. The white cell count is normal in many cases of pediatric AA, but neutrophilia is more specific. Admitting children with equivocal signs for observation is a safe option, as the chance of rupture under observation in a pediatric surgical ward is less than 1% (oops — the Editors asked for no percentages…).\\n\\nA limited helical CT with rectal contrast is highly accurate in diagnosing AA in children, but clinical examination by an experienced pediatric surgeon is just as good. Even if the CT scan is positive, appendectomy is not indicated if the child improves clinically. Moreover, in our and many other institutions, children with early appendicitis receive antibiotics and undergo appendectomy with a preference for performance of the procedure during daytime hours. Evidence suggests that perforation and complication rates, as well as operating time, are not significantly affected by the timing of the surgery.\\n```',\n", " 'md': 'Acute appendicitis (AA) (see also Chapter 23)\\n\\nAA is rare during the first year of life and is uncommon during the second. Thereafter, the incidence rises and peaks between the age of 12 and 20. AA in infancy typically presents as generalized peritonitis due to perforation. The infant looks unwell, with fever, tachycardia, and tachypnea. The abdomen is distended and generally tender with guarding. Diarrhea is more common than constipation. Pay attention to the useful ‘hunger sign’; it’s rare to see a hungry child who turns out to have AA. Consider AA in the second place on your list of differential diagnoses for an infant with an acute abdomen, and in the first three places in a child. The white cell count is normal in many cases of pediatric AA, but neutrophilia is more specific. Admitting children with equivocal signs for observation is a safe option, as the chance of rupture under observation in a pediatric surgical ward is less than 1% (oops — the Editors asked for no percentages…).\\n\\nA limited helical CT with rectal contrast is highly accurate in diagnosing AA in children, but clinical examination by an experienced pediatric surgeon is just as good. Even if the CT scan is positive, appendectomy is not indicated if the child improves clinically. Moreover, in our and many other institutions, children with early appendicitis receive antibiotics and undergo appendectomy with a preference for performance of the procedure during daytime hours. Evidence suggests that perforation and complication rates, as well as operating time, are not significantly affected by the timing of the surgery.\\n```',\n", " 'bBox': {'x': 72, 'y': 98.12, 'w': 467.7, 'h': 74.14}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 651,\n", " 'text': 'increased for patients who undergo appendectomy more than 6 hours\\nversus less than 6 hours after diagnosis.\\n\\n What is the role of laparoscopy in the doubtful case? While it offers\\nthe advantage of a diagnostic modality that can be immediately followed\\nby appendectomy, it will subject some children to an unnecessary\\noperation. If you can get the child into a CT scanner without general\\nanesthesia, this should be your preferred choice instead of diagnostic\\nlaparoscopy.\\n\\n We try to avoid CT in children as we are not comfortable with the radiation involved. The risk of\\n radiation vs. the risk of laparoscopy is not a solved dilemma. We rely on US alone if we need\\n confirmation of the diagnosis. Danny\\n A few months ago I proceeded with open appendectomy on a 5-year-old girl with a classical\\n picture of acute appendicitis. The pediatrician begged me to avoid a CT for the reasons\\n mentioned by Danny. The appendix was normal — the patient had primary bacterial peritonitis.\\n Moshe\\n But do we really need to achieve 100% accuracy? Isn’t a small RLQ incision (or a 5mm\\n scope...) a fair price in order to save little kids from excessive radiation? Danny\\n\\n Although a valid alternative to the open technique, the value of\\nlaparoscopic pediatric appendectomy remains controversial\\nbecause there are no good data to suggest that it confers an\\nadvantage. Similarly to adult patients, children after laparoscopic\\nappendectomy have significantly fewer wound infections and a shorter\\nduration of hospital stay, but higher rates of readmission, intra-abdominal\\nabscess formation, and higher hospital costs. Good evidence to\\nsupport decreased postoperative pain and earlier return to normal\\nactivities after laparoscopic appendectomy in children is lacking.\\n\\n The short distances involved and the thin abdominal wall of children\\nallow a ‘port-exteriorization appendectomy’, performed via two ports,\\nwhere the appendix is exteriorized by pulling it out of the right iliac fossa\\nport and then the entire appendectomy is performed outside the\\nabdomen, or the appendix can be pulled out of the umbilical port. If you',\n", " 'md': \"```markdown\\n## Text Extraction\\n\\nIncreased for patients who undergo appendectomy more than 6 hours versus less than 6 hours after diagnosis.\\n\\nWhat is the role of laparoscopy in the doubtful case? While it offers the advantage of a diagnostic modality that can be immediately followed by appendectomy, it will subject some children to an unnecessary operation. If you can get the child into a CT scanner without general anesthesia, this should be your preferred choice instead of diagnostic laparoscopy.\\n\\nWe try to avoid CT in children as we are not comfortable with the radiation involved. The risk of radiation vs. the risk of laparoscopy is not a solved dilemma. We rely on US alone if we need confirmation of the diagnosis. Danny\\n\\nA few months ago I proceeded with open appendectomy on a 5-year-old girl with a classical picture of acute appendicitis. The pediatrician begged me to avoid a CT for the reasons mentioned by Danny. The appendix was normal — the patient had primary bacterial peritonitis. Moshe\\n\\nBut do we really need to achieve 100% accuracy? Isn’t a small RLQ incision (or a 5mm scope...) a fair price in order to save little kids from excessive radiation? Danny\\n\\nAlthough a valid alternative to the open technique, the value of laparoscopic pediatric appendectomy remains controversial because there are no good data to suggest that it confers an advantage. Similarly to adult patients, children after laparoscopic appendectomy have significantly fewer wound infections and a shorter duration of hospital stay, but higher rates of readmission, intra-abdominal abscess formation, and higher hospital costs. Good evidence to support decreased postoperative pain and earlier return to normal activities after laparoscopic appendectomy in children is lacking.\\n\\nThe short distances involved and the thin abdominal wall of children allow a ‘port-exteriorization appendectomy’, performed via two ports, where the appendix is exteriorized by pulling it out of the right iliac fossa port and then the entire appendectomy is performed outside the abdomen, or the appendix can be pulled out of the umbilical port.\\n\\n## Image Identification and Description\\n\\n*No images or graphs were identified on this page.*\\n\\n## Summary\\n\\nThis page discusses the role of laparoscopy in appendectomy for children, weighing the benefits and risks of using CT scans versus diagnostic laparoscopy. It highlights the controversy surrounding laparoscopic appendectomy in pediatric cases, noting the lack of strong evidence supporting its advantages over traditional methods. The text also describes a specific technique called 'port-exteriorization appendectomy' that can be performed in children due to their anatomical characteristics.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Increased for patients who undergo appendectomy more than 6 hours versus less than 6 hours after diagnosis.\\n\\nWhat is the role of laparoscopy in the doubtful case? While it offers the advantage of a diagnostic modality that can be immediately followed by appendectomy, it will subject some children to an unnecessary operation. If you can get the child into a CT scanner without general anesthesia, this should be your preferred choice instead of diagnostic laparoscopy.\\n\\nWe try to avoid CT in children as we are not comfortable with the radiation involved. The risk of radiation vs. the risk of laparoscopy is not a solved dilemma. We rely on US alone if we need confirmation of the diagnosis. Danny\\n\\nA few months ago I proceeded with open appendectomy on a 5-year-old girl with a classical picture of acute appendicitis. The pediatrician begged me to avoid a CT for the reasons mentioned by Danny. The appendix was normal — the patient had primary bacterial peritonitis. Moshe\\n\\nBut do we really need to achieve 100% accuracy? Isn’t a small RLQ incision (or a 5mm scope...) a fair price in order to save little kids from excessive radiation? Danny\\n\\nAlthough a valid alternative to the open technique, the value of laparoscopic pediatric appendectomy remains controversial because there are no good data to suggest that it confers an advantage. Similarly to adult patients, children after laparoscopic appendectomy have significantly fewer wound infections and a shorter duration of hospital stay, but higher rates of readmission, intra-abdominal abscess formation, and higher hospital costs. Good evidence to support decreased postoperative pain and earlier return to normal activities after laparoscopic appendectomy in children is lacking.\\n\\nThe short distances involved and the thin abdominal wall of children allow a ‘port-exteriorization appendectomy’, performed via two ports, where the appendix is exteriorized by pulling it out of the right iliac fossa port and then the entire appendectomy is performed outside the abdomen, or the appendix can be pulled out of the umbilical port.',\n", " 'md': 'Increased for patients who undergo appendectomy more than 6 hours versus less than 6 hours after diagnosis.\\n\\nWhat is the role of laparoscopy in the doubtful case? While it offers the advantage of a diagnostic modality that can be immediately followed by appendectomy, it will subject some children to an unnecessary operation. If you can get the child into a CT scanner without general anesthesia, this should be your preferred choice instead of diagnostic laparoscopy.\\n\\nWe try to avoid CT in children as we are not comfortable with the radiation involved. The risk of radiation vs. the risk of laparoscopy is not a solved dilemma. We rely on US alone if we need confirmation of the diagnosis. Danny\\n\\nA few months ago I proceeded with open appendectomy on a 5-year-old girl with a classical picture of acute appendicitis. The pediatrician begged me to avoid a CT for the reasons mentioned by Danny. The appendix was normal — the patient had primary bacterial peritonitis. Moshe\\n\\nBut do we really need to achieve 100% accuracy? Isn’t a small RLQ incision (or a 5mm scope...) a fair price in order to save little kids from excessive radiation? Danny\\n\\nAlthough a valid alternative to the open technique, the value of laparoscopic pediatric appendectomy remains controversial because there are no good data to suggest that it confers an advantage. Similarly to adult patients, children after laparoscopic appendectomy have significantly fewer wound infections and a shorter duration of hospital stay, but higher rates of readmission, intra-abdominal abscess formation, and higher hospital costs. Good evidence to support decreased postoperative pain and earlier return to normal activities after laparoscopic appendectomy in children is lacking.\\n\\nThe short distances involved and the thin abdominal wall of children allow a ‘port-exteriorization appendectomy’, performed via two ports, where the appendix is exteriorized by pulling it out of the right iliac fossa port and then the entire appendectomy is performed outside the abdomen, or the appendix can be pulled out of the umbilical port.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or graphs were identified on this page.*',\n", " 'md': '*No images or graphs were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"This page discusses the role of laparoscopy in appendectomy for children, weighing the benefits and risks of using CT scans versus diagnostic laparoscopy. It highlights the controversy surrounding laparoscopic appendectomy in pediatric cases, noting the lack of strong evidence supporting its advantages over traditional methods. The text also describes a specific technique called 'port-exteriorization appendectomy' that can be performed in children due to their anatomical characteristics.\\n```\",\n", " 'md': \"This page discusses the role of laparoscopy in appendectomy for children, weighing the benefits and risks of using CT scans versus diagnostic laparoscopy. It highlights the controversy surrounding laparoscopic appendectomy in pediatric cases, noting the lack of strong evidence supporting its advantages over traditional methods. The text also describes a specific technique called 'port-exteriorization appendectomy' that can be performed in children due to their anatomical characteristics.\\n```\",\n", " 'bBox': {'x': 72, 'y': 220, 'w': 105.52, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 652,\n", " 'text': 'have a laparoscope with a working channel, you can perform a single-\\nport appendectomy using the same technique.\\n\\n Which would be equivalent to a conventional — ‘no-port appendectomy’ through a 2cm incision.\\n The Editors\\n\\n There is no point in culturing the peritoneal fluid in cases of obvious AA\\nbecause the results are predictable and antibiotics have usually been\\nstopped by the time the culture results become available. Decide on the\\nduration of postoperative antibiotics according to the degree of\\ncontamination/infection found in the peritoneal cavity (see Chapter 44).\\n\\n Peritoneal drains are not necessary. They do not reduce the\\nincidence of wound infection or abscess after appendectomy for\\nperforated appendicitis in children; instead they increase cost, and a child\\nis subjected to stress and pain at the removal ( Chapter 39).\\n\\n Finally, not all children with acute appendicitis have to be operated\\nupon. The indications for a non-operative approach are similar to those\\ndescribed in adults ( Chapter 23).\\n\\n Intussusception\\n\\n Telescoping of one portion of the intestine into another can turn a\\nhealthy baby into a critically ill patient within a few hours. This problem\\ntypically occurs between the ages of 5 and 7 months, and the\\netiology is idiopathic. In children older than 2 years, look for an\\nunderlying pathology, the most common being a Meckel’s\\ndiverticulum. Early intussusception is generally a benign condition,\\nalthough it becomes a strangulating obstruction eventually, if not treated\\npromptly, leading to vascular compromise. Most cases start in the\\nileum as an ileo-ileal intussusception and then progress through the\\nileocecal valve to become ileocolic intussusception.\\n\\n The diagnosis is straightforward if the infant exhibits the classic\\nclinical syndrome: a previously healthy infant suddenly starts to scream,',\n", " 'md': '```markdown\\n## Text Extraction\\n\\n- If you have a laparoscope with a working channel, you can perform a single-port appendectomy using the same technique.\\n- This would be equivalent to a conventional — ‘no-port appendectomy’ through a 2cm incision.\\n- There is no point in culturing the peritoneal fluid in cases of obvious acute appendicitis (AA) because the results are predictable and antibiotics have usually been stopped by the time the culture results become available. Decide on the duration of postoperative antibiotics according to the degree of contamination/infection found in the peritoneal cavity (see Chapter 44).\\n- Peritoneal drains are not necessary. They do not reduce the incidence of wound infection or abscess after appendectomy for perforated appendicitis in children; instead, they increase cost, and a child is subjected to stress and pain at the removal (see Chapter 39).\\n- Finally, not all children with acute appendicitis have to be operated upon. The indications for a non-operative approach are similar to those described in adults (see Chapter 23).\\n\\n### Intussusception\\n\\n- Telescoping of one portion of the intestine into another can turn a healthy baby into a critically ill patient within a few hours. This problem typically occurs between the ages of 5 and 7 months, and the etiology is idiopathic. In children older than 2 years, look for an underlying pathology, the most common being a Meckel’s diverticulum. Early intussusception is generally a benign condition, although it becomes a strangulating obstruction eventually, if not treated promptly, leading to vascular compromise. Most cases start in the ileum as an ileo-ileal intussusception and then progress through the ileocecal valve to become ileocolic intussusception.\\n- The diagnosis is straightforward if the infant exhibits the classic clinical syndrome: a previously healthy infant suddenly starts to scream.\\n\\n## Image Identification and Description\\n\\n- No images or graphs were identified on this page.\\n\\n## Summary\\n\\nThis page discusses surgical techniques for appendectomy, the management of peritoneal fluid cultures, the necessity of peritoneal drains, and the indications for non-operative approaches in pediatric appendicitis. It also introduces the condition of intussusception, highlighting its urgency and typical presentation in infants.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- If you have a laparoscope with a working channel, you can perform a single-port appendectomy using the same technique.\\n- This would be equivalent to a conventional — ‘no-port appendectomy’ through a 2cm incision.\\n- There is no point in culturing the peritoneal fluid in cases of obvious acute appendicitis (AA) because the results are predictable and antibiotics have usually been stopped by the time the culture results become available. Decide on the duration of postoperative antibiotics according to the degree of contamination/infection found in the peritoneal cavity (see Chapter 44).\\n- Peritoneal drains are not necessary. They do not reduce the incidence of wound infection or abscess after appendectomy for perforated appendicitis in children; instead, they increase cost, and a child is subjected to stress and pain at the removal (see Chapter 39).\\n- Finally, not all children with acute appendicitis have to be operated upon. The indications for a non-operative approach are similar to those described in adults (see Chapter 23).',\n", " 'md': '- If you have a laparoscope with a working channel, you can perform a single-port appendectomy using the same technique.\\n- This would be equivalent to a conventional — ‘no-port appendectomy’ through a 2cm incision.\\n- There is no point in culturing the peritoneal fluid in cases of obvious acute appendicitis (AA) because the results are predictable and antibiotics have usually been stopped by the time the culture results become available. Decide on the duration of postoperative antibiotics according to the degree of contamination/infection found in the peritoneal cavity (see Chapter 44).\\n- Peritoneal drains are not necessary. They do not reduce the incidence of wound infection or abscess after appendectomy for perforated appendicitis in children; instead, they increase cost, and a child is subjected to stress and pain at the removal (see Chapter 39).\\n- Finally, not all children with acute appendicitis have to be operated upon. The indications for a non-operative approach are similar to those described in adults (see Chapter 23).',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.29, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Intussusception',\n", " 'md': '### Intussusception',\n", " 'bBox': {'x': 86, 'y': 468, 'w': 126.9, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Telescoping of one portion of the intestine into another can turn a healthy baby into a critically ill patient within a few hours. This problem typically occurs between the ages of 5 and 7 months, and the etiology is idiopathic. In children older than 2 years, look for an underlying pathology, the most common being a Meckel’s diverticulum. Early intussusception is generally a benign condition, although it becomes a strangulating obstruction eventually, if not treated promptly, leading to vascular compromise. Most cases start in the ileum as an ileo-ileal intussusception and then progress through the ileocecal valve to become ileocolic intussusception.\\n- The diagnosis is straightforward if the infant exhibits the classic clinical syndrome: a previously healthy infant suddenly starts to scream.',\n", " 'md': '- Telescoping of one portion of the intestine into another can turn a healthy baby into a critically ill patient within a few hours. This problem typically occurs between the ages of 5 and 7 months, and the etiology is idiopathic. In children older than 2 years, look for an underlying pathology, the most common being a Meckel’s diverticulum. Early intussusception is generally a benign condition, although it becomes a strangulating obstruction eventually, if not treated promptly, leading to vascular compromise. Most cases start in the ileum as an ileo-ileal intussusception and then progress through the ileocecal valve to become ileocolic intussusception.\\n- The diagnosis is straightforward if the infant exhibits the classic clinical syndrome: a previously healthy infant suddenly starts to scream.',\n", " 'bBox': {'x': 72, 'y': 468, 'w': 467.9, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses surgical techniques for appendectomy, the management of peritoneal fluid cultures, the necessity of peritoneal drains, and the indications for non-operative approaches in pediatric appendicitis. It also introduces the condition of intussusception, highlighting its urgency and typical presentation in infants.\\n```',\n", " 'md': 'This page discusses surgical techniques for appendectomy, the management of peritoneal fluid cultures, the necessity of peritoneal drains, and the indications for non-operative approaches in pediatric appendicitis. It also introduces the condition of intussusception, highlighting its urgency and typical presentation in infants.\\n```',\n", " 'bBox': {'x': 86, 'y': 468, 'w': 126.9, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}, {'text': ''}]},\n", " {'page': 653,\n", " 'text': 'pulls up its legs and perhaps clutches the abdomen. The pain is then\\nrelieved and the child may relax for a while only to have a similar bout 15-\\n30 minutes later. This leaves the infant pale and ill. Vomiting and passing\\nof ‘redcurrant jelly’ stools is also characteristic, although salmonellosis\\nmay show a similar clinical picture.\\n\\n Atypical presentations are common, however, and lead to\\ndiagnostic errors. The infant may be fretful and restless without either\\npain or vomiting. Pallor and peripheral coolness due to vasoconstriction,\\nlethargy and seizures may also confuse the picture. The crucial\\nphysical sign is palpation of an abdominal mass. The\\nultrasonographic findings of a ‘target’ sign on cross-section and a\\n‘pseudo-kidney’ sign in a longitudinal view are important adjuncts to the\\nclinical diagnosis ( Figure 36.2).\\n b\\n Figure 36.2. Sonographic images of intussusception: a) in a longitudinal plane showing a\\n ‘pseudo-kidney’ sign; b) in a transverse plane showing a ‘target’ sign.\\n\\n With regard to the management, children with diffuse peritonitis,\\nperforation, progressive sepsis and possible gangrenous bowel\\nshould undergo an urgent laparotomy. Early intussusception without\\nperitonitis is reduced non-operatively with pneumatic or hydrostatic\\npressure under radiographic or ultrasonic guidance. Water-soluble',\n", " 'md': '```markdown\\nThe pain is then relieved and the child may relax for a while only to have a similar bout 15-30 minutes later. This leaves the infant pale and ill. Vomiting and passing of ‘redcurrant jelly’ stools is also characteristic, although salmonellosis may show a similar clinical picture.\\n\\nAtypical presentations are common, however, and lead to diagnostic errors. The infant may be fretful and restless without either pain or vomiting. Pallor and peripheral coolness due to vasoconstriction, lethargy and seizures may also confuse the picture. The crucial physical sign is palpation of an abdominal mass. The ultrasonographic findings of a ‘target’ sign on cross-section and a ‘pseudo-kidney’ sign in a longitudinal view are important adjuncts to the clinical diagnosis (Figure 36.2).\\n\\n### Figure 36.2\\nSonographic images of intussusception:\\n- a) in a longitudinal plane showing a ‘pseudo-kidney’ sign;\\n- b) in a transverse plane showing a ‘target’ sign.\\n\\nWith regard to the management, children with diffuse peritonitis, perforation, progressive sepsis and possible gangrenous bowel should undergo an urgent laparotomy. Early intussusception without peritonitis is reduced non-operatively with pneumatic or hydrostatic pressure under radiographic or ultrasonic guidance. Water-soluble\\n```',\n", " 'images': [{'name': 'img_p652_1.png',\n", " 'height': 510,\n", " 'width': 681,\n", " 'x': 137.51999999999998,\n", " 'y': 316.79999999999995,\n", " 'original_width': 1170,\n", " 'original_height': 874}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nThe pain is then relieved and the child may relax for a while only to have a similar bout 15-30 minutes later. This leaves the infant pale and ill. Vomiting and passing of ‘redcurrant jelly’ stools is also characteristic, although salmonellosis may show a similar clinical picture.\\n\\nAtypical presentations are common, however, and lead to diagnostic errors. The infant may be fretful and restless without either pain or vomiting. Pallor and peripheral coolness due to vasoconstriction, lethargy and seizures may also confuse the picture. The crucial physical sign is palpation of an abdominal mass. The ultrasonographic findings of a ‘target’ sign on cross-section and a ‘pseudo-kidney’ sign in a longitudinal view are important adjuncts to the clinical diagnosis (Figure 36.2).',\n", " 'md': '```markdown\\nThe pain is then relieved and the child may relax for a while only to have a similar bout 15-30 minutes later. This leaves the infant pale and ill. Vomiting and passing of ‘redcurrant jelly’ stools is also characteristic, although salmonellosis may show a similar clinical picture.\\n\\nAtypical presentations are common, however, and lead to diagnostic errors. The infant may be fretful and restless without either pain or vomiting. Pallor and peripheral coolness due to vasoconstriction, lethargy and seizures may also confuse the picture. The crucial physical sign is palpation of an abdominal mass. The ultrasonographic findings of a ‘target’ sign on cross-section and a ‘pseudo-kidney’ sign in a longitudinal view are important adjuncts to the clinical diagnosis (Figure 36.2).',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 36.2',\n", " 'md': '### Figure 36.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Sonographic images of intussusception:\\n- a) in a longitudinal plane showing a ‘pseudo-kidney’ sign;\\n- b) in a transverse plane showing a ‘target’ sign.\\n\\nWith regard to the management, children with diffuse peritonitis, perforation, progressive sepsis and possible gangrenous bowel should undergo an urgent laparotomy. Early intussusception without peritonitis is reduced non-operatively with pneumatic or hydrostatic pressure under radiographic or ultrasonic guidance. Water-soluble\\n```',\n", " 'md': 'Sonographic images of intussusception:\\n- a) in a longitudinal plane showing a ‘pseudo-kidney’ sign;\\n- b) in a transverse plane showing a ‘target’ sign.\\n\\nWith regard to the management, children with diffuse peritonitis, perforation, progressive sepsis and possible gangrenous bowel should undergo an urgent laparotomy. Early intussusception without peritonitis is reduced non-operatively with pneumatic or hydrostatic pressure under radiographic or ultrasonic guidance. Water-soluble\\n```',\n", " 'bBox': {'x': 193, 'y': 253, 'w': 24.79, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 654,\n", " 'text': 'contrast is potentially safer than barium in cases of suspected\\nperforation. Reduction is successful in the majority of cases but requires\\nclose collaboration between the surgeon and radiologist ( Figure 36.3).\\nAfter successful non-operative pressure reduction, a child may be\\ndischarged home safely directly from the emergency room. ħowever, one\\nin ten children may come back with a recurrence within 72 hours. Unless\\nthe aforementioned contraindications are present, repetitive\\nattempts at non-operative pressure reduction are justified. And,\\nagain, beware of anatomical abnormalities as the leading point,\\nespecially if the child is older. Do not repeat pressure\\ndecompression after the third or fourth presentation but explore —\\nCT will not show you a Meckel’s diverticulum or an intraluminal\\npolyp.\\n\\n During operative reduction of an early intussusception, in an\\nopen procedure, squeeze on the apex of the intussusception while the\\nbowel is still within the abdomen so that the intussuscepted segment\\nbegins to slide out. When the reduction reaches the region of the hepatic\\nflexure it may become more difficult, but after you eviscerate the proximal\\ncolon the reduction can be completed under direct vision.\\n\\n The classic teaching says: “never pull, only push!”, due to the risk of bowel laceration. However,\\n like many other myths, laparoscopy has changed that. If you choose to do it laparoscopically,\\n gentle pulling of the telescoped loop is acceptable, as long as you are really gentle! Danny\\n\\n After achieving complete reduction remember to examine the entire\\nbowel for any pathology serving as a lead point. If the intussusception\\nis truly irreducible or if the bowel has suffered a serious vascular\\ncompromise — resect it.',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nContrast is potentially safer than barium in cases of suspected perforation. Reduction is successful in the majority of cases but requires close collaboration between the surgeon and radiologist (Figure 36.3). After successful non-operative pressure reduction, a child may be discharged home safely directly from the emergency room. However, one in ten children may come back with a recurrence within 72 hours. Unless the aforementioned contraindications are present, repetitive attempts at non-operative pressure reduction are justified. And, again, beware of anatomical abnormalities as the leading point, especially if the child is older. Do not repeat pressure decompression after the third or fourth presentation but explore — CT will not show you a Meckel’s diverticulum or an intraluminal polyp.\\n\\nDuring operative reduction of an early intussusception, in an open procedure, squeeze on the apex of the intussusception while the bowel is still within the abdomen so that the intussuscepted segment begins to slide out. When the reduction reaches the region of the hepatic flexure it may become more difficult, but after you eviscerate the proximal colon the reduction can be completed under direct vision.\\n\\nThe classic teaching says: “never pull, only push!”, due to the risk of bowel laceration. However, like many other myths, laparoscopy has changed that. If you choose to do it laparoscopically, gentle pulling of the telescoped loop is acceptable, as long as you are really gentle!\\n\\nAfter achieving complete reduction remember to examine the entire bowel for any pathology serving as a lead point. If the intussusception is truly irreducible or if the bowel has suffered a serious vascular compromise — resect it.\\n\\n## Image Identification and Description\\n\\n**Figure 36.3**: This figure likely illustrates the collaboration between the surgeon and radiologist during the non-operative pressure reduction of intussusception. The image may depict a surgical or radiological procedure, emphasizing the importance of teamwork in managing this condition.\\n\\n**Summary**: The figure serves to highlight the critical role of both surgical and radiological expertise in the successful management of intussusception, particularly in cases where non-operative methods are employed.\\n\\n## Formula Extraction\\n\\nNo formulas were identified on this page.\\n\\n## Table Extraction\\n\\nNo tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Contrast is potentially safer than barium in cases of suspected perforation. Reduction is successful in the majority of cases but requires close collaboration between the surgeon and radiologist (Figure 36.3). After successful non-operative pressure reduction, a child may be discharged home safely directly from the emergency room. However, one in ten children may come back with a recurrence within 72 hours. Unless the aforementioned contraindications are present, repetitive attempts at non-operative pressure reduction are justified. And, again, beware of anatomical abnormalities as the leading point, especially if the child is older. Do not repeat pressure decompression after the third or fourth presentation but explore — CT will not show you a Meckel’s diverticulum or an intraluminal polyp.\\n\\nDuring operative reduction of an early intussusception, in an open procedure, squeeze on the apex of the intussusception while the bowel is still within the abdomen so that the intussuscepted segment begins to slide out. When the reduction reaches the region of the hepatic flexure it may become more difficult, but after you eviscerate the proximal colon the reduction can be completed under direct vision.\\n\\nThe classic teaching says: “never pull, only push!”, due to the risk of bowel laceration. However, like many other myths, laparoscopy has changed that. If you choose to do it laparoscopically, gentle pulling of the telescoped loop is acceptable, as long as you are really gentle!\\n\\nAfter achieving complete reduction remember to examine the entire bowel for any pathology serving as a lead point. If the intussusception is truly irreducible or if the bowel has suffered a serious vascular compromise — resect it.',\n", " 'md': 'Contrast is potentially safer than barium in cases of suspected perforation. Reduction is successful in the majority of cases but requires close collaboration between the surgeon and radiologist (Figure 36.3). After successful non-operative pressure reduction, a child may be discharged home safely directly from the emergency room. However, one in ten children may come back with a recurrence within 72 hours. Unless the aforementioned contraindications are present, repetitive attempts at non-operative pressure reduction are justified. And, again, beware of anatomical abnormalities as the leading point, especially if the child is older. Do not repeat pressure decompression after the third or fourth presentation but explore — CT will not show you a Meckel’s diverticulum or an intraluminal polyp.\\n\\nDuring operative reduction of an early intussusception, in an open procedure, squeeze on the apex of the intussusception while the bowel is still within the abdomen so that the intussuscepted segment begins to slide out. When the reduction reaches the region of the hepatic flexure it may become more difficult, but after you eviscerate the proximal colon the reduction can be completed under direct vision.\\n\\nThe classic teaching says: “never pull, only push!”, due to the risk of bowel laceration. However, like many other myths, laparoscopy has changed that. If you choose to do it laparoscopically, gentle pulling of the telescoped loop is acceptable, as long as you are really gentle!\\n\\nAfter achieving complete reduction remember to examine the entire bowel for any pathology serving as a lead point. If the intussusception is truly irreducible or if the bowel has suffered a serious vascular compromise — resect it.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.98, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 36.3**: This figure likely illustrates the collaboration between the surgeon and radiologist during the non-operative pressure reduction of intussusception. The image may depict a surgical or radiological procedure, emphasizing the importance of teamwork in managing this condition.\\n\\n**Summary**: The figure serves to highlight the critical role of both surgical and radiological expertise in the successful management of intussusception, particularly in cases where non-operative methods are employed.',\n", " 'md': '**Figure 36.3**: This figure likely illustrates the collaboration between the surgeon and radiologist during the non-operative pressure reduction of intussusception. The image may depict a surgical or radiological procedure, emphasizing the importance of teamwork in managing this condition.\\n\\n**Summary**: The figure serves to highlight the critical role of both surgical and radiological expertise in the successful management of intussusception, particularly in cases where non-operative methods are employed.',\n", " 'bBox': {'x': 72, 'y': 185, 'w': 60.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formula Extraction',\n", " 'md': '## Formula Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'No formulas were identified on this page.',\n", " 'md': 'No formulas were identified on this page.',\n", " 'bBox': {'x': 266, 'y': 234, 'w': 16, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table Extraction',\n", " 'md': '## Table Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'No tables were identified on this page.\\n```',\n", " 'md': 'No tables were identified on this page.\\n```',\n", " 'bBox': {'x': 266, 'y': 234, 'w': 16, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'After successful non-operative pressure reduction, a child may be'}]},\n", " {'page': 655,\n", " 'text': ' a b\\n d\\n Figure 36.3. a-d) Fluoroscopic monitoring of a retrograde reduction of the\\n intussusception by means of a hydrostatic barium enema, with complete reduction (in d,\\n the contrast is visible in the small intestine).\\n\\n Meckel’s diverticulum\\n\\n Two-thirds of Meckel’s diverticula encountered by surgeons are\\nincidental findings while the remaining one-third will present with a\\ncomplication. Pediatric surgeons encounter different proportions,\\nas the incidence of these complications is maximal during the first 2\\nyears of life and decreases thereafter so that more than two-thirds\\nof all complications occur in the pediatric population. These\\ncomplications include bowel obstruction (adhesive obstruction, volvulus\\nor intussusception), complications of peptic ulceration due to ectopic\\ngastric mucosa (stricture, hemorrhage, or perforation), or acute',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Figure 36.3\\n**Description:** Fluoroscopic monitoring of a retrograde reduction of the intussusception by means of a hydrostatic barium enema, with complete reduction. In part (d), the contrast is visible in the small intestine.\\n\\n### Meckel’s Diverticulum\\nTwo-thirds of Meckel’s diverticula encountered by surgeons are incidental findings while the remaining one-third will present with a complication. Pediatric surgeons encounter different proportions, as the incidence of these complications is maximal during the first 2 years of life and decreases thereafter, so that more than two-thirds of all complications occur in the pediatric population.\\n\\nThese complications include:\\n- Bowel obstruction (adhesive obstruction, volvulus, or intussusception)\\n- Complications of peptic ulceration due to ectopic gastric mucosa (stricture, hemorrhage, or perforation)\\n- Acute \\n```',\n", " 'images': [{'name': 'img_p654_1.png',\n", " 'height': 719,\n", " 'width': 802,\n", " 'x': 108,\n", " 'y': 82.79999999999995,\n", " 'original_width': 1377,\n", " 'original_height': 1234}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 116.9, 'y': 92.69, 'w': 12.86, 'h': 13.85}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 116.9, 'y': 92.69, 'w': 11.87, 'h': 11.87}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 36.3',\n", " 'md': '### Figure 36.3',\n", " 'bBox': {'x': 75, 'y': 458, 'w': 32.97, 'h': 10.8}},\n", " {'type': 'text',\n", " 'value': '**Description:** Fluoroscopic monitoring of a retrograde reduction of the intussusception by means of a hydrostatic barium enema, with complete reduction. In part (d), the contrast is visible in the small intestine.',\n", " 'md': '**Description:** Fluoroscopic monitoring of a retrograde reduction of the intussusception by means of a hydrostatic barium enema, with complete reduction. In part (d), the contrast is visible in the small intestine.',\n", " 'bBox': {'x': 116.9, 'y': 90.71, 'w': 207.76, 'h': 13.85}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Meckel’s Diverticulum',\n", " 'md': '### Meckel’s Diverticulum',\n", " 'bBox': {'x': 86, 'y': 264.84, 'w': 238.66, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Two-thirds of Meckel’s diverticula encountered by surgeons are incidental findings while the remaining one-third will present with a complication. Pediatric surgeons encounter different proportions, as the incidence of these complications is maximal during the first 2 years of life and decreases thereafter, so that more than two-thirds of all complications occur in the pediatric population.\\n\\nThese complications include:\\n- Bowel obstruction (adhesive obstruction, volvulus, or intussusception)\\n- Complications of peptic ulceration due to ectopic gastric mucosa (stricture, hemorrhage, or perforation)\\n- Acute \\n```',\n", " 'md': 'Two-thirds of Meckel’s diverticula encountered by surgeons are incidental findings while the remaining one-third will present with a complication. Pediatric surgeons encounter different proportions, as the incidence of these complications is maximal during the first 2 years of life and decreases thereafter, so that more than two-thirds of all complications occur in the pediatric population.\\n\\nThese complications include:\\n- Bowel obstruction (adhesive obstruction, volvulus, or intussusception)\\n- Complications of peptic ulceration due to ectopic gastric mucosa (stricture, hemorrhage, or perforation)\\n- Acute \\n```',\n", " 'bBox': {'x': 72, 'y': 90.71, 'w': 467.51, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 656,\n", " 'text': 'inflammation (‘second appendicitis’). There is also a distinct tendency for\\nforeign bodies to penetrate and perforate a diverticulum. We have seen a\\n5-year-old girl with complete bowel obstruction caused by a Meckel’s\\ndiverticulum filled with excessively ingested gummy bears candies.\\nLittré’s inguinal hernia contains a strangulated Meckel’s diverticulum and,\\nlike Richter’s hernia, may not produce obvious signs of intestinal\\nobstruction.\\n\\n The treatment of a symptomatic diverticulum is resection.\\nDiverticulectomy is possible if the base is wide and non-inflamed, but\\nremember to check the base of the diverticulum and the adjacent ileum\\nfor ectopic mucosa because any bleeding source may lie within it. If in\\ndoubt, or if there is any technical difficulty, resect the involved\\nsegment of ileum.\\n\\n What should you do with an incidentally found Meckel’s\\ndiverticulum during emergency surgery for another indication?\\nConsider the degree of peritoneal infection (caused by the primary\\nindication for laparotomy), the patient’s age and the shape of the\\ndiverticulum. On balance, the arguments against removing an\\nasymptomatic Meckel’s diverticulum are a little stronger than those\\nin favor, and the strength of the argument increases with the age of\\nthe patient. Thin-walled, wide-mouthed, mobile (without a fibrous band\\nto the umbilicus or mesentery) diverticula should be left alone. And, of\\ncourse, we would not touch it during an operation for intra-abdominal\\ninfection due to another cause, like perforated acute appendicitis.\\n\\n Irreducible inguinal hernia\\n\\n This emergency occurs primarily in boys during their first year of\\nlife. The fundamental difference between an irreducible inguinal\\nhernia in an infant and an adult is that the former presents a danger\\nto the viability of the testis, whereas with the latter the major\\nconcern is the potential for bowel ischemia. Neonates with symptoms\\nlasting for more than 24 hours and with intestinal obstruction are at the\\ngreatest risk of testicular infarction. Necrosis of incarcerated bowel is\\nextremely rare in pediatric hernias.',\n", " 'md': \"```markdown\\n## Page Content\\n\\nIn this section, we discuss various medical conditions and treatments related to diverticula and hernias.\\n\\n### Key Points\\n\\n- Inflammation can lead to conditions such as 'second appendicitis'.\\n- Foreign bodies may penetrate and perforate a diverticulum.\\n- A case is noted of a 5-year-old girl with complete bowel obstruction due to a Meckel’s diverticulum filled with excessively ingested gummy bear candies.\\n- Littré’s inguinal hernia can contain a strangulated Meckel’s diverticulum, similar to Richter’s hernia, which may not show obvious signs of intestinal obstruction.\\n\\n### Treatment of Symptomatic Diverticulum\\n\\n- The treatment for a symptomatic diverticulum is resection.\\n- Diverticulectomy is possible if the base is wide and non-inflamed.\\n- It is important to check the base of the diverticulum and the adjacent ileum for ectopic mucosa, as any bleeding source may lie within it.\\n- If there is any doubt or technical difficulty, resection of the involved segment of ileum is recommended.\\n\\n### Management of Incidentally Found Meckel’s Diverticulum\\n\\n- When an incidentally found Meckel’s diverticulum is discovered during emergency surgery for another indication, consider:\\n- The degree of peritoneal infection caused by the primary indication for laparotomy.\\n- The patient’s age and the shape of the diverticulum.\\n- The arguments against removing an asymptomatic Meckel’s diverticulum are generally stronger than those in favor, especially as the patient's age increases.\\n- Thin-walled, wide-mouthed, mobile diverticula should be left alone.\\n- It is advised not to touch the diverticulum during operations for intra-abdominal infections due to other causes, such as perforated acute appendicitis.\\n\\n### Irreducible Inguinal Hernia\\n\\n- This emergency condition primarily occurs in boys during their first year of life.\\n- The main difference between an irreducible inguinal hernia in infants and adults is the risk to the viability of the testis in infants, while adults face the risk of bowel ischemia.\\n- Neonates with symptoms lasting more than 24 hours and with intestinal obstruction are at the highest risk of testicular infarction.\\n- Necrosis of incarcerated bowel is extremely rare in pediatric hernias.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In this section, we discuss various medical conditions and treatments related to diverticula and hernias.',\n", " 'md': 'In this section, we discuss various medical conditions and treatments related to diverticula and hernias.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key Points',\n", " 'md': '### Key Points',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- Inflammation can lead to conditions such as 'second appendicitis'.\\n- Foreign bodies may penetrate and perforate a diverticulum.\\n- A case is noted of a 5-year-old girl with complete bowel obstruction due to a Meckel’s diverticulum filled with excessively ingested gummy bear candies.\\n- Littré’s inguinal hernia can contain a strangulated Meckel’s diverticulum, similar to Richter’s hernia, which may not show obvious signs of intestinal obstruction.\",\n", " 'md': \"- Inflammation can lead to conditions such as 'second appendicitis'.\\n- Foreign bodies may penetrate and perforate a diverticulum.\\n- A case is noted of a 5-year-old girl with complete bowel obstruction due to a Meckel’s diverticulum filled with excessively ingested gummy bear candies.\\n- Littré’s inguinal hernia can contain a strangulated Meckel’s diverticulum, similar to Richter’s hernia, which may not show obvious signs of intestinal obstruction.\",\n", " 'bBox': {'x': 72, 'y': 185, 'w': 74.37, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Treatment of Symptomatic Diverticulum',\n", " 'md': '### Treatment of Symptomatic Diverticulum',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The treatment for a symptomatic diverticulum is resection.\\n- Diverticulectomy is possible if the base is wide and non-inflamed.\\n- It is important to check the base of the diverticulum and the adjacent ileum for ectopic mucosa, as any bleeding source may lie within it.\\n- If there is any doubt or technical difficulty, resection of the involved segment of ileum is recommended.',\n", " 'md': '- The treatment for a symptomatic diverticulum is resection.\\n- Diverticulectomy is possible if the base is wide and non-inflamed.\\n- It is important to check the base of the diverticulum and the adjacent ileum for ectopic mucosa, as any bleeding source may lie within it.\\n- If there is any doubt or technical difficulty, resection of the involved segment of ileum is recommended.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management of Incidentally Found Meckel’s Diverticulum',\n", " 'md': '### Management of Incidentally Found Meckel’s Diverticulum',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- When an incidentally found Meckel’s diverticulum is discovered during emergency surgery for another indication, consider:\\n- The degree of peritoneal infection caused by the primary indication for laparotomy.\\n- The patient’s age and the shape of the diverticulum.\\n- The arguments against removing an asymptomatic Meckel’s diverticulum are generally stronger than those in favor, especially as the patient's age increases.\\n- Thin-walled, wide-mouthed, mobile diverticula should be left alone.\\n- It is advised not to touch the diverticulum during operations for intra-abdominal infections due to other causes, such as perforated acute appendicitis.\",\n", " 'md': \"- When an incidentally found Meckel’s diverticulum is discovered during emergency surgery for another indication, consider:\\n- The degree of peritoneal infection caused by the primary indication for laparotomy.\\n- The patient’s age and the shape of the diverticulum.\\n- The arguments against removing an asymptomatic Meckel’s diverticulum are generally stronger than those in favor, especially as the patient's age increases.\\n- Thin-walled, wide-mouthed, mobile diverticula should be left alone.\\n- It is advised not to touch the diverticulum during operations for intra-abdominal infections due to other causes, such as perforated acute appendicitis.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Irreducible Inguinal Hernia',\n", " 'md': '### Irreducible Inguinal Hernia',\n", " 'bBox': {'x': 86, 'y': 547, 'w': 206.86, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- This emergency condition primarily occurs in boys during their first year of life.\\n- The main difference between an irreducible inguinal hernia in infants and adults is the risk to the viability of the testis in infants, while adults face the risk of bowel ischemia.\\n- Neonates with symptoms lasting more than 24 hours and with intestinal obstruction are at the highest risk of testicular infarction.\\n- Necrosis of incarcerated bowel is extremely rare in pediatric hernias.\\n```',\n", " 'md': '- This emergency condition primarily occurs in boys during their first year of life.\\n- The main difference between an irreducible inguinal hernia in infants and adults is the risk to the viability of the testis in infants, while adults face the risk of bowel ischemia.\\n- Neonates with symptoms lasting more than 24 hours and with intestinal obstruction are at the highest risk of testicular infarction.\\n- Necrosis of incarcerated bowel is extremely rare in pediatric hernias.\\n```',\n", " 'bBox': {'x': 72, 'y': 547, 'w': 238, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 657,\n", " 'text': ' The diagnosis is straightforward because the baby cries and vomits\\nand the parents have usually noticed a tender lump in the groin. Major\\ndifferential diagnoses include torsion of a maldescended testicle, acute\\ninguinal lymphadenitis and a hydrocele of the cord (‘funiculocele’).\\n\\n The treatment, after making the diagnosis, is to sedate the infant and\\nposition him in a head-down position. In the majority of babies with the\\naddition of gentle manual pressure, or even spontaneously, this will result\\nin reduction. A reasonable time for making a decision is 1-2 hours. After\\nthat go to the OR for an incarcerated hernia, or if reduced — let the\\ntissue swelling subside for a day or two and book the child in for an\\nelective herniotomy on the next available operative list.\\n\\n The operation for an irreducible inguinal hernia in an infant is fraught\\nwith danger and should be undertaken only by a surgeon with previous\\nexperience in pediatric surgery. The hernia sac is edematous and\\nextremely fragile, and the ductus deferens is almost invisible. A simple\\nherniotomy at the level of the neck of the sac is all that is required.\\nAlways make sure that the testicle is safely replaced in the lower part of\\nthe scrotum. In a female infant, a movable tender lump may be an\\nirreducible ovary. The child may be almost asymptomatic yet require\\nemergency herniotomy because of the risk of ovarian ischemia. The boy\\nafter inguinal hernia incarceration should be followed up for ischemic\\ntesticular damage and testis positioning. Disorders of sex differentiation\\nmay present as bilateral, gonad-containing inguinal hernias.\\n\\n Testicular torsion (see also Chapter 37)\\n\\n The key to successful treatment of testicular torsion is speedy\\ndetorsion, within less than 6 hours of the onset of symptoms. The\\nincidence of torsion rises sharply around the age of 12, with two of every\\nthree cases occurring between the ages of 12 and 18. Some boys with\\ntesticular torsion present with lower abdominal and inguinal pain so\\nyou will miss the diagnosis if you fail to examine the scrotum. The\\ntestis may be localized low in the inguinal canal or high in the scrotum\\nand the pain not precisely localized by a child or projected higher. I have\\nseen children who previously had a negative appendectomy with\\natrophy of the right testis! No clinical sign or test is foolproof!',\n", " 'md': '```markdown\\n## Diagnosis and Treatment of Inguinal Hernia in Infants\\n\\nThe diagnosis is straightforward because the baby cries and vomits, and the parents have usually noticed a tender lump in the groin. Major differential diagnoses include torsion of a maldescended testicle, acute inguinal lymphadenitis, and a hydrocele of the cord (‘funiculocele’).\\n\\nThe treatment, after making the diagnosis, is to sedate the infant and position him in a head-down position. In the majority of babies, with the addition of gentle manual pressure, or even spontaneously, this will result in reduction. A reasonable time for making a decision is 1-2 hours. After that, go to the OR for an incarcerated hernia, or if reduced — let the tissue swelling subside for a day or two and book the child in for an elective herniotomy on the next available operative list.\\n\\nThe operation for an irreducible inguinal hernia in an infant is fraught with danger and should be undertaken only by a surgeon with previous experience in pediatric surgery. The hernia sac is edematous and extremely fragile, and the ductus deferens is almost invisible. A simple herniotomy at the level of the neck of the sac is all that is required. Always make sure that the testicle is safely replaced in the lower part of the scrotum. In a female infant, a movable tender lump may be an irreducible ovary. The child may be almost asymptomatic yet require emergency herniotomy because of the risk of ovarian ischemia. The boy after inguinal hernia incarceration should be followed up for ischemic testicular damage and testis positioning. Disorders of sex differentiation may present as bilateral, gonad-containing inguinal hernias.\\n\\n### Testicular Torsion\\n\\nThe key to successful treatment of testicular torsion is speedy detorsion, within less than 6 hours of the onset of symptoms. The incidence of torsion rises sharply around the age of 12, with two of every three cases occurring between the ages of 12 and 18. Some boys with testicular torsion present with lower abdominal and inguinal pain, so you will miss the diagnosis if you fail to examine the scrotum. The testis may be localized low in the inguinal canal or high in the scrotum, and the pain not precisely localized by a child or projected higher. I have seen children who previously had a negative appendectomy with atrophy of the right testis! No clinical sign or test is foolproof!\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Diagnosis and Treatment of Inguinal Hernia in Infants',\n", " 'md': '## Diagnosis and Treatment of Inguinal Hernia in Infants',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The diagnosis is straightforward because the baby cries and vomits, and the parents have usually noticed a tender lump in the groin. Major differential diagnoses include torsion of a maldescended testicle, acute inguinal lymphadenitis, and a hydrocele of the cord (‘funiculocele’).\\n\\nThe treatment, after making the diagnosis, is to sedate the infant and position him in a head-down position. In the majority of babies, with the addition of gentle manual pressure, or even spontaneously, this will result in reduction. A reasonable time for making a decision is 1-2 hours. After that, go to the OR for an incarcerated hernia, or if reduced — let the tissue swelling subside for a day or two and book the child in for an elective herniotomy on the next available operative list.\\n\\nThe operation for an irreducible inguinal hernia in an infant is fraught with danger and should be undertaken only by a surgeon with previous experience in pediatric surgery. The hernia sac is edematous and extremely fragile, and the ductus deferens is almost invisible. A simple herniotomy at the level of the neck of the sac is all that is required. Always make sure that the testicle is safely replaced in the lower part of the scrotum. In a female infant, a movable tender lump may be an irreducible ovary. The child may be almost asymptomatic yet require emergency herniotomy because of the risk of ovarian ischemia. The boy after inguinal hernia incarceration should be followed up for ischemic testicular damage and testis positioning. Disorders of sex differentiation may present as bilateral, gonad-containing inguinal hernias.',\n", " 'md': 'The diagnosis is straightforward because the baby cries and vomits, and the parents have usually noticed a tender lump in the groin. Major differential diagnoses include torsion of a maldescended testicle, acute inguinal lymphadenitis, and a hydrocele of the cord (‘funiculocele’).\\n\\nThe treatment, after making the diagnosis, is to sedate the infant and position him in a head-down position. In the majority of babies, with the addition of gentle manual pressure, or even spontaneously, this will result in reduction. A reasonable time for making a decision is 1-2 hours. After that, go to the OR for an incarcerated hernia, or if reduced — let the tissue swelling subside for a day or two and book the child in for an elective herniotomy on the next available operative list.\\n\\nThe operation for an irreducible inguinal hernia in an infant is fraught with danger and should be undertaken only by a surgeon with previous experience in pediatric surgery. The hernia sac is edematous and extremely fragile, and the ductus deferens is almost invisible. A simple herniotomy at the level of the neck of the sac is all that is required. Always make sure that the testicle is safely replaced in the lower part of the scrotum. In a female infant, a movable tender lump may be an irreducible ovary. The child may be almost asymptomatic yet require emergency herniotomy because of the risk of ovarian ischemia. The boy after inguinal hernia incarceration should be followed up for ischemic testicular damage and testis positioning. Disorders of sex differentiation may present as bilateral, gonad-containing inguinal hernias.',\n", " 'bBox': {'x': 72, 'y': 170, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Testicular Torsion',\n", " 'md': '### Testicular Torsion',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The key to successful treatment of testicular torsion is speedy detorsion, within less than 6 hours of the onset of symptoms. The incidence of torsion rises sharply around the age of 12, with two of every three cases occurring between the ages of 12 and 18. Some boys with testicular torsion present with lower abdominal and inguinal pain, so you will miss the diagnosis if you fail to examine the scrotum. The testis may be localized low in the inguinal canal or high in the scrotum, and the pain not precisely localized by a child or projected higher. I have seen children who previously had a negative appendectomy with atrophy of the right testis! No clinical sign or test is foolproof!\\n```',\n", " 'md': 'The key to successful treatment of testicular torsion is speedy detorsion, within less than 6 hours of the onset of symptoms. The incidence of torsion rises sharply around the age of 12, with two of every three cases occurring between the ages of 12 and 18. Some boys with testicular torsion present with lower abdominal and inguinal pain, so you will miss the diagnosis if you fail to examine the scrotum. The testis may be localized low in the inguinal canal or high in the scrotum, and the pain not precisely localized by a child or projected higher. I have seen children who previously had a negative appendectomy with atrophy of the right testis! No clinical sign or test is foolproof!\\n```',\n", " 'bBox': {'x': 72, 'y': 600, 'w': 467.74, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 658,\n", " 'text': ' Color Doppler US is the test of choice to differentiate testicular\\ntorsion from other acute scrotal conditions. ħowever, a “normal\\ntesticular blood flow” result does not absolutely exclude testicular torsion\\nand is operator-dependent! Last night I explored the scrotum of a child for\\nsuspected testicular torsion, finding a completely necrotic, twisted testis.\\nħe had been seen a day previously in the emergency department and\\nhad been released home because the US scan had detected testicular\\nblood flow. What shall we now tell the parents? That the child should\\nhave had a 10-minute surgical procedure via a 1cm scrotal incision which\\nwould have saved his testicle?\\n\\n Thus, common sense dictates that we have a low threshold for\\nexploring an ‘acute scrotum’.\\n\\n If prompt access to the operating room is not available, manual\\ndetorsion in a lateral direction under sedation or local anesthetic\\ninfiltration of the cord may restore testicular blood flow, but is not a\\nsubstitute for surgery. The degree of twisting of the testis may range from\\n180 to 720°, requiring multiple rounds of detorsion.\\n\\n Surgical exploration is necessary even after clinically successful\\nmanual detorsion (i.e. relief of pain, correction of the transverse lie of\\nthe testis to a longitudinal orientation, lower positioning of the testis in the\\nscrotum, return of normal arterial pulsations in a color Doppler study).\\nResidual torsion may be present that can be further relieved and anyway\\norchidopexy (fixing the testicle to the scrotal wall) must be performed to\\nprevent recurrence. Fixation of both the involved testis and the\\ncontralateral uninvolved testis should be done since inadequate\\ngubernacular fixation is usually a bilateral defect.\\n\\n The window of time to save the testis is narrow and a delay in\\ndetorsion of a few hours leads to progressively higher rates of non-\\nviability of the testis. The time to presentation is the most important factor\\naffecting the salvage rate.\\n\\n At operation, after induction of anesthesia, first examine the scrotum\\nto rule out incarcerated hernia or testicular tumor, both requiring an\\ninguinal incision. Then proceed with a scrotal exploration via a vertical',\n", " 'md': '```markdown\\n## Testicular Torsion and Management\\n\\nColor Doppler ultrasound (US) is the test of choice to differentiate testicular torsion from other acute scrotal conditions. However, a “normal testicular blood flow” result does not absolutely exclude testicular torsion and is operator-dependent! Last night I explored the scrotum of a child for suspected testicular torsion, finding a completely necrotic, twisted testis. He had been seen a day previously in the emergency department and had been released home because the US scan had detected testicular blood flow. What shall we now tell the parents? That the child should have had a 10-minute surgical procedure via a 1 cm scrotal incision which would have saved his testicle?\\n\\nThus, common sense dictates that we have a low threshold for exploring an ‘acute scrotum’.\\n\\nIf prompt access to the operating room is not available, manual detorsion in a lateral direction under sedation or local anesthetic infiltration of the cord may restore testicular blood flow, but is not a substitute for surgery. The degree of twisting of the testis may range from 180 to 720°, requiring multiple rounds of detorsion.\\n\\nSurgical exploration is necessary even after clinically successful manual detorsion (i.e., relief of pain, correction of the transverse lie of the testis to a longitudinal orientation, lower positioning of the testis in the scrotum, return of normal arterial pulsations in a color Doppler study). Residual torsion may be present that can be further relieved and anyway orchidopexy (fixing the testicle to the scrotal wall) must be performed to prevent recurrence. Fixation of both the involved testis and the contralateral uninvolved testis should be done since inadequate gubernacular fixation is usually a bilateral defect.\\n\\nThe window of time to save the testis is narrow and a delay in detorsion of a few hours leads to progressively higher rates of non-viability of the testis. The time to presentation is the most important factor affecting the salvage rate.\\n\\nAt operation, after induction of anesthesia, first examine the scrotum to rule out incarcerated hernia or testicular tumor, both requiring an inguinal incision. Then proceed with a scrotal exploration via a vertical incision.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Testicular Torsion and Management',\n", " 'md': '## Testicular Torsion and Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Color Doppler ultrasound (US) is the test of choice to differentiate testicular torsion from other acute scrotal conditions. However, a “normal testicular blood flow” result does not absolutely exclude testicular torsion and is operator-dependent! Last night I explored the scrotum of a child for suspected testicular torsion, finding a completely necrotic, twisted testis. He had been seen a day previously in the emergency department and had been released home because the US scan had detected testicular blood flow. What shall we now tell the parents? That the child should have had a 10-minute surgical procedure via a 1 cm scrotal incision which would have saved his testicle?\\n\\nThus, common sense dictates that we have a low threshold for exploring an ‘acute scrotum’.\\n\\nIf prompt access to the operating room is not available, manual detorsion in a lateral direction under sedation or local anesthetic infiltration of the cord may restore testicular blood flow, but is not a substitute for surgery. The degree of twisting of the testis may range from 180 to 720°, requiring multiple rounds of detorsion.\\n\\nSurgical exploration is necessary even after clinically successful manual detorsion (i.e., relief of pain, correction of the transverse lie of the testis to a longitudinal orientation, lower positioning of the testis in the scrotum, return of normal arterial pulsations in a color Doppler study). Residual torsion may be present that can be further relieved and anyway orchidopexy (fixing the testicle to the scrotal wall) must be performed to prevent recurrence. Fixation of both the involved testis and the contralateral uninvolved testis should be done since inadequate gubernacular fixation is usually a bilateral defect.\\n\\nThe window of time to save the testis is narrow and a delay in detorsion of a few hours leads to progressively higher rates of non-viability of the testis. The time to presentation is the most important factor affecting the salvage rate.\\n\\nAt operation, after induction of anesthesia, first examine the scrotum to rule out incarcerated hernia or testicular tumor, both requiring an inguinal incision. Then proceed with a scrotal exploration via a vertical incision.\\n```',\n", " 'md': 'Color Doppler ultrasound (US) is the test of choice to differentiate testicular torsion from other acute scrotal conditions. However, a “normal testicular blood flow” result does not absolutely exclude testicular torsion and is operator-dependent! Last night I explored the scrotum of a child for suspected testicular torsion, finding a completely necrotic, twisted testis. He had been seen a day previously in the emergency department and had been released home because the US scan had detected testicular blood flow. What shall we now tell the parents? That the child should have had a 10-minute surgical procedure via a 1 cm scrotal incision which would have saved his testicle?\\n\\nThus, common sense dictates that we have a low threshold for exploring an ‘acute scrotum’.\\n\\nIf prompt access to the operating room is not available, manual detorsion in a lateral direction under sedation or local anesthetic infiltration of the cord may restore testicular blood flow, but is not a substitute for surgery. The degree of twisting of the testis may range from 180 to 720°, requiring multiple rounds of detorsion.\\n\\nSurgical exploration is necessary even after clinically successful manual detorsion (i.e., relief of pain, correction of the transverse lie of the testis to a longitudinal orientation, lower positioning of the testis in the scrotum, return of normal arterial pulsations in a color Doppler study). Residual torsion may be present that can be further relieved and anyway orchidopexy (fixing the testicle to the scrotal wall) must be performed to prevent recurrence. Fixation of both the involved testis and the contralateral uninvolved testis should be done since inadequate gubernacular fixation is usually a bilateral defect.\\n\\nThe window of time to save the testis is narrow and a delay in detorsion of a few hours leads to progressively higher rates of non-viability of the testis. The time to presentation is the most important factor affecting the salvage rate.\\n\\nAt operation, after induction of anesthesia, first examine the scrotum to rule out incarcerated hernia or testicular tumor, both requiring an inguinal incision. Then proceed with a scrotal exploration via a vertical incision.\\n```',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.93, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 659,\n", " 'text': 'incision in the median raphae of the scrotum or, alternatively, two\\ntransverse incisions on each side. Enter the serosal compartment of the\\nscrotum to deliver and detort the testis. Place it in a warm moist sponge\\nwhile exploring the opposite hemiscrotum. If the affected testis remains\\nnecrotic, remove it. Orchidopexy of the viable testis is performed by\\nsuturing the surface of the testis (tunica albuginea) at four points to the\\nwall of the serosal compartment using non-absorbable sutures. If you find\\ntorsion of the testicular appendage, simply excise it.\\n\\n Ovarian torsion\\n\\n Should you encounter pediatric ovarian torsion, whether anticipated or\\nas a surprise finding during an operation for suspected appendicitis, the\\nadolescent girl will be fortunate in having you as the surgeon if you detort\\nthe ‘non-viable’ adnexa and leave it alone. The macroscopic appearance\\nof the ovary is not a reliable predictor of necrosis or of the potential for\\ngonad recovery. If an underlying lesion is found, then cystectomy,\\ntumorectomy (even in cases with a very large teratomata, there is a rim\\nof normal ovary at the hilum that can be preserved), or cyst aspiration,\\nwith possible oophoropexy should be considered. If you are not\\ncomfortable with this situation just detort the ovary and close the\\nabdomen — or remove the lapscope. Remember the key principle: you\\nare more likely to preserve functional ovarian tissue than cause any\\nmorbidity by leaving in situ what appears to you a non-viable ovary\\nin little girls.\\n\\n There is some controversy regarding fixation of the detorted ovary\\n(oophoropexy). Spontaneous ovarian torsion (no underlying ovarian\\npathology), recurrence of torsion and torsion of the only ovary are\\narguments in favor. Should you be faced with such circumstances, suture\\nthe ovary to the uterus, pelvic wall or simply plicate the round ligament.\\n\\n Pediatric abdominal injuries (see Chapter 32)\\n\\n Trauma is the chief cause of death among children older than a\\nyear of age, and is responsible for more deaths than all other\\ncauses combined. In one out of seven injured children, the abdominal',\n", " 'md': '```markdown\\n## Surgical Procedures for Testicular and Ovarian Torsion\\n\\n### Testicular Torsion\\n- Incision in the median raphae of the scrotum or, alternatively, two transverse incisions on each side.\\n- Enter the serosal compartment of the scrotum to deliver and detort the testis.\\n- Place it in a warm moist sponge while exploring the opposite hemiscrotum.\\n- If the affected testis remains necrotic, remove it.\\n- Orchidopexy of the viable testis is performed by suturing the surface of the testis (tunica albuginea) at four points to the wall of the serosal compartment using non-absorbable sutures.\\n- If you find torsion of the testicular appendage, simply excise it.\\n\\n### Ovarian Torsion\\n- Should you encounter pediatric ovarian torsion, whether anticipated or as a surprise finding during an operation for suspected appendicitis, the adolescent girl will be fortunate in having you as the surgeon if you detort the ‘non-viable’ adnexa and leave it alone.\\n- The macroscopic appearance of the ovary is not a reliable predictor of necrosis or of the potential for gonad recovery.\\n- If an underlying lesion is found, then cystectomy, tumorectomy (even in cases with a very large teratomata, there is a rim of normal ovary at the hilum that can be preserved), or cyst aspiration, with possible oophoropexy should be considered.\\n- If you are not comfortable with this situation just detort the ovary and close the abdomen — or remove the lapscope.\\n- Remember the key principle: you are more likely to preserve functional ovarian tissue than cause any morbidity by leaving in situ what appears to you a non-viable ovary in little girls.\\n\\n### Controversy Regarding Oophoropexy\\n- There is some controversy regarding fixation of the detorted ovary (oophoropexy).\\n- Spontaneous ovarian torsion (no underlying ovarian pathology), recurrence of torsion, and torsion of the only ovary are arguments in favor.\\n- Should you be faced with such circumstances, suture the ovary to the uterus, pelvic wall or simply plicate the round ligament.\\n\\n### Pediatric Abdominal Injuries\\n- Trauma is the chief cause of death among children older than a year of age, and is responsible for more deaths than all other causes combined.\\n- In one out of seven injured children, the abdominal...\\n```\\n\\n### Notes:\\n- No figures, images, or tables were identified on this page.\\n- The text has been structured into sections for clarity.\\n- All formulas and hyperlinks were not present in the extracted text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Procedures for Testicular and Ovarian Torsion',\n", " 'md': '## Surgical Procedures for Testicular and Ovarian Torsion',\n", " 'bBox': {'x': 86, 'y': 245, 'w': 122.29, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Testicular Torsion',\n", " 'md': '### Testicular Torsion',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Incision in the median raphae of the scrotum or, alternatively, two transverse incisions on each side.\\n- Enter the serosal compartment of the scrotum to deliver and detort the testis.\\n- Place it in a warm moist sponge while exploring the opposite hemiscrotum.\\n- If the affected testis remains necrotic, remove it.\\n- Orchidopexy of the viable testis is performed by suturing the surface of the testis (tunica albuginea) at four points to the wall of the serosal compartment using non-absorbable sutures.\\n- If you find torsion of the testicular appendage, simply excise it.',\n", " 'md': '- Incision in the median raphae of the scrotum or, alternatively, two transverse incisions on each side.\\n- Enter the serosal compartment of the scrotum to deliver and detort the testis.\\n- Place it in a warm moist sponge while exploring the opposite hemiscrotum.\\n- If the affected testis remains necrotic, remove it.\\n- Orchidopexy of the viable testis is performed by suturing the surface of the testis (tunica albuginea) at four points to the wall of the serosal compartment using non-absorbable sutures.\\n- If you find torsion of the testicular appendage, simply excise it.',\n", " 'bBox': {'x': 72, 'y': 201, 'w': 329.43, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Ovarian Torsion',\n", " 'md': '### Ovarian Torsion',\n", " 'bBox': {'x': 86, 'y': 245, 'w': 122.29, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Should you encounter pediatric ovarian torsion, whether anticipated or as a surprise finding during an operation for suspected appendicitis, the adolescent girl will be fortunate in having you as the surgeon if you detort the ‘non-viable’ adnexa and leave it alone.\\n- The macroscopic appearance of the ovary is not a reliable predictor of necrosis or of the potential for gonad recovery.\\n- If an underlying lesion is found, then cystectomy, tumorectomy (even in cases with a very large teratomata, there is a rim of normal ovary at the hilum that can be preserved), or cyst aspiration, with possible oophoropexy should be considered.\\n- If you are not comfortable with this situation just detort the ovary and close the abdomen — or remove the lapscope.\\n- Remember the key principle: you are more likely to preserve functional ovarian tissue than cause any morbidity by leaving in situ what appears to you a non-viable ovary in little girls.',\n", " 'md': '- Should you encounter pediatric ovarian torsion, whether anticipated or as a surprise finding during an operation for suspected appendicitis, the adolescent girl will be fortunate in having you as the surgeon if you detort the ‘non-viable’ adnexa and leave it alone.\\n- The macroscopic appearance of the ovary is not a reliable predictor of necrosis or of the potential for gonad recovery.\\n- If an underlying lesion is found, then cystectomy, tumorectomy (even in cases with a very large teratomata, there is a rim of normal ovary at the hilum that can be preserved), or cyst aspiration, with possible oophoropexy should be considered.\\n- If you are not comfortable with this situation just detort the ovary and close the abdomen — or remove the lapscope.\\n- Remember the key principle: you are more likely to preserve functional ovarian tissue than cause any morbidity by leaving in situ what appears to you a non-viable ovary in little girls.',\n", " 'bBox': {'x': 72, 'y': 245, 'w': 467.97, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Controversy Regarding Oophoropexy',\n", " 'md': '### Controversy Regarding Oophoropexy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- There is some controversy regarding fixation of the detorted ovary (oophoropexy).\\n- Spontaneous ovarian torsion (no underlying ovarian pathology), recurrence of torsion, and torsion of the only ovary are arguments in favor.\\n- Should you be faced with such circumstances, suture the ovary to the uterus, pelvic wall or simply plicate the round ligament.',\n", " 'md': '- There is some controversy regarding fixation of the detorted ovary (oophoropexy).\\n- Spontaneous ovarian torsion (no underlying ovarian pathology), recurrence of torsion, and torsion of the only ovary are arguments in favor.\\n- Should you be faced with such circumstances, suture the ovary to the uterus, pelvic wall or simply plicate the round ligament.',\n", " 'bBox': {'x': 72, 'y': 245, 'w': 450.94, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Pediatric Abdominal Injuries',\n", " 'md': '### Pediatric Abdominal Injuries',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Trauma is the chief cause of death among children older than a year of age, and is responsible for more deaths than all other causes combined.\\n- In one out of seven injured children, the abdominal...\\n```',\n", " 'md': '- Trauma is the chief cause of death among children older than a year of age, and is responsible for more deaths than all other causes combined.\\n- In one out of seven injured children, the abdominal...\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No figures, images, or tables were identified on this page.\\n- The text has been structured into sections for clarity.\\n- All formulas and hyperlinks were not present in the extracted text.',\n", " 'md': '- No figures, images, or tables were identified on this page.\\n- The text has been structured into sections for clarity.\\n- All formulas and hyperlinks were not present in the extracted text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 660,\n", " 'text': 'injury is dominant. The patterns of blunt abdominal trauma and the\\nclinical pictures are similar to those in adults, with injuries to the kidneys,\\nspleen, liver and the intestines being the most common. Most cases can\\nbe treated conservatively and laparotomy is required in only one child in\\nfour. The major deterrents to an operative approach to abdominal trauma\\nin children are the risks of non-therapeutic laparotomy and overwhelming\\npost-splenectomy infection.\\n\\n Even children with hemodynamic instability on admission often\\nquickly improve with crystalloid administration and remain\\nhemodynamically stable thereafter. If the situation stabilizes after three\\ninfusions of 20ml/kg of fluid, then it is safe to observe the child in an\\nintensive care unit. If the child continues to bleed and no other source of\\nhemorrhage is apparent, a prompt laparotomy is indicated.\\n\\n The Achilles’ heel of this conservative approach is the possibility\\nof missed injuries to hollow organs. Thus, if the child develops\\nincreasing abdominal tenderness or peritonitis, this too is an indication for\\nlaparotomy. A useful clinical marker of blunt bowel trauma is the triad of a\\nfastened lap belt, a seat belt sign on the abdominal wall, and fracture of a\\nlumbar vertebra.\\n\\n No discussion of pediatric trauma can be complete without emphasizing the need for\\n always suspecting child abuse. While isolated abdominal trauma is a rare presentation of\\n child abuse, unusually shaped or multiple bruises, associated long bone fractures or\\n inexplicable genital lesions should always raise the suspicion of this tragic and potentially life-\\n threatening condition.\\n\\n Special situations',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nInjury is dominant. The patterns of blunt abdominal trauma and the clinical pictures are similar to those in adults, with injuries to the kidneys, spleen, liver, and the intestines being the most common. Most cases can be treated conservatively and laparotomy is required in only one child in four. The major deterrents to an operative approach to abdominal trauma in children are the risks of non-therapeutic laparotomy and overwhelming post-splenectomy infection.\\n\\nEven children with hemodynamic instability on admission often quickly improve with crystalloid administration and remain hemodynamically stable thereafter. If the situation stabilizes after three infusions of \\\\(20 \\\\, \\\\text{ml/kg}\\\\) of fluid, then it is safe to observe the child in an intensive care unit. If the child continues to bleed and no other source of hemorrhage is apparent, a prompt laparotomy is indicated.\\n\\nThe Achilles’ heel of this conservative approach is the possibility of missed injuries to hollow organs. Thus, if the child develops increasing abdominal tenderness or peritonitis, this too is an indication for laparotomy. A useful clinical marker of blunt bowel trauma is the triad of a fastened lap belt, a seat belt sign on the abdominal wall, and fracture of a lumbar vertebra.\\n\\nNo discussion of pediatric trauma can be complete without emphasizing the need for always suspecting child abuse. While isolated abdominal trauma is a rare presentation of child abuse, unusually shaped or multiple bruises, associated long bone fractures, or inexplicable genital lesions should always raise the suspicion of this tragic and potentially life-threatening condition.\\n\\n### Special Situations\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All formulas have been converted into LaTeX MathJax notation where applicable.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Injury is dominant. The patterns of blunt abdominal trauma and the clinical pictures are similar to those in adults, with injuries to the kidneys, spleen, liver, and the intestines being the most common. Most cases can be treated conservatively and laparotomy is required in only one child in four. The major deterrents to an operative approach to abdominal trauma in children are the risks of non-therapeutic laparotomy and overwhelming post-splenectomy infection.\\n\\nEven children with hemodynamic instability on admission often quickly improve with crystalloid administration and remain hemodynamically stable thereafter. If the situation stabilizes after three infusions of \\\\(20 \\\\, \\\\text{ml/kg}\\\\) of fluid, then it is safe to observe the child in an intensive care unit. If the child continues to bleed and no other source of hemorrhage is apparent, a prompt laparotomy is indicated.\\n\\nThe Achilles’ heel of this conservative approach is the possibility of missed injuries to hollow organs. Thus, if the child develops increasing abdominal tenderness or peritonitis, this too is an indication for laparotomy. A useful clinical marker of blunt bowel trauma is the triad of a fastened lap belt, a seat belt sign on the abdominal wall, and fracture of a lumbar vertebra.\\n\\nNo discussion of pediatric trauma can be complete without emphasizing the need for always suspecting child abuse. While isolated abdominal trauma is a rare presentation of child abuse, unusually shaped or multiple bruises, associated long bone fractures, or inexplicable genital lesions should always raise the suspicion of this tragic and potentially life-threatening condition.',\n", " 'md': 'Injury is dominant. The patterns of blunt abdominal trauma and the clinical pictures are similar to those in adults, with injuries to the kidneys, spleen, liver, and the intestines being the most common. Most cases can be treated conservatively and laparotomy is required in only one child in four. The major deterrents to an operative approach to abdominal trauma in children are the risks of non-therapeutic laparotomy and overwhelming post-splenectomy infection.\\n\\nEven children with hemodynamic instability on admission often quickly improve with crystalloid administration and remain hemodynamically stable thereafter. If the situation stabilizes after three infusions of \\\\(20 \\\\, \\\\text{ml/kg}\\\\) of fluid, then it is safe to observe the child in an intensive care unit. If the child continues to bleed and no other source of hemorrhage is apparent, a prompt laparotomy is indicated.\\n\\nThe Achilles’ heel of this conservative approach is the possibility of missed injuries to hollow organs. Thus, if the child develops increasing abdominal tenderness or peritonitis, this too is an indication for laparotomy. A useful clinical marker of blunt bowel trauma is the triad of a fastened lap belt, a seat belt sign on the abdominal wall, and fracture of a lumbar vertebra.\\n\\nNo discussion of pediatric trauma can be complete without emphasizing the need for always suspecting child abuse. While isolated abdominal trauma is a rare presentation of child abuse, unusually shaped or multiple bruises, associated long bone fractures, or inexplicable genital lesions should always raise the suspicion of this tragic and potentially life-threatening condition.',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.92, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Special Situations',\n", " 'md': '### Special Situations',\n", " 'bBox': {'x': 86, 'y': 597, 'w': 140.69, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All formulas have been converted into LaTeX MathJax notation where applicable.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All formulas have been converted into LaTeX MathJax notation where applicable.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 661,\n", " 'text': ' Table 36.1. Common sense approach to pediatric abdominal\\n emergencies _\\n Most common Most serious Special situations Traps in\\n causes of erroneous diagnosis/timing\\n pediatric acute diagnosis\\n abdomen\\n Intussusception Constipation Neurologically Ischemic bowel\\n <2 y: impaired patient obstruction\\n Immunocompromised Missed incarcerated\\n patient inguinal hernia\\n Appendicitis 7y Gastroenterocolitis Adolescent girl Testicular torsion\\n Diabetic ketoacidosis\\n Pancreatitis\\n Child abuse\\n I would like to emphasize three specific situations:\\n\\n• The neurologically impaired child. In patients with spinal cord\\n dysfunction the history is crucial as physical examination may not be\\n reliable. Close observation and complementary imaging studies are\\n necessary.\\n• The immunologially compromised child. Here, perityphlitis is\\n the first diagnosis until proven otherwise — diagnosed and\\n monitored by CT. Perforation, uncontrolled bleeding and clinical\\n deterioration require surgical intervention.\\n• The adolescent girl. ħere, menstrual history, a pregnancy test and\\n ultrasound are the first-line approach. A low threshold for diagnostic\\n laparoscopy in the presence of an adnexal mass is justified to\\n exclude torsion.',\n", " 'md': '```markdown\\n## Table 36.1: Common Sense Approach to Pediatric Abdominal Emergencies\\n\\n| Most Common Causes of Pediatric Acute Abdomen | Most Serious Erroneous Diagnosis | Special Situations | Traps in Diagnosis/Timing |\\n|-----------------------------------------------|-----------------------------------|-------------------------------------|-------------------------------------|\\n| Intussusception < 2 y: | Constipation | Neurologically impaired patient | Ischemic bowel obstruction |\\n| | | Immunocompromised patient | Missed incarcerated inguinal hernia |\\n| Appendicitis 7y | Gastroenterocolitis | Adolescent girl | Testicular torsion |\\n| | | | Diabetic ketoacidosis |\\n| | | | Pancreatitis |\\n| | | | Child abuse |\\n\\n### Specific Situations Emphasized:\\n\\n1. **The neurologically impaired child**: In patients with spinal cord dysfunction, the history is crucial as physical examination may not be reliable. Close observation and complementary imaging studies are necessary.\\n\\n2. **The immunologically compromised child**: Here, perityphlitis is the first diagnosis until proven otherwise — diagnosed and monitored by CT. Perforation, uncontrolled bleeding, and clinical deterioration require surgical intervention.\\n\\n3. **The adolescent girl**: Here, menstrual history, a pregnancy test, and ultrasound are the first-line approach. A low threshold for diagnostic laparoscopy in the presence of an adnexal mass is justified to exclude torsion.\\n```',\n", " 'images': [{'name': 'img_p660_1.png',\n", " 'height': 702,\n", " 'width': 815,\n", " 'x': 104.39999999999964,\n", " 'y': 72,\n", " 'original_width': 1401,\n", " 'original_height': 1207}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 36.1: Common Sense Approach to Pediatric Abdominal Emergencies',\n", " 'md': '## Table 36.1: Common Sense Approach to Pediatric Abdominal Emergencies',\n", " 'bBox': {'x': 188.5, 'y': 76.94, 'w': 56.4, 'h': 13.84}},\n", " {'type': 'table',\n", " 'rows': [['Most Common Causes of Pediatric Acute Abdomen',\n", " 'Most Serious Erroneous Diagnosis',\n", " 'Special Situations',\n", " 'Traps in Diagnosis/Timing'],\n", " ['Intussusception < 2 y:',\n", " 'Constipation',\n", " 'Neurologically impaired patient',\n", " 'Ischemic bowel obstruction'],\n", " ['',\n", " '',\n", " 'Immunocompromised patient',\n", " 'Missed incarcerated inguinal hernia'],\n", " ['Appendicitis 7y',\n", " 'Gastroenterocolitis',\n", " 'Adolescent girl',\n", " 'Testicular torsion'],\n", " ['', '', '', 'Diabetic ketoacidosis'],\n", " ['', '', '', 'Pancreatitis'],\n", " ['', '', '', 'Child abuse']],\n", " 'md': '| Most Common Causes of Pediatric Acute Abdomen | Most Serious Erroneous Diagnosis | Special Situations | Traps in Diagnosis/Timing |\\n|-----------------------------------------------|-----------------------------------|-------------------------------------|-------------------------------------|\\n| Intussusception < 2 y: | Constipation | Neurologically impaired patient | Ischemic bowel obstruction |\\n| | | Immunocompromised patient | Missed incarcerated inguinal hernia |\\n| Appendicitis 7y | Gastroenterocolitis | Adolescent girl | Testicular torsion |\\n| | | | Diabetic ketoacidosis |\\n| | | | Pancreatitis |\\n| | | | Child abuse |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Most Common Causes of Pediatric Acute Abdomen\",\"Most Serious Erroneous Diagnosis\",\"Special Situations\",\"Traps in Diagnosis/Timing\"\\n\"Intussusception < 2 y:\",\"Constipation\",\"Neurologically impaired patient\",\"Ischemic bowel obstruction\"\\n\"\",\"\",\"Immunocompromised patient\",\"Missed incarcerated inguinal hernia\"\\n\"Appendicitis 7y\",\"Gastroenterocolitis\",\"Adolescent girl\",\"Testicular torsion\"\\n\"\",\"\",\"\",\"Diabetic ketoacidosis\"\\n\"\",\"\",\"\",\"Pancreatitis\"\\n\"\",\"\",\"\",\"Child abuse\"',\n", " 'bBox': {'x': 109.84, 'y': 76.94, 'w': 135.06, 'h': 17.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Specific Situations Emphasized:',\n", " 'md': '### Specific Situations Emphasized:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. **The neurologically impaired child**: In patients with spinal cord dysfunction, the history is crucial as physical examination may not be reliable. Close observation and complementary imaging studies are necessary.\\n\\n2. **The immunologically compromised child**: Here, perityphlitis is the first diagnosis until proven otherwise — diagnosed and monitored by CT. Perforation, uncontrolled bleeding, and clinical deterioration require surgical intervention.\\n\\n3. **The adolescent girl**: Here, menstrual history, a pregnancy test, and ultrasound are the first-line approach. A low threshold for diagnostic laparoscopy in the presence of an adnexal mass is justified to exclude torsion.\\n```',\n", " 'md': '1. **The neurologically impaired child**: In patients with spinal cord dysfunction, the history is crucial as physical examination may not be reliable. Close observation and complementary imaging studies are necessary.\\n\\n2. **The immunologically compromised child**: Here, perityphlitis is the first diagnosis until proven otherwise — diagnosed and monitored by CT. Perforation, uncontrolled bleeding, and clinical deterioration require surgical intervention.\\n\\n3. **The adolescent girl**: Here, menstrual history, a pregnancy test, and ultrasound are the first-line approach. A low threshold for diagnostic laparoscopy in the presence of an adnexal mass is justified to exclude torsion.\\n```',\n", " 'bBox': {'x': 100, 'y': 143.19, 'w': 436.56, 'h': 17.8}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 662,\n", " 'text': ' 05)\\n RERIAy\\nFigure 36.4. “But… but I’m a pediatric surgeon…”\\n\\n Now you know that… The majority of children with acute abdominal pain do not\\n require surgery, and one-third of them get no specific diagnosis. Consider the most common\\n causes of surgical abdominal pain, the most common misdiagnoses for the surgical pediatric\\n abdomen, be careful in special situations and look out for child abuse ( Table 36.1). And you\\n understand that children are not small adults but… ( Figure 36.4).',\n", " 'md': '```markdown\\n## Page Content\\n\\nThe majority of children with acute abdominal pain do not require surgery, and one-third of them get no specific diagnosis. Consider the most common causes of surgical abdominal pain, the most common misdiagnoses for the surgical pediatric abdomen, be careful in special situations and look out for child abuse (Table 36.1). And you understand that children are not small adults but...\\n\\n### Figures\\n\\n**Figure 36.4**: “But… but I’m a pediatric surgeon…”\\n\\n### Tables\\n\\n**Table 36.1**: \\n```',\n", " 'images': [{'name': 'img_p661_1.png',\n", " 'height': 495,\n", " 'width': 805,\n", " 'x': 107.27999999999975,\n", " 'y': 82.79999999999998,\n", " 'original_width': 1383,\n", " 'original_height': 850},\n", " {'name': 'img_p661_2.png',\n", " 'height': 12,\n", " 'width': 12,\n", " 'x': 420.47999999999956,\n", " 'y': 455.76}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The majority of children with acute abdominal pain do not require surgery, and one-third of them get no specific diagnosis. Consider the most common causes of surgical abdominal pain, the most common misdiagnoses for the surgical pediatric abdomen, be careful in special situations and look out for child abuse (Table 36.1). And you understand that children are not small adults but...',\n", " 'md': 'The majority of children with acute abdominal pain do not require surgery, and one-third of them get no specific diagnosis. Consider the most common causes of surgical abdominal pain, the most common misdiagnoses for the surgical pediatric abdomen, be careful in special situations and look out for child abuse (Table 36.1). And you understand that children are not small adults but...',\n", " 'bBox': {'x': 79, 'y': 445, 'w': 453.53, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 36.4**: “But… but I’m a pediatric surgeon…”',\n", " 'md': '**Figure 36.4**: “But… but I’m a pediatric surgeon…”',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Tables',\n", " 'md': '### Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Table 36.1**: \\n```',\n", " 'md': '**Table 36.1**: \\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 663,\n", " 'text': 'Chapter 37\\nUrological emergencies\\nJack Baniel\\n\\n Has the patient renal stones\\n Painful, brittle, broken bones\\n Complaints of thirst and constipation\\n Next to peptic ulceration\\n And you doubt his mental state\\n Determine calcium and phosphate\\n Sure the underlying mechanism\\n Might be hyperparathyroidism.\\n Hajo A. Bruining\\n\\n Urology is not associated with many emergencies. Actually one of the\\nmain advantages enjoyed by the senior urologist is that his nights —\\nunlike those of the general surgeon — are usually spent out of the OR\\nand in a warm bed. Most acute urological problems are managed in the\\nER with the help of other disciplines. I shall discuss here those\\ncommon scenarios that a general surgeon may encounter, and\\nsolve, while the urologist slumbers.\\n\\n Acute renal colic\\n\\n Renal colic is quite easy to diagnose and usually involves intrinsic\\nobstruction of the renal pelvis, or ureter, by a stone. The classic\\ncomplaint is of acute flank pain in a restless patient. The pain\\nradiates from the back forwards, is spasmodic and recurrent. It is often',\n", " 'md': '```markdown\\n# Chapter 37: Urological Emergencies\\n**Author:** Jack Baniel\\n\\n----\\n\\n## Poem by Hajo A. Bruining\\nHas the patient renal stones\\nPainful, brittle, broken bones\\nComplaints of thirst and constipation\\nNext to peptic ulceration\\nAnd you doubt his mental state\\nDetermine calcium and phosphate\\nSure the underlying mechanism\\nMight be hyperparathyroidism.\\n\\n----\\n\\nUrology is not associated with many emergencies. Actually, one of the main advantages enjoyed by the senior urologist is that his nights — unlike those of the general surgeon — are usually spent out of the OR and in a warm bed. Most acute urological problems are managed in the ER with the help of other disciplines. I shall discuss here those common scenarios that a general surgeon may encounter, and solve, while the urologist slumbers.\\n\\n### Acute Renal Colic\\nRenal colic is quite easy to diagnose and usually involves intrinsic obstruction of the renal pelvis, or ureter, by a stone. The classic complaint is of acute flank pain in a restless patient. The pain radiates from the back forwards, is spasmodic and recurrent. It is often...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 37: Urological Emergencies',\n", " 'md': '# Chapter 37: Urological Emergencies',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 210.54, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Jack Baniel\\n\\n----',\n", " 'md': '**Author:** Jack Baniel\\n\\n----',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 73.58, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Poem by Hajo A. Bruining',\n", " 'md': '## Poem by Hajo A. Bruining',\n", " 'bBox': {'x': 376, 'y': 442, 'w': 112.69, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Has the patient renal stones\\nPainful, brittle, broken bones\\nComplaints of thirst and constipation\\nNext to peptic ulceration\\nAnd you doubt his mental state\\nDetermine calcium and phosphate\\nSure the underlying mechanism\\nMight be hyperparathyroidism.\\n\\n----\\n\\nUrology is not associated with many emergencies. Actually, one of the main advantages enjoyed by the senior urologist is that his nights — unlike those of the general surgeon — are usually spent out of the OR and in a warm bed. Most acute urological problems are managed in the ER with the help of other disciplines. I shall discuss here those common scenarios that a general surgeon may encounter, and solve, while the urologist slumbers.',\n", " 'md': 'Has the patient renal stones\\nPainful, brittle, broken bones\\nComplaints of thirst and constipation\\nNext to peptic ulceration\\nAnd you doubt his mental state\\nDetermine calcium and phosphate\\nSure the underlying mechanism\\nMight be hyperparathyroidism.\\n\\n----\\n\\nUrology is not associated with many emergencies. Actually, one of the main advantages enjoyed by the senior urologist is that his nights — unlike those of the general surgeon — are usually spent out of the OR and in a warm bed. Most acute urological problems are managed in the ER with the help of other disciplines. I shall discuss here those common scenarios that a general surgeon may encounter, and solve, while the urologist slumbers.',\n", " 'bBox': {'x': 72, 'y': 309, 'w': 467.77, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Acute Renal Colic',\n", " 'md': '### Acute Renal Colic',\n", " 'bBox': {'x': 86, 'y': 620, 'w': 132.42, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Renal colic is quite easy to diagnose and usually involves intrinsic obstruction of the renal pelvis, or ureter, by a stone. The classic complaint is of acute flank pain in a restless patient. The pain radiates from the back forwards, is spasmodic and recurrent. It is often...\\n```',\n", " 'md': 'Renal colic is quite easy to diagnose and usually involves intrinsic obstruction of the renal pelvis, or ureter, by a stone. The classic complaint is of acute flank pain in a restless patient. The pain radiates from the back forwards, is spasmodic and recurrent. It is often...\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 664,\n", " 'text': 'associated with nausea and, less frequently, vomiting. The pain is caused\\nby the dilatation of the urinary tract proximal to the stone. As the stone\\ntravels down the ureter by force of the forward pressure caused by the\\nurine flow, the location of the pain changes, radiating toward the lower\\nabdomen, inguinal area and then to the genitalia. As the stone reaches\\nthe lower ureter the patient will complain of frequency and urgency and\\nthen all abates as the stone is expelled into the bladder. Thus, one may\\ntrace the advancement of the stone by the patient’s complaints.\\nStones need to pass three narrow spots in the collecting system on their\\nway to the bladder: the ureteropelvic junction, the iliac vessels and the\\nvesico-ureteral junction. These points are where calculi usually get stuck.\\n\\n The most important factors to assess in this situation are the stone’s size and its location within\\n the urinary system. Most stones less than 5mm in size and those in the lower ureter\\n (beyond the iliac vessels) should be expelled spontaneously (80-90%) and thus are\\n managed expectantly. Larger stones and those higher in the ureter need to be\\n manipulated out. Most stones that pass spontaneously do so within 3-4 weeks.\\n\\n Diagnosis\\n\\n Most stones are radiopaque and thus a regular plain abdominal X-ray\\nis the initial diagnostic step. (If you have ever wondered why sometimes\\na plain abdominal film is called KUB — ‘Kidney-Ureter-Bladder’ — it’s the\\nurologists’ fault, looking for stones…). Looking at the X-ray we use the 4-\\nS rule:\\n\\n When searching for Stones check that the Side corresponds to the\\npain, that the Skeleton does not hold surprises (metastasis) and that\\nthere are no suspicious Silhouettes (tumor).\\n\\n Non-contrast CT (NCCT) is the gold standard in the diagnosis of\\nstones in the ER setting. NCCT may diagnose all stones regardless of\\ntheir composition (uric acid, etc.). Ultrasound is helpful in the assessment\\nof hydronephrosis and obstruction — urine flow into the bladder is\\nvisualized by urine jets in the bladder; its absence is a surrogate marker\\nof obstruction.',\n", " 'md': '```markdown\\n## Current Page Content\\n\\nThe text discusses the symptoms and diagnosis of urinary stones.\\n\\n### Symptoms\\n- Associated with nausea and, less frequently, vomiting.\\n- Pain caused by the dilatation of the urinary tract proximal to the stone.\\n- As the stone travels down the ureter, the location of the pain changes, radiating toward:\\n- Lower abdomen\\n- Inguinal area\\n- Genitalia\\n- As the stone reaches the lower ureter, the patient will complain of frequency and urgency, which abates as the stone is expelled into the bladder.\\n- The advancement of the stone can be traced by the patient’s complaints.\\n\\n### Key Points\\n- Stones need to pass three narrow spots in the collecting system on their way to the bladder:\\n1. Ureteropelvic junction\\n2. Iliac vessels\\n3. Vesico-ureteral junction\\n- Most important factors to assess:\\n- Stone’s size\\n- Location within the urinary system\\n- Most stones less than 5mm in size and those in the lower ureter (beyond the iliac vessels) should be expelled spontaneously (80-90%) and are managed expectantly.\\n- Larger stones and those higher in the ureter need to be manipulated out.\\n- Most stones that pass spontaneously do so within 3-4 weeks.\\n\\n### Diagnosis\\n- Most stones are radiopaque; thus, a regular plain abdominal X-ray is the initial diagnostic step.\\n- The 4-S rule is used when searching for stones:\\n- **Side**: Corresponds to the pain\\n- **Skeleton**: Does not hold surprises (metastasis)\\n- **Silhouettes**: No suspicious silhouettes (tumor)\\n- Non-contrast CT (NCCT) is the gold standard in the diagnosis of stones in the ER setting.\\n- NCCT can diagnose all stones regardless of their composition (e.g., uric acid).\\n- Ultrasound is helpful in assessing hydronephrosis and obstruction; urine flow into the bladder is visualized by urine jets in the bladder, and its absence is a surrogate marker of obstruction.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the symptoms and diagnosis of urinary stones.',\n", " 'md': 'The text discusses the symptoms and diagnosis of urinary stones.',\n", " 'bBox': {'x': 86, 'y': 427, 'w': 79.09, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Symptoms',\n", " 'md': '### Symptoms',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Associated with nausea and, less frequently, vomiting.\\n- Pain caused by the dilatation of the urinary tract proximal to the stone.\\n- As the stone travels down the ureter, the location of the pain changes, radiating toward:\\n- Lower abdomen\\n- Inguinal area\\n- Genitalia\\n- As the stone reaches the lower ureter, the patient will complain of frequency and urgency, which abates as the stone is expelled into the bladder.\\n- The advancement of the stone can be traced by the patient’s complaints.',\n", " 'md': '- Associated with nausea and, less frequently, vomiting.\\n- Pain caused by the dilatation of the urinary tract proximal to the stone.\\n- As the stone travels down the ureter, the location of the pain changes, radiating toward:\\n- Lower abdomen\\n- Inguinal area\\n- Genitalia\\n- As the stone reaches the lower ureter, the patient will complain of frequency and urgency, which abates as the stone is expelled into the bladder.\\n- The advancement of the stone can be traced by the patient’s complaints.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key Points',\n", " 'md': '### Key Points',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Stones need to pass three narrow spots in the collecting system on their way to the bladder:\\n1. Ureteropelvic junction\\n2. Iliac vessels\\n3. Vesico-ureteral junction\\n- Most important factors to assess:\\n- Stone’s size\\n- Location within the urinary system\\n- Most stones less than 5mm in size and those in the lower ureter (beyond the iliac vessels) should be expelled spontaneously (80-90%) and are managed expectantly.\\n- Larger stones and those higher in the ureter need to be manipulated out.\\n- Most stones that pass spontaneously do so within 3-4 weeks.',\n", " 'md': '- Stones need to pass three narrow spots in the collecting system on their way to the bladder:\\n1. Ureteropelvic junction\\n2. Iliac vessels\\n3. Vesico-ureteral junction\\n- Most important factors to assess:\\n- Stone’s size\\n- Location within the urinary system\\n- Most stones less than 5mm in size and those in the lower ureter (beyond the iliac vessels) should be expelled spontaneously (80-90%) and are managed expectantly.\\n- Larger stones and those higher in the ureter need to be manipulated out.\\n- Most stones that pass spontaneously do so within 3-4 weeks.',\n", " 'bBox': {'x': 72, 'y': 218, 'w': 467.61, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diagnosis',\n", " 'md': '### Diagnosis',\n", " 'bBox': {'x': 86, 'y': 427, 'w': 79.09, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Most stones are radiopaque; thus, a regular plain abdominal X-ray is the initial diagnostic step.\\n- The 4-S rule is used when searching for stones:\\n- **Side**: Corresponds to the pain\\n- **Skeleton**: Does not hold surprises (metastasis)\\n- **Silhouettes**: No suspicious silhouettes (tumor)\\n- Non-contrast CT (NCCT) is the gold standard in the diagnosis of stones in the ER setting.\\n- NCCT can diagnose all stones regardless of their composition (e.g., uric acid).\\n- Ultrasound is helpful in assessing hydronephrosis and obstruction; urine flow into the bladder is visualized by urine jets in the bladder, and its absence is a surrogate marker of obstruction.\\n```',\n", " 'md': '- Most stones are radiopaque; thus, a regular plain abdominal X-ray is the initial diagnostic step.\\n- The 4-S rule is used when searching for stones:\\n- **Side**: Corresponds to the pain\\n- **Skeleton**: Does not hold surprises (metastasis)\\n- **Silhouettes**: No suspicious silhouettes (tumor)\\n- Non-contrast CT (NCCT) is the gold standard in the diagnosis of stones in the ER setting.\\n- NCCT can diagnose all stones regardless of their composition (e.g., uric acid).\\n- Ultrasound is helpful in assessing hydronephrosis and obstruction; urine flow into the bladder is visualized by urine jets in the bladder, and its absence is a surrogate marker of obstruction.\\n```',\n", " 'bBox': {'x': 72, 'y': 427, 'w': 93.09, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 665,\n", " 'text': ' Management\\n\\n The pain of ureteric colic is mediated by prostaglandins and therefore\\nintravenous NSAIDs are the drug of choice in the management of pain.\\nFluids are given to increase diuresis and force the stone down the ureter,\\nand smooth muscle relaxants (e.g. papaverine i.v.) also have merit in\\nalleviating acute pain. Steroids and calcium channel blockers have been\\ntried in the past with minimal value. Lately, tamsulosin (Flomax®,\\nOmnic®), an α-adrenergic blocker used for prostatism, has been found to\\nfacilitate stone expulsion.\\n\\n Remember: look for signs of infection or renal dysfunction.\\nThese, along with intractable pain, are indications for\\nhospitalization.\\n\\n Laboratory tests should include a complete blood count, creatinine\\nand electrolytes. Some patients presenting with renal colic will be septic\\nor in severe renal failure (beware of patients with a single kidney). These\\npatients must be admitted to hospital and have emergency\\ndecompression of the collecting system, as the penalty for a delay\\nin treatment may be death from sepsis. Decompression may be done\\nby insertion of a self-retaining stent (JJ) (now you’ll have to call your\\nurologist) or by percutaneous nephrostomy by the radiologist. The\\navailable options to get rid of the obstructing ureteral stone are (usually)\\nto insert a stent and fragment the stone later (shock wave lithotripsy), or\\nto perform immediate ureteroscopy and stone fragmentation with laser.\\nUreteroscopy is the definitive solution for most lower ureteral\\nstones. Stones in the upper ureter or in the renal pelvis are usually\\nfragmented by external shock wave lithotripsy (ESWL).\\n\\n Torsion of testis (see also Chapter 36)\\n\\n As a general surgeon you will see most ‘acute scrotal conditions’ well\\nbefore the urologist — some may present as depicted in Figure 37.1.\\nTorsion of the spermatic cord is the most dramatic ‘acute scrotum’; it\\nrequires emergency management and if missed the testis will be lost. It\\ncommonly occurs in young boys but may appear at all ages, even in the',\n", " 'md': '```markdown\\n# Management of Ureteric Colic\\n\\nThe pain of ureteric colic is mediated by prostaglandins and therefore intravenous NSAIDs are the drug of choice in the management of pain. Fluids are given to increase diuresis and force the stone down the ureter, and smooth muscle relaxants (e.g. papaverine i.v.) also have merit in alleviating acute pain. Steroids and calcium channel blockers have been tried in the past with minimal value. Lately, tamsulosin (Flomax®, Omnic®), an α-adrenergic blocker used for prostatism, has been found to facilitate stone expulsion.\\n\\n**Remember:** look for signs of infection or renal dysfunction. These, along with intractable pain, are indications for hospitalization.\\n\\nLaboratory tests should include a complete blood count, creatinine, and electrolytes. Some patients presenting with renal colic will be septic or in severe renal failure (beware of patients with a single kidney). These patients must be admitted to hospital and have emergency decompression of the collecting system, as the penalty for a delay in treatment may be death from sepsis. Decompression may be done by insertion of a self-retaining stent (JJ) (now you’ll have to call your urologist) or by percutaneous nephrostomy by the radiologist. The available options to get rid of the obstructing ureteral stone are (usually) to insert a stent and fragment the stone later (shock wave lithotripsy), or to perform immediate ureteroscopy and stone fragmentation with laser. Ureteroscopy is the definitive solution for most lower ureteral stones. Stones in the upper ureter or in the renal pelvis are usually fragmented by external shock wave lithotripsy (ESWL).\\n\\n## Torsion of Testis\\n\\nAs a general surgeon, you will see most ‘acute scrotal conditions’ well before the urologist — some may present as depicted in **Figure 37.1**. Torsion of the spermatic cord is the most dramatic ‘acute scrotum’; it requires emergency management and if missed the testis will be lost. It commonly occurs in young boys but may appear at all ages, even in the...\\n```\\n\\n### Image Identification and Description\\n- **Figure 37.1**: This figure likely depicts a clinical scenario related to torsion of the testis. The specific content of the image is not provided in the text, but it is important for understanding acute scrotal conditions. The image may include anatomical illustrations or clinical photographs relevant to the diagnosis and management of testicular torsion.\\n\\n### Summary\\nThis page discusses the management of ureteric colic, emphasizing the use of NSAIDs, fluids, and smooth muscle relaxants for pain relief, as well as the importance of recognizing signs of infection or renal dysfunction. It also touches on the emergency management of testicular torsion, highlighting the urgency of the condition and the need for immediate intervention.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management of Ureteric Colic',\n", " 'md': '# Management of Ureteric Colic',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The pain of ureteric colic is mediated by prostaglandins and therefore intravenous NSAIDs are the drug of choice in the management of pain. Fluids are given to increase diuresis and force the stone down the ureter, and smooth muscle relaxants (e.g. papaverine i.v.) also have merit in alleviating acute pain. Steroids and calcium channel blockers have been tried in the past with minimal value. Lately, tamsulosin (Flomax®, Omnic®), an α-adrenergic blocker used for prostatism, has been found to facilitate stone expulsion.\\n\\n**Remember:** look for signs of infection or renal dysfunction. These, along with intractable pain, are indications for hospitalization.\\n\\nLaboratory tests should include a complete blood count, creatinine, and electrolytes. Some patients presenting with renal colic will be septic or in severe renal failure (beware of patients with a single kidney). These patients must be admitted to hospital and have emergency decompression of the collecting system, as the penalty for a delay in treatment may be death from sepsis. Decompression may be done by insertion of a self-retaining stent (JJ) (now you’ll have to call your urologist) or by percutaneous nephrostomy by the radiologist. The available options to get rid of the obstructing ureteral stone are (usually) to insert a stent and fragment the stone later (shock wave lithotripsy), or to perform immediate ureteroscopy and stone fragmentation with laser. Ureteroscopy is the definitive solution for most lower ureteral stones. Stones in the upper ureter or in the renal pelvis are usually fragmented by external shock wave lithotripsy (ESWL).',\n", " 'md': 'The pain of ureteric colic is mediated by prostaglandins and therefore intravenous NSAIDs are the drug of choice in the management of pain. Fluids are given to increase diuresis and force the stone down the ureter, and smooth muscle relaxants (e.g. papaverine i.v.) also have merit in alleviating acute pain. Steroids and calcium channel blockers have been tried in the past with minimal value. Lately, tamsulosin (Flomax®, Omnic®), an α-adrenergic blocker used for prostatism, has been found to facilitate stone expulsion.\\n\\n**Remember:** look for signs of infection or renal dysfunction. These, along with intractable pain, are indications for hospitalization.\\n\\nLaboratory tests should include a complete blood count, creatinine, and electrolytes. Some patients presenting with renal colic will be septic or in severe renal failure (beware of patients with a single kidney). These patients must be admitted to hospital and have emergency decompression of the collecting system, as the penalty for a delay in treatment may be death from sepsis. Decompression may be done by insertion of a self-retaining stent (JJ) (now you’ll have to call your urologist) or by percutaneous nephrostomy by the radiologist. The available options to get rid of the obstructing ureteral stone are (usually) to insert a stent and fragment the stone later (shock wave lithotripsy), or to perform immediate ureteroscopy and stone fragmentation with laser. Ureteroscopy is the definitive solution for most lower ureteral stones. Stones in the upper ureter or in the renal pelvis are usually fragmented by external shock wave lithotripsy (ESWL).',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.99, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Torsion of Testis',\n", " 'md': '## Torsion of Testis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'As a general surgeon, you will see most ‘acute scrotal conditions’ well before the urologist — some may present as depicted in **Figure 37.1**. Torsion of the spermatic cord is the most dramatic ‘acute scrotum’; it requires emergency management and if missed the testis will be lost. It commonly occurs in young boys but may appear at all ages, even in the...\\n```',\n", " 'md': 'As a general surgeon, you will see most ‘acute scrotal conditions’ well before the urologist — some may present as depicted in **Figure 37.1**. Torsion of the spermatic cord is the most dramatic ‘acute scrotum’; it requires emergency management and if missed the testis will be lost. It commonly occurs in young boys but may appear at all ages, even in the...\\n```',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.59, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 37.1**: This figure likely depicts a clinical scenario related to torsion of the testis. The specific content of the image is not provided in the text, but it is important for understanding acute scrotal conditions. The image may include anatomical illustrations or clinical photographs relevant to the diagnosis and management of testicular torsion.',\n", " 'md': '- **Figure 37.1**: This figure likely depicts a clinical scenario related to torsion of the testis. The specific content of the image is not provided in the text, but it is important for understanding acute scrotal conditions. The image may include anatomical illustrations or clinical photographs relevant to the diagnosis and management of testicular torsion.',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses the management of ureteric colic, emphasizing the use of NSAIDs, fluids, and smooth muscle relaxants for pain relief, as well as the importance of recognizing signs of infection or renal dysfunction. It also touches on the emergency management of testicular torsion, highlighting the urgency of the condition and the need for immediate intervention.',\n", " 'md': 'This page discusses the management of ureteric colic, emphasizing the use of NSAIDs, fluids, and smooth muscle relaxants for pain relief, as well as the importance of recognizing signs of infection or renal dysfunction. It also touches on the emergency management of testicular torsion, highlighting the urgency of the condition and the need for immediate intervention.',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 101.17, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'Torsion of the spermatic cord is the most dramatic ‘acute scrotum’; it'}]},\n", " {'page': 666,\n", " 'text': 'neonate.\\n\\n As the testis descends through the inguinal canal it pushes ahead of it\\na sliver of peritoneum. When the testis reaches the scrotum the\\nperitoneum is sealed off and only the part attached to the lower pole of\\nthe testis is left — this actually fixes the lower testicular pole to the scrotal\\nwall. But the peritoneum may adhere higher around the spermatic cord\\nand wrap the entire testis within an isolated peritoneal sac. In this\\nsituation the testis may rotate, twist itself around its vessels within the\\ntunica vaginalis (the retained part of the peritoneum) and cause acute\\nischemia. This anomaly occurs equally on both sides of the scrotum.\\n osp0\\n ais\\n ReRyA 2007\\n Figure 37.1. “What’s that? A water melon?”\\n\\n Medical literature from the 1960s observed a high frequency of delay in\\ndiagnosis and a very high orchiectomy rate. But with more attention paid\\nto the clinical symptoms, and the adoption of an aggressive operative\\napproach, most torted testes can be saved.\\n\\n The classic symptoms are acute unilateral scrotal pain, swelling,\\nnausea and vomiting, without fever or urinary symptoms. Usually',\n", " 'md': '```markdown\\n## Page Content\\n\\nAs the testis descends through the inguinal canal it pushes ahead of it a sliver of peritoneum. When the testis reaches the scrotum the peritoneum is sealed off and only the part attached to the lower pole of the testis is left — this actually fixes the lower testicular pole to the scrotal wall. But the peritoneum may adhere higher around the spermatic cord and wrap the entire testis within an isolated peritoneal sac. In this situation, the testis may rotate, twist itself around its vessels within the tunica vaginalis (the retained part of the peritoneum) and cause acute ischemia. This anomaly occurs equally on both sides of the scrotum.\\n\\nMedical literature from the 1960s observed a high frequency of delay in diagnosis and a very high orchiectomy rate. But with more attention paid to the clinical symptoms, and the adoption of an aggressive operative approach, most torted testes can be saved.\\n\\nThe classic symptoms are acute unilateral scrotal pain, swelling, nausea and vomiting, without fever or urinary symptoms.\\n\\n## Figures\\n\\n### Figure 37.1\\n**Caption:** “What’s that? A water melon?”\\n\\n**Description:** This figure likely depicts a humorous or illustrative representation related to the medical context discussed, possibly comparing a medical condition to a watermelon. The exact content of the image is not identifiable from the text provided.\\n\\n**Summary:** The figure serves to lighten the discussion around a serious medical condition, possibly illustrating the shape or appearance of a torted testis in a metaphorical way.\\n```',\n", " 'images': [{'name': 'img_p665_1.png',\n", " 'height': 552,\n", " 'width': 816,\n", " 'x': 104.39999999999986,\n", " 'y': 267.12,\n", " 'original_width': 1403,\n", " 'original_height': 949}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'As the testis descends through the inguinal canal it pushes ahead of it a sliver of peritoneum. When the testis reaches the scrotum the peritoneum is sealed off and only the part attached to the lower pole of the testis is left — this actually fixes the lower testicular pole to the scrotal wall. But the peritoneum may adhere higher around the spermatic cord and wrap the entire testis within an isolated peritoneal sac. In this situation, the testis may rotate, twist itself around its vessels within the tunica vaginalis (the retained part of the peritoneum) and cause acute ischemia. This anomaly occurs equally on both sides of the scrotum.\\n\\nMedical literature from the 1960s observed a high frequency of delay in diagnosis and a very high orchiectomy rate. But with more attention paid to the clinical symptoms, and the adoption of an aggressive operative approach, most torted testes can be saved.\\n\\nThe classic symptoms are acute unilateral scrotal pain, swelling, nausea and vomiting, without fever or urinary symptoms.',\n", " 'md': 'As the testis descends through the inguinal canal it pushes ahead of it a sliver of peritoneum. When the testis reaches the scrotum the peritoneum is sealed off and only the part attached to the lower pole of the testis is left — this actually fixes the lower testicular pole to the scrotal wall. But the peritoneum may adhere higher around the spermatic cord and wrap the entire testis within an isolated peritoneal sac. In this situation, the testis may rotate, twist itself around its vessels within the tunica vaginalis (the retained part of the peritoneum) and cause acute ischemia. This anomaly occurs equally on both sides of the scrotum.\\n\\nMedical literature from the 1960s observed a high frequency of delay in diagnosis and a very high orchiectomy rate. But with more attention paid to the clinical symptoms, and the adoption of an aggressive operative approach, most torted testes can be saved.\\n\\nThe classic symptoms are acute unilateral scrotal pain, swelling, nausea and vomiting, without fever or urinary symptoms.',\n", " 'bBox': {'x': 72, 'y': 121, 'w': 467.71, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures',\n", " 'md': '## Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 37.1',\n", " 'md': '### Figure 37.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** “What’s that? A water melon?”\\n\\n**Description:** This figure likely depicts a humorous or illustrative representation related to the medical context discussed, possibly comparing a medical condition to a watermelon. The exact content of the image is not identifiable from the text provided.\\n\\n**Summary:** The figure serves to lighten the discussion around a serious medical condition, possibly illustrating the shape or appearance of a torted testis in a metaphorical way.\\n```',\n", " 'md': '**Caption:** “What’s that? A water melon?”\\n\\n**Description:** This figure likely depicts a humorous or illustrative representation related to the medical context discussed, possibly comparing a medical condition to a watermelon. The exact content of the image is not identifiable from the text provided.\\n\\n**Summary:** The figure serves to lighten the discussion around a serious medical condition, possibly illustrating the shape or appearance of a torted testis in a metaphorical way.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 667,\n", " 'text': 'there are difficulties in gait as the patient wishes to keep his legs apart to\\navoid pressure on the scrotum. Often the presentation is not so clear and\\npain and swelling are the only signs. The most common differential\\ndiagnoses are inflammatory intrascrotal conditions (e.g.\\nepididymitis, orchitis), but in the young patient torsion is more\\nfrequent than inflammation.\\n\\n Torsion of a testicular appendage may also occur, and confuse the\\nexamining physician. The testis has two appendages, one emanating\\nfrom the testis itself at the upper pole; another from the epididymis (\\nFigure 37.2). If they twist around their origin, a large scrotal swelling\\noccurs which is very painful. In this case the testis itself is normal. On\\nexamination one may see a local enlargement called a ‘blue dot’.\\n Spermaliccord\\n Cremaster\\n Tunica vaginalis\\n Appendix of epididymis\\n Head of epididymis\\n Tail of epididymis\\n Testis Appendix of testis\\n Figure 37.2. Testicular appendages.\\n\\n Signs of testicular torsion on examination include: a high riding testis, transverse lie, a negative\\n dartos sign (normally, stroking the thigh elevates the testis), and local pain and sensitivity.\\n\\n The diagnosis can be assisted by a Doppler ultrasound which may',\n", " 'md': '```markdown\\n## Page Content\\n\\nThere are difficulties in gait as the patient wishes to keep his legs apart to avoid pressure on the scrotum. Often the presentation is not so clear and pain and swelling are the only signs. The most common differential diagnoses are inflammatory intrascrotal conditions (e.g. epididymitis, orchitis), but in the young patient torsion is more frequent than inflammation.\\n\\nTorsion of a testicular appendage may also occur, and confuse the examining physician. The testis has two appendages, one emanating from the testis itself at the upper pole; another from the epididymis (Figure 37.2). If they twist around their origin, a large scrotal swelling occurs which is very painful. In this case, the testis itself is normal. On examination, one may see a local enlargement called a ‘blue dot’.\\n\\n### Figure 37.2: Testicular Appendages\\n\\n- **Description**: This figure illustrates the anatomical structure of the testicular appendages, including the spermal cord, cremaster muscle, tunica vaginalis, appendix of the epididymis, head of the epididymis, tail of the epididymis, testis, and appendix of the testis.\\n- **Summary**: The diagram provides a visual representation of the testicular anatomy, highlighting the appendages that can be involved in conditions such as torsion.\\n\\nSigns of testicular torsion on examination include: a high riding testis, transverse lie, a negative dartos sign (normally, stroking the thigh elevates the testis), and local pain and sensitivity.\\n\\nThe diagnosis can be assisted by a Doppler ultrasound which may...\\n```',\n", " 'images': [{'name': 'img_p666_1.png',\n", " 'height': 526,\n", " 'width': 758,\n", " 'x': 118.79999999999995,\n", " 'y': 300.23999999999995,\n", " 'original_width': 1302,\n", " 'original_height': 901}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'There are difficulties in gait as the patient wishes to keep his legs apart to avoid pressure on the scrotum. Often the presentation is not so clear and pain and swelling are the only signs. The most common differential diagnoses are inflammatory intrascrotal conditions (e.g. epididymitis, orchitis), but in the young patient torsion is more frequent than inflammation.\\n\\nTorsion of a testicular appendage may also occur, and confuse the examining physician. The testis has two appendages, one emanating from the testis itself at the upper pole; another from the epididymis (Figure 37.2). If they twist around their origin, a large scrotal swelling occurs which is very painful. In this case, the testis itself is normal. On examination, one may see a local enlargement called a ‘blue dot’.',\n", " 'md': 'There are difficulties in gait as the patient wishes to keep his legs apart to avoid pressure on the scrotum. Often the presentation is not so clear and pain and swelling are the only signs. The most common differential diagnoses are inflammatory intrascrotal conditions (e.g. epididymitis, orchitis), but in the young patient torsion is more frequent than inflammation.\\n\\nTorsion of a testicular appendage may also occur, and confuse the examining physician. The testis has two appendages, one emanating from the testis itself at the upper pole; another from the epididymis (Figure 37.2). If they twist around their origin, a large scrotal swelling occurs which is very painful. In this case, the testis itself is normal. On examination, one may see a local enlargement called a ‘blue dot’.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.64, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 37.2: Testicular Appendages',\n", " 'md': '### Figure 37.2: Testicular Appendages',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure illustrates the anatomical structure of the testicular appendages, including the spermal cord, cremaster muscle, tunica vaginalis, appendix of the epididymis, head of the epididymis, tail of the epididymis, testis, and appendix of the testis.\\n- **Summary**: The diagram provides a visual representation of the testicular anatomy, highlighting the appendages that can be involved in conditions such as torsion.\\n\\nSigns of testicular torsion on examination include: a high riding testis, transverse lie, a negative dartos sign (normally, stroking the thigh elevates the testis), and local pain and sensitivity.\\n\\nThe diagnosis can be assisted by a Doppler ultrasound which may...\\n```',\n", " 'md': '- **Description**: This figure illustrates the anatomical structure of the testicular appendages, including the spermal cord, cremaster muscle, tunica vaginalis, appendix of the epididymis, head of the epididymis, tail of the epididymis, testis, and appendix of the testis.\\n- **Summary**: The diagram provides a visual representation of the testicular anatomy, highlighting the appendages that can be involved in conditions such as torsion.\\n\\nSigns of testicular torsion on examination include: a high riding testis, transverse lie, a negative dartos sign (normally, stroking the thigh elevates the testis), and local pain and sensitivity.\\n\\nThe diagnosis can be assisted by a Doppler ultrasound which may...\\n```',\n", " 'bBox': {'x': 79, 'y': 135, 'w': 453.26, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Figure 37.2). If they twist around their origin, a large scrotal swelling occurs which is very painful. '}]},\n", " {'page': 668,\n", " 'text': 'show reduced testicular perfusion — an indication for exploration.\\nEquivocal ultrasound results along with indicative signs and\\nsymptoms warrant surgical exploration. The testis may withstand 4-\\n6 hours of ischemia, after which there are irreversible changes\\nresulting in atrophy. Practically, accurate assessment of time of onset\\nof the torsion is usually difficult and thus the recommendation is to\\nexplore the affected testis whenever signs are significant.\\n\\n Exploration is performed trans-scrotally. I prefer to place a separate\\nincision on each side. In my hands a vertical incision works better, since it\\nmay be extended to the inguinal area should you want to explore the\\ncord. So if you need to pexy the other testis use a separate vertical\\nincision (a midline incision along the raphe usually enters one side\\nanyway and you can do the other side through the common mid wall —\\nwe would do that only for elective bilateral orchiectomy as for prostate\\ncancer). The exposed testis is ‘untorted’ and wrapped in warm pads. If\\nblood flow returns as seen by a pinkish color, the testis is fixed with non-\\nabsorbable sutures to the scrotal wall in at least three places. If blood\\nflow does not return, the testis must be removed. It is accepted that if left\\nin situ, the atrophic testis may produce autoantibodies, damaging the\\ncontralateral testis, and causing infertility. At the same procedure, the\\ncontralateral testis must be explored as well and fixed as a\\nprophylactic measure. Being ‘aggressive enough’ one may expect a\\nnegative exploration in up to one-third of patients — (exactly what was\\ntrue for the appendix a few decades ago…).\\n\\n Acute retention of urine\\n\\n You will often have to deal with acute urinary retention in the ER or in\\nyour postoperative patients. Most patients with retention are men\\nsuffering from benign prostatic hypertrophy (BPħ) who give a history of\\n“lower urinary tract symptoms” (LUTS) such as urgency, nocturia, double\\nmicturition, hesitancy, etc. Other possible etiologies include urethral\\nstricture and neurological disease (e.g. multiple sclerosis). In some BPħ\\npatients, retention is precipitated by sympathomimetic drugs (ephedrine\\nfor flu) or anticholinergics (psychiatric drugs). As you know, anesthesia\\ncombined with vigorous intra-operative fluid administration predisposes\\npatients to this complication; so, for example, if you chose to repair an',\n", " 'md': '```markdown\\n## Text Extraction\\n\\n- Show reduced testicular perfusion — an indication for exploration. Equivocal ultrasound results along with indicative signs and symptoms warrant surgical exploration. The testis may withstand 4-6 hours of ischemia, after which there are irreversible changes resulting in atrophy. Practically, accurate assessment of time of onset of the torsion is usually difficult and thus the recommendation is to explore the affected testis whenever signs are significant.\\n\\n- Exploration is performed trans-scrotally. I prefer to place a separate incision on each side. In my hands, a vertical incision works better, since it may be extended to the inguinal area should you want to explore the cord. So if you need to pexy the other testis, use a separate vertical incision (a midline incision along the raphe usually enters one side anyway and you can do the other side through the common mid wall — we would do that only for elective bilateral orchiectomy as for prostate cancer). The exposed testis is ‘untorted’ and wrapped in warm pads. If blood flow returns as seen by a pinkish color, the testis is fixed with non-absorbable sutures to the scrotal wall in at least three places. If blood flow does not return, the testis must be removed. It is accepted that if left in situ, the atrophic testis may produce autoantibodies, damaging the contralateral testis, and causing infertility. At the same procedure, the contralateral testis must be explored as well and fixed as a prophylactic measure. Being ‘aggressive enough’ one may expect a negative exploration in up to one-third of patients — (exactly what was true for the appendix a few decades ago…).\\n\\n- Acute retention of urine\\n\\n- You will often have to deal with acute urinary retention in the ER or in your postoperative patients. Most patients with retention are men suffering from benign prostatic hypertrophy (BPH) who give a history of “lower urinary tract symptoms” (LUTS) such as urgency, nocturia, double micturition, hesitancy, etc. Other possible etiologies include urethral stricture and neurological disease (e.g. multiple sclerosis). In some BPH patients, retention is precipitated by sympathomimetic drugs (ephedrine for flu) or anticholinergics (psychiatric drugs). As you know, anesthesia combined with vigorous intra-operative fluid administration predisposes patients to this complication; so, for example, if you chose to repair an...\\n\\n## Image Identification and Description\\n\\n- **Figure 1**: \\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Show reduced testicular perfusion — an indication for exploration. Equivocal ultrasound results along with indicative signs and symptoms warrant surgical exploration. The testis may withstand 4-6 hours of ischemia, after which there are irreversible changes resulting in atrophy. Practically, accurate assessment of time of onset of the torsion is usually difficult and thus the recommendation is to explore the affected testis whenever signs are significant.\\n\\n- Exploration is performed trans-scrotally. I prefer to place a separate incision on each side. In my hands, a vertical incision works better, since it may be extended to the inguinal area should you want to explore the cord. So if you need to pexy the other testis, use a separate vertical incision (a midline incision along the raphe usually enters one side anyway and you can do the other side through the common mid wall — we would do that only for elective bilateral orchiectomy as for prostate cancer). The exposed testis is ‘untorted’ and wrapped in warm pads. If blood flow returns as seen by a pinkish color, the testis is fixed with non-absorbable sutures to the scrotal wall in at least three places. If blood flow does not return, the testis must be removed. It is accepted that if left in situ, the atrophic testis may produce autoantibodies, damaging the contralateral testis, and causing infertility. At the same procedure, the contralateral testis must be explored as well and fixed as a prophylactic measure. Being ‘aggressive enough’ one may expect a negative exploration in up to one-third of patients — (exactly what was true for the appendix a few decades ago…).\\n\\n- Acute retention of urine\\n\\n- You will often have to deal with acute urinary retention in the ER or in your postoperative patients. Most patients with retention are men suffering from benign prostatic hypertrophy (BPH) who give a history of “lower urinary tract symptoms” (LUTS) such as urgency, nocturia, double micturition, hesitancy, etc. Other possible etiologies include urethral stricture and neurological disease (e.g. multiple sclerosis). In some BPH patients, retention is precipitated by sympathomimetic drugs (ephedrine for flu) or anticholinergics (psychiatric drugs). As you know, anesthesia combined with vigorous intra-operative fluid administration predisposes patients to this complication; so, for example, if you chose to repair an...',\n", " 'md': '- Show reduced testicular perfusion — an indication for exploration. Equivocal ultrasound results along with indicative signs and symptoms warrant surgical exploration. The testis may withstand 4-6 hours of ischemia, after which there are irreversible changes resulting in atrophy. Practically, accurate assessment of time of onset of the torsion is usually difficult and thus the recommendation is to explore the affected testis whenever signs are significant.\\n\\n- Exploration is performed trans-scrotally. I prefer to place a separate incision on each side. In my hands, a vertical incision works better, since it may be extended to the inguinal area should you want to explore the cord. So if you need to pexy the other testis, use a separate vertical incision (a midline incision along the raphe usually enters one side anyway and you can do the other side through the common mid wall — we would do that only for elective bilateral orchiectomy as for prostate cancer). The exposed testis is ‘untorted’ and wrapped in warm pads. If blood flow returns as seen by a pinkish color, the testis is fixed with non-absorbable sutures to the scrotal wall in at least three places. If blood flow does not return, the testis must be removed. It is accepted that if left in situ, the atrophic testis may produce autoantibodies, damaging the contralateral testis, and causing infertility. At the same procedure, the contralateral testis must be explored as well and fixed as a prophylactic measure. Being ‘aggressive enough’ one may expect a negative exploration in up to one-third of patients — (exactly what was true for the appendix a few decades ago…).\\n\\n- Acute retention of urine\\n\\n- You will often have to deal with acute urinary retention in the ER or in your postoperative patients. Most patients with retention are men suffering from benign prostatic hypertrophy (BPH) who give a history of “lower urinary tract symptoms” (LUTS) such as urgency, nocturia, double micturition, hesitancy, etc. Other possible etiologies include urethral stricture and neurological disease (e.g. multiple sclerosis). In some BPH patients, retention is precipitated by sympathomimetic drugs (ephedrine for flu) or anticholinergics (psychiatric drugs). As you know, anesthesia combined with vigorous intra-operative fluid administration predisposes patients to this complication; so, for example, if you chose to repair an...',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.87, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: \\n```',\n", " 'md': '- **Figure 1**: \\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 669,\n", " 'text': 'inguinal hernia under local anesthesia, rather than a general or spinal,\\nyou are likely to spare your patient that kind of urinary tzures1.\\n Retention is manifested by severe lower abdominal pain, an inability to\\nvoid and (not surprisingly) agitation.\\n\\n Management\\n\\n Relief of this situation is by simple insertion of a urethral (Foley)\\ncatheter. The rule in this case is to insert a catheter with a moderate\\ncaliber but not too large as it may have to stay in place for some\\ntime. A good choice is a 16Fr Foley catheter. Bladder neck stenosis, a\\nlarge prostate or urethral stricture may make it difficult to pass through\\nthe urethra. If insertion of a regular Foley fails, one may use a 14Fr\\nTiemann catheter that has a special tip and an angle with a better chance\\nof negotiating the bends and curves of the urethra. Third-line catheters\\nare tougher and transparent with a Tiemann tip and no balloon, and\\nof different calibers.\\n\\n Failure of all these measures would necessitate the insertion of a\\ncystostomy tube (suprapubic catheter). In most cases we would first\\ninsert a large-bore needle in the midline above the pubic bone and when\\nurine pours out we thread the cystostomy kit de jour into the bladder.\\nCaution must be practiced if the patient has had prior surgery in the\\narea; in which case cystostomy is best done under ultrasound\\nguidance. Of course, renal function must be assessed, as some patients\\nmay have chronic retention causing renal failure.\\n\\n It is very important to measure urine output for 2-3 hours after insertion\\nof a catheter. A common occurrence is post-obstruction diuresis with\\nproduction of very large amounts of urine. The pathophysiological basis\\nfor the polyuria is an acute washout of solutes that due to retention were\\nnot excreted properly, as in a hyperosmolar state. Other reasons are: an\\ninability of the medulla to conserve water due to loss of urea or pseudo\\ndiabetes insipidus — a temporary incapacity of ADħ receptors in the\\ndistal nephron. This situation is life-threatening especially in older\\npatients due to a fluid and electrolyte imbalance.',\n", " 'md': '```markdown\\n## Management of Urinary Retention\\n\\nRelief of urinary retention is achieved by the simple insertion of a urethral (Foley) catheter. The rule in this case is to insert a catheter with a moderate caliber but not too large, as it may have to stay in place for some time. A good choice is a 16Fr Foley catheter.\\n\\nBladder neck stenosis, a large prostate, or urethral stricture may make it difficult to pass through the urethra. If insertion of a regular Foley fails, one may use a 14Fr Tiemann catheter that has a special tip and an angle with a better chance of negotiating the bends and curves of the urethra. Third-line catheters are tougher and transparent with a Tiemann tip and no balloon, and of different calibers.\\n\\nFailure of all these measures would necessitate the insertion of a cystostomy tube (suprapubic catheter). In most cases, we would first insert a large-bore needle in the midline above the pubic bone, and when urine pours out, we thread the cystostomy kit de jour into the bladder. Caution must be practiced if the patient has had prior surgery in the area; in which case, cystostomy is best done under ultrasound guidance. Of course, renal function must be assessed, as some patients may have chronic retention causing renal failure.\\n\\nIt is very important to measure urine output for 2-3 hours after insertion of a catheter. A common occurrence is post-obstruction diuresis with the production of very large amounts of urine. The pathophysiological basis for the polyuria is an acute washout of solutes that, due to retention, were not excreted properly, as in a hyperosmolar state. Other reasons include an inability of the medulla to conserve water due to loss of urea or pseudo diabetes insipidus — a temporary incapacity of ADH receptors in the distal nephron. This situation is life-threatening, especially in older patients, due to a fluid and electrolyte imbalance.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Urinary Retention',\n", " 'md': '## Management of Urinary Retention',\n", " 'bBox': {'x': 86, 'y': 199, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Relief of urinary retention is achieved by the simple insertion of a urethral (Foley) catheter. The rule in this case is to insert a catheter with a moderate caliber but not too large, as it may have to stay in place for some time. A good choice is a 16Fr Foley catheter.\\n\\nBladder neck stenosis, a large prostate, or urethral stricture may make it difficult to pass through the urethra. If insertion of a regular Foley fails, one may use a 14Fr Tiemann catheter that has a special tip and an angle with a better chance of negotiating the bends and curves of the urethra. Third-line catheters are tougher and transparent with a Tiemann tip and no balloon, and of different calibers.\\n\\nFailure of all these measures would necessitate the insertion of a cystostomy tube (suprapubic catheter). In most cases, we would first insert a large-bore needle in the midline above the pubic bone, and when urine pours out, we thread the cystostomy kit de jour into the bladder. Caution must be practiced if the patient has had prior surgery in the area; in which case, cystostomy is best done under ultrasound guidance. Of course, renal function must be assessed, as some patients may have chronic retention causing renal failure.\\n\\nIt is very important to measure urine output for 2-3 hours after insertion of a catheter. A common occurrence is post-obstruction diuresis with the production of very large amounts of urine. The pathophysiological basis for the polyuria is an acute washout of solutes that, due to retention, were not excreted properly, as in a hyperosmolar state. Other reasons include an inability of the medulla to conserve water due to loss of urea or pseudo diabetes insipidus — a temporary incapacity of ADH receptors in the distal nephron. This situation is life-threatening, especially in older patients, due to a fluid and electrolyte imbalance.\\n```',\n", " 'md': 'Relief of urinary retention is achieved by the simple insertion of a urethral (Foley) catheter. The rule in this case is to insert a catheter with a moderate caliber but not too large, as it may have to stay in place for some time. A good choice is a 16Fr Foley catheter.\\n\\nBladder neck stenosis, a large prostate, or urethral stricture may make it difficult to pass through the urethra. If insertion of a regular Foley fails, one may use a 14Fr Tiemann catheter that has a special tip and an angle with a better chance of negotiating the bends and curves of the urethra. Third-line catheters are tougher and transparent with a Tiemann tip and no balloon, and of different calibers.\\n\\nFailure of all these measures would necessitate the insertion of a cystostomy tube (suprapubic catheter). In most cases, we would first insert a large-bore needle in the midline above the pubic bone, and when urine pours out, we thread the cystostomy kit de jour into the bladder. Caution must be practiced if the patient has had prior surgery in the area; in which case, cystostomy is best done under ultrasound guidance. Of course, renal function must be assessed, as some patients may have chronic retention causing renal failure.\\n\\nIt is very important to measure urine output for 2-3 hours after insertion of a catheter. A common occurrence is post-obstruction diuresis with the production of very large amounts of urine. The pathophysiological basis for the polyuria is an acute washout of solutes that, due to retention, were not excreted properly, as in a hyperosmolar state. Other reasons include an inability of the medulla to conserve water due to loss of urea or pseudo diabetes insipidus — a temporary incapacity of ADH receptors in the distal nephron. This situation is life-threatening, especially in older patients, due to a fluid and electrolyte imbalance.\\n```',\n", " 'bBox': {'x': 72, 'y': 252, 'w': 467.96, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'tzures 1'}]},\n", " {'page': 670,\n", " 'text': ' A patient with post-obstruction diuresis (>200cc/hr) has to be\\nhospitalized. Urine output is measured every hour and i.v. fluids (0.45%\\nsaline) are given. In order to avoid ‘chasing your tail’, initially 80% of the\\nvoided volume is replaced; as urine output decreases replacement is\\ngiven at 50% of the voided volume. Usually this is a self-limiting situation\\nthat should resolve within 24 hours.\\n\\n Urological trauma\\n\\n Kidney\\n\\n Renal injuries may be blunt or penetrating and they are commonly\\nassociated with motor vehicle accidents, falls from heights and assaults.\\nAn important consideration is to check whether a deceleration injury is\\ninvolved (fall from height especially), as this may cause an arterial intimal\\ntear leading to renal artery thrombosis which is a real emergency.\\nOtherwise a tendency towards conservative management has\\nemerged over the years in all renal injuries.\\n\\n The conservative approach for stab and low-velocity gunshot wounds\\nemerged in South Africa. It was there that physicians managing masses\\nof injured patients in cramped ERs first noticed that many of those with\\nextensive renal injuries waiting for their turn for surgery survived without\\nsurgical exploration. The kidney has a good recuperation potential\\nand most injuries heal with minor sequelae. Associated urine leaks\\nare easily managed with drainage which may be either internal via a\\nstent, diverting urine from the kidney to the bladder; or by a percutaneous\\nnephrostomy tube. Obviously, penetrating injuries are commonly\\nassociated with injuries to other nearby structures according to the site of\\nentry.\\n\\n The hallmark of renal injury is hematuria. Microhematuria is defined as\\n>5 red blood cells/high power field (RBC/ħPF). We do not need to tell\\nyou what’s gross, macroscopic hematuria, right?\\n\\n Which patients need renal imaging?',\n", " 'md': '```markdown\\n# Urological Trauma\\n\\nA patient with post-obstruction diuresis (>200cc/hr) has to be hospitalized. Urine output is measured every hour and i.v. fluids (0.45% saline) are given. In order to avoid ‘chasing your tail’, initially 80% of the voided volume is replaced; as urine output decreases, replacement is given at 50% of the voided volume. Usually, this is a self-limiting situation that should resolve within 24 hours.\\n\\n## Kidney\\n\\nRenal injuries may be blunt or penetrating and they are commonly associated with motor vehicle accidents, falls from heights, and assaults. An important consideration is to check whether a deceleration injury is involved (fall from height especially), as this may cause an arterial intimal tear leading to renal artery thrombosis which is a real emergency. Otherwise, a tendency towards conservative management has emerged over the years in all renal injuries.\\n\\nThe conservative approach for stab and low-velocity gunshot wounds emerged in South Africa. It was there that physicians managing masses of injured patients in cramped ERs first noticed that many of those with extensive renal injuries waiting for their turn for surgery survived without surgical exploration. The kidney has a good recuperation potential and most injuries heal with minor sequelae. Associated urine leaks are easily managed with drainage which may be either internal via a stent, diverting urine from the kidney to the bladder; or by a percutaneous nephrostomy tube. Obviously, penetrating injuries are commonly associated with injuries to other nearby structures according to the site of entry.\\n\\nThe hallmark of renal injury is hematuria. Microhematuria is defined as \\\\(>5\\\\) red blood cells/high power field (RBC/ħPF). We do not need to tell you what’s gross, macroscopic hematuria, right?\\n\\n## Which patients need renal imaging?\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Urological Trauma',\n", " 'md': '# Urological Trauma',\n", " 'bBox': {'x': 86, 'y': 211, 'w': 140.69, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A patient with post-obstruction diuresis (>200cc/hr) has to be hospitalized. Urine output is measured every hour and i.v. fluids (0.45% saline) are given. In order to avoid ‘chasing your tail’, initially 80% of the voided volume is replaced; as urine output decreases, replacement is given at 50% of the voided volume. Usually, this is a self-limiting situation that should resolve within 24 hours.',\n", " 'md': 'A patient with post-obstruction diuresis (>200cc/hr) has to be hospitalized. Urine output is measured every hour and i.v. fluids (0.45% saline) are given. In order to avoid ‘chasing your tail’, initially 80% of the voided volume is replaced; as urine output decreases, replacement is given at 50% of the voided volume. Usually, this is a self-limiting situation that should resolve within 24 hours.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Kidney',\n", " 'md': '## Kidney',\n", " 'bBox': {'x': 86, 'y': 255, 'w': 55.19, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Renal injuries may be blunt or penetrating and they are commonly associated with motor vehicle accidents, falls from heights, and assaults. An important consideration is to check whether a deceleration injury is involved (fall from height especially), as this may cause an arterial intimal tear leading to renal artery thrombosis which is a real emergency. Otherwise, a tendency towards conservative management has emerged over the years in all renal injuries.\\n\\nThe conservative approach for stab and low-velocity gunshot wounds emerged in South Africa. It was there that physicians managing masses of injured patients in cramped ERs first noticed that many of those with extensive renal injuries waiting for their turn for surgery survived without surgical exploration. The kidney has a good recuperation potential and most injuries heal with minor sequelae. Associated urine leaks are easily managed with drainage which may be either internal via a stent, diverting urine from the kidney to the bladder; or by a percutaneous nephrostomy tube. Obviously, penetrating injuries are commonly associated with injuries to other nearby structures according to the site of entry.\\n\\nThe hallmark of renal injury is hematuria. Microhematuria is defined as \\\\(>5\\\\) red blood cells/high power field (RBC/ħPF). We do not need to tell you what’s gross, macroscopic hematuria, right?',\n", " 'md': 'Renal injuries may be blunt or penetrating and they are commonly associated with motor vehicle accidents, falls from heights, and assaults. An important consideration is to check whether a deceleration injury is involved (fall from height especially), as this may cause an arterial intimal tear leading to renal artery thrombosis which is a real emergency. Otherwise, a tendency towards conservative management has emerged over the years in all renal injuries.\\n\\nThe conservative approach for stab and low-velocity gunshot wounds emerged in South Africa. It was there that physicians managing masses of injured patients in cramped ERs first noticed that many of those with extensive renal injuries waiting for their turn for surgery survived without surgical exploration. The kidney has a good recuperation potential and most injuries heal with minor sequelae. Associated urine leaks are easily managed with drainage which may be either internal via a stent, diverting urine from the kidney to the bladder; or by a percutaneous nephrostomy tube. Obviously, penetrating injuries are commonly associated with injuries to other nearby structures according to the site of entry.\\n\\nThe hallmark of renal injury is hematuria. Microhematuria is defined as \\\\(>5\\\\) red blood cells/high power field (RBC/ħPF). We do not need to tell you what’s gross, macroscopic hematuria, right?',\n", " 'bBox': {'x': 72, 'y': 255, 'w': 467.66, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Which patients need renal imaging?',\n", " 'md': '## Which patients need renal imaging?',\n", " 'bBox': {'x': 86, 'y': 695, 'w': 246.17, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 671,\n", " 'text': ' • Blunt trauma with gross hematuria.\\n • Blunt trauma with microscopic hematuria and shock (blood\\n pressure <90mmħg measured at any time since the trauma\\n occurred).\\n\\n This does not mean that you should send a hemodynamically unstable patient with microscopic\\n hematuria to the CT! Ari\\n\\n • Penetrating trauma: all patients with penetrating wounds in the\\n anatomical vicinity of the kidneys.\\n • Pediatric patients: use imaging more liberally because children are\\n more susceptible to significant renal trauma.\\n\\n The preferred imaging study is contrast-enhanced CT. Most spiral\\nCTs are performed in a 2-3-minute sequence, which reveals an arterial\\nand a venous phase. Urine excretion and possible injury to the collecting\\nsystem may be seen only at 10 minutes, thus a delayed image must be\\ntaken at 10 minutes as well.\\n\\n Important CT findings are:\\n\\n • Medial perinephric hematoma — suggesting vascular injury.\\n • Medial extravasation of urine — ureteropelvic junction avulsion.\\n • Lack of contrast enhancement of the kidney — arterial injury.\\n The intravenous pyelogram (IVP) has been abandoned and is\\nused for only one indication — a ‘single-shot’ intra-operative IVP. If\\nat laparotomy and without prior imaging a surgeon encounters an\\nunexpected retroperitoneal, perinephric hematoma he may get an IVP to\\nassess the kidney.\\n\\n However, these days intra-op IVP is infrequently used. The common practice is: if (after\\n penetrating and/or blunt trauma) a lateral, i.e. zone 2, retroperitoneal hematoma is expanding →',\n", " 'md': '```markdown\\n## Page Content\\n\\n- Blunt trauma with gross hematuria.\\n- Blunt trauma with microscopic hematuria and shock (blood pressure <90 mmHg measured at any time since the trauma occurred).\\n\\nThis does not mean that you should send a hemodynamically unstable patient with microscopic hematuria to the CT!\\n\\n- Penetrating trauma: all patients with penetrating wounds in the anatomical vicinity of the kidneys.\\n- Pediatric patients: use imaging more liberally because children are more susceptible to significant renal trauma.\\n\\nThe preferred imaging study is contrast-enhanced CT. Most spiral CTs are performed in a 2-3-minute sequence, which reveals an arterial and a venous phase. Urine excretion and possible injury to the collecting system may be seen only at 10 minutes, thus a delayed image must be taken at 10 minutes as well.\\n\\n### Important CT findings are:\\n\\n- Medial perinephric hematoma — suggesting vascular injury.\\n- Medial extravasation of urine — ureteropelvic junction avulsion.\\n- Lack of contrast enhancement of the kidney — arterial injury.\\n\\nThe intravenous pyelogram (IVP) has been abandoned and is used for only one indication — a ‘single-shot’ intra-operative IVP. If at laparotomy and without prior imaging a surgeon encounters an unexpected retroperitoneal, perinephric hematoma he may get an IVP to assess the kidney.\\n\\nHowever, these days intra-op IVP is infrequently used. The common practice is: if (after penetrating and/or blunt trauma) a lateral, i.e. zone 2, retroperitoneal hematoma is expanding →\\n```\\n\\n### Notes:\\n- No images or figures were identified on this page.\\n- All formulas and measurements have been retained in their original format.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Blunt trauma with gross hematuria.\\n- Blunt trauma with microscopic hematuria and shock (blood pressure <90 mmHg measured at any time since the trauma occurred).\\n\\nThis does not mean that you should send a hemodynamically unstable patient with microscopic hematuria to the CT!\\n\\n- Penetrating trauma: all patients with penetrating wounds in the anatomical vicinity of the kidneys.\\n- Pediatric patients: use imaging more liberally because children are more susceptible to significant renal trauma.\\n\\nThe preferred imaging study is contrast-enhanced CT. Most spiral CTs are performed in a 2-3-minute sequence, which reveals an arterial and a venous phase. Urine excretion and possible injury to the collecting system may be seen only at 10 minutes, thus a delayed image must be taken at 10 minutes as well.',\n", " 'md': '- Blunt trauma with gross hematuria.\\n- Blunt trauma with microscopic hematuria and shock (blood pressure <90 mmHg measured at any time since the trauma occurred).\\n\\nThis does not mean that you should send a hemodynamically unstable patient with microscopic hematuria to the CT!\\n\\n- Penetrating trauma: all patients with penetrating wounds in the anatomical vicinity of the kidneys.\\n- Pediatric patients: use imaging more liberally because children are more susceptible to significant renal trauma.\\n\\nThe preferred imaging study is contrast-enhanced CT. Most spiral CTs are performed in a 2-3-minute sequence, which reveals an arterial and a venous phase. Urine excretion and possible injury to the collecting system may be seen only at 10 minutes, thus a delayed image must be taken at 10 minutes as well.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Important CT findings are:',\n", " 'md': '### Important CT findings are:',\n", " 'bBox': {'x': 86, 'y': 444, 'w': 166.04, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- Medial perinephric hematoma — suggesting vascular injury.\\n- Medial extravasation of urine — ureteropelvic junction avulsion.\\n- Lack of contrast enhancement of the kidney — arterial injury.\\n\\nThe intravenous pyelogram (IVP) has been abandoned and is used for only one indication — a ‘single-shot’ intra-operative IVP. If at laparotomy and without prior imaging a surgeon encounters an unexpected retroperitoneal, perinephric hematoma he may get an IVP to assess the kidney.\\n\\nHowever, these days intra-op IVP is infrequently used. The common practice is: if (after penetrating and/or blunt trauma) a lateral, i.e. zone 2, retroperitoneal hematoma is expanding →\\n```',\n", " 'md': '- Medial perinephric hematoma — suggesting vascular injury.\\n- Medial extravasation of urine — ureteropelvic junction avulsion.\\n- Lack of contrast enhancement of the kidney — arterial injury.\\n\\nThe intravenous pyelogram (IVP) has been abandoned and is used for only one indication — a ‘single-shot’ intra-operative IVP. If at laparotomy and without prior imaging a surgeon encounters an unexpected retroperitoneal, perinephric hematoma he may get an IVP to assess the kidney.\\n\\nHowever, these days intra-op IVP is infrequently used. The common practice is: if (after penetrating and/or blunt trauma) a lateral, i.e. zone 2, retroperitoneal hematoma is expanding →\\n```',\n", " 'bBox': {'x': 72, 'y': 480, 'w': 467.5, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or figures were identified on this page.\\n- All formulas and measurements have been retained in their original format.',\n", " 'md': '- No images or figures were identified on this page.\\n- All formulas and measurements have been retained in their original format.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 672,\n", " 'text': ' explore; if after blunt trauma and not expanding → don’t explore — see Chapter 32. Ari\\n\\n A single film is obtained 10 minutes after an i.v. push of 2ml/kg contrast\\nmedia. A kidney that looks normal may be left alone. Similarly, when\\nthere is a need for an emergency nephrectomy, it is always\\ncomforting to know that the contralateral kidney is intact. (Of course,\\nin some developing regions IVP continues to play the role of the poor\\nman’s CT.)\\n\\n Grading of injury\\n\\n As in most organs, there is a tendency to stage renal trauma and act\\naccording to the severity of injury. The staging system commonly used in\\nurology is the American Association for the Surgery of Trauma Organ\\nInjury Scale for the kidney. Basically, Grades I-III describe the magnitude\\nof perirenal hematoma and laceration of the renal parenchyma. Stage IV\\nentails either a laceration extending throughout the kidney from the\\ncortex to the collecting system or a vascular injury. Stage V includes a\\nshattered kidney or avulsion of the renal hilum.\\n\\n Managing the renal injury patient\\n\\n These are the principles:\\n\\n • Grade I-III injuries may be managed non-operatively. Patients must\\n be carefully followed in an ICU setting with frequent hemoglobin\\n assessment. If bleeding occurs on expectant management,\\n angioembolization may be therapeutic.\\n • Grade IV and V injuries often require surgical exploration.\\n • Renal artery occlusion by an intimal tear (deceleration injury) must\\n be repaired within 6-8 hours before the kidney dies.\\n • Absolute indications for operative management include\\n persistent renal bleeding, expanding perirenal hematoma and a\\n pulsatile renal hematoma denoting arterial renal injury. Relative\\n indications include incomplete pre-op imaging and major urinary',\n", " 'md': '```markdown\\n# Grading of Renal Injury\\n\\nA single film is obtained 10 minutes after an i.v. push of 2ml/kg contrast media. A kidney that looks normal may be left alone. Similarly, when there is a need for an emergency nephrectomy, it is always comforting to know that the contralateral kidney is intact. (Of course, in some developing regions IVP continues to play the role of the poor man’s CT.)\\n\\n## Grading of Injury\\n\\nAs in most organs, there is a tendency to stage renal trauma and act according to the severity of injury. The staging system commonly used in urology is the American Association for the Surgery of Trauma Organ Injury Scale for the kidney. Basically, Grades I-III describe the magnitude of perirenal hematoma and laceration of the renal parenchyma. Stage IV entails either a laceration extending throughout the kidney from the cortex to the collecting system or a vascular injury. Stage V includes a shattered kidney or avulsion of the renal hilum.\\n\\n## Managing the Renal Injury Patient\\n\\nThese are the principles:\\n\\n- Grade I-III injuries may be managed non-operatively. Patients must be carefully followed in an ICU setting with frequent hemoglobin assessment. If bleeding occurs on expectant management, angioembolization may be therapeutic.\\n- Grade IV and V injuries often require surgical exploration.\\n- Renal artery occlusion by an intimal tear (deceleration injury) must be repaired within 6-8 hours before the kidney dies.\\n- Absolute indications for operative management include persistent renal bleeding, expanding perirenal hematoma, and a pulsatile renal hematoma denoting arterial renal injury. Relative indications include incomplete pre-op imaging and major urinary .\\n```',\n", " 'images': [{'name': 'img_p671_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 419.03999999999996,\n", " 'y': 77.04}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Grading of Renal Injury',\n", " 'md': '# Grading of Renal Injury',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A single film is obtained 10 minutes after an i.v. push of 2ml/kg contrast media. A kidney that looks normal may be left alone. Similarly, when there is a need for an emergency nephrectomy, it is always comforting to know that the contralateral kidney is intact. (Of course, in some developing regions IVP continues to play the role of the poor man’s CT.)',\n", " 'md': 'A single film is obtained 10 minutes after an i.v. push of 2ml/kg contrast media. A kidney that looks normal may be left alone. Similarly, when there is a need for an emergency nephrectomy, it is always comforting to know that the contralateral kidney is intact. (Of course, in some developing regions IVP continues to play the role of the poor man’s CT.)',\n", " 'bBox': {'x': 72, 'y': 129, 'w': 467.15, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Grading of Injury',\n", " 'md': '## Grading of Injury',\n", " 'bBox': {'x': 86, 'y': 255, 'w': 133.29, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'As in most organs, there is a tendency to stage renal trauma and act according to the severity of injury. The staging system commonly used in urology is the American Association for the Surgery of Trauma Organ Injury Scale for the kidney. Basically, Grades I-III describe the magnitude of perirenal hematoma and laceration of the renal parenchyma. Stage IV entails either a laceration extending throughout the kidney from the cortex to the collecting system or a vascular injury. Stage V includes a shattered kidney or avulsion of the renal hilum.',\n", " 'md': 'As in most organs, there is a tendency to stage renal trauma and act according to the severity of injury. The staging system commonly used in urology is the American Association for the Surgery of Trauma Organ Injury Scale for the kidney. Basically, Grades I-III describe the magnitude of perirenal hematoma and laceration of the renal parenchyma. Stage IV entails either a laceration extending throughout the kidney from the cortex to the collecting system or a vascular injury. Stage V includes a shattered kidney or avulsion of the renal hilum.',\n", " 'bBox': {'x': 72, 'y': 291, 'w': 467.76, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Managing the Renal Injury Patient',\n", " 'md': '## Managing the Renal Injury Patient',\n", " 'bBox': {'x': 86, 'y': 450, 'w': 259.27, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'These are the principles:\\n\\n- Grade I-III injuries may be managed non-operatively. Patients must be carefully followed in an ICU setting with frequent hemoglobin assessment. If bleeding occurs on expectant management, angioembolization may be therapeutic.\\n- Grade IV and V injuries often require surgical exploration.\\n- Renal artery occlusion by an intimal tear (deceleration injury) must be repaired within 6-8 hours before the kidney dies.\\n- Absolute indications for operative management include persistent renal bleeding, expanding perirenal hematoma, and a pulsatile renal hematoma denoting arterial renal injury. Relative indications include incomplete pre-op imaging and major urinary .\\n```',\n", " 'md': 'These are the principles:\\n\\n- Grade I-III injuries may be managed non-operatively. Patients must be carefully followed in an ICU setting with frequent hemoglobin assessment. If bleeding occurs on expectant management, angioembolization may be therapeutic.\\n- Grade IV and V injuries often require surgical exploration.\\n- Renal artery occlusion by an intimal tear (deceleration injury) must be repaired within 6-8 hours before the kidney dies.\\n- Absolute indications for operative management include persistent renal bleeding, expanding perirenal hematoma, and a pulsatile renal hematoma denoting arterial renal injury. Relative indications include incomplete pre-op imaging and major urinary .\\n```',\n", " 'bBox': {'x': 86, 'y': 486, 'w': 436.91, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 673,\n", " 'text': ' extravasation (with a medial urinoma — a high probability of a\\n ureteropelvic junction tear which will not heal spontaneously).\\n • Experience shows that when in doubt it is better to explore and\\n repair the injury rather treat the complications.\\n\\n The operation for renal injury\\n\\n Exploration of an isolated renal injury is usually done for bleeding in an\\nunstable patient or, rarely, for delayed complications. The appropriate\\nincision is midline from the xyphoid to below the umbilicus.\\nAlthough the classic access for elective nephrectomy is retroperitoneal,\\nthrough the flank, in trauma one may need to approach the major vessels\\nand this is easier through a long midline incision.\\n\\n The old dogma maintained that the renal vessels have to be controlled\\nat their origin prior to exploring a perirenal hematoma, but this is easier\\nsaid than done. Today we know that there is no real advantage for early\\nvascular control. In practice, the perirenal hematoma ‘dissects’ all the\\nplanes around the kidney. The surgeon opens the retroperitoneum lateral\\nto or above the injured kidney, and evacuates the clots. The immediate\\naims are to mobilize the kidney — lifting it forward and medially into\\nthe wound, and to identify the hilum in order to control the renal\\npedicle and assess the parenchymal damage.\\n\\n Parenchymal tears are repaired, closing the collecting system with\\ndelicate absorbable sutures and then approximating the parenchyma —\\nover bolsters of Surgicel®, or even better, pieces of Teflon® felt to prevent\\nsutures cutting though — using blunt atraumatic liver needles\\n(absorbable sutures again). Following repair of a major tear in the\\ncollecting system, or a large partial/hemi-nephrectomy, a double J stent\\nmay be best inserted retrogradely through the bladder into the collecting\\nsystem, to prevent urinary leak.\\n\\n For a shattered kidney, or when the major vessels are not\\namenable to repair — nephrectomy is the best option. Nephrectomy\\nis also recommended if there is major trauma to adjacent organs such as\\nthe pancreas or bowel, since urinary leak from an ill-performed partial',\n", " 'md': '```markdown\\n## Renal Injury Management\\n\\nExtravasation (with a medial urinoma — a high probability of a ureteropelvic junction tear which will not heal spontaneously).\\n\\n- Experience shows that when in doubt it is better to explore and repair the injury rather than treat the complications.\\n\\n### The Operation for Renal Injury\\n\\nExploration of an isolated renal injury is usually done for bleeding in an unstable patient or, rarely, for delayed complications. The appropriate incision is midline from the xyphoid to below the umbilicus. Although the classic access for elective nephrectomy is retroperitoneal, through the flank, in trauma one may need to approach the major vessels and this is easier through a long midline incision.\\n\\nThe old dogma maintained that the renal vessels have to be controlled at their origin prior to exploring a perirenal hematoma, but this is easier said than done. Today we know that there is no real advantage for early vascular control. In practice, the perirenal hematoma ‘dissects’ all the planes around the kidney. The surgeon opens the retroperitoneum lateral to or above the injured kidney, and evacuates the clots. The immediate aims are to mobilize the kidney — lifting it forward and medially into the wound, and to identify the hilum in order to control the renal pedicle and assess the parenchymal damage.\\n\\nParenchymal tears are repaired, closing the collecting system with delicate absorbable sutures and then approximating the parenchyma — over bolsters of Surgicel®, or even better, pieces of Teflon® felt to prevent sutures cutting through — using blunt atraumatic liver needles (absorbable sutures again). Following repair of a major tear in the collecting system, or a large partial/hemi-nephrectomy, a double J stent may be best inserted retrogradely through the bladder into the collecting system, to prevent urinary leak.\\n\\nFor a shattered kidney, or when the major vessels are not amenable to repair — nephrectomy is the best option. Nephrectomy is also recommended if there is major trauma to adjacent organs such as the pancreas or bowel, since urinary leak from an ill-performed partial nephrectomy can lead to significant complications.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Renal Injury Management',\n", " 'md': '## Renal Injury Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Extravasation (with a medial urinoma — a high probability of a ureteropelvic junction tear which will not heal spontaneously).\\n\\n- Experience shows that when in doubt it is better to explore and repair the injury rather than treat the complications.',\n", " 'md': 'Extravasation (with a medial urinoma — a high probability of a ureteropelvic junction tear which will not heal spontaneously).\\n\\n- Experience shows that when in doubt it is better to explore and repair the injury rather than treat the complications.',\n", " 'bBox': {'x': 100, 'y': 103, 'w': 436.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Operation for Renal Injury',\n", " 'md': '### The Operation for Renal Injury',\n", " 'bBox': {'x': 86, 'y': 183, 'w': 229.84, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Exploration of an isolated renal injury is usually done for bleeding in an unstable patient or, rarely, for delayed complications. The appropriate incision is midline from the xyphoid to below the umbilicus. Although the classic access for elective nephrectomy is retroperitoneal, through the flank, in trauma one may need to approach the major vessels and this is easier through a long midline incision.\\n\\nThe old dogma maintained that the renal vessels have to be controlled at their origin prior to exploring a perirenal hematoma, but this is easier said than done. Today we know that there is no real advantage for early vascular control. In practice, the perirenal hematoma ‘dissects’ all the planes around the kidney. The surgeon opens the retroperitoneum lateral to or above the injured kidney, and evacuates the clots. The immediate aims are to mobilize the kidney — lifting it forward and medially into the wound, and to identify the hilum in order to control the renal pedicle and assess the parenchymal damage.\\n\\nParenchymal tears are repaired, closing the collecting system with delicate absorbable sutures and then approximating the parenchyma — over bolsters of Surgicel®, or even better, pieces of Teflon® felt to prevent sutures cutting through — using blunt atraumatic liver needles (absorbable sutures again). Following repair of a major tear in the collecting system, or a large partial/hemi-nephrectomy, a double J stent may be best inserted retrogradely through the bladder into the collecting system, to prevent urinary leak.\\n\\nFor a shattered kidney, or when the major vessels are not amenable to repair — nephrectomy is the best option. Nephrectomy is also recommended if there is major trauma to adjacent organs such as the pancreas or bowel, since urinary leak from an ill-performed partial nephrectomy can lead to significant complications.\\n```',\n", " 'md': 'Exploration of an isolated renal injury is usually done for bleeding in an unstable patient or, rarely, for delayed complications. The appropriate incision is midline from the xyphoid to below the umbilicus. Although the classic access for elective nephrectomy is retroperitoneal, through the flank, in trauma one may need to approach the major vessels and this is easier through a long midline incision.\\n\\nThe old dogma maintained that the renal vessels have to be controlled at their origin prior to exploring a perirenal hematoma, but this is easier said than done. Today we know that there is no real advantage for early vascular control. In practice, the perirenal hematoma ‘dissects’ all the planes around the kidney. The surgeon opens the retroperitoneum lateral to or above the injured kidney, and evacuates the clots. The immediate aims are to mobilize the kidney — lifting it forward and medially into the wound, and to identify the hilum in order to control the renal pedicle and assess the parenchymal damage.\\n\\nParenchymal tears are repaired, closing the collecting system with delicate absorbable sutures and then approximating the parenchyma — over bolsters of Surgicel®, or even better, pieces of Teflon® felt to prevent sutures cutting through — using blunt atraumatic liver needles (absorbable sutures again). Following repair of a major tear in the collecting system, or a large partial/hemi-nephrectomy, a double J stent may be best inserted retrogradely through the bladder into the collecting system, to prevent urinary leak.\\n\\nFor a shattered kidney, or when the major vessels are not amenable to repair — nephrectomy is the best option. Nephrectomy is also recommended if there is major trauma to adjacent organs such as the pancreas or bowel, since urinary leak from an ill-performed partial nephrectomy can lead to significant complications.\\n```',\n", " 'bBox': {'x': 72, 'y': 219, 'w': 467.92, 'h': 19.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 674,\n", " 'text': 'repair may promote local septic complications. Studies in animals show\\nthat one can survive without dialysis on 33-50% of one kidney. Thus, a\\nsafe rule of thumb is that if one can save half or more of the kidney,\\nit is worthwhile.\\n\\n Ureter\\n\\n Ureteric injuries are rare, and frequently are recognized late when\\nurine comes out of a drain after exploration for trauma. The ureter travels\\nin the retroperitoneum covered on all sides by fat and is very evasive.\\nThus, it takes a lot of bad luck to have a ureter transected by a bullet or\\ncut by a knife. Some of the injuries are partial tears due to a high-velocity\\nmissile traveling in the vicinity, injuring the ureter wall and causing a leak.\\n\\n The hallmark of ureteric injury is leakage of urine and this is what\\nappears on IVP or contrast CT. In the setting of penetrating trauma,\\nsuspect damage to the ureter if the injury is in the lateral retroperitoneal\\nareas or in the pelvis. Traumatic ureteral injuries must be carefully\\nsearched for, otherwise they will be missed.\\n\\n Iatrogenic ureteric injuries may occur during C-sections and\\ncolorectal procedures. If diagnosed intra-operatively they should be\\nrepaired immediately. Some accidental injuries occur during laparoscopic\\nsurgery and they are usually missed and diagnosed late. Sometimes the\\nureter is obstructed by a stitch or a clip; the patient may complain of flank\\npain or develop asymptomatic hydronephrosis, detected on imaging.\\n\\n Managing the injured ureter\\n The ureter must be carefully examined and any necrotic segment\\nshould be debrided although this may compromise its length. Always\\nstent the anastomosis to secure urine drainage and augment local\\ntissue apposition. Urine always finds its way out through an imperfect\\nanastomosis; this is why you see so many different types of stents and\\ntubes in urology and why some urologists consider themselves plumbers.\\n\\n Lower ureteral injuries (distal to the iliac vessels) are more common\\nand are easier to fix. Usually one sacrifices the distal part of the ureter',\n", " 'md': '```markdown\\n# Ureteric Injuries and Management\\n\\nRepair may promote local septic complications. Studies in animals show that one can survive without dialysis on 33-50% of one kidney. Thus, a safe rule of thumb is that if one can save half or more of the kidney, it is worthwhile.\\n\\n## Ureter\\n\\nUreteric injuries are rare and frequently recognized late when urine comes out of a drain after exploration for trauma. The ureter travels in the retroperitoneum covered on all sides by fat and is very evasive. Thus, it takes a lot of bad luck to have a ureter transected by a bullet or cut by a knife. Some of the injuries are partial tears due to a high-velocity missile traveling in the vicinity, injuring the ureter wall and causing a leak.\\n\\nThe hallmark of ureteric injury is leakage of urine, and this is what appears on IVP or contrast CT. In the setting of penetrating trauma, suspect damage to the ureter if the injury is in the lateral retroperitoneal areas or in the pelvis. Traumatic ureteral injuries must be carefully searched for; otherwise, they will be missed.\\n\\nIatrogenic ureteric injuries may occur during C-sections and colorectal procedures. If diagnosed intra-operatively, they should be repaired immediately. Some accidental injuries occur during laparoscopic surgery and are usually missed and diagnosed late. Sometimes the ureter is obstructed by a stitch or a clip; the patient may complain of flank pain or develop asymptomatic hydronephrosis, detected on imaging.\\n\\n## Managing the Injured Ureter\\n\\nThe ureter must be carefully examined, and any necrotic segment should be debrided, although this may compromise its length. Always stent the anastomosis to secure urine drainage and augment local tissue apposition. Urine always finds its way out through an imperfect anastomosis; this is why you see so many different types of stents and tubes in urology and why some urologists consider themselves plumbers.\\n\\nLower ureteral injuries (distal to the iliac vessels) are more common and are easier to fix. Usually, one sacrifices the distal part of the ureter.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Ureteric Injuries and Management',\n", " 'md': '# Ureteric Injuries and Management',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 48.75, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Repair may promote local septic complications. Studies in animals show that one can survive without dialysis on 33-50% of one kidney. Thus, a safe rule of thumb is that if one can save half or more of the kidney, it is worthwhile.',\n", " 'md': 'Repair may promote local septic complications. Studies in animals show that one can survive without dialysis on 33-50% of one kidney. Thus, a safe rule of thumb is that if one can save half or more of the kidney, it is worthwhile.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.39, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Ureter',\n", " 'md': '## Ureter',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 48.75, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Ureteric injuries are rare and frequently recognized late when urine comes out of a drain after exploration for trauma. The ureter travels in the retroperitoneum covered on all sides by fat and is very evasive. Thus, it takes a lot of bad luck to have a ureter transected by a bullet or cut by a knife. Some of the injuries are partial tears due to a high-velocity missile traveling in the vicinity, injuring the ureter wall and causing a leak.\\n\\nThe hallmark of ureteric injury is leakage of urine, and this is what appears on IVP or contrast CT. In the setting of penetrating trauma, suspect damage to the ureter if the injury is in the lateral retroperitoneal areas or in the pelvis. Traumatic ureteral injuries must be carefully searched for; otherwise, they will be missed.\\n\\nIatrogenic ureteric injuries may occur during C-sections and colorectal procedures. If diagnosed intra-operatively, they should be repaired immediately. Some accidental injuries occur during laparoscopic surgery and are usually missed and diagnosed late. Sometimes the ureter is obstructed by a stitch or a clip; the patient may complain of flank pain or develop asymptomatic hydronephrosis, detected on imaging.',\n", " 'md': 'Ureteric injuries are rare and frequently recognized late when urine comes out of a drain after exploration for trauma. The ureter travels in the retroperitoneum covered on all sides by fat and is very evasive. Thus, it takes a lot of bad luck to have a ureter transected by a bullet or cut by a knife. Some of the injuries are partial tears due to a high-velocity missile traveling in the vicinity, injuring the ureter wall and causing a leak.\\n\\nThe hallmark of ureteric injury is leakage of urine, and this is what appears on IVP or contrast CT. In the setting of penetrating trauma, suspect damage to the ureter if the injury is in the lateral retroperitoneal areas or in the pelvis. Traumatic ureteral injuries must be carefully searched for; otherwise, they will be missed.\\n\\nIatrogenic ureteric injuries may occur during C-sections and colorectal procedures. If diagnosed intra-operatively, they should be repaired immediately. Some accidental injuries occur during laparoscopic surgery and are usually missed and diagnosed late. Sometimes the ureter is obstructed by a stitch or a clip; the patient may complain of flank pain or develop asymptomatic hydronephrosis, detected on imaging.',\n", " 'bBox': {'x': 72, 'y': 178, 'w': 467.9, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Managing the Injured Ureter',\n", " 'md': '## Managing the Injured Ureter',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 189.42, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The ureter must be carefully examined, and any necrotic segment should be debrided, although this may compromise its length. Always stent the anastomosis to secure urine drainage and augment local tissue apposition. Urine always finds its way out through an imperfect anastomosis; this is why you see so many different types of stents and tubes in urology and why some urologists consider themselves plumbers.\\n\\nLower ureteral injuries (distal to the iliac vessels) are more common and are easier to fix. Usually, one sacrifices the distal part of the ureter.\\n```',\n", " 'md': 'The ureter must be carefully examined, and any necrotic segment should be debrided, although this may compromise its length. Always stent the anastomosis to secure urine drainage and augment local tissue apposition. Urine always finds its way out through an imperfect anastomosis; this is why you see so many different types of stents and tubes in urology and why some urologists consider themselves plumbers.\\n\\nLower ureteral injuries (distal to the iliac vessels) are more common and are easier to fix. Usually, one sacrifices the distal part of the ureter.\\n```',\n", " 'bBox': {'x': 72, 'y': 178, 'w': 466.2, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 675,\n", " 'text': 'and re-implants the ureter directly into the bladder. In this situation, if the\\nureter is too short one may pull up the bladder by suturing it to the psoas\\n— a psoas hitch; or use a flap fashioned from the bladder — the Boari\\nflap.\\n\\n Mid and upper ureteral injuries of less than 2cm in length are fixed\\nby an end-to-end (spatulated) anastomosis with optimal apposition using\\nfine absorbable sutures. Longer injuries may necessitate mobilization of\\nthe ipsilateral kidney and downward positioning which may offer another\\ncouple of centimeters. If there is a large gap, several options exist: one is\\nto connect one ureter to the other by tunneling it behind the peritoneum\\n— transuretero-ureterostomy. Another option, when a large gap is\\npresent, is to bridge it with small bowel — an ileal ureter. An extreme\\nmeasure would be to autotransplant a kidney in the ipsilateral pelvis thus\\nbridging a large gap of missing ureter. In experienced hands these\\nmeasures are all done with a high rate of success.\\n\\n Two important notes:\\n\\n If one encounters ureteral injury while dealing with an extensive and unstable\\n trauma case, an easy solution is to clip the ureter above the injury. When the\\n patient is stabilized and within 24 hours, one may insert a nephrostomy tube and\\n secure drainage of the kidney. Further repair is delayed to a more appropriate time.\\n Another point which is often overlooked: if a ureteral injury is very extensive\\n necessitating a complex reconstruction, or diagnosed late, or when a complex\\n urinary fistula already exists, then, if the contralateral kidney has good function,\\n nephrectomy may be the best option.\\n\\n Bladder\\n\\n Bladder injuries are usually associated with pelvic trauma. Isolated\\nbladder rupture occurs especially on holidays when a patient with a full\\nbladder from overdrinking gets hit in the lower abdomen. Penetrating\\nbladder injuries also are often associated with trauma to other organs.\\nIatrogenic injuries are common and obstetricians and gynecologists',\n", " 'md': '```markdown\\n## Ureteral and Bladder Injuries\\n\\n### Ureteral Injuries\\n\\n- The ureter can be re-implanted directly into the bladder. If the ureter is too short, options include:\\n- Pulling up the bladder by suturing it to the psoas (a psoas hitch).\\n- Using a flap fashioned from the bladder (the Boari flap).\\n\\n- Mid and upper ureteral injuries of less than 2 cm in length are fixed by an end-to-end (spatulated) anastomosis with optimal apposition using fine absorbable sutures.\\n- Longer injuries may necessitate mobilization of the ipsilateral kidney and downward positioning, which may offer another couple of centimeters.\\n- If there is a large gap, several options exist:\\n- Connecting one ureter to the other by tunneling it behind the peritoneum (transuretero-ureterostomy).\\n- Bridging the gap with small bowel (an ileal ureter).\\n- An extreme measure would be to autotransplant a kidney in the ipsilateral pelvis to bridge a large gap of missing ureter.\\n\\n- In experienced hands, these measures are all done with a high rate of success.\\n\\n#### Important Notes:\\n1. If one encounters ureteral injury while dealing with an extensive and unstable trauma case, an easy solution is to clip the ureter above the injury. When the patient is stabilized and within 24 hours, one may insert a nephrostomy tube and secure drainage of the kidney. Further repair is delayed to a more appropriate time.\\n2. If a ureteral injury is very extensive necessitating a complex reconstruction, diagnosed late, or when a complex urinary fistula already exists, nephrectomy may be the best option if the contralateral kidney has good function.\\n\\n### Bladder Injuries\\n\\n- Bladder injuries are usually associated with pelvic trauma.\\n- Isolated bladder rupture occurs especially on holidays when a patient with a full bladder from overdrinking gets hit in the lower abdomen.\\n- Penetrating bladder injuries are often associated with trauma to other organs.\\n- Iatrogenic injuries are common, particularly among obstetricians and gynecologists.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Ureteral and Bladder Injuries',\n", " 'md': '## Ureteral and Bladder Injuries',\n", " 'bBox': {'x': 86, 'y': 605, 'w': 61.62, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Ureteral Injuries',\n", " 'md': '### Ureteral Injuries',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The ureter can be re-implanted directly into the bladder. If the ureter is too short, options include:\\n- Pulling up the bladder by suturing it to the psoas (a psoas hitch).\\n- Using a flap fashioned from the bladder (the Boari flap).\\n\\n- Mid and upper ureteral injuries of less than 2 cm in length are fixed by an end-to-end (spatulated) anastomosis with optimal apposition using fine absorbable sutures.\\n- Longer injuries may necessitate mobilization of the ipsilateral kidney and downward positioning, which may offer another couple of centimeters.\\n- If there is a large gap, several options exist:\\n- Connecting one ureter to the other by tunneling it behind the peritoneum (transuretero-ureterostomy).\\n- Bridging the gap with small bowel (an ileal ureter).\\n- An extreme measure would be to autotransplant a kidney in the ipsilateral pelvis to bridge a large gap of missing ureter.\\n\\n- In experienced hands, these measures are all done with a high rate of success.',\n", " 'md': '- The ureter can be re-implanted directly into the bladder. If the ureter is too short, options include:\\n- Pulling up the bladder by suturing it to the psoas (a psoas hitch).\\n- Using a flap fashioned from the bladder (the Boari flap).\\n\\n- Mid and upper ureteral injuries of less than 2 cm in length are fixed by an end-to-end (spatulated) anastomosis with optimal apposition using fine absorbable sutures.\\n- Longer injuries may necessitate mobilization of the ipsilateral kidney and downward positioning, which may offer another couple of centimeters.\\n- If there is a large gap, several options exist:\\n- Connecting one ureter to the other by tunneling it behind the peritoneum (transuretero-ureterostomy).\\n- Bridging the gap with small bowel (an ileal ureter).\\n- An extreme measure would be to autotransplant a kidney in the ipsilateral pelvis to bridge a large gap of missing ureter.\\n\\n- In experienced hands, these measures are all done with a high rate of success.',\n", " 'bBox': {'x': 72, 'y': 187, 'w': 467.86, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Important Notes:',\n", " 'md': '#### Important Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. If one encounters ureteral injury while dealing with an extensive and unstable trauma case, an easy solution is to clip the ureter above the injury. When the patient is stabilized and within 24 hours, one may insert a nephrostomy tube and secure drainage of the kidney. Further repair is delayed to a more appropriate time.\\n2. If a ureteral injury is very extensive necessitating a complex reconstruction, diagnosed late, or when a complex urinary fistula already exists, nephrectomy may be the best option if the contralateral kidney has good function.',\n", " 'md': '1. If one encounters ureteral injury while dealing with an extensive and unstable trauma case, an easy solution is to clip the ureter above the injury. When the patient is stabilized and within 24 hours, one may insert a nephrostomy tube and secure drainage of the kidney. Further repair is delayed to a more appropriate time.\\n2. If a ureteral injury is very extensive necessitating a complex reconstruction, diagnosed late, or when a complex urinary fistula already exists, nephrectomy may be the best option if the contralateral kidney has good function.',\n", " 'bBox': {'x': 132, 'y': 472, 'w': 395.95, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Bladder Injuries',\n", " 'md': '### Bladder Injuries',\n", " 'bBox': {'x': 86, 'y': 605, 'w': 61.62, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Bladder injuries are usually associated with pelvic trauma.\\n- Isolated bladder rupture occurs especially on holidays when a patient with a full bladder from overdrinking gets hit in the lower abdomen.\\n- Penetrating bladder injuries are often associated with trauma to other organs.\\n- Iatrogenic injuries are common, particularly among obstetricians and gynecologists.\\n```',\n", " 'md': '- Bladder injuries are usually associated with pelvic trauma.\\n- Isolated bladder rupture occurs especially on holidays when a patient with a full bladder from overdrinking gets hit in the lower abdomen.\\n- Penetrating bladder injuries are often associated with trauma to other organs.\\n- Iatrogenic injuries are common, particularly among obstetricians and gynecologists.\\n```',\n", " 'bBox': {'x': 86, 'y': 605, 'w': 61.62, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 676,\n", " 'text': 'are the main offenders.\\n\\n Bladder rupture presents with suprapubic pain and tenderness with\\ngross hematuria. A cystogram is diagnostic in nearly all cases. Care\\nmust be taken to fill the bladder appropriately. In an unconscious\\npatient a minimum of 300cc of contrast is instilled through a\\ncatheter. In a conscious patient filling may be terminated when the\\npatient complains of discomfort.\\n\\n Bladder tears may be extraperitoneal (lateral flame-shaped) or\\nintraperitoneal (contrast outlines the small bowel contour).\\nExtraperitoneal tears are managed by draining the bladder with a\\nlarge-bore Foley catheter (20-22Fr) left in situ for 10-14 days until\\nhealing takes place. A cystogram should be performed prior to catheter\\nextraction. All intraperitoneal injuries need be explored and sutured\\nprimarily with absorbable sutures. Injury adjacent to the bladder neck\\nneeds careful assessment of the ureteral orifices.\\n\\n Scrotum\\n\\n Blunt injury of any etiology may cause rupture of the tunica albuginea\\nof the testis. Blunt injury usually involves a single testis but penetrating\\ntrauma affects both sides of the scrotum in one-third of cases. Scrotal\\nhematoma is a common clinical finding but may not correlate with the\\nextent of damage to the testis itself, as bleeding may originate from any\\nof the other structures in the scrotum. Also, failure to feel the testis does\\nnot mean that it is damaged. Severe testicular pain radiating to the\\nabdomen is suggestive that the testis has been injured. We have\\ntreated patients screaming with pain, and resistant to narcotics, who had\\nalmost no scrotal swelling or hematoma on examination; at operation,\\nhowever, their tunica albuginea was found to be ruptured. Although\\nultrasound is the best imaging modality to assess the scrotum and\\ntestis, an unequivocal report doesn’t rule out testicular trauma.\\nWhen in doubt it is best to explore the scrotum.\\n\\n Management\\n Early exploration and repair of the testis injury is the rule. Early',\n", " 'md': '```markdown\\n## Bladder and Scrotum Injuries\\n\\n### Bladder Injuries\\nBladder rupture presents with suprapubic pain and tenderness with gross hematuria. A cystogram is diagnostic in nearly all cases. Care must be taken to fill the bladder appropriately. In an unconscious patient, a minimum of 300cc of contrast is instilled through a catheter. In a conscious patient, filling may be terminated when the patient complains of discomfort.\\n\\nBladder tears may be extraperitoneal (lateral flame-shaped) or intraperitoneal (contrast outlines the small bowel contour). Extraperitoneal tears are managed by draining the bladder with a large-bore Foley catheter (20-22Fr) left in situ for 10-14 days until healing takes place. A cystogram should be performed prior to catheter extraction. All intraperitoneal injuries need to be explored and sutured primarily with absorbable sutures. Injury adjacent to the bladder neck needs careful assessment of the ureteral orifices.\\n\\n### Scrotum Injuries\\nBlunt injury of any etiology may cause rupture of the tunica albuginea of the testis. Blunt injury usually involves a single testis, but penetrating trauma affects both sides of the scrotum in one-third of cases. Scrotal hematoma is a common clinical finding but may not correlate with the extent of damage to the testis itself, as bleeding may originate from any of the other structures in the scrotum. Also, failure to feel the testis does not mean that it is damaged. Severe testicular pain radiating to the abdomen is suggestive that the testis has been injured.\\n\\nWe have treated patients screaming with pain, and resistant to narcotics, who had almost no scrotal swelling or hematoma on examination; at operation, however, their tunica albuginea was found to be ruptured. Although ultrasound is the best imaging modality to assess the scrotum and testis, an unequivocal report doesn’t rule out testicular trauma. When in doubt, it is best to explore the scrotum.\\n\\n### Management\\nEarly exploration and repair of the testis injury is the rule. Early intervention is crucial for optimal outcomes.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Bladder and Scrotum Injuries',\n", " 'md': '## Bladder and Scrotum Injuries',\n", " 'bBox': {'x': 86, 'y': 398, 'w': 67.14, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Bladder Injuries',\n", " 'md': '### Bladder Injuries',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Bladder rupture presents with suprapubic pain and tenderness with gross hematuria. A cystogram is diagnostic in nearly all cases. Care must be taken to fill the bladder appropriately. In an unconscious patient, a minimum of 300cc of contrast is instilled through a catheter. In a conscious patient, filling may be terminated when the patient complains of discomfort.\\n\\nBladder tears may be extraperitoneal (lateral flame-shaped) or intraperitoneal (contrast outlines the small bowel contour). Extraperitoneal tears are managed by draining the bladder with a large-bore Foley catheter (20-22Fr) left in situ for 10-14 days until healing takes place. A cystogram should be performed prior to catheter extraction. All intraperitoneal injuries need to be explored and sutured primarily with absorbable sutures. Injury adjacent to the bladder neck needs careful assessment of the ureteral orifices.',\n", " 'md': 'Bladder rupture presents with suprapubic pain and tenderness with gross hematuria. A cystogram is diagnostic in nearly all cases. Care must be taken to fill the bladder appropriately. In an unconscious patient, a minimum of 300cc of contrast is instilled through a catheter. In a conscious patient, filling may be terminated when the patient complains of discomfort.\\n\\nBladder tears may be extraperitoneal (lateral flame-shaped) or intraperitoneal (contrast outlines the small bowel contour). Extraperitoneal tears are managed by draining the bladder with a large-bore Foley catheter (20-22Fr) left in situ for 10-14 days until healing takes place. A cystogram should be performed prior to catheter extraction. All intraperitoneal injuries need to be explored and sutured primarily with absorbable sutures. Injury adjacent to the bladder neck needs careful assessment of the ureteral orifices.',\n", " 'bBox': {'x': 72, 'y': 137, 'w': 467.36, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Scrotum Injuries',\n", " 'md': '### Scrotum Injuries',\n", " 'bBox': {'x': 86, 'y': 398, 'w': 67.14, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Blunt injury of any etiology may cause rupture of the tunica albuginea of the testis. Blunt injury usually involves a single testis, but penetrating trauma affects both sides of the scrotum in one-third of cases. Scrotal hematoma is a common clinical finding but may not correlate with the extent of damage to the testis itself, as bleeding may originate from any of the other structures in the scrotum. Also, failure to feel the testis does not mean that it is damaged. Severe testicular pain radiating to the abdomen is suggestive that the testis has been injured.\\n\\nWe have treated patients screaming with pain, and resistant to narcotics, who had almost no scrotal swelling or hematoma on examination; at operation, however, their tunica albuginea was found to be ruptured. Although ultrasound is the best imaging modality to assess the scrotum and testis, an unequivocal report doesn’t rule out testicular trauma. When in doubt, it is best to explore the scrotum.',\n", " 'md': 'Blunt injury of any etiology may cause rupture of the tunica albuginea of the testis. Blunt injury usually involves a single testis, but penetrating trauma affects both sides of the scrotum in one-third of cases. Scrotal hematoma is a common clinical finding but may not correlate with the extent of damage to the testis itself, as bleeding may originate from any of the other structures in the scrotum. Also, failure to feel the testis does not mean that it is damaged. Severe testicular pain radiating to the abdomen is suggestive that the testis has been injured.\\n\\nWe have treated patients screaming with pain, and resistant to narcotics, who had almost no scrotal swelling or hematoma on examination; at operation, however, their tunica albuginea was found to be ruptured. Although ultrasound is the best imaging modality to assess the scrotum and testis, an unequivocal report doesn’t rule out testicular trauma. When in doubt, it is best to explore the scrotum.',\n", " 'bBox': {'x': 72, 'y': 255, 'w': 468, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Management',\n", " 'md': '### Management',\n", " 'bBox': {'x': 86, 'y': 688, 'w': 87.94, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Early exploration and repair of the testis injury is the rule. Early intervention is crucial for optimal outcomes.\\n```',\n", " 'md': 'Early exploration and repair of the testis injury is the rule. Early intervention is crucial for optimal outcomes.\\n```',\n", " 'bBox': {'x': 330, 'y': 255, 'w': 23.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 677,\n", " 'text': 'repair is associated with increased testicular salvage, quicker\\nconvalescence and preservation of testicular function. Explore the\\nscrotum through a transverse incision; pass through the various layers\\n(like cutting an onion) until reaching the tunica albuginea. When the\\ntunica has been breached you will see the seminiferous tubules flowing\\nout like tiny spaghettini. Damaged tissues should be debrided and the\\ntunica albuginea repaired. Even simple clot evacuation from a large\\nhematocele will hasten recovery.\\n\\n “Urologists are just glorified plumbers…”\\n\\n1 In Yiddish: suffering; trouble; misery.',\n", " 'md': '```markdown\\n## Page Content\\n\\nRepair is associated with increased testicular salvage, quicker convalescence, and preservation of testicular function. Explore the scrotum through a transverse incision; pass through the various layers (like cutting an onion) until reaching the tunica albuginea. When the tunica has been breached you will see the seminiferous tubules flowing out like tiny spaghettini. Damaged tissues should be debrided and the tunica albuginea repaired. Even simple clot evacuation from a large hematocele will hasten recovery.\\n\\n> “Urologists are just glorified plumbers…”\\n\\n1. In Yiddish: suffering; trouble; misery.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Repair is associated with increased testicular salvage, quicker convalescence, and preservation of testicular function. Explore the scrotum through a transverse incision; pass through the various layers (like cutting an onion) until reaching the tunica albuginea. When the tunica has been breached you will see the seminiferous tubules flowing out like tiny spaghettini. Damaged tissues should be debrided and the tunica albuginea repaired. Even simple clot evacuation from a large hematocele will hasten recovery.\\n\\n> “Urologists are just glorified plumbers…”\\n\\n1. In Yiddish: suffering; trouble; misery.\\n```',\n", " 'md': 'Repair is associated with increased testicular salvage, quicker convalescence, and preservation of testicular function. Explore the scrotum through a transverse incision; pass through the various layers (like cutting an onion) until reaching the tunica albuginea. When the tunica has been breached you will see the seminiferous tubules flowing out like tiny spaghettini. Damaged tissues should be debrided and the tunica albuginea repaired. Even simple clot evacuation from a large hematocele will hasten recovery.\\n\\n> “Urologists are just glorified plumbers…”\\n\\n1. In Yiddish: suffering; trouble; misery.\\n```',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 327.32, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the requirements.',\n", " 'bBox': {'x': 123, 'y': 86, 'w': 14.4, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 678,\n", " 'text': 'Chapter 38\\nAbdominal emergencies in the Third World\\nRobin Kaushik, Graeme Pitcher and Craig Joseph 1\\n\\n This chapter has been subdivided into the following two\\n sections:\\n\\n 1. Abdominal emergencies in Asia.\\n 2. Abdominal emergencies in Africa.\\n\\n Abdominal emergencies in Asia 1\\n 1 Robin Kaushik\\n He who runs to the doctor, vaidya, or hakim for every little\\n ailment, and swallows all kinds of vegetable and mineral\\n drugs, not only curtails his life, but by becoming the slave of\\n his body instead of remaining its master, loses self-control,\\n and ceases to be a man.\\n Mahatma Gandhi\\n\\n The spectrum of abdominal emergencies encountered in Asia is almost\\nthe same as that encountered elsewhere in the world, but with a few\\nregional differences in their pattern and presentation. As the\\n‘conventional’ causes of the acute abdomen are discussed in detail',\n", " 'md': '```markdown\\n# Chapter 38\\n## Abdominal Emergencies in the Third World\\n### Robin Kaushik, Graeme Pitcher, and Craig Joseph\\n\\nThis chapter has been subdivided into the following two sections:\\n\\n1. Abdominal emergencies in Asia.\\n2. Abdominal emergencies in Africa.\\n\\n### Abdominal Emergencies in Asia\\n> \"He who runs to the doctor, vaidya, or hakim for every little ailment, and swallows all kinds of vegetable and mineral drugs, not only curtails his life, but by becoming the slave of his body instead of remaining its master, loses self-control, and ceases to be a man.\"\\n> — Mahatma Gandhi\\n\\nThe spectrum of abdominal emergencies encountered in Asia is almost the same as that encountered elsewhere in the world, but with a few regional differences in their pattern and presentation. As the ‘conventional’ causes of the acute abdomen are discussed in detail...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 38',\n", " 'md': '# Chapter 38',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 148.79, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Emergencies in the Third World',\n", " 'md': '## Abdominal Emergencies in the Third World',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 380.37, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Robin Kaushik, Graeme Pitcher, and Craig Joseph',\n", " 'md': '### Robin Kaushik, Graeme Pitcher, and Craig Joseph',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This chapter has been subdivided into the following two sections:\\n\\n1. Abdominal emergencies in Asia.\\n2. Abdominal emergencies in Africa.',\n", " 'md': 'This chapter has been subdivided into the following two sections:\\n\\n1. Abdominal emergencies in Asia.\\n2. Abdominal emergencies in Africa.',\n", " 'bBox': {'x': 79, 'y': 319, 'w': 453.54, 'h': 18.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Abdominal Emergencies in Asia',\n", " 'md': '### Abdominal Emergencies in Asia',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '> \"He who runs to the doctor, vaidya, or hakim for every little ailment, and swallows all kinds of vegetable and mineral drugs, not only curtails his life, but by becoming the slave of his body instead of remaining its master, loses self-control, and ceases to be a man.\"\\n> — Mahatma Gandhi\\n\\nThe spectrum of abdominal emergencies encountered in Asia is almost the same as that encountered elsewhere in the world, but with a few regional differences in their pattern and presentation. As the ‘conventional’ causes of the acute abdomen are discussed in detail...\\n```',\n", " 'md': '> \"He who runs to the doctor, vaidya, or hakim for every little ailment, and swallows all kinds of vegetable and mineral drugs, not only curtails his life, but by becoming the slave of his body instead of remaining its master, loses self-control, and ceases to be a man.\"\\n> — Mahatma Gandhi\\n\\nThe spectrum of abdominal emergencies encountered in Asia is almost the same as that encountered elsewhere in the world, but with a few regional differences in their pattern and presentation. As the ‘conventional’ causes of the acute abdomen are discussed in detail...\\n```',\n", " 'bBox': {'x': 86, 'y': 526, 'w': 453.31, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Robin Kaushik, Graeme Pitcher and Craig Joseph 1'},\n", " {'text': 'Abdominal emergencies in Asia 1'}]},\n", " {'page': 679,\n", " 'text': 'elsewhere in this book, this section of the chapter will focus on what is\\nspecific to this vast continent — specific, for example, to India, as\\ndepicted in Figure 38.1.\\n\\n Duodenal ulcer perforation remains, by far, the commonest cause\\nof the acute abdomen. Although a relationship with diet (predominantly\\nrice-based), seasonal variation, genetic and environmental factors have\\nall been proposed to explain the higher incidence of duodenal ulceration\\nin this region, the exact cause remains unclear. Such perforations of\\nduodenal ulcers are usually best managed with the omental patch repair\\nas described in Chapter 18.\\n\\n Acute appendicitis, cholecystitis, acute pancreatitis — they all occur in\\npatients in this region. Other causes of the acute abdomen one may\\ncome across include colonic perforation, mesenteric vascular occlusion\\n(and intestinal ischemia) and abdominal aortic aneurysms, but the\\nincidence of these is much less than is seen in ‘developed’ countries.\\nSimilarly, medical causes such as myocardial infarction and basal\\npneumonia may also occasionally be seen presenting as an ‘acute\\nabdomen’.',\n", " 'md': '```markdown\\n## Page Content\\n\\nThis section of the chapter will focus on what is specific to this vast continent — specific, for example, to India, as depicted in Figure 38.1.\\n\\nDuodenal ulcer perforation remains, by far, the commonest cause of the acute abdomen. Although a relationship with diet (predominantly rice-based), seasonal variation, genetic and environmental factors have all been proposed to explain the higher incidence of duodenal ulceration in this region, the exact cause remains unclear. Such perforations of duodenal ulcers are usually best managed with the omental patch repair as described in Chapter 18.\\n\\nAcute appendicitis, cholecystitis, acute pancreatitis — they all occur in patients in this region. Other causes of the acute abdomen one may come across include colonic perforation, mesenteric vascular occlusion (and intestinal ischemia) and abdominal aortic aneurysms, but the incidence of these is much less than is seen in ‘developed’ countries. Similarly, medical causes such as myocardial infarction and basal pneumonia may also occasionally be seen presenting as an ‘acute abdomen’.\\n\\n## Figures\\n\\n### Figure 38.1\\n- **Description**: This figure likely illustrates a specific aspect of India related to the context of the chapter, possibly highlighting geographical, cultural, or medical factors pertinent to the discussion of duodenal ulcers and acute abdomen.\\n- **Summary**: The figure serves to contextualize the medical conditions discussed in the text, particularly in relation to the unique factors affecting the Indian population.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This section of the chapter will focus on what is specific to this vast continent — specific, for example, to India, as depicted in Figure 38.1.\\n\\nDuodenal ulcer perforation remains, by far, the commonest cause of the acute abdomen. Although a relationship with diet (predominantly rice-based), seasonal variation, genetic and environmental factors have all been proposed to explain the higher incidence of duodenal ulceration in this region, the exact cause remains unclear. Such perforations of duodenal ulcers are usually best managed with the omental patch repair as described in Chapter 18.\\n\\nAcute appendicitis, cholecystitis, acute pancreatitis — they all occur in patients in this region. Other causes of the acute abdomen one may come across include colonic perforation, mesenteric vascular occlusion (and intestinal ischemia) and abdominal aortic aneurysms, but the incidence of these is much less than is seen in ‘developed’ countries. Similarly, medical causes such as myocardial infarction and basal pneumonia may also occasionally be seen presenting as an ‘acute abdomen’.',\n", " 'md': 'This section of the chapter will focus on what is specific to this vast continent — specific, for example, to India, as depicted in Figure 38.1.\\n\\nDuodenal ulcer perforation remains, by far, the commonest cause of the acute abdomen. Although a relationship with diet (predominantly rice-based), seasonal variation, genetic and environmental factors have all been proposed to explain the higher incidence of duodenal ulceration in this region, the exact cause remains unclear. Such perforations of duodenal ulcers are usually best managed with the omental patch repair as described in Chapter 18.\\n\\nAcute appendicitis, cholecystitis, acute pancreatitis — they all occur in patients in this region. Other causes of the acute abdomen one may come across include colonic perforation, mesenteric vascular occlusion (and intestinal ischemia) and abdominal aortic aneurysms, but the incidence of these is much less than is seen in ‘developed’ countries. Similarly, medical causes such as myocardial infarction and basal pneumonia may also occasionally be seen presenting as an ‘acute abdomen’.',\n", " 'bBox': {'x': 72, 'y': 154, 'w': 467.62, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures',\n", " 'md': '## Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 38.1',\n", " 'md': '### Figure 38.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure likely illustrates a specific aspect of India related to the context of the chapter, possibly highlighting geographical, cultural, or medical factors pertinent to the discussion of duodenal ulcers and acute abdomen.\\n- **Summary**: The figure serves to contextualize the medical conditions discussed in the text, particularly in relation to the unique factors affecting the Indian population.\\n\\n```',\n", " 'md': '- **Description**: This figure likely illustrates a specific aspect of India related to the context of the chapter, possibly highlighting geographical, cultural, or medical factors pertinent to the discussion of duodenal ulcers and acute abdomen.\\n- **Summary**: The figure serves to contextualize the medical conditions discussed in the text, particularly in relation to the unique factors affecting the Indian population.\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 680,\n", " 'text': ' 0\\n PeKZA=\\n Figure 38.1. “Doc, my ass is burning! Perhaps if my wife would have added a little less\\n curry powder.” The surgeon taking a sniff: “Wow! Can I have the recipe, please?”\\n\\n Even within this region, there exists a geographical variation in the\\ndisease-specific causes presenting as an acute abdomen. Although\\nduodenal ulcer perforation remains the commonest cause of an acute\\nabdomen, the incidence of small bowel perforation varies from nearly\\n40% in the Indian subcontinent to an almost negligible 6% in China, and\\neven less in Thailand. Enteric fever, tubercular, and non-specific small\\nbowel perforations are common in the Indian subcontinent, whereas\\nCrohn’s disease, Behçet’s disease, radiation enteritis, adhesions,\\nischemic enteritis and systemic lupus erythematosus are common\\ncauses of small bowel perforation in the ‘far eastern’ countries like China\\nand Japan.\\n\\n Below we will dwell on the acute presentations of a few\\nconditions seen commonly in South East Asia: abdominal',\n", " 'md': '```markdown\\n# Page Content\\n\\n**Figure 38.1**: “Doc, my ass is burning! Perhaps if my wife would have added a little less curry powder.” The surgeon taking a sniff: “Wow! Can I have the recipe, please?”\\n\\nEven within this region, there exists a geographical variation in the disease-specific causes presenting as an acute abdomen. Although duodenal ulcer perforation remains the commonest cause of an acute abdomen, the incidence of small bowel perforation varies from nearly 40% in the Indian subcontinent to an almost negligible 6% in China, and even less in Thailand. Enteric fever, tubercular, and non-specific small bowel perforations are common in the Indian subcontinent, whereas Crohn’s disease, Behçet’s disease, radiation enteritis, adhesions, ischemic enteritis, and systemic lupus erythematosus are common causes of small bowel perforation in the ‘far eastern’ countries like China and Japan.\\n\\nBelow we will dwell on the acute presentations of a few conditions seen commonly in South East Asia: abdominal\\n```\\n\\n### Image Identification and Description\\n\\n- **Figure 38.1**: This image features a humorous cartoon depicting a conversation between a patient and a surgeon regarding a burning sensation experienced by the patient, humorously attributed to the use of curry powder. The surgeon expresses interest in the recipe, adding a light-hearted tone to the medical context.\\n\\n### Summary\\nThe text discusses the geographical variations in the causes of acute abdomen, highlighting the differences in incidence rates of small bowel perforation between the Indian subcontinent and countries like China and Thailand. It also mentions specific diseases prevalent in these regions.',\n", " 'images': [{'name': 'img_p679_1.png',\n", " 'height': 654,\n", " 'width': 803,\n", " 'x': 107.27999999999997,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1380,\n", " 'original_height': 1123}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 38.1**: “Doc, my ass is burning! Perhaps if my wife would have added a little less curry powder.” The surgeon taking a sniff: “Wow! Can I have the recipe, please?”\\n\\nEven within this region, there exists a geographical variation in the disease-specific causes presenting as an acute abdomen. Although duodenal ulcer perforation remains the commonest cause of an acute abdomen, the incidence of small bowel perforation varies from nearly 40% in the Indian subcontinent to an almost negligible 6% in China, and even less in Thailand. Enteric fever, tubercular, and non-specific small bowel perforations are common in the Indian subcontinent, whereas Crohn’s disease, Behçet’s disease, radiation enteritis, adhesions, ischemic enteritis, and systemic lupus erythematosus are common causes of small bowel perforation in the ‘far eastern’ countries like China and Japan.\\n\\nBelow we will dwell on the acute presentations of a few conditions seen commonly in South East Asia: abdominal\\n```',\n", " 'md': '**Figure 38.1**: “Doc, my ass is burning! Perhaps if my wife would have added a little less curry powder.” The surgeon taking a sniff: “Wow! Can I have the recipe, please?”\\n\\nEven within this region, there exists a geographical variation in the disease-specific causes presenting as an acute abdomen. Although duodenal ulcer perforation remains the commonest cause of an acute abdomen, the incidence of small bowel perforation varies from nearly 40% in the Indian subcontinent to an almost negligible 6% in China, and even less in Thailand. Enteric fever, tubercular, and non-specific small bowel perforations are common in the Indian subcontinent, whereas Crohn’s disease, Behçet’s disease, radiation enteritis, adhesions, ischemic enteritis, and systemic lupus erythematosus are common causes of small bowel perforation in the ‘far eastern’ countries like China and Japan.\\n\\nBelow we will dwell on the acute presentations of a few conditions seen commonly in South East Asia: abdominal\\n```',\n", " 'bBox': {'x': 72, 'y': 347.26, 'w': 467.47, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 38.1**: This image features a humorous cartoon depicting a conversation between a patient and a surgeon regarding a burning sensation experienced by the patient, humorously attributed to the use of curry powder. The surgeon expresses interest in the recipe, adding a light-hearted tone to the medical context.',\n", " 'md': '- **Figure 38.1**: This image features a humorous cartoon depicting a conversation between a patient and a surgeon regarding a burning sensation experienced by the patient, humorously attributed to the use of curry powder. The surgeon expresses interest in the recipe, adding a light-hearted tone to the medical context.',\n", " 'bBox': {'x': 291, 'y': 702, 'w': 16.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the geographical variations in the causes of acute abdomen, highlighting the differences in incidence rates of small bowel perforation between the Indian subcontinent and countries like China and Thailand. It also mentions specific diseases prevalent in these regions.',\n", " 'md': 'The text discusses the geographical variations in the causes of acute abdomen, highlighting the differences in incidence rates of small bowel perforation between the Indian subcontinent and countries like China and Thailand. It also mentions specific diseases prevalent in these regions.',\n", " 'bBox': {'x': 291, 'y': 702, 'w': 16.78, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 681,\n", " 'text': 'tuberculosis (TB), amoebiasis, and parasitic infestations.\\n\\n Abdominal tuberculosis\\n\\n The abdomen is the commonest site of extrapulmonary tuberculosis.\\nAbdominal TB can develop in the absence of pulmonary TB and does so\\nin nearly two-thirds of cases. Although classified in many ways,\\nintestinal problems due to TB are the commonest presentation of\\nabdominal TB. The disease can affect any part of the GI tract from the\\nesophagus to the rectum, the ileocecal region being the most commonly\\naffected (as a result of physiological stasis and the presence of more\\nlymphoid tissue). Infected Peyer’s patches ulcerate along the long axis of\\nthe terminal ileum and caseation of the mesenteric lymph nodes may\\noccur. Further disease progression usually depends upon the host’s\\nimmunological status.\\n\\n Abdominal TB can present as an ‘acute abdomen’ in two main\\nways: intestinal (small bowel) obstruction and peritonitis.\\n\\n Intestinal obstruction is the commonest complication of\\nabdominal TB, and is caused by stricture formation, adhesions, or\\nexternal compression of the lumen of the bowel by caseating mesenteric\\nlymph nodes. Classically, the patient gives a history of recurrent attacks\\nof small bowel obstruction (the so-called ‘sub-acute intestinal\\nobstruction’) prior to complete obstruction. Although some surgeons\\nprescribe anti-tubercular drugs in this situation and recommend waiting\\nfor a month to see a response, a patient who does not respond to\\nconservative measures needs surgery. Not uncommonly, at operation,\\nyou may encounter dense adhesions ( Figure 38.2) that may be a\\nchallenge to even the most talented of surgeons. Patience, and calling\\nfor help when the case seems beyond your skills, is the key to\\nsuccessful management in this situation.',\n", " 'md': '```markdown\\n## Abdominal Tuberculosis\\n\\nThe abdomen is the commonest site of extrapulmonary tuberculosis. Abdominal TB can develop in the absence of pulmonary TB and does so in nearly two-thirds of cases. Although classified in many ways, intestinal problems due to TB are the commonest presentation of abdominal TB. The disease can affect any part of the GI tract from the esophagus to the rectum, the ileocecal region being the most commonly affected (as a result of physiological stasis and the presence of more lymphoid tissue). Infected Peyer’s patches ulcerate along the long axis of the terminal ileum and caseation of the mesenteric lymph nodes may occur. Further disease progression usually depends upon the host’s immunological status.\\n\\nAbdominal TB can present as an ‘acute abdomen’ in two main ways: intestinal (small bowel) obstruction and peritonitis.\\n\\nIntestinal obstruction is the commonest complication of abdominal TB, and is caused by stricture formation, adhesions, or external compression of the lumen of the bowel by caseating mesenteric lymph nodes. Classically, the patient gives a history of recurrent attacks of small bowel obstruction (the so-called ‘sub-acute intestinal obstruction’) prior to complete obstruction. Although some surgeons prescribe anti-tubercular drugs in this situation and recommend waiting for a month to see a response, a patient who does not respond to conservative measures needs surgery. Not uncommonly, at operation, you may encounter dense adhesions (Figure 38.2) that may be a challenge to even the most talented of surgeons. Patience, and calling for help when the case seems beyond your skills, is the key to successful management in this situation.\\n\\n### Figure 38.2\\n**Description:** This figure likely depicts dense adhesions encountered during surgery for abdominal tuberculosis. The image illustrates the complexity and challenges faced by surgeons in managing such cases. The presence of these adhesions can complicate surgical procedures and requires careful handling to avoid further complications.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Tuberculosis',\n", " 'md': '## Abdominal Tuberculosis',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 188.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The abdomen is the commonest site of extrapulmonary tuberculosis. Abdominal TB can develop in the absence of pulmonary TB and does so in nearly two-thirds of cases. Although classified in many ways, intestinal problems due to TB are the commonest presentation of abdominal TB. The disease can affect any part of the GI tract from the esophagus to the rectum, the ileocecal region being the most commonly affected (as a result of physiological stasis and the presence of more lymphoid tissue). Infected Peyer’s patches ulcerate along the long axis of the terminal ileum and caseation of the mesenteric lymph nodes may occur. Further disease progression usually depends upon the host’s immunological status.\\n\\nAbdominal TB can present as an ‘acute abdomen’ in two main ways: intestinal (small bowel) obstruction and peritonitis.\\n\\nIntestinal obstruction is the commonest complication of abdominal TB, and is caused by stricture formation, adhesions, or external compression of the lumen of the bowel by caseating mesenteric lymph nodes. Classically, the patient gives a history of recurrent attacks of small bowel obstruction (the so-called ‘sub-acute intestinal obstruction’) prior to complete obstruction. Although some surgeons prescribe anti-tubercular drugs in this situation and recommend waiting for a month to see a response, a patient who does not respond to conservative measures needs surgery. Not uncommonly, at operation, you may encounter dense adhesions (Figure 38.2) that may be a challenge to even the most talented of surgeons. Patience, and calling for help when the case seems beyond your skills, is the key to successful management in this situation.',\n", " 'md': 'The abdomen is the commonest site of extrapulmonary tuberculosis. Abdominal TB can develop in the absence of pulmonary TB and does so in nearly two-thirds of cases. Although classified in many ways, intestinal problems due to TB are the commonest presentation of abdominal TB. The disease can affect any part of the GI tract from the esophagus to the rectum, the ileocecal region being the most commonly affected (as a result of physiological stasis and the presence of more lymphoid tissue). Infected Peyer’s patches ulcerate along the long axis of the terminal ileum and caseation of the mesenteric lymph nodes may occur. Further disease progression usually depends upon the host’s immunological status.\\n\\nAbdominal TB can present as an ‘acute abdomen’ in two main ways: intestinal (small bowel) obstruction and peritonitis.\\n\\nIntestinal obstruction is the commonest complication of abdominal TB, and is caused by stricture formation, adhesions, or external compression of the lumen of the bowel by caseating mesenteric lymph nodes. Classically, the patient gives a history of recurrent attacks of small bowel obstruction (the so-called ‘sub-acute intestinal obstruction’) prior to complete obstruction. Although some surgeons prescribe anti-tubercular drugs in this situation and recommend waiting for a month to see a response, a patient who does not respond to conservative measures needs surgery. Not uncommonly, at operation, you may encounter dense adhesions (Figure 38.2) that may be a challenge to even the most talented of surgeons. Patience, and calling for help when the case seems beyond your skills, is the key to successful management in this situation.',\n", " 'bBox': {'x': 72, 'y': 181, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 38.2',\n", " 'md': '### Figure 38.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure likely depicts dense adhesions encountered during surgery for abdominal tuberculosis. The image illustrates the complexity and challenges faced by surgeons in managing such cases. The presence of these adhesions can complicate surgical procedures and requires careful handling to avoid further complications.\\n```',\n", " 'md': '**Description:** This figure likely depicts dense adhesions encountered during surgery for abdominal tuberculosis. The image illustrates the complexity and challenges faced by surgeons in managing such cases. The presence of these adhesions can complicate surgical procedures and requires careful handling to avoid further complications.\\n```',\n", " 'bBox': {'x': 72, 'y': 129, 'w': 202.5, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'challenge to even the most talented of surgeons. '}]},\n", " {'page': 682,\n", " 'text': ' Figure 38.2. Adhesions in abdominal TB.\\n\\n Caseating lymph nodes, tubercles on the bowel or mesentery ( Figure\\n38.3), and small bowel strictures ( Figure 38.4) should make you\\nsuspect abdominal TB in a patient undergoing laparotomy for intestinal\\nobstruction. In such cases, the surgical strategy is to relieve the\\nobstruction with resection and a primary anastomosis (ileo-ileal or\\nileocolic), whenever feasible. Stricturoplasty is another option. In a few\\ncases we have seen rupture of a large caseating lymph node mass with\\npus in the general peritoneal cavity leading to peritonitis. This may be\\nmistaken for perforated appendicitis.\\n\\n Bypass of the affected segment is recommended only if resection\\nis not possible due to dense adhesions or encasement of surrounding\\nstructures (such as the ureters, root of the mesentery), or in a sick\\npatient, where operating time can be saved by bypassing the diseased\\nand densely adherent segment. ħowever, please remember to take some\\ntissue for a biopsy during surgery — it will not only confirm your\\ndiagnosis, but will also rule out other diseases such as malignancy, which\\ncan mimic TB. Also remember to start anti-tubercular therapy for\\nsuch patients in the postoperative period!',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\nFigure 38.2. Adhesions in abdominal TB.\\n\\nCaseating lymph nodes, tubercles on the bowel or mesentery (Figure 38.3), and small bowel strictures (Figure 38.4) should make you suspect abdominal TB in a patient undergoing laparotomy for intestinal obstruction. In such cases, the surgical strategy is to relieve the obstruction with resection and a primary anastomosis (ileo-ileal or ileocolic), whenever feasible. Stricturoplasty is another option. In a few cases we have seen rupture of a large caseating lymph node mass with pus in the general peritoneal cavity leading to peritonitis. This may be mistaken for perforated appendicitis.\\n\\nBypass of the affected segment is recommended only if resection is not possible due to dense adhesions or encasement of surrounding structures (such as the ureters, root of the mesentery), or in a sick patient, where operating time can be saved by bypassing the diseased and densely adherent segment. However, please remember to take some tissue for a biopsy during surgery — it will not only confirm your diagnosis, but will also rule out other diseases such as malignancy, which can mimic TB. Also remember to start anti-tubercular therapy for such patients in the postoperative period!\\n\\n## Images\\n- **Figure 38.2**: This figure illustrates adhesions in abdominal tuberculosis (TB). The image likely depicts the anatomical structures affected by TB, including caseating lymph nodes and tubercles. The caption indicates the relevance of these findings in the context of surgical intervention for intestinal obstruction.\\n\\n- **Figure 38.3**: This figure shows tubercles on the bowel or mesentery. The presence of these tubercles is a significant indicator of abdominal TB.\\n\\n- **Figure 38.4**: This figure depicts small bowel strictures, which are another critical sign of abdominal TB that may necessitate surgical intervention.\\n\\n## Summary\\nThe text discusses the surgical management of abdominal tuberculosis, emphasizing the importance of recognizing specific signs such as caseating lymph nodes, tubercles, and strictures during laparotomy. It outlines the surgical strategies available, including resection and bypass, and highlights the necessity of obtaining biopsy samples to confirm the diagnosis and rule out malignancy. Additionally, it stresses the importance of initiating anti-tubercular therapy postoperatively.\\n```',\n", " 'images': [{'name': 'img_p681_1.png',\n", " 'height': 501,\n", " 'width': 680,\n", " 'x': 138.24,\n", " 'y': 82.79999999999998,\n", " 'original_width': 1167,\n", " 'original_height': 859}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 38.2. Adhesions in abdominal TB.\\n\\nCaseating lymph nodes, tubercles on the bowel or mesentery (Figure 38.3), and small bowel strictures (Figure 38.4) should make you suspect abdominal TB in a patient undergoing laparotomy for intestinal obstruction. In such cases, the surgical strategy is to relieve the obstruction with resection and a primary anastomosis (ileo-ileal or ileocolic), whenever feasible. Stricturoplasty is another option. In a few cases we have seen rupture of a large caseating lymph node mass with pus in the general peritoneal cavity leading to peritonitis. This may be mistaken for perforated appendicitis.\\n\\nBypass of the affected segment is recommended only if resection is not possible due to dense adhesions or encasement of surrounding structures (such as the ureters, root of the mesentery), or in a sick patient, where operating time can be saved by bypassing the diseased and densely adherent segment. However, please remember to take some tissue for a biopsy during surgery — it will not only confirm your diagnosis, but will also rule out other diseases such as malignancy, which can mimic TB. Also remember to start anti-tubercular therapy for such patients in the postoperative period!',\n", " 'md': 'Figure 38.2. Adhesions in abdominal TB.\\n\\nCaseating lymph nodes, tubercles on the bowel or mesentery (Figure 38.3), and small bowel strictures (Figure 38.4) should make you suspect abdominal TB in a patient undergoing laparotomy for intestinal obstruction. In such cases, the surgical strategy is to relieve the obstruction with resection and a primary anastomosis (ileo-ileal or ileocolic), whenever feasible. Stricturoplasty is another option. In a few cases we have seen rupture of a large caseating lymph node mass with pus in the general peritoneal cavity leading to peritonitis. This may be mistaken for perforated appendicitis.\\n\\nBypass of the affected segment is recommended only if resection is not possible due to dense adhesions or encasement of surrounding structures (such as the ureters, root of the mesentery), or in a sick patient, where operating time can be saved by bypassing the diseased and densely adherent segment. However, please remember to take some tissue for a biopsy during surgery — it will not only confirm your diagnosis, but will also rule out other diseases such as malignancy, which can mimic TB. Also remember to start anti-tubercular therapy for such patients in the postoperative period!',\n", " 'bBox': {'x': 72, 'y': 350, 'w': 467.43, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 38.2**: This figure illustrates adhesions in abdominal tuberculosis (TB). The image likely depicts the anatomical structures affected by TB, including caseating lymph nodes and tubercles. The caption indicates the relevance of these findings in the context of surgical intervention for intestinal obstruction.\\n\\n- **Figure 38.3**: This figure shows tubercles on the bowel or mesentery. The presence of these tubercles is a significant indicator of abdominal TB.\\n\\n- **Figure 38.4**: This figure depicts small bowel strictures, which are another critical sign of abdominal TB that may necessitate surgical intervention.',\n", " 'md': '- **Figure 38.2**: This figure illustrates adhesions in abdominal tuberculosis (TB). The image likely depicts the anatomical structures affected by TB, including caseating lymph nodes and tubercles. The caption indicates the relevance of these findings in the context of surgical intervention for intestinal obstruction.\\n\\n- **Figure 38.3**: This figure shows tubercles on the bowel or mesentery. The presence of these tubercles is a significant indicator of abdominal TB.\\n\\n- **Figure 38.4**: This figure depicts small bowel strictures, which are another critical sign of abdominal TB that may necessitate surgical intervention.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the surgical management of abdominal tuberculosis, emphasizing the importance of recognizing specific signs such as caseating lymph nodes, tubercles, and strictures during laparotomy. It outlines the surgical strategies available, including resection and bypass, and highlights the necessity of obtaining biopsy samples to confirm the diagnosis and rule out malignancy. Additionally, it stresses the importance of initiating anti-tubercular therapy postoperatively.\\n```',\n", " 'md': 'The text discusses the surgical management of abdominal tuberculosis, emphasizing the importance of recognizing specific signs such as caseating lymph nodes, tubercles, and strictures during laparotomy. It outlines the surgical strategies available, including resection and bypass, and highlights the necessity of obtaining biopsy samples to confirm the diagnosis and rule out malignancy. Additionally, it stresses the importance of initiating anti-tubercular therapy postoperatively.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Caseating lymph nodes, tubercles on the bowel or mesentery ( Figure 38.3), and small bowel strictures ( Figure 38.4) should make you suspect abdominal TB in a patient undergoing laparotomy for intestinal'},\n", " {'text': 'suspect abdominal TB in a patient undergoing laparotomy for intestinal'}]},\n", " {'page': 683,\n", " 'text': ' Figure 38.3. Tubercles over the intestine and mesentery in abdominal TB.\\n\\n Figure 38.4. Tubercular stricture of the ileum.\\n\\n Perforation of the intestine is another way in which abdominal TB\\ncan present. The signs and symptoms are those of peritonitis, and it is\\nrare to be able to make the diagnosis of a tubercular perforation pre- or\\neven intra-operatively. These perforations usually occur in the distal small\\nintestine, proximal to tubercular strictures. These are usually ‘blow-outs’\\nsecondary to distension of the bowel. Occasionally, free perforations of\\ntubercular ulcers can be encountered in the absence of strictures and\\ndistal obstruction; these carry a very high mortality. For such cases,\\nresection and primary anastomosis whenever feasible (in stable',\n", " 'md': \"```markdown\\n## Page Content\\n\\n### Text\\nPerforation of the intestine is another way in which abdominal TB can present. The signs and symptoms are those of peritonitis, and it is rare to be able to make the diagnosis of a tubercular perforation pre- or even intra-operatively. These perforations usually occur in the distal small intestine, proximal to tubercular strictures. These are usually ‘blow-outs’ secondary to distension of the bowel. Occasionally, free perforations of tubercular ulcers can be encountered in the absence of strictures and distal obstruction; these carry a very high mortality. For such cases, resection and primary anastomosis whenever feasible (in stable...\\n\\n### Figures\\n- **Figure 38.3**: Tubercles over the intestine and mesentery in abdominal TB.\\n- **Figure 38.4**: Tubercular stricture of the ileum.\\n\\n### Image Descriptions\\n- **Figure 38.3**: This image depicts tubercles located over the intestine and mesentery, which are characteristic of abdominal tuberculosis (TB). The tubercles are small, rounded lesions that can be indicative of the disease's presence in the abdominal cavity.\\n\\n- **Figure 38.4**: This image illustrates a tubercular stricture of the ileum, showing a narrowing of the intestinal lumen due to the effects of tuberculosis. The stricture can lead to obstruction and is a significant complication of abdominal TB.\\n\\n### Summary\\nThe page discusses the complications of abdominal tuberculosis, particularly focusing on intestinal perforation and strictures. It highlights the challenges in diagnosing tubercular perforations and the high mortality associated with free perforations of tubercular ulcers. The figures provide visual representations of the conditions described.\\n```\",\n", " 'images': [{'name': 'img_p682_1.png',\n", " 'height': 408,\n", " 'width': 553,\n", " 'x': 169.19999999999982,\n", " 'y': 82.79999999999998,\n", " 'original_width': 949,\n", " 'original_height': 700},\n", " {'name': 'img_p682_2.png',\n", " 'height': 350,\n", " 'width': 549,\n", " 'x': 170.63999999999987,\n", " 'y': 329.76,\n", " 'original_width': 943,\n", " 'original_height': 600}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Perforation of the intestine is another way in which abdominal TB can present. The signs and symptoms are those of peritonitis, and it is rare to be able to make the diagnosis of a tubercular perforation pre- or even intra-operatively. These perforations usually occur in the distal small intestine, proximal to tubercular strictures. These are usually ‘blow-outs’ secondary to distension of the bowel. Occasionally, free perforations of tubercular ulcers can be encountered in the absence of strictures and distal obstruction; these carry a very high mortality. For such cases, resection and primary anastomosis whenever feasible (in stable...',\n", " 'md': 'Perforation of the intestine is another way in which abdominal TB can present. The signs and symptoms are those of peritonitis, and it is rare to be able to make the diagnosis of a tubercular perforation pre- or even intra-operatively. These perforations usually occur in the distal small intestine, proximal to tubercular strictures. These are usually ‘blow-outs’ secondary to distension of the bowel. Occasionally, free perforations of tubercular ulcers can be encountered in the absence of strictures and distal obstruction; these carry a very high mortality. For such cases, resection and primary anastomosis whenever feasible (in stable...',\n", " 'bBox': {'x': 72, 'y': 569, 'w': 467.58, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 38.3**: Tubercles over the intestine and mesentery in abdominal TB.\\n- **Figure 38.4**: Tubercular stricture of the ileum.',\n", " 'md': '- **Figure 38.3**: Tubercles over the intestine and mesentery in abdominal TB.\\n- **Figure 38.4**: Tubercular stricture of the ileum.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Descriptions',\n", " 'md': '### Image Descriptions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- **Figure 38.3**: This image depicts tubercles located over the intestine and mesentery, which are characteristic of abdominal tuberculosis (TB). The tubercles are small, rounded lesions that can be indicative of the disease's presence in the abdominal cavity.\\n\\n- **Figure 38.4**: This image illustrates a tubercular stricture of the ileum, showing a narrowing of the intestinal lumen due to the effects of tuberculosis. The stricture can lead to obstruction and is a significant complication of abdominal TB.\",\n", " 'md': \"- **Figure 38.3**: This image depicts tubercles located over the intestine and mesentery, which are characteristic of abdominal tuberculosis (TB). The tubercles are small, rounded lesions that can be indicative of the disease's presence in the abdominal cavity.\\n\\n- **Figure 38.4**: This image illustrates a tubercular stricture of the ileum, showing a narrowing of the intestinal lumen due to the effects of tuberculosis. The stricture can lead to obstruction and is a significant complication of abdominal TB.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The page discusses the complications of abdominal tuberculosis, particularly focusing on intestinal perforation and strictures. It highlights the challenges in diagnosing tubercular perforations and the high mortality associated with free perforations of tubercular ulcers. The figures provide visual representations of the conditions described.\\n```',\n", " 'md': 'The page discusses the complications of abdominal tuberculosis, particularly focusing on intestinal perforation and strictures. It highlights the challenges in diagnosing tubercular perforations and the high mortality associated with free perforations of tubercular ulcers. The figures provide visual representations of the conditions described.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 684,\n", " 'text': 'patients) is again the preferred surgical option, rather than simple\\nclosure (which is associated with a high incidence of leak and\\nfistula formation). Exteriorization is an acceptable alternative in sick and\\ndebilitated patients.\\n\\n Contrast this, however, with the more common typhoid (enteric)\\nbowel perforations. ħere, primary closure or resection with\\nanastomosis, while being viable surgical decisions, are associated with a\\nfair number of complications and mortality. Ileostomy, on the other hand,\\nmay be a safer option in terms of reducing mortality, though wound and\\nother complications may still occur. As always — try to tailor what you\\ndo to the condition of the patient and his tissues.\\n\\n Amoebiasis\\n\\n The protozoan infection common in this region is amoebiasis. This is\\ncaused by Entamoeba histolytica and spreads through the feco-oral\\nroute, usually leading to disease of the large intestine and liver. Although\\nthis remains primarily a medical disease, it can occasionally cause acute\\nabdominal symptoms that necessitate surgical consultation and\\nintervention.\\n\\n As a surgeon, you may encounter acute abdominal conditions\\ndue to amoebiasis in the following patterns:\\n\\n • Amoebic liver abscess (with or without complications).\\n • Peritonitis (secondary to colitis or rupture of a liver abscess).\\n • Intestinal obstruction or lower GI bleeding secondary to formation of\\n granulomas (rare).\\n\\n A liver abscess is the commonest complication of amoebiasis,\\nand usually presents as an acute illness with right upper quadrant pain,\\nmoderate fever and tender hepatomegaly. The abscess is usually solitary\\nand confined to the right lobe ( Figure 38.5), but occasionally can be\\nmultiple, and even in the left lobe ( Figure 38.6). Although the stools are\\noften not positive for the amoeba, serology is positive in the majority of',\n", " 'md': '```markdown\\n## Surgical Options for Bowel Perforations\\n\\nPatients with bowel perforations often face a choice between surgical options. The preferred surgical option is exteriorization rather than simple closure, which is associated with a high incidence of leak and fistula formation. Exteriorization is an acceptable alternative in sick and debilitated patients.\\n\\nIn contrast, typhoid (enteric) bowel perforations present a different scenario. Primary closure or resection with anastomosis are viable surgical decisions but come with a fair number of complications and mortality risks. Ileostomy may be a safer option in terms of reducing mortality, although wound and other complications may still occur. It is essential to tailor the surgical approach to the condition of the patient and their tissues.\\n\\n### Amoebiasis\\n\\nAmoebiasis is a protozoan infection common in this region, caused by *Entamoeba histolytica*, and spreads through the feco-oral route, usually leading to disease of the large intestine and liver. While primarily a medical disease, it can occasionally cause acute abdominal symptoms that necessitate surgical consultation and intervention.\\n\\nAs a surgeon, you may encounter acute abdominal conditions due to amoebiasis in the following patterns:\\n\\n- Amoebic liver abscess (with or without complications).\\n- Peritonitis (secondary to colitis or rupture of a liver abscess).\\n- Intestinal obstruction or lower GI bleeding secondary to the formation of granulomas (rare).\\n\\nA liver abscess is the most common complication of amoebiasis, usually presenting as an acute illness with right upper quadrant pain, moderate fever, and tender hepatomegaly. The abscess is typically solitary and confined to the right lobe (Figure 38.5), but it can occasionally be multiple or even located in the left lobe (Figure 38.6). Although stools are often not positive for the amoeba, serology is positive in the majority of cases.\\n\\n### Figures\\n\\n- **Figure 38.5**: Description of a solitary liver abscess confined to the right lobe.\\n- **Figure 38.6**: Description of multiple liver abscesses, potentially located in the left lobe.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Options for Bowel Perforations',\n", " 'md': '## Surgical Options for Bowel Perforations',\n", " 'bBox': {'x': 72, 'y': 187, 'w': 53.58, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Patients with bowel perforations often face a choice between surgical options. The preferred surgical option is exteriorization rather than simple closure, which is associated with a high incidence of leak and fistula formation. Exteriorization is an acceptable alternative in sick and debilitated patients.\\n\\nIn contrast, typhoid (enteric) bowel perforations present a different scenario. Primary closure or resection with anastomosis are viable surgical decisions but come with a fair number of complications and mortality risks. Ileostomy may be a safer option in terms of reducing mortality, although wound and other complications may still occur. It is essential to tailor the surgical approach to the condition of the patient and their tissues.',\n", " 'md': 'Patients with bowel perforations often face a choice between surgical options. The preferred surgical option is exteriorization rather than simple closure, which is associated with a high incidence of leak and fistula formation. Exteriorization is an acceptable alternative in sick and debilitated patients.\\n\\nIn contrast, typhoid (enteric) bowel perforations present a different scenario. Primary closure or resection with anastomosis are viable surgical decisions but come with a fair number of complications and mortality risks. Ileostomy may be a safer option in terms of reducing mortality, although wound and other complications may still occur. It is essential to tailor the surgical approach to the condition of the patient and their tissues.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 123.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Amoebiasis',\n", " 'md': '### Amoebiasis',\n", " 'bBox': {'x': 86, 'y': 313, 'w': 92.9, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Amoebiasis is a protozoan infection common in this region, caused by *Entamoeba histolytica*, and spreads through the feco-oral route, usually leading to disease of the large intestine and liver. While primarily a medical disease, it can occasionally cause acute abdominal symptoms that necessitate surgical consultation and intervention.\\n\\nAs a surgeon, you may encounter acute abdominal conditions due to amoebiasis in the following patterns:\\n\\n- Amoebic liver abscess (with or without complications).\\n- Peritonitis (secondary to colitis or rupture of a liver abscess).\\n- Intestinal obstruction or lower GI bleeding secondary to the formation of granulomas (rare).\\n\\nA liver abscess is the most common complication of amoebiasis, usually presenting as an acute illness with right upper quadrant pain, moderate fever, and tender hepatomegaly. The abscess is typically solitary and confined to the right lobe (Figure 38.5), but it can occasionally be multiple or even located in the left lobe (Figure 38.6). Although stools are often not positive for the amoeba, serology is positive in the majority of cases.',\n", " 'md': 'Amoebiasis is a protozoan infection common in this region, caused by *Entamoeba histolytica*, and spreads through the feco-oral route, usually leading to disease of the large intestine and liver. While primarily a medical disease, it can occasionally cause acute abdominal symptoms that necessitate surgical consultation and intervention.\\n\\nAs a surgeon, you may encounter acute abdominal conditions due to amoebiasis in the following patterns:\\n\\n- Amoebic liver abscess (with or without complications).\\n- Peritonitis (secondary to colitis or rupture of a liver abscess).\\n- Intestinal obstruction or lower GI bleeding secondary to the formation of granulomas (rare).\\n\\nA liver abscess is the most common complication of amoebiasis, usually presenting as an acute illness with right upper quadrant pain, moderate fever, and tender hepatomegaly. The abscess is typically solitary and confined to the right lobe (Figure 38.5), but it can occasionally be multiple or even located in the left lobe (Figure 38.6). Although stools are often not positive for the amoeba, serology is positive in the majority of cases.',\n", " 'bBox': {'x': 72, 'y': 187, 'w': 384.58, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 38.5**: Description of a solitary liver abscess confined to the right lobe.\\n- **Figure 38.6**: Description of multiple liver abscesses, potentially located in the left lobe.\\n```',\n", " 'md': '- **Figure 38.5**: Description of a solitary liver abscess confined to the right lobe.\\n- **Figure 38.6**: Description of multiple liver abscesses, potentially located in the left lobe.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'often not positive for the amoeba, serology is positive in the majority of'}]},\n", " {'page': 685,\n", " 'text': 'cases, and negative serology safely excludes this diagnosis. On imaging\\n(ultrasound [US] and CT scan), these abscesses appear as hypoechoic\\nmasses with smooth margins, in contrast to pyogenic abscesses (\\nFigure 38.7). Technetium-99m liver scanning can diagnose amoebic liver\\nabscesses, which appear as cold lesions on the scan (i.e. they do not\\ntake up the radio-isotope), but this investigation is rarely required.\\n HOcm\\nFigure 38.5. Solitary amoebic liver abscess.\\n\\n The management of an uncomplicated amoebic liver abscess is\\npurely medical, with oral metronidazole 800mg thrice a day for at least\\n10 days being the treatment of choice. The patient starts to respond\\nwithin a couple of days, with clinical improvement occurring in the form of\\nrelief of fever, abdominal pain and signs. If there is no improvement in the\\nclinical condition, or if the patient deteriorates, think of alternative\\ndiagnoses such as secondary infection or pyogenic abscesses: aspirate\\nthe abscess under US or CT guidance and culture.\\n\\n Routine percutaneous or surgical drainage of amoebic liver\\nabscesses is rarely required because medical therapy alone has been\\nshown to be effective. However, aspiration may be necessary when\\nthere is a large-sized abscess (>10cm); when there is no\\nimprovement in the condition of the patient within 72 hours; in left',\n", " 'md': '```markdown\\n## Page Content\\n\\nThe management of an uncomplicated amoebic liver abscess is purely medical, with oral metronidazole 800mg thrice a day for at least 10 days being the treatment of choice. The patient starts to respond within a couple of days, with clinical improvement occurring in the form of relief of fever, abdominal pain, and signs. If there is no improvement in the clinical condition, or if the patient deteriorates, think of alternative diagnoses such as secondary infection or pyogenic abscesses: aspirate the abscess under US or CT guidance and culture.\\n\\nRoutine percutaneous or surgical drainage of amoebic liver abscesses is rarely required because medical therapy alone has been shown to be effective. However, aspiration may be necessary when there is a large-sized abscess (>10cm); when there is no improvement in the condition of the patient within 72 hours; in left.\\n\\n### Figures\\n\\n- **Figure 38.5**: Solitary amoebic liver abscess.\\n- **Description**: This figure depicts a solitary amoebic liver abscess, which is a localized collection of pus in the liver caused by the parasite Entamoeba histolytica. The abscess typically appears as a hypoechoic mass on imaging studies such as ultrasound or CT scan, characterized by smooth margins. The figure is crucial for understanding the visual representation of this condition.\\n\\n- **Figure 38.7**:\\n- **Description**: The text references imaging findings of abscesses appearing as hypoechoic masses with smooth margins, contrasting with pyogenic abscesses. This figure likely illustrates these imaging characteristics, aiding in the differentiation between types of liver abscesses.\\n\\n### Notes\\n- Technetium-99m liver scanning can diagnose amoebic liver abscesses, which appear as cold lesions on the scan (i.e., they do not take up the radio-isotope), but this investigation is rarely required.\\n```',\n", " 'images': [{'name': 'img_p684_1.png',\n", " 'height': 499,\n", " 'width': 675,\n", " 'x': 138.96000000000004,\n", " 'y': 182.16000000000003,\n", " 'original_width': 1161,\n", " 'original_height': 859}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The management of an uncomplicated amoebic liver abscess is purely medical, with oral metronidazole 800mg thrice a day for at least 10 days being the treatment of choice. The patient starts to respond within a couple of days, with clinical improvement occurring in the form of relief of fever, abdominal pain, and signs. If there is no improvement in the clinical condition, or if the patient deteriorates, think of alternative diagnoses such as secondary infection or pyogenic abscesses: aspirate the abscess under US or CT guidance and culture.\\n\\nRoutine percutaneous or surgical drainage of amoebic liver abscesses is rarely required because medical therapy alone has been shown to be effective. However, aspiration may be necessary when there is a large-sized abscess (>10cm); when there is no improvement in the condition of the patient within 72 hours; in left.',\n", " 'md': 'The management of an uncomplicated amoebic liver abscess is purely medical, with oral metronidazole 800mg thrice a day for at least 10 days being the treatment of choice. The patient starts to respond within a couple of days, with clinical improvement occurring in the form of relief of fever, abdominal pain, and signs. If there is no improvement in the clinical condition, or if the patient deteriorates, think of alternative diagnoses such as secondary infection or pyogenic abscesses: aspirate the abscess under US or CT guidance and culture.\\n\\nRoutine percutaneous or surgical drainage of amoebic liver abscesses is rarely required because medical therapy alone has been shown to be effective. However, aspiration may be necessary when there is a large-sized abscess (>10cm); when there is no improvement in the condition of the patient within 72 hours; in left.',\n", " 'bBox': {'x': 72, 'y': 512, 'w': 467.45, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 38.5**: Solitary amoebic liver abscess.\\n- **Description**: This figure depicts a solitary amoebic liver abscess, which is a localized collection of pus in the liver caused by the parasite Entamoeba histolytica. The abscess typically appears as a hypoechoic mass on imaging studies such as ultrasound or CT scan, characterized by smooth margins. The figure is crucial for understanding the visual representation of this condition.\\n\\n- **Figure 38.7**:\\n- **Description**: The text references imaging findings of abscesses appearing as hypoechoic masses with smooth margins, contrasting with pyogenic abscesses. This figure likely illustrates these imaging characteristics, aiding in the differentiation between types of liver abscesses.',\n", " 'md': '- **Figure 38.5**: Solitary amoebic liver abscess.\\n- **Description**: This figure depicts a solitary amoebic liver abscess, which is a localized collection of pus in the liver caused by the parasite Entamoeba histolytica. The abscess typically appears as a hypoechoic mass on imaging studies such as ultrasound or CT scan, characterized by smooth margins. The figure is crucial for understanding the visual representation of this condition.\\n\\n- **Figure 38.7**:\\n- **Description**: The text references imaging findings of abscesses appearing as hypoechoic masses with smooth margins, contrasting with pyogenic abscesses. This figure likely illustrates these imaging characteristics, aiding in the differentiation between types of liver abscesses.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Technetium-99m liver scanning can diagnose amoebic liver abscesses, which appear as cold lesions on the scan (i.e., they do not take up the radio-isotope), but this investigation is rarely required.\\n```',\n", " 'md': '- Technetium-99m liver scanning can diagnose amoebic liver abscesses, which appear as cold lesions on the scan (i.e., they do not take up the radio-isotope), but this investigation is rarely required.\\n```',\n", " 'bBox': {'x': 72, 'y': 168, 'w': 416.56, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Figure 38.7). Technetium-99m liver scanning can diagnose amoebic liver abscesses, which appear as cold lesions on the scan (i.e. they do not'}]},\n", " {'page': 686,\n", " 'text': 'lobe or peripheral abscesses; or in cases of diagnostic uncertainty (e.g.\\nwhen the abscess is associated with negative serology for amoebiasis).\\nThe aspirate is the typical ‘anchovy paste’ pus, which is usually sterile,\\nbut may contain the characteristic trophozoites (scrapings of the wall of\\nthe abscess are a better source of trophozoites).\\n VAs3050 4\\n I0\\n 51 0.0\\n Figure 38.6. Multiple amoebic liver abscesses.\\n\\n Rupture of such a liver abscess is a dangerous condition, with a\\nhigh mortality. The rupture usually presents acutely with the classical\\nfeatures of peritonitis, and such a patient needs laparotomy (or\\nlaparoscopy) without undue delay to remove all the pus and muck from\\nthe peritoneal cavity. The abscess cavity in the liver is opened widely and\\nirrigated completely to remove any residual pus. A wide-bore tube drain is\\nthen placed into this cavity, to be removed a few weeks later, once it\\nstops draining and there is evidence of shrinkage in size on serial\\nultrasound. Occasionally, the abscess may rupture in a slow manner,\\nleading to a slow leak and a localized collection that may be drained\\nunder radiological guidance, thereby avoiding a formal laparotomy.\\n\\n Peritonitis in amoebiasis can also occur from perforation of a\\ncolon that is usually severely affected. In fact, amoebiasis is\\nconsidered to be the commonest cause of colonic perforation in',\n", " 'md': \"```markdown\\n## Page Content\\n\\nThe aspirate is the typical ‘anchovy paste’ pus, which is usually sterile, but may contain the characteristic trophozoites (scrapings of the wall of the abscess are a better source of trophozoites).\\n\\n### Figure 38.6\\n**Description:** Multiple amoebic liver abscesses. This figure illustrates the presence of multiple abscesses in the liver, which are indicative of amoebic infection. The abscesses are typically filled with pus that resembles 'anchovy paste'.\\n\\nRupture of such a liver abscess is a dangerous condition, with a high mortality. The rupture usually presents acutely with the classical features of peritonitis, and such a patient needs laparotomy (or laparoscopy) without undue delay to remove all the pus and muck from the peritoneal cavity. The abscess cavity in the liver is opened widely and irrigated completely to remove any residual pus. A wide-bore tube drain is then placed into this cavity, to be removed a few weeks later, once it stops draining and there is evidence of shrinkage in size on serial ultrasound. Occasionally, the abscess may rupture in a slow manner, leading to a slow leak and a localized collection that may be drained under radiological guidance, thereby avoiding a formal laparotomy.\\n\\nPeritonitis in amoebiasis can also occur from perforation of a colon that is usually severely affected. In fact, amoebiasis is considered to be the commonest cause of colonic perforation.\\n```\",\n", " 'images': [{'name': 'img_p685_1.png',\n", " 'height': 498,\n", " 'width': 674,\n", " 'x': 139.67999999999984,\n", " 'y': 165.6,\n", " 'original_width': 1158,\n", " 'original_height': 856}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The aspirate is the typical ‘anchovy paste’ pus, which is usually sterile, but may contain the characteristic trophozoites (scrapings of the wall of the abscess are a better source of trophozoites).',\n", " 'md': 'The aspirate is the typical ‘anchovy paste’ pus, which is usually sterile, but may contain the characteristic trophozoites (scrapings of the wall of the abscess are a better source of trophozoites).',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 308.65, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 38.6',\n", " 'md': '### Figure 38.6',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"**Description:** Multiple amoebic liver abscesses. This figure illustrates the presence of multiple abscesses in the liver, which are indicative of amoebic infection. The abscesses are typically filled with pus that resembles 'anchovy paste'.\\n\\nRupture of such a liver abscess is a dangerous condition, with a high mortality. The rupture usually presents acutely with the classical features of peritonitis, and such a patient needs laparotomy (or laparoscopy) without undue delay to remove all the pus and muck from the peritoneal cavity. The abscess cavity in the liver is opened widely and irrigated completely to remove any residual pus. A wide-bore tube drain is then placed into this cavity, to be removed a few weeks later, once it stops draining and there is evidence of shrinkage in size on serial ultrasound. Occasionally, the abscess may rupture in a slow manner, leading to a slow leak and a localized collection that may be drained under radiological guidance, thereby avoiding a formal laparotomy.\\n\\nPeritonitis in amoebiasis can also occur from perforation of a colon that is usually severely affected. In fact, amoebiasis is considered to be the commonest cause of colonic perforation.\\n```\",\n", " 'md': \"**Description:** Multiple amoebic liver abscesses. This figure illustrates the presence of multiple abscesses in the liver, which are indicative of amoebic infection. The abscesses are typically filled with pus that resembles 'anchovy paste'.\\n\\nRupture of such a liver abscess is a dangerous condition, with a high mortality. The rupture usually presents acutely with the classical features of peritonitis, and such a patient needs laparotomy (or laparoscopy) without undue delay to remove all the pus and muck from the peritoneal cavity. The abscess cavity in the liver is opened widely and irrigated completely to remove any residual pus. A wide-bore tube drain is then placed into this cavity, to be removed a few weeks later, once it stops draining and there is evidence of shrinkage in size on serial ultrasound. Occasionally, the abscess may rupture in a slow manner, leading to a slow leak and a localized collection that may be drained under radiological guidance, thereby avoiding a formal laparotomy.\\n\\nPeritonitis in amoebiasis can also occur from perforation of a colon that is usually severely affected. In fact, amoebiasis is considered to be the commonest cause of colonic perforation.\\n```\",\n", " 'bBox': {'x': 72, 'y': 545, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 687,\n", " 'text': 'this region, and an important cause of fulminant colitis and toxic\\nmegacolon. These perforations are commonly multiple. The colon is\\ndilated and friable, and easily injured during surgery, compounding the\\nsurgeon’s problems. After cleaning out the abdomen, the perforation-\\nbearing segment of the colon also needs to be dealt with. This is usually\\nachieved by limited resection of the affected segment of the colon\\n(not necessarily a formal/classical anatomical resection) with\\nexteriorization of the proximal and distal ends. Reconstruction is\\nusually deferred in view of the poor condition of the patient and the risk of\\nanastomotic breakdown, which could be fatal in such debilitated patients.\\nA few authors have treated this situation with a diverting ileostomy\\nwithout resection, when there is limited contamination of the peritoneal\\ncavity and self-sealing of the perforation by the omentum. They reported\\nsimilar mortality to that following colonic resection; however, such ‘clean’\\ncases are encountered very rarely.\\n\\n Figure 38.7. Pyogenic liver abscess.\\n\\n It may be a fair warning to the young surgeon that a tourist from a\\n‘First World’ country may present with sepsis and peritonitis in\\namoebic colitis. Foreigners tend to be less resistant to local bugs than\\nus tough Indians; they may eat the same curry as us — we go home\\nhappy and they go to the hospital. Treatment is medical, and gratifying.',\n", " 'md': '```markdown\\n## Page Content\\n\\nThis region is an important cause of fulminant colitis and toxic megacolon. These perforations are commonly multiple. The colon is dilated and friable, and easily injured during surgery, compounding the surgeon’s problems. After cleaning out the abdomen, the perforation-bearing segment of the colon also needs to be dealt with. This is usually achieved by limited resection of the affected segment of the colon (not necessarily a formal/classical anatomical resection) with exteriorization of the proximal and distal ends. Reconstruction is usually deferred in view of the poor condition of the patient and the risk of anastomotic breakdown, which could be fatal in such debilitated patients. A few authors have treated this situation with a diverting ileostomy without resection, when there is limited contamination of the peritoneal cavity and self-sealing of the perforation by the omentum. They reported similar mortality to that following colonic resection; however, such ‘clean’ cases are encountered very rarely.\\n\\n### Figure 38.7\\n**Caption:** Pyogenic liver abscess.\\n\\nIt may be a fair warning to the young surgeon that a tourist from a ‘First World’ country may present with sepsis and peritonitis in amoebic colitis. Foreigners tend to be less resistant to local bugs than us tough Indians; they may eat the same curry as us — we go home happy and they go to the hospital. Treatment is medical, and gratifying.\\n```',\n", " 'images': [{'name': 'img_p686_1.png',\n", " 'height': 495,\n", " 'width': 683,\n", " 'x': 137.51999999999953,\n", " 'y': 331.20000000000005,\n", " 'original_width': 1173,\n", " 'original_height': 850}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This region is an important cause of fulminant colitis and toxic megacolon. These perforations are commonly multiple. The colon is dilated and friable, and easily injured during surgery, compounding the surgeon’s problems. After cleaning out the abdomen, the perforation-bearing segment of the colon also needs to be dealt with. This is usually achieved by limited resection of the affected segment of the colon (not necessarily a formal/classical anatomical resection) with exteriorization of the proximal and distal ends. Reconstruction is usually deferred in view of the poor condition of the patient and the risk of anastomotic breakdown, which could be fatal in such debilitated patients. A few authors have treated this situation with a diverting ileostomy without resection, when there is limited contamination of the peritoneal cavity and self-sealing of the perforation by the omentum. They reported similar mortality to that following colonic resection; however, such ‘clean’ cases are encountered very rarely.',\n", " 'md': 'This region is an important cause of fulminant colitis and toxic megacolon. These perforations are commonly multiple. The colon is dilated and friable, and easily injured during surgery, compounding the surgeon’s problems. After cleaning out the abdomen, the perforation-bearing segment of the colon also needs to be dealt with. This is usually achieved by limited resection of the affected segment of the colon (not necessarily a formal/classical anatomical resection) with exteriorization of the proximal and distal ends. Reconstruction is usually deferred in view of the poor condition of the patient and the risk of anastomotic breakdown, which could be fatal in such debilitated patients. A few authors have treated this situation with a diverting ileostomy without resection, when there is limited contamination of the peritoneal cavity and self-sealing of the perforation by the omentum. They reported similar mortality to that following colonic resection; however, such ‘clean’ cases are encountered very rarely.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.65, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 38.7',\n", " 'md': '### Figure 38.7',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** Pyogenic liver abscess.\\n\\nIt may be a fair warning to the young surgeon that a tourist from a ‘First World’ country may present with sepsis and peritonitis in amoebic colitis. Foreigners tend to be less resistant to local bugs than us tough Indians; they may eat the same curry as us — we go home happy and they go to the hospital. Treatment is medical, and gratifying.\\n```',\n", " 'md': '**Caption:** Pyogenic liver abscess.\\n\\nIt may be a fair warning to the young surgeon that a tourist from a ‘First World’ country may present with sepsis and peritonitis in amoebic colitis. Foreigners tend to be less resistant to local bugs than us tough Indians; they may eat the same curry as us — we go home happy and they go to the hospital. Treatment is medical, and gratifying.\\n```',\n", " 'bBox': {'x': 72, 'y': 643, 'w': 467.57, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 688,\n", " 'text': ' Major hemorrhage can also occur in patients with amoebic colitis, which may require an\\n extensive colonic resection for control as the bleeding ulcer could occur anywhere in the\\n involved bowel which may appear uninvolved at laparotomy. Graeme Pitcher\\n\\n Parasitic infestations of the abdomen\\n Table 38.1. Parasites and the acute abdomen:\\n Name Geographical Transmission Acute conditions\\n distribution\\n Ascaris Worldwide Feco-oral Intestinal obstruction\\n lumbricoides Bowel perforation\\n Cholangitis\\n Pancreatitis\\n Appendicitis\\n Echinococcus Middle East; Indian Handling of infected Jaundice\\n granulosus subcontinent dogs Peritonitis\\n Infection\\n Anaphylaxis\\n Anisakis Japan Ingestion of Intestinal obstruction\\n simplex undercooked or raw Anaphylaxis\\n infected fish\\n Clonorchis Orient Ingestion of infected Cholangitis\\n sinensis fish (undercooked,\\n raw, frozen, dried or\\n pickled)\\n A variety of parasites can cause chronic and acute abdominal\\nsymptoms. The important ones that can cause an acute abdomen are\\nlisted in Table 38.1.',\n", " 'md': '```markdown\\n## Parasitic Infestations of the Abdomen\\n\\nMajor hemorrhage can also occur in patients with amoebic colitis, which may require an extensive colonic resection for control as the bleeding ulcer could occur anywhere in the involved bowel which may appear uninvolved at laparotomy. Graeme Pitcher\\n\\n### Table 38.1. Parasites and the Acute Abdomen\\n\\n| Name | Geographical Distribution | Transmission | Acute Conditions |\\n|-----------------------|-------------------------------|----------------------------------|--------------------------------------|\\n| Ascaris lumbricoides | Worldwide | Feco-oral | Intestinal obstruction |\\n| | | | Bowel perforation |\\n| | | | Cholangitis |\\n| | | | Pancreatitis |\\n| | | | Appendicitis |\\n| Echinococcus granulosus| Middle East; Indian subcontinent | Handling of infected dogs | Jaundice |\\n| | | | Peritonitis |\\n| | | | Infection |\\n| | | | Anaphylaxis |\\n| Anisakis simplex | Japan | Ingestion of undercooked or raw infected fish | Intestinal obstruction |\\n| | | | Anaphylaxis |\\n| Clonorchis sinensis | Orient | Ingestion of infected fish (undercooked, raw, frozen, dried or pickled) | Cholangitis |\\n\\nA variety of parasites can cause chronic and acute abdominal symptoms. The important ones that can cause an acute abdomen are listed in Table 38.1.\\n```',\n", " 'images': [{'name': 'img_p687_1.png',\n", " 'height': 862,\n", " 'width': 814,\n", " 'x': 105.11999999999989,\n", " 'y': 200.15999999999997,\n", " 'original_width': 1398,\n", " 'original_height': 1480}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Parasitic Infestations of the Abdomen',\n", " 'md': '## Parasitic Infestations of the Abdomen',\n", " 'bBox': {'x': 86, 'y': 186, 'w': 294.24, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Major hemorrhage can also occur in patients with amoebic colitis, which may require an extensive colonic resection for control as the bleeding ulcer could occur anywhere in the involved bowel which may appear uninvolved at laparotomy. Graeme Pitcher',\n", " 'md': 'Major hemorrhage can also occur in patients with amoebic colitis, which may require an extensive colonic resection for control as the bleeding ulcer could occur anywhere in the involved bowel which may appear uninvolved at laparotomy. Graeme Pitcher',\n", " 'bBox': {'x': 79, 'y': 133, 'w': 395.36, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 38.1. Parasites and the Acute Abdomen',\n", " 'md': '### Table 38.1. Parasites and the Acute Abdomen',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Name',\n", " 'Geographical Distribution',\n", " 'Transmission',\n", " 'Acute Conditions'],\n", " ['Ascaris lumbricoides',\n", " 'Worldwide',\n", " 'Feco-oral',\n", " 'Intestinal obstruction'],\n", " ['', '', '', 'Bowel perforation'],\n", " ['', '', '', 'Cholangitis'],\n", " ['', '', '', 'Pancreatitis'],\n", " ['', '', '', 'Appendicitis'],\n", " ['Echinococcus granulosus',\n", " 'Middle East; Indian subcontinent',\n", " 'Handling of infected dogs',\n", " 'Jaundice'],\n", " ['', '', '', 'Peritonitis'],\n", " ['', '', '', 'Infection'],\n", " ['', '', '', 'Anaphylaxis'],\n", " ['Anisakis simplex',\n", " 'Japan',\n", " 'Ingestion of undercooked or raw infected fish',\n", " 'Intestinal obstruction'],\n", " ['', '', '', 'Anaphylaxis'],\n", " ['Clonorchis sinensis',\n", " 'Orient',\n", " 'Ingestion of infected fish (undercooked, raw, frozen, dried or pickled)',\n", " 'Cholangitis']],\n", " 'md': '| Name | Geographical Distribution | Transmission | Acute Conditions |\\n|-----------------------|-------------------------------|----------------------------------|--------------------------------------|\\n| Ascaris lumbricoides | Worldwide | Feco-oral | Intestinal obstruction |\\n| | | | Bowel perforation |\\n| | | | Cholangitis |\\n| | | | Pancreatitis |\\n| | | | Appendicitis |\\n| Echinococcus granulosus| Middle East; Indian subcontinent | Handling of infected dogs | Jaundice |\\n| | | | Peritonitis |\\n| | | | Infection |\\n| | | | Anaphylaxis |\\n| Anisakis simplex | Japan | Ingestion of undercooked or raw infected fish | Intestinal obstruction |\\n| | | | Anaphylaxis |\\n| Clonorchis sinensis | Orient | Ingestion of infected fish (undercooked, raw, frozen, dried or pickled) | Cholangitis |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Name\",\"Geographical Distribution\",\"Transmission\",\"Acute Conditions\"\\n\"Ascaris lumbricoides\",\"Worldwide\",\"Feco-oral\",\"Intestinal obstruction\"\\n\"\",\"\",\"\",\"Bowel perforation\"\\n\"\",\"\",\"\",\"Cholangitis\"\\n\"\",\"\",\"\",\"Pancreatitis\"\\n\"\",\"\",\"\",\"Appendicitis\"\\n\"Echinococcus granulosus\",\"Middle East; Indian subcontinent\",\"Handling of infected dogs\",\"Jaundice\"\\n\"\",\"\",\"\",\"Peritonitis\"\\n\"\",\"\",\"\",\"Infection\"\\n\"\",\"\",\"\",\"Anaphylaxis\"\\n\"Anisakis simplex\",\"Japan\",\"Ingestion of undercooked or raw infected fish\",\"Intestinal obstruction\"\\n\"\",\"\",\"\",\"Anaphylaxis\"\\n\"Clonorchis sinensis\",\"Orient\",\"Ingestion of infected fish (undercooked, raw, frozen, dried or pickled)\",\"Cholangitis\"',\n", " 'bBox': {'x': 109.57, 'y': 243.18, 'w': 97.41, 'h': 17.31}},\n", " {'type': 'text',\n", " 'value': 'A variety of parasites can cause chronic and acute abdominal symptoms. The important ones that can cause an acute abdomen are listed in Table 38.1.\\n```',\n", " 'md': 'A variety of parasites can cause chronic and acute abdominal symptoms. The important ones that can cause an acute abdomen are listed in Table 38.1.\\n```',\n", " 'bBox': {'x': 72, 'y': 692, 'w': 74.36, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 689,\n", " 'text': ' Ascariasis\\n\\n By far the commonest helminthic infestation is by Ascaris lumbricoides\\n(ascariasis). This usually remains asymptomatic, but may present with\\nthe passage of the worm through the anus or the mouth. As a surgeon\\nyou may encounter Ascaris in the following situations:\\n\\n • Intestinal obstruction. This is usually a partial small bowel\\n obstruction, but at times, may become complete due to impaction of\\n the worms (which may be further aggravated by spasm of the\\n bowel), or by volvulus of the worm-containing, obstructed segment\\n of bowel. The initial management is conservative, with nasogastric\\n suction, intravenous fluids, antibiotics, and oral piperazine (75mg/kg\\n body weight). However, a few authors believe that antihelminthic\\n therapy should be avoided initially, as it could actually worsen\\n the symptoms and convert a partial obstruction to a complete\\n one. There are also reports of successful relief of partial worm\\n obstruction by the instillation through the nasogastric tube of\\n Gastrografin®, which, being hyperosmolar, probably acts by\\n dehydrating and separating the worm bolus ( Chapter 21).\\n ħowever, if the obstruction is complete, or there is failure of\\n conservative management, then these patients need to be operated\\n upon. The management at laparotomy should aim to milk the\\n obstructing mass of worms into the large bowel, from where\\n they will pass spontaneously through the anus. An impacted\\n bolus that cannot be manipulated needs a longitudinal enterotomy to\\n remove the worms — remember to close this transversely!\\n • Occasionally, perforation of the intestine may occur either by the\\n worm burrowing through the normal wall, or through pre-existing\\n lesions (ulcers, etc). The management remains the same as for\\n peritonitis from other causes.\\n • The biliary tract is the commonest extra-intestinal site for the worm,\\n and you may be surprised to hear that biliary ascariasis is the\\n second commonest cause of acute biliary symptoms (after calculi) in\\n the world! The presentation can either be uncomplicated (clinical\\n presentation similar to acute cholecystitis) or complicated (recurrent\\n cholangitis, jaundice, or pancreatitis). The worm can usually be\\n detected on ultrasound as a thin, echogenic tubular structure, which',\n", " 'md': '```markdown\\n# Ascariasis\\n\\nBy far the commonest helminthic infestation is by *Ascaris lumbricoides* (ascariasis). This usually remains asymptomatic, but may present with the passage of the worm through the anus or the mouth. As a surgeon, you may encounter Ascaris in the following situations:\\n\\n- **Intestinal obstruction.** This is usually a partial small bowel obstruction, but at times, may become complete due to impaction of the worms (which may be further aggravated by spasm of the bowel), or by volvulus of the worm-containing, obstructed segment of bowel. The initial management is conservative, with nasogastric suction, intravenous fluids, antibiotics, and oral piperazine (75 mg/kg body weight). However, a few authors believe that antihelminthic therapy should be avoided initially, as it could actually worsen the symptoms and convert a partial obstruction to a complete one. There are also reports of successful relief of partial worm obstruction by the instillation through the nasogastric tube of Gastrografin®, which, being hyperosmolar, probably acts by dehydrating and separating the worm bolus. However, if the obstruction is complete, or there is failure of conservative management, then these patients need to be operated upon. The management at laparotomy should aim to milk the obstructing mass of worms into the large bowel, from where they will pass spontaneously through the anus. An impacted bolus that cannot be manipulated needs a longitudinal enterotomy to remove the worms — remember to close this transversely!\\n\\n- **Perforation of the intestine.** Occasionally, perforation of the intestine may occur either by the worm burrowing through the normal wall, or through pre-existing lesions (ulcers, etc). The management remains the same as for peritonitis from other causes.\\n\\n- **Biliary tract involvement.** The biliary tract is the commonest extra-intestinal site for the worm, and you may be surprised to hear that biliary ascariasis is the second commonest cause of acute biliary symptoms (after calculi) in the world! The presentation can either be uncomplicated (clinical presentation similar to acute cholecystitis) or complicated (recurrent cholangitis, jaundice, or pancreatitis). The worm can usually be detected on ultrasound as a thin, echogenic tubular structure.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Ascariasis',\n", " 'md': '# Ascariasis',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 82.79, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'By far the commonest helminthic infestation is by *Ascaris lumbricoides* (ascariasis). This usually remains asymptomatic, but may present with the passage of the worm through the anus or the mouth. As a surgeon, you may encounter Ascaris in the following situations:\\n\\n- **Intestinal obstruction.** This is usually a partial small bowel obstruction, but at times, may become complete due to impaction of the worms (which may be further aggravated by spasm of the bowel), or by volvulus of the worm-containing, obstructed segment of bowel. The initial management is conservative, with nasogastric suction, intravenous fluids, antibiotics, and oral piperazine (75 mg/kg body weight). However, a few authors believe that antihelminthic therapy should be avoided initially, as it could actually worsen the symptoms and convert a partial obstruction to a complete one. There are also reports of successful relief of partial worm obstruction by the instillation through the nasogastric tube of Gastrografin®, which, being hyperosmolar, probably acts by dehydrating and separating the worm bolus. However, if the obstruction is complete, or there is failure of conservative management, then these patients need to be operated upon. The management at laparotomy should aim to milk the obstructing mass of worms into the large bowel, from where they will pass spontaneously through the anus. An impacted bolus that cannot be manipulated needs a longitudinal enterotomy to remove the worms — remember to close this transversely!\\n\\n- **Perforation of the intestine.** Occasionally, perforation of the intestine may occur either by the worm burrowing through the normal wall, or through pre-existing lesions (ulcers, etc). The management remains the same as for peritonitis from other causes.\\n\\n- **Biliary tract involvement.** The biliary tract is the commonest extra-intestinal site for the worm, and you may be surprised to hear that biliary ascariasis is the second commonest cause of acute biliary symptoms (after calculi) in the world! The presentation can either be uncomplicated (clinical presentation similar to acute cholecystitis) or complicated (recurrent cholangitis, jaundice, or pancreatitis). The worm can usually be detected on ultrasound as a thin, echogenic tubular structure.\\n```',\n", " 'md': 'By far the commonest helminthic infestation is by *Ascaris lumbricoides* (ascariasis). This usually remains asymptomatic, but may present with the passage of the worm through the anus or the mouth. As a surgeon, you may encounter Ascaris in the following situations:\\n\\n- **Intestinal obstruction.** This is usually a partial small bowel obstruction, but at times, may become complete due to impaction of the worms (which may be further aggravated by spasm of the bowel), or by volvulus of the worm-containing, obstructed segment of bowel. The initial management is conservative, with nasogastric suction, intravenous fluids, antibiotics, and oral piperazine (75 mg/kg body weight). However, a few authors believe that antihelminthic therapy should be avoided initially, as it could actually worsen the symptoms and convert a partial obstruction to a complete one. There are also reports of successful relief of partial worm obstruction by the instillation through the nasogastric tube of Gastrografin®, which, being hyperosmolar, probably acts by dehydrating and separating the worm bolus. However, if the obstruction is complete, or there is failure of conservative management, then these patients need to be operated upon. The management at laparotomy should aim to milk the obstructing mass of worms into the large bowel, from where they will pass spontaneously through the anus. An impacted bolus that cannot be manipulated needs a longitudinal enterotomy to remove the worms — remember to close this transversely!\\n\\n- **Perforation of the intestine.** Occasionally, perforation of the intestine may occur either by the worm burrowing through the normal wall, or through pre-existing lesions (ulcers, etc). The management remains the same as for peritonitis from other causes.\\n\\n- **Biliary tract involvement.** The biliary tract is the commonest extra-intestinal site for the worm, and you may be surprised to hear that biliary ascariasis is the second commonest cause of acute biliary symptoms (after calculi) in the world! The presentation can either be uncomplicated (clinical presentation similar to acute cholecystitis) or complicated (recurrent cholangitis, jaundice, or pancreatitis). The worm can usually be detected on ultrasound as a thin, echogenic tubular structure.\\n```',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 437.68, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'ħowever, if the obstruction is complete, or there is failure of'}]},\n", " {'page': 690,\n", " 'text': ' may even show movements, or as a worm bolus (the ‘spaghetti’\\n sign). The majority of patients with biliary ascariasis respond to\\n conservative management (intravenous fluids, antibiotics,\\n antispasmodics and antihelminthics), and the worm\\n spontaneously re-enters the bowel. Mebendazole (100mg twice a\\n day for 3 days) or albendazole (single dose of 400mg) are\\n considered the drugs of choice, but again, there are a few authors\\n who believe that therapy against Ascaris should be deferred until it\\n moves out of the biliary system and into the intestine (the dead\\n parasite cannot migrate). Therapeutic endoscopic retrograde\\n cholangiopancreatography (ERCP) may be considered in patients\\n with complicated disease, and in those who do not respond to\\n conservative therapy. At ERCP the worm is removed by a\\n Dormia® basket, taking care not to perform a sphincterotomy\\n (as this may be associated with recurrent biliary ascariasis). In\\n cases where ERCP is unsuccessful in extracting the parasites, or\\n there has been fragmentation and partial extraction, or when there\\n are associated strictures, surgery is indicated. The aim of surgery is\\n to achieve complete clearance of both the biliary tract (at common\\n bile duct exploration) and the intestine of the worm, with adequate\\n treatment of any associated conditions (such as\\n hepaticojejunostomy when biliary stricture is present). If no further\\n procedure other than ductal clearance is required, choledochotomy\\n and closure over a T-tube is recommended. Postoperative\\n deworming is essential in all such cases.\\n\\n Echinococcus\\n\\n This is another important parasite that can cause acute abdominal\\nsymptoms. It gives rise to hydatid disease of the liver ( Figure 38.8),\\nwhich is usually a chronic condition; unless the hydatid ruptures freely\\ninto the peritoneal cavity (peritonitis), or into the bile ducts (jaundice,\\ncholangitis). Asymptomatic, small (<4cm), deep-seated, calcified and\\nuncomplicated hydatids of the liver can be managed adequately by\\nnon-surgical means (chemotherapy, percutaneous aspiration and\\ninjection), but complicated cysts usually need surgical intervention.',\n", " 'md': '```markdown\\n## Biliary Ascariasis Management\\n\\nThe majority of patients with biliary ascariasis respond to conservative management, which includes:\\n- Intravenous fluids\\n- Antibiotics\\n- Antispasmodics\\n- Antiheminthics\\n\\nThe worm may spontaneously re-enter the bowel. The drugs of choice are:\\n- Mebendazole: 100 mg twice a day for 3 days\\n- Albendazole: single dose of 400 mg\\n\\nSome authors suggest that therapy against Ascaris should be deferred until it moves out of the biliary system and into the intestine, as the dead parasite cannot migrate.\\n\\n### Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP)\\n\\nERCP may be considered in patients with complicated disease or those who do not respond to conservative therapy. During ERCP, the worm is removed using a Dormia® basket, taking care not to perform a sphincterotomy, as this may be associated with recurrent biliary ascariasis.\\n\\nIn cases where ERCP is unsuccessful in extracting the parasites, or if there has been fragmentation and partial extraction, or when associated strictures are present, surgery is indicated. The aim of surgery is to achieve complete clearance of both the biliary tract (at common bile duct exploration) and the intestine of the worm, along with adequate treatment of any associated conditions (such as hepaticojejunostomy when biliary stricture is present).\\n\\nIf no further procedure other than ductal clearance is required, choledochotomy and closure over a T-tube is recommended. Postoperative deworming is essential in all such cases.\\n\\n## Echinococcus\\n\\nEchinococcus is another important parasite that can cause acute abdominal symptoms. It gives rise to hydatid disease of the liver (Figure 38.8), which is usually a chronic condition. Unless the hydatid ruptures freely into the peritoneal cavity (causing peritonitis) or into the bile ducts (leading to jaundice or cholangitis), asymptomatic, small (<4 cm), deep-seated, calcified, and uncomplicated hydatids of the liver can be managed adequately by non-surgical means (chemotherapy, percutaneous aspiration, and injection). However, complicated cysts usually require surgical intervention.\\n\\n### Figure 38.8\\n- **Description**: This figure illustrates the hydatid disease of the liver caused by Echinococcus. It typically shows the cystic formations within the liver that are characteristic of this condition.\\n- **Summary**: The image likely depicts the appearance of hydatid cysts in the liver, emphasizing the chronic nature of the disease and the potential complications that can arise if the cysts rupture.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Biliary Ascariasis Management',\n", " 'md': '## Biliary Ascariasis Management',\n", " 'bBox': {'x': 521, 'y': 419, 'w': 15.2, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The majority of patients with biliary ascariasis respond to conservative management, which includes:\\n- Intravenous fluids\\n- Antibiotics\\n- Antispasmodics\\n- Antiheminthics\\n\\nThe worm may spontaneously re-enter the bowel. The drugs of choice are:\\n- Mebendazole: 100 mg twice a day for 3 days\\n- Albendazole: single dose of 400 mg\\n\\nSome authors suggest that therapy against Ascaris should be deferred until it moves out of the biliary system and into the intestine, as the dead parasite cannot migrate.',\n", " 'md': 'The majority of patients with biliary ascariasis respond to conservative management, which includes:\\n- Intravenous fluids\\n- Antibiotics\\n- Antispasmodics\\n- Antiheminthics\\n\\nThe worm may spontaneously re-enter the bowel. The drugs of choice are:\\n- Mebendazole: 100 mg twice a day for 3 days\\n- Albendazole: single dose of 400 mg\\n\\nSome authors suggest that therapy against Ascaris should be deferred until it moves out of the biliary system and into the intestine, as the dead parasite cannot migrate.',\n", " 'bBox': {'x': 187, 'y': 135, 'w': 79.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP)',\n", " 'md': '### Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'ERCP may be considered in patients with complicated disease or those who do not respond to conservative therapy. During ERCP, the worm is removed using a Dormia® basket, taking care not to perform a sphincterotomy, as this may be associated with recurrent biliary ascariasis.\\n\\nIn cases where ERCP is unsuccessful in extracting the parasites, or if there has been fragmentation and partial extraction, or when associated strictures are present, surgery is indicated. The aim of surgery is to achieve complete clearance of both the biliary tract (at common bile duct exploration) and the intestine of the worm, along with adequate treatment of any associated conditions (such as hepaticojejunostomy when biliary stricture is present).\\n\\nIf no further procedure other than ductal clearance is required, choledochotomy and closure over a T-tube is recommended. Postoperative deworming is essential in all such cases.',\n", " 'md': 'ERCP may be considered in patients with complicated disease or those who do not respond to conservative therapy. During ERCP, the worm is removed using a Dormia® basket, taking care not to perform a sphincterotomy, as this may be associated with recurrent biliary ascariasis.\\n\\nIn cases where ERCP is unsuccessful in extracting the parasites, or if there has been fragmentation and partial extraction, or when associated strictures are present, surgery is indicated. The aim of surgery is to achieve complete clearance of both the biliary tract (at common bile duct exploration) and the intestine of the worm, along with adequate treatment of any associated conditions (such as hepaticojejunostomy when biliary stricture is present).\\n\\nIf no further procedure other than ductal clearance is required, choledochotomy and closure over a T-tube is recommended. Postoperative deworming is essential in all such cases.',\n", " 'bBox': {'x': 100, 'y': 135, 'w': 259.09, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Echinococcus',\n", " 'md': '## Echinococcus',\n", " 'bBox': {'x': 86, 'y': 530, 'w': 112.21, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Echinococcus is another important parasite that can cause acute abdominal symptoms. It gives rise to hydatid disease of the liver (Figure 38.8), which is usually a chronic condition. Unless the hydatid ruptures freely into the peritoneal cavity (causing peritonitis) or into the bile ducts (leading to jaundice or cholangitis), asymptomatic, small (<4 cm), deep-seated, calcified, and uncomplicated hydatids of the liver can be managed adequately by non-surgical means (chemotherapy, percutaneous aspiration, and injection). However, complicated cysts usually require surgical intervention.',\n", " 'md': 'Echinococcus is another important parasite that can cause acute abdominal symptoms. It gives rise to hydatid disease of the liver (Figure 38.8), which is usually a chronic condition. Unless the hydatid ruptures freely into the peritoneal cavity (causing peritonitis) or into the bile ducts (leading to jaundice or cholangitis), asymptomatic, small (<4 cm), deep-seated, calcified, and uncomplicated hydatids of the liver can be managed adequately by non-surgical means (chemotherapy, percutaneous aspiration, and injection). However, complicated cysts usually require surgical intervention.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.36, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 38.8',\n", " 'md': '### Figure 38.8',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure illustrates the hydatid disease of the liver caused by Echinococcus. It typically shows the cystic formations within the liver that are characteristic of this condition.\\n- **Summary**: The image likely depicts the appearance of hydatid cysts in the liver, emphasizing the chronic nature of the disease and the potential complications that can arise if the cysts rupture.\\n```',\n", " 'md': '- **Description**: This figure illustrates the hydatid disease of the liver caused by Echinococcus. It typically shows the cystic formations within the liver that are characteristic of this condition.\\n- **Summary**: The image likely depicts the appearance of hydatid cysts in the liver, emphasizing the chronic nature of the disease and the potential complications that can arise if the cysts rupture.\\n```',\n", " 'bBox': {'x': 86, 'y': 135, 'w': 174.57, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'which is usually a chronic condition; unless the hydatid ruptures freely'}]},\n", " {'page': 691,\n", " 'text': ' Figure 38.8. Appearance of liver hydatid disease on a CT scan.\\n\\n Free ruptured hydatid cyst\\n The aims of surgery when dealing with secondary peritonitis from a\\nruptured hydatid cyst of the liver are:\\n\\n • Elimination of the visible elements in the peritoneal cavity.\\n • Sterilization of the peritoneal cavity using scolicidal agents such as\\n 0.5% silver nitrate solution, hypertonic saline (20%), chlorhexidine\\n solution or cetrimide.\\n • Source control to remove any residual parasitic element from the\\n liver, removing the germinal layer, suturing of any visible cyst-biliary\\n communications, obliteration of the cavity (preferably by packing it\\n with omentum), and drainage.\\n\\n Rupture of hydatids into the biliary tree\\n This usually produces obstructive jaundice and cholangitis, and is often\\nconsidered to be an absolute indication for surgery. ħowever, ERCP may\\nobviate the urgency of surgery by clearing the common duct of the\\nparasitic cysts, providing free drainage of bile, and lowering the',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Figure 38.8\\n**Appearance of liver hydatid disease on a CT scan.**\\n\\n### Free ruptured hydatid cyst\\nThe aims of surgery when dealing with secondary peritonitis from a ruptured hydatid cyst of the liver are:\\n- Elimination of the visible elements in the peritoneal cavity.\\n- Sterilization of the peritoneal cavity using scolicidal agents such as:\\n- 0.5% silver nitrate solution\\n- Hypertonic saline (20%)\\n- Chlorhexidine solution\\n- Cetrimide\\n- Source control to remove any residual parasitic element from the liver, which includes:\\n- Removing the germinal layer\\n- Suturing of any visible cyst-biliary communications\\n- Obliteration of the cavity (preferably by packing it with omentum)\\n- Drainage\\n\\n### Rupture of hydatids into the biliary tree\\nThis usually produces obstructive jaundice and cholangitis, and is often considered to be an absolute indication for surgery. However, ERCP may obviate the urgency of surgery by clearing the common duct of the parasitic cysts, providing free drainage of bile, and lowering the risk of complications.\\n```',\n", " 'images': [{'name': 'img_p690_1.png',\n", " 'height': 495,\n", " 'width': 678,\n", " 'x': 138.23999999999978,\n", " 'y': 82.79999999999998,\n", " 'original_width': 1164,\n", " 'original_height': 850}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 38.8',\n", " 'md': '## Figure 38.8',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Appearance of liver hydatid disease on a CT scan.**',\n", " 'md': '**Appearance of liver hydatid disease on a CT scan.**',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Free ruptured hydatid cyst',\n", " 'md': '### Free ruptured hydatid cyst',\n", " 'bBox': {'x': 86, 'y': 398, 'w': 181.44, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The aims of surgery when dealing with secondary peritonitis from a ruptured hydatid cyst of the liver are:\\n- Elimination of the visible elements in the peritoneal cavity.\\n- Sterilization of the peritoneal cavity using scolicidal agents such as:\\n- 0.5% silver nitrate solution\\n- Hypertonic saline (20%)\\n- Chlorhexidine solution\\n- Cetrimide\\n- Source control to remove any residual parasitic element from the liver, which includes:\\n- Removing the germinal layer\\n- Suturing of any visible cyst-biliary communications\\n- Obliteration of the cavity (preferably by packing it with omentum)\\n- Drainage',\n", " 'md': 'The aims of surgery when dealing with secondary peritonitis from a ruptured hydatid cyst of the liver are:\\n- Elimination of the visible elements in the peritoneal cavity.\\n- Sterilization of the peritoneal cavity using scolicidal agents such as:\\n- 0.5% silver nitrate solution\\n- Hypertonic saline (20%)\\n- Chlorhexidine solution\\n- Cetrimide\\n- Source control to remove any residual parasitic element from the liver, which includes:\\n- Removing the germinal layer\\n- Suturing of any visible cyst-biliary communications\\n- Obliteration of the cavity (preferably by packing it with omentum)\\n- Drainage',\n", " 'bBox': {'x': 72, 'y': 435, 'w': 436.75, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Rupture of hydatids into the biliary tree',\n", " 'md': '### Rupture of hydatids into the biliary tree',\n", " 'bBox': {'x': 86, 'y': 643, 'w': 268.53, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'This usually produces obstructive jaundice and cholangitis, and is often considered to be an absolute indication for surgery. However, ERCP may obviate the urgency of surgery by clearing the common duct of the parasitic cysts, providing free drainage of bile, and lowering the risk of complications.\\n```',\n", " 'md': 'This usually produces obstructive jaundice and cholangitis, and is often considered to be an absolute indication for surgery. However, ERCP may obviate the urgency of surgery by clearing the common duct of the parasitic cysts, providing free drainage of bile, and lowering the risk of complications.\\n```',\n", " 'bBox': {'x': 86, 'y': 664, 'w': 453.3, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 692,\n", " 'text': 'intraductal pressures. Patients who fail ERCP, or in whom there are\\nrecurrent symptoms, can then be taken for surgery, where\\ncholedochotomy, clearance of the cyst remnants and closure over a T-\\ntube is performed.\\n\\n All emergency interventions must be followed up with albendazole\\n(400mg twice daily) for at least 3 weeks.\\n\\n Anisakis simplex\\n\\n This nematode can present with severe abdominal pain, nausea and\\nvomiting, typically within a few hours of ingesting raw or undercooked\\ninfected fish (sushi eaters be careful!). The larva of Anisakis usually\\ninvolves the stomach in humans, but can also occasionally affect the\\nsmall bowel. In the acute stage, the presentation has been confused with\\nappendicitis, the patients submitted to surgery, and the true nature of the\\ndiagnosis revealed only on histopathological examination. The diagnosis\\nis difficult to make with certainty in an emergency situation, but can be\\nsuspected pre-operatively in a situation where the patient spits out the\\nworm, or in endemic regions, when a history of eating raw fish a few\\nhours prior to the onset of symptoms can be elicited. In such cases,\\nupper gastrointestinal endoscopy can visualize and remove the parasite,\\nwith relief of symptoms. As human infections are a dead-end for the\\nparasite, no further treatment beyond symptom relief is required in cases\\nwhere the diagnosis can be made. If undetected, the infection can\\npresent with small bowel obstruction after 2-3 weeks and invariably\\nrequires surgical intervention.\\n\\n Liver flukes\\n\\n Liver flukes (Clonorchis sinensis) are another significant cause of\\nbiliary symptoms, especially in the Far East. These live in the biliary tract\\nfor long periods before causing significant symptoms — classically, what\\nis known as oriental cholangiohepatitis or recurrent pyogenic\\ncholangitis (pain, fever, jaundice). Chronic disease may give rise to\\nsecondary biliary cirrhosis and portal hypertension. An association of\\ncholangiocarcinoma with this infestation has also been proposed. The',\n", " 'md': '```markdown\\n## Intraductal Pressures and Surgical Interventions\\n\\nPatients who fail ERCP, or in whom there are recurrent symptoms, can then be taken for surgery, where choledochotomy, clearance of the cyst remnants, and closure over a T-tube is performed.\\n\\nAll emergency interventions must be followed up with albendazole (400mg twice daily) for at least 3 weeks.\\n\\n### Anisakis simplex\\n\\nThis nematode can present with severe abdominal pain, nausea, and vomiting, typically within a few hours of ingesting raw or undercooked infected fish (sushi eaters be careful!). The larva of Anisakis usually involves the stomach in humans, but can also occasionally affect the small bowel.\\n\\nIn the acute stage, the presentation has been confused with appendicitis, leading to patients being submitted to surgery, with the true nature of the diagnosis revealed only on histopathological examination. The diagnosis is difficult to make with certainty in an emergency situation, but can be suspected pre-operatively in cases where the patient spits out the worm, or in endemic regions, when a history of eating raw fish a few hours prior to the onset of symptoms can be elicited.\\n\\nIn such cases, upper gastrointestinal endoscopy can visualize and remove the parasite, providing relief of symptoms. As human infections are a dead-end for the parasite, no further treatment beyond symptom relief is required in cases where the diagnosis can be made. If undetected, the infection can present with small bowel obstruction after 2-3 weeks and invariably requires surgical intervention.\\n\\n### Liver Flukes\\n\\nLiver flukes (Clonorchis sinensis) are another significant cause of biliary symptoms, especially in the Far East. These live in the biliary tract for long periods before causing significant symptoms — classically, what is known as oriental cholangiohepatitis or recurrent pyogenic cholangitis (pain, fever, jaundice). Chronic disease may give rise to secondary biliary cirrhosis and portal hypertension. An association of cholangiocarcinoma with this infestation has also been proposed.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Intraductal Pressures and Surgical Interventions',\n", " 'md': '## Intraductal Pressures and Surgical Interventions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Patients who fail ERCP, or in whom there are recurrent symptoms, can then be taken for surgery, where choledochotomy, clearance of the cyst remnants, and closure over a T-tube is performed.\\n\\nAll emergency interventions must be followed up with albendazole (400mg twice daily) for at least 3 weeks.',\n", " 'md': 'Patients who fail ERCP, or in whom there are recurrent symptoms, can then be taken for surgery, where choledochotomy, clearance of the cyst remnants, and closure over a T-tube is performed.\\n\\nAll emergency interventions must be followed up with albendazole (400mg twice daily) for at least 3 weeks.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 255.86, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Anisakis simplex',\n", " 'md': '### Anisakis simplex',\n", " 'bBox': {'x': 86, 'y': 230, 'w': 134.27, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This nematode can present with severe abdominal pain, nausea, and vomiting, typically within a few hours of ingesting raw or undercooked infected fish (sushi eaters be careful!). The larva of Anisakis usually involves the stomach in humans, but can also occasionally affect the small bowel.\\n\\nIn the acute stage, the presentation has been confused with appendicitis, leading to patients being submitted to surgery, with the true nature of the diagnosis revealed only on histopathological examination. The diagnosis is difficult to make with certainty in an emergency situation, but can be suspected pre-operatively in cases where the patient spits out the worm, or in endemic regions, when a history of eating raw fish a few hours prior to the onset of symptoms can be elicited.\\n\\nIn such cases, upper gastrointestinal endoscopy can visualize and remove the parasite, providing relief of symptoms. As human infections are a dead-end for the parasite, no further treatment beyond symptom relief is required in cases where the diagnosis can be made. If undetected, the infection can present with small bowel obstruction after 2-3 weeks and invariably requires surgical intervention.',\n", " 'md': 'This nematode can present with severe abdominal pain, nausea, and vomiting, typically within a few hours of ingesting raw or undercooked infected fish (sushi eaters be careful!). The larva of Anisakis usually involves the stomach in humans, but can also occasionally affect the small bowel.\\n\\nIn the acute stage, the presentation has been confused with appendicitis, leading to patients being submitted to surgery, with the true nature of the diagnosis revealed only on histopathological examination. The diagnosis is difficult to make with certainty in an emergency situation, but can be suspected pre-operatively in cases where the patient spits out the worm, or in endemic regions, when a history of eating raw fish a few hours prior to the onset of symptoms can be elicited.\\n\\nIn such cases, upper gastrointestinal endoscopy can visualize and remove the parasite, providing relief of symptoms. As human infections are a dead-end for the parasite, no further treatment beyond symptom relief is required in cases where the diagnosis can be made. If undetected, the infection can present with small bowel obstruction after 2-3 weeks and invariably requires surgical intervention.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.89, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Liver Flukes',\n", " 'md': '### Liver Flukes',\n", " 'bBox': {'x': 86, 'y': 574, 'w': 91.96, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Liver flukes (Clonorchis sinensis) are another significant cause of biliary symptoms, especially in the Far East. These live in the biliary tract for long periods before causing significant symptoms — classically, what is known as oriental cholangiohepatitis or recurrent pyogenic cholangitis (pain, fever, jaundice). Chronic disease may give rise to secondary biliary cirrhosis and portal hypertension. An association of cholangiocarcinoma with this infestation has also been proposed.\\n```',\n", " 'md': 'Liver flukes (Clonorchis sinensis) are another significant cause of biliary symptoms, especially in the Far East. These live in the biliary tract for long periods before causing significant symptoms — classically, what is known as oriental cholangiohepatitis or recurrent pyogenic cholangitis (pain, fever, jaundice). Chronic disease may give rise to secondary biliary cirrhosis and portal hypertension. An association of cholangiocarcinoma with this infestation has also been proposed.\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.87, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 693,\n", " 'text': 'treatment is medical (praziquantel), but clearance of the bile ducts\\n(ERCP or surgical) may be required in refractory cases.\\n\\n Although a wide variety of worm infestations can give rise to acute\\nabdominal symptoms, it is important to realize that these diagnoses are\\noften not made initially, but after investigations or on histopathology, even\\nin the endemic regions. For example, appendicitis can also arise as a\\nresult of luminal obstruction by worms (Ascaris, pinworms or\\nStrongyloides), but the diagnosis is rarely made pre- or intra-operatively.\\nIt is usually made retrospectively, on examination of the specimen by the\\npathologist. Therefore, it is important to realize that the symptoms of the\\npatient indicate the need for conservative/surgical treatment, and further\\ntherapy can be added once the specific diagnosis is made.\\n\\n No sensor should be allowed to completely replace the\\n common sense.\\n Kuldip Pandey\\n\\n Abdominal emergencies in Africa 2\\n2 Graeme Pitcher and Craig Joseph\\n Like the many paradoxes in Africa, emergency surgery\\n illustrates the extremes: there may be helicopter transfer to\\n 21st century intensive care, or multiple cart and taxi\\n transfers over several days to an under-resourced mission\\n hospital.\\n David Dent\\n\\n The continent of Africa is as diverse as it is enormous. Its populace\\nranges from some of the most rural, uneducated and poverty-stricken,\\nwith limited or no medical access, to wealthy first-world citizens who have\\naccess to modern, often private, healthcare. The full range of abdominal\\nemergencies occurs, with many conditions masquerading as general\\nsurgical pathology. Indeed the surgeon must think on his or her feet and\\nbe willing to deal with urological, gynecological and even medical\\nemergencies. You will also need to be a pediatric surgeon,\\noncologist, vascular surgeon and trauma surgeon rolled into one.',\n", " 'md': '```markdown\\n## Abdominal Emergencies in Africa\\n\\n### Treatment\\nTreatment is medical (praziquantel), but clearance of the bile ducts (ERCP or surgical) may be required in refractory cases.\\n\\n### Diagnosis Challenges\\nAlthough a wide variety of worm infestations can give rise to acute abdominal symptoms, it is important to realize that these diagnoses are often not made initially, but after investigations or on histopathology, even in the endemic regions. For example, appendicitis can also arise as a result of luminal obstruction by worms (Ascaris, pinworms or Strongyloides), but the diagnosis is rarely made pre- or intra-operatively. It is usually made retrospectively, on examination of the specimen by the pathologist. Therefore, it is important to realize that the symptoms of the patient indicate the need for conservative/surgical treatment, and further therapy can be added once the specific diagnosis is made.\\n\\n### Quote\\n> No sensor should be allowed to completely replace the common sense.\\n> — Kuldip Pandey\\n\\n### Overview of Emergency Surgery in Africa\\nLike the many paradoxes in Africa, emergency surgery illustrates the extremes: there may be helicopter transfer to 21st century intensive care, or multiple cart and taxi transfers over several days to an under-resourced mission hospital.\\n— David Dent\\n\\n### Diversity of Healthcare in Africa\\nThe continent of Africa is as diverse as it is enormous. Its populace ranges from some of the most rural, uneducated and poverty-stricken, with limited or no medical access, to wealthy first-world citizens who have access to modern, often private, healthcare. The full range of abdominal emergencies occurs, with many conditions masquerading as general surgical pathology. Indeed the surgeon must think on his or her feet and be willing to deal with urological, gynecological and even medical emergencies. You will also need to be a pediatric surgeon, oncologist, vascular surgeon and trauma surgeon rolled into one.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Emergencies in Africa',\n", " 'md': '## Abdominal Emergencies in Africa',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Treatment',\n", " 'md': '### Treatment',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Treatment is medical (praziquantel), but clearance of the bile ducts (ERCP or surgical) may be required in refractory cases.',\n", " 'md': 'Treatment is medical (praziquantel), but clearance of the bile ducts (ERCP or surgical) may be required in refractory cases.',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 353.15, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diagnosis Challenges',\n", " 'md': '### Diagnosis Challenges',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Although a wide variety of worm infestations can give rise to acute abdominal symptoms, it is important to realize that these diagnoses are often not made initially, but after investigations or on histopathology, even in the endemic regions. For example, appendicitis can also arise as a result of luminal obstruction by worms (Ascaris, pinworms or Strongyloides), but the diagnosis is rarely made pre- or intra-operatively. It is usually made retrospectively, on examination of the specimen by the pathologist. Therefore, it is important to realize that the symptoms of the patient indicate the need for conservative/surgical treatment, and further therapy can be added once the specific diagnosis is made.',\n", " 'md': 'Although a wide variety of worm infestations can give rise to acute abdominal symptoms, it is important to realize that these diagnoses are often not made initially, but after investigations or on histopathology, even in the endemic regions. For example, appendicitis can also arise as a result of luminal obstruction by worms (Ascaris, pinworms or Strongyloides), but the diagnosis is rarely made pre- or intra-operatively. It is usually made retrospectively, on examination of the specimen by the pathologist. Therefore, it is important to realize that the symptoms of the patient indicate the need for conservative/surgical treatment, and further therapy can be added once the specific diagnosis is made.',\n", " 'bBox': {'x': 72, 'y': 154, 'w': 467.76, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Quote',\n", " 'md': '### Quote',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '> No sensor should be allowed to completely replace the common sense.\\n> — Kuldip Pandey',\n", " 'md': '> No sensor should be allowed to completely replace the common sense.\\n> — Kuldip Pandey',\n", " 'bBox': {'x': 108, 'y': 204, 'w': 431.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Overview of Emergency Surgery in Africa',\n", " 'md': '### Overview of Emergency Surgery in Africa',\n", " 'bBox': {'x': 121, 'y': 204, 'w': 16, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Like the many paradoxes in Africa, emergency surgery illustrates the extremes: there may be helicopter transfer to 21st century intensive care, or multiple cart and taxi transfers over several days to an under-resourced mission hospital.\\n— David Dent',\n", " 'md': 'Like the many paradoxes in Africa, emergency surgery illustrates the extremes: there may be helicopter transfer to 21st century intensive care, or multiple cart and taxi transfers over several days to an under-resourced mission hospital.\\n— David Dent',\n", " 'bBox': {'x': 73, 'y': 204, 'w': 466.79, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diversity of Healthcare in Africa',\n", " 'md': '### Diversity of Healthcare in Africa',\n", " 'bBox': {'x': 121, 'y': 204, 'w': 16, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'The continent of Africa is as diverse as it is enormous. Its populace ranges from some of the most rural, uneducated and poverty-stricken, with limited or no medical access, to wealthy first-world citizens who have access to modern, often private, healthcare. The full range of abdominal emergencies occurs, with many conditions masquerading as general surgical pathology. Indeed the surgeon must think on his or her feet and be willing to deal with urological, gynecological and even medical emergencies. You will also need to be a pediatric surgeon, oncologist, vascular surgeon and trauma surgeon rolled into one.\\n```',\n", " 'md': 'The continent of Africa is as diverse as it is enormous. Its populace ranges from some of the most rural, uneducated and poverty-stricken, with limited or no medical access, to wealthy first-world citizens who have access to modern, often private, healthcare. The full range of abdominal emergencies occurs, with many conditions masquerading as general surgical pathology. Indeed the surgeon must think on his or her feet and be willing to deal with urological, gynecological and even medical emergencies. You will also need to be a pediatric surgeon, oncologist, vascular surgeon and trauma surgeon rolled into one.\\n```',\n", " 'bBox': {'x': 72, 'y': 204, 'w': 467.83, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Abdominal emergencies in Africa 2'}]},\n", " {'page': 694,\n", " 'text': ' Though there are unique and interesting pathologies seen in Africa, the\\nvast majority of patients with abdominal emergencies share their\\npathology with their Western counterparts, but because of poor access to\\nhealthcare, political strife and civil wars, they tend to present much later\\nto the surgeon in the course of their disease, often with unique sets of\\nsurgical challenges. Delay in presentation is common to the point of\\nbeing almost the norm. The surgeon has to adapt their practice to local\\nconditions. The simplest treatment that effects surgical cure and\\nrespects the patient’s physiology may not be the one in the\\ntextbook. Recovery and postoperative care may need to be adapted\\naccordingly. There is no typical recovery period for many neglected\\ncomplicated cases.\\n\\n Many patients present with profound malnutrition; often an acute\\ngastrointestinal disease compounds chronic malnutrition. Very aggressive\\nnutritional support is difficult to provide but remains essential for a good\\noutcome. Parenteral nutrition is not as safe as in the West, so enteral\\nroutes are strongly preferred.\\n\\n Much of the surgery is the surgery of poverty and delayed presentation\\nrather than specifically ‘African problems’. In this chapter we will discuss\\nsome of the unique conditions as well as share with the reader some tips\\nto deal with the neglected case. Adequately treating these patients,\\noften in suboptimal circumstances, remains the challenge of\\nsurgery in Africa.\\n\\n Africa is not for sissies. If you are stupid you will suffer.\\n Anonymous\\n\\n Intussusception — lethal and delayed\\n\\n Intussusception remains the most common acute life-threatening\\nabdominal condition of early life. The typical Western presentation\\ndepicted elsewhere in this book is, in our experience, rarely seen in\\nindigent African populations.\\n\\n ħere are the typical features:',\n", " 'md': '```markdown\\n## Abdominal Emergencies in Africa\\n\\nThough there are unique and interesting pathologies seen in Africa, the vast majority of patients with abdominal emergencies share their pathology with their Western counterparts. However, due to poor access to healthcare, political strife, and civil wars, they tend to present much later to the surgeon in the course of their disease, often with unique sets of surgical challenges. Delay in presentation is common to the point of being almost the norm. The surgeon has to adapt their practice to local conditions. The simplest treatment that effects surgical cure and respects the patient’s physiology may not be the one in the textbook. Recovery and postoperative care may need to be adapted accordingly. There is no typical recovery period for many neglected complicated cases.\\n\\nMany patients present with profound malnutrition; often, an acute gastrointestinal disease compounds chronic malnutrition. Very aggressive nutritional support is difficult to provide but remains essential for a good outcome. Parenteral nutrition is not as safe as in the West, so enteral routes are strongly preferred.\\n\\nMuch of the surgery is the surgery of poverty and delayed presentation rather than specifically ‘African problems’. In this chapter, we will discuss some of the unique conditions as well as share with the reader some tips to deal with the neglected case. Adequately treating these patients, often in suboptimal circumstances, remains the challenge of surgery in Africa.\\n\\n> **Quote:** \"Africa is not for sissies. If you are stupid you will suffer.\"\\n> — Anonymous\\n\\n### Intussusception — lethal and delayed\\n\\nIntussusception remains the most common acute life-threatening abdominal condition of early life. The typical Western presentation depicted elsewhere in this book is, in our experience, rarely seen in indigent African populations.\\n\\nHere are the typical features:\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Emergencies in Africa',\n", " 'md': '## Abdominal Emergencies in Africa',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Though there are unique and interesting pathologies seen in Africa, the vast majority of patients with abdominal emergencies share their pathology with their Western counterparts. However, due to poor access to healthcare, political strife, and civil wars, they tend to present much later to the surgeon in the course of their disease, often with unique sets of surgical challenges. Delay in presentation is common to the point of being almost the norm. The surgeon has to adapt their practice to local conditions. The simplest treatment that effects surgical cure and respects the patient’s physiology may not be the one in the textbook. Recovery and postoperative care may need to be adapted accordingly. There is no typical recovery period for many neglected complicated cases.\\n\\nMany patients present with profound malnutrition; often, an acute gastrointestinal disease compounds chronic malnutrition. Very aggressive nutritional support is difficult to provide but remains essential for a good outcome. Parenteral nutrition is not as safe as in the West, so enteral routes are strongly preferred.\\n\\nMuch of the surgery is the surgery of poverty and delayed presentation rather than specifically ‘African problems’. In this chapter, we will discuss some of the unique conditions as well as share with the reader some tips to deal with the neglected case. Adequately treating these patients, often in suboptimal circumstances, remains the challenge of surgery in Africa.\\n\\n> **Quote:** \"Africa is not for sissies. If you are stupid you will suffer.\"\\n> — Anonymous',\n", " 'md': 'Though there are unique and interesting pathologies seen in Africa, the vast majority of patients with abdominal emergencies share their pathology with their Western counterparts. However, due to poor access to healthcare, political strife, and civil wars, they tend to present much later to the surgeon in the course of their disease, often with unique sets of surgical challenges. Delay in presentation is common to the point of being almost the norm. The surgeon has to adapt their practice to local conditions. The simplest treatment that effects surgical cure and respects the patient’s physiology may not be the one in the textbook. Recovery and postoperative care may need to be adapted accordingly. There is no typical recovery period for many neglected complicated cases.\\n\\nMany patients present with profound malnutrition; often, an acute gastrointestinal disease compounds chronic malnutrition. Very aggressive nutritional support is difficult to provide but remains essential for a good outcome. Parenteral nutrition is not as safe as in the West, so enteral routes are strongly preferred.\\n\\nMuch of the surgery is the surgery of poverty and delayed presentation rather than specifically ‘African problems’. In this chapter, we will discuss some of the unique conditions as well as share with the reader some tips to deal with the neglected case. Adequately treating these patients, often in suboptimal circumstances, remains the challenge of surgery in Africa.\\n\\n> **Quote:** \"Africa is not for sissies. If you are stupid you will suffer.\"\\n> — Anonymous',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Intussusception — lethal and delayed',\n", " 'md': '### Intussusception — lethal and delayed',\n", " 'bBox': {'x': 86, 'y': 585, 'w': 296.09, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Intussusception remains the most common acute life-threatening abdominal condition of early life. The typical Western presentation depicted elsewhere in this book is, in our experience, rarely seen in indigent African populations.\\n\\nHere are the typical features:\\n```',\n", " 'md': 'Intussusception remains the most common acute life-threatening abdominal condition of early life. The typical Western presentation depicted elsewhere in this book is, in our experience, rarely seen in indigent African populations.\\n\\nHere are the typical features:\\n```',\n", " 'bBox': {'x': 72, 'y': 621, 'w': 467.31, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 695,\n", " 'text': '• Many patients present as intestinal obstruction.\\n• Because of bowel loop distension the typical abdominal mass may\\n be difficult to palpate.\\n• Many patients are mistakenly treated for dysentery.\\n• Acute peritonitis from perforations, usually at the point of pressure of\\n the lead point on the receiving bowel is often present.\\n• Colocolic intussusception is uniquely common in Southern Africa,\\n typically in older children.\\n• The intussusception may protrude from the anus and be mistaken\\n for a rectal prolapse. Being able to pass one’s finger up adjacent\\n to the presenting bowel for a considerable distance on rectal\\n examination should make this distinction ( Figure 38.9).\\n Prolapse',\n", " 'md': '```markdown\\n## Page Content\\n\\n- Many patients present as intestinal obstruction.\\n- Because of bowel loop distension, the typical abdominal mass may be difficult to palpate.\\n- Many patients are mistakenly treated for dysentery.\\n- Acute peritonitis from perforations, usually at the point of pressure of the lead point on the receiving bowel, is often present.\\n- Colocolic intussusception is uniquely common in Southern Africa, typically in older children.\\n- The intussusception may protrude from the anus and be mistaken for a rectal prolapse. Being able to pass one’s finger up adjacent to the presenting bowel for a considerable distance on rectal examination should make this distinction (Figure 38.9).\\n\\n### Figure 38.9 Description\\n- **Figure 38.9**: This figure likely illustrates a medical condition related to intussusception or rectal prolapse. The specific content of the image is not provided, but it is referenced in the context of distinguishing between intussusception and rectal prolapse during a rectal examination.\\n- **Summary**: The figure is important for understanding the clinical presentation of intussusception in children, particularly in the context of Southern Africa, where it is more prevalent.\\n\\n```',\n", " 'images': [{'name': 'img_p694_1.png',\n", " 'height': 380,\n", " 'width': 510,\n", " 'x': 180,\n", " 'y': 324,\n", " 'original_width': 1060,\n", " 'original_height': 791}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Many patients present as intestinal obstruction.\\n- Because of bowel loop distension, the typical abdominal mass may be difficult to palpate.\\n- Many patients are mistakenly treated for dysentery.\\n- Acute peritonitis from perforations, usually at the point of pressure of the lead point on the receiving bowel, is often present.\\n- Colocolic intussusception is uniquely common in Southern Africa, typically in older children.\\n- The intussusception may protrude from the anus and be mistaken for a rectal prolapse. Being able to pass one’s finger up adjacent to the presenting bowel for a considerable distance on rectal examination should make this distinction (Figure 38.9).',\n", " 'md': '- Many patients present as intestinal obstruction.\\n- Because of bowel loop distension, the typical abdominal mass may be difficult to palpate.\\n- Many patients are mistakenly treated for dysentery.\\n- Acute peritonitis from perforations, usually at the point of pressure of the lead point on the receiving bowel, is often present.\\n- Colocolic intussusception is uniquely common in Southern Africa, typically in older children.\\n- The intussusception may protrude from the anus and be mistaken for a rectal prolapse. Being able to pass one’s finger up adjacent to the presenting bowel for a considerable distance on rectal examination should make this distinction (Figure 38.9).',\n", " 'bBox': {'x': 100, 'y': 88, 'w': 437.58, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 38.9 Description',\n", " 'md': '### Figure 38.9 Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 38.9**: This figure likely illustrates a medical condition related to intussusception or rectal prolapse. The specific content of the image is not provided, but it is referenced in the context of distinguishing between intussusception and rectal prolapse during a rectal examination.\\n- **Summary**: The figure is important for understanding the clinical presentation of intussusception in children, particularly in the context of Southern Africa, where it is more prevalent.\\n\\n```',\n", " 'md': '- **Figure 38.9**: This figure likely illustrates a medical condition related to intussusception or rectal prolapse. The specific content of the image is not provided, but it is referenced in the context of distinguishing between intussusception and rectal prolapse during a rectal examination.\\n- **Summary**: The figure is important for understanding the clinical presentation of intussusception in children, particularly in the context of Southern Africa, where it is more prevalent.\\n\\n```',\n", " 'bBox': {'x': 284.75, 'y': 502.03, 'w': 42.49, 'h': 10.88}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 696,\n", " 'text': ' Intussusception\\n Figure 38.9. Distinguishing between rectal prolapse and intussusception. In rectal\\n prolapse the examining finger cannot slide between the prolapsed bowel and the anal\\n verge, whereas in intussusception the finger can slide in alongside the intussusception\\n presenting at the anal verge.\\n\\n Intestinal obstruction in a child less than 4 years old without evidence of an incarcerated hernia\\n or previous surgery is intussusception unless proven otherwise.\\n\\n Fewer patients with intussusception can be treated by radiologically-\\nguided pressure reduction compared to the developed world. In well-\\nresuscitated patients in the age range 3 months to 2 years, with a non-\\ntender abdomen and no sign of established intestinal obstruction,\\nreduction (preferably with air) can be attempted and is successful in\\nabout a third of patients. Duration of symptoms is not used as an\\nabsolute contraindication to air reduction because that would\\npreclude almost all patients. The remainder of patients are best treated\\nby open surgical exploration as resection rates for bowel ischemia and\\nperforation are high.\\n\\n Appendicitis: neglected perforation still a fatal disease\\n\\n The management of appendicitis in the developing world is no\\ndifferent from anywhere else. One possible exception is to recognize',\n", " 'md': '```markdown\\n# Intussusception\\n\\n**Figure 38.9**: Distinguishing between rectal prolapse and intussusception. In rectal prolapse, the examining finger cannot slide between the prolapsed bowel and the anal verge, whereas in intussusception, the finger can slide in alongside the intussusception presenting at the anal verge.\\n\\nIntestinal obstruction in a child less than 4 years old without evidence of an incarcerated hernia or previous surgery is intussusception unless proven otherwise.\\n\\nFewer patients with intussusception can be treated by radiologically-guided pressure reduction compared to the developed world. In well-resuscitated patients in the age range of 3 months to 2 years, with a non-tender abdomen and no sign of established intestinal obstruction, reduction (preferably with air) can be attempted and is successful in about a third of patients. Duration of symptoms is not used as an absolute contraindication to air reduction because that would preclude almost all patients. The remainder of patients are best treated by open surgical exploration as resection rates for bowel ischemia and perforation are high.\\n\\n### Appendicitis: neglected perforation still a fatal disease\\n\\nThe management of appendicitis in the developing world is no different from anywhere else. One possible exception is to recognize...\\n```',\n", " 'images': [{'name': 'img_p695_1.png',\n", " 'height': 421,\n", " 'width': 510,\n", " 'x': 180,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1060,\n", " 'original_height': 876}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Intussusception',\n", " 'md': '# Intussusception',\n", " 'bBox': {'x': 268.94, 'y': 278.52, 'w': 74.12, 'h': 11.86}},\n", " {'type': 'text',\n", " 'value': '**Figure 38.9**: Distinguishing between rectal prolapse and intussusception. In rectal prolapse, the examining finger cannot slide between the prolapsed bowel and the anal verge, whereas in intussusception, the finger can slide in alongside the intussusception presenting at the anal verge.\\n\\nIntestinal obstruction in a child less than 4 years old without evidence of an incarcerated hernia or previous surgery is intussusception unless proven otherwise.\\n\\nFewer patients with intussusception can be treated by radiologically-guided pressure reduction compared to the developed world. In well-resuscitated patients in the age range of 3 months to 2 years, with a non-tender abdomen and no sign of established intestinal obstruction, reduction (preferably with air) can be attempted and is successful in about a third of patients. Duration of symptoms is not used as an absolute contraindication to air reduction because that would preclude almost all patients. The remainder of patients are best treated by open surgical exploration as resection rates for bowel ischemia and perforation are high.',\n", " 'md': '**Figure 38.9**: Distinguishing between rectal prolapse and intussusception. In rectal prolapse, the examining finger cannot slide between the prolapsed bowel and the anal verge, whereas in intussusception, the finger can slide in alongside the intussusception presenting at the anal verge.\\n\\nIntestinal obstruction in a child less than 4 years old without evidence of an incarcerated hernia or previous surgery is intussusception unless proven otherwise.\\n\\nFewer patients with intussusception can be treated by radiologically-guided pressure reduction compared to the developed world. In well-resuscitated patients in the age range of 3 months to 2 years, with a non-tender abdomen and no sign of established intestinal obstruction, reduction (preferably with air) can be attempted and is successful in about a third of patients. Duration of symptoms is not used as an absolute contraindication to air reduction because that would preclude almost all patients. The remainder of patients are best treated by open surgical exploration as resection rates for bowel ischemia and perforation are high.',\n", " 'bBox': {'x': 72, 'y': 278.52, 'w': 467.07, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Appendicitis: neglected perforation still a fatal disease',\n", " 'md': '### Appendicitis: neglected perforation still a fatal disease',\n", " 'bBox': {'x': 86, 'y': 661, 'w': 429.38, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The management of appendicitis in the developing world is no different from anywhere else. One possible exception is to recognize...\\n```',\n", " 'md': 'The management of appendicitis in the developing world is no different from anywhere else. One possible exception is to recognize...\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 697,\n", " 'text': 'the patient with life-threatening longstanding perforation, often of up to 2-\\n3 weeks’ (!) duration. Such patients usually present with severe\\nsepsis, dehydration, wasting, organ dysfunction and a grossly\\ndistended abdomen with diffuse peritonitis and multiple loculated\\ncollections. They are best managed by very aggressive pre-\\noperative resuscitation, antibiotic treatment and exploration by a\\nmidline laparotomy as they may not tolerate the hemodynamic\\nimpact of pneumoperitoneum.\\n\\n Ascaris infestations\\n\\n The Ascaris parasite has certainly found a happy home in the intestinal\\ntract of many Africans. The commonest presentation to the surgeon is\\nwith intestinal obstruction. Most patients will report the vomiting or\\npassage of worms rectally. Plain abdominal X-rays show a picture of\\nintestinal obstruction with the typical curvilinear shadows of worms in the\\nlumen of the bowel. Most patients can be treated conservatively with fluid\\nresuscitation and nasogastric drainage. Vermicidal agents are\\ntraditionally not used in the acute stage of obstruction for fear of\\nparalyzing the worms in the bolus and aggravating the situation (but this\\nmay be a myth!). Disobstruction is aided by the administration of\\nGastrografin® (which is slippery and hypertonic) given usually from\\nabove via a nasogastric tube ( Figure 38.10) but also as an enema in\\ncases of distal obstruction. Indications for surgical intervention include\\nperitonitis, severe systemic toxicity, failure to respond in 24-36 hours and\\nsevere rectal bleeding.',\n", " 'md': '```markdown\\n## Patient Management in Life-Threatening Perforation\\n\\nThe patient with life-threatening longstanding perforation, often of up to 2-3 weeks’ duration. Such patients usually present with severe sepsis, dehydration, wasting, organ dysfunction, and a grossly distended abdomen with diffuse peritonitis and multiple loculated collections. They are best managed by very aggressive pre-operative resuscitation, antibiotic treatment, and exploration by a midline laparotomy as they may not tolerate the hemodynamic impact of pneumoperitoneum.\\n\\n### Ascaris Infestations\\n\\nThe Ascaris parasite has certainly found a happy home in the intestinal tract of many Africans. The commonest presentation to the surgeon is with intestinal obstruction. Most patients will report the vomiting or passage of worms rectally. Plain abdominal X-rays show a picture of intestinal obstruction with the typical curvilinear shadows of worms in the lumen of the bowel. Most patients can be treated conservatively with fluid resuscitation and nasogastric drainage. Vermicidal agents are traditionally not used in the acute stage of obstruction for fear of paralyzing the worms in the bolus and aggravating the situation (but this may be a myth!). Disobstruction is aided by the administration of Gastrografin® (which is slippery and hypertonic) given usually from above via a nasogastric tube (Figure 38.10) but also as an enema in cases of distal obstruction. Indications for surgical intervention include peritonitis, severe systemic toxicity, failure to respond in 24-36 hours, and severe rectal bleeding.\\n\\n### Figure 38.10\\n- **Description**: This figure likely illustrates the administration of Gastrografin® for disobstruction in cases of intestinal obstruction due to Ascaris infestation. The image may depict the method of administration via a nasogastric tube or enema.\\n- **Summary**: The figure emphasizes the use of Gastrografin® as a treatment option for aiding disobstruction in patients with intestinal obstruction caused by Ascaris, highlighting its hypertonic and slippery properties.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Patient Management in Life-Threatening Perforation',\n", " 'md': '## Patient Management in Life-Threatening Perforation',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The patient with life-threatening longstanding perforation, often of up to 2-3 weeks’ duration. Such patients usually present with severe sepsis, dehydration, wasting, organ dysfunction, and a grossly distended abdomen with diffuse peritonitis and multiple loculated collections. They are best managed by very aggressive pre-operative resuscitation, antibiotic treatment, and exploration by a midline laparotomy as they may not tolerate the hemodynamic impact of pneumoperitoneum.',\n", " 'md': 'The patient with life-threatening longstanding perforation, often of up to 2-3 weeks’ duration. Such patients usually present with severe sepsis, dehydration, wasting, organ dysfunction, and a grossly distended abdomen with diffuse peritonitis and multiple loculated collections. They are best managed by very aggressive pre-operative resuscitation, antibiotic treatment, and exploration by a midline laparotomy as they may not tolerate the hemodynamic impact of pneumoperitoneum.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Ascaris Infestations',\n", " 'md': '### Ascaris Infestations',\n", " 'bBox': {'x': 86, 'y': 245, 'w': 157.26, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The Ascaris parasite has certainly found a happy home in the intestinal tract of many Africans. The commonest presentation to the surgeon is with intestinal obstruction. Most patients will report the vomiting or passage of worms rectally. Plain abdominal X-rays show a picture of intestinal obstruction with the typical curvilinear shadows of worms in the lumen of the bowel. Most patients can be treated conservatively with fluid resuscitation and nasogastric drainage. Vermicidal agents are traditionally not used in the acute stage of obstruction for fear of paralyzing the worms in the bolus and aggravating the situation (but this may be a myth!). Disobstruction is aided by the administration of Gastrografin® (which is slippery and hypertonic) given usually from above via a nasogastric tube (Figure 38.10) but also as an enema in cases of distal obstruction. Indications for surgical intervention include peritonitis, severe systemic toxicity, failure to respond in 24-36 hours, and severe rectal bleeding.',\n", " 'md': 'The Ascaris parasite has certainly found a happy home in the intestinal tract of many Africans. The commonest presentation to the surgeon is with intestinal obstruction. Most patients will report the vomiting or passage of worms rectally. Plain abdominal X-rays show a picture of intestinal obstruction with the typical curvilinear shadows of worms in the lumen of the bowel. Most patients can be treated conservatively with fluid resuscitation and nasogastric drainage. Vermicidal agents are traditionally not used in the acute stage of obstruction for fear of paralyzing the worms in the bolus and aggravating the situation (but this may be a myth!). Disobstruction is aided by the administration of Gastrografin® (which is slippery and hypertonic) given usually from above via a nasogastric tube (Figure 38.10) but also as an enema in cases of distal obstruction. Indications for surgical intervention include peritonitis, severe systemic toxicity, failure to respond in 24-36 hours, and severe rectal bleeding.',\n", " 'bBox': {'x': 72, 'y': 281, 'w': 467.83, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 38.10',\n", " 'md': '### Figure 38.10',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure likely illustrates the administration of Gastrografin® for disobstruction in cases of intestinal obstruction due to Ascaris infestation. The image may depict the method of administration via a nasogastric tube or enema.\\n- **Summary**: The figure emphasizes the use of Gastrografin® as a treatment option for aiding disobstruction in patients with intestinal obstruction caused by Ascaris, highlighting its hypertonic and slippery properties.\\n```',\n", " 'md': '- **Description**: This figure likely illustrates the administration of Gastrografin® for disobstruction in cases of intestinal obstruction due to Ascaris infestation. The image may depict the method of administration via a nasogastric tube or enema.\\n- **Summary**: The figure emphasizes the use of Gastrografin® as a treatment option for aiding disobstruction in patients with intestinal obstruction caused by Ascaris, highlighting its hypertonic and slippery properties.\\n```',\n", " 'bBox': {'x': 169, 'y': 380, 'w': 77.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'cases of distal obstruction. Indications for surgical intervention include'}]},\n", " {'page': 698,\n", " 'text': ' Figure 38.10. Gastrografin® administered via a nasogastric tube in an obstructed patient.\\n Note the linear shadows indicating worms in the proximal bowel.\\n\\n Leiomyopathy\\n\\n This is a relatively common problem in African children. It is not well\\ndescribed in the textbooks or literature because it is virtually non-existent\\nin developed countries and the cause is not known — we think that it may\\nbe a toxic injury from enemas or other muti (see below).\\n\\n This condition presents with an onset of (initially fairly benign and\\nasymptomatic) abdominal distension at 3-7 years of age followed by\\nprogressive massive predominantly gaseous distension with frank\\nobstructive features and progression to death from intestinal failure,\\nusually before the third decade of life. The cause is unknown and the\\npathology of affected bowel (usually starting distally and progressing\\nmore proximally) shows replacement of muscle in the muscularis propria\\nwith sheets of fibrous tissue. These patients are typically enormously\\ndistended clinically and radiologically, but usually show no signs of\\nintestinal obstruction and often arrive in surprisingly little distress, eating\\nnormally. The abdomen is soft and tympanitic to percussion.',\n", " 'md': '```markdown\\n## Page Content\\n\\n### Figure 38.10\\n**Description:** Gastrografin® administered via a nasogastric tube in an obstructed patient. The image shows linear shadows indicating worms in the proximal bowel.\\n\\n### Leiomyopathy\\nThis is a relatively common problem in African children. It is not well described in the textbooks or literature because it is virtually non-existent in developed countries and the cause is not known — we think that it may be a toxic injury from enemas or other muti (see below).\\n\\nThis condition presents with an onset of (initially fairly benign and asymptomatic) abdominal distension at 3-7 years of age followed by progressive massive predominantly gaseous distension with frank obstructive features and progression to death from intestinal failure, usually before the third decade of life. The cause is unknown and the pathology of affected bowel (usually starting distally and progressing more proximally) shows replacement of muscle in the muscularis propria with sheets of fibrous tissue. These patients are typically enormously distended clinically and radiologically, but usually show no signs of intestinal obstruction and often arrive in surprisingly little distress, eating normally. The abdomen is soft and tympanitic to percussion.\\n```',\n", " 'images': [{'name': 'img_p697_1.png',\n", " 'height': 491,\n", " 'width': 678,\n", " 'x': 138.23999999999978,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1164,\n", " 'original_height': 841}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 38.10',\n", " 'md': '### Figure 38.10',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** Gastrografin® administered via a nasogastric tube in an obstructed patient. The image shows linear shadows indicating worms in the proximal bowel.',\n", " 'md': '**Description:** Gastrografin® administered via a nasogastric tube in an obstructed patient. The image shows linear shadows indicating worms in the proximal bowel.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Leiomyopathy',\n", " 'md': '### Leiomyopathy',\n", " 'bBox': {'x': 86, 'y': 414, 'w': 112.2, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is a relatively common problem in African children. It is not well described in the textbooks or literature because it is virtually non-existent in developed countries and the cause is not known — we think that it may be a toxic injury from enemas or other muti (see below).\\n\\nThis condition presents with an onset of (initially fairly benign and asymptomatic) abdominal distension at 3-7 years of age followed by progressive massive predominantly gaseous distension with frank obstructive features and progression to death from intestinal failure, usually before the third decade of life. The cause is unknown and the pathology of affected bowel (usually starting distally and progressing more proximally) shows replacement of muscle in the muscularis propria with sheets of fibrous tissue. These patients are typically enormously distended clinically and radiologically, but usually show no signs of intestinal obstruction and often arrive in surprisingly little distress, eating normally. The abdomen is soft and tympanitic to percussion.\\n```',\n", " 'md': 'This is a relatively common problem in African children. It is not well described in the textbooks or literature because it is virtually non-existent in developed countries and the cause is not known — we think that it may be a toxic injury from enemas or other muti (see below).\\n\\nThis condition presents with an onset of (initially fairly benign and asymptomatic) abdominal distension at 3-7 years of age followed by progressive massive predominantly gaseous distension with frank obstructive features and progression to death from intestinal failure, usually before the third decade of life. The cause is unknown and the pathology of affected bowel (usually starting distally and progressing more proximally) shows replacement of muscle in the muscularis propria with sheets of fibrous tissue. These patients are typically enormously distended clinically and radiologically, but usually show no signs of intestinal obstruction and often arrive in surprisingly little distress, eating normally. The abdomen is soft and tympanitic to percussion.\\n```',\n", " 'bBox': {'x': 72, 'y': 467, 'w': 468, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 699,\n", " 'text': ' The common pitfall with this condition is to look at the X-ray,\\nassume a life-threatening obstruction and operate to find huge\\nloops of colon and then to perform a stoma. These stomas are\\nmassive and bulky, prone to complications and generally fail to\\nadequately relieve distension. Instead, these patients are best served by\\nrectal decompression by tube or endoscopy, a regular ‘bowel program’,\\nmainly ‘from below’ and nutritional support. No form of surgery helps\\nthese patients significantly, although a small number can be palliated by\\ntotal colectomy and ileorectal anastomosis for a few years. Intestinal\\ntransplant is the only curative therapy and is not available to most.\\n\\n HIV-related abdominal emergencies\\n\\n The high incidence of ħIV/AIDS, and the associated opportunistic\\ninfections, in particular, tuberculosis, greatly increases the possible\\nspectrum of pathology. The commonest abdominal complications of\\nHIV/AIDS in our experience are Cytomegalovirus (CMV) enteritis and\\nperforation in the young infant (3 to 18 months of age) and\\nabdominal tuberculosis in the older child.\\n\\n CMV disease presents typically with acute abdominal distension,\\nvomiting and cardiovascular collapse in a severely immunocompromised\\nand malnourished child. At laparotomy, multiple, sometimes hundreds of\\nsmall holes are found along the entire length of bowel. ħistology will\\nsometimes reveal the typical intracytoplasmic viral inclusions. Even with\\naggressive treatment, including the use of intravenous ganciclovir, the\\nprognosis is poor.\\n\\n Never forget that the incidence of HIV infection in the general population is high (possibly 70%\\n in hospitalized patients) and that appropriate protection of the surgeon and his assistants is\\n crucial in all cases.\\n\\n Traditional ‘witch doctor’ enemas\\n\\n Although there is a paucity of literature on the topic, the use of',\n", " 'md': '```markdown\\n## Common Pitfalls in Abdominal Emergencies\\n\\nThe common pitfall with this condition is to look at the X-ray, assume a life-threatening obstruction and operate to find huge loops of colon and then to perform a stoma. These stomas are massive and bulky, prone to complications and generally fail to adequately relieve distension. Instead, these patients are best served by rectal decompression by tube or endoscopy, a regular ‘bowel program’, mainly ‘from below’ and nutritional support. No form of surgery helps these patients significantly, although a small number can be palliated by total colectomy and ileorectal anastomosis for a few years. Intestinal transplant is the only curative therapy and is not available to most.\\n\\n## HIV-related Abdominal Emergencies\\n\\nThe high incidence of HIV/AIDS, and the associated opportunistic infections, in particular, tuberculosis, greatly increases the possible spectrum of pathology. The commonest abdominal complications of HIV/AIDS in our experience are Cytomegalovirus (CMV) enteritis and perforation in the young infant (3 to 18 months of age) and abdominal tuberculosis in the older child.\\n\\nCMV disease presents typically with acute abdominal distension, vomiting and cardiovascular collapse in a severely immunocompromised and malnourished child. At laparotomy, multiple, sometimes hundreds of small holes are found along the entire length of bowel. Histology will sometimes reveal the typical intracytoplasmic viral inclusions. Even with aggressive treatment, including the use of intravenous ganciclovir, the prognosis is poor.\\n\\nNever forget that the incidence of HIV infection in the general population is high (possibly 70% in hospitalized patients) and that appropriate protection of the surgeon and his assistants is crucial in all cases.\\n\\n## Traditional ‘Witch Doctor’ Enemas\\n\\nAlthough there is a paucity of literature on the topic, the use of\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Common Pitfalls in Abdominal Emergencies',\n", " 'md': '## Common Pitfalls in Abdominal Emergencies',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The common pitfall with this condition is to look at the X-ray, assume a life-threatening obstruction and operate to find huge loops of colon and then to perform a stoma. These stomas are massive and bulky, prone to complications and generally fail to adequately relieve distension. Instead, these patients are best served by rectal decompression by tube or endoscopy, a regular ‘bowel program’, mainly ‘from below’ and nutritional support. No form of surgery helps these patients significantly, although a small number can be palliated by total colectomy and ileorectal anastomosis for a few years. Intestinal transplant is the only curative therapy and is not available to most.',\n", " 'md': 'The common pitfall with this condition is to look at the X-ray, assume a life-threatening obstruction and operate to find huge loops of colon and then to perform a stoma. These stomas are massive and bulky, prone to complications and generally fail to adequately relieve distension. Instead, these patients are best served by rectal decompression by tube or endoscopy, a regular ‘bowel program’, mainly ‘from below’ and nutritional support. No form of surgery helps these patients significantly, although a small number can be palliated by total colectomy and ileorectal anastomosis for a few years. Intestinal transplant is the only curative therapy and is not available to most.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.81, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'HIV-related Abdominal Emergencies',\n", " 'md': '## HIV-related Abdominal Emergencies',\n", " 'bBox': {'x': 86, 'y': 278, 'w': 279.57, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The high incidence of HIV/AIDS, and the associated opportunistic infections, in particular, tuberculosis, greatly increases the possible spectrum of pathology. The commonest abdominal complications of HIV/AIDS in our experience are Cytomegalovirus (CMV) enteritis and perforation in the young infant (3 to 18 months of age) and abdominal tuberculosis in the older child.\\n\\nCMV disease presents typically with acute abdominal distension, vomiting and cardiovascular collapse in a severely immunocompromised and malnourished child. At laparotomy, multiple, sometimes hundreds of small holes are found along the entire length of bowel. Histology will sometimes reveal the typical intracytoplasmic viral inclusions. Even with aggressive treatment, including the use of intravenous ganciclovir, the prognosis is poor.\\n\\nNever forget that the incidence of HIV infection in the general population is high (possibly 70% in hospitalized patients) and that appropriate protection of the surgeon and his assistants is crucial in all cases.',\n", " 'md': 'The high incidence of HIV/AIDS, and the associated opportunistic infections, in particular, tuberculosis, greatly increases the possible spectrum of pathology. The commonest abdominal complications of HIV/AIDS in our experience are Cytomegalovirus (CMV) enteritis and perforation in the young infant (3 to 18 months of age) and abdominal tuberculosis in the older child.\\n\\nCMV disease presents typically with acute abdominal distension, vomiting and cardiovascular collapse in a severely immunocompromised and malnourished child. At laparotomy, multiple, sometimes hundreds of small holes are found along the entire length of bowel. Histology will sometimes reveal the typical intracytoplasmic viral inclusions. Even with aggressive treatment, including the use of intravenous ganciclovir, the prognosis is poor.\\n\\nNever forget that the incidence of HIV infection in the general population is high (possibly 70% in hospitalized patients) and that appropriate protection of the surgeon and his assistants is crucial in all cases.',\n", " 'bBox': {'x': 72, 'y': 363, 'w': 467.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Traditional ‘Witch Doctor’ Enemas',\n", " 'md': '## Traditional ‘Witch Doctor’ Enemas',\n", " 'bBox': {'x': 86, 'y': 669, 'w': 261.75, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Although there is a paucity of literature on the topic, the use of\\n```',\n", " 'md': 'Although there is a paucity of literature on the topic, the use of\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 700,\n", " 'text': 'traditional muti enemas is commonplace among many of the African\\ntribes (see Figure 38.11). The addition of toxic chemicals by the\\ntraditional healer or sangoma, such as potassium dichromate (a potent\\ncaustic agent), can result in corrosive injuries causing tissue necrosis,\\nperforations and/or late strictures ( Figure 38.12). Mechanical\\ninstrumentation alone can result in direct rectal trauma and any of these\\ninjuries may lead to peritonitis and/or retroperitoneal necrotizing fasciitis.\\nThe clinical picture may be further complicated by the addition of\\nnephrotoxins, typically cantharidins (an extract which the Tswana tribe\\nderive from grinding the bodies of dead blister beetles which is used to\\naugment potency and as an abortifacient), resulting in acute renal failure.\\nPatients are often not forthcoming, with a history of having used\\ntraditional medicines and a very high index of suspicion is required.\\nStudies have shown that the majority of African infants and children\\nadmitted to hospital with gastroenteritis have already been\\nadministered traditional enemas. It is also vitally important to ascertain\\nif the onset of illness predated the administration of the muti or not. It is a\\ncommon mistake to blame all the sequelae on the potion and therefore\\nmiss other underlying conditions.',\n", " 'md': '```markdown\\n## Traditional Muti Enemas and Associated Risks\\n\\nTraditional muti enemas are commonplace among many of the African tribes (see Figure 38.11). The addition of toxic chemicals by the traditional healer or sangoma, such as potassium dichromate (a potent caustic agent), can result in corrosive injuries causing tissue necrosis, perforations, and/or late strictures (Figure 38.12). Mechanical instrumentation alone can result in direct rectal trauma, and any of these injuries may lead to peritonitis and/or retroperitoneal necrotizing fasciitis.\\n\\nThe clinical picture may be further complicated by the addition of nephrotoxins, typically cantharidins (an extract which the Tswana tribe derives from grinding the bodies of dead blister beetles, which is used to augment potency and as an abortifacient), resulting in acute renal failure. Patients are often not forthcoming with a history of having used traditional medicines, and a very high index of suspicion is required.\\n\\nStudies have shown that the majority of African infants and children admitted to hospital with gastroenteritis have already been administered traditional enemas. It is also vitally important to ascertain if the onset of illness predated the administration of the muti or not. It is a common mistake to blame all the sequelae on the potion and therefore miss other underlying conditions.\\n\\n### Figures\\n\\n- **Figure 38.11**: [Description of the image related to traditional muti enemas]\\n- **Figure 38.12**: [Description of the image related to corrosive injuries from toxic chemicals]\\n```\\n\\n### Notes:\\n- The text has been transcribed while excluding any diagonal text, headers, and footers.\\n- The figures are referenced but not described in detail as the actual images are not provided. Please replace the placeholder descriptions with actual content once the images are available.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Traditional Muti Enemas and Associated Risks',\n", " 'md': '## Traditional Muti Enemas and Associated Risks',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Traditional muti enemas are commonplace among many of the African tribes (see Figure 38.11). The addition of toxic chemicals by the traditional healer or sangoma, such as potassium dichromate (a potent caustic agent), can result in corrosive injuries causing tissue necrosis, perforations, and/or late strictures (Figure 38.12). Mechanical instrumentation alone can result in direct rectal trauma, and any of these injuries may lead to peritonitis and/or retroperitoneal necrotizing fasciitis.\\n\\nThe clinical picture may be further complicated by the addition of nephrotoxins, typically cantharidins (an extract which the Tswana tribe derives from grinding the bodies of dead blister beetles, which is used to augment potency and as an abortifacient), resulting in acute renal failure. Patients are often not forthcoming with a history of having used traditional medicines, and a very high index of suspicion is required.\\n\\nStudies have shown that the majority of African infants and children admitted to hospital with gastroenteritis have already been administered traditional enemas. It is also vitally important to ascertain if the onset of illness predated the administration of the muti or not. It is a common mistake to blame all the sequelae on the potion and therefore miss other underlying conditions.',\n", " 'md': 'Traditional muti enemas are commonplace among many of the African tribes (see Figure 38.11). The addition of toxic chemicals by the traditional healer or sangoma, such as potassium dichromate (a potent caustic agent), can result in corrosive injuries causing tissue necrosis, perforations, and/or late strictures (Figure 38.12). Mechanical instrumentation alone can result in direct rectal trauma, and any of these injuries may lead to peritonitis and/or retroperitoneal necrotizing fasciitis.\\n\\nThe clinical picture may be further complicated by the addition of nephrotoxins, typically cantharidins (an extract which the Tswana tribe derives from grinding the bodies of dead blister beetles, which is used to augment potency and as an abortifacient), resulting in acute renal failure. Patients are often not forthcoming with a history of having used traditional medicines, and a very high index of suspicion is required.\\n\\nStudies have shown that the majority of African infants and children admitted to hospital with gastroenteritis have already been administered traditional enemas. It is also vitally important to ascertain if the onset of illness predated the administration of the muti or not. It is a common mistake to blame all the sequelae on the potion and therefore miss other underlying conditions.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.94, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures',\n", " 'md': '### Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 38.11**: [Description of the image related to traditional muti enemas]\\n- **Figure 38.12**: [Description of the image related to corrosive injuries from toxic chemicals]\\n```',\n", " 'md': '- **Figure 38.11**: [Description of the image related to traditional muti enemas]\\n- **Figure 38.12**: [Description of the image related to corrosive injuries from toxic chemicals]\\n```',\n", " 'bBox': {'x': 353, 'y': 152, 'w': 44.77, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text has been transcribed while excluding any diagonal text, headers, and footers.\\n- The figures are referenced but not described in detail as the actual images are not provided. Please replace the placeholder descriptions with actual content once the images are available.',\n", " 'md': '- The text has been transcribed while excluding any diagonal text, headers, and footers.\\n- The figures are referenced but not described in detail as the actual images are not provided. Please replace the placeholder descriptions with actual content once the images are available.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'traditional healer or '},\n", " {'text': 'Figure 38.12). instrumentation alone can result in direct rectal trauma and any of these'}]},\n", " {'page': 701,\n", " 'text': ' Ooo\\n PeRYA200+1+\\nFigure 38.11. “Hey Doc, let me just call for a second opinion. Yes, I am calling my\\nsangoma.”',\n", " 'md': '```markdown\\n### Page Content\\n\\n- **Figure 38.11**: “Hey Doc, let me just call for a second opinion. Yes, I am calling my sangoma.”\\n\\n#### Image Description\\n- **Figure 38**: This image likely depicts a humorous or satirical scenario involving a patient seeking a second opinion from a traditional healer, referred to as a \"sangoma.\" The context suggests a light-hearted take on the medical profession and alternative medicine.\\n\\n\\n```',\n", " 'images': [{'name': 'img_p700_1.png',\n", " 'height': 562,\n", " 'width': 803,\n", " 'x': 107.27999999999884,\n", " 'y': 82.79999999999995,\n", " 'original_width': 1380,\n", " 'original_height': 964}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Page Content',\n", " 'md': '### Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 38.11**: “Hey Doc, let me just call for a second opinion. Yes, I am calling my sangoma.”',\n", " 'md': '- **Figure 38.11**: “Hey Doc, let me just call for a second opinion. Yes, I am calling my sangoma.”',\n", " 'bBox': {'x': 75, 'y': 393, 'w': 55.75, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Image Description',\n", " 'md': '#### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 38**: This image likely depicts a humorous or satirical scenario involving a patient seeking a second opinion from a traditional healer, referred to as a \"sangoma.\" The context suggests a light-hearted take on the medical profession and alternative medicine.\\n\\n\\n```',\n", " 'md': '- **Figure 38**: This image likely depicts a humorous or satirical scenario involving a patient seeking a second opinion from a traditional healer, referred to as a \"sangoma.\" The context suggests a light-hearted take on the medical profession and alternative medicine.\\n\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 702,\n", " 'text': ' 750\\n veise\\nFigure 38.12. A sagittal abdominal CT in a 5-year-old boy treated erroneously for acute\\nappendicitis found later to have a large posterior rectal perforation with a retrorectal\\ncollection — a complication of a ‘traditional enema’. The arrows on the left point to the\\nbladder and rectum, whereas the large air-filled structure posterior to the rectum, arrowed\\non the right, is the collection.\\n\\n Sigmoid volvulus and ileosigmoid knotting (see\\n Chapter 27)\\n\\n Unlike in the ‘developed’ world where sigmoid volvulus typically affects\\nelderly patients, in Africa it tends to occur in younger males. The African\\nvariety of sigmoid volvulus is associated with a degree of mega-\\ncolon/rectum and the bowel wall and mesosigmoid are thick and\\nrelatively resistant to ischemia. Bowel necrosis is therefore less common\\nthan in the thinner-walled colons of the older Western counterparts, but\\nstill occurs when a prolonged delay in presentation occurs. Patients',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Figure 38.12\\nA sagittal abdominal CT in a 5-year-old boy treated erroneously for acute appendicitis found later to have a large posterior rectal perforation with a retrorectal collection — a complication of a ‘traditional enema’. The arrows on the left point to the bladder and rectum, whereas the large air-filled structure posterior to the rectum, arrowed on the right, is the collection.\\n\\n### Summary of Figure 38.12\\n- **Description**: The CT scan shows a sagittal view of the abdomen, highlighting a significant posterior rectal perforation and a retrorectal collection. The image includes arrows indicating the bladder and rectum, as well as the air-filled structure behind the rectum.\\n- **Caption**: A sagittal abdominal CT in a 5-year-old boy treated erroneously for acute appendicitis found later to have a large posterior rectal perforation with a retrorectal collection — a complication of a ‘traditional enema’.\\n\\n## Text Content\\n- Sigmoid volvulus and ileosigmoid knotting (see Chapter 27).\\n\\nUnlike in the ‘developed’ world where sigmoid volvulus typically affects elderly patients, in Africa it tends to occur in younger males. The African variety of sigmoid volvulus is associated with a degree of megacolon/rectum and the bowel wall and mesosigmoid are thick and relatively resistant to ischemia. Bowel necrosis is therefore less common than in the thinner-walled colons of the older Western counterparts, but still occurs when a prolonged delay in presentation occurs. Patients\\n```',\n", " 'images': [{'name': 'img_p701_1.png',\n", " 'height': 747,\n", " 'width': 542,\n", " 'x': 172.07999999999993,\n", " 'y': 71.99999999999994,\n", " 'original_width': 930,\n", " 'original_height': 1282}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 38.12',\n", " 'md': '## Figure 38.12',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A sagittal abdominal CT in a 5-year-old boy treated erroneously for acute appendicitis found later to have a large posterior rectal perforation with a retrorectal collection — a complication of a ‘traditional enema’. The arrows on the left point to the bladder and rectum, whereas the large air-filled structure posterior to the rectum, arrowed on the right, is the collection.',\n", " 'md': 'A sagittal abdominal CT in a 5-year-old boy treated erroneously for acute appendicitis found later to have a large posterior rectal perforation with a retrorectal collection — a complication of a ‘traditional enema’. The arrows on the left point to the bladder and rectum, whereas the large air-filled structure posterior to the rectum, arrowed on the right, is the collection.',\n", " 'bBox': {'x': 75, 'y': 474, 'w': 460.83, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary of Figure 38.12',\n", " 'md': '### Summary of Figure 38.12',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: The CT scan shows a sagittal view of the abdomen, highlighting a significant posterior rectal perforation and a retrorectal collection. The image includes arrows indicating the bladder and rectum, as well as the air-filled structure behind the rectum.\\n- **Caption**: A sagittal abdominal CT in a 5-year-old boy treated erroneously for acute appendicitis found later to have a large posterior rectal perforation with a retrorectal collection — a complication of a ‘traditional enema’.',\n", " 'md': '- **Description**: The CT scan shows a sagittal view of the abdomen, highlighting a significant posterior rectal perforation and a retrorectal collection. The image includes arrows indicating the bladder and rectum, as well as the air-filled structure behind the rectum.\\n- **Caption**: A sagittal abdominal CT in a 5-year-old boy treated erroneously for acute appendicitis found later to have a large posterior rectal perforation with a retrorectal collection — a complication of a ‘traditional enema’.',\n", " 'bBox': {'x': 75, 'y': 474, 'w': 460.24, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Content',\n", " 'md': '## Text Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Sigmoid volvulus and ileosigmoid knotting (see Chapter 27).\\n\\nUnlike in the ‘developed’ world where sigmoid volvulus typically affects elderly patients, in Africa it tends to occur in younger males. The African variety of sigmoid volvulus is associated with a degree of megacolon/rectum and the bowel wall and mesosigmoid are thick and relatively resistant to ischemia. Bowel necrosis is therefore less common than in the thinner-walled colons of the older Western counterparts, but still occurs when a prolonged delay in presentation occurs. Patients\\n```',\n", " 'md': '- Sigmoid volvulus and ileosigmoid knotting (see Chapter 27).\\n\\nUnlike in the ‘developed’ world where sigmoid volvulus typically affects elderly patients, in Africa it tends to occur in younger males. The African variety of sigmoid volvulus is associated with a degree of megacolon/rectum and the bowel wall and mesosigmoid are thick and relatively resistant to ischemia. Bowel necrosis is therefore less common than in the thinner-walled colons of the older Western counterparts, but still occurs when a prolonged delay in presentation occurs. Patients\\n```',\n", " 'bBox': {'x': 72, 'y': 554, 'w': 467.84, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 703,\n", " 'text': 'presenting with bowel necrosis require prompt resuscitation and\\nemergency resection. Primary anastomosis is considered safe in cases\\nwhere an experienced operator is present and the patient’s condition is\\nstable. Cases presenting without signs of bowel necrosis or perforation\\nshould undergo sigmoidoscopic decompression. This is best achieved via\\nthe use of a rigid sigmoidoscope inserted with the patient kneeling on all\\nfours with their buttocks elevated above the head and shoulders.\\nTypically, a ‘flatus’ (rectal) tube is inserted following successful\\ndecompression. Due to the high recurrence rate, patients should have a\\ndefinitive procedure during the same hospital admission ( Chapter 27).\\n\\n Ileosigmoid knotting is a rare condition where the ileum wraps itself\\ntypically around the sigmoid colon causing a closed loop obstruction with\\nthe potential for gangrene in both viscera. The ileum may also wrap\\naround the transverse colon. It occurs mainly in Africa, Asia and the\\nMiddle East, typically in healthy individuals of middle age. It is thought to\\nbe caused by redundancy or narrowing of the base of the mesenteries of\\nboth the sigmoid and the ileum and possibly aggravated by a high bulk\\ndiet. Principles of management include resection of bowel when\\nnecessary and applying judgment as above regarding the advisability of\\nprimary anastomosis. When the abdomen is opened a mass of\\ngangrenous bowel presents to the operator and it may take some time to\\nwork out what is going on. ħowever, it is important to resect the bowel\\nintact to prevent the lethal bacterial soup from spilling into the abdominal\\ncavity and aggravating septic shock.\\n\\n Typhoid fever\\n\\n Infection contracted by feco-oral transmission of the Gram-negative\\nbacillus, Salmonella typhi, is still an important cause of small bowel\\nperforation and peritonitis in poorer communities. Initially characterized\\nby high fevers and a relative leukopenia, a small percentage of patients\\nwill develop intestinal perforations, usually in the second to fourth weeks\\nof illness.\\n\\n Most perforations occur outside hospital but some patients may\\nperforate whilst in hospital when the diagnosis may be difficult. Typhoid\\npatients often have distended uncomfortable abdomens (‘typhoid belly’)',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nPresenting with bowel necrosis requires prompt resuscitation and emergency resection. Primary anastomosis is considered safe in cases where an experienced operator is present and the patient’s condition is stable. Cases presenting without signs of bowel necrosis or perforation should undergo sigmoidoscopic decompression. This is best achieved via the use of a rigid sigmoidoscope inserted with the patient kneeling on all fours with their buttocks elevated above the head and shoulders. Typically, a ‘flatus’ (rectal) tube is inserted following successful decompression. Due to the high recurrence rate, patients should have a definitive procedure during the same hospital admission.\\n\\nIleosigmoid knotting is a rare condition where the ileum wraps itself typically around the sigmoid colon causing a closed loop obstruction with the potential for gangrene in both viscera. The ileum may also wrap around the transverse colon. It occurs mainly in Africa, Asia, and the Middle East, typically in healthy individuals of middle age. It is thought to be caused by redundancy or narrowing of the base of the mesenteries of both the sigmoid and the ileum and possibly aggravated by a high bulk diet. Principles of management include resection of bowel when necessary and applying judgment as above regarding the advisability of primary anastomosis. When the abdomen is opened, a mass of gangrenous bowel presents to the operator and it may take some time to work out what is going on. However, it is important to resect the bowel intact to prevent the lethal bacterial soup from spilling into the abdominal cavity and aggravating septic shock.\\n\\n### Typhoid Fever\\n\\nInfection contracted by feco-oral transmission of the Gram-negative bacillus, *Salmonella typhi*, is still an important cause of small bowel perforation and peritonitis in poorer communities. Initially characterized by high fevers and a relative leukopenia, a small percentage of patients will develop intestinal perforations, usually in the second to fourth weeks of illness.\\n\\nMost perforations occur outside hospital but some patients may perforate whilst in hospital when the diagnosis may be difficult. Typhoid patients often have distended uncomfortable abdomens (‘typhoid belly’).\\n\\n## Figures and Images\\n\\n- **Figure 1**: \\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Presenting with bowel necrosis requires prompt resuscitation and emergency resection. Primary anastomosis is considered safe in cases where an experienced operator is present and the patient’s condition is stable. Cases presenting without signs of bowel necrosis or perforation should undergo sigmoidoscopic decompression. This is best achieved via the use of a rigid sigmoidoscope inserted with the patient kneeling on all fours with their buttocks elevated above the head and shoulders. Typically, a ‘flatus’ (rectal) tube is inserted following successful decompression. Due to the high recurrence rate, patients should have a definitive procedure during the same hospital admission.\\n\\nIleosigmoid knotting is a rare condition where the ileum wraps itself typically around the sigmoid colon causing a closed loop obstruction with the potential for gangrene in both viscera. The ileum may also wrap around the transverse colon. It occurs mainly in Africa, Asia, and the Middle East, typically in healthy individuals of middle age. It is thought to be caused by redundancy or narrowing of the base of the mesenteries of both the sigmoid and the ileum and possibly aggravated by a high bulk diet. Principles of management include resection of bowel when necessary and applying judgment as above regarding the advisability of primary anastomosis. When the abdomen is opened, a mass of gangrenous bowel presents to the operator and it may take some time to work out what is going on. However, it is important to resect the bowel intact to prevent the lethal bacterial soup from spilling into the abdominal cavity and aggravating septic shock.',\n", " 'md': 'Presenting with bowel necrosis requires prompt resuscitation and emergency resection. Primary anastomosis is considered safe in cases where an experienced operator is present and the patient’s condition is stable. Cases presenting without signs of bowel necrosis or perforation should undergo sigmoidoscopic decompression. This is best achieved via the use of a rigid sigmoidoscope inserted with the patient kneeling on all fours with their buttocks elevated above the head and shoulders. Typically, a ‘flatus’ (rectal) tube is inserted following successful decompression. Due to the high recurrence rate, patients should have a definitive procedure during the same hospital admission.\\n\\nIleosigmoid knotting is a rare condition where the ileum wraps itself typically around the sigmoid colon causing a closed loop obstruction with the potential for gangrene in both viscera. The ileum may also wrap around the transverse colon. It occurs mainly in Africa, Asia, and the Middle East, typically in healthy individuals of middle age. It is thought to be caused by redundancy or narrowing of the base of the mesenteries of both the sigmoid and the ileum and possibly aggravated by a high bulk diet. Principles of management include resection of bowel when necessary and applying judgment as above regarding the advisability of primary anastomosis. When the abdomen is opened, a mass of gangrenous bowel presents to the operator and it may take some time to work out what is going on. However, it is important to resect the bowel intact to prevent the lethal bacterial soup from spilling into the abdominal cavity and aggravating septic shock.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 467.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Typhoid Fever',\n", " 'md': '### Typhoid Fever',\n", " 'bBox': {'x': 86, 'y': 528, 'w': 107.29, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Infection contracted by feco-oral transmission of the Gram-negative bacillus, *Salmonella typhi*, is still an important cause of small bowel perforation and peritonitis in poorer communities. Initially characterized by high fevers and a relative leukopenia, a small percentage of patients will develop intestinal perforations, usually in the second to fourth weeks of illness.\\n\\nMost perforations occur outside hospital but some patients may perforate whilst in hospital when the diagnosis may be difficult. Typhoid patients often have distended uncomfortable abdomens (‘typhoid belly’).',\n", " 'md': 'Infection contracted by feco-oral transmission of the Gram-negative bacillus, *Salmonella typhi*, is still an important cause of small bowel perforation and peritonitis in poorer communities. Initially characterized by high fevers and a relative leukopenia, a small percentage of patients will develop intestinal perforations, usually in the second to fourth weeks of illness.\\n\\nMost perforations occur outside hospital but some patients may perforate whilst in hospital when the diagnosis may be difficult. Typhoid patients often have distended uncomfortable abdomens (‘typhoid belly’).',\n", " 'bBox': {'x': 72, 'y': 614, 'w': 467.76, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures and Images',\n", " 'md': '## Figures and Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: \\n```',\n", " 'md': '- **Figure 1**: \\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 704,\n", " 'text': 'but a sudden increase in pain and clinical deterioration whilst on\\ntreatment would be the trigger for an urgent laparotomy. The bradycardia\\nand leukopenia of typhoid may also mask the development of septicemia\\nfrom a perforation.\\n\\n Following a perforation, mortality rises exponentially with a delay to\\nsurgical intervention. Expeditious resuscitation and urgent surgical\\nexploration are required. Perforations may be minimally debrided and\\nsimply closed. Multiple perforations may require segmental resection,\\ntypically of the terminal ileum. Primary anastomosis is deemed safe\\nunless the patient is physiologically compromised, in which case the\\nbowel is best exteriorized as a stoma. Appropriate antibiotic cover is vital\\nto success. With increases in resistance to amoxicillin and\\nchloramphenicol, a quinolone antibiotic is a safer first choice in very ill\\npatients. The diagnosis may be confirmed by histology of the resected\\nspecimen, a positive blood culture or positive serology in the form of a\\nWidal test.\\n\\n Melena can also occur in typhoid fever, the clue being the clinical\\npresentation and obviously not being amenable to endoscopic control.\\nThe terminal ileum may require resection if bleeding does not settle\\nspontaneously as the bleeding ulcer could be in any of the involved\\nPeyer’s patches.\\n\\n Sickle cell disease (SCD)\\n\\n This autosomal recessive hemoglobinopathy is relatively common in\\nparts of Central Africa. ħeterozygotes, who have only one abnormal\\ngene, have a sickle cell trait (SCT); a beneficial condition that confers a\\nnatural survival benefit against malaria.\\n\\n Unfortunately, individuals with a double dose of ħbS (i.e. sickle cell\\ndisease) have no such luck! The abnormal hemoglobin becomes\\nunstable under conditions of low oxygen tension and aggregates into\\nlarge polymers. This results in distortion of the erythrocytes and a\\nreduction in their deformability. The disease is characterized by a chronic\\nhemolytic anemia and painful vaso-occlusive crises. Acute abdominal',\n", " 'md': '```markdown\\n## Clinical Considerations in Typhoid Fever and Sickle Cell Disease\\n\\n### Typhoid Fever\\n\\nA sudden increase in pain and clinical deterioration whilst on treatment would be the trigger for an urgent laparotomy. The bradycardia and leukopenia of typhoid may also mask the development of septicemia from a perforation.\\n\\nFollowing a perforation, mortality rises exponentially with a delay to surgical intervention. Expeditious resuscitation and urgent surgical exploration are required. Perforations may be minimally debrided and simply closed. Multiple perforations may require segmental resection, typically of the terminal ileum. Primary anastomosis is deemed safe unless the patient is physiologically compromised, in which case the bowel is best exteriorized as a stoma. Appropriate antibiotic cover is vital to success. With increases in resistance to amoxicillin and chloramphenicol, a quinolone antibiotic is a safer first choice in very ill patients. The diagnosis may be confirmed by histology of the resected specimen, a positive blood culture, or positive serology in the form of a Widal test.\\n\\nMelena can also occur in typhoid fever, the clue being the clinical presentation and obviously not being amenable to endoscopic control. The terminal ileum may require resection if bleeding does not settle spontaneously as the bleeding ulcer could be in any of the involved Peyer’s patches.\\n\\n### Sickle Cell Disease (SCD)\\n\\nThis autosomal recessive hemoglobinopathy is relatively common in parts of Central Africa. Heterozygotes, who have only one abnormal gene, have a sickle cell trait (SCT); a beneficial condition that confers a natural survival benefit against malaria.\\n\\nUnfortunately, individuals with a double dose of HbS (i.e., sickle cell disease) have no such luck! The abnormal hemoglobin becomes unstable under conditions of low oxygen tension and aggregates into large polymers. This results in distortion of the erythrocytes and a reduction in their deformability. The disease is characterized by a chronic hemolytic anemia and painful vaso-occlusive crises. Acute abdominal pain is a common symptom associated with this condition.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Considerations in Typhoid Fever and Sickle Cell Disease',\n", " 'md': '## Clinical Considerations in Typhoid Fever and Sickle Cell Disease',\n", " 'bBox': {'x': 295, 'y': 286, 'w': 24, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Typhoid Fever',\n", " 'md': '### Typhoid Fever',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A sudden increase in pain and clinical deterioration whilst on treatment would be the trigger for an urgent laparotomy. The bradycardia and leukopenia of typhoid may also mask the development of septicemia from a perforation.\\n\\nFollowing a perforation, mortality rises exponentially with a delay to surgical intervention. Expeditious resuscitation and urgent surgical exploration are required. Perforations may be minimally debrided and simply closed. Multiple perforations may require segmental resection, typically of the terminal ileum. Primary anastomosis is deemed safe unless the patient is physiologically compromised, in which case the bowel is best exteriorized as a stoma. Appropriate antibiotic cover is vital to success. With increases in resistance to amoxicillin and chloramphenicol, a quinolone antibiotic is a safer first choice in very ill patients. The diagnosis may be confirmed by histology of the resected specimen, a positive blood culture, or positive serology in the form of a Widal test.\\n\\nMelena can also occur in typhoid fever, the clue being the clinical presentation and obviously not being amenable to endoscopic control. The terminal ileum may require resection if bleeding does not settle spontaneously as the bleeding ulcer could be in any of the involved Peyer’s patches.',\n", " 'md': 'A sudden increase in pain and clinical deterioration whilst on treatment would be the trigger for an urgent laparotomy. The bradycardia and leukopenia of typhoid may also mask the development of septicemia from a perforation.\\n\\nFollowing a perforation, mortality rises exponentially with a delay to surgical intervention. Expeditious resuscitation and urgent surgical exploration are required. Perforations may be minimally debrided and simply closed. Multiple perforations may require segmental resection, typically of the terminal ileum. Primary anastomosis is deemed safe unless the patient is physiologically compromised, in which case the bowel is best exteriorized as a stoma. Appropriate antibiotic cover is vital to success. With increases in resistance to amoxicillin and chloramphenicol, a quinolone antibiotic is a safer first choice in very ill patients. The diagnosis may be confirmed by histology of the resected specimen, a positive blood culture, or positive serology in the form of a Widal test.\\n\\nMelena can also occur in typhoid fever, the clue being the clinical presentation and obviously not being amenable to endoscopic control. The terminal ileum may require resection if bleeding does not settle spontaneously as the bleeding ulcer could be in any of the involved Peyer’s patches.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.9, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Sickle Cell Disease (SCD)',\n", " 'md': '### Sickle Cell Disease (SCD)',\n", " 'bBox': {'x': 86, 'y': 497, 'w': 195.88, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This autosomal recessive hemoglobinopathy is relatively common in parts of Central Africa. Heterozygotes, who have only one abnormal gene, have a sickle cell trait (SCT); a beneficial condition that confers a natural survival benefit against malaria.\\n\\nUnfortunately, individuals with a double dose of HbS (i.e., sickle cell disease) have no such luck! The abnormal hemoglobin becomes unstable under conditions of low oxygen tension and aggregates into large polymers. This results in distortion of the erythrocytes and a reduction in their deformability. The disease is characterized by a chronic hemolytic anemia and painful vaso-occlusive crises. Acute abdominal pain is a common symptom associated with this condition.\\n```',\n", " 'md': 'This autosomal recessive hemoglobinopathy is relatively common in parts of Central Africa. Heterozygotes, who have only one abnormal gene, have a sickle cell trait (SCT); a beneficial condition that confers a natural survival benefit against malaria.\\n\\nUnfortunately, individuals with a double dose of HbS (i.e., sickle cell disease) have no such luck! The abnormal hemoglobin becomes unstable under conditions of low oxygen tension and aggregates into large polymers. This results in distortion of the erythrocytes and a reduction in their deformability. The disease is characterized by a chronic hemolytic anemia and painful vaso-occlusive crises. Acute abdominal pain is a common symptom associated with this condition.\\n```',\n", " 'bBox': {'x': 72, 'y': 286, 'w': 467.79, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 705,\n", " 'text': 'pain is a common mode of presentation and may be difficult to\\ndifferentiate from other surgical or urological emergencies. The\\nfollowing clues may point towards a ‘sickle cell crisis’:\\n\\n • Pain occurs at multiple sites; typically the chest, back and\\n extremities.\\n • The pattern of pain is similar to prior episodes.\\n • Bowel sounds are preserved.\\n • Improvement occurs with general supportive measures such as\\n hydration, oxygenation and the judicious use of analgesia.\\n • A precipitating factor (trigger) is present (e.g. a respiratory tract\\n infection).\\n\\n Most sickle cell crises will settle on supportive therapy, but very rarely\\nischemic bowel perforations may require surgery and massive splenic or\\nhepatic sequestration crises may prove fatal. The usual commonly\\nencountered surgical pathologies also occur in this patient group and\\nabdominal CT scanning has proven to be a reliable modality that will\\nidentify most surgical conditions, but ultimately clinical observation of the\\npatient’s course will determine the appropriate management. Diagnosis\\nof sickle cell disease in suspected cases is confirmed by observing sickle\\ncells on a peripheral blood smear.\\n\\n To recap\\n\\n Acute abdominal conditions challenge surgeons in Africa not so\\nmuch because of their disease diversity but because the patients\\nare often severely ill, their disease neglected, and the working\\nenvironment is poorly staffed and equipped. Sophisticated peri-\\noperative care including intensive care which has revolutionized the\\nresults of the treatment of these patients in the West is simply not present\\nin the vast majority of hospitals. Where such facilities are available, they\\nhave to be used for the greatest possible benefit and difficult decision-\\nmaking is often required. The withdrawal of care in some patients with no\\nmeaningful expectation of survival is a painful and frequent reality facing\\nhealthcare providers. African surgeons have to be innovative and tailor',\n", " 'md': '```markdown\\n# Sickle Cell Crisis Presentation\\n\\nPain is a common mode of presentation and may be difficult to differentiate from other surgical or urological emergencies. The following clues may point towards a ‘sickle cell crisis’:\\n\\n- Pain occurs at multiple sites; typically the chest, back, and extremities.\\n- The pattern of pain is similar to prior episodes.\\n- Bowel sounds are preserved.\\n- Improvement occurs with general supportive measures such as hydration, oxygenation, and the judicious use of analgesia.\\n- A precipitating factor (trigger) is present (e.g., a respiratory tract infection).\\n\\nMost sickle cell crises will settle on supportive therapy, but very rarely ischemic bowel perforations may require surgery and massive splenic or hepatic sequestration crises may prove fatal. The usual commonly encountered surgical pathologies also occur in this patient group, and abdominal CT scanning has proven to be a reliable modality that will identify most surgical conditions. Ultimately, clinical observation of the patient’s course will determine the appropriate management. Diagnosis of sickle cell disease in suspected cases is confirmed by observing sickle cells on a peripheral blood smear.\\n\\n## To Recap\\n\\nAcute abdominal conditions challenge surgeons in Africa not so much because of their disease diversity but because the patients are often severely ill, their disease neglected, and the working environment is poorly staffed and equipped. Sophisticated peri-operative care, including intensive care, which has revolutionized the results of the treatment of these patients in the West, is simply not present in the vast majority of hospitals. Where such facilities are available, they have to be used for the greatest possible benefit, and difficult decision-making is often required. The withdrawal of care in some patients with no meaningful expectation of survival is a painful and frequent reality facing healthcare providers. African surgeons have to be innovative and tailor their approaches to the unique challenges they face.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Sickle Cell Crisis Presentation',\n", " 'md': '# Sickle Cell Crisis Presentation',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Pain is a common mode of presentation and may be difficult to differentiate from other surgical or urological emergencies. The following clues may point towards a ‘sickle cell crisis’:\\n\\n- Pain occurs at multiple sites; typically the chest, back, and extremities.\\n- The pattern of pain is similar to prior episodes.\\n- Bowel sounds are preserved.\\n- Improvement occurs with general supportive measures such as hydration, oxygenation, and the judicious use of analgesia.\\n- A precipitating factor (trigger) is present (e.g., a respiratory tract infection).\\n\\nMost sickle cell crises will settle on supportive therapy, but very rarely ischemic bowel perforations may require surgery and massive splenic or hepatic sequestration crises may prove fatal. The usual commonly encountered surgical pathologies also occur in this patient group, and abdominal CT scanning has proven to be a reliable modality that will identify most surgical conditions. Ultimately, clinical observation of the patient’s course will determine the appropriate management. Diagnosis of sickle cell disease in suspected cases is confirmed by observing sickle cells on a peripheral blood smear.',\n", " 'md': 'Pain is a common mode of presentation and may be difficult to differentiate from other surgical or urological emergencies. The following clues may point towards a ‘sickle cell crisis’:\\n\\n- Pain occurs at multiple sites; typically the chest, back, and extremities.\\n- The pattern of pain is similar to prior episodes.\\n- Bowel sounds are preserved.\\n- Improvement occurs with general supportive measures such as hydration, oxygenation, and the judicious use of analgesia.\\n- A precipitating factor (trigger) is present (e.g., a respiratory tract infection).\\n\\nMost sickle cell crises will settle on supportive therapy, but very rarely ischemic bowel perforations may require surgery and massive splenic or hepatic sequestration crises may prove fatal. The usual commonly encountered surgical pathologies also occur in this patient group, and abdominal CT scanning has proven to be a reliable modality that will identify most surgical conditions. Ultimately, clinical observation of the patient’s course will determine the appropriate management. Diagnosis of sickle cell disease in suspected cases is confirmed by observing sickle cells on a peripheral blood smear.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.7, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'To Recap',\n", " 'md': '## To Recap',\n", " 'bBox': {'x': 86, 'y': 512, 'w': 67.75, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Acute abdominal conditions challenge surgeons in Africa not so much because of their disease diversity but because the patients are often severely ill, their disease neglected, and the working environment is poorly staffed and equipped. Sophisticated peri-operative care, including intensive care, which has revolutionized the results of the treatment of these patients in the West, is simply not present in the vast majority of hospitals. Where such facilities are available, they have to be used for the greatest possible benefit, and difficult decision-making is often required. The withdrawal of care in some patients with no meaningful expectation of survival is a painful and frequent reality facing healthcare providers. African surgeons have to be innovative and tailor their approaches to the unique challenges they face.\\n```',\n", " 'md': 'Acute abdominal conditions challenge surgeons in Africa not so much because of their disease diversity but because the patients are often severely ill, their disease neglected, and the working environment is poorly staffed and equipped. Sophisticated peri-operative care, including intensive care, which has revolutionized the results of the treatment of these patients in the West, is simply not present in the vast majority of hospitals. Where such facilities are available, they have to be used for the greatest possible benefit, and difficult decision-making is often required. The withdrawal of care in some patients with no meaningful expectation of survival is a painful and frequent reality facing healthcare providers. African surgeons have to be innovative and tailor their approaches to the unique challenges they face.\\n```',\n", " 'bBox': {'x': 72, 'y': 648, 'w': 467.6, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 706,\n", " 'text': 'the patient’s treatment according to their facilities and circumstances.\\nPatients’ physiological reserves are frequently compromised by\\nmalnutrition and severe infectious diseases, particularly\\ntuberculosis and HIV/AIDS, and the pressure is on the surgeon to\\n“get it right the first time with the simplest and safest operation”.\\nThere is no leeway for errors of operative strategy!\\n\\n “After climbing a great hill, one only finds that there are\\n many more hills to climb.”\\n Nelson Mandela\\n\\n1 I wish to thank Dr. B. Ramana (Kolkata) for his wise advice.\\n2 Thanks to Dr. Slava Ryndine and Dr. Matt Oliver for their advice.',\n", " 'md': '```markdown\\nPatients’ physiological reserves are frequently compromised by malnutrition and severe infectious diseases, particularly tuberculosis and HIV/AIDS, and the pressure is on the surgeon to “get it right the first time with the simplest and safest operation”. There is no leeway for errors of operative strategy!\\n\\n“After climbing a great hill, one only finds that there are many more hills to climb.”\\n— Nelson Mandela\\n\\n1. I wish to thank Dr. B. Ramana (Kolkata) for his wise advice.\\n2. Thanks to Dr. Slava Ryndine and Dr. Matt Oliver for their advice.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nPatients’ physiological reserves are frequently compromised by malnutrition and severe infectious diseases, particularly tuberculosis and HIV/AIDS, and the pressure is on the surgeon to “get it right the first time with the simplest and safest operation”. There is no leeway for errors of operative strategy!\\n\\n“After climbing a great hill, one only finds that there are many more hills to climb.”\\n— Nelson Mandela\\n\\n1. I wish to thank Dr. B. Ramana (Kolkata) for his wise advice.\\n2. Thanks to Dr. Slava Ryndine and Dr. Matt Oliver for their advice.\\n```',\n", " 'md': '```markdown\\nPatients’ physiological reserves are frequently compromised by malnutrition and severe infectious diseases, particularly tuberculosis and HIV/AIDS, and the pressure is on the surgeon to “get it right the first time with the simplest and safest operation”. There is no leeway for errors of operative strategy!\\n\\n“After climbing a great hill, one only finds that there are many more hills to climb.”\\n— Nelson Mandela\\n\\n1. I wish to thank Dr. B. Ramana (Kolkata) for his wise advice.\\n2. Thanks to Dr. Slava Ryndine and Dr. Matt Oliver for their advice.\\n```',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 453.45, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}, {'text': '2'}]},\n", " {'page': 707,\n", " 'text': 'Chapter 39\\nAbdominal drainage\\nMoshe Schein and Paul N. Rogers\\n\\n The more imperfect the technique of the surgeon the\\n greater the necessity for drainage.\\n William Stewart Halsted\\n\\n The history of abdominal drainage is as old as the history of surgery.\\nħowever, abdominal drainage was always a subject of controversy,\\npracticed in confusion and subjected to local dogmas. One hundred\\nyears ago there were ardent enthusiasts of drainage, like Robert Lawson\\nTait, who stated: “When in doubt drain!” Then there were the skeptics,\\nlike J. L. Yates, who understood that: “Drainage of the general peritoneal\\ncavity is a physical and physiological impossibility.” And, as always, there\\nwere the undecided, such as Joseph Price: “There are those who\\nardently advocate it, there are those who in great part reject it, there are\\nthose who are lukewarm concerning it, and finally, some who, without\\nconvictions, are either for or against it… as chance or whim, not logic\\nmay determine.”\\n\\n A century has passed, during which operative surgery and\\nsupporting care have progressed astonishingly; but, looking around\\nus, it seems that not much has changed concerning the use of\\ndrains — the same old chaos. So please forget for a moment the\\nlocal dogma, dictated by your boss or mentor and listen to us.\\n\\n In this chapter we will discuss when and how to use intra-abdominal',\n", " 'md': '```markdown\\n# Chapter 39: Abdominal Drainage\\n**Authors:** Moshe Schein and Paul N. Rogers\\n\\n> \"The more imperfect the technique of the surgeon the greater the necessity for drainage.\"\\n> — William Stewart Halsted\\n\\nThe history of abdominal drainage is as old as the history of surgery. However, abdominal drainage was always a subject of controversy, practiced in confusion and subjected to local dogmas. One hundred years ago there were ardent enthusiasts of drainage, like Robert Lawson Tait, who stated: “When in doubt drain!” Then there were the skeptics, like J. L. Yates, who understood that: “Drainage of the general peritoneal cavity is a physical and physiological impossibility.” And, as always, there were the undecided, such as Joseph Price: “There are those who ardently advocate it, there are those who in great part reject it, there are those who are lukewarm concerning it, and finally, some who, without convictions, are either for or against it… as chance or whim, not logic may determine.”\\n\\nA century has passed, during which operative surgery and supporting care have progressed astonishingly; but, looking around us, it seems that not much has changed concerning the use of drains — the same old chaos. So please forget for a moment the local dogma, dictated by your boss or mentor and listen to us.\\n\\nIn this chapter we will discuss when and how to use intra-abdominal drainage.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 39: Abdominal Drainage',\n", " 'md': '# Chapter 39: Abdominal Drainage',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 179.22, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Moshe Schein and Paul N. Rogers\\n\\n> \"The more imperfect the technique of the surgeon the greater the necessity for drainage.\"\\n> — William Stewart Halsted\\n\\nThe history of abdominal drainage is as old as the history of surgery. However, abdominal drainage was always a subject of controversy, practiced in confusion and subjected to local dogmas. One hundred years ago there were ardent enthusiasts of drainage, like Robert Lawson Tait, who stated: “When in doubt drain!” Then there were the skeptics, like J. L. Yates, who understood that: “Drainage of the general peritoneal cavity is a physical and physiological impossibility.” And, as always, there were the undecided, such as Joseph Price: “There are those who ardently advocate it, there are those who in great part reject it, there are those who are lukewarm concerning it, and finally, some who, without convictions, are either for or against it… as chance or whim, not logic may determine.”\\n\\nA century has passed, during which operative surgery and supporting care have progressed astonishingly; but, looking around us, it seems that not much has changed concerning the use of drains — the same old chaos. So please forget for a moment the local dogma, dictated by your boss or mentor and listen to us.\\n\\nIn this chapter we will discuss when and how to use intra-abdominal drainage.\\n```',\n", " 'md': '**Authors:** Moshe Schein and Paul N. Rogers\\n\\n> \"The more imperfect the technique of the surgeon the greater the necessity for drainage.\"\\n> — William Stewart Halsted\\n\\nThe history of abdominal drainage is as old as the history of surgery. However, abdominal drainage was always a subject of controversy, practiced in confusion and subjected to local dogmas. One hundred years ago there were ardent enthusiasts of drainage, like Robert Lawson Tait, who stated: “When in doubt drain!” Then there were the skeptics, like J. L. Yates, who understood that: “Drainage of the general peritoneal cavity is a physical and physiological impossibility.” And, as always, there were the undecided, such as Joseph Price: “There are those who ardently advocate it, there are those who in great part reject it, there are those who are lukewarm concerning it, and finally, some who, without convictions, are either for or against it… as chance or whim, not logic may determine.”\\n\\nA century has passed, during which operative surgery and supporting care have progressed astonishingly; but, looking around us, it seems that not much has changed concerning the use of drains — the same old chaos. So please forget for a moment the local dogma, dictated by your boss or mentor and listen to us.\\n\\nIn this chapter we will discuss when and how to use intra-abdominal drainage.\\n```',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.91, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 708,\n", " 'text': 'drains after emergency abdominal operations. (Percutaneous drainage of\\nprimary and postoperative abdominal abscesses and collections is\\ndiscussed in Chapter 46. Wound drains are mentioned in Chapter\\n49.)\\n\\n Let us start with the classification of drains.\\n\\n Surgeons may give the following reasons for draining the abdomen.\\n\\n Therapeutic:\\n\\n • To provide egress for established intra-abdominal contamination or\\n infection (e.g. peri-appendicular abscess, diffuse fecal peritonitis).\\n • To control a source of infection that cannot be controlled by other\\n means, by creating a ‘controlled’ external fistula (e.g. leaking\\n duodenal suture line).\\n\\n Prophylactic:\\n\\n • To prevent recurrent infection (e.g. hoping that by evacuating\\n residual serum and blood they will prevent abscess formation).\\n • To control ‘prospective’ or ‘expected’ leakage from a suture line\\n (e.g. drainage of a colonic anastomosis, duodenal closure, or cystic\\n duct closure).\\n • To warn about complications (believing that drains would sound the\\n warning bell about postoperative bleeding or anastomotic leakage).\\n\\n (Many surgeons around the world that we have seen leaving drains in\\nthe abdomen do so for no reason other than that they were brainwashed\\nto do so by their dogmatic boss, who had been similarly brainwashed by\\nhis mentor…).\\n\\n But rather than dwell on the subject using rigid classifications let us\\ndeal with it through the eyes of a general surgeon: what is the current\\npractice and what should the current practice be concerning\\ndrainage after common abdominal procedures?',\n", " 'md': '```markdown\\n## Classification of Drains\\n\\nSurgeons may give the following reasons for draining the abdomen.\\n\\n### Therapeutic:\\n- To provide egress for established intra-abdominal contamination or infection (e.g. peri-appendicular abscess, diffuse fecal peritonitis).\\n- To control a source of infection that cannot be controlled by other means, by creating a ‘controlled’ external fistula (e.g. leaking duodenal suture line).\\n\\n### Prophylactic:\\n- To prevent recurrent infection (e.g. hoping that by evacuating residual serum and blood they will prevent abscess formation).\\n- To control ‘prospective’ or ‘expected’ leakage from a suture line (e.g. drainage of a colonic anastomosis, duodenal closure, or cystic duct closure).\\n- To warn about complications (believing that drains would sound the warning bell about postoperative bleeding or anastomotic leakage).\\n\\n(Many surgeons around the world that we have seen leaving drains in the abdomen do so for no reason other than that they were brainwashed to do so by their dogmatic boss, who had been similarly brainwashed by his mentor…).\\n\\nBut rather than dwell on the subject using rigid classifications let us deal with it through the eyes of a general surgeon: what is the current practice and what should the current practice be concerning drainage after common abdominal procedures?\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Classification of Drains',\n", " 'md': '## Classification of Drains',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Surgeons may give the following reasons for draining the abdomen.',\n", " 'md': 'Surgeons may give the following reasons for draining the abdomen.',\n", " 'bBox': {'x': 86, 'y': 206, 'w': 430.2, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Therapeutic:',\n", " 'md': '### Therapeutic:',\n", " 'bBox': {'x': 86, 'y': 241, 'w': 85, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- To provide egress for established intra-abdominal contamination or infection (e.g. peri-appendicular abscess, diffuse fecal peritonitis).\\n- To control a source of infection that cannot be controlled by other means, by creating a ‘controlled’ external fistula (e.g. leaking duodenal suture line).',\n", " 'md': '- To provide egress for established intra-abdominal contamination or infection (e.g. peri-appendicular abscess, diffuse fecal peritonitis).\\n- To control a source of infection that cannot be controlled by other means, by creating a ‘controlled’ external fistula (e.g. leaking duodenal suture line).',\n", " 'bBox': {'x': 100, 'y': 277, 'w': 436.25, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Prophylactic:',\n", " 'md': '### Prophylactic:',\n", " 'bBox': {'x': 86, 'y': 384, 'w': 90, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- To prevent recurrent infection (e.g. hoping that by evacuating residual serum and blood they will prevent abscess formation).\\n- To control ‘prospective’ or ‘expected’ leakage from a suture line (e.g. drainage of a colonic anastomosis, duodenal closure, or cystic duct closure).\\n- To warn about complications (believing that drains would sound the warning bell about postoperative bleeding or anastomotic leakage).\\n\\n(Many surgeons around the world that we have seen leaving drains in the abdomen do so for no reason other than that they were brainwashed to do so by their dogmatic boss, who had been similarly brainwashed by his mentor…).\\n\\nBut rather than dwell on the subject using rigid classifications let us deal with it through the eyes of a general surgeon: what is the current practice and what should the current practice be concerning drainage after common abdominal procedures?\\n```',\n", " 'md': '- To prevent recurrent infection (e.g. hoping that by evacuating residual serum and blood they will prevent abscess formation).\\n- To control ‘prospective’ or ‘expected’ leakage from a suture line (e.g. drainage of a colonic anastomosis, duodenal closure, or cystic duct closure).\\n- To warn about complications (believing that drains would sound the warning bell about postoperative bleeding or anastomotic leakage).\\n\\n(Many surgeons around the world that we have seen leaving drains in the abdomen do so for no reason other than that they were brainwashed to do so by their dogmatic boss, who had been similarly brainwashed by his mentor…).\\n\\nBut rather than dwell on the subject using rigid classifications let us deal with it through the eyes of a general surgeon: what is the current practice and what should the current practice be concerning drainage after common abdominal procedures?\\n```',\n", " 'bBox': {'x': 72, 'y': 436, 'w': 467.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'discussed in Chapter 46. Wound drains are mentioned in Chapter 49.)'}]},\n", " {'page': 709,\n", " 'text': ' What is the current practice?\\n\\n The published literature is not much help when exploring the\\nprevalence of abdominal drainage after emergency surgery. Therefore,\\nwe polled the opinions of general surgeons who are members of\\nSURGINET — an international surgical discussion forum on the Internet,\\non their approach to abdominal drainage.\\n\\n Common situations during which drains may be used\\n\\n Drainage in acute appendicitis ( Chapter 23)\\n\\n Question: Should you place a drain after an appendectomy for\\n gangrenous appendicitis? This is not ‘simple’ or ‘phlegmonous’ appendicitis but\\n gangrenous appendicitis: the appendix is black; usually there is some fluid around it or in the\\n pelvis, but no frank pus.\\n Answer: Only 2% of responders would leave a drain in this situation.\\n\\n Question: Should you place a drain after an appendectomy for\\n perforated appendicitis with local pus formation? You found a perforated\\n appendix, you removed it and sucked out the pus floating around it. Perhaps you had to break\\n the adhesions formed by omentum or small bowel, exposing a small abscess; when you\\n inserted the suction into the pelvis you evacuated a few cc of pus. The procedure you did could\\n have been open or laparoscopic.\\n Answer: Only 20% of responders would consider drainage in this situation.\\n\\n Question: Would you place a drain after an appendectomy for\\n perforated appendicitis with diffuse pus formation? Here you deal with\\n one of those advanced, neglected cases, where the perforated appendix is associated with pus\\n ‘everywhere’ — in the pelvis, right paracolic gutter, and even in the upper abdomen.\\n Answer: Again, 80% of responders would not use a drain but there was a\\n geographical pattern: while almost none of the North American and Latin surgeons would\\n drain, many of the surgeons in Asia would. This difference has to do with how',\n", " 'md': '# Current Practice in Abdominal Drainage After Emergency Surgery\\n\\nThe published literature is not much help when exploring the prevalence of abdominal drainage after emergency surgery. Therefore, we polled the opinions of general surgeons who are members of SURGINET — an international surgical discussion forum on the Internet, on their approach to abdominal drainage.\\n\\n## Common Situations During Which Drains May Be Used\\n\\n### Drainage in Acute Appendicitis (Chapter 23)\\n\\n**Question:** Should you place a drain after an appendectomy for gangrenous appendicitis? This is not ‘simple’ or ‘phlegmonous’ appendicitis but gangrenous appendicitis: the appendix is black; usually, there is some fluid around it or in the pelvis, but no frank pus.\\n**Answer:** Only 2% of responders would leave a drain in this situation.\\n\\n**Question:** Should you place a drain after an appendectomy for perforated appendicitis with local pus formation? You found a perforated appendix, you removed it and sucked out the pus floating around it. Perhaps you had to break the adhesions formed by omentum or small bowel, exposing a small abscess; when you inserted the suction into the pelvis you evacuated a few cc of pus. The procedure you did could have been open or laparoscopic.\\n**Answer:** Only 20% of responders would consider drainage in this situation.\\n\\n**Question:** Would you place a drain after an appendectomy for perforated appendicitis with diffuse pus formation? Here you deal with one of those advanced, neglected cases, where the perforated appendix is associated with pus ‘everywhere’ — in the pelvis, right paracolic gutter, and even in the upper abdomen.\\n**Answer:** Again, 80% of responders would not use a drain but there was a geographical pattern: while almost none of the North American and Latin surgeons would drain, many of the surgeons in Asia would. This difference has to do with how...\\n\\n----\\n\\n*Note: There are no images, graphs, or tables present on this page.*',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Current Practice in Abdominal Drainage After Emergency Surgery',\n", " 'md': '# Current Practice in Abdominal Drainage After Emergency Surgery',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The published literature is not much help when exploring the prevalence of abdominal drainage after emergency surgery. Therefore, we polled the opinions of general surgeons who are members of SURGINET — an international surgical discussion forum on the Internet, on their approach to abdominal drainage.',\n", " 'md': 'The published literature is not much help when exploring the prevalence of abdominal drainage after emergency surgery. Therefore, we polled the opinions of general surgeons who are members of SURGINET — an international surgical discussion forum on the Internet, on their approach to abdominal drainage.',\n", " 'bBox': {'x': 72, 'y': 173, 'w': 467.57, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Common Situations During Which Drains May Be Used',\n", " 'md': '## Common Situations During Which Drains May Be Used',\n", " 'bBox': {'x': 86, 'y': 233, 'w': 421.11, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Drainage in Acute Appendicitis (Chapter 23)',\n", " 'md': '### Drainage in Acute Appendicitis (Chapter 23)',\n", " 'bBox': {'x': 86, 'y': 277, 'w': 249.18, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**Question:** Should you place a drain after an appendectomy for gangrenous appendicitis? This is not ‘simple’ or ‘phlegmonous’ appendicitis but gangrenous appendicitis: the appendix is black; usually, there is some fluid around it or in the pelvis, but no frank pus.\\n**Answer:** Only 2% of responders would leave a drain in this situation.\\n\\n**Question:** Should you place a drain after an appendectomy for perforated appendicitis with local pus formation? You found a perforated appendix, you removed it and sucked out the pus floating around it. Perhaps you had to break the adhesions formed by omentum or small bowel, exposing a small abscess; when you inserted the suction into the pelvis you evacuated a few cc of pus. The procedure you did could have been open or laparoscopic.\\n**Answer:** Only 20% of responders would consider drainage in this situation.\\n\\n**Question:** Would you place a drain after an appendectomy for perforated appendicitis with diffuse pus formation? Here you deal with one of those advanced, neglected cases, where the perforated appendix is associated with pus ‘everywhere’ — in the pelvis, right paracolic gutter, and even in the upper abdomen.\\n**Answer:** Again, 80% of responders would not use a drain but there was a geographical pattern: while almost none of the North American and Latin surgeons would drain, many of the surgeons in Asia would. This difference has to do with how...\\n\\n----\\n\\n*Note: There are no images, graphs, or tables present on this page.*',\n", " 'md': '**Question:** Should you place a drain after an appendectomy for gangrenous appendicitis? This is not ‘simple’ or ‘phlegmonous’ appendicitis but gangrenous appendicitis: the appendix is black; usually, there is some fluid around it or in the pelvis, but no frank pus.\\n**Answer:** Only 2% of responders would leave a drain in this situation.\\n\\n**Question:** Should you place a drain after an appendectomy for perforated appendicitis with local pus formation? You found a perforated appendix, you removed it and sucked out the pus floating around it. Perhaps you had to break the adhesions formed by omentum or small bowel, exposing a small abscess; when you inserted the suction into the pelvis you evacuated a few cc of pus. The procedure you did could have been open or laparoscopic.\\n**Answer:** Only 20% of responders would consider drainage in this situation.\\n\\n**Question:** Would you place a drain after an appendectomy for perforated appendicitis with diffuse pus formation? Here you deal with one of those advanced, neglected cases, where the perforated appendix is associated with pus ‘everywhere’ — in the pelvis, right paracolic gutter, and even in the upper abdomen.\\n**Answer:** Again, 80% of responders would not use a drain but there was a geographical pattern: while almost none of the North American and Latin surgeons would drain, many of the surgeons in Asia would. This difference has to do with how...\\n\\n----\\n\\n*Note: There are no images, graphs, or tables present on this page.*',\n", " 'bBox': {'x': 79, 'y': 383, 'w': 453.19, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 710,\n", " 'text': ' surgeons view the value of drainage in diffuse peritonitis — see the\\n separate section below.\\n\\n As elsewhere in this book, we are not going to burden you with a\\ndetailed review of the available literature regarding drainage in acute\\nappendicitis short of mentiong one superb meta-analysis by Petrowsky et\\nal 1 which concluded that “drainage did not reduce postoperative\\ncomplications and even appeared harmful in respect to the development\\nof fecal fistula [fecal fistula was observed only in drained patients]…\\ndrains should be avoided in any stage of appendicitis.”\\n\\n We agree: drainage after appendectomy for phlegmonous or\\ngangrenous appendicitis is unnecessary. It seems that most surgeons\\nunderstand this. But what about perforated appendicitis with local pus\\nformation? Even though the literature cannot support — and even\\ncondemns — drainage in such situations, a fifth of our responders would\\nleave a drain. ‘Formed’ or ‘non-collapsible’ abscesses are considered by\\nmany to be a good indication for drainage, and this is probably why some\\nsurgeons feel compelled to leave a drain in any collection of pus. But the\\nabscesses associated with perforated appendicitis are never ‘non-\\ncollapsible’; after you break down the walls, and evacuate the pus the\\npotential space for the abscess is filled up by adjacent bowel, mesentery\\nand omentum.\\n\\n So, the source of infection has been removed, the peritoneum has been cleansed by\\n ‘peritoneal toilet’; now — for God’s sake — let the superb peritoneal defense\\n mechanisms, supported by a short course of systemic antibiotics, complete the\\n eradication of bacteria, without being disturbed by a foreign body — the silly drain.\\n\\n Insecure closure of the appendix stump as a justification for\\ndrainage sounds anachronistic: secure closure is possible (even in the\\nrare event when the appendix is perforated at its base) by including in the\\nsuture or stapler line a ‘disk’ of adjacent cecal wall.\\n\\n Almost a quarter of our responders would use drains if the appendicitis',\n", " 'md': '```markdown\\n## Drainage in Appendicitis\\n\\nSurgeons view the value of drainage in diffuse peritonitis — see the separate section below.\\n\\nAs elsewhere in this book, we are not going to burden you with a detailed review of the available literature regarding drainage in acute appendicitis short of mentioning one superb meta-analysis by Petrowsky et al. which concluded that “drainage did not reduce postoperative complications and even appeared harmful in respect to the development of fecal fistula [fecal fistula was observed only in drained patients]… drains should be avoided in any stage of appendicitis.”\\n\\nWe agree: drainage after appendectomy for phlegmonous or gangrenous appendicitis is unnecessary. It seems that most surgeons understand this. But what about perforated appendicitis with local pus formation? Even though the literature cannot support — and even condemns — drainage in such situations, a fifth of our responders would leave a drain. ‘Formed’ or ‘non-collapsible’ abscesses are considered by many to be a good indication for drainage, and this is probably why some surgeons feel compelled to leave a drain in any collection of pus. But the abscesses associated with perforated appendicitis are never ‘non-collapsible’; after you break down the walls, and evacuate the pus the potential space for the abscess is filled up by adjacent bowel, mesentery, and omentum.\\n\\nSo, the source of infection has been removed, the peritoneum has been cleansed by ‘peritoneal toilet’; now — for God’s sake — let the superb peritoneal defense mechanisms, supported by a short course of systemic antibiotics, complete the eradication of bacteria, without being disturbed by a foreign body — the silly drain.\\n\\nInsecure closure of the appendix stump as a justification for drainage sounds anachronistic: secure closure is possible (even in the rare event when the appendix is perforated at its base) by including in the suture or stapler line a ‘disk’ of adjacent cecal wall.\\n\\nAlmost a quarter of our responders would use drains if the appendicitis...\\n```\\n\\n### Notes:\\n- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Drainage in Appendicitis',\n", " 'md': '## Drainage in Appendicitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Surgeons view the value of drainage in diffuse peritonitis — see the separate section below.\\n\\nAs elsewhere in this book, we are not going to burden you with a detailed review of the available literature regarding drainage in acute appendicitis short of mentioning one superb meta-analysis by Petrowsky et al. which concluded that “drainage did not reduce postoperative complications and even appeared harmful in respect to the development of fecal fistula [fecal fistula was observed only in drained patients]… drains should be avoided in any stage of appendicitis.”\\n\\nWe agree: drainage after appendectomy for phlegmonous or gangrenous appendicitis is unnecessary. It seems that most surgeons understand this. But what about perforated appendicitis with local pus formation? Even though the literature cannot support — and even condemns — drainage in such situations, a fifth of our responders would leave a drain. ‘Formed’ or ‘non-collapsible’ abscesses are considered by many to be a good indication for drainage, and this is probably why some surgeons feel compelled to leave a drain in any collection of pus. But the abscesses associated with perforated appendicitis are never ‘non-collapsible’; after you break down the walls, and evacuate the pus the potential space for the abscess is filled up by adjacent bowel, mesentery, and omentum.\\n\\nSo, the source of infection has been removed, the peritoneum has been cleansed by ‘peritoneal toilet’; now — for God’s sake — let the superb peritoneal defense mechanisms, supported by a short course of systemic antibiotics, complete the eradication of bacteria, without being disturbed by a foreign body — the silly drain.\\n\\nInsecure closure of the appendix stump as a justification for drainage sounds anachronistic: secure closure is possible (even in the rare event when the appendix is perforated at its base) by including in the suture or stapler line a ‘disk’ of adjacent cecal wall.\\n\\nAlmost a quarter of our responders would use drains if the appendicitis...\\n```',\n", " 'md': 'Surgeons view the value of drainage in diffuse peritonitis — see the separate section below.\\n\\nAs elsewhere in this book, we are not going to burden you with a detailed review of the available literature regarding drainage in acute appendicitis short of mentioning one superb meta-analysis by Petrowsky et al. which concluded that “drainage did not reduce postoperative complications and even appeared harmful in respect to the development of fecal fistula [fecal fistula was observed only in drained patients]… drains should be avoided in any stage of appendicitis.”\\n\\nWe agree: drainage after appendectomy for phlegmonous or gangrenous appendicitis is unnecessary. It seems that most surgeons understand this. But what about perforated appendicitis with local pus formation? Even though the literature cannot support — and even condemns — drainage in such situations, a fifth of our responders would leave a drain. ‘Formed’ or ‘non-collapsible’ abscesses are considered by many to be a good indication for drainage, and this is probably why some surgeons feel compelled to leave a drain in any collection of pus. But the abscesses associated with perforated appendicitis are never ‘non-collapsible’; after you break down the walls, and evacuate the pus the potential space for the abscess is filled up by adjacent bowel, mesentery, and omentum.\\n\\nSo, the source of infection has been removed, the peritoneum has been cleansed by ‘peritoneal toilet’; now — for God’s sake — let the superb peritoneal defense mechanisms, supported by a short course of systemic antibiotics, complete the eradication of bacteria, without being disturbed by a foreign body — the silly drain.\\n\\nInsecure closure of the appendix stump as a justification for drainage sounds anachronistic: secure closure is possible (even in the rare event when the appendix is perforated at its base) by including in the suture or stapler line a ‘disk’ of adjacent cecal wall.\\n\\nAlmost a quarter of our responders would use drains if the appendicitis...\\n```',\n", " 'bBox': {'x': 72, 'y': 87, 'w': 467.85, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 711,\n", " 'text': 'is associated with diffuse peritonitis: but, as we’ll see below, those are the\\npeople who advocate drainage in generalized intra-abdominal infection,\\nand drainage in this situation — after the source control of infection has\\nbeen achieved — is an exercise in futility!\\n\\n Drainage after cholecystectomy for acute cholecystitis (\\n Chapter 20)\\n\\n Question: Would you place a drain following an open or\\n laparoscopic cholecystectomy for severe acute cholecystitis? Now\\n you are performing a ‘difficult’ laparoscopic cholecystectomy on advanced acute cholecystitis.\\n The dissection is not easy; it is time consuming and associated with irritating ooze from the\\n liver. Or perhaps you are forced to convert to an open procedure in order to complete the\\n procedure. Would you leave a drain in the gallbladder bed or below the liver?\\n Answer: A third of the responders would leave a drain.\\n\\n Toward the end of the open cholecystectomy era, based on a large\\nbody of data showing no advantage whatsoever for drainage, routine\\ndrainage — once a holy cow of gallbladder surgery — disappeared from\\nmany centers. But if routine drainage is not beneficial in open\\ncholecystectomy, why should it be in the laparoscopic one? We\\nknow very well from ultrasonographic studies carried out during the open\\ncholecystectomy era that most post-cholecystectomy collections, whether\\ncomposed of bile, serum or blood, remain asymptomatic and are\\nabsorbed by the peritoneum. However, drains are much more effective\\nin draining bile than evacuating feces or pus. So it makes sense to\\nleave a drain if the surgeon has a reason to worry about an unsolved or\\npotential bile leak; for example, if the cystic duct opening cannot securely\\nbe controlled in subtotal cholecystectomy; bile staining in the lavage fluid\\nor in the gallbladder bed — hinting at the possibility that a duct of\\nLuschka has been missed; or what appears to be a non-perfect closure\\nof the cystic duct for whatever reason. So, most patients do not need a\\ndrain, but if you are worried about the possibility of bile leak, then\\nleave a drain! Most drains produce almost nothing; only very rarely\\nwould the prophylactic drain become therapeutic by draining a large and',\n", " 'md': '```markdown\\n## Drainage after Cholecystectomy for Acute Cholecystitis\\n\\n### Question\\nWould you place a drain following an open or laparoscopic cholecystectomy for severe acute cholecystitis? Now you are performing a ‘difficult’ laparoscopic cholecystectomy on advanced acute cholecystitis. The dissection is not easy; it is time-consuming and associated with irritating ooze from the liver. Or perhaps you are forced to convert to an open procedure in order to complete the procedure. Would you leave a drain in the gallbladder bed or below the liver?\\n\\n### Answer\\nA third of the responders would leave a drain.\\n\\nToward the end of the open cholecystectomy era, based on a large body of data showing no advantage whatsoever for drainage, routine drainage — once a holy cow of gallbladder surgery — disappeared from many centers. But if routine drainage is not beneficial in open cholecystectomy, why should it be in the laparoscopic one?\\n\\nWe know very well from ultrasonographic studies carried out during the open cholecystectomy era that most post-cholecystectomy collections, whether composed of bile, serum, or blood, remain asymptomatic and are absorbed by the peritoneum. However, drains are much more effective in draining bile than evacuating feces or pus.\\n\\nSo it makes sense to leave a drain if the surgeon has a reason to worry about an unsolved or potential bile leak; for example, if the cystic duct opening cannot securely be controlled in subtotal cholecystectomy; bile staining in the lavage fluid or in the gallbladder bed — hinting at the possibility that a duct of Luschka has been missed; or what appears to be a non-perfect closure of the cystic duct for whatever reason.\\n\\nSo, most patients do not need a drain, but if you are worried about the possibility of bile leak, then leave a drain! Most drains produce almost nothing; only very rarely would the prophylactic drain become therapeutic by draining a large and .\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Drainage after Cholecystectomy for Acute Cholecystitis',\n", " 'md': '## Drainage after Cholecystectomy for Acute Cholecystitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Question',\n", " 'md': '### Question',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Would you place a drain following an open or laparoscopic cholecystectomy for severe acute cholecystitis? Now you are performing a ‘difficult’ laparoscopic cholecystectomy on advanced acute cholecystitis. The dissection is not easy; it is time-consuming and associated with irritating ooze from the liver. Or perhaps you are forced to convert to an open procedure in order to complete the procedure. Would you leave a drain in the gallbladder bed or below the liver?',\n", " 'md': 'Would you place a drain following an open or laparoscopic cholecystectomy for severe acute cholecystitis? Now you are performing a ‘difficult’ laparoscopic cholecystectomy on advanced acute cholecystitis. The dissection is not easy; it is time-consuming and associated with irritating ooze from the liver. Or perhaps you are forced to convert to an open procedure in order to complete the procedure. Would you leave a drain in the gallbladder bed or below the liver?',\n", " 'bBox': {'x': 79, 'y': 265, 'w': 453.45, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Answer',\n", " 'md': '### Answer',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A third of the responders would leave a drain.\\n\\nToward the end of the open cholecystectomy era, based on a large body of data showing no advantage whatsoever for drainage, routine drainage — once a holy cow of gallbladder surgery — disappeared from many centers. But if routine drainage is not beneficial in open cholecystectomy, why should it be in the laparoscopic one?\\n\\nWe know very well from ultrasonographic studies carried out during the open cholecystectomy era that most post-cholecystectomy collections, whether composed of bile, serum, or blood, remain asymptomatic and are absorbed by the peritoneum. However, drains are much more effective in draining bile than evacuating feces or pus.\\n\\nSo it makes sense to leave a drain if the surgeon has a reason to worry about an unsolved or potential bile leak; for example, if the cystic duct opening cannot securely be controlled in subtotal cholecystectomy; bile staining in the lavage fluid or in the gallbladder bed — hinting at the possibility that a duct of Luschka has been missed; or what appears to be a non-perfect closure of the cystic duct for whatever reason.\\n\\nSo, most patients do not need a drain, but if you are worried about the possibility of bile leak, then leave a drain! Most drains produce almost nothing; only very rarely would the prophylactic drain become therapeutic by draining a large and .\\n```',\n", " 'md': 'A third of the responders would leave a drain.\\n\\nToward the end of the open cholecystectomy era, based on a large body of data showing no advantage whatsoever for drainage, routine drainage — once a holy cow of gallbladder surgery — disappeared from many centers. But if routine drainage is not beneficial in open cholecystectomy, why should it be in the laparoscopic one?\\n\\nWe know very well from ultrasonographic studies carried out during the open cholecystectomy era that most post-cholecystectomy collections, whether composed of bile, serum, or blood, remain asymptomatic and are absorbed by the peritoneum. However, drains are much more effective in draining bile than evacuating feces or pus.\\n\\nSo it makes sense to leave a drain if the surgeon has a reason to worry about an unsolved or potential bile leak; for example, if the cystic duct opening cannot securely be controlled in subtotal cholecystectomy; bile staining in the lavage fluid or in the gallbladder bed — hinting at the possibility that a duct of Luschka has been missed; or what appears to be a non-perfect closure of the cystic duct for whatever reason.\\n\\nSo, most patients do not need a drain, but if you are worried about the possibility of bile leak, then leave a drain! Most drains produce almost nothing; only very rarely would the prophylactic drain become therapeutic by draining a large and .\\n```',\n", " 'bBox': {'x': 72, 'y': 448, 'w': 467.92, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 712,\n", " 'text': 'persisting amount of bile. It is very important that drains with such\\nhazy indications are removed as soon as possible. A dry drain after\\n24 hours indicates that it has served its limited role. Lastly, ħoward Kelly\\nsaid that “Drainage is a confession of imperfect surgery.” Don’t justify this\\nstatement in your own practice: it may be better to convert to an open\\nprocedure and safely suture an ultra-short cystic duct than rely on faulty\\nclip closure and a drain.\\n\\n Drainage after omentopexy for perforated ulcer (\\n Chapter 18)\\n\\n Question: Would you place a drain following repair of a perforated\\n peptic ulcer with an omental patch? You have just repaired a perforated\\n duodenal ulcer with a patch of omentum. Would you leave a drain?\\n Answer: 80% of the responders would not.\\n\\n The literature dealing specifically with this issue is scanty but does not\\nsupport drainage. Omental patch repair, if correctly performed, and\\ntested, should be leak-proof. In addition, the presence of drains when a\\nleak occurs is usually not a life-saver 2. Futile reliance on the drain when\\na leak develops simply postpones life-saving reoperation and hastens\\ndeath.\\n\\n But what about laparoscopic omental patch repair — an\\nincreasingly popular procedure: should it change the (non)\\nindication for drainage? With leaks after omentopexy being so rare and\\nlarge series comparing open to laparoscopic repair so scanty, it is difficult\\nto know whether leaks are more common after laparoscopic repairs.\\nħowever, those of us used to open omentopexy should be alarmed to\\nsee the reported leakage following laparoscopic repairs. It may be that\\nthe ‘learning curves’, the inability to feel the tension placed on the sutures\\nto tie down the patch, or the reliance on suture closure rather than using\\nthe omentum, make the laparoscopic approach more prone to leakage.\\nBut would the drain help to avoid the ensuing disaster? We doubt it (\\nChapter 17). So if you know how to do a proper and safe omental repair,',\n", " 'md': '```markdown\\n## Drainage after Omentopexy for Perforated Ulcer (Chapter 18)\\n\\n**Question:** Would you place a drain following repair of a perforated peptic ulcer with an omental patch? You have just repaired a perforated duodenal ulcer with a patch of omentum. Would you leave a drain?\\n**Answer:** 80% of the responders would not.\\n\\nThe literature dealing specifically with this issue is scanty but does not support drainage. Omental patch repair, if correctly performed and tested, should be leak-proof. In addition, the presence of drains when a leak occurs is usually not a life-saver. Futile reliance on the drain when a leak develops simply postpones life-saving reoperation and hastens death.\\n\\nBut what about laparoscopic omental patch repair — an increasingly popular procedure: should it change the (non) indication for drainage? With leaks after omentopexy being so rare and large series comparing open to laparoscopic repair so scanty, it is difficult to know whether leaks are more common after laparoscopic repairs. However, those of us used to open omentopexy should be alarmed to see the reported leakage following laparoscopic repairs. It may be that the ‘learning curves’, the inability to feel the tension placed on the sutures to tie down the patch, or the reliance on suture closure rather than using the omentum, make the laparoscopic approach more prone to leakage. But would the drain help to avoid the ensuing disaster? We doubt it (Chapter 17). So if you know how to do a proper and safe omental repair,\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Drainage after Omentopexy for Perforated Ulcer (Chapter 18)',\n", " 'md': '## Drainage after Omentopexy for Perforated Ulcer (Chapter 18)',\n", " 'bBox': {'x': 86, 'y': 228, 'w': 97.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**Question:** Would you place a drain following repair of a perforated peptic ulcer with an omental patch? You have just repaired a perforated duodenal ulcer with a patch of omentum. Would you leave a drain?\\n**Answer:** 80% of the responders would not.\\n\\nThe literature dealing specifically with this issue is scanty but does not support drainage. Omental patch repair, if correctly performed and tested, should be leak-proof. In addition, the presence of drains when a leak occurs is usually not a life-saver. Futile reliance on the drain when a leak develops simply postpones life-saving reoperation and hastens death.\\n\\nBut what about laparoscopic omental patch repair — an increasingly popular procedure: should it change the (non) indication for drainage? With leaks after omentopexy being so rare and large series comparing open to laparoscopic repair so scanty, it is difficult to know whether leaks are more common after laparoscopic repairs. However, those of us used to open omentopexy should be alarmed to see the reported leakage following laparoscopic repairs. It may be that the ‘learning curves’, the inability to feel the tension placed on the sutures to tie down the patch, or the reliance on suture closure rather than using the omentum, make the laparoscopic approach more prone to leakage. But would the drain help to avoid the ensuing disaster? We doubt it (Chapter 17). So if you know how to do a proper and safe omental repair,\\n```',\n", " 'md': '**Question:** Would you place a drain following repair of a perforated peptic ulcer with an omental patch? You have just repaired a perforated duodenal ulcer with a patch of omentum. Would you leave a drain?\\n**Answer:** 80% of the responders would not.\\n\\nThe literature dealing specifically with this issue is scanty but does not support drainage. Omental patch repair, if correctly performed and tested, should be leak-proof. In addition, the presence of drains when a leak occurs is usually not a life-saver. Futile reliance on the drain when a leak develops simply postpones life-saving reoperation and hastens death.\\n\\nBut what about laparoscopic omental patch repair — an increasingly popular procedure: should it change the (non) indication for drainage? With leaks after omentopexy being so rare and large series comparing open to laparoscopic repair so scanty, it is difficult to know whether leaks are more common after laparoscopic repairs. However, those of us used to open omentopexy should be alarmed to see the reported leakage following laparoscopic repairs. It may be that the ‘learning curves’, the inability to feel the tension placed on the sutures to tie down the patch, or the reliance on suture closure rather than using the omentum, make the laparoscopic approach more prone to leakage. But would the drain help to avoid the ensuing disaster? We doubt it (Chapter 17). So if you know how to do a proper and safe omental repair,\\n```',\n", " 'bBox': {'x': 72, 'y': 228, 'w': 467.71, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': '2'},\n", " {'text': 'Chapter 17). So if you know how to do a proper and safe omental repair,'}]},\n", " {'page': 713,\n", " 'text': 'draining it would be superfluous. If you are learning to do a laparoscopic\\nrepair (with the declining incidence of peptic ulceration you may never\\nreach the top of the learning curve…), you may want to leave a drain. In\\nmost cases it won’t avoid the need for reoperation should leakage\\ndevelop but it may warn you early that this is the case. On the other\\nhand, a well-timed contrast study (with or without CT) would provide you\\nwith more information than the often poorly placed and non-productive\\ndrain.\\n\\n Drainage after emergency left colon resection with or\\n without anastomosis ( Chapter 28)\\n\\n Question: Would you place a drain following a Hartmann’s\\n procedure for perforated sigmoid diverticulitis or cancer? Would\\n you place a drain following a colectomy and primary anastomosis\\n for perforated sigmoid diverticulitis or cancer?\\n Answer: These two questions, about drainage after emergency resection of perforated\\n sigmoid colon, without, or with, primary anastomosis, can be discussed together. In both\\n situations source control has been achieved by the colectomy, thus the rationale for drainage\\n would be ‘therapeutic’ — to help treat the associated intraperitoneal infection, or ‘prophylactic’\\n — to prevent collections or to ‘control’ potential leakage from a suture line (e.g. rectal stump\\n closure). About two-thirds of responders to both questions would not drain routinely.\\n\\n The topic of drainage after colonic resection has been subjected to\\nintensive debate for the last 30 years; proponents claim that drains would\\navoid reoperation if anastomotic leaks develop, while critics contend that\\ndrains actually contribute to leaks. It would be difficult to improve on the\\nreview and meta-analysis by Petrowski et al 1 which denied any benefits\\nto drainage. Even the usually overly cautious Cochrane Review\\nconcluded that “there is insufficient evidence showing that routine\\ndrainage after colorectal anastomoses prevents anastomotic and other\\ncomplications.”\\n\\n The reasons given by those in favor of drains are varied:',\n", " 'md': '```markdown\\n## Drainage After Emergency Left Colon Resection\\n\\nIf you are learning to do a laparoscopic repair (with the declining incidence of peptic ulceration you may never reach the top of the learning curve…), you may want to leave a drain. In most cases, it won’t avoid the need for reoperation should leakage develop, but it may warn you early that this is the case. On the other hand, a well-timed contrast study (with or without CT) would provide you with more information than the often poorly placed and non-productive drain.\\n\\n### Question:\\nWould you place a drain following a Hartmann’s procedure for perforated sigmoid diverticulitis or cancer? Would you place a drain following a colectomy and primary anastomosis for perforated sigmoid diverticulitis or cancer?\\n\\n### Answer:\\nThese two questions, about drainage after emergency resection of perforated sigmoid colon, without, or with, primary anastomosis, can be discussed together. In both situations, source control has been achieved by the colectomy, thus the rationale for drainage would be ‘therapeutic’ — to help treat the associated intraperitoneal infection, or ‘prophylactic’ — to prevent collections or to ‘control’ potential leakage from a suture line (e.g., rectal stump closure). About two-thirds of responders to both questions would not drain routinely.\\n\\nThe topic of drainage after colonic resection has been subjected to intensive debate for the last 30 years; proponents claim that drains would avoid reoperation if anastomotic leaks develop, while critics contend that drains actually contribute to leaks. It would be difficult to improve on the review and meta-analysis by Petrowski et al. which denied any benefits to drainage. Even the usually overly cautious Cochrane Review concluded that “there is insufficient evidence showing that routine drainage after colorectal anastomoses prevents anastomotic and other complications.”\\n\\nThe reasons given by those in favor of drains are varied:\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Drainage After Emergency Left Colon Resection',\n", " 'md': '## Drainage After Emergency Left Colon Resection',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'If you are learning to do a laparoscopic repair (with the declining incidence of peptic ulceration you may never reach the top of the learning curve…), you may want to leave a drain. In most cases, it won’t avoid the need for reoperation should leakage develop, but it may warn you early that this is the case. On the other hand, a well-timed contrast study (with or without CT) would provide you with more information than the often poorly placed and non-productive drain.',\n", " 'md': 'If you are learning to do a laparoscopic repair (with the declining incidence of peptic ulceration you may never reach the top of the learning curve…), you may want to leave a drain. In most cases, it won’t avoid the need for reoperation should leakage develop, but it may warn you early that this is the case. On the other hand, a well-timed contrast study (with or without CT) would provide you with more information than the often poorly placed and non-productive drain.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.57, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Question:',\n", " 'md': '### Question:',\n", " 'bBox': {'x': 79, 'y': 312, 'w': 67.13, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Would you place a drain following a Hartmann’s procedure for perforated sigmoid diverticulitis or cancer? Would you place a drain following a colectomy and primary anastomosis for perforated sigmoid diverticulitis or cancer?',\n", " 'md': 'Would you place a drain following a Hartmann’s procedure for perforated sigmoid diverticulitis or cancer? Would you place a drain following a colectomy and primary anastomosis for perforated sigmoid diverticulitis or cancer?',\n", " 'bBox': {'x': 79, 'y': 350, 'w': 452.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Answer:',\n", " 'md': '### Answer:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'These two questions, about drainage after emergency resection of perforated sigmoid colon, without, or with, primary anastomosis, can be discussed together. In both situations, source control has been achieved by the colectomy, thus the rationale for drainage would be ‘therapeutic’ — to help treat the associated intraperitoneal infection, or ‘prophylactic’ — to prevent collections or to ‘control’ potential leakage from a suture line (e.g., rectal stump closure). About two-thirds of responders to both questions would not drain routinely.\\n\\nThe topic of drainage after colonic resection has been subjected to intensive debate for the last 30 years; proponents claim that drains would avoid reoperation if anastomotic leaks develop, while critics contend that drains actually contribute to leaks. It would be difficult to improve on the review and meta-analysis by Petrowski et al. which denied any benefits to drainage. Even the usually overly cautious Cochrane Review concluded that “there is insufficient evidence showing that routine drainage after colorectal anastomoses prevents anastomotic and other complications.”\\n\\nThe reasons given by those in favor of drains are varied:\\n```',\n", " 'md': 'These two questions, about drainage after emergency resection of perforated sigmoid colon, without, or with, primary anastomosis, can be discussed together. In both situations, source control has been achieved by the colectomy, thus the rationale for drainage would be ‘therapeutic’ — to help treat the associated intraperitoneal infection, or ‘prophylactic’ — to prevent collections or to ‘control’ potential leakage from a suture line (e.g., rectal stump closure). About two-thirds of responders to both questions would not drain routinely.\\n\\nThe topic of drainage after colonic resection has been subjected to intensive debate for the last 30 years; proponents claim that drains would avoid reoperation if anastomotic leaks develop, while critics contend that drains actually contribute to leaks. It would be difficult to improve on the review and meta-analysis by Petrowski et al. which denied any benefits to drainage. Even the usually overly cautious Cochrane Review concluded that “there is insufficient evidence showing that routine drainage after colorectal anastomoses prevents anastomotic and other complications.”\\n\\nThe reasons given by those in favor of drains are varied:\\n```',\n", " 'bBox': {'x': 72, 'y': 448, 'w': 467.77, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 714,\n", " 'text': ' • The first is to help combat residual, or prevent recurrent, intra-\\n abdominal infection, by draining the pericolic abscess found and\\n already drained during operation or by removing secretions. The\\n futility of peritoneal drainage in achieving such goals has been\\n discussed above (see acute appendicitis) and will be re-emphasized\\n below (see next question).\\n • The second is to drain the anastomosis should it leak. But, surely,\\n high-risk, leak-prone anastomoses should not be constructed in the\\n emergency situation anyway; furthermore, as the literature points\\n out, drains do not help much if leakage does develop — to say\\n nothing about the false sense of security it tends to provide.\\n • The third reason given is to provide drainage to the rectal closure\\n (ħartmann’s pouch) — should it leak. But a solid stapler or hand\\n closure of the healthy rectum away from the colonic inflammation\\n should provide a leak-proof closure. When, however, the closure is\\n deemed ‘too difficult’, then the rectal stump should be left partially\\n open as advocated by the late John Goligher of Leeds. In any event\\n only a pathological optimist could hope that feces will climb up\\n the drain and out of the pelvis, that is, if the drain is not already\\n clogged by fibrin, clots or feces. In conclusion: drains after\\n emergency colonic resection are a waste of time and possibly\\n harmful!\\n\\n Drainage in generalized peritonitis ( Chapter 13)\\n\\n Question: Would you drain the peritoneum in generalized\\n peritonitis?\\n Answer: Only about a third of responders would drain the peritoneal cavity in\\n generalized peritonitis.\\n\\n No comparative studies of drainage versus non-drainage in patients\\nwith diffuse peritonitis have ever been conducted, because the futility of\\ndrainage in this situation was perceived long ago by experts in surgical\\ninfections. The modern view, endorsed by the Surgical Infection Society,\\nmaintains the following.',\n", " 'md': '```markdown\\n## Drainage in Generalized Peritonitis\\n\\n- The first reason for drainage is to help combat residual or prevent recurrent intra-abdominal infection by draining the pericolic abscess found and already drained during operation or by removing secretions. The futility of peritoneal drainage in achieving such goals has been discussed above (see acute appendicitis) and will be re-emphasized below (see next question).\\n\\n- The second reason is to drain the anastomosis should it leak. However, high-risk, leak-prone anastomoses should not be constructed in emergency situations. Furthermore, as the literature points out, drains do not help much if leakage does develop — to say nothing about the false sense of security it tends to provide.\\n\\n- The third reason given is to provide drainage to the rectal closure (Hartmann’s pouch) should it leak. A solid stapler or hand closure of the healthy rectum away from the colonic inflammation should provide a leak-proof closure. When, however, the closure is deemed ‘too difficult’, then the rectal stump should be left partially open as advocated by the late John Goligher of Leeds. In any event, only a pathological optimist could hope that feces will climb up the drain and out of the pelvis, that is, if the drain is not already clogged by fibrin, clots, or feces. In conclusion: drains after emergency colonic resection are a waste of time and possibly harmful!\\n\\n### Question: Would you drain the peritoneum in generalized peritonitis?\\n**Answer:** Only about a third of responders would drain the peritoneal cavity in generalized peritonitis.\\n\\nNo comparative studies of drainage versus non-drainage in patients with diffuse peritonitis have ever been conducted, because the futility of drainage in this situation was perceived long ago by experts in surgical infections. The modern view, endorsed by the Surgical Infection Society, maintains the following.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Drainage in Generalized Peritonitis',\n", " 'md': '## Drainage in Generalized Peritonitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The first reason for drainage is to help combat residual or prevent recurrent intra-abdominal infection by draining the pericolic abscess found and already drained during operation or by removing secretions. The futility of peritoneal drainage in achieving such goals has been discussed above (see acute appendicitis) and will be re-emphasized below (see next question).\\n\\n- The second reason is to drain the anastomosis should it leak. However, high-risk, leak-prone anastomoses should not be constructed in emergency situations. Furthermore, as the literature points out, drains do not help much if leakage does develop — to say nothing about the false sense of security it tends to provide.\\n\\n- The third reason given is to provide drainage to the rectal closure (Hartmann’s pouch) should it leak. A solid stapler or hand closure of the healthy rectum away from the colonic inflammation should provide a leak-proof closure. When, however, the closure is deemed ‘too difficult’, then the rectal stump should be left partially open as advocated by the late John Goligher of Leeds. In any event, only a pathological optimist could hope that feces will climb up the drain and out of the pelvis, that is, if the drain is not already clogged by fibrin, clots, or feces. In conclusion: drains after emergency colonic resection are a waste of time and possibly harmful!',\n", " 'md': '- The first reason for drainage is to help combat residual or prevent recurrent intra-abdominal infection by draining the pericolic abscess found and already drained during operation or by removing secretions. The futility of peritoneal drainage in achieving such goals has been discussed above (see acute appendicitis) and will be re-emphasized below (see next question).\\n\\n- The second reason is to drain the anastomosis should it leak. However, high-risk, leak-prone anastomoses should not be constructed in emergency situations. Furthermore, as the literature points out, drains do not help much if leakage does develop — to say nothing about the false sense of security it tends to provide.\\n\\n- The third reason given is to provide drainage to the rectal closure (Hartmann’s pouch) should it leak. A solid stapler or hand closure of the healthy rectum away from the colonic inflammation should provide a leak-proof closure. When, however, the closure is deemed ‘too difficult’, then the rectal stump should be left partially open as advocated by the late John Goligher of Leeds. In any event, only a pathological optimist could hope that feces will climb up the drain and out of the pelvis, that is, if the drain is not already clogged by fibrin, clots, or feces. In conclusion: drains after emergency colonic resection are a waste of time and possibly harmful!',\n", " 'bBox': {'x': 100, 'y': 154, 'w': 437.02, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Question: Would you drain the peritoneum in generalized peritonitis?',\n", " 'md': '### Question: Would you drain the peritoneum in generalized peritonitis?',\n", " 'bBox': {'x': 79, 'y': 534, 'w': 78.32, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '**Answer:** Only about a third of responders would drain the peritoneal cavity in generalized peritonitis.\\n\\nNo comparative studies of drainage versus non-drainage in patients with diffuse peritonitis have ever been conducted, because the futility of drainage in this situation was perceived long ago by experts in surgical infections. The modern view, endorsed by the Surgical Infection Society, maintains the following.\\n```',\n", " 'md': '**Answer:** Only about a third of responders would drain the peritoneal cavity in generalized peritonitis.\\n\\nNo comparative studies of drainage versus non-drainage in patients with diffuse peritonitis have ever been conducted, because the futility of drainage in this situation was perceived long ago by experts in surgical infections. The modern view, endorsed by the Surgical Infection Society, maintains the following.\\n```',\n", " 'bBox': {'x': 72, 'y': 592, 'w': 467.96, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 715,\n", " 'text': ' “It is impossible to drain the peritoneal cavity in patients with\\n diffuse peritonitis. Therefore, the use of drains in these patients is\\n not indicated unless:\\n\\n The drain is to be used for postoperative lavage.\\n The drain is placed into a well-defined abscess cavity.\\n The drain is used to establish a controlled fistula.”\\n\\n We recall, when we were junior residents, postoperative patients with\\nmultiple rubber drains sticking out of each and every quadrant of their\\ndistended bellies — like porcupines. Those drains produced some old\\nblood, or perhaps a little pus or foul-smelling fluid. Then the patient would\\ndie with his death blamed on ‘pneumonia’. ħow stupid we were —\\nbelieving that these drains were useful! We gradually understood how\\nworthless it is — all intraperitoneal drains seal off by adjacent tissue\\nwithin 24-48 hours, unless ‘perfused’ by liquid effluent such as bile. So in\\nperitonitis, if you use a suction drain it drains almost nothing, and if you\\nleave a rubber drain (e.g. Penrose, ‘corrugated’), it simply drains the\\ninfected tract it has created.\\n\\n The only indication to use a drain in general peritonitis is to\\ncontrol an uncontrollable source of infection such as a leaking\\nduodenal suture line or a leaking gastroesophageal anastomosis.\\nAs pointed out above, we are skeptical about the term ‘well defined’ or\\n‘formed’ abscess as an indication for peritoneal drainage. Such\\n‘abscesses’ are pus collections which are part of the spectrum of\\nperitonitis; after evacuation they should be treated like the rest of the\\ninfected peritoneum. Let peritoneal defenses and antibiotics do the job. In\\nconclusion: drains in diffuse peritonitis are senseless. Recurrent or\\npersistent intra-abdominal infection can develop, however, and may\\nneed percutaneous drainage ( Chapter 46), or a reoperation (\\nChapter 48). Drains won’t change this.\\n\\n Solid indications for drainage',\n", " 'md': '```markdown\\n## Current Page Content\\n\\nIt is impossible to drain the peritoneal cavity in patients with diffuse peritonitis. Therefore, the use of drains in these patients is not indicated unless:\\n\\n- The drain is to be used for postoperative lavage.\\n- The drain is placed into a well-defined abscess cavity.\\n- The drain is used to establish a controlled fistula.\\n\\nWe recall, when we were junior residents, postoperative patients with multiple rubber drains sticking out of each and every quadrant of their distended bellies — like porcupines. Those drains produced some old blood, or perhaps a little pus or foul-smelling fluid. Then the patient would die with his death blamed on ‘pneumonia’. How stupid we were — believing that these drains were useful! We gradually understood how worthless it is — all intraperitoneal drains seal off by adjacent tissue within 24-48 hours, unless ‘perfused’ by liquid effluent such as bile. So in peritonitis, if you use a suction drain it drains almost nothing, and if you leave a rubber drain (e.g. Penrose, ‘corrugated’), it simply drains the infected tract it has created.\\n\\nThe only indication to use a drain in general peritonitis is to control an uncontrollable source of infection such as a leaking duodenal suture line or a leaking gastroesophageal anastomosis. As pointed out above, we are skeptical about the term ‘well defined’ or ‘formed’ abscess as an indication for peritoneal drainage. Such ‘abscesses’ are pus collections which are part of the spectrum of peritonitis; after evacuation they should be treated like the rest of the infected peritoneum. Let peritoneal defenses and antibiotics do the job. In conclusion: drains in diffuse peritonitis are senseless. Recurrent or persistent intra-abdominal infection can develop, however, and may need percutaneous drainage (Chapter 46), or a reoperation (Chapter 48). Drains won’t change this.\\n\\n### Solid indications for drainage\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'images': [{'name': 'img_p714_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 154.07999999999998},\n", " {'name': 'img_p714_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 175.67999999999998},\n", " {'name': 'img_p714_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 197.27999999999997}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'It is impossible to drain the peritoneal cavity in patients with diffuse peritonitis. Therefore, the use of drains in these patients is not indicated unless:\\n\\n- The drain is to be used for postoperative lavage.\\n- The drain is placed into a well-defined abscess cavity.\\n- The drain is used to establish a controlled fistula.\\n\\nWe recall, when we were junior residents, postoperative patients with multiple rubber drains sticking out of each and every quadrant of their distended bellies — like porcupines. Those drains produced some old blood, or perhaps a little pus or foul-smelling fluid. Then the patient would die with his death blamed on ‘pneumonia’. How stupid we were — believing that these drains were useful! We gradually understood how worthless it is — all intraperitoneal drains seal off by adjacent tissue within 24-48 hours, unless ‘perfused’ by liquid effluent such as bile. So in peritonitis, if you use a suction drain it drains almost nothing, and if you leave a rubber drain (e.g. Penrose, ‘corrugated’), it simply drains the infected tract it has created.\\n\\nThe only indication to use a drain in general peritonitis is to control an uncontrollable source of infection such as a leaking duodenal suture line or a leaking gastroesophageal anastomosis. As pointed out above, we are skeptical about the term ‘well defined’ or ‘formed’ abscess as an indication for peritoneal drainage. Such ‘abscesses’ are pus collections which are part of the spectrum of peritonitis; after evacuation they should be treated like the rest of the infected peritoneum. Let peritoneal defenses and antibiotics do the job. In conclusion: drains in diffuse peritonitis are senseless. Recurrent or persistent intra-abdominal infection can develop, however, and may need percutaneous drainage (Chapter 46), or a reoperation (Chapter 48). Drains won’t change this.',\n", " 'md': 'It is impossible to drain the peritoneal cavity in patients with diffuse peritonitis. Therefore, the use of drains in these patients is not indicated unless:\\n\\n- The drain is to be used for postoperative lavage.\\n- The drain is placed into a well-defined abscess cavity.\\n- The drain is used to establish a controlled fistula.\\n\\nWe recall, when we were junior residents, postoperative patients with multiple rubber drains sticking out of each and every quadrant of their distended bellies — like porcupines. Those drains produced some old blood, or perhaps a little pus or foul-smelling fluid. Then the patient would die with his death blamed on ‘pneumonia’. How stupid we were — believing that these drains were useful! We gradually understood how worthless it is — all intraperitoneal drains seal off by adjacent tissue within 24-48 hours, unless ‘perfused’ by liquid effluent such as bile. So in peritonitis, if you use a suction drain it drains almost nothing, and if you leave a rubber drain (e.g. Penrose, ‘corrugated’), it simply drains the infected tract it has created.\\n\\nThe only indication to use a drain in general peritonitis is to control an uncontrollable source of infection such as a leaking duodenal suture line or a leaking gastroesophageal anastomosis. As pointed out above, we are skeptical about the term ‘well defined’ or ‘formed’ abscess as an indication for peritoneal drainage. Such ‘abscesses’ are pus collections which are part of the spectrum of peritonitis; after evacuation they should be treated like the rest of the infected peritoneum. Let peritoneal defenses and antibiotics do the job. In conclusion: drains in diffuse peritonitis are senseless. Recurrent or persistent intra-abdominal infection can develop, however, and may need percutaneous drainage (Chapter 46), or a reoperation (Chapter 48). Drains won’t change this.',\n", " 'bBox': {'x': 72, 'y': 114, 'w': 467.92, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Solid indications for drainage',\n", " 'md': '### Solid indications for drainage',\n", " 'bBox': {'x': 86, 'y': 682, 'w': 232.6, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Drains won’t change this'}, {'text': 'Chapter 48). '}]},\n", " {'page': 716,\n", " 'text': 'Question: In which situations would you always drain?\\nAnswer: Few data are available to support any ‘scientific’ opinion but here are the\\nsituations considered by experienced surgeons as ‘obligatory’ for drainage:\\n\\n High probability of leakage of bile or pancreatic juice. This\\n is the number one indication, and rightly so. Bile and pancreatic juice are well\\n collected and evacuated by drains. A drain placed for biliary or pancreatic leak\\n may be life-saving and curative.\\n Established pus-containing abscess. This is the number two\\n indication, showing that many surgeons believe that a well-formed collection of pus\\n deserves a drain. Many responders emphasized the term ‘non-collapsible abscess’\\n or ‘thick-walled abscess’ as an indication for drains, but, I wonder, does one really\\n find such an animal within the abdomen?\\n Not satisfied with ‘source control’. This is the number three\\n indication; it overlaps with other indications such as bile leak, urinary leak or the\\n impossibility of exteriorizing a leaking proximal jejunum or duodenum.\\n Difficult duodenal suture line: the ‘difficult’ or leak-prone duodenal\\n stump after Billroth II gastrectomy is another reasonable indication for prophylactic\\n drainage. The retroperitoneal duodenum is more susceptible to leakage and thus\\n draining it would make sense (e.g. after duodenotomy to control post-endoscopic\\n retrograde cholangiopancreatography hemorrhage).\\n Other indications: prophylactic drainage when leakage of urine is\\n likely is another good indication as is drainage of esophageal suture\\n lines. About drainage for expected bleeding it has been said: “If you\\n have to use drains to take care of postoperative hemorrhage, then you did\\n not finish the operation.” In most cases in which you leave drains for bleeding or\\n oozing, they are unnecessary and produce little; they also produce little even when\\n severe bleeding develops — showing only the tip of the iceberg.\\n\\n The ‘optimal’ drain',\n", " 'md': '```markdown\\n## Question: In which situations would you always drain?\\n\\n### Answer:\\nFew data are available to support any ‘scientific’ opinion but here are the situations considered by experienced surgeons as ‘obligatory’ for drainage:\\n\\n1. **High probability of leakage of bile or pancreatic juice.** This is the number one indication, and rightly so. Bile and pancreatic juice are well collected and evacuated by drains. A drain placed for biliary or pancreatic leak may be life-saving and curative.\\n\\n2. **Established pus-containing abscess.** This is the number two indication, showing that many surgeons believe that a well-formed collection of pus deserves a drain. Many responders emphasized the term ‘non-collapsible abscess’ or ‘thick-walled abscess’ as an indication for drains, but, I wonder, does one really find such an animal within the abdomen?\\n\\n3. **Not satisfied with ‘source control’.** This is the number three indication; it overlaps with other indications such as bile leak, urinary leak or the impossibility of exteriorizing a leaking proximal jejunum or duodenum.\\n\\n4. **Difficult duodenal suture line:** The ‘difficult’ or leak-prone duodenal stump after Billroth II gastrectomy is another reasonable indication for prophylactic drainage. The retroperitoneal duodenum is more susceptible to leakage and thus draining it would make sense (e.g. after duodenotomy to control post-endoscopic retrograde cholangiopancreatography hemorrhage).\\n\\n5. **Other indications:** Prophylactic drainage when leakage of urine is likely is another good indication as is drainage of esophageal suture lines. About drainage for expected bleeding it has been said: “If you have to use drains to take care of postoperative hemorrhage, then you did not finish the operation.” In most cases in which you leave drains for bleeding or oozing, they are unnecessary and produce little; they also produce little even when severe bleeding develops — showing only the tip of the iceberg.\\n\\n### The ‘optimal’ drain\\n```',\n", " 'images': [{'name': 'img_p715_1.png',\n", " 'height': 13,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 154.8},\n", " {'name': 'img_p715_1.png',\n", " 'height': 13,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 234},\n", " {'name': 'img_p715_1.png',\n", " 'height': 13,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 331.91999999999996},\n", " {'name': 'img_p715_1.png',\n", " 'height': 13,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 392.4},\n", " {'name': 'img_p715_1.png',\n", " 'height': 13,\n", " 'width': 13,\n", " 'x': 92.15999999999985,\n", " 'y': 490.32}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Question: In which situations would you always drain?',\n", " 'md': '## Question: In which situations would you always drain?',\n", " 'bBox': {'x': 79, 'y': 94, 'w': 374.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Answer:',\n", " 'md': '### Answer:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Few data are available to support any ‘scientific’ opinion but here are the situations considered by experienced surgeons as ‘obligatory’ for drainage:\\n\\n1. **High probability of leakage of bile or pancreatic juice.** This is the number one indication, and rightly so. Bile and pancreatic juice are well collected and evacuated by drains. A drain placed for biliary or pancreatic leak may be life-saving and curative.\\n\\n2. **Established pus-containing abscess.** This is the number two indication, showing that many surgeons believe that a well-formed collection of pus deserves a drain. Many responders emphasized the term ‘non-collapsible abscess’ or ‘thick-walled abscess’ as an indication for drains, but, I wonder, does one really find such an animal within the abdomen?\\n\\n3. **Not satisfied with ‘source control’.** This is the number three indication; it overlaps with other indications such as bile leak, urinary leak or the impossibility of exteriorizing a leaking proximal jejunum or duodenum.\\n\\n4. **Difficult duodenal suture line:** The ‘difficult’ or leak-prone duodenal stump after Billroth II gastrectomy is another reasonable indication for prophylactic drainage. The retroperitoneal duodenum is more susceptible to leakage and thus draining it would make sense (e.g. after duodenotomy to control post-endoscopic retrograde cholangiopancreatography hemorrhage).\\n\\n5. **Other indications:** Prophylactic drainage when leakage of urine is likely is another good indication as is drainage of esophageal suture lines. About drainage for expected bleeding it has been said: “If you have to use drains to take care of postoperative hemorrhage, then you did not finish the operation.” In most cases in which you leave drains for bleeding or oozing, they are unnecessary and produce little; they also produce little even when severe bleeding develops — showing only the tip of the iceberg.',\n", " 'md': 'Few data are available to support any ‘scientific’ opinion but here are the situations considered by experienced surgeons as ‘obligatory’ for drainage:\\n\\n1. **High probability of leakage of bile or pancreatic juice.** This is the number one indication, and rightly so. Bile and pancreatic juice are well collected and evacuated by drains. A drain placed for biliary or pancreatic leak may be life-saving and curative.\\n\\n2. **Established pus-containing abscess.** This is the number two indication, showing that many surgeons believe that a well-formed collection of pus deserves a drain. Many responders emphasized the term ‘non-collapsible abscess’ or ‘thick-walled abscess’ as an indication for drains, but, I wonder, does one really find such an animal within the abdomen?\\n\\n3. **Not satisfied with ‘source control’.** This is the number three indication; it overlaps with other indications such as bile leak, urinary leak or the impossibility of exteriorizing a leaking proximal jejunum or duodenum.\\n\\n4. **Difficult duodenal suture line:** The ‘difficult’ or leak-prone duodenal stump after Billroth II gastrectomy is another reasonable indication for prophylactic drainage. The retroperitoneal duodenum is more susceptible to leakage and thus draining it would make sense (e.g. after duodenotomy to control post-endoscopic retrograde cholangiopancreatography hemorrhage).\\n\\n5. **Other indications:** Prophylactic drainage when leakage of urine is likely is another good indication as is drainage of esophageal suture lines. About drainage for expected bleeding it has been said: “If you have to use drains to take care of postoperative hemorrhage, then you did not finish the operation.” In most cases in which you leave drains for bleeding or oozing, they are unnecessary and produce little; they also produce little even when severe bleeding develops — showing only the tip of the iceberg.',\n", " 'bBox': {'x': 79, 'y': 133, 'w': 398.02, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The ‘optimal’ drain',\n", " 'md': '### The ‘optimal’ drain',\n", " 'bBox': {'x': 86, 'y': 681, 'w': 146.18, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 717,\n", " 'text': ' Question: Which type of drain do you use?\\n Answer: The responders came up with a potpourri of drains. Sixty percent prefer ‘active’\\n drains. While North American surgeons use predominantly ‘active’, suction drainage (e.g.\\n Jackson-Pratt [JP] drain), many others prefer ‘passive’ drains, be they round (hollow) or flat\\n (e.g. Penrose, or the ‘corrugated’ rubber). But which drains are best?\\n\\n Preferably, all drains should be soft and malleable to minimize the real\\ndangers of pressure necrosis and erosion of bowel and blood vessels.\\nPassive drains work by capillary action, gravity or overflow caused by\\nslight pressure differences. Active drains are connected to a source of\\nsuction. Passive drains are considered to be an ‘open system’, proven to\\nbe associated with contamination of the drain tract by retrograde spread\\nof skin bacteria (“drains drain both ways!”). Theoretically, applying a\\nsterile colostomy bag over a drain site should convert the open system to\\na closed one, but we doubt that this remains ‘closed’ for more than a day.\\nWhether, as some claim, passive drains are relatively inefficient in the\\nupper abdomen because of the negative, inward sucking pressures\\ngenerated during respiration, is controversial. Active drains tend to be\\nclogged by tissue or clots which are ‘sucked in’ — the higher the sucking\\npressure, the more prone to blockage the drain is. ‘Sump’ suction drains\\n(double-lumen system) are more resistant to blockage but usually are of\\nrigid construction and thus not considered safe for a prolonged stay in the\\nperitoneal cavity. Evidently, the larger the drain, the wider the exit\\nopening in the skin — the more effective is the drainage but also the\\nmore it is prone to complications.\\n\\n But practically:\\n\\n • The flat and soft ‘active’ JP is the only intraperitoneal drain that we\\n use these days in routine practice, usually for the rare case of\\n difficult cholecystectomy. This is the drain we would use for\\n indications such as a potential duodenal or pancreatic fistula.\\n\\n We mostly use the Blake® drain; it does not get blocked so easily and is soft and safe… Ari',\n", " 'md': '```markdown\\n## Drain Types and Preferences\\n\\n### Question: Which type of drain do you use?\\n\\n### Answer:\\nThe responders came up with a potpourri of drains. Sixty percent prefer ‘active’ drains. While North American surgeons use predominantly ‘active’ suction drainage (e.g. Jackson-Pratt [JP] drain), many others prefer ‘passive’ drains, be they round (hollow) or flat (e.g. Penrose, or the ‘corrugated’ rubber). But which drains are best?\\n\\nPreferably, all drains should be soft and malleable to minimize the real dangers of pressure necrosis and erosion of bowel and blood vessels. Passive drains work by capillary action, gravity, or overflow caused by slight pressure differences. Active drains are connected to a source of suction. Passive drains are considered to be an ‘open system’, proven to be associated with contamination of the drain tract by retrograde spread of skin bacteria (“drains drain both ways!”). Theoretically, applying a sterile colostomy bag over a drain site should convert the open system to a closed one, but we doubt that this remains ‘closed’ for more than a day.\\n\\nWhether, as some claim, passive drains are relatively inefficient in the upper abdomen because of the negative, inward sucking pressures generated during respiration, is controversial. Active drains tend to be clogged by tissue or clots which are ‘sucked in’ — the higher the sucking pressure, the more prone to blockage the drain is. ‘Sump’ suction drains (double-lumen system) are more resistant to blockage but usually are of rigid construction and thus not considered safe for a prolonged stay in the peritoneal cavity. Evidently, the larger the drain, the wider the exit opening in the skin — the more effective is the drainage but also the more it is prone to complications.\\n\\n### Practical Considerations:\\n- The flat and soft ‘active’ JP is the only intraperitoneal drain that we use these days in routine practice, usually for the rare case of difficult cholecystectomy. This is the drain we would use for indications such as a potential duodenal or pancreatic fistula.\\n- We mostly use the Blake® drain; it does not get blocked so easily and is soft and safe… Ari\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Drain Types and Preferences',\n", " 'md': '## Drain Types and Preferences',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Question: Which type of drain do you use?',\n", " 'md': '### Question: Which type of drain do you use?',\n", " 'bBox': {'x': 79, 'y': 94, 'w': 293.17, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Answer:',\n", " 'md': '### Answer:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The responders came up with a potpourri of drains. Sixty percent prefer ‘active’ drains. While North American surgeons use predominantly ‘active’ suction drainage (e.g. Jackson-Pratt [JP] drain), many others prefer ‘passive’ drains, be they round (hollow) or flat (e.g. Penrose, or the ‘corrugated’ rubber). But which drains are best?\\n\\nPreferably, all drains should be soft and malleable to minimize the real dangers of pressure necrosis and erosion of bowel and blood vessels. Passive drains work by capillary action, gravity, or overflow caused by slight pressure differences. Active drains are connected to a source of suction. Passive drains are considered to be an ‘open system’, proven to be associated with contamination of the drain tract by retrograde spread of skin bacteria (“drains drain both ways!”). Theoretically, applying a sterile colostomy bag over a drain site should convert the open system to a closed one, but we doubt that this remains ‘closed’ for more than a day.\\n\\nWhether, as some claim, passive drains are relatively inefficient in the upper abdomen because of the negative, inward sucking pressures generated during respiration, is controversial. Active drains tend to be clogged by tissue or clots which are ‘sucked in’ — the higher the sucking pressure, the more prone to blockage the drain is. ‘Sump’ suction drains (double-lumen system) are more resistant to blockage but usually are of rigid construction and thus not considered safe for a prolonged stay in the peritoneal cavity. Evidently, the larger the drain, the wider the exit opening in the skin — the more effective is the drainage but also the more it is prone to complications.',\n", " 'md': 'The responders came up with a potpourri of drains. Sixty percent prefer ‘active’ drains. While North American surgeons use predominantly ‘active’ suction drainage (e.g. Jackson-Pratt [JP] drain), many others prefer ‘passive’ drains, be they round (hollow) or flat (e.g. Penrose, or the ‘corrugated’ rubber). But which drains are best?\\n\\nPreferably, all drains should be soft and malleable to minimize the real dangers of pressure necrosis and erosion of bowel and blood vessels. Passive drains work by capillary action, gravity, or overflow caused by slight pressure differences. Active drains are connected to a source of suction. Passive drains are considered to be an ‘open system’, proven to be associated with contamination of the drain tract by retrograde spread of skin bacteria (“drains drain both ways!”). Theoretically, applying a sterile colostomy bag over a drain site should convert the open system to a closed one, but we doubt that this remains ‘closed’ for more than a day.\\n\\nWhether, as some claim, passive drains are relatively inefficient in the upper abdomen because of the negative, inward sucking pressures generated during respiration, is controversial. Active drains tend to be clogged by tissue or clots which are ‘sucked in’ — the higher the sucking pressure, the more prone to blockage the drain is. ‘Sump’ suction drains (double-lumen system) are more resistant to blockage but usually are of rigid construction and thus not considered safe for a prolonged stay in the peritoneal cavity. Evidently, the larger the drain, the wider the exit opening in the skin — the more effective is the drainage but also the more it is prone to complications.',\n", " 'bBox': {'x': 72, 'y': 173, 'w': 467.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Practical Considerations:',\n", " 'md': '### Practical Considerations:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The flat and soft ‘active’ JP is the only intraperitoneal drain that we use these days in routine practice, usually for the rare case of difficult cholecystectomy. This is the drain we would use for indications such as a potential duodenal or pancreatic fistula.\\n- We mostly use the Blake® drain; it does not get blocked so easily and is soft and safe… Ari\\n```',\n", " 'md': '- The flat and soft ‘active’ JP is the only intraperitoneal drain that we use these days in routine practice, usually for the rare case of difficult cholecystectomy. This is the drain we would use for indications such as a potential duodenal or pancreatic fistula.\\n- We mostly use the Blake® drain; it does not get blocked so easily and is soft and safe… Ari\\n```',\n", " 'bBox': {'x': 77, 'y': 594, 'w': 459.47, 'h': 18.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 718,\n", " 'text': \" • If you are one of those who drain peritonitis remember that\\n your suction drain will be plugged with fibrin and pus within a\\n few hours, and your open passive drain would serve mostly as\\n a one-way autobahn for skin bacteria.\\n • For those who place drains adjacent to colonic anastomoses — do\\n you really believe that suction drains will evacuate feces? To form a\\n channel capable of transferring fecal material to the outside, one has\\n to use a large passive drain (e.g. corrugated) through a generous\\n two-finger opening in the skin and abdominal wall. By doing so we\\n would go back to the old days of drain-site hernias, intestinal\\n obstruction, bleeding and drain-site abscess formation.\\n\\n For a list of complications of drains look at Table 39.1. These\\ncomplications are real; some are rare but we have experienced each of\\nthem in the dark ages of excessive drainage. Such complications can be\\nprevented by the correct placement and management of drains (see\\nTable 39.2) or, better, avoiding drains when not indicated.\\n Table 39.1. Complications of intraperitoneal drains.\\n Drain 'fever'\\n Drain tract infection.\\n Drain tract hernia.\\n Drain tract bleeding:\\n Intestinal obstruction.\\n Erosion of bowel:\\n Erosion of vessels\\n Contamination of sterile tissues\\n Prevention of healing of fistulas_\\n Failure to retrieve: caught by fascial sutures, torn, knotted or tissue sucked\\n in/growing into drain:\\n 'Lost' drain: migration into the abdomen or breakage:\",\n", " 'md': \"```markdown\\n## Drain Management and Complications\\n\\n- If you are one of those who drain peritonitis, remember that your suction drain will be plugged with fibrin and pus within a few hours, and your open passive drain would serve mostly as a one-way autobahn for skin bacteria.\\n- For those who place drains adjacent to colonic anastomoses — do you really believe that suction drains will evacuate feces? To form a channel capable of transferring fecal material to the outside, one has to use a large passive drain (e.g., corrugated) through a generous two-finger opening in the skin and abdominal wall. By doing so, we would go back to the old days of drain-site hernias, intestinal obstruction, bleeding, and drain-site abscess formation.\\n\\nFor a list of complications of drains, look at Table 39.1. These complications are real; some are rare, but we have experienced each of them in the dark ages of excessive drainage. Such complications can be prevented by the correct placement and management of drains (see Table 39.2) or, better, avoiding drains when not indicated.\\n\\n### Table 39.1. Complications of Intraperitoneal Drains\\n\\n| Complication |\\n|--------------------------------------------------|\\n| Drain 'fever' |\\n| Drain tract infection |\\n| Drain tract hernia |\\n| Drain tract bleeding |\\n| Intestinal obstruction |\\n| Erosion of bowel |\\n| Erosion of vessels |\\n| Contamination of sterile tissues |\\n| Prevention of healing of fistulas |\\n| Failure to retrieve: caught by fascial sutures, torn, knotted or tissue sucked in/growing into drain |\\n| 'Lost' drain: migration into the abdomen or breakage |\\n```\",\n", " 'images': [{'name': 'img_p717_1.png',\n", " 'height': 629,\n", " 'width': 812,\n", " 'x': 105.11999999999989,\n", " 'y': 371.52,\n", " 'original_width': 1394,\n", " 'original_height': 1080}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Drain Management and Complications',\n", " 'md': '## Drain Management and Complications',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- If you are one of those who drain peritonitis, remember that your suction drain will be plugged with fibrin and pus within a few hours, and your open passive drain would serve mostly as a one-way autobahn for skin bacteria.\\n- For those who place drains adjacent to colonic anastomoses — do you really believe that suction drains will evacuate feces? To form a channel capable of transferring fecal material to the outside, one has to use a large passive drain (e.g., corrugated) through a generous two-finger opening in the skin and abdominal wall. By doing so, we would go back to the old days of drain-site hernias, intestinal obstruction, bleeding, and drain-site abscess formation.\\n\\nFor a list of complications of drains, look at Table 39.1. These complications are real; some are rare, but we have experienced each of them in the dark ages of excessive drainage. Such complications can be prevented by the correct placement and management of drains (see Table 39.2) or, better, avoiding drains when not indicated.',\n", " 'md': '- If you are one of those who drain peritonitis, remember that your suction drain will be plugged with fibrin and pus within a few hours, and your open passive drain would serve mostly as a one-way autobahn for skin bacteria.\\n- For those who place drains adjacent to colonic anastomoses — do you really believe that suction drains will evacuate feces? To form a channel capable of transferring fecal material to the outside, one has to use a large passive drain (e.g., corrugated) through a generous two-finger opening in the skin and abdominal wall. By doing so, we would go back to the old days of drain-site hernias, intestinal obstruction, bleeding, and drain-site abscess formation.\\n\\nFor a list of complications of drains, look at Table 39.1. These complications are real; some are rare, but we have experienced each of them in the dark ages of excessive drainage. Such complications can be prevented by the correct placement and management of drains (see Table 39.2) or, better, avoiding drains when not indicated.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.81, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 39.1. Complications of Intraperitoneal Drains',\n", " 'md': '### Table 39.1. Complications of Intraperitoneal Drains',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'table',\n", " 'rows': [['Complication'],\n", " [\"Drain 'fever'\"],\n", " ['Drain tract infection'],\n", " ['Drain tract hernia'],\n", " ['Drain tract bleeding'],\n", " ['Intestinal obstruction'],\n", " ['Erosion of bowel'],\n", " ['Erosion of vessels'],\n", " ['Contamination of sterile tissues'],\n", " ['Prevention of healing of fistulas'],\n", " ['Failure to retrieve: caught by fascial sutures, torn, knotted or tissue sucked in/growing into drain'],\n", " [\"'Lost' drain: migration into the abdomen or breakage\"]],\n", " 'md': \"| Complication |\\n|--------------------------------------------------|\\n| Drain 'fever' |\\n| Drain tract infection |\\n| Drain tract hernia |\\n| Drain tract bleeding |\\n| Intestinal obstruction |\\n| Erosion of bowel |\\n| Erosion of vessels |\\n| Contamination of sterile tissues |\\n| Prevention of healing of fistulas |\\n| Failure to retrieve: caught by fascial sutures, torn, knotted or tissue sucked in/growing into drain |\\n| 'Lost' drain: migration into the abdomen or breakage |\",\n", " 'isPerfectTable': True,\n", " 'csv': '\"Complication\"\\n\"Drain \\'fever\\'\"\\n\"Drain tract infection\"\\n\"Drain tract hernia\"\\n\"Drain tract bleeding\"\\n\"Intestinal obstruction\"\\n\"Erosion of bowel\"\\n\"Erosion of vessels\"\\n\"Contamination of sterile tissues\"\\n\"Prevention of healing of fistulas\"\\n\"Failure to retrieve: caught by fascial sutures, torn, knotted or tissue sucked in/growing into drain\"\\n\"\\'Lost\\' drain: migration into the abdomen or breakage\"',\n", " 'bBox': {'x': 150.14, 'y': 418, 'w': 354.26, 'h': 12.86}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '; some are rare but we have experienced each of'},\n", " {'text': 'Table 39.2) or, better, avoiding drains when not indicated.'}]},\n", " {'page': 719,\n", " 'text': \"Table 39.2. The placement and management of drains.\\n Insertion:\\n Choose a suitable drain for the specific job but in general go with the softest\\n and smallest\\n Place the drain carefully in the desired region, trim it to remove excessive\\n length but leave some 'slack':\\n Place it away from bowel wall or vessels:\\n Trv to bring omentum between the drain and vital structures to prevent\\n erosion:\\n Bring the drain out through the skin, away from the main wound to prevent\\n wound infection.\\n Plan the shortest track possible and depending on the indication for drainage\\n and type of drain try to exit it in a dependent location:\\n When closing the main wound be careful not to catch the adjacent drain with\\n your fascial sutures.\\n Secure the drain to the skin with sutures and tape:\\n Management:\\n Use a closed system whenever possible:\\n Use low suction to prevent sucking adjacent tissue into the drain's holes\\n To keep small-caliber tube drains patent they can be flushed twice daily with\\n small amounts of saline under sterile conditions.\\n When a fistula is established (eg: biliary), suction can be disconnected and the\\n drain connected to adependent bag, draining on gravity:\\n Be careful that the drain's tip is not abutting the visceral defect it is draining\\n this would prevent the closure of the defect: check for drain position with a\\n sinogram:.\\n Removal:\\n Remove as soon as the drain is not productive or seems to have outdone its\\n prophylactic task:\\n Long-term drains should be removed in stages to prevent abscess formation in\\n the deep tract:\\n Removal and shortening of drains could be guided (selectively) with sinograms\\n and/or CTs:\\n When shortening the drain refix it to the skin to prevent proximal migration:\",\n", " 'md': \"```markdown\\n# Table 39.2: The Placement and Management of Drains\\n\\n## Insertion\\n- Choose a suitable drain for the specific job but in general go with the softest and smallest.\\n- Place the drain carefully in the desired region, trim it to remove excessive length but leave some 'slack'.\\n- Place it away from bowel wall or vessels.\\n- Try to bring omentum between the drain and vital structures to prevent erosion.\\n- Bring the drain out through the skin, away from the main wound to prevent wound infection.\\n- Plan the shortest track possible and depending on the indication for drainage and type of drain, try to exit it in a dependent location.\\n- When closing the main wound, be careful not to catch the adjacent drain with your fascial sutures.\\n- Secure the drain to the skin with sutures and tape.\\n\\n## Management\\n- Use a closed system whenever possible.\\n- Use low suction to prevent sucking adjacent tissue into the drain's holes.\\n- To keep small-caliber tube drains patent, they can be flushed twice daily with small amounts of saline under sterile conditions.\\n- When a fistula is established (e.g., biliary), suction can be disconnected and the drain connected to a dependent bag, draining on gravity.\\n- Be careful that the drain's tip is not abutting the visceral defect it is draining; this would prevent the closure of the defect: check for drain position with a sinogram.\\n\\n## Removal\\n- Remove as soon as the drain is not productive or seems to have outdone its prophylactic task.\\n- Long-term drains should be removed in stages to prevent abscess formation in the deep tract.\\n- Removal and shortening of drains could be guided (selectively) with sinograms and/or CTs.\\n- When shortening the drain, refix it to the skin to prevent proximal migration.\\n```\",\n", " 'images': [{'name': 'img_p718_1.png',\n", " 'height': 1310,\n", " 'width': 819,\n", " 'x': 72,\n", " 'y': 72,\n", " 'original_width': 1408,\n", " 'original_height': 2444}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Table 39.2: The Placement and Management of Drains',\n", " 'md': '# Table 39.2: The Placement and Management of Drains',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Insertion',\n", " 'md': '## Insertion',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- Choose a suitable drain for the specific job but in general go with the softest and smallest.\\n- Place the drain carefully in the desired region, trim it to remove excessive length but leave some 'slack'.\\n- Place it away from bowel wall or vessels.\\n- Try to bring omentum between the drain and vital structures to prevent erosion.\\n- Bring the drain out through the skin, away from the main wound to prevent wound infection.\\n- Plan the shortest track possible and depending on the indication for drainage and type of drain, try to exit it in a dependent location.\\n- When closing the main wound, be careful not to catch the adjacent drain with your fascial sutures.\\n- Secure the drain to the skin with sutures and tape.\",\n", " 'md': \"- Choose a suitable drain for the specific job but in general go with the softest and smallest.\\n- Place the drain carefully in the desired region, trim it to remove excessive length but leave some 'slack'.\\n- Place it away from bowel wall or vessels.\\n- Try to bring omentum between the drain and vital structures to prevent erosion.\\n- Bring the drain out through the skin, away from the main wound to prevent wound infection.\\n- Plan the shortest track possible and depending on the indication for drainage and type of drain, try to exit it in a dependent location.\\n- When closing the main wound, be careful not to catch the adjacent drain with your fascial sutures.\\n- Secure the drain to the skin with sutures and tape.\",\n", " 'bBox': {'x': 115.06, 'y': 144.22, 'w': 322.21, 'h': 15.33}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management',\n", " 'md': '## Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- Use a closed system whenever possible.\\n- Use low suction to prevent sucking adjacent tissue into the drain's holes.\\n- To keep small-caliber tube drains patent, they can be flushed twice daily with small amounts of saline under sterile conditions.\\n- When a fistula is established (e.g., biliary), suction can be disconnected and the drain connected to a dependent bag, draining on gravity.\\n- Be careful that the drain's tip is not abutting the visceral defect it is draining; this would prevent the closure of the defect: check for drain position with a sinogram.\",\n", " 'md': \"- Use a closed system whenever possible.\\n- Use low suction to prevent sucking adjacent tissue into the drain's holes.\\n- To keep small-caliber tube drains patent, they can be flushed twice daily with small amounts of saline under sterile conditions.\\n- When a fistula is established (e.g., biliary), suction can be disconnected and the drain connected to a dependent bag, draining on gravity.\\n- Be careful that the drain's tip is not abutting the visceral defect it is draining; this would prevent the closure of the defect: check for drain position with a sinogram.\",\n", " 'bBox': {'x': 115.56, 'y': 424.2, 'w': 321.71, 'h': 14.35}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Removal',\n", " 'md': '## Removal',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Remove as soon as the drain is not productive or seems to have outdone its prophylactic task.\\n- Long-term drains should be removed in stages to prevent abscess formation in the deep tract.\\n- Removal and shortening of drains could be guided (selectively) with sinograms and/or CTs.\\n- When shortening the drain, refix it to the skin to prevent proximal migration.\\n```',\n", " 'md': '- Remove as soon as the drain is not productive or seems to have outdone its prophylactic task.\\n- Long-term drains should be removed in stages to prevent abscess formation in the deep tract.\\n- Removal and shortening of drains could be guided (selectively) with sinograms and/or CTs.\\n- When shortening the drain, refix it to the skin to prevent proximal migration.\\n```',\n", " 'bBox': {'x': 114.57, 'y': 594.36, 'w': 322.7, 'h': 15.33}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 720,\n", " 'text': ' Regional differences in practice\\n\\n From the international feedback we received this trend is obvious:\\nNorth American surgeons tend to be abandoning drainage for most\\nindications while surgeons in Asia and Eastern Europe still seem to be\\nenthusiastic about drainage. Such differences are particularly notable\\nconcerning drain placement in diffuse intra-abdominal infections and\\nemergency colonic surgery. But why do North American, West European\\nand South American surgeons tend to rely less on drains? Such a shift\\nin habits has surely occurred gradually and is due to multiple\\nfactors:\\n\\n • With improved surgical techniques, antibiotic administration, and\\n better imaging, the results of emergency abdominal procedures are\\n improving. Thus, surgeons are noticing fewer complications that\\n could allegedly be prevented by drains. This has provided surgeons\\n with a new sense of confidence — why should they leave drains if\\n the drains seem mostly unnecessary?\\n • Readily available CT scanning has added to the surgeons’\\n confidence. Now the mysterious postoperative abdominal cavity is\\n no longer a black box. We do not need a drain to warn us that there\\n is an abscess — we can see it on the CT.\\n • The immense success of image-guided percutaneous drainage of\\n intra-abdominal collections and abscesses has obviously added to\\n that confidence. And it has also taught us much about the\\n methodology of drainage itself — that you do not need huge\\n tubes, for many days, to get rid of an abscess — the elaborate\\n rituals surrounding the management of drains are evaporating\\n as well.\\n • So modern surgeons have found out that they do not need drains to\\n ‘prevent or treat’ persistent or recurrent infection after, say,\\n perforated appendicitis. They have learned that most patients do\\n well with source control (appendectomy) and antibiotics. And if not,\\n they CT scan them, and if necessary drain whatever is there under\\n CT guidance.',\n", " 'md': '```markdown\\n# Regional Differences in Practice\\n\\nFrom the international feedback we received, this trend is obvious: North American surgeons tend to be abandoning drainage for most indications while surgeons in Asia and Eastern Europe still seem to be enthusiastic about drainage. Such differences are particularly notable concerning drain placement in diffuse intra-abdominal infections and emergency colonic surgery.\\n\\nBut why do North American, West European, and South American surgeons tend to rely less on drains? Such a shift in habits has surely occurred gradually and is due to multiple factors:\\n\\n- With improved surgical techniques, antibiotic administration, and better imaging, the results of emergency abdominal procedures are improving. Thus, surgeons are noticing fewer complications that could allegedly be prevented by drains. This has provided surgeons with a new sense of confidence — why should they leave drains if the drains seem mostly unnecessary?\\n- Readily available CT scanning has added to the surgeons’ confidence. Now the mysterious postoperative abdominal cavity is no longer a black box. We do not need a drain to warn us that there is an abscess — we can see it on the CT.\\n- The immense success of image-guided percutaneous drainage of intra-abdominal collections and abscesses has obviously added to that confidence. And it has also taught us much about the methodology of drainage itself — that you do not need huge tubes, for many days, to get rid of an abscess — the elaborate rituals surrounding the management of drains are evaporating as well.\\n- So modern surgeons have found out that they do not need drains to ‘prevent or treat’ persistent or recurrent infection after, say, perforated appendicitis. They have learned that most patients do well with source control (appendectomy) and antibiotics. And if not, they CT scan them, and if necessary drain whatever is there under CT guidance.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Regional Differences in Practice',\n", " 'md': '# Regional Differences in Practice',\n", " 'bBox': {'x': 86, 'y': 112, 'w': 250.11, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'From the international feedback we received, this trend is obvious: North American surgeons tend to be abandoning drainage for most indications while surgeons in Asia and Eastern Europe still seem to be enthusiastic about drainage. Such differences are particularly notable concerning drain placement in diffuse intra-abdominal infections and emergency colonic surgery.\\n\\nBut why do North American, West European, and South American surgeons tend to rely less on drains? Such a shift in habits has surely occurred gradually and is due to multiple factors:\\n\\n- With improved surgical techniques, antibiotic administration, and better imaging, the results of emergency abdominal procedures are improving. Thus, surgeons are noticing fewer complications that could allegedly be prevented by drains. This has provided surgeons with a new sense of confidence — why should they leave drains if the drains seem mostly unnecessary?\\n- Readily available CT scanning has added to the surgeons’ confidence. Now the mysterious postoperative abdominal cavity is no longer a black box. We do not need a drain to warn us that there is an abscess — we can see it on the CT.\\n- The immense success of image-guided percutaneous drainage of intra-abdominal collections and abscesses has obviously added to that confidence. And it has also taught us much about the methodology of drainage itself — that you do not need huge tubes, for many days, to get rid of an abscess — the elaborate rituals surrounding the management of drains are evaporating as well.\\n- So modern surgeons have found out that they do not need drains to ‘prevent or treat’ persistent or recurrent infection after, say, perforated appendicitis. They have learned that most patients do well with source control (appendectomy) and antibiotics. And if not, they CT scan them, and if necessary drain whatever is there under CT guidance.\\n```',\n", " 'md': 'From the international feedback we received, this trend is obvious: North American surgeons tend to be abandoning drainage for most indications while surgeons in Asia and Eastern Europe still seem to be enthusiastic about drainage. Such differences are particularly notable concerning drain placement in diffuse intra-abdominal infections and emergency colonic surgery.\\n\\nBut why do North American, West European, and South American surgeons tend to rely less on drains? Such a shift in habits has surely occurred gradually and is due to multiple factors:\\n\\n- With improved surgical techniques, antibiotic administration, and better imaging, the results of emergency abdominal procedures are improving. Thus, surgeons are noticing fewer complications that could allegedly be prevented by drains. This has provided surgeons with a new sense of confidence — why should they leave drains if the drains seem mostly unnecessary?\\n- Readily available CT scanning has added to the surgeons’ confidence. Now the mysterious postoperative abdominal cavity is no longer a black box. We do not need a drain to warn us that there is an abscess — we can see it on the CT.\\n- The immense success of image-guided percutaneous drainage of intra-abdominal collections and abscesses has obviously added to that confidence. And it has also taught us much about the methodology of drainage itself — that you do not need huge tubes, for many days, to get rid of an abscess — the elaborate rituals surrounding the management of drains are evaporating as well.\\n- So modern surgeons have found out that they do not need drains to ‘prevent or treat’ persistent or recurrent infection after, say, perforated appendicitis. They have learned that most patients do well with source control (appendectomy) and antibiotics. And if not, they CT scan them, and if necessary drain whatever is there under CT guidance.\\n```',\n", " 'bBox': {'x': 72, 'y': 247, 'w': 467.68, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 721,\n", " 'text': ' What is behind the persisting enthusiasm for drains in\\n Asia and East Europe?\\n\\n Is it that because of the relative unavailability of postoperative CT in\\nthe ‘developing countries’, surgeons cannot gather the confidence to omit\\ndrains? Or are they more forcefully subjected to local dogmas,\\nentrenched by strict discipline? It seems so. It was during the mid-1980s\\nthat we abandoned routine drainage for the conditions discussed above.\\nAt that time we did not have CT and percutaneous drainage to bail us\\nout, but we understood then what surgeons should understand today —\\nthat with CT or without CT, most drains are unnecessary and\\ncounterproductive.\\n\\n Let us then repeat William Stewart ħalsted’s motto: “No drainage is\\nbetter than the ignorant employment of it.”\\n\\n Final words…\\n 1\\n PeRyA 2oo+\\n Figure 39.1. Confused resident: “Boss, he’s still sick.” Old-fashioned surgeon: “Perhaps\\n we should have placed more drains...”',\n", " 'md': '```markdown\\n## Page Content\\n\\nWhat is behind the persisting enthusiasm for drains in Asia and East Europe?\\n\\nIs it that because of the relative unavailability of postoperative CT in the ‘developing countries’, surgeons cannot gather the confidence to omit drains? Or are they more forcefully subjected to local dogmas, entrenched by strict discipline? It seems so. It was during the mid-1980s that we abandoned routine drainage for the conditions discussed above. At that time we did not have CT and percutaneous drainage to bail us out, but we understood then what surgeons should understand today — that with CT or without CT, most drains are unnecessary and counterproductive.\\n\\nLet us then repeat William Stewart Halsted’s motto: “No drainage is better than the ignorant employment of it.”\\n\\nFinal words…\\n\\n----\\n\\n### Figure 39.1\\n\\n**Description:** This figure depicts a humorous exchange between a confused resident and an old-fashioned surgeon. The resident expresses concern about a patient still being sick, while the surgeon suggests that perhaps more drains should have been placed.\\n\\n**Summary:** The image illustrates the ongoing debate and differing perspectives on the use of drains in surgical practice, highlighting the tension between modern practices and traditional beliefs.\\n\\n![Figure 39.1]()\\n```',\n", " 'images': [{'name': 'img_p720_1.png',\n", " 'height': 578,\n", " 'width': 800,\n", " 'x': 108,\n", " 'y': 385.2,\n", " 'original_width': 1376,\n", " 'original_height': 994}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'What is behind the persisting enthusiasm for drains in Asia and East Europe?\\n\\nIs it that because of the relative unavailability of postoperative CT in the ‘developing countries’, surgeons cannot gather the confidence to omit drains? Or are they more forcefully subjected to local dogmas, entrenched by strict discipline? It seems so. It was during the mid-1980s that we abandoned routine drainage for the conditions discussed above. At that time we did not have CT and percutaneous drainage to bail us out, but we understood then what surgeons should understand today — that with CT or without CT, most drains are unnecessary and counterproductive.\\n\\nLet us then repeat William Stewart Halsted’s motto: “No drainage is better than the ignorant employment of it.”\\n\\nFinal words…\\n\\n----',\n", " 'md': 'What is behind the persisting enthusiasm for drains in Asia and East Europe?\\n\\nIs it that because of the relative unavailability of postoperative CT in the ‘developing countries’, surgeons cannot gather the confidence to omit drains? Or are they more forcefully subjected to local dogmas, entrenched by strict discipline? It seems so. It was during the mid-1980s that we abandoned routine drainage for the conditions discussed above. At that time we did not have CT and percutaneous drainage to bail us out, but we understood then what surgeons should understand today — that with CT or without CT, most drains are unnecessary and counterproductive.\\n\\nLet us then repeat William Stewart Halsted’s motto: “No drainage is better than the ignorant employment of it.”\\n\\nFinal words…\\n\\n----',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.65, 'h': 29.67}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 39.1',\n", " 'md': '### Figure 39.1',\n", " 'bBox': {'x': 484.7, 'y': 418.33, 'w': 17.82, 'h': 29.67}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure depicts a humorous exchange between a confused resident and an old-fashioned surgeon. The resident expresses concern about a patient still being sick, while the surgeon suggests that perhaps more drains should have been placed.\\n\\n**Summary:** The image illustrates the ongoing debate and differing perspectives on the use of drains in surgical practice, highlighting the tension between modern practices and traditional beliefs.\\n\\n![Figure 39.1]()\\n```',\n", " 'md': '**Description:** This figure depicts a humorous exchange between a confused resident and an old-fashioned surgeon. The resident expresses concern about a patient still being sick, while the surgeon suggests that perhaps more drains should have been placed.\\n\\n**Summary:** The image illustrates the ongoing debate and differing perspectives on the use of drains in surgical practice, highlighting the tension between modern practices and traditional beliefs.\\n\\n![Figure 39.1]()\\n```',\n", " 'bBox': {'x': 484.7, 'y': 418.33, 'w': 17.82, 'h': 29.67}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 722,\n", " 'text': ' The use of routine drainage in contaminated and infected abdominal\\nsurgery is declining but still practiced in some regions of the world. Drains\\nshould be used very selectively: when their placement is the only way to\\ncontrol the source of infection, to provide escape for highly predicted\\nleaking fluids (bile, pancreatic juice, urine), to drain a non-collapsible\\nabscess (a rare animal!), or to drain, for a short while, a very oozy\\nsurface (we are not sure about this last ‘indication’!). Prophylactic\\ndrainage of the general peritoneal cavity is senseless ( Figure 39.1);\\nwhile drainage of an intestinal anastomosis may be dangerous!\\n\\n “Although more than five million surgical drains are used\\n each year in the United States, their effectiveness,\\n therapeutic indications, and efficiency remains an\\n unsolved controversy.”\\n J. P. Moss\\n\\n1 Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidence-based value of prophylactic\\n drainage in gastrointestinal surgery: a systematic review and meta-analysis. Ann Surg 2004;\\n 204: 1074-85.\\n2 See Chapter 6 on anastomotic leaks in Schein’s Common Sense Prevention and\\n Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013.',\n", " 'md': '```markdown\\nThe use of routine drainage in contaminated and infected abdominal surgery is declining but still practiced in some regions of the world. Drains should be used very selectively: when their placement is the only way to control the source of infection, to provide escape for highly predicted leaking fluids (bile, pancreatic juice, urine), to drain a non-collapsible abscess (a rare animal!), or to drain, for a short while, a very oozy surface (we are not sure about this last ‘indication’!). Prophylactic drainage of the general peritoneal cavity is senseless (Figure 39.1); while drainage of an intestinal anastomosis may be dangerous!\\n\\n“Although more than five million surgical drains are used each year in the United States, their effectiveness, therapeutic indications, and efficiency remains an unsolved controversy.”\\n— J. P. Moss\\n\\n1. Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analysis. Ann Surg 2004; 204: 1074-85.\\n2. See Chapter 6 on anastomotic leaks in Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013.\\n```\\n\\n### Figure Description\\n- **Figure 39.1**: This figure is referenced in the text but not provided in the current content. It likely illustrates the concept of prophylactic drainage in the general peritoneal cavity, which is described as senseless in the text. Further details about the figure would be needed to provide a complete description.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nThe use of routine drainage in contaminated and infected abdominal surgery is declining but still practiced in some regions of the world. Drains should be used very selectively: when their placement is the only way to control the source of infection, to provide escape for highly predicted leaking fluids (bile, pancreatic juice, urine), to drain a non-collapsible abscess (a rare animal!), or to drain, for a short while, a very oozy surface (we are not sure about this last ‘indication’!). Prophylactic drainage of the general peritoneal cavity is senseless (Figure 39.1); while drainage of an intestinal anastomosis may be dangerous!\\n\\n“Although more than five million surgical drains are used each year in the United States, their effectiveness, therapeutic indications, and efficiency remains an unsolved controversy.”\\n— J. P. Moss\\n\\n1. Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analysis. Ann Surg 2004; 204: 1074-85.\\n2. See Chapter 6 on anastomotic leaks in Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013.\\n```',\n", " 'md': '```markdown\\nThe use of routine drainage in contaminated and infected abdominal surgery is declining but still practiced in some regions of the world. Drains should be used very selectively: when their placement is the only way to control the source of infection, to provide escape for highly predicted leaking fluids (bile, pancreatic juice, urine), to drain a non-collapsible abscess (a rare animal!), or to drain, for a short while, a very oozy surface (we are not sure about this last ‘indication’!). Prophylactic drainage of the general peritoneal cavity is senseless (Figure 39.1); while drainage of an intestinal anastomosis may be dangerous!\\n\\n“Although more than five million surgical drains are used each year in the United States, their effectiveness, therapeutic indications, and efficiency remains an unsolved controversy.”\\n— J. P. Moss\\n\\n1. Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analysis. Ann Surg 2004; 204: 1074-85.\\n2. See Chapter 6 on anastomotic leaks in Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013.\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.73, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Description',\n", " 'md': '### Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 39.1**: This figure is referenced in the text but not provided in the current content. It likely illustrates the concept of prophylactic drainage in the general peritoneal cavity, which is described as senseless in the text. Further details about the figure would be needed to provide a complete description.',\n", " 'md': '- **Figure 39.1**: This figure is referenced in the text but not provided in the current content. It likely illustrates the concept of prophylactic drainage in the general peritoneal cavity, which is described as senseless in the text. Further details about the figure would be needed to provide a complete description.',\n", " 'bBox': {'x': 73, 'y': 285, 'w': 128.83, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'while drainage of an intestinal anastomosis may be dangerous!'},\n", " {'text': '1'},\n", " {'text': '2'}]},\n", " {'page': 723,\n", " 'text': 'Chapter 40\\nAbdominal closure\\nMoshe Schein and Danny Rosin\\n\\n Big bites, with a continuous monofilament suture and —\\n above all — avoiding tension — this is how to avoid\\n dehiscence and herniation. (Or is it?)\\n\\n Finally, it is time to “get the hell out of here”. You have been working all\\nnight and it is tempting to finish hastily. Impatience, however, is\\ninadvisable since correct abdominal closure protects the patient from\\nabdominal wound dehiscence (and later on from the development of a\\nhernia), and it spares you a potential humiliation (‘everybody knows’).\\nYes, you are tired but, before closing, stop and think; ask your assistants:\\n“Did we forget to do anything?” See the checklist in the next chapter.\\n\\n Generally, an abdominal closure fails because of poor quality of\\nthe tissues, increased intra-abdominal pressure, faulty technique, or\\na combination of all of these. Very rarely, a suture knot comes undone,\\nor a damaged suture breaks, but more typically, the fault lies with the\\ntissue and not the suture. In order to achieve secure closure, keep in\\nmind (and hands) the following.\\n\\n Principles of closure\\n\\n Suture material',\n", " 'md': '```markdown\\n# Chapter 40: Abdominal Closure\\n**Authors:** Moshe Schein and Danny Rosin\\n\\nBig bites, with a continuous monofilament suture and — above all — avoiding tension — this is how to avoid dehiscence and herniation. (Or is it?)\\n\\nFinally, it is time to “get the hell out of here”. You have been working all night and it is tempting to finish hastily. Impatience, however, is inadvisable since correct abdominal closure protects the patient from abdominal wound dehiscence (and later on from the development of a hernia), and it spares you a potential humiliation (‘everybody knows’). Yes, you are tired but, before closing, stop and think; ask your assistants: “Did we forget to do anything?” See the checklist in the next chapter.\\n\\nGenerally, an abdominal closure fails because of poor quality of the tissues, increased intra-abdominal pressure, faulty technique, or a combination of all of these. Very rarely, a suture knot comes undone, or a damaged suture breaks, but more typically, the fault lies with the tissue and not the suture. In order to achieve secure closure, keep in mind (and hands) the following.\\n\\n## Principles of Closure\\n\\n### Suture Material\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 40: Abdominal Closure',\n", " 'md': '# Chapter 40: Abdominal Closure',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 165.76, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Moshe Schein and Danny Rosin\\n\\nBig bites, with a continuous monofilament suture and — above all — avoiding tension — this is how to avoid dehiscence and herniation. (Or is it?)\\n\\nFinally, it is time to “get the hell out of here”. You have been working all night and it is tempting to finish hastily. Impatience, however, is inadvisable since correct abdominal closure protects the patient from abdominal wound dehiscence (and later on from the development of a hernia), and it spares you a potential humiliation (‘everybody knows’). Yes, you are tired but, before closing, stop and think; ask your assistants: “Did we forget to do anything?” See the checklist in the next chapter.\\n\\nGenerally, an abdominal closure fails because of poor quality of the tissues, increased intra-abdominal pressure, faulty technique, or a combination of all of these. Very rarely, a suture knot comes undone, or a damaged suture breaks, but more typically, the fault lies with the tissue and not the suture. In order to achieve secure closure, keep in mind (and hands) the following.',\n", " 'md': '**Authors:** Moshe Schein and Danny Rosin\\n\\nBig bites, with a continuous monofilament suture and — above all — avoiding tension — this is how to avoid dehiscence and herniation. (Or is it?)\\n\\nFinally, it is time to “get the hell out of here”. You have been working all night and it is tempting to finish hastily. Impatience, however, is inadvisable since correct abdominal closure protects the patient from abdominal wound dehiscence (and later on from the development of a hernia), and it spares you a potential humiliation (‘everybody knows’). Yes, you are tired but, before closing, stop and think; ask your assistants: “Did we forget to do anything?” See the checklist in the next chapter.\\n\\nGenerally, an abdominal closure fails because of poor quality of the tissues, increased intra-abdominal pressure, faulty technique, or a combination of all of these. Very rarely, a suture knot comes undone, or a damaged suture breaks, but more typically, the fault lies with the tissue and not the suture. In order to achieve secure closure, keep in mind (and hands) the following.',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.73, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Principles of Closure',\n", " 'md': '## Principles of Closure',\n", " 'bBox': {'x': 86, 'y': 638, 'w': 162.75, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Suture Material',\n", " 'md': '### Suture Material',\n", " 'bBox': {'x': 86, 'y': 682, 'w': 120.47, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 724,\n", " 'text': ' Use slowly absorbable monofilament sutures (e.g. PDS® or Maxon®),\\nbut non-absorbable monofilament (e.g. nylon or Prolene®) would do as\\nwell. Rapidly absorbed material such as Vicryl® and Dexon® are still\\nwidely used even though their use is suboptimal in view of wound-repair\\nkinetics. Those who fancy such suture material produce the hernias for\\nthe rest of us to repair. Slowly absorbable or non-absorbable suture\\nmaterial, on the other hand, keeps the edges of the wound together\\nuntil its own tensile strength takes over. Monofilament sutures are\\nadvantageous because they slide better, inflicting less ‘saw injury’ to the\\ntissues and, when used in the preferred continuous fashion, distribute the\\ntension evenly along the length of the wound. The use of braided non-\\nabsorbable material (e.g. silk) is associated with chronic infected\\nsinus formation and belongs, we hope, to remote history. Not that\\nwe do not occasionally see a sinus developing after the use of PDS® or\\nnylon — this is, however, quite rare. Monofilament material is not prone\\nto breakage but damage to the suture during insertion can make this\\nmore likely. It is therefore important to avoid grasping the suture\\nmaterial itself with forceps because this can damage its integrity\\nand weaken it.\\n\\n Closing an abdomen is like catching a big fish — the rules are the same: attach a line of\\n good quality and the correct size to the hook with perfect knots; do not damage the line and\\n keep it under optimal tension; if the fish fights then play with it for a while — if the patient starts\\n waking up, wait for him to get ‘deeper’ — take your time and be patient. If you don’t follow\\n the rules you will end up with postop dehiscence… or a hernia… and lose the fish.\\n\\n ‘Mass closure’\\n\\n This is the preferred technique as documented in numerous studies. It\\nhas been popularized for the closure of midline incisions but is as\\neffective for the closure of transverse muscle-cutting incisions. For the\\nlatter, however, many surgeons, including us, still prefer layered\\n(posterior fascia-anterior fascia) closure. For example, to close a\\nsubcostal incision you could run a looped #1 PDS® from the midline\\nlaterally — taking the posterior sheath together with the peritoneum; at',\n", " 'md': '```markdown\\n## Suture Material and Techniques\\n\\nUse slowly absorbable monofilament sutures (e.g. PDS® or Maxon®), but non-absorbable monofilament (e.g. nylon or Prolene®) would do as well. Rapidly absorbed material such as Vicryl® and Dexon® are still widely used even though their use is suboptimal in view of wound-repair kinetics. Those who fancy such suture material produce the hernias for the rest of us to repair. Slowly absorbable or non-absorbable suture material, on the other hand, keeps the edges of the wound together until its own tensile strength takes over.\\n\\nMonofilament sutures are advantageous because they slide better, inflicting less ‘saw injury’ to the tissues and, when used in the preferred continuous fashion, distribute the tension evenly along the length of the wound. The use of braided non-absorbable material (e.g. silk) is associated with chronic infected sinus formation and belongs, we hope, to remote history. Not that we do not occasionally see a sinus developing after the use of PDS® or nylon — this is, however, quite rare. Monofilament material is not prone to breakage but damage to the suture during insertion can make this more likely. It is therefore important to avoid grasping the suture material itself with forceps because this can damage its integrity and weaken it.\\n\\nClosing an abdomen is like catching a big fish — the rules are the same: attach a line of good quality and the correct size to the hook with perfect knots; do not damage the line and keep it under optimal tension; if the fish fights then play with it for a while — if the patient starts waking up, wait for him to get ‘deeper’ — take your time and be patient. If you don’t follow the rules you will end up with postop dehiscence… or a hernia… and lose the fish.\\n\\n### Mass Closure\\n\\nThis is the preferred technique as documented in numerous studies. It has been popularized for the closure of midline incisions but is as effective for the closure of transverse muscle-cutting incisions. For the latter, however, many surgeons, including us, still prefer layered (posterior fascia-anterior fascia) closure. For example, to close a subcostal incision you could run a looped #1 PDS® from the midline laterally — taking the posterior sheath together with the peritoneum; at\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Suture Material and Techniques',\n", " 'md': '## Suture Material and Techniques',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Use slowly absorbable monofilament sutures (e.g. PDS® or Maxon®), but non-absorbable monofilament (e.g. nylon or Prolene®) would do as well. Rapidly absorbed material such as Vicryl® and Dexon® are still widely used even though their use is suboptimal in view of wound-repair kinetics. Those who fancy such suture material produce the hernias for the rest of us to repair. Slowly absorbable or non-absorbable suture material, on the other hand, keeps the edges of the wound together until its own tensile strength takes over.\\n\\nMonofilament sutures are advantageous because they slide better, inflicting less ‘saw injury’ to the tissues and, when used in the preferred continuous fashion, distribute the tension evenly along the length of the wound. The use of braided non-absorbable material (e.g. silk) is associated with chronic infected sinus formation and belongs, we hope, to remote history. Not that we do not occasionally see a sinus developing after the use of PDS® or nylon — this is, however, quite rare. Monofilament material is not prone to breakage but damage to the suture during insertion can make this more likely. It is therefore important to avoid grasping the suture material itself with forceps because this can damage its integrity and weaken it.\\n\\nClosing an abdomen is like catching a big fish — the rules are the same: attach a line of good quality and the correct size to the hook with perfect knots; do not damage the line and keep it under optimal tension; if the fish fights then play with it for a while — if the patient starts waking up, wait for him to get ‘deeper’ — take your time and be patient. If you don’t follow the rules you will end up with postop dehiscence… or a hernia… and lose the fish.',\n", " 'md': 'Use slowly absorbable monofilament sutures (e.g. PDS® or Maxon®), but non-absorbable monofilament (e.g. nylon or Prolene®) would do as well. Rapidly absorbed material such as Vicryl® and Dexon® are still widely used even though their use is suboptimal in view of wound-repair kinetics. Those who fancy such suture material produce the hernias for the rest of us to repair. Slowly absorbable or non-absorbable suture material, on the other hand, keeps the edges of the wound together until its own tensile strength takes over.\\n\\nMonofilament sutures are advantageous because they slide better, inflicting less ‘saw injury’ to the tissues and, when used in the preferred continuous fashion, distribute the tension evenly along the length of the wound. The use of braided non-absorbable material (e.g. silk) is associated with chronic infected sinus formation and belongs, we hope, to remote history. Not that we do not occasionally see a sinus developing after the use of PDS® or nylon — this is, however, quite rare. Monofilament material is not prone to breakage but damage to the suture during insertion can make this more likely. It is therefore important to avoid grasping the suture material itself with forceps because this can damage its integrity and weaken it.\\n\\nClosing an abdomen is like catching a big fish — the rules are the same: attach a line of good quality and the correct size to the hook with perfect knots; do not damage the line and keep it under optimal tension; if the fish fights then play with it for a while — if the patient starts waking up, wait for him to get ‘deeper’ — take your time and be patient. If you don’t follow the rules you will end up with postop dehiscence… or a hernia… and lose the fish.',\n", " 'bBox': {'x': 72, 'y': 142, 'w': 467.66, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Mass Closure',\n", " 'md': '### Mass Closure',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This is the preferred technique as documented in numerous studies. It has been popularized for the closure of midline incisions but is as effective for the closure of transverse muscle-cutting incisions. For the latter, however, many surgeons, including us, still prefer layered (posterior fascia-anterior fascia) closure. For example, to close a subcostal incision you could run a looped #1 PDS® from the midline laterally — taking the posterior sheath together with the peritoneum; at\\n```',\n", " 'md': 'This is the preferred technique as documented in numerous studies. It has been popularized for the closure of midline incisions but is as effective for the closure of transverse muscle-cutting incisions. For the latter, however, many surgeons, including us, still prefer layered (posterior fascia-anterior fascia) closure. For example, to close a subcostal incision you could run a looped #1 PDS® from the midline laterally — taking the posterior sheath together with the peritoneum; at\\n```',\n", " 'bBox': {'x': 86, 'y': 605, 'w': 453.29, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 725,\n", " 'text': 'the lateral corner lock the suture and run it back medially, taking the\\nanterior sheath. Do the same on the other side, meet in the middle and\\ntie.\\n\\n Mass closure entails monolayered suturing of all structures of the\\nabdominal wall in a continuous manner to provide ‘one strong scar’.\\nThe secret here is to take large bites of tissue, at least 1cm away from\\nthe wound’s edges; the bites should be closely spaced so as not to\\ncreate gaps greater than 1cm. The intervening muscle is included in the\\nbites. No less important is the issue of the correct tension to be set\\non the suture ( Figure 40.1). If you pull the suture too tight the tissue\\nis strangulated and necrosed, which may cause the sutures to cut\\nthrough the tissue — the source of the so-called buttonhole hernias. But\\nif you keep the suture too loose the wound edges gape. Bear in mind\\nthat the muscles are relaxed as you close (or should be) and that\\npostoperatively they will acquire their normal tone, the tissues in the\\nwound will swell and abdominal girth will increase. All of these changes\\nmake the wound closure tighter; if it is tight when you put the sutures in\\nthen something must give way when these changes take place — the\\ntissue tears. A suture-length to wound-length ratio of at least 4:1 will\\nensure a moderate but secure tension of closure (well, one always\\nneeds some excess to tie the knot… and since we usually start from both\\nends we have to use more suture length… so we are not too obsessed\\nabout measuring the exact length of suture…). The corners of the\\nincision are the Achilles’ heel of closure, especially the corner that is\\nclosed last. Do not compromise complete closure of the corner because\\nyou are afraid of injuring the underlying bowel; there are good tricks to\\naccomplish this endeavor — learn them from one of your mentors. (If you\\ndon’t have a mentor just email us.) A good way to avoid difficult\\n‘corners’ is to start closing from both ends and tie the two sutures\\nin the middle of the wound.\\n\\n Do not harm the underlying bowel, which frequently bulges towards\\nyour large needle. At the end of the operation the anesthetist always\\nswears to God that the patient is ‘maximally relaxed’; he lies. Make him\\nrelax the patient again — do not concede. Protect the bowel by\\nwhichever instrument is available, the best, in our experience, being the\\ncommercially available rubber Fish® retractor. The assistant’s hand also',\n", " 'md': '```markdown\\n## Page Content\\n\\nThe lateral corner lock the suture and run it back medially, taking the anterior sheath. Do the same on the other side, meet in the middle and tie.\\n\\nMass closure entails monolayered suturing of all structures of the abdominal wall in a continuous manner to provide ‘one strong scar’. The secret here is to take large bites of tissue, at least 1cm away from the wound’s edges; the bites should be closely spaced so as not to create gaps greater than 1cm. The intervening muscle is included in the bites. No less important is the issue of the correct tension to be set on the suture (Figure 40.1). If you pull the suture too tight the tissue is strangulated and necrosed, which may cause the sutures to cut through the tissue — the source of the so-called buttonhole hernias. But if you keep the suture too loose the wound edges gape. Bear in mind that the muscles are relaxed as you close (or should be) and that postoperatively they will acquire their normal tone, the tissues in the wound will swell and abdominal girth will increase. All of these changes make the wound closure tighter; if it is tight when you put the sutures in then something must give way when these changes take place — the tissue tears. A suture-length to wound-length ratio of at least 4:1 will ensure a moderate but secure tension of closure (well, one always needs some excess to tie the knot… and since we usually start from both ends we have to use more suture length… so we are not too obsessed about measuring the exact length of suture…). The corners of the incision are the Achilles’ heel of closure, especially the corner that is closed last. Do not compromise complete closure of the corner because you are afraid of injuring the underlying bowel; there are good tricks to accomplish this endeavor — learn them from one of your mentors. (If you don’t have a mentor just email us.) A good way to avoid difficult ‘corners’ is to start closing from both ends and tie the two sutures in the middle of the wound.\\n\\nDo not harm the underlying bowel, which frequently bulges towards your large needle. At the end of the operation the anesthetist always swears to God that the patient is ‘maximally relaxed’; he lies. Make him relax the patient again — do not concede. Protect the bowel by whichever instrument is available, the best, in our experience, being the commercially available rubber Fish® retractor. The assistant’s hand also...\\n\\n## Figures\\n\\n### Figure 40.1\\n- **Description**: This figure illustrates the correct tension to be set on the suture during mass closure of the abdominal wall. It emphasizes the importance of maintaining a balance between too tight and too loose sutures to prevent complications such as strangulation or gaping of the wound edges.\\n- **Summary**: The figure serves as a visual guide for surgeons to understand the implications of suture tension during closure, highlighting the risks associated with improper tension settings.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The lateral corner lock the suture and run it back medially, taking the anterior sheath. Do the same on the other side, meet in the middle and tie.\\n\\nMass closure entails monolayered suturing of all structures of the abdominal wall in a continuous manner to provide ‘one strong scar’. The secret here is to take large bites of tissue, at least 1cm away from the wound’s edges; the bites should be closely spaced so as not to create gaps greater than 1cm. The intervening muscle is included in the bites. No less important is the issue of the correct tension to be set on the suture (Figure 40.1). If you pull the suture too tight the tissue is strangulated and necrosed, which may cause the sutures to cut through the tissue — the source of the so-called buttonhole hernias. But if you keep the suture too loose the wound edges gape. Bear in mind that the muscles are relaxed as you close (or should be) and that postoperatively they will acquire their normal tone, the tissues in the wound will swell and abdominal girth will increase. All of these changes make the wound closure tighter; if it is tight when you put the sutures in then something must give way when these changes take place — the tissue tears. A suture-length to wound-length ratio of at least 4:1 will ensure a moderate but secure tension of closure (well, one always needs some excess to tie the knot… and since we usually start from both ends we have to use more suture length… so we are not too obsessed about measuring the exact length of suture…). The corners of the incision are the Achilles’ heel of closure, especially the corner that is closed last. Do not compromise complete closure of the corner because you are afraid of injuring the underlying bowel; there are good tricks to accomplish this endeavor — learn them from one of your mentors. (If you don’t have a mentor just email us.) A good way to avoid difficult ‘corners’ is to start closing from both ends and tie the two sutures in the middle of the wound.\\n\\nDo not harm the underlying bowel, which frequently bulges towards your large needle. At the end of the operation the anesthetist always swears to God that the patient is ‘maximally relaxed’; he lies. Make him relax the patient again — do not concede. Protect the bowel by whichever instrument is available, the best, in our experience, being the commercially available rubber Fish® retractor. The assistant’s hand also...',\n", " 'md': 'The lateral corner lock the suture and run it back medially, taking the anterior sheath. Do the same on the other side, meet in the middle and tie.\\n\\nMass closure entails monolayered suturing of all structures of the abdominal wall in a continuous manner to provide ‘one strong scar’. The secret here is to take large bites of tissue, at least 1cm away from the wound’s edges; the bites should be closely spaced so as not to create gaps greater than 1cm. The intervening muscle is included in the bites. No less important is the issue of the correct tension to be set on the suture (Figure 40.1). If you pull the suture too tight the tissue is strangulated and necrosed, which may cause the sutures to cut through the tissue — the source of the so-called buttonhole hernias. But if you keep the suture too loose the wound edges gape. Bear in mind that the muscles are relaxed as you close (or should be) and that postoperatively they will acquire their normal tone, the tissues in the wound will swell and abdominal girth will increase. All of these changes make the wound closure tighter; if it is tight when you put the sutures in then something must give way when these changes take place — the tissue tears. A suture-length to wound-length ratio of at least 4:1 will ensure a moderate but secure tension of closure (well, one always needs some excess to tie the knot… and since we usually start from both ends we have to use more suture length… so we are not too obsessed about measuring the exact length of suture…). The corners of the incision are the Achilles’ heel of closure, especially the corner that is closed last. Do not compromise complete closure of the corner because you are afraid of injuring the underlying bowel; there are good tricks to accomplish this endeavor — learn them from one of your mentors. (If you don’t have a mentor just email us.) A good way to avoid difficult ‘corners’ is to start closing from both ends and tie the two sutures in the middle of the wound.\\n\\nDo not harm the underlying bowel, which frequently bulges towards your large needle. At the end of the operation the anesthetist always swears to God that the patient is ‘maximally relaxed’; he lies. Make him relax the patient again — do not concede. Protect the bowel by whichever instrument is available, the best, in our experience, being the commercially available rubber Fish® retractor. The assistant’s hand also...',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 468.01, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures',\n", " 'md': '## Figures',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 40.1',\n", " 'md': '### Figure 40.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure illustrates the correct tension to be set on the suture during mass closure of the abdominal wall. It emphasizes the importance of maintaining a balance between too tight and too loose sutures to prevent complications such as strangulation or gaping of the wound edges.\\n- **Summary**: The figure serves as a visual guide for surgeons to understand the implications of suture tension during closure, highlighting the risks associated with improper tension settings.\\n\\n```',\n", " 'md': '- **Description**: This figure illustrates the correct tension to be set on the suture during mass closure of the abdominal wall. It emphasizes the importance of maintaining a balance between too tight and too loose sutures to prevent complications such as strangulation or gaping of the wound edges.\\n- **Summary**: The figure serves as a visual guide for surgeons to understand the implications of suture tension during closure, highlighting the risks associated with improper tension settings.\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'is strangulated and necrosed, which may cause the sutures to cut'}]},\n", " {'page': 726,\n", " 'text': 'may be useful for this purpose but with all the hepatitis and ħIV around\\nwe do not find many volunteers willing to offer a retracting hand, except\\nour own.\\n\\n We use a ‘looped’ #1 PDS® suture (but using non-absorbable Prolene®\\nis OK as well). It is a slowly absorbable monofilament, usually long\\nenough to provide a suture-to-wound ratio of 4:1. Threading the needle\\nthrough the loop after the first ‘bite’ replaces the need for the initial knot. If\\none uses a single suture then the final (corner) knot in our hands would\\nbe the ‘Aberdeen’ one — you can learn it on YouTube. We cut it long —\\nabout 1cm — and bury it deep in the subcutaneous space with any thin\\nabsorbable suture. Be careful with the knots. Our friend Berni Cristalli of\\nParis said: “I once asked my boss why he tied his knots seven times?\\n‘Last time I did six, it didn’t hold’, was his reply.”\\n TOPERATING]\\n Figure 40.1. “Jack, what are you doing?”… “The boss told me to close it tight…”\\n\\n Small-bite closure?',\n", " 'md': '```markdown\\nWe use a ‘looped’ #1 PDS® suture (but using non-absorbable Prolene® is OK as well). It is a slowly absorbable monofilament, usually long enough to provide a suture-to-wound ratio of 4:1. Threading the needle through the loop after the first ‘bite’ replaces the need for the initial knot. If one uses a single suture then the final (corner) knot in our hands would be the ‘Aberdeen’ one — you can learn it on YouTube. We cut it long — about 1cm — and bury it deep in the subcutaneous space with any thin absorbable suture. Be careful with the knots. Our friend Berni Cristalli of Paris said: “I once asked my boss why he tied his knots seven times? ‘Last time I did six, it didn’t hold’, was his reply.”\\n\\n### Figure 40.1\\n**Caption:** “Jack, what are you doing?”… “The boss told me to close it tight…”\\n\\n**Description:** This image likely depicts a humorous or illustrative scene related to surgical practices, possibly showing a character named Jack in a surgical context. The figure emphasizes the importance of proper knot tying in surgical procedures, reflecting on a conversation about the necessity of securing knots effectively.\\n\\n**Summary:** The image serves to highlight the significance of knot security in surgical suturing, using a light-hearted dialogue to convey the message.\\n```',\n", " 'images': [{'name': 'img_p725_1.png',\n", " 'height': 584,\n", " 'width': 822,\n", " 'x': 102.96000000000004,\n", " 'y': 318.96,\n", " 'original_width': 1413,\n", " 'original_height': 1003}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nWe use a ‘looped’ #1 PDS® suture (but using non-absorbable Prolene® is OK as well). It is a slowly absorbable monofilament, usually long enough to provide a suture-to-wound ratio of 4:1. Threading the needle through the loop after the first ‘bite’ replaces the need for the initial knot. If one uses a single suture then the final (corner) knot in our hands would be the ‘Aberdeen’ one — you can learn it on YouTube. We cut it long — about 1cm — and bury it deep in the subcutaneous space with any thin absorbable suture. Be careful with the knots. Our friend Berni Cristalli of Paris said: “I once asked my boss why he tied his knots seven times? ‘Last time I did six, it didn’t hold’, was his reply.”',\n", " 'md': '```markdown\\nWe use a ‘looped’ #1 PDS® suture (but using non-absorbable Prolene® is OK as well). It is a slowly absorbable monofilament, usually long enough to provide a suture-to-wound ratio of 4:1. Threading the needle through the loop after the first ‘bite’ replaces the need for the initial knot. If one uses a single suture then the final (corner) knot in our hands would be the ‘Aberdeen’ one — you can learn it on YouTube. We cut it long — about 1cm — and bury it deep in the subcutaneous space with any thin absorbable suture. Be careful with the knots. Our friend Berni Cristalli of Paris said: “I once asked my boss why he tied his knots seven times? ‘Last time I did six, it didn’t hold’, was his reply.”',\n", " 'bBox': {'x': 72, 'y': 151, 'w': 467.96, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 40.1',\n", " 'md': '### Figure 40.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** “Jack, what are you doing?”… “The boss told me to close it tight…”\\n\\n**Description:** This image likely depicts a humorous or illustrative scene related to surgical practices, possibly showing a character named Jack in a surgical context. The figure emphasizes the importance of proper knot tying in surgical procedures, reflecting on a conversation about the necessity of securing knots effectively.\\n\\n**Summary:** The image serves to highlight the significance of knot security in surgical suturing, using a light-hearted dialogue to convey the message.\\n```',\n", " 'md': '**Caption:** “Jack, what are you doing?”… “The boss told me to close it tight…”\\n\\n**Description:** This image likely depicts a humorous or illustrative scene related to surgical practices, possibly showing a character named Jack in a surgical context. The figure emphasizes the importance of proper knot tying in surgical procedures, reflecting on a conversation about the necessity of securing knots effectively.\\n\\n**Summary:** The image serves to highlight the significance of knot security in surgical suturing, using a light-hearted dialogue to convey the message.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 727,\n", " 'text': ' Experienced fishermen are able to catch a 50-pound fish on a 5-pound\\ntest line. And, indeed, a few recent studies from Europe suggest that a\\nsmall-bite closure is advantageous over the above mentioned mass\\nclosure. Using thinner suture material (PDS®, 2-0) on smaller\\nneedles, taking 0.5cm bites in the medial edge of the fascia, closely\\nspaced (0.5cm), and avoiding the muscle altogether, they showed a\\nlower incidence of dehiscence and hernia formation than when\\nmass closure was used. In one such study, even the rate of wound\\ninfection was lower with small bites. The theoretical explanation for such\\nsurprising results: less tissue damage/inflammation, a higher suture-to-\\nwound ratio — a better ‘spring’ effect which allows the tissue to ‘breathe’.\\n\\n So should we discard mass closure as yet another refuted dogma\\nand start closing abdomens as if we were plastic surgeons or\\nophthalmologists?\\n\\n Well. Not yet. At least we are not going to jump on the wagon. Those\\nstudies included mainly elective cases (including gynecological\\nlaparotomies). Would the results be the same in acute surgery or very\\nobese patients who are less common in northern Europe? We don’t\\nknow. We can envisage a small bite tearing away from the fascia with the\\nwhole suture line unravelling. So our advice: take healthy bites in the\\nfascia, avoiding excessive tension — if you wish to avoid the muscle in\\nthe bites then be our guest. Try ‘small bites’? Maybe on your next\\nelective case…\\n\\n Back to fishing wisdom: resist the common feeling that there are\\nmore fish on the other side of the lake or river; continue fishing\\nwhere you stand!\\n\\n The subcutaneous space\\n\\n Now when the fascia is closed what to do with the subcutis?\\nSome people (we did too) would say “nothing”, stating that there is no\\nevidence that the so-called dead space reduction using subcutaneous fat\\napproximation reduces wound complications; that subcutaneous sutures\\nact like a foreign body and strangulate viable fat while not producing a',\n", " 'md': '```markdown\\n# Page Content\\n\\nExperienced fishermen are able to catch a 50-pound fish on a 5-pound test line. And, indeed, a few recent studies from Europe suggest that a small-bite closure is advantageous over the above mentioned mass closure. Using thinner suture material (PDS®, 2-0) on smaller needles, taking 0.5cm bites in the medial edge of the fascia, closely spaced (0.5cm), and avoiding the muscle altogether, they showed a lower incidence of dehiscence and hernia formation than when mass closure was used. In one such study, even the rate of wound infection was lower with small bites. The theoretical explanation for such surprising results: less tissue damage/inflammation, a higher suture-to-wound ratio — a better ‘spring’ effect which allows the tissue to ‘breathe’.\\n\\nSo should we discard mass closure as yet another refuted dogma and start closing abdomens as if we were plastic surgeons or ophthalmologists?\\n\\nWell. Not yet. At least we are not going to jump on the wagon. Those studies included mainly elective cases (including gynecological laparotomies). Would the results be the same in acute surgery or very obese patients who are less common in northern Europe? We don’t know. We can envisage a small bite tearing away from the fascia with the whole suture line unravelling. So our advice: take healthy bites in the fascia, avoiding excessive tension — if you wish to avoid the muscle in the bites then be our guest. Try ‘small bites’? Maybe on your next elective case…\\n\\nBack to fishing wisdom: resist the common feeling that there are more fish on the other side of the lake or river; continue fishing where you stand!\\n\\n## The subcutaneous space\\n\\nNow when the fascia is closed what to do with the subcutis? Some people (we did too) would say “nothing”, stating that there is no evidence that the so-called dead space reduction using subcutaneous fat approximation reduces wound complications; that subcutaneous sutures act like a foreign body and strangulate viable fat while not producing a\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Experienced fishermen are able to catch a 50-pound fish on a 5-pound test line. And, indeed, a few recent studies from Europe suggest that a small-bite closure is advantageous over the above mentioned mass closure. Using thinner suture material (PDS®, 2-0) on smaller needles, taking 0.5cm bites in the medial edge of the fascia, closely spaced (0.5cm), and avoiding the muscle altogether, they showed a lower incidence of dehiscence and hernia formation than when mass closure was used. In one such study, even the rate of wound infection was lower with small bites. The theoretical explanation for such surprising results: less tissue damage/inflammation, a higher suture-to-wound ratio — a better ‘spring’ effect which allows the tissue to ‘breathe’.\\n\\nSo should we discard mass closure as yet another refuted dogma and start closing abdomens as if we were plastic surgeons or ophthalmologists?\\n\\nWell. Not yet. At least we are not going to jump on the wagon. Those studies included mainly elective cases (including gynecological laparotomies). Would the results be the same in acute surgery or very obese patients who are less common in northern Europe? We don’t know. We can envisage a small bite tearing away from the fascia with the whole suture line unravelling. So our advice: take healthy bites in the fascia, avoiding excessive tension — if you wish to avoid the muscle in the bites then be our guest. Try ‘small bites’? Maybe on your next elective case…\\n\\nBack to fishing wisdom: resist the common feeling that there are more fish on the other side of the lake or river; continue fishing where you stand!',\n", " 'md': 'Experienced fishermen are able to catch a 50-pound fish on a 5-pound test line. And, indeed, a few recent studies from Europe suggest that a small-bite closure is advantageous over the above mentioned mass closure. Using thinner suture material (PDS®, 2-0) on smaller needles, taking 0.5cm bites in the medial edge of the fascia, closely spaced (0.5cm), and avoiding the muscle altogether, they showed a lower incidence of dehiscence and hernia formation than when mass closure was used. In one such study, even the rate of wound infection was lower with small bites. The theoretical explanation for such surprising results: less tissue damage/inflammation, a higher suture-to-wound ratio — a better ‘spring’ effect which allows the tissue to ‘breathe’.\\n\\nSo should we discard mass closure as yet another refuted dogma and start closing abdomens as if we were plastic surgeons or ophthalmologists?\\n\\nWell. Not yet. At least we are not going to jump on the wagon. Those studies included mainly elective cases (including gynecological laparotomies). Would the results be the same in acute surgery or very obese patients who are less common in northern Europe? We don’t know. We can envisage a small bite tearing away from the fascia with the whole suture line unravelling. So our advice: take healthy bites in the fascia, avoiding excessive tension — if you wish to avoid the muscle in the bites then be our guest. Try ‘small bites’? Maybe on your next elective case…\\n\\nBack to fishing wisdom: resist the common feeling that there are more fish on the other side of the lake or river; continue fishing where you stand!',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The subcutaneous space',\n", " 'md': '## The subcutaneous space',\n", " 'bBox': {'x': 86, 'y': 601, 'w': 197.75, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Now when the fascia is closed what to do with the subcutis? Some people (we did too) would say “nothing”, stating that there is no evidence that the so-called dead space reduction using subcutaneous fat approximation reduces wound complications; that subcutaneous sutures act like a foreign body and strangulate viable fat while not producing a\\n```',\n", " 'md': 'Now when the fascia is closed what to do with the subcutis? Some people (we did too) would say “nothing”, stating that there is no evidence that the so-called dead space reduction using subcutaneous fat approximation reduces wound complications; that subcutaneous sutures act like a foreign body and strangulate viable fat while not producing a\\n```',\n", " 'bBox': {'x': 72, 'y': 670, 'w': 467.73, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 728,\n", " 'text': 'more satisfactory wound. ħowever, over the years we have realized that\\ncareful approximation of the subcutaneous layer (we use interrupted\\nVicryl® 3-0) produces ‘healthier’ and better-looking wounds. In very\\nobese patients, we would even place two layers of subcut sutures.\\n\\n Subcutaneous drains increase the rate of infection and are\\nindicated only in special situations — see the chapter on wound\\nmanagement ( Chapter 49). If you are unfortunate to have a boss who\\nis forcing you to use such drains routinely, then remove them within 24-\\n48 hours — sucking out moist fat has no real value.\\n\\n Plain saline irrigation has been shown to be useless, but the use of\\ntopical antibiotics (solution or powder) has been demonstrated to further\\ndecrease wound infection rates in contaminated wounds in patients who\\nhave already received systemic antibiotic prophylaxis. Well anyway, we\\nirrigate the wound liberally, telling the nurse “bring the ħoly Water!”\\nMaking the OR room happy is almost as important as preventing wound\\ncomplications… if not more. We suppose you could even try educating\\nthe OR team about the futility of dogmas…\\n\\n ‘Delayed primary’ or ‘secondary closure’\\n\\n What about the well-entrenched ritual of ‘delayed primary’ or\\n‘secondary closure’ after contaminated or infected laparotomies?\\n\\n We believe that these techniques are only rarely indicated. In spite of\\nsurgeons’ obsession with tradition, lessons learned years ago under\\ncertain circumstances are not necessarily true today. Thus, 30 years ago\\nwhen antibiotic prophylaxis was given incorrectly, heavy silk sutures were\\nburied in the fat, and rubber drains were mushrooming through every\\nwound, the infection rate in primarily closed wounds was intolerable.\\nToday, on the other hand, with proper surgical technique and modern\\nantibiotic prophylaxis, primary suture of the wound can be undertaken\\nuneventfully in the majority of emergency laparotomy cases. When a\\nwound infection develops it usually responds to local measures. Thus,\\nleaving all contaminated, potentially infected wounds gaping open\\n— awaiting spontaneous or secondary closure — produces',\n", " 'md': \"```markdown\\n## Wound Management Insights\\n\\nMore satisfactory wound healing can be achieved through careful approximation of the subcutaneous layer. We use interrupted Vicryl® 3-0 sutures, which produce 'healthier' and better-looking wounds. In very obese patients, we may even place two layers of subcutaneous sutures.\\n\\nSubcutaneous drains increase the rate of infection and are indicated only in special situations — see the chapter on wound management (Chapter 49). If you are unfortunate enough to have a boss who is forcing you to use such drains routinely, then remove them within 24-48 hours — sucking out moist fat has no real value.\\n\\nPlain saline irrigation has been shown to be useless, but the use of topical antibiotics (solution or powder) has been demonstrated to further decrease wound infection rates in contaminated wounds in patients who have already received systemic antibiotic prophylaxis. We irrigate the wound liberally, telling the nurse, “bring the holy water!” Making the OR room happy is almost as important as preventing wound complications… if not more. We suppose you could even try educating the OR team about the futility of dogmas.\\n\\n### Delayed Primary or Secondary Closure\\n\\nWhat about the well-entrenched ritual of ‘delayed primary’ or ‘secondary closure’ after contaminated or infected laparotomies?\\n\\nWe believe that these techniques are only rarely indicated. In spite of surgeons’ obsession with tradition, lessons learned years ago under certain circumstances are not necessarily true today. Thus, 30 years ago when antibiotic prophylaxis was given incorrectly, heavy silk sutures were buried in the fat, and rubber drains were mushrooming through every wound, the infection rate in primarily closed wounds was intolerable. Today, on the other hand, with proper surgical technique and modern antibiotic prophylaxis, primary suture of the wound can be undertaken uneventfully in the majority of emergency laparotomy cases. When a wound infection develops, it usually responds to local measures. Thus, leaving all contaminated, potentially infected wounds gaping open — awaiting spontaneous or secondary closure — produces...\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Wound Management Insights',\n", " 'md': '## Wound Management Insights',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"More satisfactory wound healing can be achieved through careful approximation of the subcutaneous layer. We use interrupted Vicryl® 3-0 sutures, which produce 'healthier' and better-looking wounds. In very obese patients, we may even place two layers of subcutaneous sutures.\\n\\nSubcutaneous drains increase the rate of infection and are indicated only in special situations — see the chapter on wound management (Chapter 49). If you are unfortunate enough to have a boss who is forcing you to use such drains routinely, then remove them within 24-48 hours — sucking out moist fat has no real value.\\n\\nPlain saline irrigation has been shown to be useless, but the use of topical antibiotics (solution or powder) has been demonstrated to further decrease wound infection rates in contaminated wounds in patients who have already received systemic antibiotic prophylaxis. We irrigate the wound liberally, telling the nurse, “bring the holy water!” Making the OR room happy is almost as important as preventing wound complications… if not more. We suppose you could even try educating the OR team about the futility of dogmas.\",\n", " 'md': \"More satisfactory wound healing can be achieved through careful approximation of the subcutaneous layer. We use interrupted Vicryl® 3-0 sutures, which produce 'healthier' and better-looking wounds. In very obese patients, we may even place two layers of subcutaneous sutures.\\n\\nSubcutaneous drains increase the rate of infection and are indicated only in special situations — see the chapter on wound management (Chapter 49). If you are unfortunate enough to have a boss who is forcing you to use such drains routinely, then remove them within 24-48 hours — sucking out moist fat has no real value.\\n\\nPlain saline irrigation has been shown to be useless, but the use of topical antibiotics (solution or powder) has been demonstrated to further decrease wound infection rates in contaminated wounds in patients who have already received systemic antibiotic prophylaxis. We irrigate the wound liberally, telling the nurse, “bring the holy water!” Making the OR room happy is almost as important as preventing wound complications… if not more. We suppose you could even try educating the OR team about the futility of dogmas.\",\n", " 'bBox': {'x': 72, 'y': 206, 'w': 467.56, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Delayed Primary or Secondary Closure',\n", " 'md': '### Delayed Primary or Secondary Closure',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'What about the well-entrenched ritual of ‘delayed primary’ or ‘secondary closure’ after contaminated or infected laparotomies?\\n\\nWe believe that these techniques are only rarely indicated. In spite of surgeons’ obsession with tradition, lessons learned years ago under certain circumstances are not necessarily true today. Thus, 30 years ago when antibiotic prophylaxis was given incorrectly, heavy silk sutures were buried in the fat, and rubber drains were mushrooming through every wound, the infection rate in primarily closed wounds was intolerable. Today, on the other hand, with proper surgical technique and modern antibiotic prophylaxis, primary suture of the wound can be undertaken uneventfully in the majority of emergency laparotomy cases. When a wound infection develops, it usually responds to local measures. Thus, leaving all contaminated, potentially infected wounds gaping open — awaiting spontaneous or secondary closure — produces...\\n```',\n", " 'md': 'What about the well-entrenched ritual of ‘delayed primary’ or ‘secondary closure’ after contaminated or infected laparotomies?\\n\\nWe believe that these techniques are only rarely indicated. In spite of surgeons’ obsession with tradition, lessons learned years ago under certain circumstances are not necessarily true today. Thus, 30 years ago when antibiotic prophylaxis was given incorrectly, heavy silk sutures were buried in the fat, and rubber drains were mushrooming through every wound, the infection rate in primarily closed wounds was intolerable. Today, on the other hand, with proper surgical technique and modern antibiotic prophylaxis, primary suture of the wound can be undertaken uneventfully in the majority of emergency laparotomy cases. When a wound infection develops, it usually responds to local measures. Thus, leaving all contaminated, potentially infected wounds gaping open — awaiting spontaneous or secondary closure — produces...\\n```',\n", " 'bBox': {'x': 72, 'y': 433, 'w': 467.66, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'is forcing you to use such drains routinely, then remove them within 24-'}]},\n", " {'page': 729,\n", " 'text': 'unnecessary physical and financial morbidity.\\n\\n Only rarely do we decide to leave a wound open, usually in patients\\nwith gross, established purulent or fecal peritonitis, in patients planned for\\nfurther reoperations or in the relaparotomized abdomen. In the vast\\nmajority of patients, we irrigate the subcutaneous tissues with antibiotics\\n(after fascial closure) and close the skin with interrupted sutures.\\n\\n We use a ‘middle of the road’ option, in selected patients (e.g. the\\nfat guy with a badly perforated appendix). This involves inserting ‘wicks’\\n(like candle wicks) between the sutures into the depths of the wound —\\nread about it in Chapter 49.\\n\\n I use a subcutaneous Penrose drain — for example, in stoma closure. Rarely do I have a\\n wound infection despite skin closure. Danny\\n\\n Truly modern surgeons, however, are happy to close almost all wounds\\nwith a subcuticular stitch of absorbable material. This obviates the\\ndiscomfort and expense of arranging staple or suture removal and gives\\na much neater scar. (This is the only part of your handiwork that the\\nfamily and the patient can see, and you’d be surprised to discover how\\nmuch this little thing matters to most patients!). An occasional wound\\ninfection is not a disaster and is simple to treat ( Chapter 49).\\n\\n The high-risk abdominal closure\\n\\n Classically, in patients with systemic (e.g. cancer) or local (e.g.\\nabdominal distension) factors predisposing to abdominal dehiscence (\\nChapter 49), ‘retention’ sutures were and are still used by surgeons.\\nThose heavy ‘through-and-through’, interrupted sutures take bites of at\\nleast 2cm through all abdominal-wall layers — including the skin —\\npreventing evisceration but not the occurrence of late hernia formation.',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nUnnecessary physical and financial morbidity.\\n\\nOnly rarely do we decide to leave a wound open, usually in patients with gross, established purulent or fecal peritonitis, in patients planned for further reoperations or in the relaparotomized abdomen. In the vast majority of patients, we irrigate the subcutaneous tissues with antibiotics (after fascial closure) and close the skin with interrupted sutures.\\n\\nWe use a ‘middle of the road’ option, in selected patients (e.g. the fat guy with a badly perforated appendix). This involves inserting ‘wicks’ (like candle wicks) between the sutures into the depths of the wound — read about it in [Chapter 49](#).\\n\\nI use a subcutaneous Penrose drain — for example, in stoma closure. Rarely do I have a wound infection despite skin closure. Danny\\n\\nTruly modern surgeons, however, are happy to close almost all wounds with a subcuticular stitch of absorbable material. This obviates the discomfort and expense of arranging staple or suture removal and gives a much neater scar. (This is the only part of your handiwork that the family and the patient can see, and you’d be surprised to discover how much this little thing matters to most patients!). An occasional wound infection is not a disaster and is simple to treat (Chapter 49).\\n\\n### The high-risk abdominal closure\\n\\nClassically, in patients with systemic (e.g. cancer) or local (e.g. abdominal distension) factors predisposing to abdominal dehiscence (Chapter 49), ‘retention’ sutures were and are still used by surgeons. Those heavy ‘through-and-through’, interrupted sutures take bites of at least 2cm through all abdominal-wall layers — including the skin — preventing evisceration but not the occurrence of late hernia formation.\\n```\\n\\n### Image Identification and Description\\n\\nNo images or graphs were identified on this page.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Unnecessary physical and financial morbidity.\\n\\nOnly rarely do we decide to leave a wound open, usually in patients with gross, established purulent or fecal peritonitis, in patients planned for further reoperations or in the relaparotomized abdomen. In the vast majority of patients, we irrigate the subcutaneous tissues with antibiotics (after fascial closure) and close the skin with interrupted sutures.\\n\\nWe use a ‘middle of the road’ option, in selected patients (e.g. the fat guy with a badly perforated appendix). This involves inserting ‘wicks’ (like candle wicks) between the sutures into the depths of the wound — read about it in [Chapter 49](#).\\n\\nI use a subcutaneous Penrose drain — for example, in stoma closure. Rarely do I have a wound infection despite skin closure. Danny\\n\\nTruly modern surgeons, however, are happy to close almost all wounds with a subcuticular stitch of absorbable material. This obviates the discomfort and expense of arranging staple or suture removal and gives a much neater scar. (This is the only part of your handiwork that the family and the patient can see, and you’d be surprised to discover how much this little thing matters to most patients!). An occasional wound infection is not a disaster and is simple to treat (Chapter 49).',\n", " 'md': 'Unnecessary physical and financial morbidity.\\n\\nOnly rarely do we decide to leave a wound open, usually in patients with gross, established purulent or fecal peritonitis, in patients planned for further reoperations or in the relaparotomized abdomen. In the vast majority of patients, we irrigate the subcutaneous tissues with antibiotics (after fascial closure) and close the skin with interrupted sutures.\\n\\nWe use a ‘middle of the road’ option, in selected patients (e.g. the fat guy with a badly perforated appendix). This involves inserting ‘wicks’ (like candle wicks) between the sutures into the depths of the wound — read about it in [Chapter 49](#).\\n\\nI use a subcutaneous Penrose drain — for example, in stoma closure. Rarely do I have a wound infection despite skin closure. Danny\\n\\nTruly modern surgeons, however, are happy to close almost all wounds with a subcuticular stitch of absorbable material. This obviates the discomfort and expense of arranging staple or suture removal and gives a much neater scar. (This is the only part of your handiwork that the family and the patient can see, and you’d be surprised to discover how much this little thing matters to most patients!). An occasional wound infection is not a disaster and is simple to treat (Chapter 49).',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.9, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The high-risk abdominal closure',\n", " 'md': '### The high-risk abdominal closure',\n", " 'bBox': {'x': 86, 'y': 518, 'w': 254.69, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Classically, in patients with systemic (e.g. cancer) or local (e.g. abdominal distension) factors predisposing to abdominal dehiscence (Chapter 49), ‘retention’ sutures were and are still used by surgeons. Those heavy ‘through-and-through’, interrupted sutures take bites of at least 2cm through all abdominal-wall layers — including the skin — preventing evisceration but not the occurrence of late hernia formation.\\n```',\n", " 'md': 'Classically, in patients with systemic (e.g. cancer) or local (e.g. abdominal distension) factors predisposing to abdominal dehiscence (Chapter 49), ‘retention’ sutures were and are still used by surgeons. Those heavy ‘through-and-through’, interrupted sutures take bites of at least 2cm through all abdominal-wall layers — including the skin — preventing evisceration but not the occurrence of late hernia formation.\\n```',\n", " 'bBox': {'x': 72, 'y': 571, 'w': 454.68, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'No images or graphs were identified on this page.',\n", " 'md': 'No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': 'Chapter 49), ‘retention’ sutures were and are still used by surgeons. Those heavy ‘through-and-through’, interrupted sutures take bites of at'}]},\n", " {'page': 730,\n", " 'text': ' Figure 40.2. A single horizontal mattress retention suture was added to reinforce the\\n closure where a tumor was resected from the abdominal wall. The suture is tied without\\n excessive tension, but will add force to the closure if abdominal tension increases\\n postoperatively. Its configuration leaves the abdominal wound exposed, allowing for\\n wound care as needed. It also results in a better cosmetic result, preventing the long ugly\\n scars across the incision.\\n\\n We abhor the classic retention sutures, which cut through the skin and\\nproduce parietal damage (e.g. tissue necrosis, abdominal wall infection)\\nand ugly skin wounds and scars. Moreoever, the use of retention\\nsutures, together with abdominal distension, results in intra-\\nabdominal hypertension. Forceful closure under excessive tension may\\nresult in an abdominal compartment syndrome with its deleterious\\nphysiological consequences ( Chapter 33). Thus, when the fascia is\\ndestroyed as is often the case after multiple abdominal re-entries, or\\nwhen closure may produce excessive intra-abdominal pressure, we\\nsuggest that you do not close the abdomen but cover it with a\\ntemporary abdominal closure device (TACD — ‘laparostomy’ —\\nChapter 48); for example, the vacuum-assisted closure (VAC) using\\nmesh — Chapter 19).\\n\\n However, in indeterminate/intermediate cases, when a high risk\\nfor dehiscence exists without immediate abdominal hypertension, a',\n", " 'md': '```markdown\\n## Page Content\\n\\nFigure 40.2. A single horizontal mattress retention suture was added to reinforce the closure where a tumor was resected from the abdominal wall. The suture is tied without excessive tension, but will add force to the closure if abdominal tension increases postoperatively. Its configuration leaves the abdominal wound exposed, allowing for wound care as needed. It also results in a better cosmetic result, preventing the long ugly scars across the incision.\\n\\nWe abhor the classic retention sutures, which cut through the skin and produce parietal damage (e.g. tissue necrosis, abdominal wall infection) and ugly skin wounds and scars. Moreover, the use of retention sutures, together with abdominal distension, results in intra-abdominal hypertension. Forceful closure under excessive tension may result in an abdominal compartment syndrome with its deleterious physiological consequences (Chapter 33). Thus, when the fascia is destroyed as is often the case after multiple abdominal re-entries, or when closure may produce excessive intra-abdominal pressure, we suggest that you do not close the abdomen but cover it with a temporary abdominal closure device (TACD — ‘laparostomy’ — Chapter 48); for example, the vacuum-assisted closure (VAC) using mesh — Chapter 19).\\n\\nHowever, in indeterminate/intermediate cases, when a high risk for dehiscence exists without immediate abdominal hypertension, a...\\n\\n## Image Identification and Description\\n\\n**Figure 40.2**: The image depicts a single horizontal mattress retention suture applied to the abdominal wall after tumor resection. The suture is designed to reinforce the closure while allowing for postoperative wound care. The configuration of the suture is intended to minimize tension and improve cosmetic outcomes by preventing long, unsightly scars.\\n\\n### Summary\\n- The image illustrates a surgical technique involving a retention suture.\\n- It emphasizes the benefits of this method over traditional retention sutures, which can cause skin damage and complications.\\n- The text discusses the implications of using retention sutures in various surgical scenarios, including the risks of intra-abdominal hypertension and compartment syndrome.\\n\\n### Note\\n- The text references several chapters for further reading on related topics, such as abdominal closure devices and complications associated with surgical techniques.\\n```',\n", " 'images': [{'name': 'img_p729_1.png',\n", " 'height': 508,\n", " 'width': 675,\n", " 'x': 138.96000000000004,\n", " 'y': 82.79999999999998,\n", " 'original_width': 1161,\n", " 'original_height': 874}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 40.2. A single horizontal mattress retention suture was added to reinforce the closure where a tumor was resected from the abdominal wall. The suture is tied without excessive tension, but will add force to the closure if abdominal tension increases postoperatively. Its configuration leaves the abdominal wound exposed, allowing for wound care as needed. It also results in a better cosmetic result, preventing the long ugly scars across the incision.\\n\\nWe abhor the classic retention sutures, which cut through the skin and produce parietal damage (e.g. tissue necrosis, abdominal wall infection) and ugly skin wounds and scars. Moreover, the use of retention sutures, together with abdominal distension, results in intra-abdominal hypertension. Forceful closure under excessive tension may result in an abdominal compartment syndrome with its deleterious physiological consequences (Chapter 33). Thus, when the fascia is destroyed as is often the case after multiple abdominal re-entries, or when closure may produce excessive intra-abdominal pressure, we suggest that you do not close the abdomen but cover it with a temporary abdominal closure device (TACD — ‘laparostomy’ — Chapter 48); for example, the vacuum-assisted closure (VAC) using mesh — Chapter 19).\\n\\nHowever, in indeterminate/intermediate cases, when a high risk for dehiscence exists without immediate abdominal hypertension, a...',\n", " 'md': 'Figure 40.2. A single horizontal mattress retention suture was added to reinforce the closure where a tumor was resected from the abdominal wall. The suture is tied without excessive tension, but will add force to the closure if abdominal tension increases postoperatively. Its configuration leaves the abdominal wound exposed, allowing for wound care as needed. It also results in a better cosmetic result, preventing the long ugly scars across the incision.\\n\\nWe abhor the classic retention sutures, which cut through the skin and produce parietal damage (e.g. tissue necrosis, abdominal wall infection) and ugly skin wounds and scars. Moreover, the use of retention sutures, together with abdominal distension, results in intra-abdominal hypertension. Forceful closure under excessive tension may result in an abdominal compartment syndrome with its deleterious physiological consequences (Chapter 33). Thus, when the fascia is destroyed as is often the case after multiple abdominal re-entries, or when closure may produce excessive intra-abdominal pressure, we suggest that you do not close the abdomen but cover it with a temporary abdominal closure device (TACD — ‘laparostomy’ — Chapter 48); for example, the vacuum-assisted closure (VAC) using mesh — Chapter 19).\\n\\nHowever, in indeterminate/intermediate cases, when a high risk for dehiscence exists without immediate abdominal hypertension, a...',\n", " 'bBox': {'x': 72, 'y': 354, 'w': 467.85, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 40.2**: The image depicts a single horizontal mattress retention suture applied to the abdominal wall after tumor resection. The suture is designed to reinforce the closure while allowing for postoperative wound care. The configuration of the suture is intended to minimize tension and improve cosmetic outcomes by preventing long, unsightly scars.',\n", " 'md': '**Figure 40.2**: The image depicts a single horizontal mattress retention suture applied to the abdominal wall after tumor resection. The suture is designed to reinforce the closure while allowing for postoperative wound care. The configuration of the suture is intended to minimize tension and improve cosmetic outcomes by preventing long, unsightly scars.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The image illustrates a surgical technique involving a retention suture.\\n- It emphasizes the benefits of this method over traditional retention sutures, which can cause skin damage and complications.\\n- The text discusses the implications of using retention sutures in various surgical scenarios, including the risks of intra-abdominal hypertension and compartment syndrome.',\n", " 'md': '- The image illustrates a surgical technique involving a retention suture.\\n- It emphasizes the benefits of this method over traditional retention sutures, which can cause skin damage and complications.\\n- The text discusses the implications of using retention sutures in various surgical scenarios, including the risks of intra-abdominal hypertension and compartment syndrome.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Note',\n", " 'md': '### Note',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text references several chapters for further reading on related topics, such as abdominal closure devices and complications associated with surgical techniques.\\n```',\n", " 'md': '- The text references several chapters for further reading on related topics, such as abdominal closure devices and complications associated with surgical techniques.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'destroyed as is often the case after multiple abdominal re-entries, or'},\n", " {'text': 'Chapter 48); for example, the vacuum-assisted closure (VAC) using mesh — '},\n", " {'text': ''}]},\n", " {'page': 731,\n", " 'text': 'few retention sutures may prevent evisceration and the need to\\nreturn to the OR. Placing them as horizontal mattress sutures, without\\ncrossing the skin, will cause less disfiguring scarring, and allows for\\nappropriate wound care ( Figure 40.2).\\n\\n Closing the skin only\\n\\n Occasionaly, in situations when we wish to avoid fascial closure — or it\\nis deemed impossible — but do not want to condemn the patient to the\\nnot insignificant morbidity associated with laparostomy, we leave the\\nfascia unsutured but close the skin.\\n\\n Scenarios ideal for such an approach would be when you feel that\\nno reoperation would be necessary but visceral ‘bulging’ prevents\\nfascial closure without excessive tension (e.g. at the end of a\\nlaparotomy for a giant strangulated incisional hernia). Of course, all\\nsurviving patients will develop a large incisional hernia; the very old and\\ninfirm will live with the hernia for the rest of their lives. In others, an\\nelective repair of the hernia is associated with lower morbidity than the\\nstaged management of laparostomy. How to do it: always spread the\\nomentum, if available, over the viscera; the skin is closed with 2-0 nylon\\ninterrupted mattress sutures, taking bites of at least 1cm from the skin\\nedge. You may want to add a generous subcutaneus layer to make it\\n‘stronger’. Do not let anyone remove these sutures until you approve —\\nusually not before 3 weeks. Remember — the patient’s own normal\\nskin is better than the VAC system or skin grafts.\\n\\n P.S.: Some, obsessed with the need to ‘close the fascia’ — even if it is\\nunfeasible — would bridge the defect with one of those mega$\\n‘bioprostheses’ — the brand and composition of which seem to change\\nfrom one conference to the next. They believe that in doing so they\\nprevent a hernia. Let them believe.\\n\\n In conclusion, remember — big continuous bites, with a monofilament, not too tight —\\n this is how to avoid dehiscence and herniation.',\n", " 'md': '```markdown\\n### Text Extraction\\n\\nFew retention sutures may prevent evisceration and the need to return to the OR. Placing them as horizontal mattress sutures, without crossing the skin, will cause less disfiguring scarring, and allows for appropriate wound care (Figure 40.2).\\n\\nClosing the skin only\\n\\nOccasionally, in situations when we wish to avoid fascial closure — or it is deemed impossible — but do not want to condemn the patient to the not insignificant morbidity associated with laparostomy, we leave the fascia unsutured but close the skin.\\n\\nScenarios ideal for such an approach would be when you feel that no reoperation would be necessary but visceral ‘bulging’ prevents fascial closure without excessive tension (e.g. at the end of a laparotomy for a giant strangulated incisional hernia). Of course, all surviving patients will develop a large incisional hernia; the very old and infirm will live with the hernia for the rest of their lives. In others, an elective repair of the hernia is associated with lower morbidity than the staged management of laparostomy.\\n\\nHow to do it: always spread the omentum, if available, over the viscera; the skin is closed with 2-0 nylon interrupted mattress sutures, taking bites of at least 1cm from the skin edge. You may want to add a generous subcutaneous layer to make it ‘stronger’. Do not let anyone remove these sutures until you approve — usually not before 3 weeks. Remember — the patient’s own normal skin is better than the VAC system or skin grafts.\\n\\nP.S.: Some, obsessed with the need to ‘close the fascia’ — even if it is unfeasible — would bridge the defect with one of those mega$ ‘bioprostheses’ — the brand and composition of which seem to change from one conference to the next. They believe that in doing so they prevent a hernia. Let them believe.\\n\\nIn conclusion, remember — big continuous bites, with a monofilament, not too tight — this is how to avoid dehiscence and herniation.\\n\\n### Image Identification and Description\\n\\n**Figure 40.2**: The image referenced in the text is not provided, but it is likely a diagram or illustration related to the placement of retention sutures. The description would typically include details about the technique of horizontal mattress sutures and their impact on scarring and wound care.\\n\\n### Summary\\n\\nThe text discusses the use of retention sutures to prevent evisceration and the need for reoperation. It outlines scenarios where fascial closure may not be possible and emphasizes the importance of proper skin closure techniques. The author advises on the use of specific suturing methods and cautions against premature removal of sutures. The conclusion reinforces the importance of technique in preventing complications such as dehiscence and herniation.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text Extraction',\n", " 'md': '### Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Few retention sutures may prevent evisceration and the need to return to the OR. Placing them as horizontal mattress sutures, without crossing the skin, will cause less disfiguring scarring, and allows for appropriate wound care (Figure 40.2).\\n\\nClosing the skin only\\n\\nOccasionally, in situations when we wish to avoid fascial closure — or it is deemed impossible — but do not want to condemn the patient to the not insignificant morbidity associated with laparostomy, we leave the fascia unsutured but close the skin.\\n\\nScenarios ideal for such an approach would be when you feel that no reoperation would be necessary but visceral ‘bulging’ prevents fascial closure without excessive tension (e.g. at the end of a laparotomy for a giant strangulated incisional hernia). Of course, all surviving patients will develop a large incisional hernia; the very old and infirm will live with the hernia for the rest of their lives. In others, an elective repair of the hernia is associated with lower morbidity than the staged management of laparostomy.\\n\\nHow to do it: always spread the omentum, if available, over the viscera; the skin is closed with 2-0 nylon interrupted mattress sutures, taking bites of at least 1cm from the skin edge. You may want to add a generous subcutaneous layer to make it ‘stronger’. Do not let anyone remove these sutures until you approve — usually not before 3 weeks. Remember — the patient’s own normal skin is better than the VAC system or skin grafts.\\n\\nP.S.: Some, obsessed with the need to ‘close the fascia’ — even if it is unfeasible — would bridge the defect with one of those mega$ ‘bioprostheses’ — the brand and composition of which seem to change from one conference to the next. They believe that in doing so they prevent a hernia. Let them believe.\\n\\nIn conclusion, remember — big continuous bites, with a monofilament, not too tight — this is how to avoid dehiscence and herniation.',\n", " 'md': 'Few retention sutures may prevent evisceration and the need to return to the OR. Placing them as horizontal mattress sutures, without crossing the skin, will cause less disfiguring scarring, and allows for appropriate wound care (Figure 40.2).\\n\\nClosing the skin only\\n\\nOccasionally, in situations when we wish to avoid fascial closure — or it is deemed impossible — but do not want to condemn the patient to the not insignificant morbidity associated with laparostomy, we leave the fascia unsutured but close the skin.\\n\\nScenarios ideal for such an approach would be when you feel that no reoperation would be necessary but visceral ‘bulging’ prevents fascial closure without excessive tension (e.g. at the end of a laparotomy for a giant strangulated incisional hernia). Of course, all surviving patients will develop a large incisional hernia; the very old and infirm will live with the hernia for the rest of their lives. In others, an elective repair of the hernia is associated with lower morbidity than the staged management of laparostomy.\\n\\nHow to do it: always spread the omentum, if available, over the viscera; the skin is closed with 2-0 nylon interrupted mattress sutures, taking bites of at least 1cm from the skin edge. You may want to add a generous subcutaneous layer to make it ‘stronger’. Do not let anyone remove these sutures until you approve — usually not before 3 weeks. Remember — the patient’s own normal skin is better than the VAC system or skin grafts.\\n\\nP.S.: Some, obsessed with the need to ‘close the fascia’ — even if it is unfeasible — would bridge the defect with one of those mega$ ‘bioprostheses’ — the brand and composition of which seem to change from one conference to the next. They believe that in doing so they prevent a hernia. Let them believe.\\n\\nIn conclusion, remember — big continuous bites, with a monofilament, not too tight — this is how to avoid dehiscence and herniation.',\n", " 'bBox': {'x': 72, 'y': 178, 'w': 468, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 40.2**: The image referenced in the text is not provided, but it is likely a diagram or illustration related to the placement of retention sutures. The description would typically include details about the technique of horizontal mattress sutures and their impact on scarring and wound care.',\n", " 'md': '**Figure 40.2**: The image referenced in the text is not provided, but it is likely a diagram or illustration related to the placement of retention sutures. The description would typically include details about the technique of horizontal mattress sutures and their impact on scarring and wound care.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the use of retention sutures to prevent evisceration and the need for reoperation. It outlines scenarios where fascial closure may not be possible and emphasizes the importance of proper skin closure techniques. The author advises on the use of specific suturing methods and cautions against premature removal of sutures. The conclusion reinforces the importance of technique in preventing complications such as dehiscence and herniation.\\n```',\n", " 'md': 'The text discusses the use of retention sutures to prevent evisceration and the need for reoperation. It outlines scenarios where fascial closure may not be possible and emphasizes the importance of proper skin closure techniques. The author advises on the use of specific suturing methods and cautions against premature removal of sutures. The conclusion reinforces the importance of technique in preventing complications such as dehiscence and herniation.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 732,\n", " 'text': ' Closure of laparoscopic ports\\n FeRyA2ol\\n Figure 40.3. Resident: “Sir, last week this patient underwent a lap chole for biliary\\n dyskinesia…” Surgeon: “The good news is that the dyskinesia has been cured…”\\n\\n ħowever small they are, trocar site wounds are not devoid of\\ncomplications, and trocar site hernia is a real entity. While in children\\neven 5mm incisions may be significant, in adults these small holes are\\nusually left alone, closing the skin only. But 10mm and larger wounds\\nmay (rarely) cause acute postoperative bowel incarceration, or lead\\nto later development of small and not-so-small hernias.\\n\\n Closing the fascial defect is such a hassle, especially in obese\\npatients, that many surgeons elect to avoid it. Some surgeons\\nintentionally place the trocars obliquely, hoping that the transabdominal\\n‘canal’ will collapse and close. Some just leave them open, trusting that\\nthe resultant hernia will be fixed by a hernia surgeon… and indeed —\\nwhy would the patient return to her gynecologist?',\n", " 'md': '```markdown\\n## Closure of Laparoscopic Ports\\n\\n**Figure 40.3**\\nResident: “Sir, last week this patient underwent a lap chole for biliary dyskinesia…”\\nSurgeon: “The good news is that the dyskinesia has been cured…”\\n\\nTrocar site wounds, no matter how small, are not devoid of complications, and trocar site hernia is a real entity. While in children even 5mm incisions may be significant, in adults these small holes are usually left alone, closing the skin only. However, 10mm and larger wounds may (rarely) cause acute postoperative bowel incarceration or lead to later development of small and not-so-small hernias.\\n\\nClosing the fascial defect is such a hassle, especially in obese patients, that many surgeons elect to avoid it. Some surgeons intentionally place the trocars obliquely, hoping that the transabdominal ‘canal’ will collapse and close. Some just leave them open, trusting that the resultant hernia will be fixed by a hernia surgeon… and indeed — why would the patient return to her gynecologist?\\n```',\n", " 'images': [{'name': 'img_p731_1.png',\n", " 'height': 626,\n", " 'width': 803,\n", " 'x': 107.27999999999975,\n", " 'y': 102.24000000000001,\n", " 'original_width': 1380,\n", " 'original_height': 1076}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Closure of Laparoscopic Ports',\n", " 'md': '## Closure of Laparoscopic Ports',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 234.48, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**Figure 40.3**\\nResident: “Sir, last week this patient underwent a lap chole for biliary dyskinesia…”\\nSurgeon: “The good news is that the dyskinesia has been cured…”\\n\\nTrocar site wounds, no matter how small, are not devoid of complications, and trocar site hernia is a real entity. While in children even 5mm incisions may be significant, in adults these small holes are usually left alone, closing the skin only. However, 10mm and larger wounds may (rarely) cause acute postoperative bowel incarceration or lead to later development of small and not-so-small hernias.\\n\\nClosing the fascial defect is such a hassle, especially in obese patients, that many surgeons elect to avoid it. Some surgeons intentionally place the trocars obliquely, hoping that the transabdominal ‘canal’ will collapse and close. Some just leave them open, trusting that the resultant hernia will be fixed by a hernia surgeon… and indeed — why would the patient return to her gynecologist?\\n```',\n", " 'md': '**Figure 40.3**\\nResident: “Sir, last week this patient underwent a lap chole for biliary dyskinesia…”\\nSurgeon: “The good news is that the dyskinesia has been cured…”\\n\\nTrocar site wounds, no matter how small, are not devoid of complications, and trocar site hernia is a real entity. While in children even 5mm incisions may be significant, in adults these small holes are usually left alone, closing the skin only. However, 10mm and larger wounds may (rarely) cause acute postoperative bowel incarceration or lead to later development of small and not-so-small hernias.\\n\\nClosing the fascial defect is such a hassle, especially in obese patients, that many surgeons elect to avoid it. Some surgeons intentionally place the trocars obliquely, hoping that the transabdominal ‘canal’ will collapse and close. Some just leave them open, trusting that the resultant hernia will be fixed by a hernia surgeon… and indeed — why would the patient return to her gynecologist?\\n```',\n", " 'bBox': {'x': 72, 'y': 574, 'w': 467.87, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 733,\n", " 'text': ' But we trust you that you would not like to leave an abdominal\\nwall defect that may ruin your perfect laparoscopy, forcing you to\\nreturn in the middle of the night to release the stuck bowel (or God forbid\\nresect it — Figure 40.3). And surely you would not like the pretty patient\\nwith the scar well hidden in the umbilicus (were you tempted to try single-\\nincision surgery?) to come back with an unsightly umbilical bulge.\\n\\n So how to do it? In most cases a pair of small retractors will help you\\nexpose the fascia and simply close it with a figure-of-8 absorbable suture\\n— it should be enough. In more challenging conditions you can use a\\nsuture-passer to close the fascia under laparoscopic vision — the\\ncamera placed through another trocar port. If budget allows, there are\\nsome more sophisticated port closure devices on the market, which make\\nit a snap. You may consider adding them to the patient’s bill if you are a\\nbusy bariatric surgeon. Time is money!\\n\\n Abdominal binder\\n\\n At the end of the procedure, before the patient is rolled off the\\ntable, we apply a Velcro abdominal binder (over the dressing) to\\n‘support’ the abdominal closure. The binder provides a counter-\\npressure to the intra-abdominal pressure thus negating bursting forces.\\nWith the binder applied, the patient may develop an incisional hernia but\\nyou will never see a free dehiscence. Don’t laugh at the binder before\\nyou see how it helps patients to ambulate early, with reduced discomfort.\\nOf course, the binders come in all sizes and should not be applied so\\ntightly as to produce an abdominal compartment syndrome. They should\\nbe opened when the patient lies in bed.\\n\\n Final point…\\n\\n Close up by yourself! If you have residents then be present and\\nteach them how to do it correctly. An unsupervised second-year\\nresident closing the abdomen, an unsupervised first-year registrar closing\\nthe skin — this is a good way to produce a nice series of abdominal\\ndehiscence and increase the rate of wound complications.',\n", " 'md': '```markdown\\n## Abdominal Wall Closure\\n\\nBut we trust you that you would not like to leave an abdominal wall defect that may ruin your perfect laparoscopy, forcing you to return in the middle of the night to release the stuck bowel (or God forbid resect it — **Figure 40.3**). And surely you would not like the pretty patient with the scar well hidden in the umbilicus (were you tempted to try single-incision surgery?) to come back with an unsightly umbilical bulge.\\n\\n### How to Close the Fascia\\n\\nSo how to do it? In most cases, a pair of small retractors will help you expose the fascia and simply close it with a figure-of-8 absorbable suture — it should be enough. In more challenging conditions, you can use a suture-passer to close the fascia under laparoscopic vision — the camera placed through another trocar port. If budget allows, there are some more sophisticated port closure devices on the market, which make it a snap. You may consider adding them to the patient’s bill if you are a busy bariatric surgeon. Time is money!\\n\\n### Abdominal Binder\\n\\nAt the end of the procedure, before the patient is rolled off the table, we apply a Velcro abdominal binder (over the dressing) to ‘support’ the abdominal closure. The binder provides a counter-pressure to the intra-abdominal pressure thus negating bursting forces. With the binder applied, the patient may develop an incisional hernia but you will never see a free dehiscence. Don’t laugh at the binder before you see how it helps patients to ambulate early, with reduced discomfort. Of course, the binders come in all sizes and should not be applied so tightly as to produce an abdominal compartment syndrome. They should be opened when the patient lies in bed.\\n\\n### Final Point\\n\\nClose up by yourself! If you have residents then be present and teach them how to do it correctly. An unsupervised second-year resident closing the abdomen, an unsupervised first-year registrar closing the skin — this is a good way to produce a nice series of abdominal dehiscence and increase the rate of wound complications.\\n\\n----\\n\\n**Figure 40.3**: This figure likely illustrates a scenario related to abdominal wall defects and the implications of improper closure during laparoscopic surgery. The specific content of the figure is not provided in the text, but it emphasizes the importance of proper technique to avoid complications.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Wall Closure',\n", " 'md': '## Abdominal Wall Closure',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'But we trust you that you would not like to leave an abdominal wall defect that may ruin your perfect laparoscopy, forcing you to return in the middle of the night to release the stuck bowel (or God forbid resect it — **Figure 40.3**). And surely you would not like the pretty patient with the scar well hidden in the umbilicus (were you tempted to try single-incision surgery?) to come back with an unsightly umbilical bulge.',\n", " 'md': 'But we trust you that you would not like to leave an abdominal wall defect that may ruin your perfect laparoscopy, forcing you to return in the middle of the night to release the stuck bowel (or God forbid resect it — **Figure 40.3**). And surely you would not like the pretty patient with the scar well hidden in the umbilicus (were you tempted to try single-incision surgery?) to come back with an unsightly umbilical bulge.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.81, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'How to Close the Fascia',\n", " 'md': '### How to Close the Fascia',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'So how to do it? In most cases, a pair of small retractors will help you expose the fascia and simply close it with a figure-of-8 absorbable suture — it should be enough. In more challenging conditions, you can use a suture-passer to close the fascia under laparoscopic vision — the camera placed through another trocar port. If budget allows, there are some more sophisticated port closure devices on the market, which make it a snap. You may consider adding them to the patient’s bill if you are a busy bariatric surgeon. Time is money!',\n", " 'md': 'So how to do it? In most cases, a pair of small retractors will help you expose the fascia and simply close it with a figure-of-8 absorbable suture — it should be enough. In more challenging conditions, you can use a suture-passer to close the fascia under laparoscopic vision — the camera placed through another trocar port. If budget allows, there are some more sophisticated port closure devices on the market, which make it a snap. You may consider adding them to the patient’s bill if you are a busy bariatric surgeon. Time is money!',\n", " 'bBox': {'x': 72, 'y': 220, 'w': 467.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Abdominal Binder',\n", " 'md': '### Abdominal Binder',\n", " 'bBox': {'x': 86, 'y': 363, 'w': 140.68, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'At the end of the procedure, before the patient is rolled off the table, we apply a Velcro abdominal binder (over the dressing) to ‘support’ the abdominal closure. The binder provides a counter-pressure to the intra-abdominal pressure thus negating bursting forces. With the binder applied, the patient may develop an incisional hernia but you will never see a free dehiscence. Don’t laugh at the binder before you see how it helps patients to ambulate early, with reduced discomfort. Of course, the binders come in all sizes and should not be applied so tightly as to produce an abdominal compartment syndrome. They should be opened when the patient lies in bed.',\n", " 'md': 'At the end of the procedure, before the patient is rolled off the table, we apply a Velcro abdominal binder (over the dressing) to ‘support’ the abdominal closure. The binder provides a counter-pressure to the intra-abdominal pressure thus negating bursting forces. With the binder applied, the patient may develop an incisional hernia but you will never see a free dehiscence. Don’t laugh at the binder before you see how it helps patients to ambulate early, with reduced discomfort. Of course, the binders come in all sizes and should not be applied so tightly as to produce an abdominal compartment syndrome. They should be opened when the patient lies in bed.',\n", " 'bBox': {'x': 72, 'y': 363, 'w': 467.78, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Final Point',\n", " 'md': '### Final Point',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Close up by yourself! If you have residents then be present and teach them how to do it correctly. An unsupervised second-year resident closing the abdomen, an unsupervised first-year registrar closing the skin — this is a good way to produce a nice series of abdominal dehiscence and increase the rate of wound complications.\\n\\n----\\n\\n**Figure 40.3**: This figure likely illustrates a scenario related to abdominal wall defects and the implications of improper closure during laparoscopic surgery. The specific content of the figure is not provided in the text, but it emphasizes the importance of proper technique to avoid complications.\\n```',\n", " 'md': 'Close up by yourself! If you have residents then be present and teach them how to do it correctly. An unsupervised second-year resident closing the abdomen, an unsupervised first-year registrar closing the skin — this is a good way to produce a nice series of abdominal dehiscence and increase the rate of wound complications.\\n\\n----\\n\\n**Figure 40.3**: This figure likely illustrates a scenario related to abdominal wall defects and the implications of improper closure during laparoscopic surgery. The specific content of the figure is not provided in the text, but it emphasizes the importance of proper technique to avoid complications.\\n```',\n", " 'bBox': {'x': 72, 'y': 660, 'w': 467.69, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'with the scar well hidden in the umbilicus (were you tempted to try single-'}]},\n", " {'page': 734,\n", " 'text': '“Abdominal closure: if it looks all right, it’s too tight — if\\nit looks too loose, it’s all right.”\\n Matt Oliver',\n", " 'md': '```markdown\\n## Abdominal Closure Quote\\n\\n“Abdominal closure: if it looks all right, it’s too tight — if it looks too loose, it’s all right.”\\n— Matt Oliver\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Closure Quote',\n", " 'md': '## Abdominal Closure Quote',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '“Abdominal closure: if it looks all right, it’s too tight — if it looks too loose, it’s all right.”\\n— Matt Oliver\\n```',\n", " 'md': '“Abdominal closure: if it looks all right, it’s too tight — if it looks too loose, it’s all right.”\\n— Matt Oliver\\n```',\n", " 'bBox': {'x': 79, 'y': 93, 'w': 453.42, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 735,\n", " 'text': 'Chapter 41\\nBefore landing\\nMoshe Schein\\n\\n Pilots may have more incentive than surgeons to be\\n perfect, right or wrong. When they botch a landing, it’s\\n usually their last. Fortunately, modern day aircraft are a lot\\n more predictable and reliable than any of our patients.\\n Tim Eldridge\\n\\n Take-offs are optional. Landings are mandatory.\\n\\n Everyone knows that a ‘good landing’ is one from which you can walk\\naway. But very few know the definition of a ‘great landing’. It’s one after\\nwhich you can use the airplane another time. Yes, we know that you\\nare tired; you may have worked all night and this may be the last of many\\nlong cases. But any landing must be perfect and even this last operation\\nhas to succeed.\\n\\n Before closing the abdomen you must be absolutely happy with\\nwhat you did. You don’t want to spend the next week in guilt and worry\\nas your patient fails to recover promptly. Prevent ‘guilt-worry’. Always ask\\nyourself “Am I totally satisfied with my procedure?” ( Figure 41.1).\\n\\n Don’t silence the little voice within you that informs you that the\\n anastomosis is somewhat dusky, or it needs another stitch. A little\\n paranoia makes you a better surgeon, and your patients have fewer complications. You must',\n", " 'md': '```markdown\\n# Chapter 41: Before Landing\\n**Author: Moshe Schein**\\n\\n> \"Pilots may have more incentive than surgeons to be perfect, right or wrong. When they botch a landing, it’s usually their last. Fortunately, modern day aircraft are a lot more predictable and reliable than any of our patients.\"\\n> — Tim Eldridge\\n\\n> \"Take-offs are optional. Landings are mandatory.\"\\n\\nEveryone knows that a ‘good landing’ is one from which you can walk away. But very few know the definition of a ‘great landing’. It’s one after which you can use the airplane another time. Yes, we know that you are tired; you may have worked all night and this may be the last of many long cases. But any landing must be perfect and even this last operation has to succeed.\\n\\nBefore closing the abdomen you must be absolutely happy with what you did. You don’t want to spend the next week in guilt and worry as your patient fails to recover promptly. Prevent ‘guilt-worry’. Always ask yourself “Am I totally satisfied with my procedure?” (Figure 41.1).\\n\\nDon’t silence the little voice within you that informs you that the anastomosis is somewhat dusky, or it needs another stitch. A little paranoia makes you a better surgeon, and your patients have fewer complications. You must...\\n\\n## Figure 41.1\\n*Description*: This figure likely illustrates a surgical procedure or concept related to the text, emphasizing the importance of self-assessment and satisfaction in surgical practice. The specific content of the figure is not provided in the text.\\n\\n*Summary*: The figure serves as a visual reminder for surgeons to reflect on their work and ensure they are content with their procedures before concluding an operation.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 41: Before Landing',\n", " 'md': '# Chapter 41: Before Landing',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 148.79, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author: Moshe Schein**\\n\\n> \"Pilots may have more incentive than surgeons to be perfect, right or wrong. When they botch a landing, it’s usually their last. Fortunately, modern day aircraft are a lot more predictable and reliable than any of our patients.\"\\n> — Tim Eldridge\\n\\n> \"Take-offs are optional. Landings are mandatory.\"\\n\\nEveryone knows that a ‘good landing’ is one from which you can walk away. But very few know the definition of a ‘great landing’. It’s one after which you can use the airplane another time. Yes, we know that you are tired; you may have worked all night and this may be the last of many long cases. But any landing must be perfect and even this last operation has to succeed.\\n\\nBefore closing the abdomen you must be absolutely happy with what you did. You don’t want to spend the next week in guilt and worry as your patient fails to recover promptly. Prevent ‘guilt-worry’. Always ask yourself “Am I totally satisfied with my procedure?” (Figure 41.1).\\n\\nDon’t silence the little voice within you that informs you that the anastomosis is somewhat dusky, or it needs another stitch. A little paranoia makes you a better surgeon, and your patients have fewer complications. You must...',\n", " 'md': '**Author: Moshe Schein**\\n\\n> \"Pilots may have more incentive than surgeons to be perfect, right or wrong. When they botch a landing, it’s usually their last. Fortunately, modern day aircraft are a lot more predictable and reliable than any of our patients.\"\\n> — Tim Eldridge\\n\\n> \"Take-offs are optional. Landings are mandatory.\"\\n\\nEveryone knows that a ‘good landing’ is one from which you can walk away. But very few know the definition of a ‘great landing’. It’s one after which you can use the airplane another time. Yes, we know that you are tired; you may have worked all night and this may be the last of many long cases. But any landing must be perfect and even this last operation has to succeed.\\n\\nBefore closing the abdomen you must be absolutely happy with what you did. You don’t want to spend the next week in guilt and worry as your patient fails to recover promptly. Prevent ‘guilt-worry’. Always ask yourself “Am I totally satisfied with my procedure?” (Figure 41.1).\\n\\nDon’t silence the little voice within you that informs you that the anastomosis is somewhat dusky, or it needs another stitch. A little paranoia makes you a better surgeon, and your patients have fewer complications. You must...',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 467.85, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 41.1',\n", " 'md': '## Figure 41.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*Description*: This figure likely illustrates a surgical procedure or concept related to the text, emphasizing the importance of self-assessment and satisfaction in surgical practice. The specific content of the figure is not provided in the text.\\n\\n*Summary*: The figure serves as a visual reminder for surgeons to reflect on their work and ensure they are content with their procedures before concluding an operation.\\n```',\n", " 'md': '*Description*: This figure likely illustrates a surgical procedure or concept related to the text, emphasizing the importance of self-assessment and satisfaction in surgical practice. The specific content of the figure is not provided in the text.\\n\\n*Summary*: The figure serves as a visual reminder for surgeons to reflect on their work and ensure they are content with their procedures before concluding an operation.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 736,\n", " 'text': ' be absolutely convinced, at this stage, that you have done the best that your patient deserves.\\n\\n Figure 41.1. “Am I satisfied?”\\n\\n If not, swallow your pride, summon the last vestige of your patience, do\\nit again, or call for help. ħiding a potential problem will not solve it. And\\nyou will go back to sleep so much better. ħowever, bear in mind that — to\\nparaphrase Voltaire — better is the enemy of good. You must be sure\\nthat any attempts to improve a less-than-perfect situation are justified.\\n(Remember the philosophy of the abbreviated laparotomy.)\\n\\n You may want to go over a pre-closure checklist — see Table\\n41.1 below.',\n", " 'md': '```markdown\\n## Page Content\\n\\nBe absolutely convinced, at this stage, that you have done the best that your patient deserves.\\n\\nIf not, swallow your pride, summon the last vestige of your patience, do it again, or call for help. Hiding a potential problem will not solve it. And you will go back to sleep so much better. However, bear in mind that — to paraphrase Voltaire — better is the enemy of good. You must be sure that any attempts to improve a less-than-perfect situation are justified. (Remember the philosophy of the abbreviated laparotomy.)\\n\\nYou may want to go over a pre-closure checklist — see Table 41.1 below.\\n\\n## Figures and Tables\\n\\n### Figure 41.1\\n**Caption:** “Am I satisfied?”\\n\\n**Description:** This figure likely represents a visual or graphical element that poses the question of satisfaction in a medical context. The content of the figure is not provided in the text, but it is implied to be a reflective or evaluative tool for practitioners.\\n\\n### Table 41.1\\n**Description:** This table is referenced but not included in the text. It presumably contains a checklist or relevant information related to pre-closure procedures in a medical setting.\\n```',\n", " 'images': [{'name': 'img_p735_1.png',\n", " 'height': 581,\n", " 'width': 815,\n", " 'x': 104.39999999999998,\n", " 'y': 116.63999999999999,\n", " 'original_width': 1401,\n", " 'original_height': 997}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Be absolutely convinced, at this stage, that you have done the best that your patient deserves.\\n\\nIf not, swallow your pride, summon the last vestige of your patience, do it again, or call for help. Hiding a potential problem will not solve it. And you will go back to sleep so much better. However, bear in mind that — to paraphrase Voltaire — better is the enemy of good. You must be sure that any attempts to improve a less-than-perfect situation are justified. (Remember the philosophy of the abbreviated laparotomy.)\\n\\nYou may want to go over a pre-closure checklist — see Table 41.1 below.',\n", " 'md': 'Be absolutely convinced, at this stage, that you have done the best that your patient deserves.\\n\\nIf not, swallow your pride, summon the last vestige of your patience, do it again, or call for help. Hiding a potential problem will not solve it. And you will go back to sleep so much better. However, bear in mind that — to paraphrase Voltaire — better is the enemy of good. You must be sure that any attempts to improve a less-than-perfect situation are justified. (Remember the philosophy of the abbreviated laparotomy.)\\n\\nYou may want to go over a pre-closure checklist — see Table 41.1 below.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 466.75, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures and Tables',\n", " 'md': '## Figures and Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 41.1',\n", " 'md': '### Figure 41.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** “Am I satisfied?”\\n\\n**Description:** This figure likely represents a visual or graphical element that poses the question of satisfaction in a medical context. The content of the figure is not provided in the text, but it is implied to be a reflective or evaluative tool for practitioners.',\n", " 'md': '**Caption:** “Am I satisfied?”\\n\\n**Description:** This figure likely represents a visual or graphical element that poses the question of satisfaction in a medical context. The content of the figure is not provided in the text, but it is implied to be a reflective or evaluative tool for practitioners.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 41.1',\n", " 'md': '### Table 41.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This table is referenced but not included in the text. It presumably contains a checklist or relevant information related to pre-closure procedures in a medical setting.\\n```',\n", " 'md': '**Description:** This table is referenced but not included in the text. It presumably contains a checklist or relevant information related to pre-closure procedures in a medical setting.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'You may want to go over a pre-closure checklist — see Table 41.1 below .'}]},\n", " {'page': 737,\n", " 'text': \" Table 41.1. Pre-closure checklist:\\n Hemostasis perfect? This does not mean that you have to run after each red\\n blood corpuscle.\\n Source control achieved?\\n Peritoneal 'toilet' completed? All fluid sucked out?\\n Anastomosis: Viable? Not under tension, lying well?\\n Potential sites for internal herniation dealt with?\\n Small bowel comfortably arranged in place below the transverse colon?\\n Omentum placed between intestine and incision?\\n All additional fascial defects (e.g trocar sites) closed?\\n Nasogastric tube in position (if needed)?\\n Drains (only if indicated!) in place?\\n Need a feeding jejunostomy\\n Should close the abdomen at all? Or leave it open?\\n Do not compromise. Keep looking around; there’s always something\\nyou’ve missed. Remember: when the abdomen is open you control it,\\nwhen closed it controls you!\\n\\n And then, even if everything seems perfect you will start worrying\\n — nay, you have to worry. The more experience you gain the more you will worry,\\n going over in your mind everything that, from now on, may go wrong within that abdominal\\n ‘black box’.\\n\\n Remember that jejunum belongs to the upper part of the abdomen and ileum to the lower part…\\n Ari\\n\\n ħappy landing!\\n\\n “I have many colleagues of varying levels of knowledge\\n and skill. But the ones I trust most are the ones that\\n worry. You can see the concern, sometimes even anguish\",\n", " 'md': \"```markdown\\n# Page Content\\n\\n## Table 41.1. Pre-closure checklist:\\n- Hemostasis perfect? This does not mean that you have to run after each red blood corpuscle.\\n- Source control achieved?\\n- Peritoneal 'toilet' completed? All fluid sucked out?\\n- Anastomosis: Viable? Not under tension, lying well?\\n- Potential sites for internal herniation dealt with?\\n- Small bowel comfortably arranged in place below the transverse colon?\\n- Omentum placed between intestine and incision?\\n- All additional fascial defects (e.g., trocar sites) closed?\\n- Nasogastric tube in position (if needed)?\\n- Drains (only if indicated!) in place?\\n- Need a feeding jejunostomy.\\n- Should close the abdomen at all? Or leave it open?\\n\\nDo not compromise. Keep looking around; there’s always something you’ve missed. Remember: when the abdomen is open you control it, when closed it controls you!\\n\\nAnd then, even if everything seems perfect you will start worrying — nay, you have to worry. The more experience you gain the more you will worry, going over in your mind everything that, from now on, may go wrong within that abdominal ‘black box’.\\n\\nRemember that jejunum belongs to the upper part of the abdomen and ileum to the lower part…\\n\\nAri\\n\\nHappy landing!\\n\\n“I have many colleagues of varying levels of knowledge and skill. But the ones I trust most are the ones that worry. You can see the concern, sometimes even anguish.”\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and formatted as per the requirements.\",\n", " 'images': [{'name': 'img_p736_1.png',\n", " 'height': 550,\n", " 'width': 812,\n", " 'x': 105.12,\n", " 'y': 72,\n", " 'original_width': 1394,\n", " 'original_height': 944}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 41.1. Pre-closure checklist:',\n", " 'md': '## Table 41.1. Pre-closure checklist:',\n", " 'bBox': {'x': 110.07, 'y': 76.95, 'w': 203.85, 'h': 15.83}},\n", " {'type': 'text',\n", " 'value': \"- Hemostasis perfect? This does not mean that you have to run after each red blood corpuscle.\\n- Source control achieved?\\n- Peritoneal 'toilet' completed? All fluid sucked out?\\n- Anastomosis: Viable? Not under tension, lying well?\\n- Potential sites for internal herniation dealt with?\\n- Small bowel comfortably arranged in place below the transverse colon?\\n- Omentum placed between intestine and incision?\\n- All additional fascial defects (e.g., trocar sites) closed?\\n- Nasogastric tube in position (if needed)?\\n- Drains (only if indicated!) in place?\\n- Need a feeding jejunostomy.\\n- Should close the abdomen at all? Or leave it open?\\n\\nDo not compromise. Keep looking around; there’s always something you’ve missed. Remember: when the abdomen is open you control it, when closed it controls you!\\n\\nAnd then, even if everything seems perfect you will start worrying — nay, you have to worry. The more experience you gain the more you will worry, going over in your mind everything that, from now on, may go wrong within that abdominal ‘black box’.\\n\\nRemember that jejunum belongs to the upper part of the abdomen and ileum to the lower part…\\n\\nAri\\n\\nHappy landing!\\n\\n“I have many colleagues of varying levels of knowledge and skill. But the ones I trust most are the ones that worry. You can see the concern, sometimes even anguish.”\\n```\",\n", " 'md': \"- Hemostasis perfect? This does not mean that you have to run after each red blood corpuscle.\\n- Source control achieved?\\n- Peritoneal 'toilet' completed? All fluid sucked out?\\n- Anastomosis: Viable? Not under tension, lying well?\\n- Potential sites for internal herniation dealt with?\\n- Small bowel comfortably arranged in place below the transverse colon?\\n- Omentum placed between intestine and incision?\\n- All additional fascial defects (e.g., trocar sites) closed?\\n- Nasogastric tube in position (if needed)?\\n- Drains (only if indicated!) in place?\\n- Need a feeding jejunostomy.\\n- Should close the abdomen at all? Or leave it open?\\n\\nDo not compromise. Keep looking around; there’s always something you’ve missed. Remember: when the abdomen is open you control it, when closed it controls you!\\n\\nAnd then, even if everything seems perfect you will start worrying — nay, you have to worry. The more experience you gain the more you will worry, going over in your mind everything that, from now on, may go wrong within that abdominal ‘black box’.\\n\\nRemember that jejunum belongs to the upper part of the abdomen and ileum to the lower part…\\n\\nAri\\n\\nHappy landing!\\n\\n“I have many colleagues of varying levels of knowledge and skill. But the ones I trust most are the ones that worry. You can see the concern, sometimes even anguish.”\\n```\",\n", " 'bBox': {'x': 72, 'y': 118.51, 'w': 467.31, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and formatted as per the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and formatted as per the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 738,\n", " 'text': 'on their faces. Then, there are the sociopaths...”\\n Tom Gilas\\n“There are old pilots, and there are bold pilots, but there\\nare no old, bold, pilots! There are however old, bold\\nsurgeons — but their patients do not live long…”\\n Moshe',\n", " 'md': '```markdown\\n### Page Content\\n\\n- \"on their faces. Then, there are the sociopaths...\"\\n— Tom Gilas\\n\\n- \"There are old pilots, and there are bold pilots, but there are no old, bold, pilots! There are however old, bold surgeons — but their patients do not live long...\"\\n— Moshe\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Page Content',\n", " 'md': '### Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- \"on their faces. Then, there are the sociopaths...\"\\n— Tom Gilas\\n\\n- \"There are old pilots, and there are bold pilots, but there are no old, bold, pilots! There are however old, bold surgeons — but their patients do not live long...\"\\n— Moshe\\n```',\n", " 'md': '- \"on their faces. Then, there are the sociopaths...\"\\n— Tom Gilas\\n\\n- \"There are old pilots, and there are bold pilots, but there are no old, bold, pilots! There are however old, bold surgeons — but their patients do not live long...\"\\n— Moshe\\n```',\n", " 'bBox': {'x': 79, 'y': 111, 'w': 453.13, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 739,\n", " 'text': ' PART IV\\n\\nAfter the operation',\n", " 'md': '# PART IV\\n\\n## After the operation\\n\\n(Note: There are no images, graphs, or tables on this page. The text has been extracted as per the instructions.)',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'PART IV',\n", " 'md': '# PART IV',\n", " 'bBox': {'x': 251, 'y': 172, 'w': 108.82, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'After the operation',\n", " 'md': '## After the operation',\n", " 'bBox': {'x': 177, 'y': 235, 'w': 257.5, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '(Note: There are no images, graphs, or tables on this page. The text has been extracted as per the instructions.)',\n", " 'md': '(Note: There are no images, graphs, or tables on this page. The text has been extracted as per the instructions.)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 740,\n", " 'text': 'Chapter 42\\nPostoperative care\\nMoshe Schein\\n\\n When is a surgeon… nervous? Not during operations. But\\n basically a surgeon’s nervousness begins after the\\n operations, when for some reason the patient’s temperature\\n refuses to drop or a stomach remains bloated and one has\\n to open it not with a knife, but in one’s mind, to see what\\n had happened, to understand and put it right. When time is\\n slipping away, you have to grab it by the tail.\\n Alexander Solzhenitsyn (Cancer Ward)\\n\\n We repeat: As long as the abdomen is open you control it.\\n Once closed it controls you.\\n\\n The long operation is finished, leaving you to savor the sweet\\npostoperative ‘high’ and elation. But very soon, when your serum levels\\nof endorphins decline, you start worrying about the outcome. And worry\\nyou must, for the cocksure, macho attitude is a recipe for disaster. We do\\nnot intend to bring here a detailed discussion of postoperative care or to\\nwrite a new surgical intensive care manual. (For an in depth discussion\\non how to prevent and treat postoperative complications look at our\\nSchein’s Common Sense Prevention and Management of Surgical\\nComplications.) We only wish to share with you some basic precepts,\\nwhich may have been forgotten, drowned in a sea of fancy technology\\nand gimmicks. The following are a few practical commandments for\\npostoperative care.',\n", " 'md': '```markdown\\n# Chapter 42: Postoperative Care\\n**Author: Moshe Schein**\\n\\nWhen is a surgeon… nervous? Not during operations. But basically a surgeon’s nervousness begins after the operations, when for some reason the patient’s temperature refuses to drop or a stomach remains bloated and one has to open it not with a knife, but in one’s mind, to see what had happened, to understand and put it right. When time is slipping away, you have to grab it by the tail.\\n— Alexander Solzhenitsyn (Cancer Ward)\\n\\nWe repeat: As long as the abdomen is open you control it. Once closed it controls you.\\n\\nThe long operation is finished, leaving you to savor the sweet postoperative ‘high’ and elation. But very soon, when your serum levels of endorphins decline, you start worrying about the outcome. And worry you must, for the cocksure, macho attitude is a recipe for disaster. We do not intend to bring here a detailed discussion of postoperative care or to write a new surgical intensive care manual. (For an in-depth discussion on how to prevent and treat postoperative complications look at our [Schein’s Common Sense Prevention and Management of Surgical Complications]()). We only wish to share with you some basic precepts, which may have been forgotten, drowned in a sea of fancy technology and gimmicks. The following are a few practical commandments for postoperative care.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 42: Postoperative Care',\n", " 'md': '# Chapter 42: Postoperative Care',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 167.99, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author: Moshe Schein**\\n\\nWhen is a surgeon… nervous? Not during operations. But basically a surgeon’s nervousness begins after the operations, when for some reason the patient’s temperature refuses to drop or a stomach remains bloated and one has to open it not with a knife, but in one’s mind, to see what had happened, to understand and put it right. When time is slipping away, you have to grab it by the tail.\\n— Alexander Solzhenitsyn (Cancer Ward)\\n\\nWe repeat: As long as the abdomen is open you control it. Once closed it controls you.\\n\\nThe long operation is finished, leaving you to savor the sweet postoperative ‘high’ and elation. But very soon, when your serum levels of endorphins decline, you start worrying about the outcome. And worry you must, for the cocksure, macho attitude is a recipe for disaster. We do not intend to bring here a detailed discussion of postoperative care or to write a new surgical intensive care manual. (For an in-depth discussion on how to prevent and treat postoperative complications look at our [Schein’s Common Sense Prevention and Management of Surgical Complications]()). We only wish to share with you some basic precepts, which may have been forgotten, drowned in a sea of fancy technology and gimmicks. The following are a few practical commandments for postoperative care.\\n```',\n", " 'md': '**Author: Moshe Schein**\\n\\nWhen is a surgeon… nervous? Not during operations. But basically a surgeon’s nervousness begins after the operations, when for some reason the patient’s temperature refuses to drop or a stomach remains bloated and one has to open it not with a knife, but in one’s mind, to see what had happened, to understand and put it right. When time is slipping away, you have to grab it by the tail.\\n— Alexander Solzhenitsyn (Cancer Ward)\\n\\nWe repeat: As long as the abdomen is open you control it. Once closed it controls you.\\n\\nThe long operation is finished, leaving you to savor the sweet postoperative ‘high’ and elation. But very soon, when your serum levels of endorphins decline, you start worrying about the outcome. And worry you must, for the cocksure, macho attitude is a recipe for disaster. We do not intend to bring here a detailed discussion of postoperative care or to write a new surgical intensive care manual. (For an in-depth discussion on how to prevent and treat postoperative complications look at our [Schein’s Common Sense Prevention and Management of Surgical Complications]()). We only wish to share with you some basic precepts, which may have been forgotten, drowned in a sea of fancy technology and gimmicks. The following are a few practical commandments for postoperative care.\\n```',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.88, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 741,\n", " 'text': ' Know your patient\\n\\n This is no joke! ħow often do we encounter a postoperative patient\\nlooked after by someone who has no clue about the patient’s pre-\\noperative and intra-operative details? The emerging ‘shift mentality’ and\\nthe increasing reliance on physicians who call themsleves ‘hospitalists’\\nare depriving the modern surgical patient of direct contact with his\\nsurgeon! Mistakes in management are more commonly made by those\\nwho ‘temporarily adopt’ the case. Once you operate on a patient he or\\nshe is yours forever…!\\n\\n Shared responsibility often means that no one is responsible!\\n(See more in the section “Be the leader and take responsibility”.)\\n\\n Touch/examine your patient\\n\\n Not only from the foot of the bed. Examining the chart — or browsing\\nthe EMR from your laptop at home — or even looking at the ICU monitor\\nis not enough. Look at the patient, smell and palpate him at least\\ntwice a day. Wouldn’t it be embarrassing to load your patient with\\nintravenous antibiotics or CT scan his abdomen, while an unsuspected\\nabscess is cooking under the wound dressing, begging to be simply\\ndrained at the bedside?\\n\\n Leo Tolstoy wrote in War and Peace:\\n\\n When he came to himself the splintered portions of his thigh\\n bone had been extracted, the torn flesh cut away and the\\n wound bandaged. Water was being sprinkled on his face.\\n As soon as Prince Andrei opened his eyes the doctor bent\\n down, kissed him on the lips with not a word and hurried\\n away.\\n\\n We do not ask you to kiss your patients — just touch them! And you\\nmay hug their elderly wives (please be careful with the young ones…).\\n\\n Treat the pain',\n", " 'md': '```markdown\\n# Know Your Patient\\n\\nThis is no joke! How often do we encounter a postoperative patient looked after by someone who has no clue about the patient’s pre-operative and intra-operative details? The emerging ‘shift mentality’ and the increasing reliance on physicians who call themselves ‘hospitalists’ are depriving the modern surgical patient of direct contact with his surgeon! Mistakes in management are more commonly made by those who ‘temporarily adopt’ the case. Once you operate on a patient he or she is yours forever…!\\n\\nShared responsibility often means that no one is responsible! (See more in the section “Be the leader and take responsibility”.)\\n\\n## Touch/Examine Your Patient\\n\\nNot only from the foot of the bed. Examining the chart — or browsing the EMR from your laptop at home — or even looking at the ICU monitor is not enough. Look at the patient, smell and palpate him at least twice a day. Wouldn’t it be embarrassing to load your patient with intravenous antibiotics or CT scan his abdomen, while an unsuspected abscess is cooking under the wound dressing, begging to be simply drained at the bedside?\\n\\nLeo Tolstoy wrote in *War and Peace*:\\n\\n> When he came to himself the splintered portions of his thigh bone had been extracted, the torn flesh cut away and the wound bandaged. Water was being sprinkled on his face. As soon as Prince Andrei opened his eyes the doctor bent down, kissed him on the lips with not a word and hurried away.\\n\\nWe do not ask you to kiss your patients — just touch them! And you may hug their elderly wives (please be careful with the young ones…).\\n\\n## Treat the Pain\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Know Your Patient',\n", " 'md': '# Know Your Patient',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 144.35, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This is no joke! How often do we encounter a postoperative patient looked after by someone who has no clue about the patient’s pre-operative and intra-operative details? The emerging ‘shift mentality’ and the increasing reliance on physicians who call themselves ‘hospitalists’ are depriving the modern surgical patient of direct contact with his surgeon! Mistakes in management are more commonly made by those who ‘temporarily adopt’ the case. Once you operate on a patient he or she is yours forever…!\\n\\nShared responsibility often means that no one is responsible! (See more in the section “Be the leader and take responsibility”.)',\n", " 'md': 'This is no joke! How often do we encounter a postoperative patient looked after by someone who has no clue about the patient’s pre-operative and intra-operative details? The emerging ‘shift mentality’ and the increasing reliance on physicians who call themselves ‘hospitalists’ are depriving the modern surgical patient of direct contact with his surgeon! Mistakes in management are more commonly made by those who ‘temporarily adopt’ the case. Once you operate on a patient he or she is yours forever…!\\n\\nShared responsibility often means that no one is responsible! (See more in the section “Be the leader and take responsibility”.)',\n", " 'bBox': {'x': 72, 'y': 223, 'w': 467.4, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Touch/Examine Your Patient',\n", " 'md': '## Touch/Examine Your Patient',\n", " 'bBox': {'x': 86, 'y': 335, 'w': 218.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Not only from the foot of the bed. Examining the chart — or browsing the EMR from your laptop at home — or even looking at the ICU monitor is not enough. Look at the patient, smell and palpate him at least twice a day. Wouldn’t it be embarrassing to load your patient with intravenous antibiotics or CT scan his abdomen, while an unsuspected abscess is cooking under the wound dressing, begging to be simply drained at the bedside?\\n\\nLeo Tolstoy wrote in *War and Peace*:\\n\\n> When he came to himself the splintered portions of his thigh bone had been extracted, the torn flesh cut away and the wound bandaged. Water was being sprinkled on his face. As soon as Prince Andrei opened his eyes the doctor bent down, kissed him on the lips with not a word and hurried away.\\n\\nWe do not ask you to kiss your patients — just touch them! And you may hug their elderly wives (please be careful with the young ones…).',\n", " 'md': 'Not only from the foot of the bed. Examining the chart — or browsing the EMR from your laptop at home — or even looking at the ICU monitor is not enough. Look at the patient, smell and palpate him at least twice a day. Wouldn’t it be embarrassing to load your patient with intravenous antibiotics or CT scan his abdomen, while an unsuspected abscess is cooking under the wound dressing, begging to be simply drained at the bedside?\\n\\nLeo Tolstoy wrote in *War and Peace*:\\n\\n> When he came to himself the splintered portions of his thigh bone had been extracted, the torn flesh cut away and the wound bandaged. Water was being sprinkled on his face. As soon as Prince Andrei opened his eyes the doctor bent down, kissed him on the lips with not a word and hurried away.\\n\\nWe do not ask you to kiss your patients — just touch them! And you may hug their elderly wives (please be careful with the young ones…).',\n", " 'bBox': {'x': 72, 'y': 371, 'w': 467.73, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Treat the Pain',\n", " 'md': '## Treat the Pain',\n", " 'bBox': {'x': 86, 'y': 714, 'w': 107.59, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 742,\n", " 'text': ' You know the different drugs, and their modes of administration. Sure,\\nyou always prescribe postoperative analgesia, but ordering is not nearly\\nenough. Most randomly questioned postoperative patients complain that\\nthey are under-treated for pain. Nurses tend to be stingy with analgesia.\\nYou are the man on the spot; consider pain as the ‘fifth vital sign’ and\\nsee that your patient does not suffer unnecessarily.\\n\\n Do not ‘crucify’ your patient in the horizontal position\\n\\n Typically the modern patient is ‘crucified’ horizontally, tethered by a\\nspaghetti of monitoring cables, nasogastric tubes, venous lines, drains,\\nleg pumps and urinary catheters. Free the patient from these\\nparaphernalia as soon as possible; the nurses won’t do it without\\nyour order. The earlier your patient is out of bed, sitting or walking\\nabout, the faster he will be going home. Conversely, keeping the\\npatient in the supine position increases the incidence of\\natelectasis/pneumonia, deep vein thrombosis, decubitus ulcers, and\\nprolongs paralytic ileus, all adding fuel to the inflammatory fire of SIRS.\\nHave your patient out of bed ASAP and this often means only a few\\nhours after the operation. If the nurses are reluctant or lazy, lift the\\npatient out of bed by yourself — lead by example!\\n\\n One of my main tasks when doing a ward round on postoperative patients is to ask two\\n questions: “Have you been up already?” and “Have they given you something to eat?” Ari\\n\\n Decrease the plastic and rubber load\\n\\n The monitoring of vital signs functions as an early warning system to\\ndetect physiological disturbances so that prompt corrective therapy can\\nbe instituted. The invasiveness of monitoring employed in the\\nindividual patient should be proportionate to the severity of the\\ndisease: The sicker the patient, the greater the number of monitoring\\ntubes used, the less likely is survival.\\n\\n Complete discussion of the continuously growing number of monitoring\\nmethods available today is beyond the scope of this chapter. ħowever,',\n", " 'md': '```markdown\\n## Postoperative Care Considerations\\n\\nYou know the different drugs and their modes of administration. Sure, you always prescribe postoperative analgesia, but ordering is not nearly enough. Most randomly questioned postoperative patients complain that they are under-treated for pain. Nurses tend to be stingy with analgesia. You are the man on the spot; consider pain as the ‘fifth vital sign’ and see that your patient does not suffer unnecessarily.\\n\\n### Do not ‘crucify’ your patient in the horizontal position\\n\\nTypically, the modern patient is ‘crucified’ horizontally, tethered by a spaghetti of monitoring cables, nasogastric tubes, venous lines, drains, leg pumps, and urinary catheters. Free the patient from these paraphernalia as soon as possible; the nurses won’t do it without your order. The earlier your patient is out of bed, sitting or walking about, the faster he will be going home. Conversely, keeping the patient in the supine position increases the incidence of atelectasis/pneumonia, deep vein thrombosis, decubitus ulcers, and prolongs paralytic ileus, all adding fuel to the inflammatory fire of SIRS. Have your patient out of bed ASAP and this often means only a few hours after the operation. If the nurses are reluctant or lazy, lift the patient out of bed by yourself — lead by example!\\n\\nOne of my main tasks when doing a ward round on postoperative patients is to ask two questions: “Have you been up already?” and “Have they given you something to eat?”\\n\\n### Decrease the plastic and rubber load\\n\\nThe monitoring of vital signs functions as an early warning system to detect physiological disturbances so that prompt corrective therapy can be instituted. The invasiveness of monitoring employed in the individual patient should be proportionate to the severity of the disease: The sicker the patient, the greater the number of monitoring tubes used, the less likely is survival.\\n\\nComplete discussion of the continuously growing number of monitoring methods available today is beyond the scope of this chapter. However,\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Postoperative Care Considerations',\n", " 'md': '## Postoperative Care Considerations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'You know the different drugs and their modes of administration. Sure, you always prescribe postoperative analgesia, but ordering is not nearly enough. Most randomly questioned postoperative patients complain that they are under-treated for pain. Nurses tend to be stingy with analgesia. You are the man on the spot; consider pain as the ‘fifth vital sign’ and see that your patient does not suffer unnecessarily.',\n", " 'md': 'You know the different drugs and their modes of administration. Sure, you always prescribe postoperative analgesia, but ordering is not nearly enough. Most randomly questioned postoperative patients complain that they are under-treated for pain. Nurses tend to be stingy with analgesia. You are the man on the spot; consider pain as the ‘fifth vital sign’ and see that your patient does not suffer unnecessarily.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.64, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Do not ‘crucify’ your patient in the horizontal position',\n", " 'md': '### Do not ‘crucify’ your patient in the horizontal position',\n", " 'bBox': {'x': 72, 'y': 211, 'w': 434.12, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Typically, the modern patient is ‘crucified’ horizontally, tethered by a spaghetti of monitoring cables, nasogastric tubes, venous lines, drains, leg pumps, and urinary catheters. Free the patient from these paraphernalia as soon as possible; the nurses won’t do it without your order. The earlier your patient is out of bed, sitting or walking about, the faster he will be going home. Conversely, keeping the patient in the supine position increases the incidence of atelectasis/pneumonia, deep vein thrombosis, decubitus ulcers, and prolongs paralytic ileus, all adding fuel to the inflammatory fire of SIRS. Have your patient out of bed ASAP and this often means only a few hours after the operation. If the nurses are reluctant or lazy, lift the patient out of bed by yourself — lead by example!\\n\\nOne of my main tasks when doing a ward round on postoperative patients is to ask two questions: “Have you been up already?” and “Have they given you something to eat?”',\n", " 'md': 'Typically, the modern patient is ‘crucified’ horizontally, tethered by a spaghetti of monitoring cables, nasogastric tubes, venous lines, drains, leg pumps, and urinary catheters. Free the patient from these paraphernalia as soon as possible; the nurses won’t do it without your order. The earlier your patient is out of bed, sitting or walking about, the faster he will be going home. Conversely, keeping the patient in the supine position increases the incidence of atelectasis/pneumonia, deep vein thrombosis, decubitus ulcers, and prolongs paralytic ileus, all adding fuel to the inflammatory fire of SIRS. Have your patient out of bed ASAP and this often means only a few hours after the operation. If the nurses are reluctant or lazy, lift the patient out of bed by yourself — lead by example!\\n\\nOne of my main tasks when doing a ward round on postoperative patients is to ask two questions: “Have you been up already?” and “Have they given you something to eat?”',\n", " 'bBox': {'x': 72, 'y': 314, 'w': 467.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Decrease the plastic and rubber load',\n", " 'md': '### Decrease the plastic and rubber load',\n", " 'bBox': {'x': 86, 'y': 347, 'w': 289.67, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The monitoring of vital signs functions as an early warning system to detect physiological disturbances so that prompt corrective therapy can be instituted. The invasiveness of monitoring employed in the individual patient should be proportionate to the severity of the disease: The sicker the patient, the greater the number of monitoring tubes used, the less likely is survival.\\n\\nComplete discussion of the continuously growing number of monitoring methods available today is beyond the scope of this chapter. However,\\n```',\n", " 'md': 'The monitoring of vital signs functions as an early warning system to detect physiological disturbances so that prompt corrective therapy can be instituted. The invasiveness of monitoring employed in the individual patient should be proportionate to the severity of the disease: The sicker the patient, the greater the number of monitoring tubes used, the less likely is survival.\\n\\nComplete discussion of the continuously growing number of monitoring methods available today is beyond the scope of this chapter. However,\\n```',\n", " 'bBox': {'x': 72, 'y': 347, 'w': 453.15, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 743,\n", " 'text': 'please note:\\n\\n • In order to be able to respond to monitor-generated warning signs\\n you must fully understand the technology being employed. You\\n should be able to distinguish between real acute physiological\\n changes and electrical or mechanical artifacts of observation.\\n • Understand that all methods of monitoring are liable to a myriad of\\n potential errors, specific to the technique or caused by patient-\\n related variables. Alertness and sound clinical judgment are\\n paramount!\\n • Because of improving technology, monitoring is becoming more and\\n more sophisticated (and expensive). Furthermore, monitoring\\n techniques are responsible for a significant number of iatrogenic\\n complications in the surgical intensive care unit. Use monitoring\\n discriminately and do not succumb to the Everest syndrome: “I\\n climb it because it is there.” Before embarking on invasive\\n monitoring ask yourself “Does this patient really need it?”\\n Remember, there are safer and cheaper alternatives to invasive\\n monitoring: for example, in a stable patient, remove the arterial line,\\n as the blood pressure can be measured with a conventional\\n sphygmomanometer, pO2 determined transcutaneously, and blood\\n tests drawn by phlebotomy. Each time you see your patient ask\\n yourself which of the following can be removed: nasogastric tube,\\n Swan-Ganz catheter, central venous line, arterial line, peripheral\\n venous line, Foley catheter?\\n\\n Nasogastric (NG) tubes. Prolonged postoperative NG decompression to combat\\n gastric and intestinal ileus is a common ritual. The concept that the NG tube ‘protects’ distally-\\n placed bowel anastomoses is ridiculous, as liters of juices are secreted each day below the\\n decompressed stomach. Nasogastric tubes are extremely irritating to the patient, interfere with\\n breathing, cause esophageal erosions and promote gastroesophageal reflux. Traditionally,\\n surgeons keep the tube in until the daily output drops below a certain volume (e.g. 400ml);\\n such a policy often results in unnecessary torture. It has been repeatedly demonstrated that\\n most post-laparotomy patients do not need nasogastric decompression — not even following\\n upper gastrointestinal procedures — or need it for a day or two at most. In fully conscious',\n", " 'md': '```markdown\\n## Key Points on Monitoring and Nasogastric Tubes\\n\\n### Monitoring Considerations\\n- In order to respond to monitor-generated warning signs, you must fully understand the technology being employed. You should be able to distinguish between real acute physiological changes and electrical or mechanical artifacts of observation.\\n- Understand that all methods of monitoring are liable to a myriad of potential errors, specific to the technique or caused by patient-related variables. Alertness and sound clinical judgment are paramount!\\n- Because of improving technology, monitoring is becoming more sophisticated (and expensive). Furthermore, monitoring techniques are responsible for a significant number of iatrogenic complications in the surgical intensive care unit. Use monitoring discriminately and do not succumb to the Everest syndrome: “I climb it because it is there.” Before embarking on invasive monitoring, ask yourself, “Does this patient really need it?”\\n- Remember, there are safer and cheaper alternatives to invasive monitoring: for example, in a stable patient, remove the arterial line, as the blood pressure can be measured with a conventional sphygmomanometer, pO2 determined transcutaneously, and blood tests drawn by phlebotomy. Each time you see your patient, ask yourself which of the following can be removed: nasogastric tube, Swan-Ganz catheter, central venous line, arterial line, peripheral venous line, Foley catheter?\\n\\n### Nasogastric (NG) Tubes\\n- Prolonged postoperative NG decompression to combat gastric and intestinal ileus is a common ritual. The concept that the NG tube ‘protects’ distally-placed bowel anastomoses is ridiculous, as liters of juices are secreted each day below the decompressed stomach.\\n- Nasogastric tubes are extremely irritating to the patient, interfere with breathing, cause esophageal erosions, and promote gastroesophageal reflux. Traditionally, surgeons keep the tube in until the daily output drops below a certain volume (e.g., 400ml); such a policy often results in unnecessary torture.\\n- It has been repeatedly demonstrated that most post-laparotomy patients do not need nasogastric decompression — not even following upper gastrointestinal procedures — or need it for a day or two at most.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Key Points on Monitoring and Nasogastric Tubes',\n", " 'md': '## Key Points on Monitoring and Nasogastric Tubes',\n", " 'bBox': {'x': 470, 'y': 276, 'w': 67.17, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Monitoring Considerations',\n", " 'md': '### Monitoring Considerations',\n", " 'bBox': {'x': 470, 'y': 276, 'w': 67.17, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- In order to respond to monitor-generated warning signs, you must fully understand the technology being employed. You should be able to distinguish between real acute physiological changes and electrical or mechanical artifacts of observation.\\n- Understand that all methods of monitoring are liable to a myriad of potential errors, specific to the technique or caused by patient-related variables. Alertness and sound clinical judgment are paramount!\\n- Because of improving technology, monitoring is becoming more sophisticated (and expensive). Furthermore, monitoring techniques are responsible for a significant number of iatrogenic complications in the surgical intensive care unit. Use monitoring discriminately and do not succumb to the Everest syndrome: “I climb it because it is there.” Before embarking on invasive monitoring, ask yourself, “Does this patient really need it?”\\n- Remember, there are safer and cheaper alternatives to invasive monitoring: for example, in a stable patient, remove the arterial line, as the blood pressure can be measured with a conventional sphygmomanometer, pO2 determined transcutaneously, and blood tests drawn by phlebotomy. Each time you see your patient, ask yourself which of the following can be removed: nasogastric tube, Swan-Ganz catheter, central venous line, arterial line, peripheral venous line, Foley catheter?',\n", " 'md': '- In order to respond to monitor-generated warning signs, you must fully understand the technology being employed. You should be able to distinguish between real acute physiological changes and electrical or mechanical artifacts of observation.\\n- Understand that all methods of monitoring are liable to a myriad of potential errors, specific to the technique or caused by patient-related variables. Alertness and sound clinical judgment are paramount!\\n- Because of improving technology, monitoring is becoming more sophisticated (and expensive). Furthermore, monitoring techniques are responsible for a significant number of iatrogenic complications in the surgical intensive care unit. Use monitoring discriminately and do not succumb to the Everest syndrome: “I climb it because it is there.” Before embarking on invasive monitoring, ask yourself, “Does this patient really need it?”\\n- Remember, there are safer and cheaper alternatives to invasive monitoring: for example, in a stable patient, remove the arterial line, as the blood pressure can be measured with a conventional sphygmomanometer, pO2 determined transcutaneously, and blood tests drawn by phlebotomy. Each time you see your patient, ask yourself which of the following can be removed: nasogastric tube, Swan-Ganz catheter, central venous line, arterial line, peripheral venous line, Foley catheter?',\n", " 'bBox': {'x': 100, 'y': 155, 'w': 436.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Nasogastric (NG) Tubes',\n", " 'md': '### Nasogastric (NG) Tubes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Prolonged postoperative NG decompression to combat gastric and intestinal ileus is a common ritual. The concept that the NG tube ‘protects’ distally-placed bowel anastomoses is ridiculous, as liters of juices are secreted each day below the decompressed stomach.\\n- Nasogastric tubes are extremely irritating to the patient, interfere with breathing, cause esophageal erosions, and promote gastroesophageal reflux. Traditionally, surgeons keep the tube in until the daily output drops below a certain volume (e.g., 400ml); such a policy often results in unnecessary torture.\\n- It has been repeatedly demonstrated that most post-laparotomy patients do not need nasogastric decompression — not even following upper gastrointestinal procedures — or need it for a day or two at most.\\n```',\n", " 'md': '- Prolonged postoperative NG decompression to combat gastric and intestinal ileus is a common ritual. The concept that the NG tube ‘protects’ distally-placed bowel anastomoses is ridiculous, as liters of juices are secreted each day below the decompressed stomach.\\n- Nasogastric tubes are extremely irritating to the patient, interfere with breathing, cause esophageal erosions, and promote gastroesophageal reflux. Traditionally, surgeons keep the tube in until the daily output drops below a certain volume (e.g., 400ml); such a policy often results in unnecessary torture.\\n- It has been repeatedly demonstrated that most post-laparotomy patients do not need nasogastric decompression — not even following upper gastrointestinal procedures — or need it for a day or two at most.\\n```',\n", " 'bBox': {'x': 79, 'y': 564, 'w': 453.32, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 744,\n", " 'text': ' patients, who are able to protect their airway from aspiration, NG tubes can be safely omitted\\n in most cases. However, following an emergency abdominal operation, nasogastric\\n decompression is compulsory in mechanically ventilated patients, in obtunded patients,\\n and after operations for intestinal obstruction. In all other cases, consider removing the NG\\n tube on the morning after surgery. If in doubt you may want to cap or clamp the tube for 4-6\\n hours and observe how this is tolerated by the patient before removing it. A small percentage\\n of patients will need the tube to be reinserted because of persistent ileus or early postoperative\\n small bowel obstruction ( Chapter 45).\\n\\n Drains. Despite the widely publicized dictum that it is impossible\\n to drain the free peritoneal cavity effectively, drains are still\\n commonly used and misused ( Chapters 13 and 39). In addition to the false\\n sense of security and reassurance they provide, drains can erode into intestine or blood\\n vessels and promote infective complications. We suggest that you limit the use of drains to the\\n evacuation of an established abscess, to allow escape of potential visceral secretions (e.g.\\n biliary, pancreatic) and to establish a controlled intestinal fistula when the bowel cannot be\\n exteriorized. Passive, open-system drainage offers a bi-directional route for micro-organisms\\n and should be avoided. Use only active, closed-system drainage systems, placed away from\\n the viscera. Leaving a drain close to an anastomosis in the belief that a possible leak will result\\n in a fistula rather than in peritonitis is a long-enduring but unproven dogma; drains have been\\n shown to contribute to the dehiscence of a suture line. A policy like “I always drain my\\n colonic anastomoses for 7 days” belongs to the dark ages of surgical practice. Remove\\n drains as soon as they have fulfilled their purpose.\\n\\n Obtain postoperative tests selectively\\n\\n Unnecessary diagnostic procedures or interpretative errors in\\nindicated diagnostic procedures commonly result in false-positive\\nfindings, leading in turn to an increasingly invasive escalation of\\ndiagnostic or therapeutic measures. Added morbidity is the invariable\\nprice. If the results of a test are not going to affect your management,\\ndon’t order the test!',\n", " 'md': '```markdown\\n## Postoperative Care Guidelines\\n\\n### Nasogastric (NG) Tubes\\nPatients who are able to protect their airway from aspiration can safely omit NG tubes in most cases. However, following an emergency abdominal operation, nasogastric decompression is compulsory in:\\n- Mechanically ventilated patients\\n- Obtunded patients\\n- After operations for intestinal obstruction\\n\\nIn all other cases, consider removing the NG tube on the morning after surgery. If in doubt, you may want to cap or clamp the tube for 4-6 hours and observe how this is tolerated by the patient before removing it. A small percentage of patients will need the tube to be reinserted because of persistent ileus or early postoperative small bowel obstruction (see Chapter 45).\\n\\n### Drains\\nDespite the widely publicized dictum that it is impossible to drain the free peritoneal cavity effectively, drains are still commonly used and misused (see Chapters 13 and 39). In addition to the false sense of security and reassurance they provide, drains can erode into the intestine or blood vessels and promote infective complications.\\n\\nWe suggest that you limit the use of drains to:\\n- The evacuation of an established abscess\\n- Allowing escape of potential visceral secretions (e.g., biliary, pancreatic)\\n- Establishing a controlled intestinal fistula when the bowel cannot be exteriorized\\n\\nPassive, open-system drainage offers a bi-directional route for microorganisms and should be avoided. Use only active, closed-system drainage systems, placed away from the viscera. Leaving a drain close to an anastomosis in the belief that a possible leak will result in a fistula rather than in peritonitis is a long-enduring but unproven dogma; drains have been shown to contribute to the dehiscence of a suture line. A policy like “I always drain my colonic anastomoses for 7 days” belongs to the dark ages of surgical practice. Remove drains as soon as they have fulfilled their purpose.\\n\\n### Postoperative Tests\\nObtain postoperative tests selectively. Unnecessary diagnostic procedures or interpretative errors in indicated diagnostic procedures commonly result in false-positive findings, leading in turn to an increasingly invasive escalation of diagnostic or therapeutic measures. Added morbidity is the invariable price. If the results of a test are not going to affect your management, don’t order the test!\\n```',\n", " 'images': [{'name': 'img_p743_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 198,\n", " 'y': 212.39999999999998},\n", " {'name': 'img_p743_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 293.03999999999996,\n", " 'y': 308.88}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Postoperative Care Guidelines',\n", " 'md': '## Postoperative Care Guidelines',\n", " 'bBox': {'x': 79, 'y': 299, 'w': 21.61, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Nasogastric (NG) Tubes',\n", " 'md': '### Nasogastric (NG) Tubes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Patients who are able to protect their airway from aspiration can safely omit NG tubes in most cases. However, following an emergency abdominal operation, nasogastric decompression is compulsory in:\\n- Mechanically ventilated patients\\n- Obtunded patients\\n- After operations for intestinal obstruction\\n\\nIn all other cases, consider removing the NG tube on the morning after surgery. If in doubt, you may want to cap or clamp the tube for 4-6 hours and observe how this is tolerated by the patient before removing it. A small percentage of patients will need the tube to be reinserted because of persistent ileus or early postoperative small bowel obstruction (see Chapter 45).',\n", " 'md': 'Patients who are able to protect their airway from aspiration can safely omit NG tubes in most cases. However, following an emergency abdominal operation, nasogastric decompression is compulsory in:\\n- Mechanically ventilated patients\\n- Obtunded patients\\n- After operations for intestinal obstruction\\n\\nIn all other cases, consider removing the NG tube on the morning after surgery. If in doubt, you may want to cap or clamp the tube for 4-6 hours and observe how this is tolerated by the patient before removing it. A small percentage of patients will need the tube to be reinserted because of persistent ileus or early postoperative small bowel obstruction (see Chapter 45).',\n", " 'bBox': {'x': 79, 'y': 183, 'w': 453.37, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Drains',\n", " 'md': '### Drains',\n", " 'bBox': {'x': 102, 'y': 299, 'w': 43.17, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Despite the widely publicized dictum that it is impossible to drain the free peritoneal cavity effectively, drains are still commonly used and misused (see Chapters 13 and 39). In addition to the false sense of security and reassurance they provide, drains can erode into the intestine or blood vessels and promote infective complications.\\n\\nWe suggest that you limit the use of drains to:\\n- The evacuation of an established abscess\\n- Allowing escape of potential visceral secretions (e.g., biliary, pancreatic)\\n- Establishing a controlled intestinal fistula when the bowel cannot be exteriorized\\n\\nPassive, open-system drainage offers a bi-directional route for microorganisms and should be avoided. Use only active, closed-system drainage systems, placed away from the viscera. Leaving a drain close to an anastomosis in the belief that a possible leak will result in a fistula rather than in peritonitis is a long-enduring but unproven dogma; drains have been shown to contribute to the dehiscence of a suture line. A policy like “I always drain my colonic anastomoses for 7 days” belongs to the dark ages of surgical practice. Remove drains as soon as they have fulfilled their purpose.',\n", " 'md': 'Despite the widely publicized dictum that it is impossible to drain the free peritoneal cavity effectively, drains are still commonly used and misused (see Chapters 13 and 39). In addition to the false sense of security and reassurance they provide, drains can erode into the intestine or blood vessels and promote infective complications.\\n\\nWe suggest that you limit the use of drains to:\\n- The evacuation of an established abscess\\n- Allowing escape of potential visceral secretions (e.g., biliary, pancreatic)\\n- Establishing a controlled intestinal fistula when the bowel cannot be exteriorized\\n\\nPassive, open-system drainage offers a bi-directional route for microorganisms and should be avoided. Use only active, closed-system drainage systems, placed away from the viscera. Leaving a drain close to an anastomosis in the belief that a possible leak will result in a fistula rather than in peritonitis is a long-enduring but unproven dogma; drains have been shown to contribute to the dehiscence of a suture line. A policy like “I always drain my colonic anastomoses for 7 days” belongs to the dark ages of surgical practice. Remove drains as soon as they have fulfilled their purpose.',\n", " 'bBox': {'x': 79, 'y': 299, 'w': 453.61, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Postoperative Tests',\n", " 'md': '### Postoperative Tests',\n", " 'bBox': {'x': 79, 'y': 299, 'w': 13.59, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Obtain postoperative tests selectively. Unnecessary diagnostic procedures or interpretative errors in indicated diagnostic procedures commonly result in false-positive findings, leading in turn to an increasingly invasive escalation of diagnostic or therapeutic measures. Added morbidity is the invariable price. If the results of a test are not going to affect your management, don’t order the test!\\n```',\n", " 'md': 'Obtain postoperative tests selectively. Unnecessary diagnostic procedures or interpretative errors in indicated diagnostic procedures commonly result in false-positive findings, leading in turn to an increasingly invasive escalation of diagnostic or therapeutic measures. Added morbidity is the invariable price. If the results of a test are not going to affect your management, don’t order the test!\\n```',\n", " 'bBox': {'x': 72, 'y': 299, 'w': 466.64, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}, {'text': ''}]},\n", " {'page': 745,\n", " 'text': ' Realize that the problem usually lies at the operative site\\n\\n The cause of fever or a ‘septic state’ in the surgical patient is\\nusually at the primary site of operation unless proven otherwise. Do\\nnot become a ‘surgical ostrich’ by treating your patient for ‘pneumonia’\\nwhile he is slowly sinking in multiple organ failure from an intra-abdominal\\nabscess ( Figure 42.1).\\n\\n Remember: In the postoperative patient everything is related to the operation unless\\n proven otherwise — so your patient is tachypneic after his laparotomy not only due to\\n exacerbation of his COPD, but mainly because you closed his tummy too tight!\\n PeRYADo14\\n Figure 42.1. “Are you a surgical ostrich?”\\n\\n Temperature is not a disease; do not treat it as such\\n\\n Postoperative fever represents the patient’s inflammatory response',\n", " 'md': '```markdown\\n## Page Content\\n\\nRealize that the problem usually lies at the operative site.\\n\\nThe cause of fever or a ‘septic state’ in the surgical patient is usually at the primary site of operation unless proven otherwise. Do not become a ‘surgical ostrich’ by treating your patient for ‘pneumonia’ while he is slowly sinking in multiple organ failure from an intra-abdominal abscess (Figure 42.1).\\n\\nRemember: In the postoperative patient everything is related to the operation unless proven otherwise — so your patient is tachypneic after his laparotomy not only due to exacerbation of his COPD, but mainly because you closed his tummy too tight!\\n\\n### Figure 42.1\\n**Caption:** “Are you a surgical ostrich?”\\n\\n**Description:** This figure likely depicts a metaphorical representation of a \"surgical ostrich,\" illustrating the concept of ignoring the obvious problem at the operative site while focusing on unrelated issues. The image may include visual elements that symbolize denial or oversight in surgical practice.\\n\\n### Additional Notes\\nTemperature is not a disease; do not treat it as such.\\n\\nPostoperative fever represents the patient’s inflammatory response.\\n```',\n", " 'images': [{'name': 'img_p744_1.png',\n", " 'height': 579,\n", " 'width': 803,\n", " 'x': 107.27999999999975,\n", " 'y': 306.71999999999997,\n", " 'original_width': 1380,\n", " 'original_height': 994}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Realize that the problem usually lies at the operative site.\\n\\nThe cause of fever or a ‘septic state’ in the surgical patient is usually at the primary site of operation unless proven otherwise. Do not become a ‘surgical ostrich’ by treating your patient for ‘pneumonia’ while he is slowly sinking in multiple organ failure from an intra-abdominal abscess (Figure 42.1).\\n\\nRemember: In the postoperative patient everything is related to the operation unless proven otherwise — so your patient is tachypneic after his laparotomy not only due to exacerbation of his COPD, but mainly because you closed his tummy too tight!',\n", " 'md': 'Realize that the problem usually lies at the operative site.\\n\\nThe cause of fever or a ‘septic state’ in the surgical patient is usually at the primary site of operation unless proven otherwise. Do not become a ‘surgical ostrich’ by treating your patient for ‘pneumonia’ while he is slowly sinking in multiple organ failure from an intra-abdominal abscess (Figure 42.1).\\n\\nRemember: In the postoperative patient everything is related to the operation unless proven otherwise — so your patient is tachypneic after his laparotomy not only due to exacerbation of his COPD, but mainly because you closed his tummy too tight!',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.72, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 42.1',\n", " 'md': '### Figure 42.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** “Are you a surgical ostrich?”\\n\\n**Description:** This figure likely depicts a metaphorical representation of a \"surgical ostrich,\" illustrating the concept of ignoring the obvious problem at the operative site while focusing on unrelated issues. The image may include visual elements that symbolize denial or oversight in surgical practice.',\n", " 'md': '**Caption:** “Are you a surgical ostrich?”\\n\\n**Description:** This figure likely depicts a metaphorical representation of a \"surgical ostrich,\" illustrating the concept of ignoring the obvious problem at the operative site while focusing on unrelated issues. The image may include visual elements that symbolize denial or oversight in surgical practice.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Additional Notes',\n", " 'md': '### Additional Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Temperature is not a disease; do not treat it as such.\\n\\nPostoperative fever represents the patient’s inflammatory response.\\n```',\n", " 'md': 'Temperature is not a disease; do not treat it as such.\\n\\nPostoperative fever represents the patient’s inflammatory response.\\n```',\n", " 'bBox': {'x': 86, 'y': 668, 'w': 408.86, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 746,\n", " 'text': '(SIRS) to different insults including infection as well as surgical trauma,\\natelectasis, transfusion and others. SIRS does not always mean sepsis\\n(sepsis = SIRS + infection). Therefore, fever should not be treated\\nautomatically with antibiotics. Also, it should not be stifled with\\nantipyretics, as the febrile response has been shown to be\\nbeneficial to the host’s defenses. You will have to argue with your\\nnurses about this. “The patient will be more comfortable, he’ll convulse,\\nwe always give Tylenol®,” they will claim. The absolute level of\\ntemperature is of less importance than its trend and it’s difficult to\\nassess this important sign when you are artificially suppressing it.\\n\\n Fever is not a disease caused by the absence of antibiotics. Ari\\n\\n Fever is, in a measure, a beneficial process operating to\\n protect the economy.\\n Augustus Charles Bernays\\n\\n Avoid poisoning your patient with antibiotics\\n\\n Tailor antibiotic administration to the patient. Avoid the common\\npractice of administering antibiotics for as long as the patient is in the\\nhospital and beyond ( Chapter 44).\\n\\n Be frugal with blood-product transfusions\\n\\n Generally, the amount of blood or derived products transfused\\ninversely and independently correlates with the outcome of the\\nacute surgical disease. Donated blood is immunosuppressive and is\\nassociated with an increased risk of infection, sepsis and organ failure,\\nnot to mention the other well-known hazards. Cancer patients in\\nparticular fare worse in the long term if they receive a transfusion.\\nTransfuse your patient only if absolutely necessary. A patient ‘requiring’\\nonly one unit of blood probably does not require any at all (but if you\\ndecided on giving one unit this is not a free ticket to a second one...). For\\nthe vast majority of patients, a hematocrit of 30% is more than\\nsatisfactory. We would rarely transfuse a postoperative patient with',\n", " 'md': '```markdown\\n## Page Content\\n\\nSIRS (Systemic Inflammatory Response Syndrome) can be triggered by various insults, including infection, surgical trauma, atelectasis, transfusion, and others. It is important to note that SIRS does not always indicate sepsis (where sepsis = SIRS + infection). Therefore, fever should not be treated automatically with antibiotics. Additionally, it should not be suppressed with antipyretics, as the febrile response has been shown to be beneficial to the host’s defenses. This may lead to discussions with nursing staff, who may argue that \"The patient will be more comfortable, he’ll convulse, we always give Tylenol®.\" However, the absolute level of temperature is less important than its trend, and it is difficult to assess this important sign when artificially suppressed.\\n\\nFever is not a disease caused by the absence of antibiotics.\\n\\n> **Ari**\\n> Fever is, in a measure, a beneficial process operating to protect the economy.\\n> **Augustus Charles Bernays**\\n\\n### Recommendations\\n\\n- **Avoid poisoning your patient with antibiotics**\\nTailor antibiotic administration to the patient. Avoid the common practice of administering antibiotics for as long as the patient is in the hospital and beyond (see Chapter 44).\\n\\n- **Be frugal with blood-product transfusions**\\nGenerally, the amount of blood or derived products transfused inversely and independently correlates with the outcome of acute surgical disease. Donated blood is immunosuppressive and is associated with an increased risk of infection, sepsis, and organ failure, not to mention other well-known hazards. Cancer patients, in particular, fare worse in the long term if they receive a transfusion. Transfuse your patient only if absolutely necessary. A patient ‘requiring’ only one unit of blood probably does not require any at all (but if you decide to give one unit, this is not a free ticket to a second one...). For the vast majority of patients, a hematocrit of 30% is more than satisfactory. We would rarely transfuse a postoperative patient with...\\n\\n```',\n", " 'images': [{'name': 'img_p745_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 209.51999999999998,\n", " 'y': 458.64}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'SIRS (Systemic Inflammatory Response Syndrome) can be triggered by various insults, including infection, surgical trauma, atelectasis, transfusion, and others. It is important to note that SIRS does not always indicate sepsis (where sepsis = SIRS + infection). Therefore, fever should not be treated automatically with antibiotics. Additionally, it should not be suppressed with antipyretics, as the febrile response has been shown to be beneficial to the host’s defenses. This may lead to discussions with nursing staff, who may argue that \"The patient will be more comfortable, he’ll convulse, we always give Tylenol®.\" However, the absolute level of temperature is less important than its trend, and it is difficult to assess this important sign when artificially suppressed.\\n\\nFever is not a disease caused by the absence of antibiotics.\\n\\n> **Ari**\\n> Fever is, in a measure, a beneficial process operating to protect the economy.\\n> **Augustus Charles Bernays**',\n", " 'md': 'SIRS (Systemic Inflammatory Response Syndrome) can be triggered by various insults, including infection, surgical trauma, atelectasis, transfusion, and others. It is important to note that SIRS does not always indicate sepsis (where sepsis = SIRS + infection). Therefore, fever should not be treated automatically with antibiotics. Additionally, it should not be suppressed with antipyretics, as the febrile response has been shown to be beneficial to the host’s defenses. This may lead to discussions with nursing staff, who may argue that \"The patient will be more comfortable, he’ll convulse, we always give Tylenol®.\" However, the absolute level of temperature is less important than its trend, and it is difficult to assess this important sign when artificially suppressed.\\n\\nFever is not a disease caused by the absence of antibiotics.\\n\\n> **Ari**\\n> Fever is, in a measure, a beneficial process operating to protect the economy.\\n> **Augustus Charles Bernays**',\n", " 'bBox': {'x': 108, 'y': 333, 'w': 183.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Recommendations',\n", " 'md': '### Recommendations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Avoid poisoning your patient with antibiotics**\\nTailor antibiotic administration to the patient. Avoid the common practice of administering antibiotics for as long as the patient is in the hospital and beyond (see Chapter 44).\\n\\n- **Be frugal with blood-product transfusions**\\nGenerally, the amount of blood or derived products transfused inversely and independently correlates with the outcome of acute surgical disease. Donated blood is immunosuppressive and is associated with an increased risk of infection, sepsis, and organ failure, not to mention other well-known hazards. Cancer patients, in particular, fare worse in the long term if they receive a transfusion. Transfuse your patient only if absolutely necessary. A patient ‘requiring’ only one unit of blood probably does not require any at all (but if you decide to give one unit, this is not a free ticket to a second one...). For the vast majority of patients, a hematocrit of 30% is more than satisfactory. We would rarely transfuse a postoperative patient with...\\n\\n```',\n", " 'md': '- **Avoid poisoning your patient with antibiotics**\\nTailor antibiotic administration to the patient. Avoid the common practice of administering antibiotics for as long as the patient is in the hospital and beyond (see Chapter 44).\\n\\n- **Be frugal with blood-product transfusions**\\nGenerally, the amount of blood or derived products transfused inversely and independently correlates with the outcome of acute surgical disease. Donated blood is immunosuppressive and is associated with an increased risk of infection, sepsis, and organ failure, not to mention other well-known hazards. Cancer patients, in particular, fare worse in the long term if they receive a transfusion. Transfuse your patient only if absolutely necessary. A patient ‘requiring’ only one unit of blood probably does not require any at all (but if you decide to give one unit, this is not a free ticket to a second one...). For the vast majority of patients, a hematocrit of 30% is more than satisfactory. We would rarely transfuse a postoperative patient with...\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 400, 'w': 467.9, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 747,\n", " 'text': 'a hemoglobin above 8g/dL unless he is critically ill or suffers from\\nan underlying cardiorespiratory disease. Those at risk of recurrent\\nhemorrhage, from upper GI bleeding, for example, may need a higher\\nbaseline.\\n\\n Do not drown your patient in salty water\\n\\n The current, exaggerated ‘protocols’ of postoperative fluid\\nmanagement provide too much water and salt, resulting in obligatory\\nweight gain and swelling of tissues. And edematous tissues do not\\nfunction well and do not heal well — causing a higher rate of\\nmedical and surgical complications (see Chapter 6). All your patient\\nneeds is enough water to replace insensible losses (500-1000ml) and to\\nprovide for urinary flow of 0.5ml/kg per hour. Additional losses (e.g. NG\\ntube) should be replaced selectively on an ad hoc basis, but carelessly\\nwriting an order for 150ml/hour of saline and going to sleep will result in a\\nswollen patient.\\n\\n According to Tim Fabian: “Patients never die of fluid overload on\\nthe medical service or dehydration on the surgical one.” But the\\nopposite may be true. You need to fine tune the fluid balance in real\\ntime and that means doing it more than once a day… We do not\\nhesitate adding a drop of Lasix® (furosemide) early on, to overcome the\\n‘antidiuretic respose’ typical to the postoperative state — this is especially\\nof value in patients who have been receiving diuretics before the\\noperation. And get rid of the intravenous line as soon as possible!\\n\\n Fluids given intravenously bypass all the defenses set up\\n by the body to protect itself against excess of any\\n constituent, against bacterial entry… they give the patient\\n what the surgeon thinks his tissues need and what they are\\n damned well going to get.\\n William Heneage Ogilvie\\n\\n Do not starve or over-feed your patient\\n\\n Use the enteral route whenever possible ( Chapter 43).',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nA hemoglobin above 8g/dL unless he is critically ill or suffers from an underlying cardiorespiratory disease. Those at risk of recurrent hemorrhage, from upper GI bleeding, for example, may need a higher baseline.\\n\\nDo not drown your patient in salty water\\n\\nThe current, exaggerated ‘protocols’ of postoperative fluid management provide too much water and salt, resulting in obligatory weight gain and swelling of tissues. And edematous tissues do not function well and do not heal well — causing a higher rate of medical and surgical complications (see Chapter 6). All your patient needs is enough water to replace insensible losses (500-1000ml) and to provide for urinary flow of 0.5ml/kg per hour. Additional losses (e.g. NG tube) should be replaced selectively on an ad hoc basis, but carelessly writing an order for 150ml/hour of saline and going to sleep will result in a swollen patient.\\n\\nAccording to Tim Fabian: “Patients never die of fluid overload on the medical service or dehydration on the surgical one.” But the opposite may be true. You need to fine-tune the fluid balance in real time and that means doing it more than once a day… We do not hesitate adding a drop of Lasix® (furosemide) early on, to overcome the ‘antidiuretic response’ typical to the postoperative state — this is especially of value in patients who have been receiving diuretics before the operation. And get rid of the intravenous line as soon as possible!\\n\\nFluids given intravenously bypass all the defenses set up by the body to protect itself against excess of any constituent, against bacterial entry… they give the patient what the surgeon thinks his tissues need and what they are damned well going to get.\\n**William Heneage Ogilvie**\\n\\nDo not starve or over-feed your patient\\n\\nUse the enteral route whenever possible (Chapter 43).\\n\\n## Hyperlinks\\n- Chapter 6\\n- Chapter 43\\n\\n## Image Identification and Description\\n- No images or graphs were identified on this page.\\n\\n## Formulas\\n- No formulas were identified on this page.\\n\\n## Tables\\n- No tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A hemoglobin above 8g/dL unless he is critically ill or suffers from an underlying cardiorespiratory disease. Those at risk of recurrent hemorrhage, from upper GI bleeding, for example, may need a higher baseline.\\n\\nDo not drown your patient in salty water\\n\\nThe current, exaggerated ‘protocols’ of postoperative fluid management provide too much water and salt, resulting in obligatory weight gain and swelling of tissues. And edematous tissues do not function well and do not heal well — causing a higher rate of medical and surgical complications (see Chapter 6). All your patient needs is enough water to replace insensible losses (500-1000ml) and to provide for urinary flow of 0.5ml/kg per hour. Additional losses (e.g. NG tube) should be replaced selectively on an ad hoc basis, but carelessly writing an order for 150ml/hour of saline and going to sleep will result in a swollen patient.\\n\\nAccording to Tim Fabian: “Patients never die of fluid overload on the medical service or dehydration on the surgical one.” But the opposite may be true. You need to fine-tune the fluid balance in real time and that means doing it more than once a day… We do not hesitate adding a drop of Lasix® (furosemide) early on, to overcome the ‘antidiuretic response’ typical to the postoperative state — this is especially of value in patients who have been receiving diuretics before the operation. And get rid of the intravenous line as soon as possible!\\n\\nFluids given intravenously bypass all the defenses set up by the body to protect itself against excess of any constituent, against bacterial entry… they give the patient what the surgeon thinks his tissues need and what they are damned well going to get.\\n**William Heneage Ogilvie**\\n\\nDo not starve or over-feed your patient\\n\\nUse the enteral route whenever possible (Chapter 43).',\n", " 'md': 'A hemoglobin above 8g/dL unless he is critically ill or suffers from an underlying cardiorespiratory disease. Those at risk of recurrent hemorrhage, from upper GI bleeding, for example, may need a higher baseline.\\n\\nDo not drown your patient in salty water\\n\\nThe current, exaggerated ‘protocols’ of postoperative fluid management provide too much water and salt, resulting in obligatory weight gain and swelling of tissues. And edematous tissues do not function well and do not heal well — causing a higher rate of medical and surgical complications (see Chapter 6). All your patient needs is enough water to replace insensible losses (500-1000ml) and to provide for urinary flow of 0.5ml/kg per hour. Additional losses (e.g. NG tube) should be replaced selectively on an ad hoc basis, but carelessly writing an order for 150ml/hour of saline and going to sleep will result in a swollen patient.\\n\\nAccording to Tim Fabian: “Patients never die of fluid overload on the medical service or dehydration on the surgical one.” But the opposite may be true. You need to fine-tune the fluid balance in real time and that means doing it more than once a day… We do not hesitate adding a drop of Lasix® (furosemide) early on, to overcome the ‘antidiuretic response’ typical to the postoperative state — this is especially of value in patients who have been receiving diuretics before the operation. And get rid of the intravenous line as soon as possible!\\n\\nFluids given intravenously bypass all the defenses set up by the body to protect itself against excess of any constituent, against bacterial entry… they give the patient what the surgeon thinks his tissues need and what they are damned well going to get.\\n**William Heneage Ogilvie**\\n\\nDo not starve or over-feed your patient\\n\\nUse the enteral route whenever possible (Chapter 43).',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.97, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Hyperlinks',\n", " 'md': '## Hyperlinks',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Chapter 6\\n- Chapter 43',\n", " 'md': '- Chapter 6\\n- Chapter 43',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formulas',\n", " 'md': '## Formulas',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No formulas were identified on this page.',\n", " 'md': '- No formulas were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No tables were identified on this page.\\n```',\n", " 'md': '- No tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'needs is enough water to replace insensible losses (500-1000ml) and to'},\n", " {'text': ''}]},\n", " {'page': 748,\n", " 'text': ' Please do not torture your patient with the useless and baseless ritual\\nof slowly increasing the permitted consumption of oral fluids from 30ml\\nhourly to 60ml, then 90ml, and so on over several days.\\n\\n Ari’s rule: Keep the enterocytes happy, start oral feeding on day 1, let the patient decide how\\n much he wants to drink/eat, and stop only if the patient vomits. Ari\\n\\n Recognize and treat postoperative intra-abdominal\\n hypertension\\n\\n This is so important that we have dedicated an entire chapter to it.\\nPlease see Chapter 33 — “Abdominal compartment syndrome”. Don’t\\nbe lazy!\\n\\n Prevent deep vein thrombosis (DVT) and pulmonary\\n embolism\\n\\n It is easy to forget DVT prophylaxis in the pre-operative chaos of\\nemergency surgery. As a pilot goes over a checklist prior to any flight —\\nyou should be the one to inject the subcutaneous heparin and place the\\nanti-DVT pneumatic device — before the operation. DVT prophylaxis\\nshould be continued postoperatively as long as the patient continues to\\nbe at high risk of thrombosis. Selected patients (e.g. after operations\\nfor cancer) may need to continue DVT prophylaxis at home.\\n Do remember, however, that anticoagulation is not good for patients at risk of bleeding to death.\\n Paul\\n\\n Be the leader and take responsibility\\n\\n Many people tend to dance around your postoperative patient, giving\\nconsults and advice. But remember, this is not their patient; he or she is\\nyours. At the Mortality and Morbidity meeting (or in court), the others will\\nsay “I just gave a consult — it was his patient…” ( Chapter 50). The\\nultimate responsibility for all aspects of your patient’s management',\n", " 'md': '```markdown\\n## Page Content\\n\\nPlease do not torture your patient with the useless and baseless ritual of slowly increasing the permitted consumption of oral fluids from 30ml hourly to 60ml, then 90ml, and so on over several days.\\n\\n**Ari’s rule:** Keep the enterocytes happy, start oral feeding on day 1, let the patient decide how much he wants to drink/eat, and stop only if the patient vomits.\\n\\nRecognize and treat postoperative intra-abdominal hypertension\\n\\nThis is so important that we have dedicated an entire chapter to it. Please see Chapter 33 — “Abdominal compartment syndrome”. Don’t be lazy!\\n\\nPrevent deep vein thrombosis (DVT) and pulmonary embolism\\n\\nIt is easy to forget DVT prophylaxis in the pre-operative chaos of emergency surgery. As a pilot goes over a checklist prior to any flight — you should be the one to inject the subcutaneous heparin and place the anti-DVT pneumatic device — before the operation. DVT prophylaxis should be continued postoperatively as long as the patient continues to be at high risk of thrombosis. Selected patients (e.g. after operations for cancer) may need to continue DVT prophylaxis at home. Do remember, however, that anticoagulation is not good for patients at risk of bleeding to death.\\n\\n**Paul**\\n\\nBe the leader and take responsibility\\n\\nMany people tend to dance around your postoperative patient, giving consults and advice. But remember, this is not their patient; he or she is yours. At the Mortality and Morbidity meeting (or in court), the others will say “I just gave a consult — it was his patient…” (Chapter 50). The ultimate responsibility for all aspects of your patient’s management.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Please do not torture your patient with the useless and baseless ritual of slowly increasing the permitted consumption of oral fluids from 30ml hourly to 60ml, then 90ml, and so on over several days.\\n\\n**Ari’s rule:** Keep the enterocytes happy, start oral feeding on day 1, let the patient decide how much he wants to drink/eat, and stop only if the patient vomits.\\n\\nRecognize and treat postoperative intra-abdominal hypertension\\n\\nThis is so important that we have dedicated an entire chapter to it. Please see Chapter 33 — “Abdominal compartment syndrome”. Don’t be lazy!\\n\\nPrevent deep vein thrombosis (DVT) and pulmonary embolism\\n\\nIt is easy to forget DVT prophylaxis in the pre-operative chaos of emergency surgery. As a pilot goes over a checklist prior to any flight — you should be the one to inject the subcutaneous heparin and place the anti-DVT pneumatic device — before the operation. DVT prophylaxis should be continued postoperatively as long as the patient continues to be at high risk of thrombosis. Selected patients (e.g. after operations for cancer) may need to continue DVT prophylaxis at home. Do remember, however, that anticoagulation is not good for patients at risk of bleeding to death.\\n\\n**Paul**\\n\\nBe the leader and take responsibility\\n\\nMany people tend to dance around your postoperative patient, giving consults and advice. But remember, this is not their patient; he or she is yours. At the Mortality and Morbidity meeting (or in court), the others will say “I just gave a consult — it was his patient…” (Chapter 50). The ultimate responsibility for all aspects of your patient’s management.\\n```',\n", " 'md': 'Please do not torture your patient with the useless and baseless ritual of slowly increasing the permitted consumption of oral fluids from 30ml hourly to 60ml, then 90ml, and so on over several days.\\n\\n**Ari’s rule:** Keep the enterocytes happy, start oral feeding on day 1, let the patient decide how much he wants to drink/eat, and stop only if the patient vomits.\\n\\nRecognize and treat postoperative intra-abdominal hypertension\\n\\nThis is so important that we have dedicated an entire chapter to it. Please see Chapter 33 — “Abdominal compartment syndrome”. Don’t be lazy!\\n\\nPrevent deep vein thrombosis (DVT) and pulmonary embolism\\n\\nIt is easy to forget DVT prophylaxis in the pre-operative chaos of emergency surgery. As a pilot goes over a checklist prior to any flight — you should be the one to inject the subcutaneous heparin and place the anti-DVT pneumatic device — before the operation. DVT prophylaxis should be continued postoperatively as long as the patient continues to be at high risk of thrombosis. Selected patients (e.g. after operations for cancer) may need to continue DVT prophylaxis at home. Do remember, however, that anticoagulation is not good for patients at risk of bleeding to death.\\n\\n**Paul**\\n\\nBe the leader and take responsibility\\n\\nMany people tend to dance around your postoperative patient, giving consults and advice. But remember, this is not their patient; he or she is yours. At the Mortality and Morbidity meeting (or in court), the others will say “I just gave a consult — it was his patient…” (Chapter 50). The ultimate responsibility for all aspects of your patient’s management.\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.97, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'bBox': {'x': 187, 'y': 230, 'w': 29.43, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'ultimate responsibility for all aspects of your patient’s management'}]},\n", " {'page': 749,\n", " 'text': 'falls squarely on your shoulders.\\n 31\\n DzerAY/\\nFigure 42.2. “Who is missing, guys? Where is the podiatrist?”\\n\\n Know when you need help and request it, preferably from one of your\\nmentors. As Francis D. Moore said: “Seek consultation even if it is not\\nsure to help; never be a lone wolf.” But solicit advice judiciously and\\napply it selectively. Relinquishing blindly the care of your\\npostoperative patient to anesthetists, medical intensivists,\\nhospitalists, or other modern ‘experts’ may be a recipe for disaster\\n— oh, how common it is and how often we have had to relearn this\\nmessage from sad experience. It is much better in this era to form\\nclose working relationships with colleagues who share your philosophy of\\ncare and who have expertise in areas beyond your own. We all need help\\nwith patients suffering multi-system failure; while we can take care of the\\nabdominal problem we do need assistance and advice to manage\\ncardiac, respiratory and renal failure appropriately. As Mark M. Ravitch\\nsaid: “The problem with calling in a consultant is that you may feel\\nobliged to take his advice” ( Figure 42.2).\\n\\n If the consultant gives an answer you disagree with, change the consultant. Ari',\n", " 'md': '```markdown\\n## Page Content\\n\\nKnow when you need help and request it, preferably from one of your mentors. As Francis D. Moore said: “Seek consultation even if it is not sure to help; never be a lone wolf.” But solicit advice judiciously and apply it selectively. Relinquishing blindly the care of your postoperative patient to anesthetists, medical intensivists, hospitalists, or other modern ‘experts’ may be a recipe for disaster — oh, how common it is and how often we have had to relearn this message from sad experience. It is much better in this era to form close working relationships with colleagues who share your philosophy of care and who have expertise in areas beyond your own. We all need help with patients suffering multi-system failure; while we can take care of the abdominal problem we do need assistance and advice to manage cardiac, respiratory and renal failure appropriately. As Mark M. Ravitch said: “The problem with calling in a consultant is that you may feel obliged to take his advice” (Figure 42.2).\\n\\nIf the consultant gives an answer you disagree with, change the consultant.\\n\\n## Images\\n\\n### Figure 42.2\\n- **Description**: The image depicts a humorous cartoon or illustration with the caption “Who is missing, guys? Where is the podiatrist?” It likely portrays a scenario in a medical or clinical setting where the absence of a podiatrist is noted, emphasizing the importance of having all necessary specialists available in patient care.\\n- **Summary**: This figure highlights the necessity of having a complete team of specialists in medical practice, particularly in situations where multi-system failures are present.\\n\\n```',\n", " 'images': [{'name': 'img_p748_1.png',\n", " 'height': 547,\n", " 'width': 809,\n", " 'x': 105.84000000000015,\n", " 'y': 99.36000000000001,\n", " 'original_width': 1389,\n", " 'original_height': 940}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Know when you need help and request it, preferably from one of your mentors. As Francis D. Moore said: “Seek consultation even if it is not sure to help; never be a lone wolf.” But solicit advice judiciously and apply it selectively. Relinquishing blindly the care of your postoperative patient to anesthetists, medical intensivists, hospitalists, or other modern ‘experts’ may be a recipe for disaster — oh, how common it is and how often we have had to relearn this message from sad experience. It is much better in this era to form close working relationships with colleagues who share your philosophy of care and who have expertise in areas beyond your own. We all need help with patients suffering multi-system failure; while we can take care of the abdominal problem we do need assistance and advice to manage cardiac, respiratory and renal failure appropriately. As Mark M. Ravitch said: “The problem with calling in a consultant is that you may feel obliged to take his advice” (Figure 42.2).\\n\\nIf the consultant gives an answer you disagree with, change the consultant.',\n", " 'md': 'Know when you need help and request it, preferably from one of your mentors. As Francis D. Moore said: “Seek consultation even if it is not sure to help; never be a lone wolf.” But solicit advice judiciously and apply it selectively. Relinquishing blindly the care of your postoperative patient to anesthetists, medical intensivists, hospitalists, or other modern ‘experts’ may be a recipe for disaster — oh, how common it is and how often we have had to relearn this message from sad experience. It is much better in this era to form close working relationships with colleagues who share your philosophy of care and who have expertise in areas beyond your own. We all need help with patients suffering multi-system failure; while we can take care of the abdominal problem we do need assistance and advice to manage cardiac, respiratory and renal failure appropriately. As Mark M. Ravitch said: “The problem with calling in a consultant is that you may feel obliged to take his advice” (Figure 42.2).\\n\\nIf the consultant gives an answer you disagree with, change the consultant.',\n", " 'bBox': {'x': 72, 'y': 437, 'w': 467.89, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 42.2',\n", " 'md': '### Figure 42.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: The image depicts a humorous cartoon or illustration with the caption “Who is missing, guys? Where is the podiatrist?” It likely portrays a scenario in a medical or clinical setting where the absence of a podiatrist is noted, emphasizing the importance of having all necessary specialists available in patient care.\\n- **Summary**: This figure highlights the necessity of having a complete team of specialists in medical practice, particularly in situations where multi-system failures are present.\\n\\n```',\n", " 'md': '- **Description**: The image depicts a humorous cartoon or illustration with the caption “Who is missing, guys? Where is the podiatrist?” It likely portrays a scenario in a medical or clinical setting where the absence of a podiatrist is noted, emphasizing the importance of having all necessary specialists available in patient care.\\n- **Summary**: This figure highlights the necessity of having a complete team of specialists in medical practice, particularly in situations where multi-system failures are present.\\n\\n```',\n", " 'bBox': {'x': 121, 'y': 486, 'w': 57.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 750,\n", " 'text': ' Analyze your care\\n\\n When all is said and done, step back and assess your management.\\nAsk yourself “What did I do well?”, “What could I do better the next time\\nI’m confronted with a situation like this?” ħow else will you get any\\nbetter?\\n\\n Oops, what about ERAS (enhanced recovery after surgery), you\\nmay ask — why didn’t they mention this catchphrase? Well, despite the\\never growing number of guidelines and protocols, and abstracts and\\npublications, there is nothing new here. It is all ‘common sense’ and\\ndiscussed above and depicted in Figure 42.3.\\n\\n We do, however, welcome the ERAS surgeons to the world of ‘modern’ surgery, which we have\\n inhabited for some time, albeit without the fancy acronym. Paul\\n EvhANCEd RecoveRy Arter Surgery( ERAS)|\\n ReRA214\\n Figure 42.3. A surgeon to a visiting professor: “Sir, we have implemented an ERAS\\n protocol.”',\n", " 'md': '```markdown\\n# Analyze Your Care\\n\\nWhen all is said and done, step back and assess your management. Ask yourself “What did I do well?”, “What could I do better the next time I’m confronted with a situation like this?” How else will you get any better?\\n\\nOops, what about ERAS (enhanced recovery after surgery), you may ask — why didn’t they mention this catchphrase? Well, despite the ever-growing number of guidelines and protocols, and abstracts and publications, there is nothing new here. It is all ‘common sense’ and discussed above and depicted in **Figure 42.3**.\\n\\nWe do, however, welcome the ERAS surgeons to the world of ‘modern’ surgery, which we have inhabited for some time, albeit without the fancy acronym. Paul EvhANCEd RecoveRy Arter Surgery (ERAS).\\n\\n## Figure 42.3\\nA surgeon to a visiting professor: “Sir, we have implemented an ERAS protocol.”\\n```\\n\\n### Image Description\\n- **Figure 42.3**: This image likely depicts a conversation between a surgeon and a visiting professor regarding the implementation of an ERAS protocol. The context suggests a modern surgical environment where enhanced recovery protocols are being discussed. The image may include visual elements that represent the surgical setting or the interaction between the two individuals, but specific details are not provided in the text.\\n\\n### Summary\\nThe text emphasizes the importance of self-assessment in surgical management and introduces the concept of ERAS, highlighting its common-sense approach despite the lack of new guidelines. The figure illustrates a practical application of these principles in a surgical context.',\n", " 'images': [{'name': 'img_p749_1.png',\n", " 'height': 582,\n", " 'width': 819,\n", " 'x': 103.67999999999938,\n", " 'y': 382.31999999999994,\n", " 'original_width': 1407,\n", " 'original_height': 1000}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Analyze Your Care',\n", " 'md': '# Analyze Your Care',\n", " 'bBox': {'x': 86, 'y': 113, 'w': 141.64, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'When all is said and done, step back and assess your management. Ask yourself “What did I do well?”, “What could I do better the next time I’m confronted with a situation like this?” How else will you get any better?\\n\\nOops, what about ERAS (enhanced recovery after surgery), you may ask — why didn’t they mention this catchphrase? Well, despite the ever-growing number of guidelines and protocols, and abstracts and publications, there is nothing new here. It is all ‘common sense’ and discussed above and depicted in **Figure 42.3**.\\n\\nWe do, however, welcome the ERAS surgeons to the world of ‘modern’ surgery, which we have inhabited for some time, albeit without the fancy acronym. Paul EvhANCEd RecoveRy Arter Surgery (ERAS).',\n", " 'md': 'When all is said and done, step back and assess your management. Ask yourself “What did I do well?”, “What could I do better the next time I’m confronted with a situation like this?” How else will you get any better?\\n\\nOops, what about ERAS (enhanced recovery after surgery), you may ask — why didn’t they mention this catchphrase? Well, despite the ever-growing number of guidelines and protocols, and abstracts and publications, there is nothing new here. It is all ‘common sense’ and discussed above and depicted in **Figure 42.3**.\\n\\nWe do, however, welcome the ERAS surgeons to the world of ‘modern’ surgery, which we have inhabited for some time, albeit without the fancy acronym. Paul EvhANCEd RecoveRy Arter Surgery (ERAS).',\n", " 'bBox': {'x': 72, 'y': 165, 'w': 467.72, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 42.3',\n", " 'md': '## Figure 42.3',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A surgeon to a visiting professor: “Sir, we have implemented an ERAS protocol.”\\n```',\n", " 'md': 'A surgeon to a visiting professor: “Sir, we have implemented an ERAS protocol.”\\n```',\n", " 'bBox': {'x': 75, 'y': 702, 'w': 51.54, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 42.3**: This image likely depicts a conversation between a surgeon and a visiting professor regarding the implementation of an ERAS protocol. The context suggests a modern surgical environment where enhanced recovery protocols are being discussed. The image may include visual elements that represent the surgical setting or the interaction between the two individuals, but specific details are not provided in the text.',\n", " 'md': '- **Figure 42.3**: This image likely depicts a conversation between a surgeon and a visiting professor regarding the implementation of an ERAS protocol. The context suggests a modern surgical environment where enhanced recovery protocols are being discussed. The image may include visual elements that represent the surgical setting or the interaction between the two individuals, but specific details are not provided in the text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text emphasizes the importance of self-assessment in surgical management and introduces the concept of ERAS, highlighting its common-sense approach despite the lack of new guidelines. The figure illustrates a practical application of these principles in a surgical context.',\n", " 'md': 'The text emphasizes the importance of self-assessment in surgical management and introduces the concept of ERAS, highlighting its common-sense approach despite the lack of new guidelines. The figure illustrates a practical application of these principles in a surgical context.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 751,\n", " 'text': '“The operation is over when the patient is eating a\\ncheeseburger and can’t remember your name.”\\n Leo A. Gordon\\n“Big surgeons are those who are not too big to deal with\\nthe small things!”',\n", " 'md': '```markdown\\n### Text\\n“The operation is over when the patient is eating a cheeseburger and can’t remember your name.”\\n— Leo A. Gordon\\n\\n“Big surgeons are those who are not too big to deal with the small things!”\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '“The operation is over when the patient is eating a cheeseburger and can’t remember your name.”\\n— Leo A. Gordon\\n\\n“Big surgeons are those who are not too big to deal with the small things!”\\n```',\n", " 'md': '“The operation is over when the patient is eating a cheeseburger and can’t remember your name.”\\n— Leo A. Gordon\\n\\n“Big surgeons are those who are not too big to deal with the small things!”\\n```',\n", " 'bBox': {'x': 79, 'y': 95, 'w': 453.21, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 752,\n", " 'text': 'Chapter 43\\nNutrition\\nJames C. Rucinski\\n\\n In every disease it is a good sign when the patient’s intellect\\n is sound, and he is disposed to take whatever food is\\n offered to him; but the contrary is bad.\\n Hippocrates\\n\\n God created man with a mouth, a stomach and gut — not a\\n TPN line.\\n\\n The relatively brief interval available to you to prepare an\\nemergency abdominal patient for an operation does not allow for\\nnutritional considerations. This issue, therefore, is addressed only\\nduring and after the operation. Towards the end of the laparotomy you\\nshould ponder whether there is a need to provide enteral access to\\nfacilitate postoperative feeding. After the operation the issues to think\\nabout are how early, and by which route, the patient should be fed.\\n\\n Starvation\\n\\n Starvation results in a state of adaptation. After hepatic glycogen\\nstores are consumed in 24-48 hours, the liver synthesizes glucose, using\\namino acids derived from protein breakdown. This ‘auto-cannibalization’\\nof functional protein stores is ameliorated, to some degree, by conversion\\nto ketone metabolism of the two major ‘obligate’ glucose users: the\\ncentral nervous system and the kidney. Fat stores help by providing',\n", " 'md': '```markdown\\n# Chapter 43: Nutrition\\n**Author:** James C. Rucinski\\n\\n> \"In every disease it is a good sign when the patient’s intellect is sound, and he is disposed to take whatever food is offered to him; but the contrary is bad.\"\\n> — Hippocrates\\n\\n> \"God created man with a mouth, a stomach and gut — not a TPN line.\"\\n\\nThe relatively brief interval available to you to prepare an emergency abdominal patient for an operation does not allow for nutritional considerations. This issue, therefore, is addressed only during and after the operation. Towards the end of the laparotomy, you should ponder whether there is a need to provide enteral access to facilitate postoperative feeding. After the operation, the issues to think about are how early, and by which route, the patient should be fed.\\n\\n## Starvation\\n\\nStarvation results in a state of adaptation. After hepatic glycogen stores are consumed in 24-48 hours, the liver synthesizes glucose, using amino acids derived from protein breakdown. This ‘auto-cannibalization’ of functional protein stores is ameliorated, to some degree, by conversion to ketone metabolism of the two major ‘obligate’ glucose users: the central nervous system and the kidney. Fat stores help by providing...\\n```\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the provided content. If there are any images or additional elements on the page, please provide that information for further extraction.*',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 43: Nutrition',\n", " 'md': '# Chapter 43: Nutrition',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 148.79, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** James C. Rucinski\\n\\n> \"In every disease it is a good sign when the patient’s intellect is sound, and he is disposed to take whatever food is offered to him; but the contrary is bad.\"\\n> — Hippocrates\\n\\n> \"God created man with a mouth, a stomach and gut — not a TPN line.\"\\n\\nThe relatively brief interval available to you to prepare an emergency abdominal patient for an operation does not allow for nutritional considerations. This issue, therefore, is addressed only during and after the operation. Towards the end of the laparotomy, you should ponder whether there is a need to provide enteral access to facilitate postoperative feeding. After the operation, the issues to think about are how early, and by which route, the patient should be fed.',\n", " 'md': '**Author:** James C. Rucinski\\n\\n> \"In every disease it is a good sign when the patient’s intellect is sound, and he is disposed to take whatever food is offered to him; but the contrary is bad.\"\\n> — Hippocrates\\n\\n> \"God created man with a mouth, a stomach and gut — not a TPN line.\"\\n\\nThe relatively brief interval available to you to prepare an emergency abdominal patient for an operation does not allow for nutritional considerations. This issue, therefore, is addressed only during and after the operation. Towards the end of the laparotomy, you should ponder whether there is a need to provide enteral access to facilitate postoperative feeding. After the operation, the issues to think about are how early, and by which route, the patient should be fed.',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 423.52, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Starvation',\n", " 'md': '## Starvation',\n", " 'bBox': {'x': 86, 'y': 592, 'w': 80.93, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Starvation results in a state of adaptation. After hepatic glycogen stores are consumed in 24-48 hours, the liver synthesizes glucose, using amino acids derived from protein breakdown. This ‘auto-cannibalization’ of functional protein stores is ameliorated, to some degree, by conversion to ketone metabolism of the two major ‘obligate’ glucose users: the central nervous system and the kidney. Fat stores help by providing...\\n```\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the provided content. If there are any images or additional elements on the page, please provide that information for further extraction.*',\n", " 'md': 'Starvation results in a state of adaptation. After hepatic glycogen stores are consumed in 24-48 hours, the liver synthesizes glucose, using amino acids derived from protein breakdown. This ‘auto-cannibalization’ of functional protein stores is ameliorated, to some degree, by conversion to ketone metabolism of the two major ‘obligate’ glucose users: the central nervous system and the kidney. Fat stores help by providing...\\n```\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the provided content. If there are any images or additional elements on the page, please provide that information for further extraction.*',\n", " 'bBox': {'x': 72, 'y': 592, 'w': 467.68, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 753,\n", " 'text': 'ketones and, through glycerol metabolism, adding a small amount of\\nglucose. Injury, illness or operation greatly increases the demand for\\nglucose to answer the hyper-metabolic demands made by SIRS and\\nto provide energy for wound repair and for the bone marrow and its\\noffspring, the leukocytes. The end result is the breakdown of\\nprotein leading to a general debility, impaired reparative processes,\\nattenuated immune function and respiratory muscle weakness that\\nin turn may cause atelectasis, pneumonia, ventilator-dependence\\nand death.\\n\\n The need for nutritional support is based on:\\n\\n Your physical and laboratory assessment of the patient’s nutritional reserves.\\n An estimate of the associated stress of the underlying illness.\\n An estimate of the time interval that will pass before the patient can resume a\\n normal diet.\\n\\n Assessment of need for nutritional support\\n\\n You must ask patients how long they have felt sick and how much\\nweight they have lost, if any, in the weeks prior to the operation. You must\\nalso ask when they last ate. By looking at the person you can estimate\\nwhat their ideal weight might be and make a ‘guesstimate’ regarding the\\npercentage that has been lost. (Your rule of thumb standard is the fabled\\n‘70kg man’.) A loss of more than 10% is associated with a higher rate\\nof complications and death after abdominal surgery. This will give\\nyou the first two pieces of information necessary for decision-making:\\n\\n • Percentage weight loss and available reserves.\\n • Time since normal feeding was stopped.\\n Serum albumin level reflects the balance of synthesis and\\ndegradation of one of the products of hepatic metabolism. In the\\nemergency setting, the albumin level and total lymphocyte count will be',\n", " 'md': '```markdown\\n## Nutritional Support Assessment\\n\\nKetones and, through glycerol metabolism, adding a small amount of glucose. Injury, illness, or operation greatly increases the demand for glucose to answer the hyper-metabolic demands made by SIRS and to provide energy for wound repair and for the bone marrow and its offspring, the leukocytes. The end result is the breakdown of protein leading to a general debility, impaired reparative processes, attenuated immune function, and respiratory muscle weakness that in turn may cause atelectasis, pneumonia, ventilator-dependence, and death.\\n\\nThe need for nutritional support is based on:\\n\\n- Your physical and laboratory assessment of the patient’s nutritional reserves.\\n- An estimate of the associated stress of the underlying illness.\\n- An estimate of the time interval that will pass before the patient can resume a normal diet.\\n\\n### Assessment of Need for Nutritional Support\\n\\nYou must ask patients how long they have felt sick and how much weight they have lost, if any, in the weeks prior to the operation. You must also ask when they last ate. By looking at the person you can estimate what their ideal weight might be and make a ‘guesstimate’ regarding the percentage that has been lost. (Your rule of thumb standard is the fabled ‘70kg man’.) A loss of more than 10% is associated with a higher rate of complications and death after abdominal surgery. This will give you the first two pieces of information necessary for decision-making:\\n\\n- Percentage weight loss and available reserves.\\n- Time since normal feeding was stopped.\\n\\nSerum albumin level reflects the balance of synthesis and degradation of one of the products of hepatic metabolism. In the emergency setting, the albumin level and total lymphocyte count will be .\\n```',\n", " 'images': [{'name': 'img_p752_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999997,\n", " 'y': 285.84},\n", " {'name': 'img_p752_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999997,\n", " 'y': 307.44},\n", " {'name': 'img_p752_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999997,\n", " 'y': 329.03999999999996}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Nutritional Support Assessment',\n", " 'md': '## Nutritional Support Assessment',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Ketones and, through glycerol metabolism, adding a small amount of glucose. Injury, illness, or operation greatly increases the demand for glucose to answer the hyper-metabolic demands made by SIRS and to provide energy for wound repair and for the bone marrow and its offspring, the leukocytes. The end result is the breakdown of protein leading to a general debility, impaired reparative processes, attenuated immune function, and respiratory muscle weakness that in turn may cause atelectasis, pneumonia, ventilator-dependence, and death.\\n\\nThe need for nutritional support is based on:\\n\\n- Your physical and laboratory assessment of the patient’s nutritional reserves.\\n- An estimate of the associated stress of the underlying illness.\\n- An estimate of the time interval that will pass before the patient can resume a normal diet.',\n", " 'md': 'Ketones and, through glycerol metabolism, adding a small amount of glucose. Injury, illness, or operation greatly increases the demand for glucose to answer the hyper-metabolic demands made by SIRS and to provide energy for wound repair and for the bone marrow and its offspring, the leukocytes. The end result is the breakdown of protein leading to a general debility, impaired reparative processes, attenuated immune function, and respiratory muscle weakness that in turn may cause atelectasis, pneumonia, ventilator-dependence, and death.\\n\\nThe need for nutritional support is based on:\\n\\n- Your physical and laboratory assessment of the patient’s nutritional reserves.\\n- An estimate of the associated stress of the underlying illness.\\n- An estimate of the time interval that will pass before the patient can resume a normal diet.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Assessment of Need for Nutritional Support',\n", " 'md': '### Assessment of Need for Nutritional Support',\n", " 'bBox': {'x': 86, 'y': 414, 'w': 339.28, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'You must ask patients how long they have felt sick and how much weight they have lost, if any, in the weeks prior to the operation. You must also ask when they last ate. By looking at the person you can estimate what their ideal weight might be and make a ‘guesstimate’ regarding the percentage that has been lost. (Your rule of thumb standard is the fabled ‘70kg man’.) A loss of more than 10% is associated with a higher rate of complications and death after abdominal surgery. This will give you the first two pieces of information necessary for decision-making:\\n\\n- Percentage weight loss and available reserves.\\n- Time since normal feeding was stopped.\\n\\nSerum albumin level reflects the balance of synthesis and degradation of one of the products of hepatic metabolism. In the emergency setting, the albumin level and total lymphocyte count will be .\\n```',\n", " 'md': 'You must ask patients how long they have felt sick and how much weight they have lost, if any, in the weeks prior to the operation. You must also ask when they last ate. By looking at the person you can estimate what their ideal weight might be and make a ‘guesstimate’ regarding the percentage that has been lost. (Your rule of thumb standard is the fabled ‘70kg man’.) A loss of more than 10% is associated with a higher rate of complications and death after abdominal surgery. This will give you the first two pieces of information necessary for decision-making:\\n\\n- Percentage weight loss and available reserves.\\n- Time since normal feeding was stopped.\\n\\nSerum albumin level reflects the balance of synthesis and degradation of one of the products of hepatic metabolism. In the emergency setting, the albumin level and total lymphocyte count will be .\\n```',\n", " 'bBox': {'x': 72, 'y': 467, 'w': 467.75, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 754,\n", " 'text': 'the only obtainable laboratory parameters for you to estimate available\\nreserves. A serum albumin level of <3mg/dL and a total lymphocyte\\ncount <1500 cells/ml are associated with a higher morbidity and\\nmortality.\\n\\n The associated stress of illness may be roughly estimated as minor,\\nmoderate or major. It is better, though, to characterize stress by the use\\nof a physiologic scoring system that measures the severity of the acute\\nillness — such as the APACħE II 1 system ( Chapter 6). An increased\\nlevel of stress is associated with a higher rate of protein breakdown,\\nas well as complications and death.\\n\\n The third piece of information necessary for decision-making is the\\ntime interval that will pass before the patient can resume a normal\\ndiet. This estimate is based on the nature of the primary illness and the\\ntype of operation that is required or has been performed. For example, a\\nperson with ‘simple’ acute appendicitis will experience cessation of\\nnormal feeding for a period of 24-72 hours; a person with perforated\\ndiverticulitis and generalized peritonitis may experience cessation of\\nfeeding for a period of perhaps 5-7 days. But patients who develop\\ncomplications, such as an anastomotic leak or ileus may be deprived of\\nnormal oral food intake for as long as 10-14 days — or even longer. With\\nthe above information you can decide which patients will be most\\nlikely to benefit from nutritional support:\\n\\n • At one end of the spectrum, the patient with normal reserves by\\n history and examination, with minimal to moderate associated\\n stress, and with less than 7-10 days estimated before resumption of\\n a normal diet, is unlikely to benefit from nutritional support.\\n • At the other end of the spectrum, the patient with depleted available\\n reserves, moderate to severe stress, and with more than 7-10 days\\n estimated before resumption of a normal diet, is likely to benefit\\n from nutritional support.\\n\\n Enteral versus parenteral nutrition\\n\\n Nutritional support may be provided by enteral (through the alimentary',\n", " 'md': '```markdown\\n## Nutritional Support in Illness\\n\\nThe only obtainable laboratory parameters for you to estimate available reserves are:\\n- A serum albumin level of <3 mg/dL\\n- A total lymphocyte count <1500 cells/ml\\n\\nThese parameters are associated with a higher morbidity and mortality.\\n\\nThe associated stress of illness may be roughly estimated as minor, moderate, or major. It is better, though, to characterize stress by the use of a physiologic scoring system that measures the severity of the acute illness — such as the APACHE II system (Chapter 6). An increased level of stress is associated with a higher rate of protein breakdown, as well as complications and death.\\n\\nThe third piece of information necessary for decision-making is the time interval that will pass before the patient can resume a normal diet. This estimate is based on the nature of the primary illness and the type of operation that is required or has been performed. For example:\\n- A person with ‘simple’ acute appendicitis will experience cessation of normal feeding for a period of 24-72 hours.\\n- A person with perforated diverticulitis and generalized peritonitis may experience cessation of feeding for a period of perhaps 5-7 days.\\n- Patients who develop complications, such as an anastomotic leak or ileus, may be deprived of normal oral food intake for as long as 10-14 days — or even longer.\\n\\nWith the above information, you can decide which patients will be most likely to benefit from nutritional support:\\n\\n- At one end of the spectrum, the patient with normal reserves by history and examination, with minimal to moderate associated stress, and with less than 7-10 days estimated before resumption of a normal diet, is unlikely to benefit from nutritional support.\\n- At the other end of the spectrum, the patient with depleted available reserves, moderate to severe stress, and with more than 7-10 days estimated before resumption of a normal diet, is likely to benefit from nutritional support.\\n\\n### Enteral versus Parenteral Nutrition\\n\\nNutritional support may be provided by enteral (through the alimentary tract)...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Nutritional Support in Illness',\n", " 'md': '## Nutritional Support in Illness',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The only obtainable laboratory parameters for you to estimate available reserves are:\\n- A serum albumin level of <3 mg/dL\\n- A total lymphocyte count <1500 cells/ml\\n\\nThese parameters are associated with a higher morbidity and mortality.\\n\\nThe associated stress of illness may be roughly estimated as minor, moderate, or major. It is better, though, to characterize stress by the use of a physiologic scoring system that measures the severity of the acute illness — such as the APACHE II system (Chapter 6). An increased level of stress is associated with a higher rate of protein breakdown, as well as complications and death.\\n\\nThe third piece of information necessary for decision-making is the time interval that will pass before the patient can resume a normal diet. This estimate is based on the nature of the primary illness and the type of operation that is required or has been performed. For example:\\n- A person with ‘simple’ acute appendicitis will experience cessation of normal feeding for a period of 24-72 hours.\\n- A person with perforated diverticulitis and generalized peritonitis may experience cessation of feeding for a period of perhaps 5-7 days.\\n- Patients who develop complications, such as an anastomotic leak or ileus, may be deprived of normal oral food intake for as long as 10-14 days — or even longer.\\n\\nWith the above information, you can decide which patients will be most likely to benefit from nutritional support:\\n\\n- At one end of the spectrum, the patient with normal reserves by history and examination, with minimal to moderate associated stress, and with less than 7-10 days estimated before resumption of a normal diet, is unlikely to benefit from nutritional support.\\n- At the other end of the spectrum, the patient with depleted available reserves, moderate to severe stress, and with more than 7-10 days estimated before resumption of a normal diet, is likely to benefit from nutritional support.',\n", " 'md': 'The only obtainable laboratory parameters for you to estimate available reserves are:\\n- A serum albumin level of <3 mg/dL\\n- A total lymphocyte count <1500 cells/ml\\n\\nThese parameters are associated with a higher morbidity and mortality.\\n\\nThe associated stress of illness may be roughly estimated as minor, moderate, or major. It is better, though, to characterize stress by the use of a physiologic scoring system that measures the severity of the acute illness — such as the APACHE II system (Chapter 6). An increased level of stress is associated with a higher rate of protein breakdown, as well as complications and death.\\n\\nThe third piece of information necessary for decision-making is the time interval that will pass before the patient can resume a normal diet. This estimate is based on the nature of the primary illness and the type of operation that is required or has been performed. For example:\\n- A person with ‘simple’ acute appendicitis will experience cessation of normal feeding for a period of 24-72 hours.\\n- A person with perforated diverticulitis and generalized peritonitis may experience cessation of feeding for a period of perhaps 5-7 days.\\n- Patients who develop complications, such as an anastomotic leak or ileus, may be deprived of normal oral food intake for as long as 10-14 days — or even longer.\\n\\nWith the above information, you can decide which patients will be most likely to benefit from nutritional support:\\n\\n- At one end of the spectrum, the patient with normal reserves by history and examination, with minimal to moderate associated stress, and with less than 7-10 days estimated before resumption of a normal diet, is unlikely to benefit from nutritional support.\\n- At the other end of the spectrum, the patient with depleted available reserves, moderate to severe stress, and with more than 7-10 days estimated before resumption of a normal diet, is likely to benefit from nutritional support.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.6, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Enteral versus Parenteral Nutrition',\n", " 'md': '### Enteral versus Parenteral Nutrition',\n", " 'bBox': {'x': 86, 'y': 673, 'w': 270.33, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Nutritional support may be provided by enteral (through the alimentary tract)...\\n```',\n", " 'md': 'Nutritional support may be provided by enteral (through the alimentary tract)...\\n```',\n", " 'bBox': {'x': 86, 'y': 709, 'w': 452.79, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'level of stress is associated with a higher rate of protein breakdown,'}]},\n", " {'page': 755,\n", " 'text': 'tract) or parenteral (intravenous) routes. The advantage of enteral\\nnutrition is that it is associated with reduced rates of infection, sepsis,\\nlength of hospital stay and costs. Although the exact reasons for the\\neffectiveness of enteral over parenteral nutrition are not clear, almost all\\noutcome studies of acutely ill adults with functioning GI tracts fail to\\ndocument improved outcomes from parenteral nutrition. The\\nadvantage of parenteral nutrition is that it can be used when the\\ngastrointestinal tract is not functional.\\n\\n This is no longer controversial; when the gut functions, use it!\\nClearly, enteral feeding is safer, cheaper, and more physiologic than\\nparenteral nutrition.\\n\\n Alexander Solzhenitsyn (no, he was not a surgeon...) knew this 40\\nyears ago, writing in Cancer Ward: “If I need grape sugar, give it to me\\nthrough the mouth! Why this 20th century gimmick? Why should every\\nmedicine be given by injection? You do not see anything similar in nature\\nor among animals, do you? In a hundred years’ time they’ll laugh at us\\nand call us savages…”\\n\\n Enteral nutrition\\n\\n Tasty food given by mouth is the ideal. Oral feeding requires the\\ncooperation of the patient, a normal swallowing mechanism and normal\\ngastric motility. Unconscious and intubated patients obviously cannot\\nswallow, but the main problem following abdominal operations is that the\\nstomach is lazier than the intestine. In other words, after laparotomy the\\nsmall bowel recovers motility before the stomach. In most cases the gut\\nis ready to absorb nutrients in the first postoperative day, whereas the\\nstomach may have delayed emptying for a few days ( Chapter 45). It is\\nclear then, that when early postoperative feeding is deemed\\nnecessary, or when oral intake is inadequate, the food should be\\ninstilled distally — beyond the esophagus and the stomach.\\n\\n Routes for enteral nutrition\\n\\n In general when the mouth is not available the following feeding',\n", " 'md': '```markdown\\n## Enteral Nutrition\\n\\nEnteral nutrition can be administered through oral or parenteral (intravenous) routes. The advantage of enteral nutrition is that it is associated with reduced rates of infection, sepsis, length of hospital stay, and costs. Although the exact reasons for the effectiveness of enteral over parenteral nutrition are not clear, almost all outcome studies of acutely ill adults with functioning GI tracts fail to document improved outcomes from parenteral nutrition. The advantage of parenteral nutrition is that it can be used when the gastrointestinal tract is not functional.\\n\\nThis is no longer controversial; when the gut functions, use it! Clearly, enteral feeding is safer, cheaper, and more physiologic than parenteral nutrition.\\n\\nAlexander Solzhenitsyn (no, he was not a surgeon...) knew this 40 years ago, writing in *Cancer Ward*: “If I need grape sugar, give it to me through the mouth! Why this 20th century gimmick? Why should every medicine be given by injection? You do not see anything similar in nature or among animals, do you? In a hundred years’ time they’ll laugh at us and call us savages…”\\n\\n### Enteral Nutrition\\n\\nTasty food given by mouth is the ideal. Oral feeding requires the cooperation of the patient, a normal swallowing mechanism, and normal gastric motility. Unconscious and intubated patients obviously cannot swallow, but the main problem following abdominal operations is that the stomach is lazier than the intestine. In other words, after laparotomy the small bowel recovers motility before the stomach. In most cases, the gut is ready to absorb nutrients in the first postoperative day, whereas the stomach may have delayed emptying for a few days (Chapter 45). It is clear then, that when early postoperative feeding is deemed necessary, or when oral intake is inadequate, the food should be instilled distally — beyond the esophagus and the stomach.\\n\\n### Routes for Enteral Nutrition\\n\\nIn general, when the mouth is not available, the following feeding...\\n```\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the provided content.*',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Enteral Nutrition',\n", " 'md': '## Enteral Nutrition',\n", " 'bBox': {'x': 86, 'y': 431, 'w': 127.78, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Enteral nutrition can be administered through oral or parenteral (intravenous) routes. The advantage of enteral nutrition is that it is associated with reduced rates of infection, sepsis, length of hospital stay, and costs. Although the exact reasons for the effectiveness of enteral over parenteral nutrition are not clear, almost all outcome studies of acutely ill adults with functioning GI tracts fail to document improved outcomes from parenteral nutrition. The advantage of parenteral nutrition is that it can be used when the gastrointestinal tract is not functional.\\n\\nThis is no longer controversial; when the gut functions, use it! Clearly, enteral feeding is safer, cheaper, and more physiologic than parenteral nutrition.\\n\\nAlexander Solzhenitsyn (no, he was not a surgeon...) knew this 40 years ago, writing in *Cancer Ward*: “If I need grape sugar, give it to me through the mouth! Why this 20th century gimmick? Why should every medicine be given by injection? You do not see anything similar in nature or among animals, do you? In a hundred years’ time they’ll laugh at us and call us savages…”',\n", " 'md': 'Enteral nutrition can be administered through oral or parenteral (intravenous) routes. The advantage of enteral nutrition is that it is associated with reduced rates of infection, sepsis, length of hospital stay, and costs. Although the exact reasons for the effectiveness of enteral over parenteral nutrition are not clear, almost all outcome studies of acutely ill adults with functioning GI tracts fail to document improved outcomes from parenteral nutrition. The advantage of parenteral nutrition is that it can be used when the gastrointestinal tract is not functional.\\n\\nThis is no longer controversial; when the gut functions, use it! Clearly, enteral feeding is safer, cheaper, and more physiologic than parenteral nutrition.\\n\\nAlexander Solzhenitsyn (no, he was not a surgeon...) knew this 40 years ago, writing in *Cancer Ward*: “If I need grape sugar, give it to me through the mouth! Why this 20th century gimmick? Why should every medicine be given by injection? You do not see anything similar in nature or among animals, do you? In a hundred years’ time they’ll laugh at us and call us savages…”',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.68, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Enteral Nutrition',\n", " 'md': '### Enteral Nutrition',\n", " 'bBox': {'x': 86, 'y': 431, 'w': 127.78, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Tasty food given by mouth is the ideal. Oral feeding requires the cooperation of the patient, a normal swallowing mechanism, and normal gastric motility. Unconscious and intubated patients obviously cannot swallow, but the main problem following abdominal operations is that the stomach is lazier than the intestine. In other words, after laparotomy the small bowel recovers motility before the stomach. In most cases, the gut is ready to absorb nutrients in the first postoperative day, whereas the stomach may have delayed emptying for a few days (Chapter 45). It is clear then, that when early postoperative feeding is deemed necessary, or when oral intake is inadequate, the food should be instilled distally — beyond the esophagus and the stomach.',\n", " 'md': 'Tasty food given by mouth is the ideal. Oral feeding requires the cooperation of the patient, a normal swallowing mechanism, and normal gastric motility. Unconscious and intubated patients obviously cannot swallow, but the main problem following abdominal operations is that the stomach is lazier than the intestine. In other words, after laparotomy the small bowel recovers motility before the stomach. In most cases, the gut is ready to absorb nutrients in the first postoperative day, whereas the stomach may have delayed emptying for a few days (Chapter 45). It is clear then, that when early postoperative feeding is deemed necessary, or when oral intake is inadequate, the food should be instilled distally — beyond the esophagus and the stomach.',\n", " 'bBox': {'x': 72, 'y': 517, 'w': 467.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Routes for Enteral Nutrition',\n", " 'md': '### Routes for Enteral Nutrition',\n", " 'bBox': {'x': 86, 'y': 431, 'w': 213.29, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In general, when the mouth is not available, the following feeding...\\n```\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the provided content.*',\n", " 'md': 'In general, when the mouth is not available, the following feeding...\\n```\\n\\n*Note: The text extraction does not include any images, graphs, or tables from the provided content.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'clear then, that when early postoperative feeding is deemed'}]},\n", " {'page': 756,\n", " 'text': 'routes are options:\\n\\n • Nasogastric and nasoenteric. The former is of course not usable\\n when the stomach is not functioning. The latter delivers the nutrients\\n directly into the duodenum and jejunum. Transnasal intubation in\\n conscious patients is only tolerated with narrow-bore and soft tubes.\\n Rare complications include nasal trauma, sinus infection and even\\n (very rarely) misplacement into the bronchial tree with inadvertent\\n instillation of the feeding solution into the lungs.\\n • Gastrostomy and transgastric jejunal tube. The feeding tube is\\n placed directly into the stomach, and may be advanced through the\\n pylorus into the jejunum. This is a surgical procedure, which violates\\n the gastric wall. The chief complication is leakage at the insertion\\n site: around the tube — which is not uncommon — or into the\\n peritoneal cavity — which is rare but potentially fatal.\\n • Jejunostomy tube. The feeding tube (or a catheter) is inserted\\n directly into the proximal jejunum as discussed below.\\n\\n Feeding directly into the jejunum, as opposed to gastric feeding, is\\nsupported by randomized controlled trials and is intuitively associated\\nwith less risk of aspiration, better delivery of nutrients and fewer problems\\nwith gastric retention.\\n\\n Should I place a jejunal feeding tube?\\n\\n This is the question you should ask yourself at the end of the\\nemergency laparotomy. It is much more convenient to do it at this stage\\nas opposed to doing it postoperatively. You should consider the three\\nquestions mentioned above: What is the likelihood that this patient will be\\neating in 7-10 days? Are they malnourished or not? What is the\\nmagnitude of this illness?\\n\\n A malnourished alcoholic patient who requires a total gastrectomy with\\nesophagojejunal anastomosis for massive upper gastrointestinal bleeding\\nrepresents a classic indication for a jejunal (J) feeding tube. A patient\\nsuffering multi-trauma involving the thorax, pelvis and long bones, who\\nundergoes a laparotomy for hepatic injury, could also benefit from',\n", " 'md': '```markdown\\n## Feeding Routes\\n\\n### Options for Nutritional Support\\n\\n- **Nasogastric and Nasoenteric Tubes**:\\n- The nasogastric route is not usable when the stomach is not functioning. The nasoenteric route delivers nutrients directly into the duodenum and jejunum. Transnasal intubation in conscious patients is only tolerated with narrow-bore and soft tubes. Rare complications include nasal trauma, sinus infection, and very rarely, misplacement into the bronchial tree with inadvertent instillation of the feeding solution into the lungs.\\n\\n- **Gastrostomy and Transgastric Jejunal Tube**:\\n- The feeding tube is placed directly into the stomach and may be advanced through the pylorus into the jejunum. This is a surgical procedure that violates the gastric wall. The chief complication is leakage at the insertion site, which is not uncommon, or into the peritoneal cavity, which is rare but potentially fatal.\\n\\n- **Jejunostomy Tube**:\\n- The feeding tube (or a catheter) is inserted directly into the proximal jejunum.\\n\\nFeeding directly into the jejunum, as opposed to gastric feeding, is supported by randomized controlled trials and is intuitively associated with less risk of aspiration, better delivery of nutrients, and fewer problems with gastric retention.\\n\\n### Considerations for Jejunal Feeding Tube Placement\\n\\nShould I place a jejunal feeding tube? This is the question you should ask yourself at the end of the emergency laparotomy. It is much more convenient to do it at this stage as opposed to doing it postoperatively. You should consider the three questions mentioned above:\\n1. What is the likelihood that this patient will be eating in 7-10 days?\\n2. Are they malnourished or not?\\n3. What is the magnitude of this illness?\\n\\nA malnourished alcoholic patient who requires a total gastrectomy with esophagojejunal anastomosis for massive upper gastrointestinal bleeding represents a classic indication for a jejunal (J) feeding tube. A patient suffering multi-trauma involving the thorax, pelvis, and long bones, who undergoes a laparotomy for hepatic injury, could also benefit from this approach.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Feeding Routes',\n", " 'md': '## Feeding Routes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Options for Nutritional Support',\n", " 'md': '### Options for Nutritional Support',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Nasogastric and Nasoenteric Tubes**:\\n- The nasogastric route is not usable when the stomach is not functioning. The nasoenteric route delivers nutrients directly into the duodenum and jejunum. Transnasal intubation in conscious patients is only tolerated with narrow-bore and soft tubes. Rare complications include nasal trauma, sinus infection, and very rarely, misplacement into the bronchial tree with inadvertent instillation of the feeding solution into the lungs.\\n\\n- **Gastrostomy and Transgastric Jejunal Tube**:\\n- The feeding tube is placed directly into the stomach and may be advanced through the pylorus into the jejunum. This is a surgical procedure that violates the gastric wall. The chief complication is leakage at the insertion site, which is not uncommon, or into the peritoneal cavity, which is rare but potentially fatal.\\n\\n- **Jejunostomy Tube**:\\n- The feeding tube (or a catheter) is inserted directly into the proximal jejunum.\\n\\nFeeding directly into the jejunum, as opposed to gastric feeding, is supported by randomized controlled trials and is intuitively associated with less risk of aspiration, better delivery of nutrients, and fewer problems with gastric retention.',\n", " 'md': '- **Nasogastric and Nasoenteric Tubes**:\\n- The nasogastric route is not usable when the stomach is not functioning. The nasoenteric route delivers nutrients directly into the duodenum and jejunum. Transnasal intubation in conscious patients is only tolerated with narrow-bore and soft tubes. Rare complications include nasal trauma, sinus infection, and very rarely, misplacement into the bronchial tree with inadvertent instillation of the feeding solution into the lungs.\\n\\n- **Gastrostomy and Transgastric Jejunal Tube**:\\n- The feeding tube is placed directly into the stomach and may be advanced through the pylorus into the jejunum. This is a surgical procedure that violates the gastric wall. The chief complication is leakage at the insertion site, which is not uncommon, or into the peritoneal cavity, which is rare but potentially fatal.\\n\\n- **Jejunostomy Tube**:\\n- The feeding tube (or a catheter) is inserted directly into the proximal jejunum.\\n\\nFeeding directly into the jejunum, as opposed to gastric feeding, is supported by randomized controlled trials and is intuitively associated with less risk of aspiration, better delivery of nutrients, and fewer problems with gastric retention.',\n", " 'bBox': {'x': 72, 'y': 171, 'w': 464.9, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Considerations for Jejunal Feeding Tube Placement',\n", " 'md': '### Considerations for Jejunal Feeding Tube Placement',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Should I place a jejunal feeding tube? This is the question you should ask yourself at the end of the emergency laparotomy. It is much more convenient to do it at this stage as opposed to doing it postoperatively. You should consider the three questions mentioned above:\\n1. What is the likelihood that this patient will be eating in 7-10 days?\\n2. Are they malnourished or not?\\n3. What is the magnitude of this illness?\\n\\nA malnourished alcoholic patient who requires a total gastrectomy with esophagojejunal anastomosis for massive upper gastrointestinal bleeding represents a classic indication for a jejunal (J) feeding tube. A patient suffering multi-trauma involving the thorax, pelvis, and long bones, who undergoes a laparotomy for hepatic injury, could also benefit from this approach.\\n```',\n", " 'md': 'Should I place a jejunal feeding tube? This is the question you should ask yourself at the end of the emergency laparotomy. It is much more convenient to do it at this stage as opposed to doing it postoperatively. You should consider the three questions mentioned above:\\n1. What is the likelihood that this patient will be eating in 7-10 days?\\n2. Are they malnourished or not?\\n3. What is the magnitude of this illness?\\n\\nA malnourished alcoholic patient who requires a total gastrectomy with esophagojejunal anastomosis for massive upper gastrointestinal bleeding represents a classic indication for a jejunal (J) feeding tube. A patient suffering multi-trauma involving the thorax, pelvis, and long bones, who undergoes a laparotomy for hepatic injury, could also benefit from this approach.\\n```',\n", " 'bBox': {'x': 72, 'y': 489, 'w': 467.73, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 757,\n", " 'text': 'immediate J-tube feedings. On the other hand, after a partial gastrectomy\\nin a previously well-nourished patient, J-tube placement is not indicated\\nas the potential risks override the assumed benefits. ħey, you don’t want\\nto place a J-tube in a patient who won’t need it.\\n\\n There are three methods to place the J-tube during the operation:\\n\\n • Transnasally — into the stomach from which you can manipulate it\\n by palpation into the proximal jejunum. The advantage is that it does\\n not require a gastrotomy or enterotomy; disadvantages are its nasal\\n presence and risk of accidental dislodgment. In addition, in a patient\\n with peritonitis and edematous viscera, it is really hard to advance\\n the tube all the way to the jejunum.\\n • Transgastric — combined gastrostomy/jejunostomy tubes are\\n available to allow gastric aspiration and jejunal feeding at the same\\n time. Obviously, gastrostomy has its own complications — mainly\\n leakage around the tube, leakage into the peritoneal cavity and\\n abdominal wall cellulitis. A meticulous fixation of the stomach\\n onto the abdominal wall is mandatory.\\n • Jejunostomy — a 16Fr or larger tube may be placed through a\\n purse-string controlled enterotomy and then suture-tunneled with\\n serosa over the site of entry extending 5-7cm proximally (Witzel\\n technique).\\n Alternatively, a 12- or 14-gauge catheter may be tunneled into the\\n jejunal lumen through a needle (‘needle catheter technique’). Both\\n techniques require suture fixation of the bowel to the site of catheter\\n entry in the abdominal wall in order to prevent intra-abdominal\\n leakage of small bowel contents — or leakage of feed, if the tube is\\n accidentally removed before an enterocutaneous tract has\\n developed (in 7 to 10 days). Additional useful tricks are: fix the\\n efferent and afferent portions of the loop to the abdominal wall to\\n prevent kinking and obstruction at the site of the jejunostomy. The\\n needle and catheter should pierce the abdominal wall obliquely in\\n line with the bowel-wall tunnel; this will prevent kinking — followed\\n by breaking — of the fine tube at the bowel-abdominal wall junction.\\n\\n I use a silicone NG tube with a cut-off at the tip to achieve a wider hole so it does not get',\n", " 'md': '```markdown\\n# J-Tube Placement Methods\\n\\nThere are three methods to place the J-tube during the operation:\\n\\n1. **Transnasally** — into the stomach from which you can manipulate it by palpation into the proximal jejunum. The advantage is that it does not require a gastrotomy or enterotomy; disadvantages are its nasal presence and risk of accidental dislodgment. In addition, in a patient with peritonitis and edematous viscera, it is really hard to advance the tube all the way to the jejunum.\\n\\n2. **Transgastric** — combined gastrostomy/jejunostomy tubes are available to allow gastric aspiration and jejunal feeding at the same time. Obviously, gastrostomy has its own complications — mainly leakage around the tube, leakage into the peritoneal cavity, and abdominal wall cellulitis. A meticulous fixation of the stomach onto the abdominal wall is mandatory.\\n\\n3. **Jejunostomy** — a 16Fr or larger tube may be placed through a purse-string controlled enterotomy and then suture-tunneled with serosa over the site of entry extending 5-7cm proximally (Witzel technique). Alternatively, a 12- or 14-gauge catheter may be tunneled into the jejunal lumen through a needle (‘needle catheter technique’). Both techniques require suture fixation of the bowel to the site of catheter entry in the abdominal wall in order to prevent intra-abdominal leakage of small bowel contents — or leakage of feed, if the tube is accidentally removed before an enterocutaneous tract has developed (in 7 to 10 days).\\n\\nAdditional useful tricks are: fix the efferent and afferent portions of the loop to the abdominal wall to prevent kinking and obstruction at the site of the jejunostomy. The needle and catheter should pierce the abdominal wall obliquely in line with the bowel-wall tunnel; this will prevent kinking — followed by breaking — of the fine tube at the bowel-abdominal wall junction.\\n\\nI use a silicone NG tube with a cut-off at the tip to achieve a wider hole so it does not get .\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'J-Tube Placement Methods',\n", " 'md': '# J-Tube Placement Methods',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'There are three methods to place the J-tube during the operation:\\n\\n1. **Transnasally** — into the stomach from which you can manipulate it by palpation into the proximal jejunum. The advantage is that it does not require a gastrotomy or enterotomy; disadvantages are its nasal presence and risk of accidental dislodgment. In addition, in a patient with peritonitis and edematous viscera, it is really hard to advance the tube all the way to the jejunum.\\n\\n2. **Transgastric** — combined gastrostomy/jejunostomy tubes are available to allow gastric aspiration and jejunal feeding at the same time. Obviously, gastrostomy has its own complications — mainly leakage around the tube, leakage into the peritoneal cavity, and abdominal wall cellulitis. A meticulous fixation of the stomach onto the abdominal wall is mandatory.\\n\\n3. **Jejunostomy** — a 16Fr or larger tube may be placed through a purse-string controlled enterotomy and then suture-tunneled with serosa over the site of entry extending 5-7cm proximally (Witzel technique). Alternatively, a 12- or 14-gauge catheter may be tunneled into the jejunal lumen through a needle (‘needle catheter technique’). Both techniques require suture fixation of the bowel to the site of catheter entry in the abdominal wall in order to prevent intra-abdominal leakage of small bowel contents — or leakage of feed, if the tube is accidentally removed before an enterocutaneous tract has developed (in 7 to 10 days).\\n\\nAdditional useful tricks are: fix the efferent and afferent portions of the loop to the abdominal wall to prevent kinking and obstruction at the site of the jejunostomy. The needle and catheter should pierce the abdominal wall obliquely in line with the bowel-wall tunnel; this will prevent kinking — followed by breaking — of the fine tube at the bowel-abdominal wall junction.\\n\\nI use a silicone NG tube with a cut-off at the tip to achieve a wider hole so it does not get .\\n```',\n", " 'md': 'There are three methods to place the J-tube during the operation:\\n\\n1. **Transnasally** — into the stomach from which you can manipulate it by palpation into the proximal jejunum. The advantage is that it does not require a gastrotomy or enterotomy; disadvantages are its nasal presence and risk of accidental dislodgment. In addition, in a patient with peritonitis and edematous viscera, it is really hard to advance the tube all the way to the jejunum.\\n\\n2. **Transgastric** — combined gastrostomy/jejunostomy tubes are available to allow gastric aspiration and jejunal feeding at the same time. Obviously, gastrostomy has its own complications — mainly leakage around the tube, leakage into the peritoneal cavity, and abdominal wall cellulitis. A meticulous fixation of the stomach onto the abdominal wall is mandatory.\\n\\n3. **Jejunostomy** — a 16Fr or larger tube may be placed through a purse-string controlled enterotomy and then suture-tunneled with serosa over the site of entry extending 5-7cm proximally (Witzel technique). Alternatively, a 12- or 14-gauge catheter may be tunneled into the jejunal lumen through a needle (‘needle catheter technique’). Both techniques require suture fixation of the bowel to the site of catheter entry in the abdominal wall in order to prevent intra-abdominal leakage of small bowel contents — or leakage of feed, if the tube is accidentally removed before an enterocutaneous tract has developed (in 7 to 10 days).\\n\\nAdditional useful tricks are: fix the efferent and afferent portions of the loop to the abdominal wall to prevent kinking and obstruction at the site of the jejunostomy. The needle and catheter should pierce the abdominal wall obliquely in line with the bowel-wall tunnel; this will prevent kinking — followed by breaking — of the fine tube at the bowel-abdominal wall junction.\\n\\nI use a silicone NG tube with a cut-off at the tip to achieve a wider hole so it does not get .\\n```',\n", " 'bBox': {'x': 86, 'y': 170, 'w': 447, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 758,\n", " 'text': ' blocked so easily. Ari\\n\\n Continuous J-feeding may be instituted immediately following\\noperation in most cases. Diarrhea is a common problem requiring\\nadjustment of the volume and concentration of the specific solution you\\nprefer to use. Be aware that nasojejunal tube feeding can be instilled\\nproximal to enteric suture lines.\\n\\n There is no way a patient is going to eat a hole in the\\n anastomosis.\\n P. O. Nyström.\\n\\n Note that cases of massive intestinal infarction have been\\nreported in critically ill patients receiving early postoperative jejunal\\nfeeding. This is possibly due to increased metabolic demands on an\\nalready poorly perfused gut — especially if you use large volumes of\\nenteral feeding, exceeding 60ml/hour. Therefore, hold J-feedings in\\nunstable patients and those on vasopressors.\\n\\n Small bowel ileus can prevent adequate J-feeding; always consider\\nthat behind the non-resolving or reappearing ileus there may be a\\ntreatable cause ( Chapter 45).\\n\\n You may have been approached by the manufacturers of the new\\n‘immuno-enhancing diets’. These are tube feeding formulas that contain\\nhigh concentrations of certain nutrients and are claimed to ‘increase\\nimmunity’, thus reducing the postoperative infection rate. The value of\\nsuch expensive diets is questionable, as is the value of enteral\\nsupplementation with the amino acid, glutamine.\\n\\n Postoperative placement of a transnasal J-tube\\n\\n You can also place a transnasal J-tube after the operation — if\\nindicated. This, however, is not easy and requires prolonged\\nmanipulation under fluoroscopy. An alternative is to use a gastroscope,\\nwith a long tube (e.g. nasobiliary) placed into the distal duodenum\\nthrough the biopsy channel of the scope and under vision. Clearly, intra-',\n", " 'md': '```markdown\\n## Continuous J-Feeding Post-Operation\\n\\nContinuous J-feeding may be instituted immediately following operation in most cases. Diarrhea is a common problem requiring adjustment of the volume and concentration of the specific solution you prefer to use. Be aware that nasojejunal tube feeding can be instilled proximal to enteric suture lines.\\n\\n> There is no way a patient is going to eat a hole in the anastomosis.\\n> — P. O. Nyström\\n\\nNote that cases of massive intestinal infarction have been reported in critically ill patients receiving early postoperative jejunal feeding. This is possibly due to increased metabolic demands on an already poorly perfused gut — especially if you use large volumes of enteral feeding, exceeding 60 ml/hour. Therefore, hold J-feedings in unstable patients and those on vasopressors.\\n\\nSmall bowel ileus can prevent adequate J-feeding; always consider that behind the non-resolving or reappearing ileus there may be a treatable cause (Chapter 45).\\n\\nYou may have been approached by the manufacturers of the new ‘immuno-enhancing diets’. These are tube feeding formulas that contain high concentrations of certain nutrients and are claimed to ‘increase immunity’, thus reducing the postoperative infection rate. The value of such expensive diets is questionable, as is the value of enteral supplementation with the amino acid, glutamine.\\n\\n### Postoperative Placement of a Transnasal J-Tube\\n\\nYou can also place a transnasal J-tube after the operation — if indicated. This, however, is not easy and requires prolonged manipulation under fluoroscopy. An alternative is to use a gastroscope, with a long tube (e.g., nasobiliary) placed into the distal duodenum through the biopsy channel of the scope and under vision.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Continuous J-Feeding Post-Operation',\n", " 'md': '## Continuous J-Feeding Post-Operation',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Continuous J-feeding may be instituted immediately following operation in most cases. Diarrhea is a common problem requiring adjustment of the volume and concentration of the specific solution you prefer to use. Be aware that nasojejunal tube feeding can be instilled proximal to enteric suture lines.\\n\\n> There is no way a patient is going to eat a hole in the anastomosis.\\n> — P. O. Nyström\\n\\nNote that cases of massive intestinal infarction have been reported in critically ill patients receiving early postoperative jejunal feeding. This is possibly due to increased metabolic demands on an already poorly perfused gut — especially if you use large volumes of enteral feeding, exceeding 60 ml/hour. Therefore, hold J-feedings in unstable patients and those on vasopressors.\\n\\nSmall bowel ileus can prevent adequate J-feeding; always consider that behind the non-resolving or reappearing ileus there may be a treatable cause (Chapter 45).\\n\\nYou may have been approached by the manufacturers of the new ‘immuno-enhancing diets’. These are tube feeding formulas that contain high concentrations of certain nutrients and are claimed to ‘increase immunity’, thus reducing the postoperative infection rate. The value of such expensive diets is questionable, as is the value of enteral supplementation with the amino acid, glutamine.',\n", " 'md': 'Continuous J-feeding may be instituted immediately following operation in most cases. Diarrhea is a common problem requiring adjustment of the volume and concentration of the specific solution you prefer to use. Be aware that nasojejunal tube feeding can be instilled proximal to enteric suture lines.\\n\\n> There is no way a patient is going to eat a hole in the anastomosis.\\n> — P. O. Nyström\\n\\nNote that cases of massive intestinal infarction have been reported in critically ill patients receiving early postoperative jejunal feeding. This is possibly due to increased metabolic demands on an already poorly perfused gut — especially if you use large volumes of enteral feeding, exceeding 60 ml/hour. Therefore, hold J-feedings in unstable patients and those on vasopressors.\\n\\nSmall bowel ileus can prevent adequate J-feeding; always consider that behind the non-resolving or reappearing ileus there may be a treatable cause (Chapter 45).\\n\\nYou may have been approached by the manufacturers of the new ‘immuno-enhancing diets’. These are tube feeding formulas that contain high concentrations of certain nutrients and are claimed to ‘increase immunity’, thus reducing the postoperative infection rate. The value of such expensive diets is questionable, as is the value of enteral supplementation with the amino acid, glutamine.',\n", " 'bBox': {'x': 72, 'y': 196, 'w': 467.37, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Postoperative Placement of a Transnasal J-Tube',\n", " 'md': '### Postoperative Placement of a Transnasal J-Tube',\n", " 'bBox': {'x': 86, 'y': 615, 'w': 371.51, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'You can also place a transnasal J-tube after the operation — if indicated. This, however, is not easy and requires prolonged manipulation under fluoroscopy. An alternative is to use a gastroscope, with a long tube (e.g., nasobiliary) placed into the distal duodenum through the biopsy channel of the scope and under vision.\\n```',\n", " 'md': 'You can also place a transnasal J-tube after the operation — if indicated. This, however, is not easy and requires prolonged manipulation under fluoroscopy. An alternative is to use a gastroscope, with a long tube (e.g., nasobiliary) placed into the distal duodenum through the biopsy channel of the scope and under vision.\\n```',\n", " 'bBox': {'x': 72, 'y': 667, 'w': 65.57, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 759,\n", " 'text': 'operative placement is much easier. Please do not forget this option\\nbefore closing the abdomen.\\n\\n Parenteral nutrition\\n\\n Patients who cannot eat and won’t tolerate enteral feeding may need\\nparenteral nutritional support and in that circumstance it may be life-\\nsaving. Parenteral nutrition comes in three ‘flavors’:\\n\\n • Protein-sparing hydration takes advantage of the fact that 100g of\\n glucose a day suppresses hepatic gluconeogenesis by supplying\\n much of the obligate daily glucose need. Two liters of dextrose 5%\\n provide this amount of sugar. For the average ‘not so stressed’\\n patient this is more than enough for the first 7 postoperative\\n days.\\n • Peripheral parenteral nutrition (PPN) contains amino acids in\\n addition to a low concentration of glucose and may provide an\\n additional protein-sparing effect when ‘stress’ is added to starvation.\\n It is useful in the maintenance of nutrition for an intermediate period\\n of postoperative starvation, 7-14 days, or as long as the patient’s\\n peripheral veins last. This is because PPN is a ‘vein destroyer’,\\n which often requires frequent change of the venous access.\\n However, this can be avoided if you, or your radiologist, inserts\\n a PICC line (peripherally inserted central catheter) that can be\\n used for a prolonged period of time.\\n • Total parenteral nutrition (TPN) contains amino acids and a\\n concentrated dextrose solution, into which a lipid solution is usually\\n added. This can provide the total amount of nutritional requirements,\\n even in the face of maximal stress, for an indefinite period. As usual,\\n bypassing physiology has a price — TPN is associated with a long\\n list of mechanical, catheter-related, infectious and metabolic\\n complications and is rather expensive. These days we prefer to\\n administer TPN through a PICC line thus avoiding the\\n complications associated with insertion of central lines.\\n\\n Do not forget that replenishing electrolytes (e.g. magnesium,\\nphosphorus), trace elements and vitamins is crucial in patients in need of',\n", " 'md': '```markdown\\n## Parenteral Nutrition\\n\\nPatients who cannot eat and won’t tolerate enteral feeding may need parenteral nutritional support, which can be life-saving. Parenteral nutrition comes in three ‘flavors’:\\n\\n1. **Protein-sparing hydration**: This takes advantage of the fact that 100g of glucose a day suppresses hepatic gluconeogenesis by supplying much of the obligate daily glucose need. Two liters of dextrose 5% provide this amount of sugar. For the average ‘not so stressed’ patient, this is more than enough for the first 7 postoperative days.\\n\\n2. **Peripheral parenteral nutrition (PPN)**: This contains amino acids in addition to a low concentration of glucose and may provide an additional protein-sparing effect when ‘stress’ is added to starvation. It is useful in the maintenance of nutrition for an intermediate period of postoperative starvation, 7-14 days, or as long as the patient’s peripheral veins last. This is because PPN is a ‘vein destroyer’, which often requires frequent change of the venous access. However, this can be avoided if you, or your radiologist, inserts a PICC line (peripherally inserted central catheter) that can be used for a prolonged period of time.\\n\\n3. **Total parenteral nutrition (TPN)**: This contains amino acids and a concentrated dextrose solution, into which a lipid solution is usually added. TPN can provide the total amount of nutritional requirements, even in the face of maximal stress, for an indefinite period. However, bypassing physiology has a price — TPN is associated with a long list of mechanical, catheter-related, infectious, and metabolic complications and is rather expensive. Nowadays, we prefer to administer TPN through a PICC line, thus avoiding the complications associated with the insertion of central lines.\\n\\nDo not forget that replenishing electrolytes (e.g., magnesium, phosphorus), trace elements, and vitamins is crucial in patients in need of parenteral nutrition.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Parenteral Nutrition',\n", " 'md': '## Parenteral Nutrition',\n", " 'bBox': {'x': 86, 'y': 145, 'w': 152.62, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Patients who cannot eat and won’t tolerate enteral feeding may need parenteral nutritional support, which can be life-saving. Parenteral nutrition comes in three ‘flavors’:\\n\\n1. **Protein-sparing hydration**: This takes advantage of the fact that 100g of glucose a day suppresses hepatic gluconeogenesis by supplying much of the obligate daily glucose need. Two liters of dextrose 5% provide this amount of sugar. For the average ‘not so stressed’ patient, this is more than enough for the first 7 postoperative days.\\n\\n2. **Peripheral parenteral nutrition (PPN)**: This contains amino acids in addition to a low concentration of glucose and may provide an additional protein-sparing effect when ‘stress’ is added to starvation. It is useful in the maintenance of nutrition for an intermediate period of postoperative starvation, 7-14 days, or as long as the patient’s peripheral veins last. This is because PPN is a ‘vein destroyer’, which often requires frequent change of the venous access. However, this can be avoided if you, or your radiologist, inserts a PICC line (peripherally inserted central catheter) that can be used for a prolonged period of time.\\n\\n3. **Total parenteral nutrition (TPN)**: This contains amino acids and a concentrated dextrose solution, into which a lipid solution is usually added. TPN can provide the total amount of nutritional requirements, even in the face of maximal stress, for an indefinite period. However, bypassing physiology has a price — TPN is associated with a long list of mechanical, catheter-related, infectious, and metabolic complications and is rather expensive. Nowadays, we prefer to administer TPN through a PICC line, thus avoiding the complications associated with the insertion of central lines.\\n\\nDo not forget that replenishing electrolytes (e.g., magnesium, phosphorus), trace elements, and vitamins is crucial in patients in need of parenteral nutrition.\\n```',\n", " 'md': 'Patients who cannot eat and won’t tolerate enteral feeding may need parenteral nutritional support, which can be life-saving. Parenteral nutrition comes in three ‘flavors’:\\n\\n1. **Protein-sparing hydration**: This takes advantage of the fact that 100g of glucose a day suppresses hepatic gluconeogenesis by supplying much of the obligate daily glucose need. Two liters of dextrose 5% provide this amount of sugar. For the average ‘not so stressed’ patient, this is more than enough for the first 7 postoperative days.\\n\\n2. **Peripheral parenteral nutrition (PPN)**: This contains amino acids in addition to a low concentration of glucose and may provide an additional protein-sparing effect when ‘stress’ is added to starvation. It is useful in the maintenance of nutrition for an intermediate period of postoperative starvation, 7-14 days, or as long as the patient’s peripheral veins last. This is because PPN is a ‘vein destroyer’, which often requires frequent change of the venous access. However, this can be avoided if you, or your radiologist, inserts a PICC line (peripherally inserted central catheter) that can be used for a prolonged period of time.\\n\\n3. **Total parenteral nutrition (TPN)**: This contains amino acids and a concentrated dextrose solution, into which a lipid solution is usually added. TPN can provide the total amount of nutritional requirements, even in the face of maximal stress, for an indefinite period. However, bypassing physiology has a price — TPN is associated with a long list of mechanical, catheter-related, infectious, and metabolic complications and is rather expensive. Nowadays, we prefer to administer TPN through a PICC line, thus avoiding the complications associated with the insertion of central lines.\\n\\nDo not forget that replenishing electrolytes (e.g., magnesium, phosphorus), trace elements, and vitamins is crucial in patients in need of parenteral nutrition.\\n```',\n", " 'bBox': {'x': 72, 'y': 145, 'w': 436.98, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 760,\n", " 'text': 'parenteral nutrition and may help to prevent the development of the\\n‘refeeding syndrome’ — potentially fatal shifts in fluids and electrolytes\\nthat may be seen in malnourished patients receiving artificial nutrition\\n(enteral or parenteral).\\n\\n Control of hyperglycemia\\n\\n Data derived in the last 5-10 years suggest that optimal control of\\nblood glucose is far more important than the route of nutrition in critical\\nillness. Maintenance of the blood glucose below 180mg/dL, aiming\\nfor a range of 140 to 180 (7.8-10.0mmol/L) has been shown to\\ndecrease morbidity and mortality among critically ill patients. This is\\nin contrast to previous evidence suggesting the need for tighter (80 to\\n110mg/dL, 4.4-6.2mmol/L) control. Tight maintenance is easier to\\naccomplish with enteral, rather than parenteral, nutritional support. Wide\\nswings in serum glucose resulting in either hypoglycemia or\\nhyperglycemia should be avoided.\\n\\n Measurement of effectiveness of nutritional support\\n\\n Prolonged overfeeding and underfeeding must be avoided. In the long\\nterm, the optimal amount of nutrition can be calculated by observing the\\nbalance of protein synthesis and degradation reflected in serum protein\\nlevels such as albumin (half-life 17 days), transferrin (half-life 8 days) or\\ntransthyretin (prealbumin, half-life 48 hours). In the short term,\\nparticularly in the critically ill, nitrogen balance can be assessed by\\ncomparing the amount of nitrogen that is produced in the urine (24-hour\\nurine specimen analyzed in the laboratory) with the amount of nitrogen\\nthat is given by nutritional support (written on the package).\\n\\n So what should you do?\\n\\n • First decide if nutritional support will be helpful by estimating\\n nutritional reserve, degree of stress and the time interval to\\n normal diet.\\n • ħold off starting nutritional supplements until peri-operative',\n", " 'md': '```markdown\\n## Parenteral Nutrition and Hyperglycemia Control\\n\\nParenteral nutrition may help to prevent the development of the ‘refeeding syndrome’ — potentially fatal shifts in fluids and electrolytes that may be seen in malnourished patients receiving artificial nutrition (enteral or parenteral).\\n\\n### Control of Hyperglycemia\\n\\nData derived in the last 5-10 years suggest that optimal control of blood glucose is far more important than the route of nutrition in critical illness. Maintenance of the blood glucose below 180 mg/dL, aiming for a range of 140 to 180 (7.8-10.0 mmol/L) has been shown to decrease morbidity and mortality among critically ill patients. This is in contrast to previous evidence suggesting the need for tighter (80 to 110 mg/dL, 4.4-6.2 mmol/L) control. Tight maintenance is easier to accomplish with enteral, rather than parenteral, nutritional support. Wide swings in serum glucose resulting in either hypoglycemia or hyperglycemia should be avoided.\\n\\n### Measurement of Effectiveness of Nutritional Support\\n\\nProlonged overfeeding and underfeeding must be avoided. In the long term, the optimal amount of nutrition can be calculated by observing the balance of protein synthesis and degradation reflected in serum protein levels such as albumin (half-life 17 days), transferrin (half-life 8 days) or transthyretin (prealbumin, half-life 48 hours). In the short term, particularly in the critically ill, nitrogen balance can be assessed by comparing the amount of nitrogen that is produced in the urine (24-hour urine specimen analyzed in the laboratory) with the amount of nitrogen that is given by nutritional support (written on the package).\\n\\n### So What Should You Do?\\n\\n- First decide if nutritional support will be helpful by estimating nutritional reserve, degree of stress, and the time interval to normal diet.\\n- Hold off starting nutritional supplements until peri-operative.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Parenteral Nutrition and Hyperglycemia Control',\n", " 'md': '## Parenteral Nutrition and Hyperglycemia Control',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Parenteral nutrition may help to prevent the development of the ‘refeeding syndrome’ — potentially fatal shifts in fluids and electrolytes that may be seen in malnourished patients receiving artificial nutrition (enteral or parenteral).',\n", " 'md': 'Parenteral nutrition may help to prevent the development of the ‘refeeding syndrome’ — potentially fatal shifts in fluids and electrolytes that may be seen in malnourished patients receiving artificial nutrition (enteral or parenteral).',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 143.11, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Control of Hyperglycemia',\n", " 'md': '### Control of Hyperglycemia',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 199.53, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Data derived in the last 5-10 years suggest that optimal control of blood glucose is far more important than the route of nutrition in critical illness. Maintenance of the blood glucose below 180 mg/dL, aiming for a range of 140 to 180 (7.8-10.0 mmol/L) has been shown to decrease morbidity and mortality among critically ill patients. This is in contrast to previous evidence suggesting the need for tighter (80 to 110 mg/dL, 4.4-6.2 mmol/L) control. Tight maintenance is easier to accomplish with enteral, rather than parenteral, nutritional support. Wide swings in serum glucose resulting in either hypoglycemia or hyperglycemia should be avoided.',\n", " 'md': 'Data derived in the last 5-10 years suggest that optimal control of blood glucose is far more important than the route of nutrition in critical illness. Maintenance of the blood glucose below 180 mg/dL, aiming for a range of 140 to 180 (7.8-10.0 mmol/L) has been shown to decrease morbidity and mortality among critically ill patients. This is in contrast to previous evidence suggesting the need for tighter (80 to 110 mg/dL, 4.4-6.2 mmol/L) control. Tight maintenance is easier to accomplish with enteral, rather than parenteral, nutritional support. Wide swings in serum glucose resulting in either hypoglycemia or hyperglycemia should be avoided.',\n", " 'bBox': {'x': 72, 'y': 281, 'w': 467.57, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Measurement of Effectiveness of Nutritional Support',\n", " 'md': '### Measurement of Effectiveness of Nutritional Support',\n", " 'bBox': {'x': 86, 'y': 347, 'w': 452.79, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Prolonged overfeeding and underfeeding must be avoided. In the long term, the optimal amount of nutrition can be calculated by observing the balance of protein synthesis and degradation reflected in serum protein levels such as albumin (half-life 17 days), transferrin (half-life 8 days) or transthyretin (prealbumin, half-life 48 hours). In the short term, particularly in the critically ill, nitrogen balance can be assessed by comparing the amount of nitrogen that is produced in the urine (24-hour urine specimen analyzed in the laboratory) with the amount of nitrogen that is given by nutritional support (written on the package).',\n", " 'md': 'Prolonged overfeeding and underfeeding must be avoided. In the long term, the optimal amount of nutrition can be calculated by observing the balance of protein synthesis and degradation reflected in serum protein levels such as albumin (half-life 17 days), transferrin (half-life 8 days) or transthyretin (prealbumin, half-life 48 hours). In the short term, particularly in the critically ill, nitrogen balance can be assessed by comparing the amount of nitrogen that is produced in the urine (24-hour urine specimen analyzed in the laboratory) with the amount of nitrogen that is given by nutritional support (written on the package).',\n", " 'bBox': {'x': 72, 'y': 347, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'So What Should You Do?',\n", " 'md': '### So What Should You Do?',\n", " 'bBox': {'x': 86, 'y': 618, 'w': 191.23, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- First decide if nutritional support will be helpful by estimating nutritional reserve, degree of stress, and the time interval to normal diet.\\n- Hold off starting nutritional supplements until peri-operative.\\n```',\n", " 'md': '- First decide if nutritional support will be helpful by estimating nutritional reserve, degree of stress, and the time interval to normal diet.\\n- Hold off starting nutritional supplements until peri-operative.\\n```',\n", " 'bBox': {'x': 100, 'y': 347, 'w': 438.79, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 761,\n", " 'text': ' intravenous fluid resuscitation has attenuated the effect of third-\\n space fluid sequestration and the initial hypermetabolic,\\n hyperglycemic physiologic picture has abated somewhat (usually\\n within 24 hours).\\n • Calculate the nutritional requirement by formula (there is no shame\\n in looking this up) or indirect calorimetry.\\n • Institute nutritional support. Enteral nutritional support should be the\\n first option. Parenteral nutritional support should be instituted if the\\n nutritional goals cannot be achieved with enteral support within 7\\n days.\\n • Closely control the serum glucose with the use of constant\\n intravenous insulin infusion and reassessment every 1-4 hours. But\\n do not get too enthusiastic — hypoglycemia is not healthy...\\n • Measure the effectiveness of treatment by analysis of urinary\\n nitrogen loss compared with the amount of nitrogen provided by the\\n treatment.\\n\\n ‘Routine’ oral feeding\\n\\n Fortunately, most of your emergency abdominal patients recover from\\nthe ileus, induced by the underlying disease and its surgical treatment,\\nwithin a few days. Traditionally, resumption of oral intake was completed\\nin stages. First there was the nasogastric tube, which was kept in situ for\\nvariable periods; then the tube was removed (according to the rules\\nestablished by the local dogma guru). After the patient professed the\\nblessed sounds of flatus he was started on ‘sips’; thereafter gradually\\nbeing advanced from ‘clear fluids’ to ‘full fluids’ to ‘soft diet’, until the great\\nday when ‘regular diet’ was allowed, usually indicating that discharge\\nhome was imminent. Is such a ritual or its variant still practiced in your\\nenvironment? If yes, you should know that its value is based on no\\nevidence at all. In fact, there is scientific evidence to prove that\\nstarting the patient on solid feeds is as safe and tolerable as the\\nstaged method still practiced by many.\\n\\n Do you mean that you start your patients on a clear liquid\\n diet and then progress to a full liquid diet before a regular\\n diet? If so, this is a silly practice that should be ceased. It is',\n", " 'md': '```markdown\\n## Nutritional Management in Emergency Abdominal Patients\\n\\n- Intravenous fluid resuscitation has attenuated the effect of third-space fluid sequestration, and the initial hypermetabolic, hyperglycemic physiologic picture has abated somewhat (usually within 24 hours).\\n- Calculate the nutritional requirement by formula (there is no shame in looking this up) or indirect calorimetry.\\n- Institute nutritional support. Enteral nutritional support should be the first option. Parenteral nutritional support should be instituted if the nutritional goals cannot be achieved with enteral support within 7 days.\\n- Closely control the serum glucose with the use of constant intravenous insulin infusion and reassessment every 1-4 hours. But do not get too enthusiastic — hypoglycemia is not healthy...\\n- Measure the effectiveness of treatment by analysis of urinary nitrogen loss compared with the amount of nitrogen provided by the treatment.\\n\\n### ‘Routine’ Oral Feeding\\n\\nFortunately, most of your emergency abdominal patients recover from the ileus induced by the underlying disease and its surgical treatment within a few days. Traditionally, resumption of oral intake was completed in stages. First, there was the nasogastric tube, which was kept in situ for variable periods; then the tube was removed (according to the rules established by the local dogma guru). After the patient professed the blessed sounds of flatus, he was started on ‘sips’; thereafter gradually being advanced from ‘clear fluids’ to ‘full fluids’ to ‘soft diet’, until the great day when ‘regular diet’ was allowed, usually indicating that discharge home was imminent.\\n\\nIs such a ritual or its variant still practiced in your environment? If yes, you should know that its value is based on no evidence at all. In fact, there is scientific evidence to prove that starting the patient on solid feeds is as safe and tolerable as the staged method still practiced by many.\\n\\nDo you mean that you start your patients on a clear liquid diet and then progress to a full liquid diet before a regular diet? If so, this is a silly practice that should be ceased.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Nutritional Management in Emergency Abdominal Patients',\n", " 'md': '## Nutritional Management in Emergency Abdominal Patients',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Intravenous fluid resuscitation has attenuated the effect of third-space fluid sequestration, and the initial hypermetabolic, hyperglycemic physiologic picture has abated somewhat (usually within 24 hours).\\n- Calculate the nutritional requirement by formula (there is no shame in looking this up) or indirect calorimetry.\\n- Institute nutritional support. Enteral nutritional support should be the first option. Parenteral nutritional support should be instituted if the nutritional goals cannot be achieved with enteral support within 7 days.\\n- Closely control the serum glucose with the use of constant intravenous insulin infusion and reassessment every 1-4 hours. But do not get too enthusiastic — hypoglycemia is not healthy...\\n- Measure the effectiveness of treatment by analysis of urinary nitrogen loss compared with the amount of nitrogen provided by the treatment.',\n", " 'md': '- Intravenous fluid resuscitation has attenuated the effect of third-space fluid sequestration, and the initial hypermetabolic, hyperglycemic physiologic picture has abated somewhat (usually within 24 hours).\\n- Calculate the nutritional requirement by formula (there is no shame in looking this up) or indirect calorimetry.\\n- Institute nutritional support. Enteral nutritional support should be the first option. Parenteral nutritional support should be instituted if the nutritional goals cannot be achieved with enteral support within 7 days.\\n- Closely control the serum glucose with the use of constant intravenous insulin infusion and reassessment every 1-4 hours. But do not get too enthusiastic — hypoglycemia is not healthy...\\n- Measure the effectiveness of treatment by analysis of urinary nitrogen loss compared with the amount of nitrogen provided by the treatment.',\n", " 'bBox': {'x': 100, 'y': 102, 'w': 436.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': '‘Routine’ Oral Feeding',\n", " 'md': '### ‘Routine’ Oral Feeding',\n", " 'bBox': {'x': 86, 'y': 391, 'w': 168.25, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Fortunately, most of your emergency abdominal patients recover from the ileus induced by the underlying disease and its surgical treatment within a few days. Traditionally, resumption of oral intake was completed in stages. First, there was the nasogastric tube, which was kept in situ for variable periods; then the tube was removed (according to the rules established by the local dogma guru). After the patient professed the blessed sounds of flatus, he was started on ‘sips’; thereafter gradually being advanced from ‘clear fluids’ to ‘full fluids’ to ‘soft diet’, until the great day when ‘regular diet’ was allowed, usually indicating that discharge home was imminent.\\n\\nIs such a ritual or its variant still practiced in your environment? If yes, you should know that its value is based on no evidence at all. In fact, there is scientific evidence to prove that starting the patient on solid feeds is as safe and tolerable as the staged method still practiced by many.\\n\\nDo you mean that you start your patients on a clear liquid diet and then progress to a full liquid diet before a regular diet? If so, this is a silly practice that should be ceased.\\n```',\n", " 'md': 'Fortunately, most of your emergency abdominal patients recover from the ileus induced by the underlying disease and its surgical treatment within a few days. Traditionally, resumption of oral intake was completed in stages. First, there was the nasogastric tube, which was kept in situ for variable periods; then the tube was removed (according to the rules established by the local dogma guru). After the patient professed the blessed sounds of flatus, he was started on ‘sips’; thereafter gradually being advanced from ‘clear fluids’ to ‘full fluids’ to ‘soft diet’, until the great day when ‘regular diet’ was allowed, usually indicating that discharge home was imminent.\\n\\nIs such a ritual or its variant still practiced in your environment? If yes, you should know that its value is based on no evidence at all. In fact, there is scientific evidence to prove that starting the patient on solid feeds is as safe and tolerable as the staged method still practiced by many.\\n\\nDo you mean that you start your patients on a clear liquid diet and then progress to a full liquid diet before a regular diet? If so, this is a silly practice that should be ceased.\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 762,\n", " 'text': ' all solid s**t when it goes thru the anastomosis so who\\n cares how it starts.\\n Karen Draper\\n\\n On the other side of the coin, there are surgeons who maintain that a\\npatient who devours a beefsteak a day after a colectomy is a testimony to\\ntheir superb surgical skills. This attitude is probably wrong as well —\\nwhat’s the point of force-feeding a patient who does not have an\\nappetite? Interventions to hasten the resolution of postoperative ileus\\nhave been promoted (such as μ-opioid receptor antagonists and early\\npostoperative chewing gum use), but the physiological postoperative\\nileus is a response that must have some purpose; appetite and desire to\\neat return when intestinal motility recovers. Our approach is therefore\\nto let the patient decide when to eat, what to eat and how much;\\nthey’ll tell you when their stomach is ready for a steak or the\\ncornmeal ( Figure 43.1).\\n Ml\\n Rr44\\n Figure 43.1. Postoperative day 1: “Let her eat as much as she wants…”\\n\\n Final words…\\n\\n Abdominal catastrophes and their operative treatment are often',\n", " 'md': '```markdown\\n# Page Content\\n\\nOn the other side of the coin, there are surgeons who maintain that a patient who devours a beefsteak a day after a colectomy is a testimony to their superb surgical skills. This attitude is probably wrong as well — what’s the point of force-feeding a patient who does not have an appetite? Interventions to hasten the resolution of postoperative ileus have been promoted (such as μ-opioid receptor antagonists and early postoperative chewing gum use), but the physiological postoperative ileus is a response that must have some purpose; appetite and desire to eat return when intestinal motility recovers. Our approach is therefore to let the patient decide when to eat, what to eat and how much; they’ll tell you when their stomach is ready for a steak or the cornmeal (Figure 43.1).\\n\\n## Figure 43.1\\n**Caption:** Postoperative day 1: “Let her eat as much as she wants…”\\n\\n**Description:** This image likely depicts a postoperative patient in a hospital setting, possibly enjoying a meal. The context suggests a focus on patient autonomy in dietary choices following surgery. The figure emphasizes the importance of allowing patients to eat according to their appetite rather than enforcing strict dietary restrictions.\\n\\n----\\n\\nFinal words…\\n\\nAbdominal catastrophes and their operative treatment are often...\\n```',\n", " 'images': [{'name': 'img_p761_1.png',\n", " 'height': 491,\n", " 'width': 814,\n", " 'x': 105.11999999999989,\n", " 'y': 357.12,\n", " 'original_width': 1398,\n", " 'original_height': 844}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'On the other side of the coin, there are surgeons who maintain that a patient who devours a beefsteak a day after a colectomy is a testimony to their superb surgical skills. This attitude is probably wrong as well — what’s the point of force-feeding a patient who does not have an appetite? Interventions to hasten the resolution of postoperative ileus have been promoted (such as μ-opioid receptor antagonists and early postoperative chewing gum use), but the physiological postoperative ileus is a response that must have some purpose; appetite and desire to eat return when intestinal motility recovers. Our approach is therefore to let the patient decide when to eat, what to eat and how much; they’ll tell you when their stomach is ready for a steak or the cornmeal (Figure 43.1).',\n", " 'md': 'On the other side of the coin, there are surgeons who maintain that a patient who devours a beefsteak a day after a colectomy is a testimony to their superb surgical skills. This attitude is probably wrong as well — what’s the point of force-feeding a patient who does not have an appetite? Interventions to hasten the resolution of postoperative ileus have been promoted (such as μ-opioid receptor antagonists and early postoperative chewing gum use), but the physiological postoperative ileus is a response that must have some purpose; appetite and desire to eat return when intestinal motility recovers. Our approach is therefore to let the patient decide when to eat, what to eat and how much; they’ll tell you when their stomach is ready for a steak or the cornmeal (Figure 43.1).',\n", " 'bBox': {'x': 72, 'y': 161, 'w': 467.77, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 43.1',\n", " 'md': '## Figure 43.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Caption:** Postoperative day 1: “Let her eat as much as she wants…”\\n\\n**Description:** This image likely depicts a postoperative patient in a hospital setting, possibly enjoying a meal. The context suggests a focus on patient autonomy in dietary choices following surgery. The figure emphasizes the importance of allowing patients to eat according to their appetite rather than enforcing strict dietary restrictions.\\n\\n----\\n\\nFinal words…\\n\\nAbdominal catastrophes and their operative treatment are often...\\n```',\n", " 'md': '**Caption:** Postoperative day 1: “Let her eat as much as she wants…”\\n\\n**Description:** This image likely depicts a postoperative patient in a hospital setting, possibly enjoying a meal. The context suggests a focus on patient autonomy in dietary choices following surgery. The figure emphasizes the importance of allowing patients to eat according to their appetite rather than enforcing strict dietary restrictions.\\n\\n----\\n\\nFinal words…\\n\\nAbdominal catastrophes and their operative treatment are often...\\n```',\n", " 'bBox': {'x': 86, 'y': 674, 'w': 108.5, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 763,\n", " 'text': 'complicated by compromised nutritional reserve, stress and a long\\ninterval before a normal diet is resumed. The result of these factors is the\\nproduction of immunoparesis by ‘auto-cannibalization’ of functional\\nprotein with associated morbidity and mortality. Nutritional support in\\nselected patients may help to attenuate these effects. Driven by\\nmanufacturers, nutrition hospital services or ‘TPN teams’, the current\\ntrend is towards unnecessary overfeeding of the surgical patient —\\nprovoking additional morbidity and costs. Artificial feeding is a double-\\nedged sword. So, be selective and cautious.\\n\\n “Some people never seem able to allow their patients to\\n use the channels designed by nature to receive\\n nourishment… food and fluids given by the alimentary\\n canal allow the tissues to select and keep what they\\n want, and to reject what is harmful or surplus to\\n requirements.”\\n William Heneage Ogilvie\\n “In most conditions, foods that agree with the patients\\n may be eaten, those which do not, should not be eaten.”\\n Mark M. Ravitch\\n\\n1 Acute Physiology and Chronic Health Evaluation II.',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nComplicated by compromised nutritional reserve, stress, and a long interval before a normal diet is resumed. The result of these factors is the production of immunoparesis by ‘auto-cannibalization’ of functional protein with associated morbidity and mortality. Nutritional support in selected patients may help to attenuate these effects. Driven by manufacturers, nutrition hospital services or ‘TPN teams’, the current trend is towards unnecessary overfeeding of the surgical patient — provoking additional morbidity and costs. Artificial feeding is a double-edged sword. So, be selective and cautious.\\n\\n> “Some people never seem able to allow their patients to use the channels designed by nature to receive nourishment… food and fluids given by the alimentary canal allow the tissues to select and keep what they want, and to reject what is harmful or surplus to requirements.”\\n> — William Heneage Ogilvie\\n\\n> “In most conditions, foods that agree with the patients may be eaten, those which do not, should not be eaten.”\\n> — Mark M. Ravitch\\n\\n1. Acute Physiology and Chronic Health Evaluation II.\\n```\\n\\n### Notes:\\n- No formulas or images were identified on this page.\\n- The text has been extracted without any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Complicated by compromised nutritional reserve, stress, and a long interval before a normal diet is resumed. The result of these factors is the production of immunoparesis by ‘auto-cannibalization’ of functional protein with associated morbidity and mortality. Nutritional support in selected patients may help to attenuate these effects. Driven by manufacturers, nutrition hospital services or ‘TPN teams’, the current trend is towards unnecessary overfeeding of the surgical patient — provoking additional morbidity and costs. Artificial feeding is a double-edged sword. So, be selective and cautious.\\n\\n> “Some people never seem able to allow their patients to use the channels designed by nature to receive nourishment… food and fluids given by the alimentary canal allow the tissues to select and keep what they want, and to reject what is harmful or surplus to requirements.”\\n> — William Heneage Ogilvie\\n\\n> “In most conditions, foods that agree with the patients may be eaten, those which do not, should not be eaten.”\\n> — Mark M. Ravitch\\n\\n1. Acute Physiology and Chronic Health Evaluation II.\\n```',\n", " 'md': 'Complicated by compromised nutritional reserve, stress, and a long interval before a normal diet is resumed. The result of these factors is the production of immunoparesis by ‘auto-cannibalization’ of functional protein with associated morbidity and mortality. Nutritional support in selected patients may help to attenuate these effects. Driven by manufacturers, nutrition hospital services or ‘TPN teams’, the current trend is towards unnecessary overfeeding of the surgical patient — provoking additional morbidity and costs. Artificial feeding is a double-edged sword. So, be selective and cautious.\\n\\n> “Some people never seem able to allow their patients to use the channels designed by nature to receive nourishment… food and fluids given by the alimentary canal allow the tissues to select and keep what they want, and to reject what is harmful or surplus to requirements.”\\n> — William Heneage Ogilvie\\n\\n> “In most conditions, foods that agree with the patients may be eaten, those which do not, should not be eaten.”\\n> — Mark M. Ravitch\\n\\n1. Acute Physiology and Chronic Health Evaluation II.\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.48, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No formulas or images were identified on this page.\\n- The text has been extracted without any headers, footers, or diagonal text.',\n", " 'md': '- No formulas or images were identified on this page.\\n- The text has been extracted without any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 123, 'y': 285, 'w': 24.83, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 764,\n", " 'text': 'Chapter 44\\nPostoperative antibiotics\\nMoshe Schein\\n\\n No amount of postoperative antibiotics can compensate for\\n intra-operative mishaps and faulty technique, nor can they\\n abort postoperative suppuration necessitating drainage.\\n\\n The issue\\n\\n Perhaps an issue as apparently banal as postoperative antibiotics does\\nnot deserve a separate chapter. Already in Chapter 7 you read about\\npre-operative antibiotics, and in Chapter 13 you were introduced to the\\nconcepts of contamination and infection and their therapeutic\\nimplications.\\n\\n You may ask: why not just administer postoperative antibiotics\\nroutinely for any emergency abdominal operation until the patient is\\n‘well’? In fact, this is a common practice in the ‘surgical community’\\naround the world — patients receiving postoperative antibiotics for many\\ndays, many of them are even discharged home on oral agents ‘just in\\ncase’. What is wrong with this approach? One important problem with\\nthis approach is that thoughtless antibiotic administration has\\ncomplications including antibiotic-associated diarrhea, colitis and\\nthe emergence of resistant strains (methicillin-resistant\\nStaphylococcus aureus [MRSA] and Clostridium difficile colitis are\\nmajor, worldwide health problems). The other problem is cost — not\\nonly of the drugs themselves but also the expense of administration and',\n", " 'md': '# Chapter 44: Postoperative Antibiotics\\n**Author: Moshe Schein**\\n\\nNo amount of postoperative antibiotics can compensate for intra-operative mishaps and faulty technique, nor can they abort postoperative suppuration necessitating drainage.\\n\\n## The Issue\\n\\nPerhaps an issue as apparently banal as postoperative antibiotics does not deserve a separate chapter. Already in Chapter 7 you read about pre-operative antibiotics, and in Chapter 13 you were introduced to the concepts of contamination and infection and their therapeutic implications.\\n\\nYou may ask: why not just administer postoperative antibiotics routinely for any emergency abdominal operation until the patient is ‘well’? In fact, this is a common practice in the ‘surgical community’ around the world — patients receiving postoperative antibiotics for many days, many of them are even discharged home on oral agents ‘just in case’.\\n\\nWhat is wrong with this approach? One important problem with this approach is that thoughtless antibiotic administration has complications including antibiotic-associated diarrhea, colitis and the emergence of resistant strains (methicillin-resistant Staphylococcus aureus [MRSA] and Clostridium difficile colitis are major, worldwide health problems). The other problem is cost — not only of the drugs themselves but also the expense of administration and...\\n\\n----\\n\\n*Note: The text is extracted without any headers, footers, or diagonal text. There are no images, graphs, or tables identified on this page.*',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 44: Postoperative Antibiotics',\n", " 'md': '# Chapter 44: Postoperative Antibiotics',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 218.39, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author: Moshe Schein**\\n\\nNo amount of postoperative antibiotics can compensate for intra-operative mishaps and faulty technique, nor can they abort postoperative suppuration necessitating drainage.',\n", " 'md': '**Author: Moshe Schein**\\n\\nNo amount of postoperative antibiotics can compensate for intra-operative mishaps and faulty technique, nor can they abort postoperative suppuration necessitating drainage.',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 381.5, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Issue',\n", " 'md': '## The Issue',\n", " 'bBox': {'x': 72, 'y': 386, 'w': 90.34, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Perhaps an issue as apparently banal as postoperative antibiotics does not deserve a separate chapter. Already in Chapter 7 you read about pre-operative antibiotics, and in Chapter 13 you were introduced to the concepts of contamination and infection and their therapeutic implications.\\n\\nYou may ask: why not just administer postoperative antibiotics routinely for any emergency abdominal operation until the patient is ‘well’? In fact, this is a common practice in the ‘surgical community’ around the world — patients receiving postoperative antibiotics for many days, many of them are even discharged home on oral agents ‘just in case’.\\n\\nWhat is wrong with this approach? One important problem with this approach is that thoughtless antibiotic administration has complications including antibiotic-associated diarrhea, colitis and the emergence of resistant strains (methicillin-resistant Staphylococcus aureus [MRSA] and Clostridium difficile colitis are major, worldwide health problems). The other problem is cost — not only of the drugs themselves but also the expense of administration and...\\n\\n----\\n\\n*Note: The text is extracted without any headers, footers, or diagonal text. There are no images, graphs, or tables identified on this page.*',\n", " 'md': 'Perhaps an issue as apparently banal as postoperative antibiotics does not deserve a separate chapter. Already in Chapter 7 you read about pre-operative antibiotics, and in Chapter 13 you were introduced to the concepts of contamination and infection and their therapeutic implications.\\n\\nYou may ask: why not just administer postoperative antibiotics routinely for any emergency abdominal operation until the patient is ‘well’? In fact, this is a common practice in the ‘surgical community’ around the world — patients receiving postoperative antibiotics for many days, many of them are even discharged home on oral agents ‘just in case’.\\n\\nWhat is wrong with this approach? One important problem with this approach is that thoughtless antibiotic administration has complications including antibiotic-associated diarrhea, colitis and the emergence of resistant strains (methicillin-resistant Staphylococcus aureus [MRSA] and Clostridium difficile colitis are major, worldwide health problems). The other problem is cost — not only of the drugs themselves but also the expense of administration and...\\n\\n----\\n\\n*Note: The text is extracted without any headers, footers, or diagonal text. There are no images, graphs, or tables identified on this page.*',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 467.69, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ' Chapter 13 you were introduced to the'},\n", " {'text': 'and '}]},\n", " {'page': 765,\n", " 'text': 'the treatment of complications. Our aim is to convince you that\\nindiscriminate postoperative antimicrobial administration is wrong and to\\nprovide guidelines in order to approach this issue in a more rational way.\\n\\n Only over the last decade or two (oh, how slowly are old dogmas\\neradicated) has the topic of duration of administration been addressed in\\nthe literature; for years we endured the common laconic recommendation\\nthat antibiotics should be continued until all signs of infection, including\\nfever, leukocytosis, and even ileus subside, and the patient is clinically\\nwell. No evidence existed, however, to prove that the continuation of\\nantibiotics along these lines could abort an infection-in-evolution,\\nor cure an existing one ( Figure 44.1).\\n 8 1\\n 2s14RErxa\\n Figure 44.1. “This will cure your fever…”\\n\\n Duration of postoperative administration',\n", " 'md': \"```markdown\\n## Text\\n\\nThe treatment of complications. Our aim is to convince you that indiscriminate postoperative antimicrobial administration is wrong and to provide guidelines in order to approach this issue in a more rational way.\\n\\nOnly over the last decade or two (oh, how slowly are old dogmas eradicated) has the topic of duration of administration been addressed in the literature; for years we endured the common laconic recommendation that antibiotics should be continued until all signs of infection, including fever, leukocytosis, and even ileus subside, and the patient is clinically well. No evidence existed, however, to prove that the continuation of antibiotics along these lines could abort an infection-in-evolution, or cure an existing one (Figure 44.1).\\n\\n## Figure 44.1\\n\\n**Caption:** “This will cure your fever…”\\n\\n**Description:** This figure likely illustrates a common misconception regarding the treatment of fever with antibiotics. The content of the image is not fully extractable, and it may contain graphical elements that support the text's argument against the indiscriminate use of antibiotics postoperatively.\\n\\n**Summary:** The figure serves to highlight the outdated belief that prolonged antibiotic use is necessary to treat postoperative infections, emphasizing the need for a more evidence-based approach.\\n```\",\n", " 'images': [{'name': 'img_p764_1.png',\n", " 'height': 648,\n", " 'width': 510,\n", " 'x': 180,\n", " 'y': 283.67999999999995,\n", " 'original_width': 1048,\n", " 'original_height': 1332}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The treatment of complications. Our aim is to convince you that indiscriminate postoperative antimicrobial administration is wrong and to provide guidelines in order to approach this issue in a more rational way.\\n\\nOnly over the last decade or two (oh, how slowly are old dogmas eradicated) has the topic of duration of administration been addressed in the literature; for years we endured the common laconic recommendation that antibiotics should be continued until all signs of infection, including fever, leukocytosis, and even ileus subside, and the patient is clinically well. No evidence existed, however, to prove that the continuation of antibiotics along these lines could abort an infection-in-evolution, or cure an existing one (Figure 44.1).',\n", " 'md': 'The treatment of complications. Our aim is to convince you that indiscriminate postoperative antimicrobial administration is wrong and to provide guidelines in order to approach this issue in a more rational way.\\n\\nOnly over the last decade or two (oh, how slowly are old dogmas eradicated) has the topic of duration of administration been addressed in the literature; for years we endured the common laconic recommendation that antibiotics should be continued until all signs of infection, including fever, leukocytosis, and even ileus subside, and the patient is clinically well. No evidence existed, however, to prove that the continuation of antibiotics along these lines could abort an infection-in-evolution, or cure an existing one (Figure 44.1).',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.85, 'h': 125.09}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 44.1',\n", " 'md': '## Figure 44.1',\n", " 'bBox': {'x': 353.93, 'y': 408.28, 'w': 0, 'h': 125.09}},\n", " {'type': 'text',\n", " 'value': \"**Caption:** “This will cure your fever…”\\n\\n**Description:** This figure likely illustrates a common misconception regarding the treatment of fever with antibiotics. The content of the image is not fully extractable, and it may contain graphical elements that support the text's argument against the indiscriminate use of antibiotics postoperatively.\\n\\n**Summary:** The figure serves to highlight the outdated belief that prolonged antibiotic use is necessary to treat postoperative infections, emphasizing the need for a more evidence-based approach.\\n```\",\n", " 'md': \"**Caption:** “This will cure your fever…”\\n\\n**Description:** This figure likely illustrates a common misconception regarding the treatment of fever with antibiotics. The content of the image is not fully extractable, and it may contain graphical elements that support the text's argument against the indiscriminate use of antibiotics postoperatively.\\n\\n**Summary:** The figure serves to highlight the outdated belief that prolonged antibiotic use is necessary to treat postoperative infections, emphasizing the need for a more evidence-based approach.\\n```\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 766,\n", " 'text': 'Table 44.1. Duration of postoperative antibiotic therapy\\n Contamination: no postoperative antibiotics (assuming appropriate pre-\\n operative prophylaxis administered)\\n Gastroduodenal peptic perforations operated within 12 hours_\\n Traumatic enteric perforations operated within 12 hours\\n Peritoneal contamination with bowel contents during elective or emergency\\n procedures.\\n Appendectomy for early or phlegmonous appendicitis_\\n Cholecystectomy for early or phlegmonous cholecystitis\\n \\'Resectable\\' infection: 24-hour postoperative antibiotic course\\n Appendectomy for gangrenous appendicitis.\\n Cholecystectomy for gangrenous cholecystitis.\\n Bowel resection for ischemic or strangulated necrotic bowel without frank\\n perforation:\\n \\'Mild/moderate\\' infection: 2-5 days postoperative antibiotic course\\n Intra-abdominal infection from diverse sources with localized pus formation\\n \\'Late\\' (> 12 hours traumatic bowel lacerations and gastroduodenal perforation\\n with no established intra-abdominal infection:\\n Diffuse, established intra-abdominal infection from any source\\n \\'Severe\\' infection: more than 5 days of postoperative antibiotics\\n Severe intra-abdominal infection with source not easily controllable (e.g:\\n infected pancreatic necrosis):\\n Postoperative intra-abdominal infection.\\n These are what we recommend in general. It is not written in stone SO use your\\n clinical judgment in the individual patient: These days you also have to think about the\\n lawyer who may be, sooner or later; evaluating what you did. Keep the lawyer in mind\\n and write for him a brief note in the chart or the EMR. For example: after removing a\\n non-perforated appendix we write: \"No postop antibiotics are indicated because_ And\\n when discharging a patient a day after removing a gangrenous appendix we would\\n write: \"The patient received a 24-hour course of antibiotics which is sufficient_\\n shows that you are a careful surgeon andknow what you are doing-',\n", " 'md': '```markdown\\n## Table 44.1. Duration of Postoperative Antibiotic Therapy\\n\\n| Infection Type | Duration of Antibiotic Therapy |\\n|--------------------------------------------------------------------------------|----------------------------------------|\\n| Contamination: no postoperative antibiotics (assuming appropriate pre-operative prophylaxis administered) | |\\n| - Gastroduodenal peptic perforations operated within 12 hours | |\\n| - Traumatic enteric perforations operated within 12 hours | |\\n| - Peritoneal contamination with bowel contents during elective or emergency procedures | |\\n| - Appendectomy for early or phlegmonous appendicitis | |\\n| - Cholecystectomy for early or phlegmonous cholecystitis | |\\n| \\'Resectable\\' infection: 24-hour postoperative antibiotic course | |\\n| - Appendectomy for gangrenous appendicitis | 24-hour postoperative antibiotic course |\\n| - Cholecystectomy for gangrenous cholecystitis | 24-hour postoperative antibiotic course |\\n| - Bowel resection for ischemic or strangulated necrotic bowel without frank perforation | 24-hour postoperative antibiotic course |\\n| \\'Mild/moderate\\' infection: 2-5 days postoperative antibiotic course | |\\n| - Intra-abdominal infection from diverse sources with localized pus formation | 2-5 days postoperative antibiotic course |\\n| - \\'Late\\' (> 12 hours) traumatic bowel lacerations and gastroduodenal perforation with no established intra-abdominal infection | 2-5 days postoperative antibiotic course |\\n| - Diffuse, established intra-abdominal infection from any source | 2-5 days postoperative antibiotic course |\\n| \\'Severe\\' infection: more than 5 days of postoperative antibiotics | |\\n| - Severe intra-abdominal infection with source not easily controllable (e.g: infected pancreatic necrosis) | more than 5 days of postoperative antibiotics |\\n| - Postoperative intra-abdominal infection | more than 5 days of postoperative antibiotics |\\n\\n> These are what we recommend in general. It is not written in stone, so use your clinical judgment in the individual patient. These days you also have to think about the lawyer who may be, sooner or later, evaluating what you did. Keep the lawyer in mind and write for him a brief note in the chart or the EMR. For example: after removing a non-perforated appendix we write: \"No postop antibiotics are indicated because...\" And when discharging a patient a day after removing a gangrenous appendix we would write: \"The patient received a 24-hour course of antibiotics which is sufficient...\" This shows that you are a careful surgeon and know what you are doing.\\n```',\n", " 'images': [{'name': 'img_p765_1.png',\n", " 'height': 1310,\n", " 'width': 818,\n", " 'x': 72,\n", " 'y': 72,\n", " 'original_width': 1404,\n", " 'original_height': 2368}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 44.1. Duration of Postoperative Antibiotic Therapy',\n", " 'md': '## Table 44.1. Duration of Postoperative Antibiotic Therapy',\n", " 'bBox': {'x': 77.44, 'y': 77.94, 'w': 323.51, 'h': 18.8}},\n", " {'type': 'table',\n", " 'rows': [['Infection Type', 'Duration of Antibiotic Therapy'],\n", " ['Contamination: no postoperative antibiotics (assuming appropriate pre-operative prophylaxis administered)',\n", " ''],\n", " ['- Gastroduodenal peptic perforations operated within 12 hours', ''],\n", " ['- Traumatic enteric perforations operated within 12 hours', ''],\n", " ['- Peritoneal contamination with bowel contents during elective or emergency procedures',\n", " ''],\n", " ['- Appendectomy for early or phlegmonous appendicitis', ''],\n", " ['- Cholecystectomy for early or phlegmonous cholecystitis', ''],\n", " [\"'Resectable' infection: 24-hour postoperative antibiotic course\", ''],\n", " ['- Appendectomy for gangrenous appendicitis',\n", " '24-hour postoperative antibiotic course'],\n", " ['- Cholecystectomy for gangrenous cholecystitis',\n", " '24-hour postoperative antibiotic course'],\n", " ['- Bowel resection for ischemic or strangulated necrotic bowel without frank perforation',\n", " '24-hour postoperative antibiotic course'],\n", " [\"'Mild/moderate' infection: 2-5 days postoperative antibiotic course\",\n", " ''],\n", " ['- Intra-abdominal infection from diverse sources with localized pus formation',\n", " '2-5 days postoperative antibiotic course'],\n", " [\"- 'Late' (> 12 hours) traumatic bowel lacerations and gastroduodenal perforation with no established intra-abdominal infection\",\n", " '2-5 days postoperative antibiotic course'],\n", " ['- Diffuse, established intra-abdominal infection from any source',\n", " '2-5 days postoperative antibiotic course'],\n", " [\"'Severe' infection: more than 5 days of postoperative antibiotics\",\n", " ''],\n", " ['- Severe intra-abdominal infection with source not easily controllable (e.g: infected pancreatic necrosis)',\n", " 'more than 5 days of postoperative antibiotics'],\n", " ['- Postoperative intra-abdominal infection',\n", " 'more than 5 days of postoperative antibiotics']],\n", " 'md': \"| Infection Type | Duration of Antibiotic Therapy |\\n|--------------------------------------------------------------------------------|----------------------------------------|\\n| Contamination: no postoperative antibiotics (assuming appropriate pre-operative prophylaxis administered) | |\\n| - Gastroduodenal peptic perforations operated within 12 hours | |\\n| - Traumatic enteric perforations operated within 12 hours | |\\n| - Peritoneal contamination with bowel contents during elective or emergency procedures | |\\n| - Appendectomy for early or phlegmonous appendicitis | |\\n| - Cholecystectomy for early or phlegmonous cholecystitis | |\\n| 'Resectable' infection: 24-hour postoperative antibiotic course | |\\n| - Appendectomy for gangrenous appendicitis | 24-hour postoperative antibiotic course |\\n| - Cholecystectomy for gangrenous cholecystitis | 24-hour postoperative antibiotic course |\\n| - Bowel resection for ischemic or strangulated necrotic bowel without frank perforation | 24-hour postoperative antibiotic course |\\n| 'Mild/moderate' infection: 2-5 days postoperative antibiotic course | |\\n| - Intra-abdominal infection from diverse sources with localized pus formation | 2-5 days postoperative antibiotic course |\\n| - 'Late' (> 12 hours) traumatic bowel lacerations and gastroduodenal perforation with no established intra-abdominal infection | 2-5 days postoperative antibiotic course |\\n| - Diffuse, established intra-abdominal infection from any source | 2-5 days postoperative antibiotic course |\\n| 'Severe' infection: more than 5 days of postoperative antibiotics | |\\n| - Severe intra-abdominal infection with source not easily controllable (e.g: infected pancreatic necrosis) | more than 5 days of postoperative antibiotics |\\n| - Postoperative intra-abdominal infection | more than 5 days of postoperative antibiotics |\",\n", " 'isPerfectTable': True,\n", " 'csv': '\"Infection Type\",\"Duration of Antibiotic Therapy\"\\n\"Contamination: no postoperative antibiotics (assuming appropriate pre-operative prophylaxis administered)\",\"\"\\n\"- Gastroduodenal peptic perforations operated within 12 hours\",\"\"\\n\"- Traumatic enteric perforations operated within 12 hours\",\"\"\\n\"- Peritoneal contamination with bowel contents during elective or emergency procedures\",\"\"\\n\"- Appendectomy for early or phlegmonous appendicitis\",\"\"\\n\"- Cholecystectomy for early or phlegmonous cholecystitis\",\"\"\\n\"\\'Resectable\\' infection: 24-hour postoperative antibiotic course\",\"\"\\n\"- Appendectomy for gangrenous appendicitis\",\"24-hour postoperative antibiotic course\"\\n\"- Cholecystectomy for gangrenous cholecystitis\",\"24-hour postoperative antibiotic course\"\\n\"- Bowel resection for ischemic or strangulated necrotic bowel without frank perforation\",\"24-hour postoperative antibiotic course\"\\n\"\\'Mild/moderate\\' infection: 2-5 days postoperative antibiotic course\",\"\"\\n\"- Intra-abdominal infection from diverse sources with localized pus formation\",\"2-5 days postoperative antibiotic course\"\\n\"- \\'Late\\' (> 12 hours) traumatic bowel lacerations and gastroduodenal perforation with no established intra-abdominal infection\",\"2-5 days postoperative antibiotic course\"\\n\"- Diffuse, established intra-abdominal infection from any source\",\"2-5 days postoperative antibiotic course\"\\n\"\\'Severe\\' infection: more than 5 days of postoperative antibiotics\",\"\"\\n\"- Severe intra-abdominal infection with source not easily controllable (e.g: infected pancreatic necrosis)\",\"more than 5 days of postoperative antibiotics\"\\n\"- Postoperative intra-abdominal infection\",\"more than 5 days of postoperative antibiotics\"',\n", " 'bBox': {'x': 79.91, 'y': 115.04, 'w': 367.05, 'h': 17.81}},\n", " {'type': 'text',\n", " 'value': '> These are what we recommend in general. It is not written in stone, so use your clinical judgment in the individual patient. These days you also have to think about the lawyer who may be, sooner or later, evaluating what you did. Keep the lawyer in mind and write for him a brief note in the chart or the EMR. For example: after removing a non-perforated appendix we write: \"No postop antibiotics are indicated because...\" And when discharging a patient a day after removing a gangrenous appendix we would write: \"The patient received a 24-hour course of antibiotics which is sufficient...\" This shows that you are a careful surgeon and know what you are doing.\\n```',\n", " 'md': '> These are what we recommend in general. It is not written in stone, so use your clinical judgment in the individual patient. These days you also have to think about the lawyer who may be, sooner or later, evaluating what you did. Keep the lawyer in mind and write for him a brief note in the chart or the EMR. For example: after removing a non-perforated appendix we write: \"No postop antibiotics are indicated because...\" And when discharging a patient a day after removing a gangrenous appendix we would write: \"The patient received a 24-hour course of antibiotics which is sufficient...\" This shows that you are a careful surgeon and know what you are doing.\\n```',\n", " 'bBox': {'x': 79.91, 'y': 579.02, 'w': 368.03, 'h': 15.33}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 767,\n", " 'text': ' In the 1990s, we learned that fever and white cell response are part of\\nthe patient’s inflammatory response to a variety of infective and non-\\ninfective causes. We realized that sterile inflammation is common after\\nany operation, manifesting itself as a local inflammatory response\\nsyndrome (LIRS), or a systemic one (SIRS). Is there a need to\\nadminister antibiotics after the bacteria are already dead?\\n\\n The evolving policy of minimal antibiotic administration (strongly\\nsupported by the Surgical Infection Society — see Mazuski et al 2002 1)\\nrepresents a trend away from the use of postoperative therapeutic\\ncourses of fixed and often long duration; rather, you should attempt to\\nstratify the infective processes into grades of risks, and to tailor the\\nduration of administration to the severity of infection.\\n\\n We recommend the policy summarized in Table 44.1. It is based on\\nthe following arguments:\\n\\n • Conditions representing contamination (e.g. early managed\\n gunshot wound of the colon) do not require postoperative\\n administration since the infectious source has been dealt with at\\n operation; bacteria and adjuvants of infection are effectively\\n removed by the host’s defenses, supplemented by peritoneal toilet,\\n and adequate tissue levels of pre- and intra-operative prophylactic\\n antibiotics. By definition, prophylaxis should not be continued\\n beyond the immediate operative phase. ħaving said this, we\\n won’t send you to the guillotine for giving a few more doses,\\n especially in high-risk patients (e.g. immunosuppressed, morbidly\\n obese, etc).\\n • In processes limited to an organ amenable to excision (‘resectable\\n infection’ — for example, gangrenous appendicitis), the residual\\n bacterial inoculum is minimal. A postoperative antimicrobial\\n course of 24 hours should suffice to sterilize the surrounding\\n inflammatory reaction and deal with gut bacteria, which may\\n have escaped across the necrotic bowel wall by translocation.\\n But again, we won’t ridicule you at the M & M meeting for continuing\\n antibiotics for another day…\\n ‘Non-resectable infections’ with a significant spread beyond the',\n", " 'md': '```markdown\\n## Inflammatory Response and Antibiotic Administration\\n\\nIn the 1990s, we learned that fever and white cell response are part of the patient’s inflammatory response to a variety of infective and non-infective causes. We realized that sterile inflammation is common after any operation, manifesting itself as a local inflammatory response syndrome (LIRS), or a systemic one (SIRS). Is there a need to administer antibiotics after the bacteria are already dead?\\n\\nThe evolving policy of minimal antibiotic administration (strongly supported by the Surgical Infection Society — see Mazuski et al 2002 [1](#)) represents a trend away from the use of postoperative therapeutic courses of fixed and often long duration; rather, you should attempt to stratify the infective processes into grades of risks, and to tailor the duration of administration to the severity of infection.\\n\\nWe recommend the policy summarized in **Table 44.1**. It is based on the following arguments:\\n\\n- Conditions representing contamination (e.g. early managed gunshot wound of the colon) do not require postoperative administration since the infectious source has been dealt with at operation; bacteria and adjuvants of infection are effectively removed by the host’s defenses, supplemented by peritoneal toilet, and adequate tissue levels of pre- and intra-operative prophylactic antibiotics. By definition, prophylaxis should not be continued beyond the immediate operative phase. Having said this, we won’t send you to the guillotine for giving a few more doses, especially in high-risk patients (e.g. immunosuppressed, morbidly obese, etc).\\n- In processes limited to an organ amenable to excision (‘resectable infection’ — for example, gangrenous appendicitis), the residual bacterial inoculum is minimal. A postoperative antimicrobial course of 24 hours should suffice to sterilize the surrounding inflammatory reaction and deal with gut bacteria, which may have escaped across the necrotic bowel wall by translocation. But again, we won’t ridicule you at the M & M meeting for continuing antibiotics for another day…\\n- ‘Non-resectable infections’ with a significant spread beyond the...\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Inflammatory Response and Antibiotic Administration',\n", " 'md': '## Inflammatory Response and Antibiotic Administration',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In the 1990s, we learned that fever and white cell response are part of the patient’s inflammatory response to a variety of infective and non-infective causes. We realized that sterile inflammation is common after any operation, manifesting itself as a local inflammatory response syndrome (LIRS), or a systemic one (SIRS). Is there a need to administer antibiotics after the bacteria are already dead?\\n\\nThe evolving policy of minimal antibiotic administration (strongly supported by the Surgical Infection Society — see Mazuski et al 2002 [1](#)) represents a trend away from the use of postoperative therapeutic courses of fixed and often long duration; rather, you should attempt to stratify the infective processes into grades of risks, and to tailor the duration of administration to the severity of infection.\\n\\nWe recommend the policy summarized in **Table 44.1**. It is based on the following arguments:\\n\\n- Conditions representing contamination (e.g. early managed gunshot wound of the colon) do not require postoperative administration since the infectious source has been dealt with at operation; bacteria and adjuvants of infection are effectively removed by the host’s defenses, supplemented by peritoneal toilet, and adequate tissue levels of pre- and intra-operative prophylactic antibiotics. By definition, prophylaxis should not be continued beyond the immediate operative phase. Having said this, we won’t send you to the guillotine for giving a few more doses, especially in high-risk patients (e.g. immunosuppressed, morbidly obese, etc).\\n- In processes limited to an organ amenable to excision (‘resectable infection’ — for example, gangrenous appendicitis), the residual bacterial inoculum is minimal. A postoperative antimicrobial course of 24 hours should suffice to sterilize the surrounding inflammatory reaction and deal with gut bacteria, which may have escaped across the necrotic bowel wall by translocation. But again, we won’t ridicule you at the M & M meeting for continuing antibiotics for another day…\\n- ‘Non-resectable infections’ with a significant spread beyond the...\\n\\n```',\n", " 'md': 'In the 1990s, we learned that fever and white cell response are part of the patient’s inflammatory response to a variety of infective and non-infective causes. We realized that sterile inflammation is common after any operation, manifesting itself as a local inflammatory response syndrome (LIRS), or a systemic one (SIRS). Is there a need to administer antibiotics after the bacteria are already dead?\\n\\nThe evolving policy of minimal antibiotic administration (strongly supported by the Surgical Infection Society — see Mazuski et al 2002 [1](#)) represents a trend away from the use of postoperative therapeutic courses of fixed and often long duration; rather, you should attempt to stratify the infective processes into grades of risks, and to tailor the duration of administration to the severity of infection.\\n\\nWe recommend the policy summarized in **Table 44.1**. It is based on the following arguments:\\n\\n- Conditions representing contamination (e.g. early managed gunshot wound of the colon) do not require postoperative administration since the infectious source has been dealt with at operation; bacteria and adjuvants of infection are effectively removed by the host’s defenses, supplemented by peritoneal toilet, and adequate tissue levels of pre- and intra-operative prophylactic antibiotics. By definition, prophylaxis should not be continued beyond the immediate operative phase. Having said this, we won’t send you to the guillotine for giving a few more doses, especially in high-risk patients (e.g. immunosuppressed, morbidly obese, etc).\\n- In processes limited to an organ amenable to excision (‘resectable infection’ — for example, gangrenous appendicitis), the residual bacterial inoculum is minimal. A postoperative antimicrobial course of 24 hours should suffice to sterilize the surrounding inflammatory reaction and deal with gut bacteria, which may have escaped across the necrotic bowel wall by translocation. But again, we won’t ridicule you at the M & M meeting for continuing antibiotics for another day…\\n- ‘Non-resectable infections’ with a significant spread beyond the...\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 104, 'w': 467.91, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 768,\n", " 'text': ' • confines of the involved organ (e.g. perforated appendicitis) should\\n be stratified according to their severity. A therapeutic\\n postoperative course of more than 5 days is usually not\\n necessary. ħowever, certain complex situations may need\\n extended courses of postoperative antibiotics. A typical example is\\n infected pancreatic necrosis where the nidus of infection is not\\n readily eradicated in a once-and-for-all surgical procedure.\\n Similarly, patients with postoperative peritonitis, where the\\n control of the source of infection is questionable, should be\\n considered for prolonged antibiotic therapy.\\n\\n It should be quite clear that the commonplace blind, extended antibiotic\\nadministration for as long as fever or leukocytosis are present should be\\nabandoned. Pyrexia and white cell response often represent a sterile,\\nperitoneal (LIRS) or systemic (SIRS), cytokine-mediated, inflammatory\\nresponse; admittedly they may on occasion indicate the presence of a\\nfocus of persistent or recurrent infection. The former situation is self-\\nlimiting and resolves without antibiotics. The latter usually represents\\nsuppurative infection, which should be treated by drainage of the intra-\\nabdominal abscess ( Chapter 46) or the infected wound ( Chapter\\n49). Antibiotic treatment can neither prevent nor treat suppurative\\ninfection; it may only succeed in masking it.\\n\\n By now you should understand that the persistence of\\ninflammation beyond the appropriate therapeutic course is not an\\nindication to continue, restart or change antibiotics. What should be\\navoided is complacent reliance on the advice of the average infectious\\ndisease (ID) specialist; this can only lead to an expensive and often\\nunnecessary diagnostic work-up and, even more alarmingly, to the\\nprescribing of the latest antibiotic agent on the market (e.g. dinnericillin,\\nlunchicillin).\\n\\n What should instead be done first, is to stop the antibiotics. The fever\\nwill subside spontaneously in most patients within a day or two, with little\\nmore than chest physiotherapy. At the same time, a directed search is\\nundertaken for a treatable source of intraperitoneal or\\nextraperitoneal infection. Surgeons are best placed to anticipate',\n", " 'md': '```markdown\\n## Page Content\\n\\n- The confines of the involved organ (e.g. perforated appendicitis) should be stratified according to their severity. A therapeutic postoperative course of more than 5 days is usually not necessary. However, certain complex situations may need extended courses of postoperative antibiotics. A typical example is infected pancreatic necrosis where the nidus of infection is not readily eradicated in a once-and-for-all surgical procedure. Similarly, patients with postoperative peritonitis, where the control of the source of infection is questionable, should be considered for prolonged antibiotic therapy.\\n\\n- It should be quite clear that the commonplace blind, extended antibiotic administration for as long as fever or leukocytosis are present should be abandoned. Pyrexia and white cell response often represent a sterile, peritoneal (LIRS) or systemic (SIRS), cytokine-mediated, inflammatory response; admittedly they may on occasion indicate the presence of a focus of persistent or recurrent infection. The former situation is self-limiting and resolves without antibiotics. The latter usually represents suppurative infection, which should be treated by drainage of the intra-abdominal abscess (Chapter 46) or the infected wound (Chapter 49). Antibiotic treatment can neither prevent nor treat suppurative infection; it may only succeed in masking it.\\n\\n- By now you should understand that the persistence of inflammation beyond the appropriate therapeutic course is not an indication to continue, restart or change antibiotics. What should be avoided is complacent reliance on the advice of the average infectious disease (ID) specialist; this can only lead to an expensive and often unnecessary diagnostic work-up and, even more alarmingly, to the prescribing of the latest antibiotic agent on the market (e.g. dinnericillin, lunchicillin).\\n\\n- What should instead be done first, is to stop the antibiotics. The fever will subside spontaneously in most patients within a day or two, with little more than chest physiotherapy. At the same time, a directed search is undertaken for a treatable source of intraperitoneal or extraperitoneal infection. Surgeons are best placed to anticipate.\\n\\n## Figures and Images\\n\\n- **Figure 1**: \\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The confines of the involved organ (e.g. perforated appendicitis) should be stratified according to their severity. A therapeutic postoperative course of more than 5 days is usually not necessary. However, certain complex situations may need extended courses of postoperative antibiotics. A typical example is infected pancreatic necrosis where the nidus of infection is not readily eradicated in a once-and-for-all surgical procedure. Similarly, patients with postoperative peritonitis, where the control of the source of infection is questionable, should be considered for prolonged antibiotic therapy.\\n\\n- It should be quite clear that the commonplace blind, extended antibiotic administration for as long as fever or leukocytosis are present should be abandoned. Pyrexia and white cell response often represent a sterile, peritoneal (LIRS) or systemic (SIRS), cytokine-mediated, inflammatory response; admittedly they may on occasion indicate the presence of a focus of persistent or recurrent infection. The former situation is self-limiting and resolves without antibiotics. The latter usually represents suppurative infection, which should be treated by drainage of the intra-abdominal abscess (Chapter 46) or the infected wound (Chapter 49). Antibiotic treatment can neither prevent nor treat suppurative infection; it may only succeed in masking it.\\n\\n- By now you should understand that the persistence of inflammation beyond the appropriate therapeutic course is not an indication to continue, restart or change antibiotics. What should be avoided is complacent reliance on the advice of the average infectious disease (ID) specialist; this can only lead to an expensive and often unnecessary diagnostic work-up and, even more alarmingly, to the prescribing of the latest antibiotic agent on the market (e.g. dinnericillin, lunchicillin).\\n\\n- What should instead be done first, is to stop the antibiotics. The fever will subside spontaneously in most patients within a day or two, with little more than chest physiotherapy. At the same time, a directed search is undertaken for a treatable source of intraperitoneal or extraperitoneal infection. Surgeons are best placed to anticipate.',\n", " 'md': '- The confines of the involved organ (e.g. perforated appendicitis) should be stratified according to their severity. A therapeutic postoperative course of more than 5 days is usually not necessary. However, certain complex situations may need extended courses of postoperative antibiotics. A typical example is infected pancreatic necrosis where the nidus of infection is not readily eradicated in a once-and-for-all surgical procedure. Similarly, patients with postoperative peritonitis, where the control of the source of infection is questionable, should be considered for prolonged antibiotic therapy.\\n\\n- It should be quite clear that the commonplace blind, extended antibiotic administration for as long as fever or leukocytosis are present should be abandoned. Pyrexia and white cell response often represent a sterile, peritoneal (LIRS) or systemic (SIRS), cytokine-mediated, inflammatory response; admittedly they may on occasion indicate the presence of a focus of persistent or recurrent infection. The former situation is self-limiting and resolves without antibiotics. The latter usually represents suppurative infection, which should be treated by drainage of the intra-abdominal abscess (Chapter 46) or the infected wound (Chapter 49). Antibiotic treatment can neither prevent nor treat suppurative infection; it may only succeed in masking it.\\n\\n- By now you should understand that the persistence of inflammation beyond the appropriate therapeutic course is not an indication to continue, restart or change antibiotics. What should be avoided is complacent reliance on the advice of the average infectious disease (ID) specialist; this can only lead to an expensive and often unnecessary diagnostic work-up and, even more alarmingly, to the prescribing of the latest antibiotic agent on the market (e.g. dinnericillin, lunchicillin).\\n\\n- What should instead be done first, is to stop the antibiotics. The fever will subside spontaneously in most patients within a day or two, with little more than chest physiotherapy. At the same time, a directed search is undertaken for a treatable source of intraperitoneal or extraperitoneal infection. Surgeons are best placed to anticipate.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.82, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures and Images',\n", " 'md': '## Figures and Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 1**: \\n```',\n", " 'md': '- **Figure 1**: \\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '49). Antibiotic treatment can neither prevent nor treat suppurative'},\n", " {'text': 'abdominal abscess ( Chapter 46) or the infected wound ( Chapter 49). Antibiotic treatment can neither prevent nor treat suppurative infection; it may only succeed in masking it.'}]},\n", " {'page': 769,\n", " 'text': \"complications in their patients, and this is what is meant by a directed\\nsearch: a search that is conducted with the full knowledge of the patient’s\\ninitial disease process, the operative findings and the natural history of\\nthe surgical disease.\\n\\n We have nothing personal against the so-called medical ID specialists\\n— who, at least on this side of the Atlantic, are considered the gurus on\\nantibiotic therapy. But we have reasons to believe that many of them do\\nnot understand the concept of ‘surgical’ infection and how it differs from\\n‘medical’ infections (see Table 44.2). So let them focus on HIV, TB\\nand the Ebola virus.\\n Table 44.2. Differences between 'medical' and 'surgical'\\n infections.\\n Medical infection (eg: pneumonia)| Surgical infection (e.g. appendicitis)\\n Not amenable to surgical source control Amenable to surgical source control\\n Antibiotics mainstay of treatment Antibiotics only an adjunct to source control\\n A host of potential causative organisms Predictable causative organisms\\n Prolonged formal course of antibiotics Antibiotics tailored to operative findings\\n We are aware that there are local variations in the ‘usefulness’ of ID specialists and\\n consequently their understanding of surgical infections. If you do not recognize the somewhat\\n bleak description above then be sure to modify your attitude to your own experts accordingly.\\n The Editors\\n\\n We hope that you realize that unnecessary antibiotics are wrong\\nbecause anything unnecessary in medicine is bad medicine. In addition,\\nthe price to be paid is high, not only financially. Antibiotics are associated\\nwith patient-specific adverse effects (the list is long, think of the gravity of\\nC. difficile colitis) and ecological repercussions such as drug-resistant\\nnosocomial infections in your hospital.\",\n", " 'md': \"```markdown\\n## Text\\n\\nComplications in their patients, and this is what is meant by a directed search: a search that is conducted with the full knowledge of the patient’s initial disease process, the operative findings, and the natural history of the surgical disease.\\n\\nWe have nothing personal against the so-called medical ID specialists — who, at least on this side of the Atlantic, are considered the gurus on antibiotic therapy. But we have reasons to believe that many of them do not understand the concept of ‘surgical’ infection and how it differs from ‘medical’ infections (see Table 44.2). So let them focus on HIV, TB, and the Ebola virus.\\n\\n## Table 44.2. Differences between 'medical' and 'surgical' infections.\\n\\n| Medical infection (e.g., pneumonia) | Surgical infection (e.g., appendicitis) |\\n|---------------------------------------------------------|---------------------------------------------------------|\\n| Not amenable to surgical source control | Amenable to surgical source control |\\n| Antibiotics mainstay of treatment | Antibiotics only an adjunct to source control |\\n| A host of potential causative organisms | Predictable causative organisms |\\n| Prolonged formal course of antibiotics | Antibiotics tailored to operative findings |\\n\\nWe are aware that there are local variations in the ‘usefulness’ of ID specialists and consequently their understanding of surgical infections. If you do not recognize the somewhat bleak description above then be sure to modify your attitude to your own experts accordingly. The Editors.\\n\\nWe hope that you realize that unnecessary antibiotics are wrong because anything unnecessary in medicine is bad medicine. In addition, the price to be paid is high, not only financially. Antibiotics are associated with patient-specific adverse effects (the list is long, think of the gravity of C. difficile colitis) and ecological repercussions such as drug-resistant nosocomial infections in your hospital.\\n```\",\n", " 'images': [{'name': 'img_p768_1.png',\n", " 'height': 425,\n", " 'width': 812,\n", " 'x': 105.11999999999989,\n", " 'y': 267.12,\n", " 'original_width': 1394,\n", " 'original_height': 730}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Complications in their patients, and this is what is meant by a directed search: a search that is conducted with the full knowledge of the patient’s initial disease process, the operative findings, and the natural history of the surgical disease.\\n\\nWe have nothing personal against the so-called medical ID specialists — who, at least on this side of the Atlantic, are considered the gurus on antibiotic therapy. But we have reasons to believe that many of them do not understand the concept of ‘surgical’ infection and how it differs from ‘medical’ infections (see Table 44.2). So let them focus on HIV, TB, and the Ebola virus.',\n", " 'md': 'Complications in their patients, and this is what is meant by a directed search: a search that is conducted with the full knowledge of the patient’s initial disease process, the operative findings, and the natural history of the surgical disease.\\n\\nWe have nothing personal against the so-called medical ID specialists — who, at least on this side of the Atlantic, are considered the gurus on antibiotic therapy. But we have reasons to believe that many of them do not understand the concept of ‘surgical’ infection and how it differs from ‘medical’ infections (see Table 44.2). So let them focus on HIV, TB, and the Ebola virus.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.97, 'h': 14.84}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': \"Table 44.2. Differences between 'medical' and 'surgical' infections.\",\n", " 'md': \"## Table 44.2. Differences between 'medical' and 'surgical' infections.\",\n", " 'bBox': {'x': 109.08, 'y': 272.56, 'w': 403.24, 'h': 17.81}},\n", " {'type': 'table',\n", " 'rows': [['Medical infection (e.g., pneumonia)',\n", " 'Surgical infection (e.g., appendicitis)'],\n", " ['Not amenable to surgical source control',\n", " 'Amenable to surgical source control'],\n", " ['Antibiotics mainstay of treatment',\n", " 'Antibiotics only an adjunct to source control'],\n", " ['A host of potential causative organisms',\n", " 'Predictable causative organisms'],\n", " ['Prolonged formal course of antibiotics',\n", " 'Antibiotics tailored to operative findings']],\n", " 'md': '| Medical infection (e.g., pneumonia) | Surgical infection (e.g., appendicitis) |\\n|---------------------------------------------------------|---------------------------------------------------------|\\n| Not amenable to surgical source control | Amenable to surgical source control |\\n| Antibiotics mainstay of treatment | Antibiotics only an adjunct to source control |\\n| A host of potential causative organisms | Predictable causative organisms |\\n| Prolonged formal course of antibiotics | Antibiotics tailored to operative findings |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Medical infection (e.g., pneumonia)\",\"Surgical infection (e.g., appendicitis)\"\\n\"Not amenable to surgical source control\",\"Amenable to surgical source control\"\\n\"Antibiotics mainstay of treatment\",\"Antibiotics only an adjunct to source control\"\\n\"A host of potential causative organisms\",\"Predictable causative organisms\"\\n\"Prolonged formal course of antibiotics\",\"Antibiotics tailored to operative findings\"',\n", " 'bBox': {'x': 109.57, 'y': 273.06, 'w': 202.36, 'h': 90.03}},\n", " {'type': 'text',\n", " 'value': 'We are aware that there are local variations in the ‘usefulness’ of ID specialists and consequently their understanding of surgical infections. If you do not recognize the somewhat bleak description above then be sure to modify your attitude to your own experts accordingly. The Editors.\\n\\nWe hope that you realize that unnecessary antibiotics are wrong because anything unnecessary in medicine is bad medicine. In addition, the price to be paid is high, not only financially. Antibiotics are associated with patient-specific adverse effects (the list is long, think of the gravity of C. difficile colitis) and ecological repercussions such as drug-resistant nosocomial infections in your hospital.\\n```',\n", " 'md': 'We are aware that there are local variations in the ‘usefulness’ of ID specialists and consequently their understanding of surgical infections. If you do not recognize the somewhat bleak description above then be sure to modify your attitude to your own experts accordingly. The Editors.\\n\\nWe hope that you realize that unnecessary antibiotics are wrong because anything unnecessary in medicine is bad medicine. In addition, the price to be paid is high, not only financially. Antibiotics are associated with patient-specific adverse effects (the list is long, think of the gravity of C. difficile colitis) and ecological repercussions such as drug-resistant nosocomial infections in your hospital.\\n```',\n", " 'bBox': {'x': 72, 'y': 273.06, 'w': 467.81, 'h': 15.83}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 770,\n", " 'text': ' Are you convinced?\\n\\n Start antibiotics prior to any emergency laparotomy; whether to continue administration after\\n the operation depends on your findings. Know the target flora and use the cheapest and\\n simplest regimen. The bacteria cannot be confused, nor should you be.\\n\\n1 Mazuski JE, Sawyer RG, Nathens AB, et al. Surgical Infection Society Guidelines on\\n antimicrobial therapy for intra-abdominal infections. Surg Infect 2002; 3: 161-73.',\n", " 'md': '```markdown\\n## Page Content\\n\\nAre you convinced?\\n\\nStart antibiotics prior to any emergency laparotomy; whether to continue administration after the operation depends on your findings. Know the target flora and use the cheapest and simplest regimen. The bacteria cannot be confused, nor should you be.\\n\\n1. Mazuski JE, Sawyer RG, Nathens AB, et al. Surgical Infection Society Guidelines on antimicrobial therapy for intra-abdominal infections. Surg Infect 2002; 3: 161-73. [Link](https://doi.org/10.1089/sur.2002.3.161)\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Are you convinced?\\n\\nStart antibiotics prior to any emergency laparotomy; whether to continue administration after the operation depends on your findings. Know the target flora and use the cheapest and simplest regimen. The bacteria cannot be confused, nor should you be.\\n\\n1. Mazuski JE, Sawyer RG, Nathens AB, et al. Surgical Infection Society Guidelines on antimicrobial therapy for intra-abdominal infections. Surg Infect 2002; 3: 161-73. [Link](https://doi.org/10.1089/sur.2002.3.161)\\n\\n```',\n", " 'md': 'Are you convinced?\\n\\nStart antibiotics prior to any emergency laparotomy; whether to continue administration after the operation depends on your findings. Know the target flora and use the cheapest and simplest regimen. The bacteria cannot be confused, nor should you be.\\n\\n1. Mazuski JE, Sawyer RG, Nathens AB, et al. Surgical Infection Society Guidelines on antimicrobial therapy for intra-abdominal infections. Surg Infect 2002; 3: 161-73. [Link](https://doi.org/10.1089/sur.2002.3.161)\\n\\n```',\n", " 'bBox': {'x': 73, 'y': 85, 'w': 380.52, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 771,\n", " 'text': 'Chapter 45\\nPostoperative ileus vs. intestinal obstruction\\nMoshe Schein\\n\\n In ileus the belly becomes hard, there are no motions, the\\n whole abdomen is painful, there are fever and thirst and\\n sometimes the patient is so tormented that he vomits bile…\\n Medicines are not retained and enemas do not penetrate. It\\n is an acute and dangerous disease.\\n Hippocrates\\n\\n Five days ago you removed this patient’s perforated appendix; you\\ngave him antibiotics for 2-3 days, and by today you expected him to eat\\nand go home. Instead, your patient lies in bed with a long face and a\\ndistended abdomen, vomiting bile from time to time. The wife looks at\\nyou suspiciously/accusingly and says: “our son had his appendix out in\\nMinneapolis… he went home on the same day.” The daughter refuses to\\nmeet your eyes; you overhear her whispering to her mother: “we\\nshouldn’t have let him have the operation in this provincial s**thole.” So\\nwhat is the problem? And what now?\\n\\n Definitions and mechanisms\\n\\n The term ‘ileus’ as used in this book, and in daily practice,\\nsignifies a ‘paralytic ileus’ — as distinct from mechanical ileus,\\nwhich is a synonym for intestinal obstruction. In essence, the latter\\nconsists of a mechanical stoppage to the normal transit along the\\nintestine whereas the former denotes hindered transit because the',\n", " 'md': '```markdown\\n# Chapter 45\\n## Postoperative ileus vs. intestinal obstruction\\n### Moshe Schein\\n\\n> \"In ileus the belly becomes hard, there are no motions, the whole abdomen is painful, there are fever and thirst and sometimes the patient is so tormented that he vomits bile… Medicines are not retained and enemas do not penetrate. It is an acute and dangerous disease.\"\\n> — Hippocrates\\n\\nFive days ago you removed this patient’s perforated appendix; you gave him antibiotics for 2-3 days, and by today you expected him to eat and go home. Instead, your patient lies in bed with a long face and a distended abdomen, vomiting bile from time to time. The wife looks at you suspiciously/accusingly and says: “our son had his appendix out in Minneapolis… he went home on the same day.” The daughter refuses to meet your eyes; you overhear her whispering to her mother: “we shouldn’t have let him have the operation in this provincial s**thole.” So what is the problem? And what now?\\n\\n## Definitions and mechanisms\\n\\nThe term ‘ileus’ as used in this book, and in daily practice, signifies a ‘paralytic ileus’ — as distinct from mechanical ileus, which is a synonym for intestinal obstruction. In essence, the latter consists of a mechanical stoppage to the normal transit along the intestine whereas the former denotes hindered transit because the\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 45',\n", " 'md': '# Chapter 45',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 148.79, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Postoperative ileus vs. intestinal obstruction',\n", " 'md': '## Postoperative ileus vs. intestinal obstruction',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 390.83, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Moshe Schein',\n", " 'md': '### Moshe Schein',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 91.18, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '> \"In ileus the belly becomes hard, there are no motions, the whole abdomen is painful, there are fever and thirst and sometimes the patient is so tormented that he vomits bile… Medicines are not retained and enemas do not penetrate. It is an acute and dangerous disease.\"\\n> — Hippocrates\\n\\nFive days ago you removed this patient’s perforated appendix; you gave him antibiotics for 2-3 days, and by today you expected him to eat and go home. Instead, your patient lies in bed with a long face and a distended abdomen, vomiting bile from time to time. The wife looks at you suspiciously/accusingly and says: “our son had his appendix out in Minneapolis… he went home on the same day.” The daughter refuses to meet your eyes; you overhear her whispering to her mother: “we shouldn’t have let him have the operation in this provincial s**thole.” So what is the problem? And what now?',\n", " 'md': '> \"In ileus the belly becomes hard, there are no motions, the whole abdomen is painful, there are fever and thirst and sometimes the patient is so tormented that he vomits bile… Medicines are not retained and enemas do not penetrate. It is an acute and dangerous disease.\"\\n> — Hippocrates\\n\\nFive days ago you removed this patient’s perforated appendix; you gave him antibiotics for 2-3 days, and by today you expected him to eat and go home. Instead, your patient lies in bed with a long face and a distended abdomen, vomiting bile from time to time. The wife looks at you suspiciously/accusingly and says: “our son had his appendix out in Minneapolis… he went home on the same day.” The daughter refuses to meet your eyes; you overhear her whispering to her mother: “we shouldn’t have let him have the operation in this provincial s**thole.” So what is the problem? And what now?',\n", " 'bBox': {'x': 72, 'y': 342, 'w': 467.77, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Definitions and mechanisms',\n", " 'md': '## Definitions and mechanisms',\n", " 'bBox': {'x': 86, 'y': 610, 'w': 224.37, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The term ‘ileus’ as used in this book, and in daily practice, signifies a ‘paralytic ileus’ — as distinct from mechanical ileus, which is a synonym for intestinal obstruction. In essence, the latter consists of a mechanical stoppage to the normal transit along the intestine whereas the former denotes hindered transit because the\\n```',\n", " 'md': 'The term ‘ileus’ as used in this book, and in daily practice, signifies a ‘paralytic ileus’ — as distinct from mechanical ileus, which is a synonym for intestinal obstruction. In essence, the latter consists of a mechanical stoppage to the normal transit along the intestine whereas the former denotes hindered transit because the\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers or footers.\\n- There are no formulas present to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 772,\n", " 'text': 'intestines are ‘lazy’.\\n\\n In previous chapters you noted that ileus of the small bowel, colon or\\nboth, can be secondary to a variety of intra-abdominal (e.g. acute\\nappendicitis), retroperitoneal (e.g. hematoma) or extra-abdominal (e.g.\\nhypokalemia) causes, which adversely affect normal intestinal motility.\\nFollowing abdominal operations, however, ileus is a ‘normal’\\nphenomenon — its extent directly proportional to the complexity of\\nthe operation. In general, the more you do within the abdomen, the\\nmore you manipulate, the more prolonged will be the postoperative\\nileus.\\n\\n Ileus\\n\\n Unlike mechanical intestinal obstruction, which involves a segment of\\nthe (small) bowel, postoperative ileus concerns the whole length of\\nthe gut, from the stomach to the rectum. The physiological postoperative\\nileus resolves gradually. The small bowel resumes activity almost\\nimmediately, followed, a day or so later, by the stomach, and then the\\ncolon, being the laziest, is the last to start moving.\\n\\n The magnitude of postoperative ileus correlates to some extent\\nwith that of the operation performed and the specific underlying\\ncondition. Major dissections, prolonged intestinal displacement and\\nexposure, denuded and inflamed peritoneum, residual intraperitoneal or\\nretroperitoneal pus or clots, are associated with a prolonged ileus. Thus,\\nfor example, after simple appendectomy for non-perforated appendicitis,\\nileus should be almost non-existent, whereas after a laparotomy for a\\nruptured abdominal aortic aneurysm expect the ileus to be prolonged.\\nCommon postoperative factors, which can aggravate ileus, are the\\nadministration of opiates and an electrolyte imbalance. It seems that,\\nin general, laparoscopic abdominal procedures are followed with a lesser\\nmagnitude of ileus than their ‘open’ counterparts.\\n\\n While the physiological postoperative ileus is diffuse, ileus due to\\ncomplications may be local. A classic example is a postoperative\\nabscess that may ‘paralyze’ an adjacent segment of bowel. Other',\n", " 'md': '```markdown\\n## Postoperative Ileus\\n\\nIntestines are ‘lazy’.\\n\\nIn previous chapters, you noted that ileus of the small bowel, colon, or both can be secondary to a variety of intra-abdominal (e.g., acute appendicitis), retroperitoneal (e.g., hematoma), or extra-abdominal (e.g., hypokalemia) causes, which adversely affect normal intestinal motility. Following abdominal operations, however, ileus is a ‘normal’ phenomenon — its extent directly proportional to the complexity of the operation. In general, the more you do within the abdomen, the more you manipulate, the more prolonged will be the postoperative ileus.\\n\\n### Ileus\\n\\nUnlike mechanical intestinal obstruction, which involves a segment of the (small) bowel, postoperative ileus concerns the whole length of the gut, from the stomach to the rectum. The physiological postoperative ileus resolves gradually. The small bowel resumes activity almost immediately, followed, a day or so later, by the stomach, and then the colon, being the laziest, is the last to start moving.\\n\\nThe magnitude of postoperative ileus correlates to some extent with that of the operation performed and the specific underlying condition. Major dissections, prolonged intestinal displacement and exposure, denuded and inflamed peritoneum, residual intraperitoneal or retroperitoneal pus or clots, are associated with a prolonged ileus. Thus, for example, after simple appendectomy for non-perforated appendicitis, ileus should be almost non-existent, whereas after a laparotomy for a ruptured abdominal aortic aneurysm expect the ileus to be prolonged. Common postoperative factors, which can aggravate ileus, are the administration of opiates and an electrolyte imbalance. It seems that, in general, laparoscopic abdominal procedures are followed with a lesser magnitude of ileus than their ‘open’ counterparts.\\n\\nWhile the physiological postoperative ileus is diffuse, ileus due to complications may be local. A classic example is a postoperative abscess that may ‘paralyze’ an adjacent segment of bowel.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Postoperative Ileus',\n", " 'md': '## Postoperative Ileus',\n", " 'bBox': {'x': 86, 'y': 296, 'w': 37.7, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Intestines are ‘lazy’.\\n\\nIn previous chapters, you noted that ileus of the small bowel, colon, or both can be secondary to a variety of intra-abdominal (e.g., acute appendicitis), retroperitoneal (e.g., hematoma), or extra-abdominal (e.g., hypokalemia) causes, which adversely affect normal intestinal motility. Following abdominal operations, however, ileus is a ‘normal’ phenomenon — its extent directly proportional to the complexity of the operation. In general, the more you do within the abdomen, the more you manipulate, the more prolonged will be the postoperative ileus.',\n", " 'md': 'Intestines are ‘lazy’.\\n\\nIn previous chapters, you noted that ileus of the small bowel, colon, or both can be secondary to a variety of intra-abdominal (e.g., acute appendicitis), retroperitoneal (e.g., hematoma), or extra-abdominal (e.g., hypokalemia) causes, which adversely affect normal intestinal motility. Following abdominal operations, however, ileus is a ‘normal’ phenomenon — its extent directly proportional to the complexity of the operation. In general, the more you do within the abdomen, the more you manipulate, the more prolonged will be the postoperative ileus.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.76, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Ileus',\n", " 'md': '### Ileus',\n", " 'bBox': {'x': 86, 'y': 296, 'w': 37.7, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Unlike mechanical intestinal obstruction, which involves a segment of the (small) bowel, postoperative ileus concerns the whole length of the gut, from the stomach to the rectum. The physiological postoperative ileus resolves gradually. The small bowel resumes activity almost immediately, followed, a day or so later, by the stomach, and then the colon, being the laziest, is the last to start moving.\\n\\nThe magnitude of postoperative ileus correlates to some extent with that of the operation performed and the specific underlying condition. Major dissections, prolonged intestinal displacement and exposure, denuded and inflamed peritoneum, residual intraperitoneal or retroperitoneal pus or clots, are associated with a prolonged ileus. Thus, for example, after simple appendectomy for non-perforated appendicitis, ileus should be almost non-existent, whereas after a laparotomy for a ruptured abdominal aortic aneurysm expect the ileus to be prolonged. Common postoperative factors, which can aggravate ileus, are the administration of opiates and an electrolyte imbalance. It seems that, in general, laparoscopic abdominal procedures are followed with a lesser magnitude of ileus than their ‘open’ counterparts.\\n\\nWhile the physiological postoperative ileus is diffuse, ileus due to complications may be local. A classic example is a postoperative abscess that may ‘paralyze’ an adjacent segment of bowel.\\n```',\n", " 'md': 'Unlike mechanical intestinal obstruction, which involves a segment of the (small) bowel, postoperative ileus concerns the whole length of the gut, from the stomach to the rectum. The physiological postoperative ileus resolves gradually. The small bowel resumes activity almost immediately, followed, a day or so later, by the stomach, and then the colon, being the laziest, is the last to start moving.\\n\\nThe magnitude of postoperative ileus correlates to some extent with that of the operation performed and the specific underlying condition. Major dissections, prolonged intestinal displacement and exposure, denuded and inflamed peritoneum, residual intraperitoneal or retroperitoneal pus or clots, are associated with a prolonged ileus. Thus, for example, after simple appendectomy for non-perforated appendicitis, ileus should be almost non-existent, whereas after a laparotomy for a ruptured abdominal aortic aneurysm expect the ileus to be prolonged. Common postoperative factors, which can aggravate ileus, are the administration of opiates and an electrolyte imbalance. It seems that, in general, laparoscopic abdominal procedures are followed with a lesser magnitude of ileus than their ‘open’ counterparts.\\n\\nWhile the physiological postoperative ileus is diffuse, ileus due to complications may be local. A classic example is a postoperative abscess that may ‘paralyze’ an adjacent segment of bowel.\\n```',\n", " 'bBox': {'x': 72, 'y': 253, 'w': 467.6, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 773,\n", " 'text': 'examples include a localized leak from an ileo-transverse anastomosis\\nafter right hemicolectomy that may paralyze the adjacent duodenum,\\nmimicking a picture of gastric outlet obstruction, or a pancreatic\\nphlegmon paralyzing the adjacent stomach.\\n\\n Early postoperative mechanical intestinal obstruction\\n\\n You have become familiar with small bowel obstruction (SBO) in\\nChapter 21. Early postoperative SBO (EPSBO) is defined as one\\ndeveloping immediately after the operation or within 4 weeks. Two\\nprimary mechanisms are responsible: adhesions and internal hernia.\\n\\n Early post-laparotomy adhesions are immature, inflammatory, poor in\\ncollagen — thus ‘soft’ — and vascular. Such characteristics indicate\\nthat early adhesions may resolve spontaneously and that surgical\\nlysis may be difficult, traumatic to involved viscera, and bloody.\\n\\n Postoperative adhesions may be diffuse, involving the whole length of\\nthe small bowel at multiple sites, as is occasionally seen following\\nextensive lysis of adhesions for SBO. Localized obstructing adhesions\\nmay also develop at the operative site with the bowel adherent, for\\ninstance, to exposed mesh or raw peritoneal surfaces.\\n\\n The operation also may create new potential spaces in which the\\nbowel can become trapped and obstructed — forming internal\\nhernias. Typical examples are the partially closed pelvic peritoneum after\\nabdominoperineal resection, or the space behind an emerging colostomy.\\nThe narrower the opening into the space, the more likely the bowel is to\\nbe trapped. And let us not forget trocar sites!\\n\\n Diagnosis\\n\\n Failure of your patient to eat, pass flatus or evacuate his bowel\\nwithin 5 days after a laparotomy signifies a persistent ileus or a\\npossible EPSBO. This does not mean that you do not start worrying\\nmuch earlier — it depends on the individual case. So, for example, you\\nwould be much more concerned about a patient developing vomiting and',\n", " 'md': '```markdown\\n## Early Postoperative Mechanical Intestinal Obstruction\\n\\nExamples include a localized leak from an ileo-transverse anastomosis after right hemicolectomy that may paralyze the adjacent duodenum, mimicking a picture of gastric outlet obstruction, or a pancreatic phlegmon paralyzing the adjacent stomach.\\n\\n### Definition\\nEarly postoperative small bowel obstruction (EPSBO) is defined as one developing immediately after the operation or within 4 weeks. Two primary mechanisms are responsible: adhesions and internal hernia.\\n\\n### Early Post-laparotomy Adhesions\\nEarly post-laparotomy adhesions are immature, inflammatory, poor in collagen — thus ‘soft’ — and vascular. Such characteristics indicate that early adhesions may resolve spontaneously and that surgical lysis may be difficult, traumatic to involved viscera, and bloody.\\n\\nPostoperative adhesions may be diffuse, involving the whole length of the small bowel at multiple sites, as is occasionally seen following extensive lysis of adhesions for SBO. Localized obstructing adhesions may also develop at the operative site with the bowel adherent, for instance, to exposed mesh or raw peritoneal surfaces.\\n\\n### Internal Hernias\\nThe operation may also create new potential spaces in which the bowel can become trapped and obstructed — forming internal hernias. Typical examples are the partially closed pelvic peritoneum after abdominoperineal resection, or the space behind an emerging colostomy. The narrower the opening into the space, the more likely the bowel is to be trapped. And let us not forget trocar sites!\\n\\n### Diagnosis\\nFailure of your patient to eat, pass flatus, or evacuate his bowel within 5 days after a laparotomy signifies a persistent ileus or a possible EPSBO. This does not mean that you do not start worrying much earlier — it depends on the individual case. So, for example, you would be much more concerned about a patient developing vomiting and...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Early Postoperative Mechanical Intestinal Obstruction',\n", " 'md': '## Early Postoperative Mechanical Intestinal Obstruction',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 421.14, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Examples include a localized leak from an ileo-transverse anastomosis after right hemicolectomy that may paralyze the adjacent duodenum, mimicking a picture of gastric outlet obstruction, or a pancreatic phlegmon paralyzing the adjacent stomach.',\n", " 'md': 'Examples include a localized leak from an ileo-transverse anastomosis after right hemicolectomy that may paralyze the adjacent duodenum, mimicking a picture of gastric outlet obstruction, or a pancreatic phlegmon paralyzing the adjacent stomach.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 277.49, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Definition',\n", " 'md': '### Definition',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Early postoperative small bowel obstruction (EPSBO) is defined as one developing immediately after the operation or within 4 weeks. Two primary mechanisms are responsible: adhesions and internal hernia.',\n", " 'md': 'Early postoperative small bowel obstruction (EPSBO) is defined as one developing immediately after the operation or within 4 weeks. Two primary mechanisms are responsible: adhesions and internal hernia.',\n", " 'bBox': {'x': 72, 'y': 264, 'w': 449, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Early Post-laparotomy Adhesions',\n", " 'md': '### Early Post-laparotomy Adhesions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Early post-laparotomy adhesions are immature, inflammatory, poor in collagen — thus ‘soft’ — and vascular. Such characteristics indicate that early adhesions may resolve spontaneously and that surgical lysis may be difficult, traumatic to involved viscera, and bloody.\\n\\nPostoperative adhesions may be diffuse, involving the whole length of the small bowel at multiple sites, as is occasionally seen following extensive lysis of adhesions for SBO. Localized obstructing adhesions may also develop at the operative site with the bowel adherent, for instance, to exposed mesh or raw peritoneal surfaces.',\n", " 'md': 'Early post-laparotomy adhesions are immature, inflammatory, poor in collagen — thus ‘soft’ — and vascular. Such characteristics indicate that early adhesions may resolve spontaneously and that surgical lysis may be difficult, traumatic to involved viscera, and bloody.\\n\\nPostoperative adhesions may be diffuse, involving the whole length of the small bowel at multiple sites, as is occasionally seen following extensive lysis of adhesions for SBO. Localized obstructing adhesions may also develop at the operative site with the bowel adherent, for instance, to exposed mesh or raw peritoneal surfaces.',\n", " 'bBox': {'x': 72, 'y': 299, 'w': 466.74, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Internal Hernias',\n", " 'md': '### Internal Hernias',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The operation may also create new potential spaces in which the bowel can become trapped and obstructed — forming internal hernias. Typical examples are the partially closed pelvic peritoneum after abdominoperineal resection, or the space behind an emerging colostomy. The narrower the opening into the space, the more likely the bowel is to be trapped. And let us not forget trocar sites!',\n", " 'md': 'The operation may also create new potential spaces in which the bowel can become trapped and obstructed — forming internal hernias. Typical examples are the partially closed pelvic peritoneum after abdominoperineal resection, or the space behind an emerging colostomy. The narrower the opening into the space, the more likely the bowel is to be trapped. And let us not forget trocar sites!',\n", " 'bBox': {'x': 72, 'y': 519, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diagnosis',\n", " 'md': '### Diagnosis',\n", " 'bBox': {'x': 86, 'y': 612, 'w': 79.09, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Failure of your patient to eat, pass flatus, or evacuate his bowel within 5 days after a laparotomy signifies a persistent ileus or a possible EPSBO. This does not mean that you do not start worrying much earlier — it depends on the individual case. So, for example, you would be much more concerned about a patient developing vomiting and...\\n```',\n", " 'md': 'Failure of your patient to eat, pass flatus, or evacuate his bowel within 5 days after a laparotomy signifies a persistent ileus or a possible EPSBO. This does not mean that you do not start worrying much earlier — it depends on the individual case. So, for example, you would be much more concerned about a patient developing vomiting and...\\n```',\n", " 'bBox': {'x': 72, 'y': 697, 'w': 467.46, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 21. developing immediately after the operation or within 4 weeks'}]},\n", " {'page': 774,\n", " 'text': 'abdominal distension, a day after a repair of his umbilical hernia than\\nafter undergoing a total colectomy.\\n\\n In ileus, the abdomen is usually distended and silent to auscultation.\\nPlain abdominal X-ray typically shows significant gaseous distension of\\nboth the small bowel and the colon ( Chapters 4 and 5). ħowever, the\\ndiagnosis of EPSBO in the recently operated abdomen is much subtler.\\nTextbooks teach you that on abdominal auscultation “ileus is silent and\\nSBO noisy” — this may be theoretically true but almost impossible to\\nassess in the recently operated upon belly.\\n\\n If your patient has already passed flatus or defecated and then ceases to manifest these\\n comforting features, SBO is the most likely diagnosis. The truth is that in most\\n instances the patient will improve spontaneously without you ever knowing whether it\\n was an EPSBO or just an ileus.\\n\\n The natural tendency of the operating surgeon is to attribute the ‘failure\\nto progress’ to an ileus rather than SBO and to procrastinate.\\nProcrastination is not a good idea, however. A distended and non-eating\\npatient is prone to the iatrogenic hazards of nasogastric tubes,\\nintravenous lines, parenteral nutrition, and bed rest ( Chapter 42). Be\\nactive and proceed with diagnostic steps in parallel to therapy.\\n\\n Prevention and management\\n\\n There is no need to remind you that optimal peri-operative\\nmanagement (e.g. avoiding overhydration — tissue swelling) and a\\nperfect operation can help prevent ileus or decrease its severity. Correct\\npostoperative management (your cliché ridden nurse-managers would\\nuse the term ‘ERAS’ or ‘goal-directed’…) would have beneficial effects as\\nwell.\\n\\n What else can you do?\\n\\n • Reduce the dose and duration of opiates which are the most',\n", " 'md': '```markdown\\n## Abdominal Distension and Ileus\\n\\nAbdominal distension is observed a day after a repair of an umbilical hernia, more so than after undergoing a total colectomy.\\n\\nIn ileus, the abdomen is usually distended and silent to auscultation. Plain abdominal X-ray typically shows significant gaseous distension of both the small bowel and the colon (Chapters 4 and 5). However, the diagnosis of EPSBO (Early Postoperative Small Bowel Obstruction) in the recently operated abdomen is much subtler. Textbooks teach that on abdominal auscultation “ileus is silent and SBO (Small Bowel Obstruction) noisy” — this may be theoretically true but almost impossible to assess in the recently operated abdomen.\\n\\nIf your patient has already passed flatus or defecated and then ceases to manifest these comforting features, SBO is the most likely diagnosis. The truth is that in most instances, the patient will improve spontaneously without you ever knowing whether it was an EPSBO or just an ileus.\\n\\nThe natural tendency of the operating surgeon is to attribute the ‘failure to progress’ to an ileus rather than SBO and to procrastinate. Procrastination is not a good idea, however. A distended and non-eating patient is prone to the iatrogenic hazards of nasogastric tubes, intravenous lines, parenteral nutrition, and bed rest (Chapter 42). Be active and proceed with diagnostic steps in parallel to therapy.\\n\\n### Prevention and Management\\n\\nThere is no need to remind you that optimal peri-operative management (e.g., avoiding overhydration — tissue swelling) and a perfect operation can help prevent ileus or decrease its severity. Correct postoperative management (your cliché-ridden nurse-managers would use the term ‘ERAS’ or ‘goal-directed’…) would have beneficial effects as well.\\n\\n### What Else Can You Do?\\n\\n- Reduce the dose and duration of opiates which are the most...\\n```\\n\\n### Notes:\\n- The text has been extracted and structured into markdown format.\\n- No images or figures were identified on this page.\\n- The text has been organized into sections for clarity.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abdominal Distension and Ileus',\n", " 'md': '## Abdominal Distension and Ileus',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Abdominal distension is observed a day after a repair of an umbilical hernia, more so than after undergoing a total colectomy.\\n\\nIn ileus, the abdomen is usually distended and silent to auscultation. Plain abdominal X-ray typically shows significant gaseous distension of both the small bowel and the colon (Chapters 4 and 5). However, the diagnosis of EPSBO (Early Postoperative Small Bowel Obstruction) in the recently operated abdomen is much subtler. Textbooks teach that on abdominal auscultation “ileus is silent and SBO (Small Bowel Obstruction) noisy” — this may be theoretically true but almost impossible to assess in the recently operated abdomen.\\n\\nIf your patient has already passed flatus or defecated and then ceases to manifest these comforting features, SBO is the most likely diagnosis. The truth is that in most instances, the patient will improve spontaneously without you ever knowing whether it was an EPSBO or just an ileus.\\n\\nThe natural tendency of the operating surgeon is to attribute the ‘failure to progress’ to an ileus rather than SBO and to procrastinate. Procrastination is not a good idea, however. A distended and non-eating patient is prone to the iatrogenic hazards of nasogastric tubes, intravenous lines, parenteral nutrition, and bed rest (Chapter 42). Be active and proceed with diagnostic steps in parallel to therapy.',\n", " 'md': 'Abdominal distension is observed a day after a repair of an umbilical hernia, more so than after undergoing a total colectomy.\\n\\nIn ileus, the abdomen is usually distended and silent to auscultation. Plain abdominal X-ray typically shows significant gaseous distension of both the small bowel and the colon (Chapters 4 and 5). However, the diagnosis of EPSBO (Early Postoperative Small Bowel Obstruction) in the recently operated abdomen is much subtler. Textbooks teach that on abdominal auscultation “ileus is silent and SBO (Small Bowel Obstruction) noisy” — this may be theoretically true but almost impossible to assess in the recently operated abdomen.\\n\\nIf your patient has already passed flatus or defecated and then ceases to manifest these comforting features, SBO is the most likely diagnosis. The truth is that in most instances, the patient will improve spontaneously without you ever knowing whether it was an EPSBO or just an ileus.\\n\\nThe natural tendency of the operating surgeon is to attribute the ‘failure to progress’ to an ileus rather than SBO and to procrastinate. Procrastination is not a good idea, however. A distended and non-eating patient is prone to the iatrogenic hazards of nasogastric tubes, intravenous lines, parenteral nutrition, and bed rest (Chapter 42). Be active and proceed with diagnostic steps in parallel to therapy.',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.54, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Prevention and Management',\n", " 'md': '### Prevention and Management',\n", " 'bBox': {'x': 86, 'y': 512, 'w': 226.23, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'There is no need to remind you that optimal peri-operative management (e.g., avoiding overhydration — tissue swelling) and a perfect operation can help prevent ileus or decrease its severity. Correct postoperative management (your cliché-ridden nurse-managers would use the term ‘ERAS’ or ‘goal-directed’…) would have beneficial effects as well.',\n", " 'md': 'There is no need to remind you that optimal peri-operative management (e.g., avoiding overhydration — tissue swelling) and a perfect operation can help prevent ileus or decrease its severity. Correct postoperative management (your cliché-ridden nurse-managers would use the term ‘ERAS’ or ‘goal-directed’…) would have beneficial effects as well.',\n", " 'bBox': {'x': 72, 'y': 581, 'w': 467.98, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'What Else Can You Do?',\n", " 'md': '### What Else Can You Do?',\n", " 'bBox': {'x': 86, 'y': 666, 'w': 155.86, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- Reduce the dose and duration of opiates which are the most...\\n```',\n", " 'md': '- Reduce the dose and duration of opiates which are the most...\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text has been extracted and structured into markdown format.\\n- No images or figures were identified on this page.\\n- The text has been organized into sections for clarity.',\n", " 'md': '- The text has been extracted and structured into markdown format.\\n- No images or figures were identified on this page.\\n- The text has been organized into sections for clarity.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ' in the recently operated abdomen is much subtler.'},\n", " {'text': ' in the recently operated abdomen is much subtler.'},\n", " {'text': 'active and proceed with diagnostic steps in parallel to therapy'}]},\n", " {'page': 775,\n", " 'text': ' common promoters of ileus. Pain should be controlled but not\\n excessively nor for too long. Consider the use of alternative\\n medications (e.g. NSAIDs).\\n • Measure and correct electrolyte imbalances, especially potassium!\\n • There is some evidence that manual abdominal massage\\n (hopefully by the wife or girlfriend), positional changes and/or\\n chewing gum hasten the resolution of ileus. We carry chewing gum\\n in our pockets and distribute it generously to our postoperative\\n patients. Even if it does not alleviate ileus it will surely promote\\n salivary flow and oral hygiene in the fasting patient and improve his\\n or her mood.\\n • Gimmicks? It does not seem that prokinetic agents like\\n metoclopramide or erythromycin alleviate or shorten ileus. Patients\\n receiving laxatives (e.g. bisacodyl suppositories) were shown to\\n defecate a little earlier but to stay just as long in the hospital. What\\n about alvimopan — a peripherally acting μ-opioid receptor agonist\\n shown to accelerate the time to GI recovery after elective surgery in\\n a few randomized trials? We have no personal experience with this\\n very expensive agent and do not know anyone who has been using\\n it after emergency abdominal operations — so stay tuned for the\\n next edition. Finally, the use of epidural anesthesia doesn’t have\\n much influence.\\n\\n A management algorithm is presented in Figure 45.1. Pass an NG\\ntube — if not already in situ — to decompress the stomach, prevent\\naerophagia, relieve nausea and vomiting, and measure gastric residue.\\nNow carefully search for and correct any potential causes of\\nprolonged ileus: a hematoma, an abscess, an anastomotic leak,\\npostoperative pancreatitis, postoperative acalculous cholecystitis — all\\ncan produce ileus or mimic EPSBO.',\n", " 'md': '```markdown\\n## Management of Ileus\\n\\n- Common promoters of ileus. Pain should be controlled but not excessively nor for too long. Consider the use of alternative medications (e.g. NSAIDs).\\n- Measure and correct electrolyte imbalances, especially potassium!\\n- There is some evidence that manual abdominal massage (hopefully by the wife or girlfriend), positional changes and/or chewing gum hasten the resolution of ileus. We carry chewing gum in our pockets and distribute it generously to our postoperative patients. Even if it does not alleviate ileus it will surely promote salivary flow and oral hygiene in the fasting patient and improve his or her mood.\\n- Gimmicks? It does not seem that prokinetic agents like metoclopramide or erythromycin alleviate or shorten ileus. Patients receiving laxatives (e.g. bisacodyl suppositories) were shown to defecate a little earlier but to stay just as long in the hospital. What about alvimopan — a peripherally acting μ-opioid receptor agonist shown to accelerate the time to GI recovery after elective surgery in a few randomized trials? We have no personal experience with this very expensive agent and do not know anyone who has been using it after emergency abdominal operations — so stay tuned for the next edition. Finally, the use of epidural anesthesia doesn’t have much influence.\\n\\nA management algorithm is presented in **Figure 45.1**. Pass an NG tube — if not already in situ — to decompress the stomach, prevent aerophagia, relieve nausea and vomiting, and measure gastric residue. Now carefully search for and correct any potential causes of prolonged ileus: a hematoma, an abscess, an anastomotic leak, postoperative pancreatitis, postoperative acalculous cholecystitis — all can produce ileus or mimic EPSBO.\\n```\\n\\n### Image Identification and Description\\n- **Figure 45.1**: A management algorithm for ileus. The algorithm likely outlines the steps to take in managing a patient with ileus, including the use of an NG tube and identifying potential causes of prolonged ileus. The specific details of the algorithm are not provided in the text, and the image is not available for extraction.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Ileus',\n", " 'md': '## Management of Ileus',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Common promoters of ileus. Pain should be controlled but not excessively nor for too long. Consider the use of alternative medications (e.g. NSAIDs).\\n- Measure and correct electrolyte imbalances, especially potassium!\\n- There is some evidence that manual abdominal massage (hopefully by the wife or girlfriend), positional changes and/or chewing gum hasten the resolution of ileus. We carry chewing gum in our pockets and distribute it generously to our postoperative patients. Even if it does not alleviate ileus it will surely promote salivary flow and oral hygiene in the fasting patient and improve his or her mood.\\n- Gimmicks? It does not seem that prokinetic agents like metoclopramide or erythromycin alleviate or shorten ileus. Patients receiving laxatives (e.g. bisacodyl suppositories) were shown to defecate a little earlier but to stay just as long in the hospital. What about alvimopan — a peripherally acting μ-opioid receptor agonist shown to accelerate the time to GI recovery after elective surgery in a few randomized trials? We have no personal experience with this very expensive agent and do not know anyone who has been using it after emergency abdominal operations — so stay tuned for the next edition. Finally, the use of epidural anesthesia doesn’t have much influence.\\n\\nA management algorithm is presented in **Figure 45.1**. Pass an NG tube — if not already in situ — to decompress the stomach, prevent aerophagia, relieve nausea and vomiting, and measure gastric residue. Now carefully search for and correct any potential causes of prolonged ileus: a hematoma, an abscess, an anastomotic leak, postoperative pancreatitis, postoperative acalculous cholecystitis — all can produce ileus or mimic EPSBO.\\n```',\n", " 'md': '- Common promoters of ileus. Pain should be controlled but not excessively nor for too long. Consider the use of alternative medications (e.g. NSAIDs).\\n- Measure and correct electrolyte imbalances, especially potassium!\\n- There is some evidence that manual abdominal massage (hopefully by the wife or girlfriend), positional changes and/or chewing gum hasten the resolution of ileus. We carry chewing gum in our pockets and distribute it generously to our postoperative patients. Even if it does not alleviate ileus it will surely promote salivary flow and oral hygiene in the fasting patient and improve his or her mood.\\n- Gimmicks? It does not seem that prokinetic agents like metoclopramide or erythromycin alleviate or shorten ileus. Patients receiving laxatives (e.g. bisacodyl suppositories) were shown to defecate a little earlier but to stay just as long in the hospital. What about alvimopan — a peripherally acting μ-opioid receptor agonist shown to accelerate the time to GI recovery after elective surgery in a few randomized trials? We have no personal experience with this very expensive agent and do not know anyone who has been using it after emergency abdominal operations — so stay tuned for the next edition. Finally, the use of epidural anesthesia doesn’t have much influence.\\n\\nA management algorithm is presented in **Figure 45.1**. Pass an NG tube — if not already in situ — to decompress the stomach, prevent aerophagia, relieve nausea and vomiting, and measure gastric residue. Now carefully search for and correct any potential causes of prolonged ileus: a hematoma, an abscess, an anastomotic leak, postoperative pancreatitis, postoperative acalculous cholecystitis — all can produce ileus or mimic EPSBO.\\n```',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 464.75, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 45.1**: A management algorithm for ileus. The algorithm likely outlines the steps to take in managing a patient with ileus, including the use of an NG tube and identifying potential causes of prolonged ileus. The specific details of the algorithm are not provided in the text, and the image is not available for extraction.',\n", " 'md': '- **Figure 45.1**: A management algorithm for ileus. The algorithm likely outlines the steps to take in managing a patient with ileus, including the use of an NG tube and identifying potential causes of prolonged ileus. The specific details of the algorithm are not provided in the text, and the image is not available for extraction.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ' — to decompress the stomach, prevent'}]},\n", " {'page': 776,\n", " 'text': ' Sth postoperative\\n No flatusino bowel movementday Plain abdominalX-ray\\n Abdominal distension\\n Post-laparoscopy EPSBO? Ileus? Contrast in colon\\n Clinical resolution\\n Contrast CT Gastrografin? \\'challenge\\' No Yes\\n Bowel incarcerated Conservative treatment Clinical \\\\\\'sepsis\"?\\n Suspect specific cause?\\n at the trocar site\\n Explore through No resolution >10-14 days No Yes\\n Iocal incision\\n EPSBO Contrast CT\\n Reoperation strangulation\\n EPSBO Ileus Treat cause\\nFigure 45.1. Management algorithm for ileus and EPSBO.\\n\\n And do not forget that significant hypoalbuminemia leads to\\ngeneralized edema, involving the bowel too. Edematous and swollen\\nbowel does not move well; this is called ‘hypoalbuminemic enteropathy’\\nand should be considered.\\n\\n Practically speaking, if on the fifth post-laparotomy day your patient still\\nhas features of ileus/EPSBO, we recommend a plain abdominal X-ray to\\nassess the gas pattern. If the latter suggests an ileus or EPSBO, a\\nGastrografin® challenge, as described in Chapter 21, may be\\nuseful in relieving both conditions.\\n\\n When the clinical picture suggests one of the above mentioned intra-\\nabdominal causes of persistent ileus, an abdominal CT is indicated to',\n", " 'md': \"```markdown\\n## Page Content\\n\\n### Text\\n- Sth postoperative\\n- No flatus or bowel movement day\\n- Plain abdominal X-ray\\n- Abdominal distension\\n- Post-laparoscopy\\n- EPSBO? Ileus?\\n- Contrast in colon\\n- Clinical resolution\\n- Contrast CT\\n- Gastrografin? 'challenge'\\n- No\\n- Yes\\n- Bowel incarcerated\\n- Conservative treatment\\n- Clinical 'sepsis'?\\n- Suspect specific cause?\\n- at the trocar site\\n- Explore through local incision\\n- No resolution >10-14 days\\n- No\\n- Yes\\n- Reoperation\\n- EPSBO\\n- strangulation\\n- EPSBO\\n- Ileus\\n- Treat cause\\n\\n### Figure\\n**Figure 45.1**: Management algorithm for ileus and EPSBO.\\nThis figure presents a management algorithm that outlines the steps to take in cases of ileus and EPSBO (Enteric Post-Surgical Bowel Obstruction). The flowchart includes decision points regarding the use of imaging (plain abdominal X-ray, contrast CT) and treatment options (conservative treatment, reoperation) based on the clinical findings.\\n\\n### Additional Notes\\n- Significant hypoalbuminemia leads to generalized edema, involving the bowel too. Edematous and swollen bowel does not move well; this is called ‘hypoalbuminemic enteropathy’ and should be considered.\\n- If on the fifth post-laparotomy day your patient still has features of ileus/EPSBO, a plain abdominal X-ray is recommended to assess the gas pattern. If the latter suggests an ileus or EPSBO, a Gastrografin® challenge may be useful in relieving both conditions.\\n- When the clinical picture suggests one of the above-mentioned intra-abdominal causes of persistent ileus, an abdominal CT is indicated.\\n```\",\n", " 'images': [{'name': 'img_p775_1.png',\n", " 'height': 709,\n", " 'width': 853,\n", " 'x': 95.03999999999996,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1464,\n", " 'original_height': 1216}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- Sth postoperative\\n- No flatus or bowel movement day\\n- Plain abdominal X-ray\\n- Abdominal distension\\n- Post-laparoscopy\\n- EPSBO? Ileus?\\n- Contrast in colon\\n- Clinical resolution\\n- Contrast CT\\n- Gastrografin? 'challenge'\\n- No\\n- Yes\\n- Bowel incarcerated\\n- Conservative treatment\\n- Clinical 'sepsis'?\\n- Suspect specific cause?\\n- at the trocar site\\n- Explore through local incision\\n- No resolution >10-14 days\\n- No\\n- Yes\\n- Reoperation\\n- EPSBO\\n- strangulation\\n- EPSBO\\n- Ileus\\n- Treat cause\",\n", " 'md': \"- Sth postoperative\\n- No flatus or bowel movement day\\n- Plain abdominal X-ray\\n- Abdominal distension\\n- Post-laparoscopy\\n- EPSBO? Ileus?\\n- Contrast in colon\\n- Clinical resolution\\n- Contrast CT\\n- Gastrografin? 'challenge'\\n- No\\n- Yes\\n- Bowel incarcerated\\n- Conservative treatment\\n- Clinical 'sepsis'?\\n- Suspect specific cause?\\n- at the trocar site\\n- Explore through local incision\\n- No resolution >10-14 days\\n- No\\n- Yes\\n- Reoperation\\n- EPSBO\\n- strangulation\\n- EPSBO\\n- Ileus\\n- Treat cause\",\n", " 'bBox': {'x': 98.01, 'y': 87.25, 'w': 131.57, 'h': 18.3}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure',\n", " 'md': '### Figure',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 45.1**: Management algorithm for ileus and EPSBO.\\nThis figure presents a management algorithm that outlines the steps to take in cases of ileus and EPSBO (Enteric Post-Surgical Bowel Obstruction). The flowchart includes decision points regarding the use of imaging (plain abdominal X-ray, contrast CT) and treatment options (conservative treatment, reoperation) based on the clinical findings.',\n", " 'md': '**Figure 45.1**: Management algorithm for ileus and EPSBO.\\nThis figure presents a management algorithm that outlines the steps to take in cases of ileus and EPSBO (Enteric Post-Surgical Bowel Obstruction). The flowchart includes decision points regarding the use of imaging (plain abdominal X-ray, contrast CT) and treatment options (conservative treatment, reoperation) based on the clinical findings.',\n", " 'bBox': {'x': 98.01, 'y': 95.16, 'w': 337.83, 'h': 17.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Additional Notes',\n", " 'md': '### Additional Notes',\n", " 'bBox': {'x': 392.81, 'y': 213.36, 'w': 16.82, 'h': 11.87}},\n", " {'type': 'text',\n", " 'value': '- Significant hypoalbuminemia leads to generalized edema, involving the bowel too. Edematous and swollen bowel does not move well; this is called ‘hypoalbuminemic enteropathy’ and should be considered.\\n- If on the fifth post-laparotomy day your patient still has features of ileus/EPSBO, a plain abdominal X-ray is recommended to assess the gas pattern. If the latter suggests an ileus or EPSBO, a Gastrografin® challenge may be useful in relieving both conditions.\\n- When the clinical picture suggests one of the above-mentioned intra-abdominal causes of persistent ileus, an abdominal CT is indicated.\\n```',\n", " 'md': '- Significant hypoalbuminemia leads to generalized edema, involving the bowel too. Edematous and swollen bowel does not move well; this is called ‘hypoalbuminemic enteropathy’ and should be considered.\\n- If on the fifth post-laparotomy day your patient still has features of ileus/EPSBO, a plain abdominal X-ray is recommended to assess the gas pattern. If the latter suggests an ileus or EPSBO, a Gastrografin® challenge may be useful in relieving both conditions.\\n- When the clinical picture suggests one of the above-mentioned intra-abdominal causes of persistent ileus, an abdominal CT is indicated.\\n```',\n", " 'bBox': {'x': 72, 'y': 87.25, 'w': 238, 'h': 16.81}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 777,\n", " 'text': 'pinpoint the problem and, at times, to guide treatment. Nowadays, we\\noften order a CT with oral Gastrografin® — a single imaging study\\nwhich achieves all the above goals in one shot.\\n\\n Failure of the Gastrografin® to arrive at the colon denotes an\\nEPSBO. In the early postoperative phase this is not an indication for a\\nlaparotomy. Intestinal strangulation almost never occurs in this\\nsituation and spontaneous resolution is common. Resolution of\\nSBO, however, rarely occurs beyond postoperative days 10-14.\\n\\n In the absence of intra-abdominal or extra-abdominal causes for\\nileus, and when the ‘ileus’ does not respond to the Gastrografin®\\nchallenge, the most likely diagnosis is EPSBO. Do not rush to\\nreoperate; treat conservatively while providing nutritional support (\\nChapter 43). Lack of resolution beyond 2 weeks is an indication for\\nrelaparotomy, which in itself may be difficult and hazardous because of\\nthe typical early, dense and vascular adhesions cementing the bowel at\\nmany points.\\n\\n Specific considerations\\n\\n EPSBO following laparoscopy\\n\\n Cholecystectomy, transperitoneal hernia repair and appendectomy are\\nthe three most common procedures associated with post-laparoscopic\\nEPSBO. Adhesions are the culprit in half of the patients and small\\nbowel incarceration at the port site in the other half. All port-site\\nherniations involve the use of 10 or 12mm trocars and the umbilical port\\nis the commonest site. In the majority of port-site herniations,\\nadequate fascial closure was thought to have been achieved at the\\ninitial operation. Adequate closure of the fascial defect does not\\npreclude the possibility of trocar site incarceration of bowel; a\\nstrangulated hernia may develop, with the bowel caught in the\\npreperitoneal space behind a well-repaired fascial defect. Another cause\\nfor EPSBO following laparoscopic surgery are spilled gallstones during\\ncholecystectomy, which can lead to the development of an inflammatory\\nmass to which the bowel adheres.',\n", " 'md': '```markdown\\n## Current Page Content\\n\\nPinpoint the problem and, at times, to guide treatment. Nowadays, we often order a CT with oral Gastrografin® — a single imaging study which achieves all the above goals in one shot.\\n\\nFailure of the Gastrografin® to arrive at the colon denotes an EPSBO. In the early postoperative phase, this is not an indication for a laparotomy. Intestinal strangulation almost never occurs in this situation and spontaneous resolution is common. Resolution of SBO, however, rarely occurs beyond postoperative days 10-14.\\n\\nIn the absence of intra-abdominal or extra-abdominal causes for ileus, and when the ‘ileus’ does not respond to the Gastrografin® challenge, the most likely diagnosis is EPSBO. Do not rush to reoperate; treat conservatively while providing nutritional support (Chapter 43). Lack of resolution beyond 2 weeks is an indication for relaparotomy, which in itself may be difficult and hazardous because of the typical early, dense and vascular adhesions cementing the bowel at many points.\\n\\n### Specific Considerations\\n\\n#### EPSBO Following Laparoscopy\\n\\nCholecystectomy, transperitoneal hernia repair, and appendectomy are the three most common procedures associated with post-laparoscopic EPSBO. Adhesions are the culprit in half of the patients and small bowel incarceration at the port site in the other half. All port-site herniations involve the use of 10 or 12mm trocars and the umbilical port is the commonest site. In the majority of port-site herniations, adequate fascial closure was thought to have been achieved at the initial operation. Adequate closure of the fascial defect does not preclude the possibility of trocar site incarceration of bowel; a strangulated hernia may develop, with the bowel caught in the preperitoneal space behind a well-repaired fascial defect. Another cause for EPSBO following laparoscopic surgery are spilled gallstones during cholecystectomy, which can lead to the development of an inflammatory mass to which the bowel adheres.\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- All text has been extracted and structured according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Current Page Content',\n", " 'md': '## Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Pinpoint the problem and, at times, to guide treatment. Nowadays, we often order a CT with oral Gastrografin® — a single imaging study which achieves all the above goals in one shot.\\n\\nFailure of the Gastrografin® to arrive at the colon denotes an EPSBO. In the early postoperative phase, this is not an indication for a laparotomy. Intestinal strangulation almost never occurs in this situation and spontaneous resolution is common. Resolution of SBO, however, rarely occurs beyond postoperative days 10-14.\\n\\nIn the absence of intra-abdominal or extra-abdominal causes for ileus, and when the ‘ileus’ does not respond to the Gastrografin® challenge, the most likely diagnosis is EPSBO. Do not rush to reoperate; treat conservatively while providing nutritional support (Chapter 43). Lack of resolution beyond 2 weeks is an indication for relaparotomy, which in itself may be difficult and hazardous because of the typical early, dense and vascular adhesions cementing the bowel at many points.',\n", " 'md': 'Pinpoint the problem and, at times, to guide treatment. Nowadays, we often order a CT with oral Gastrografin® — a single imaging study which achieves all the above goals in one shot.\\n\\nFailure of the Gastrografin® to arrive at the colon denotes an EPSBO. In the early postoperative phase, this is not an indication for a laparotomy. Intestinal strangulation almost never occurs in this situation and spontaneous resolution is common. Resolution of SBO, however, rarely occurs beyond postoperative days 10-14.\\n\\nIn the absence of intra-abdominal or extra-abdominal causes for ileus, and when the ‘ileus’ does not respond to the Gastrografin® challenge, the most likely diagnosis is EPSBO. Do not rush to reoperate; treat conservatively while providing nutritional support (Chapter 43). Lack of resolution beyond 2 weeks is an indication for relaparotomy, which in itself may be difficult and hazardous because of the typical early, dense and vascular adhesions cementing the bowel at many points.',\n", " 'bBox': {'x': 72, 'y': 121, 'w': 467.84, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Specific Considerations',\n", " 'md': '### Specific Considerations',\n", " 'bBox': {'x': 86, 'y': 421, 'w': 185.75, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'EPSBO Following Laparoscopy',\n", " 'md': '#### EPSBO Following Laparoscopy',\n", " 'bBox': {'x': 86, 'y': 465, 'w': 237.22, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Cholecystectomy, transperitoneal hernia repair, and appendectomy are the three most common procedures associated with post-laparoscopic EPSBO. Adhesions are the culprit in half of the patients and small bowel incarceration at the port site in the other half. All port-site herniations involve the use of 10 or 12mm trocars and the umbilical port is the commonest site. In the majority of port-site herniations, adequate fascial closure was thought to have been achieved at the initial operation. Adequate closure of the fascial defect does not preclude the possibility of trocar site incarceration of bowel; a strangulated hernia may develop, with the bowel caught in the preperitoneal space behind a well-repaired fascial defect. Another cause for EPSBO following laparoscopic surgery are spilled gallstones during cholecystectomy, which can lead to the development of an inflammatory mass to which the bowel adheres.\\n```',\n", " 'md': 'Cholecystectomy, transperitoneal hernia repair, and appendectomy are the three most common procedures associated with post-laparoscopic EPSBO. Adhesions are the culprit in half of the patients and small bowel incarceration at the port site in the other half. All port-site herniations involve the use of 10 or 12mm trocars and the umbilical port is the commonest site. In the majority of port-site herniations, adequate fascial closure was thought to have been achieved at the initial operation. Adequate closure of the fascial defect does not preclude the possibility of trocar site incarceration of bowel; a strangulated hernia may develop, with the bowel caught in the preperitoneal space behind a well-repaired fascial defect. Another cause for EPSBO following laparoscopic surgery are spilled gallstones during cholecystectomy, which can lead to the development of an inflammatory mass to which the bowel adheres.\\n```',\n", " 'bBox': {'x': 72, 'y': 567, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- All text has been extracted and structured according to the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- No formulas were present to convert into LaTeX MathJax notation.\\n- All text has been extracted and structured according to the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 43). relaparotomy'}]},\n", " {'page': 778,\n", " 'text': ' Therefore, remember that when EPSBO follows laparoscopy, the\\nfirst question in your mind should be whether the bowel is caught in\\none of the trocar sites. Because physical findings suggestive of this\\ncondition such as a mass or exceptional tenderness at the trocar site are\\nrarely present, CT examination of the abdomen is recommended to\\nprovide an early diagnosis. CT detects the trocar site responsible for\\nthe EPSBO, allowing immediate operation to relieve the obstruction.\\nSurgery can be carried out through the (extended) actual trocar site itself\\nobviating the need for a formal laparotomy. Unlike EPSBO following\\nopen procedures, post-laparoscopy obstruction usually won’t\\nresolve without a reoperation. You have to understand that post-\\nlaparoscopy EPSBO is a specific entity which calls for immediate\\naction. (See also Chapter 12.)\\n\\n The ‘hostile’ abdomen (see also Chapter 21)\\n\\n Any mixed series of patients with EPSBO includes a subgroup of\\npatients in whom the index operation has disclosed a ‘hostile’ peritoneal\\ncavity suggesting that any further surgery to relieve the obstructive\\nprocess would be hazardous and futile. To this group belong patients with\\nextensive radiation enteritis in whom persisting obstruction can be\\ndefined as ‘intestinal failure’ and who are best managed with long-term\\nparenteral nutrition. Indiscriminate reoperation in such patients often\\nleads to massive bowel resection, multiple fistulas and death, and\\nshould be avoided. Patients with evidence of peritoneal\\ncarcinomatosis at the index operation also belong to this group. In\\ngeneral, only one-third of patients with ‘malignant’ bowel\\nobstruction from peritoneal carcinomatosis will have prolonged\\npostoperative palliation. Thus, EPSBO in such patients is an ominous\\nsign; abdominal reoperation should be avoided and future palliative\\ntreatment planned, based on the individual patient’s functional status and\\nthe burden of cancer.\\n\\n Finally, every surgeon has some personal experience with a little\\nreported entity, the frozen abdomen, in which intractable SBO is caused\\nby dense, vascular and inseparable adhesions — fixing the bowel at\\nmany points. The astute surgeon knows when to abort early from a\\nfutile dissection before multiple enterotomies — necessitating',\n", " 'md': \"```markdown\\n## Text Extraction\\n\\nTherefore, remember that when EPSBO follows laparoscopy, the first question in your mind should be whether the bowel is caught in one of the trocar sites. Because physical findings suggestive of this condition such as a mass or exceptional tenderness at the trocar site are rarely present, CT examination of the abdomen is recommended to provide an early diagnosis. CT detects the trocar site responsible for the EPSBO, allowing immediate operation to relieve the obstruction. Surgery can be carried out through the (extended) actual trocar site itself obviating the need for a formal laparotomy. Unlike EPSBO following open procedures, post-laparoscopy obstruction usually won’t resolve without a reoperation. You have to understand that post-laparoscopy EPSBO is a specific entity which calls for immediate action. (See also Chapter 12.)\\n\\nThe ‘hostile’ abdomen (see also Chapter 21)\\n\\nAny mixed series of patients with EPSBO includes a subgroup of patients in whom the index operation has disclosed a ‘hostile’ peritoneal cavity suggesting that any further surgery to relieve the obstructive process would be hazardous and futile. To this group belong patients with extensive radiation enteritis in whom persisting obstruction can be defined as ‘intestinal failure’ and who are best managed with long-term parenteral nutrition. Indiscriminate reoperation in such patients often leads to massive bowel resection, multiple fistulas and death, and should be avoided. Patients with evidence of peritoneal carcinomatosis at the index operation also belong to this group. In general, only one-third of patients with ‘malignant’ bowel obstruction from peritoneal carcinomatosis will have prolonged postoperative palliation. Thus, EPSBO in such patients is an ominous sign; abdominal reoperation should be avoided and future palliative treatment planned, based on the individual patient’s functional status and the burden of cancer.\\n\\nFinally, every surgeon has some personal experience with a little reported entity, the frozen abdomen, in which intractable SBO is caused by dense, vascular and inseparable adhesions — fixing the bowel at many points. The astute surgeon knows when to abort early from a futile dissection before multiple enterotomies — necessitating\\n\\n## Image Identification and Description\\n\\n*No images or figures were identified on this page.*\\n\\n## Summary\\n\\nThis page discusses the management of early postoperative small bowel obstruction (EPSBO) following laparoscopy, emphasizing the importance of CT examination for diagnosis and the specific challenges posed by a 'hostile' abdomen. It highlights the risks associated with reoperation in patients with extensive radiation enteritis and peritoneal carcinomatosis, advocating for careful consideration of palliative care. The concept of a 'frozen abdomen' is also introduced, describing the complications arising from dense adhesions.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Therefore, remember that when EPSBO follows laparoscopy, the first question in your mind should be whether the bowel is caught in one of the trocar sites. Because physical findings suggestive of this condition such as a mass or exceptional tenderness at the trocar site are rarely present, CT examination of the abdomen is recommended to provide an early diagnosis. CT detects the trocar site responsible for the EPSBO, allowing immediate operation to relieve the obstruction. Surgery can be carried out through the (extended) actual trocar site itself obviating the need for a formal laparotomy. Unlike EPSBO following open procedures, post-laparoscopy obstruction usually won’t resolve without a reoperation. You have to understand that post-laparoscopy EPSBO is a specific entity which calls for immediate action. (See also Chapter 12.)\\n\\nThe ‘hostile’ abdomen (see also Chapter 21)\\n\\nAny mixed series of patients with EPSBO includes a subgroup of patients in whom the index operation has disclosed a ‘hostile’ peritoneal cavity suggesting that any further surgery to relieve the obstructive process would be hazardous and futile. To this group belong patients with extensive radiation enteritis in whom persisting obstruction can be defined as ‘intestinal failure’ and who are best managed with long-term parenteral nutrition. Indiscriminate reoperation in such patients often leads to massive bowel resection, multiple fistulas and death, and should be avoided. Patients with evidence of peritoneal carcinomatosis at the index operation also belong to this group. In general, only one-third of patients with ‘malignant’ bowel obstruction from peritoneal carcinomatosis will have prolonged postoperative palliation. Thus, EPSBO in such patients is an ominous sign; abdominal reoperation should be avoided and future palliative treatment planned, based on the individual patient’s functional status and the burden of cancer.\\n\\nFinally, every surgeon has some personal experience with a little reported entity, the frozen abdomen, in which intractable SBO is caused by dense, vascular and inseparable adhesions — fixing the bowel at many points. The astute surgeon knows when to abort early from a futile dissection before multiple enterotomies — necessitating',\n", " 'md': 'Therefore, remember that when EPSBO follows laparoscopy, the first question in your mind should be whether the bowel is caught in one of the trocar sites. Because physical findings suggestive of this condition such as a mass or exceptional tenderness at the trocar site are rarely present, CT examination of the abdomen is recommended to provide an early diagnosis. CT detects the trocar site responsible for the EPSBO, allowing immediate operation to relieve the obstruction. Surgery can be carried out through the (extended) actual trocar site itself obviating the need for a formal laparotomy. Unlike EPSBO following open procedures, post-laparoscopy obstruction usually won’t resolve without a reoperation. You have to understand that post-laparoscopy EPSBO is a specific entity which calls for immediate action. (See also Chapter 12.)\\n\\nThe ‘hostile’ abdomen (see also Chapter 21)\\n\\nAny mixed series of patients with EPSBO includes a subgroup of patients in whom the index operation has disclosed a ‘hostile’ peritoneal cavity suggesting that any further surgery to relieve the obstructive process would be hazardous and futile. To this group belong patients with extensive radiation enteritis in whom persisting obstruction can be defined as ‘intestinal failure’ and who are best managed with long-term parenteral nutrition. Indiscriminate reoperation in such patients often leads to massive bowel resection, multiple fistulas and death, and should be avoided. Patients with evidence of peritoneal carcinomatosis at the index operation also belong to this group. In general, only one-third of patients with ‘malignant’ bowel obstruction from peritoneal carcinomatosis will have prolonged postoperative palliation. Thus, EPSBO in such patients is an ominous sign; abdominal reoperation should be avoided and future palliative treatment planned, based on the individual patient’s functional status and the burden of cancer.\\n\\nFinally, every surgeon has some personal experience with a little reported entity, the frozen abdomen, in which intractable SBO is caused by dense, vascular and inseparable adhesions — fixing the bowel at many points. The astute surgeon knows when to abort early from a futile dissection before multiple enterotomies — necessitating',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.94, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*',\n", " 'md': '*No images or figures were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"This page discusses the management of early postoperative small bowel obstruction (EPSBO) following laparoscopy, emphasizing the importance of CT examination for diagnosis and the specific challenges posed by a 'hostile' abdomen. It highlights the risks associated with reoperation in patients with extensive radiation enteritis and peritoneal carcinomatosis, advocating for careful consideration of palliative care. The concept of a 'frozen abdomen' is also introduced, describing the complications arising from dense adhesions.\\n```\",\n", " 'md': \"This page discusses the management of early postoperative small bowel obstruction (EPSBO) following laparoscopy, emphasizing the importance of CT examination for diagnosis and the specific challenges posed by a 'hostile' abdomen. It highlights the risks associated with reoperation in patients with extensive radiation enteritis and peritoneal carcinomatosis, advocating for careful consideration of palliative care. The concept of a 'frozen abdomen' is also introduced, describing the complications arising from dense adhesions.\\n```\",\n", " 'bBox': {'x': 249, 'y': 496, 'w': 68.75, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 779,\n", " 'text': 'massive bowel resection — are created. ħe also knows not to\\nreoperate on such patients even if persisting EPSBO develops after what\\nappeared to be a successful adhesiolysis. Prolonged parenteral nutrition\\nover a period of months, with complete gastrointestinal rest, may allow\\nthe adhesions to mature — with resolution of the SBO, or at least\\nallowing a safer reoperation.\\n\\n Anastomotic obstruction\\n\\n A bowel anastomosis at any level may cause early postoperative upper\\ngastrointestinal, small bowel or colonic obstruction. Faulty technique (\\nChapter 14) is usually the cause. A self-limiting ‘mini’ anastomotic leak is\\noften responsible but under-diagnosed ( Chapter 47). Diagnosis is\\nreached with a contrast study (water-soluble please!) and/or CT. Most of\\nthese early postoperative anastomotic obstructions are ‘soft’ and\\nedematous, resolving spontaneously within a week or two. Do not\\nrush to reoperate; gentle passage of an endoscope — if practical —\\nmay confirm the diagnosis and ‘dilate’ the lumen.\\n\\n Delayed gastric emptying\\n\\n Often the stomach fails to empty following a partial gastrectomy or a\\ngastrojejunostomy performed for any indication. This is more common\\nwhen a vagotomy has been added or when a Roux-en-Y loop has been\\nconstructed. A Gastrografin® study will show that the contrast persistently\\nsits in the stomach. The differential diagnosis is between a gastric\\nileus (gastroparesis) and mechanical obstruction at the\\ngastrojejunostomy or below it (yes, do not miss the mechanical\\nobstruction in the small bowel just ‘below’ the stomach!). A complete\\ndiscussion of the various post-gastrectomy syndromes is beyond the\\nscope of this volume but remember this fundamental principle —\\npostoperative gastric paresis is self-limiting — it will always resolve\\nspontaneously but may take as long as 6 weeks to do so. Exclude\\nmechanical stomal obstruction with an endoscope and contrast study and\\nthen treat conservatively with nasogastric suction and nutritional support.\\nTry to pass a feeding tube distal to the stomach. Parenteral erythromycin\\nhas been shown to enhance gastric motility and is always worth a trial in',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nMassive bowel resection — are created. He also knows not to reoperate on such patients even if persisting EPSBO develops after what appeared to be a successful adhesiolysis. Prolonged parenteral nutrition over a period of months, with complete gastrointestinal rest, may allow the adhesions to mature — with resolution of the SBO, or at least allowing a safer reoperation.\\n\\n### Anastomotic Obstruction\\n\\nA bowel anastomosis at any level may cause early postoperative upper gastrointestinal, small bowel or colonic obstruction. Faulty technique (Chapter 14) is usually the cause. A self-limiting ‘mini’ anastomotic leak is often responsible but under-diagnosed (Chapter 47). Diagnosis is reached with a contrast study (water-soluble please!) and/or CT. Most of these early postoperative anastomotic obstructions are ‘soft’ and edematous, resolving spontaneously within a week or two. Do not rush to reoperate; gentle passage of an endoscope — if practical — may confirm the diagnosis and ‘dilate’ the lumen.\\n\\n### Delayed Gastric Emptying\\n\\nOften the stomach fails to empty following a partial gastrectomy or a gastrojejunostomy performed for any indication. This is more common when a vagotomy has been added or when a Roux-en-Y loop has been constructed. A Gastrografin® study will show that the contrast persistently sits in the stomach. The differential diagnosis is between a gastric ileus (gastroparesis) and mechanical obstruction at the gastrojejunostomy or below it (yes, do not miss the mechanical obstruction in the small bowel just ‘below’ the stomach!). A complete discussion of the various post-gastrectomy syndromes is beyond the scope of this volume but remember this fundamental principle — postoperative gastric paresis is self-limiting — it will always resolve spontaneously but may take as long as 6 weeks to do so. Exclude mechanical stomal obstruction with an endoscope and contrast study and then treat conservatively with nasogastric suction and nutritional support. Try to pass a feeding tube distal to the stomach. Parenteral erythromycin has been shown to enhance gastric motility and is always worth a trial in.\\n\\n## Image Identification and Description\\n\\n*No images or figures were identified on this page.*\\n\\n## Summary\\n\\nThis page discusses complications related to bowel surgery, specifically focusing on massive bowel resection, anastomotic obstruction, and delayed gastric emptying. It emphasizes the importance of conservative management and the potential for spontaneous resolution of postoperative complications.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Massive bowel resection — are created. He also knows not to reoperate on such patients even if persisting EPSBO develops after what appeared to be a successful adhesiolysis. Prolonged parenteral nutrition over a period of months, with complete gastrointestinal rest, may allow the adhesions to mature — with resolution of the SBO, or at least allowing a safer reoperation.',\n", " 'md': 'Massive bowel resection — are created. He also knows not to reoperate on such patients even if persisting EPSBO develops after what appeared to be a successful adhesiolysis. Prolonged parenteral nutrition over a period of months, with complete gastrointestinal rest, may allow the adhesions to mature — with resolution of the SBO, or at least allowing a safer reoperation.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.72, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Anastomotic Obstruction',\n", " 'md': '### Anastomotic Obstruction',\n", " 'bBox': {'x': 86, 'y': 211, 'w': 195.86, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A bowel anastomosis at any level may cause early postoperative upper gastrointestinal, small bowel or colonic obstruction. Faulty technique (Chapter 14) is usually the cause. A self-limiting ‘mini’ anastomotic leak is often responsible but under-diagnosed (Chapter 47). Diagnosis is reached with a contrast study (water-soluble please!) and/or CT. Most of these early postoperative anastomotic obstructions are ‘soft’ and edematous, resolving spontaneously within a week or two. Do not rush to reoperate; gentle passage of an endoscope — if practical — may confirm the diagnosis and ‘dilate’ the lumen.',\n", " 'md': 'A bowel anastomosis at any level may cause early postoperative upper gastrointestinal, small bowel or colonic obstruction. Faulty technique (Chapter 14) is usually the cause. A self-limiting ‘mini’ anastomotic leak is often responsible but under-diagnosed (Chapter 47). Diagnosis is reached with a contrast study (water-soluble please!) and/or CT. Most of these early postoperative anastomotic obstructions are ‘soft’ and edematous, resolving spontaneously within a week or two. Do not rush to reoperate; gentle passage of an endoscope — if practical — may confirm the diagnosis and ‘dilate’ the lumen.',\n", " 'bBox': {'x': 72, 'y': 211, 'w': 468, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Delayed Gastric Emptying',\n", " 'md': '### Delayed Gastric Emptying',\n", " 'bBox': {'x': 86, 'y': 423, 'w': 200.48, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Often the stomach fails to empty following a partial gastrectomy or a gastrojejunostomy performed for any indication. This is more common when a vagotomy has been added or when a Roux-en-Y loop has been constructed. A Gastrografin® study will show that the contrast persistently sits in the stomach. The differential diagnosis is between a gastric ileus (gastroparesis) and mechanical obstruction at the gastrojejunostomy or below it (yes, do not miss the mechanical obstruction in the small bowel just ‘below’ the stomach!). A complete discussion of the various post-gastrectomy syndromes is beyond the scope of this volume but remember this fundamental principle — postoperative gastric paresis is self-limiting — it will always resolve spontaneously but may take as long as 6 weeks to do so. Exclude mechanical stomal obstruction with an endoscope and contrast study and then treat conservatively with nasogastric suction and nutritional support. Try to pass a feeding tube distal to the stomach. Parenteral erythromycin has been shown to enhance gastric motility and is always worth a trial in.',\n", " 'md': 'Often the stomach fails to empty following a partial gastrectomy or a gastrojejunostomy performed for any indication. This is more common when a vagotomy has been added or when a Roux-en-Y loop has been constructed. A Gastrografin® study will show that the contrast persistently sits in the stomach. The differential diagnosis is between a gastric ileus (gastroparesis) and mechanical obstruction at the gastrojejunostomy or below it (yes, do not miss the mechanical obstruction in the small bowel just ‘below’ the stomach!). A complete discussion of the various post-gastrectomy syndromes is beyond the scope of this volume but remember this fundamental principle — postoperative gastric paresis is self-limiting — it will always resolve spontaneously but may take as long as 6 weeks to do so. Exclude mechanical stomal obstruction with an endoscope and contrast study and then treat conservatively with nasogastric suction and nutritional support. Try to pass a feeding tube distal to the stomach. Parenteral erythromycin has been shown to enhance gastric motility and is always worth a trial in.',\n", " 'bBox': {'x': 72, 'y': 492, 'w': 468.01, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 246, 'y': 544, 'w': 29.57, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*',\n", " 'md': '*No images or figures were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary',\n", " 'md': '## Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This page discusses complications related to bowel surgery, specifically focusing on massive bowel resection, anastomotic obstruction, and delayed gastric emptying. It emphasizes the importance of conservative management and the potential for spontaneous resolution of postoperative complications.\\n```',\n", " 'md': 'This page discusses complications related to bowel surgery, specifically focusing on massive bowel resection, anastomotic obstruction, and delayed gastric emptying. It emphasizes the importance of conservative management and the potential for spontaneous resolution of postoperative complications.\\n```',\n", " 'bBox': {'x': 86, 'y': 211, 'w': 200.48, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 14) is usually the cause. A self-limiting ‘mini’ anastomotic leak is often responsible but under-diagnosed ('},\n", " {'text': 'reached with a contrast study (water-soluble please!) and/or CT. '}]},\n", " {'page': 780,\n", " 'text': 'this situation. Resist the devil within you — tempting you to\\nreoperate for gastric paresis — for it will eventually resolve, while\\nreoperation may only make things worse.\\n\\n Acute gastric dilatation\\n\\n This chapter gives us an opportunity to mention the entity of acute\\ngastric dilatation — well known and feared by previous generations of\\nsurgeons — but for some reason vanishing from our collective\\nawareness. It can develop after any operation or following trauma but\\nmay occur spontaneously as well — especially in debilitated and\\nimmobilized patients. It has been described in patients with eating\\ndisorders such as bulimia.\\n\\n Acute gastric dilatation manifests itself with abdominal\\ndistension, pain, nausea and vomiting, and if not treated promptly\\ncan result in aspiration, abdominal compartment syndrome and\\neven gastric necrosis.\\n\\n Our waning obsession with the need for nasogastric tubes may explain\\nwhy we see more of these cases in the postoperative phase.\\n\\n A young lady underwent repair of an umbilical hernia with mesh under local anesthesia and i.v.\\n sedataion. An hour after the operation she complained about severe, diffuse abdominal pain.\\n Her heart rate was 120/min and the abdomen was diffusely tender. “Did I injure her\\n intestines?,” I asked myself. Abdominal X-ray showed a huge stomach. A nasogastric tube, left\\n in situ for a few hours, cured the acute gastric dilatation.\\n\\n A middle-aged man underwent an uneventful laparoscopic cholecystectomy. An orogastric tube\\n was inserted by the anesthetist during the procedure and removed at its end. An hour after\\n being discharged from the recovery room the patient complained about severe abdominal pain,\\n which persisted despite repeated doses of opiates. He developed tachycardia despite\\n adequate hydration. The abdomen was diffusely tender. These worrying features of possible',\n", " 'md': '```markdown\\n# Acute Gastric Dilatation\\n\\nThis chapter gives us an opportunity to mention the entity of acute gastric dilatation — well known and feared by previous generations of surgeons — but for some reason vanishing from our collective awareness. It can develop after any operation or following trauma but may occur spontaneously as well — especially in debilitated and immobilized patients. It has been described in patients with eating disorders such as bulimia.\\n\\nAcute gastric dilatation manifests itself with abdominal distension, pain, nausea, and vomiting, and if not treated promptly can result in aspiration, abdominal compartment syndrome, and even gastric necrosis.\\n\\nOur waning obsession with the need for nasogastric tubes may explain why we see more of these cases in the postoperative phase.\\n\\n## Case Studies\\n\\n1. A young lady underwent repair of an umbilical hernia with mesh under local anesthesia and i.v. sedation. An hour after the operation, she complained about severe, diffuse abdominal pain. Her heart rate was 120/min and the abdomen was diffusely tender. “Did I injure her intestines?,” I asked myself. Abdominal X-ray showed a huge stomach. A nasogastric tube, left in situ for a few hours, cured the acute gastric dilatation.\\n\\n2. A middle-aged man underwent an uneventful laparoscopic cholecystectomy. An orogastric tube was inserted by the anesthetist during the procedure and removed at its end. An hour after being discharged from the recovery room, the patient complained about severe abdominal pain, which persisted despite repeated doses of opiates. He developed tachycardia despite adequate hydration. The abdomen was diffusely tender. These worrying features of possible...\\n```\\n\\n### Notes:\\n- The text has been extracted and structured into markdown format.\\n- No images or figures were identified in the provided text. If there are any images or graphs on the page, please provide the relevant details for further extraction.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Acute Gastric Dilatation',\n", " 'md': '# Acute Gastric Dilatation',\n", " 'bBox': {'x': 86, 'y': 162, 'w': 182.97, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'This chapter gives us an opportunity to mention the entity of acute gastric dilatation — well known and feared by previous generations of surgeons — but for some reason vanishing from our collective awareness. It can develop after any operation or following trauma but may occur spontaneously as well — especially in debilitated and immobilized patients. It has been described in patients with eating disorders such as bulimia.\\n\\nAcute gastric dilatation manifests itself with abdominal distension, pain, nausea, and vomiting, and if not treated promptly can result in aspiration, abdominal compartment syndrome, and even gastric necrosis.\\n\\nOur waning obsession with the need for nasogastric tubes may explain why we see more of these cases in the postoperative phase.',\n", " 'md': 'This chapter gives us an opportunity to mention the entity of acute gastric dilatation — well known and feared by previous generations of surgeons — but for some reason vanishing from our collective awareness. It can develop after any operation or following trauma but may occur spontaneously as well — especially in debilitated and immobilized patients. It has been described in patients with eating disorders such as bulimia.\\n\\nAcute gastric dilatation manifests itself with abdominal distension, pain, nausea, and vomiting, and if not treated promptly can result in aspiration, abdominal compartment syndrome, and even gastric necrosis.\\n\\nOur waning obsession with the need for nasogastric tubes may explain why we see more of these cases in the postoperative phase.',\n", " 'bBox': {'x': 72, 'y': 162, 'w': 467.21, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Case Studies',\n", " 'md': '## Case Studies',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. A young lady underwent repair of an umbilical hernia with mesh under local anesthesia and i.v. sedation. An hour after the operation, she complained about severe, diffuse abdominal pain. Her heart rate was 120/min and the abdomen was diffusely tender. “Did I injure her intestines?,” I asked myself. Abdominal X-ray showed a huge stomach. A nasogastric tube, left in situ for a few hours, cured the acute gastric dilatation.\\n\\n2. A middle-aged man underwent an uneventful laparoscopic cholecystectomy. An orogastric tube was inserted by the anesthetist during the procedure and removed at its end. An hour after being discharged from the recovery room, the patient complained about severe abdominal pain, which persisted despite repeated doses of opiates. He developed tachycardia despite adequate hydration. The abdomen was diffusely tender. These worrying features of possible...\\n```',\n", " 'md': '1. A young lady underwent repair of an umbilical hernia with mesh under local anesthesia and i.v. sedation. An hour after the operation, she complained about severe, diffuse abdominal pain. Her heart rate was 120/min and the abdomen was diffusely tender. “Did I injure her intestines?,” I asked myself. Abdominal X-ray showed a huge stomach. A nasogastric tube, left in situ for a few hours, cured the acute gastric dilatation.\\n\\n2. A middle-aged man underwent an uneventful laparoscopic cholecystectomy. An orogastric tube was inserted by the anesthetist during the procedure and removed at its end. An hour after being discharged from the recovery room, the patient complained about severe abdominal pain, which persisted despite repeated doses of opiates. He developed tachycardia despite adequate hydration. The abdomen was diffusely tender. These worrying features of possible...\\n```',\n", " 'bBox': {'x': 79, 'y': 162, 'w': 453.56, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text has been extracted and structured into markdown format.\\n- No images or figures were identified in the provided text. If there are any images or graphs on the page, please provide the relevant details for further extraction.',\n", " 'md': '- The text has been extracted and structured into markdown format.\\n- No images or figures were identified in the provided text. If there are any images or graphs on the page, please provide the relevant details for further extraction.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 781,\n", " 'text': ' injury to intestine or an early bile leak, persisted for a few hours. I took the patient back to the\\n OR for relaparoscopy — which proved to be normal, except for massive distension of the\\n stomach. An NG tube was inserted and the patient went home the next morning.\\n\\n Message: always think about the possibility of acute gastric\\ndilatation.\\n\\n Prevention\\n\\n It is imperative to emphasize that you can, and ought to, prevent\\nprolonged postoperative ileus or SBO by sound operative technique\\nand attention to detail. Gentle dissection and handling of tissues,\\ncareful hemostasis to avoid hematoma formation, not using the cautery\\nlike a blowtorch, leaving as little foreign material as possible (e.g. large\\nsilk knots, spilled gallstones during laparoscopic cholecystectomy), not\\ndenuding the peritoneum unnecessarily, not creating orifices for internal\\nhernias, folding back the bowel loops into a nice gently-curved position,\\ncarefully closing large port sites, and not catching loops of bowel during\\nabdominal closure, are self-explanatory essentials. We are not yet too\\nimpressed with the evidence supporting recently developed expensive\\ncommercial products that allegedly “prevent adhesions”.\\n\\n In summary, exclude and treat causes of persistent ileus, treat\\nEPSBO conservatively as long as indicated, think about specific causes\\nof SBO (e.g. herniation at a laparoscopic trocar site) and reoperate when\\nnecessary. In most instances ileus/EPSBO will resolve\\nspontaneously ( Figure 45.2).',\n", " 'md': '```markdown\\n## Prevention of Postoperative Ileus and SBO\\n\\nIt is imperative to emphasize that you can, and ought to, prevent prolonged postoperative ileus or SBO by sound operative technique and attention to detail. Gentle dissection and handling of tissues, careful hemostasis to avoid hematoma formation, not using the cautery like a blowtorch, leaving as little foreign material as possible (e.g. large silk knots, spilled gallstones during laparoscopic cholecystectomy), not denuding the peritoneum unnecessarily, not creating orifices for internal hernias, folding back the bowel loops into a nice gently-curved position, carefully closing large port sites, and not catching loops of bowel during abdominal closure, are self-explanatory essentials. We are not yet too impressed with the evidence supporting recently developed expensive commercial products that allegedly “prevent adhesions”.\\n\\nIn summary, exclude and treat causes of persistent ileus, treat EPSBO conservatively as long as indicated, think about specific causes of SBO (e.g. herniation at a laparoscopic trocar site) and reoperate when necessary. In most instances ileus/EPSBO will resolve spontaneously (Figure 45.2).\\n\\n### Message\\nAlways think about the possibility of acute gastric dilatation.\\n\\n### Figure 45.2\\n- **Description**: This figure likely illustrates a case or example related to the discussion of postoperative ileus or SBO, but the specific content of the figure is not provided in the text.\\n- **Summary**: The figure is referenced in the context of ileus and SBO, indicating its relevance to the prevention and treatment strategies discussed.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Prevention of Postoperative Ileus and SBO',\n", " 'md': '## Prevention of Postoperative Ileus and SBO',\n", " 'bBox': {'x': 86, 'y': 237, 'w': 85.53, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'It is imperative to emphasize that you can, and ought to, prevent prolonged postoperative ileus or SBO by sound operative technique and attention to detail. Gentle dissection and handling of tissues, careful hemostasis to avoid hematoma formation, not using the cautery like a blowtorch, leaving as little foreign material as possible (e.g. large silk knots, spilled gallstones during laparoscopic cholecystectomy), not denuding the peritoneum unnecessarily, not creating orifices for internal hernias, folding back the bowel loops into a nice gently-curved position, carefully closing large port sites, and not catching loops of bowel during abdominal closure, are self-explanatory essentials. We are not yet too impressed with the evidence supporting recently developed expensive commercial products that allegedly “prevent adhesions”.\\n\\nIn summary, exclude and treat causes of persistent ileus, treat EPSBO conservatively as long as indicated, think about specific causes of SBO (e.g. herniation at a laparoscopic trocar site) and reoperate when necessary. In most instances ileus/EPSBO will resolve spontaneously (Figure 45.2).',\n", " 'md': 'It is imperative to emphasize that you can, and ought to, prevent prolonged postoperative ileus or SBO by sound operative technique and attention to detail. Gentle dissection and handling of tissues, careful hemostasis to avoid hematoma formation, not using the cautery like a blowtorch, leaving as little foreign material as possible (e.g. large silk knots, spilled gallstones during laparoscopic cholecystectomy), not denuding the peritoneum unnecessarily, not creating orifices for internal hernias, folding back the bowel loops into a nice gently-curved position, carefully closing large port sites, and not catching loops of bowel during abdominal closure, are self-explanatory essentials. We are not yet too impressed with the evidence supporting recently developed expensive commercial products that allegedly “prevent adhesions”.\\n\\nIn summary, exclude and treat causes of persistent ileus, treat EPSBO conservatively as long as indicated, think about specific causes of SBO (e.g. herniation at a laparoscopic trocar site) and reoperate when necessary. In most instances ileus/EPSBO will resolve spontaneously (Figure 45.2).',\n", " 'bBox': {'x': 72, 'y': 273, 'w': 467.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Message',\n", " 'md': '### Message',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Always think about the possibility of acute gastric dilatation.',\n", " 'md': 'Always think about the possibility of acute gastric dilatation.',\n", " 'bBox': {'x': 72, 'y': 193, 'w': 67, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 45.2',\n", " 'md': '### Figure 45.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure likely illustrates a case or example related to the discussion of postoperative ileus or SBO, but the specific content of the figure is not provided in the text.\\n- **Summary**: The figure is referenced in the context of ileus and SBO, indicating its relevance to the prevention and treatment strategies discussed.\\n```',\n", " 'md': '- **Description**: This figure likely illustrates a case or example related to the discussion of postoperative ileus or SBO, but the specific content of the figure is not provided in the text.\\n- **Summary**: The figure is referenced in the context of ileus and SBO, indicating its relevance to the prevention and treatment strategies discussed.\\n```',\n", " 'bBox': {'x': 86, 'y': 237, 'w': 85.53, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 782,\n", " 'text': ' TeRaU\\n Figure 45.2. “Doctor, is it mechanical obstruction or ileus?”… “Shh… let me hear…”\\n\\n Look also at Chapter 8, Schein’s Common Sense Prevention and\\nManagement of Surgical Complications.\\n\\n “Better to leave a piece of peritoneum on the bowel than\\n a piece of bowel on the peritoneum.”\\n “The postoperative fart is the best music to the surgeon’s\\n ears…”',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\n- \"Doctor, is it mechanical obstruction or ileus?”… “Shh… let me hear…”\\n- Look also at Chapter 8, Schein’s Common Sense Prevention and Management of Surgical Complications.\\n- “Better to leave a piece of peritoneum on the bowel than a piece of bowel on the peritoneum.”\\n- “The postoperative fart is the best music to the surgeon’s ears…”\\n\\n## Images\\n### Figure 45.2\\n- **Description**: This figure depicts a dialogue between a doctor and a patient regarding a medical condition, specifically mechanical obstruction or ileus. The image captures a moment of inquiry and response, emphasizing the importance of listening in a clinical setting.\\n- **Summary**: The figure illustrates a humorous yet insightful exchange in a surgical context, highlighting the significance of postoperative recovery signals.\\n\\n```',\n", " 'images': [{'name': 'img_p781_1.png',\n", " 'height': 536,\n", " 'width': 795,\n", " 'x': 109.4399999999996,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1365,\n", " 'original_height': 919}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- \"Doctor, is it mechanical obstruction or ileus?”… “Shh… let me hear…”\\n- Look also at Chapter 8, Schein’s Common Sense Prevention and Management of Surgical Complications.\\n- “Better to leave a piece of peritoneum on the bowel than a piece of bowel on the peritoneum.”\\n- “The postoperative fart is the best music to the surgeon’s ears…”',\n", " 'md': '- \"Doctor, is it mechanical obstruction or ileus?”… “Shh… let me hear…”\\n- Look also at Chapter 8, Schein’s Common Sense Prevention and Management of Surgical Complications.\\n- “Better to leave a piece of peritoneum on the bowel than a piece of bowel on the peritoneum.”\\n- “The postoperative fart is the best music to the surgeon’s ears…”',\n", " 'bBox': {'x': 72, 'y': 431, 'w': 453.6, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 45.2',\n", " 'md': '### Figure 45.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure depicts a dialogue between a doctor and a patient regarding a medical condition, specifically mechanical obstruction or ileus. The image captures a moment of inquiry and response, emphasizing the importance of listening in a clinical setting.\\n- **Summary**: The figure illustrates a humorous yet insightful exchange in a surgical context, highlighting the significance of postoperative recovery signals.\\n\\n```',\n", " 'md': '- **Description**: This figure depicts a dialogue between a doctor and a patient regarding a medical condition, specifically mechanical obstruction or ileus. The image captures a moment of inquiry and response, emphasizing the importance of listening in a clinical setting.\\n- **Summary**: The figure illustrates a humorous yet insightful exchange in a surgical context, highlighting the significance of postoperative recovery signals.\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Management of Surgical Complications'}]},\n", " {'page': 783,\n", " 'text': 'Chapter 46\\nIntra-abdominal abscesses\\nMoshe Schein\\n\\n Signs of pus somewhere, signs of pus nowhere else, signs\\n of pus there — under the diaphragm. This was 100% true\\n when I was a student, 50% true when I was a resident.\\n Today it is irrelevant…\\n\\n The contents of this chapter could have been summarized in a\\nsentence: an abscess is a pus-containing, confined structure, which\\nrequires drainage by whichever means available. The ancients said\\nit even more aptly — Ubi pus, ibi evacua. We believe, however, that\\nyou want us to elaborate.\\n\\n Abscesses may develop anywhere within the abdomen, resulting from\\nnumerous conditions. Specific types such as diverticular or peri-\\nappendicular abscesses are covered elsewhere in this book; this chapter\\nwill introduce you to general concepts — with emphasis on what is\\nprobably the commonest abscess in your practice — the postoperative\\nabscess.\\n\\n Definition and significance\\n\\n Erroneously, the term ‘intra-abdominal abscess’ has been and still is\\nused as a synonym for secondary peritonitis ( Chapter 13). This is not\\ntrue as abscesses develop as a result of effective host defenses and\\nrepresent a relatively successful outcome of peritonitis.',\n", " 'md': '```markdown\\n# Chapter 46: Intra-abdominal Abscesses\\n**Author:** Moshe Schein\\n\\nSigns of pus somewhere, signs of pus nowhere else, signs of pus there — under the diaphragm. This was 100% true when I was a student, 50% true when I was a resident. Today it is irrelevant…\\n\\nThe contents of this chapter could have been summarized in a sentence: an abscess is a pus-containing, confined structure, which requires drainage by whichever means available. The ancients said it even more aptly — *Ubi pus, ibi evacua*. We believe, however, that you want us to elaborate.\\n\\nAbscesses may develop anywhere within the abdomen, resulting from numerous conditions. Specific types such as diverticular or peri-appendicular abscesses are covered elsewhere in this book; this chapter will introduce you to general concepts — with emphasis on what is probably the commonest abscess in your practice — the postoperative abscess.\\n\\n## Definition and Significance\\n\\nErroneously, the term ‘intra-abdominal abscess’ has been and still is used as a synonym for secondary peritonitis (Chapter 13). This is not true as abscesses develop as a result of effective host defenses and represent a relatively successful outcome of peritonitis.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 46: Intra-abdominal Abscesses',\n", " 'md': '# Chapter 46: Intra-abdominal Abscesses',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 240.78, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Moshe Schein\\n\\nSigns of pus somewhere, signs of pus nowhere else, signs of pus there — under the diaphragm. This was 100% true when I was a student, 50% true when I was a resident. Today it is irrelevant…\\n\\nThe contents of this chapter could have been summarized in a sentence: an abscess is a pus-containing, confined structure, which requires drainage by whichever means available. The ancients said it even more aptly — *Ubi pus, ibi evacua*. We believe, however, that you want us to elaborate.\\n\\nAbscesses may develop anywhere within the abdomen, resulting from numerous conditions. Specific types such as diverticular or peri-appendicular abscesses are covered elsewhere in this book; this chapter will introduce you to general concepts — with emphasis on what is probably the commonest abscess in your practice — the postoperative abscess.',\n", " 'md': '**Author:** Moshe Schein\\n\\nSigns of pus somewhere, signs of pus nowhere else, signs of pus there — under the diaphragm. This was 100% true when I was a student, 50% true when I was a resident. Today it is irrelevant…\\n\\nThe contents of this chapter could have been summarized in a sentence: an abscess is a pus-containing, confined structure, which requires drainage by whichever means available. The ancients said it even more aptly — *Ubi pus, ibi evacua*. We believe, however, that you want us to elaborate.\\n\\nAbscesses may develop anywhere within the abdomen, resulting from numerous conditions. Specific types such as diverticular or peri-appendicular abscesses are covered elsewhere in this book; this chapter will introduce you to general concepts — with emphasis on what is probably the commonest abscess in your practice — the postoperative abscess.',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 467.51, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Definition and Significance',\n", " 'md': '## Definition and Significance',\n", " 'bBox': {'x': 86, 'y': 622, 'w': 210.55, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Erroneously, the term ‘intra-abdominal abscess’ has been and still is used as a synonym for secondary peritonitis (Chapter 13). This is not true as abscesses develop as a result of effective host defenses and represent a relatively successful outcome of peritonitis.\\n```',\n", " 'md': 'Erroneously, the term ‘intra-abdominal abscess’ has been and still is used as a synonym for secondary peritonitis (Chapter 13). This is not true as abscesses develop as a result of effective host defenses and represent a relatively successful outcome of peritonitis.\\n```',\n", " 'bBox': {'x': 72, 'y': 674, 'w': 467.65, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'true as abscesses develop as a result of effective host defenses and'}]},\n", " {'page': 784,\n", " 'text': ' To be termed an abscess, the confined structure has to be walled off by an inflammatory wall\\n and possess a viscous interior. In contrast, free-flowing, contaminated or infected peritoneal\\n fluid or loculated collections, which are deprived of a wall, represent a phase in the\\n spectrum/continuum of peritoneal contamination/infection and not an abscess.\\n\\n Classification and pathogenesis\\n Table 46.1. Classification of abdominal abscesses.\\n Classification Examples\\n Visceral vs. non-visceral Hepatic vs. subphrenic\\n Primary VS. secondary Splenic vs. appendiceal\\n Spontaneous VS. postoperative Diverticular vS. peri-anastomotic\\n Intraperitoneal vS. retroperitoneal Tubo-ovarian VS. psoas\\n Simple vs. complex Complex:\\n Multiple (liver)\\n Multiloculated\\n Communication with bowel\\n (leaking anastomosis)\\n Associated with necrotic tissue\\n (pancreatic)\\n Associated with cancer\\n Anatomical Subphrenic, subhepatic, lesser sac,\\n paracolic, pelvic, interloop, perinephric,\\n psoas\\n The myriad forms of intra-abdominal abscesses makes their\\nclassification complex ( Table 46.1), but practically, abscesses are\\nvisceral (e.g. intrahepatic or splenic) or non-visceral (e.g. subphrenic,',\n", " 'md': '```markdown\\nTo be termed an abscess, the confined structure has to be walled off by an inflammatory wall and possess a viscous interior. In contrast, free-flowing, contaminated or infected peritoneal fluid or loculated collections, which are deprived of a wall, represent a phase in the spectrum/continuum of peritoneal contamination/infection and not an abscess.\\n\\n## Classification and Pathogenesis\\n\\n### Table 46.1. Classification of Abdominal Abscesses\\n\\n| Classification | Examples |\\n|-----------------------------------------|-----------------------------------------------|\\n| Visceral vs. non-visceral | Hepatic vs. subphrenic |\\n| Primary vs. secondary | Splenic vs. appendiceal |\\n| Spontaneous vs. postoperative | Diverticular vs. peri-anastomotic |\\n| Intraperitoneal vs. retroperitoneal | Tubo-ovarian vs. psoas |\\n| Simple vs. complex | Complex: |\\n| | - Multiple (liver) |\\n| | - Multiloculated |\\n| | - Communication with bowel (leaking anastomosis) |\\n| | - Associated with necrotic tissue (pancreatic) |\\n| | - Associated with cancer |\\n| Anatomical | Subphrenic, subhepatic, lesser sac, |\\n| | paracolic, pelvic, interloop, perinephric, |\\n| | psoas |\\n\\nThe myriad forms of intra-abdominal abscesses makes their classification complex (Table 46.1), but practically, abscesses are visceral (e.g. intrahepatic or splenic) or non-visceral (e.g. subphrenic).\\n```',\n", " 'images': [{'name': 'img_p783_1.png',\n", " 'height': 867,\n", " 'width': 818,\n", " 'x': 103.68,\n", " 'y': 218.88,\n", " 'original_width': 1404,\n", " 'original_height': 1489},\n", " {'name': 'img_p783_2.png',\n", " 'height': 12,\n", " 'width': 12,\n", " 'x': 229.67999999999995,\n", " 'y': 687.6}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nTo be termed an abscess, the confined structure has to be walled off by an inflammatory wall and possess a viscous interior. In contrast, free-flowing, contaminated or infected peritoneal fluid or loculated collections, which are deprived of a wall, represent a phase in the spectrum/continuum of peritoneal contamination/infection and not an abscess.',\n", " 'md': '```markdown\\nTo be termed an abscess, the confined structure has to be walled off by an inflammatory wall and possess a viscous interior. In contrast, free-flowing, contaminated or infected peritoneal fluid or loculated collections, which are deprived of a wall, represent a phase in the spectrum/continuum of peritoneal contamination/infection and not an abscess.',\n", " 'bBox': {'x': 79, 'y': 93, 'w': 453.07, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Classification and Pathogenesis',\n", " 'md': '## Classification and Pathogenesis',\n", " 'bBox': {'x': 86, 'y': 204, 'w': 252.88, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 46.1. Classification of Abdominal Abscesses',\n", " 'md': '### Table 46.1. Classification of Abdominal Abscesses',\n", " 'bBox': {'x': 109.62, 'y': 264.42, 'w': 75.19, 'h': 14.4}},\n", " {'type': 'table',\n", " 'rows': [['Classification', 'Examples'],\n", " ['Visceral vs. non-visceral', 'Hepatic vs. subphrenic'],\n", " ['Primary vs. secondary', 'Splenic vs. appendiceal'],\n", " ['Spontaneous vs. postoperative', 'Diverticular vs. peri-anastomotic'],\n", " ['Intraperitoneal vs. retroperitoneal', 'Tubo-ovarian vs. psoas'],\n", " ['Simple vs. complex', 'Complex:'],\n", " ['', '- Multiple (liver)'],\n", " ['', '- Multiloculated'],\n", " ['', '- Communication with bowel (leaking anastomosis)'],\n", " ['', '- Associated with necrotic tissue (pancreatic)'],\n", " ['', '- Associated with cancer'],\n", " ['Anatomical', 'Subphrenic, subhepatic, lesser sac,'],\n", " ['', 'paracolic, pelvic, interloop, perinephric,'],\n", " ['', 'psoas']],\n", " 'md': '| Classification | Examples |\\n|-----------------------------------------|-----------------------------------------------|\\n| Visceral vs. non-visceral | Hepatic vs. subphrenic |\\n| Primary vs. secondary | Splenic vs. appendiceal |\\n| Spontaneous vs. postoperative | Diverticular vs. peri-anastomotic |\\n| Intraperitoneal vs. retroperitoneal | Tubo-ovarian vs. psoas |\\n| Simple vs. complex | Complex: |\\n| | - Multiple (liver) |\\n| | - Multiloculated |\\n| | - Communication with bowel (leaking anastomosis) |\\n| | - Associated with necrotic tissue (pancreatic) |\\n| | - Associated with cancer |\\n| Anatomical | Subphrenic, subhepatic, lesser sac, |\\n| | paracolic, pelvic, interloop, perinephric, |\\n| | psoas |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Classification\",\"Examples\"\\n\"Visceral vs. non-visceral\",\"Hepatic vs. subphrenic\"\\n\"Primary vs. secondary\",\"Splenic vs. appendiceal\"\\n\"Spontaneous vs. postoperative\",\"Diverticular vs. peri-anastomotic\"\\n\"Intraperitoneal vs. retroperitoneal\",\"Tubo-ovarian vs. psoas\"\\n\"Simple vs. complex\",\"Complex:\"\\n\"\",\"- Multiple (liver)\"\\n\"\",\"- Multiloculated\"\\n\"\",\"- Communication with bowel (leaking anastomosis)\"\\n\"\",\"- Associated with necrotic tissue (pancreatic)\"\\n\"\",\"- Associated with cancer\"\\n\"Anatomical\",\"Subphrenic, subhepatic, lesser sac,\"\\n\"\",\"paracolic, pelvic, interloop, perinephric,\"\\n\"\",\"psoas\"',\n", " 'bBox': {'x': 109.12, 'y': 264.42, 'w': 180.06, 'h': 15.34}},\n", " {'type': 'text',\n", " 'value': 'The myriad forms of intra-abdominal abscesses makes their classification complex (Table 46.1), but practically, abscesses are visceral (e.g. intrahepatic or splenic) or non-visceral (e.g. subphrenic).\\n```',\n", " 'md': 'The myriad forms of intra-abdominal abscesses makes their classification complex (Table 46.1), but practically, abscesses are visceral (e.g. intrahepatic or splenic) or non-visceral (e.g. subphrenic).\\n```',\n", " 'bBox': {'x': 86, 'y': 264.42, 'w': 103.15, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ' (e.g. intrahepatic or splenic) or '}]},\n", " {'page': 785,\n", " 'text': 'pelvic), intraperitoneal or extraperitoneal. Non-visceral abscesses\\narise following the resolution of diffuse peritonitis during which loculated\\nareas of infection and suppuration are ‘walled off’ and persist; or arise\\nafter a perforation of a viscus, which is effectively localized by peritoneal\\ndefenses. Visceral abscesses are usually caused by hematogenous or\\nlymphatic dissemination of bacteria to a solid organ; but a direct invasion\\nis also possible, like in hepatic abscess secondary to posterior wall\\nperforation of a gallbladder, or a splenic abscess in continuity with a\\nsplenic flexure perforation due to cancer or diverticulitis. Retroperitoneal\\nabscesses may result from perforation of a hollow viscus into the\\nretroperitoneum as well as by hematogenous or lymphatic spread.\\n\\n Another distinction is between the postoperative abscess — for the\\ndevelopment of which we surgeons feel responsible — and\\nspontaneous abscesses, unassociated with a previous operation.\\n\\n A further clinically significant separation is between simple abscesses\\nand complex abscesses (e.g. multiple; multiloculated; or associated\\nwith tissue necrosis, enteric communication or tumor), which\\nrequire a more aggressive therapy and carry a poorer prognosis.\\nThe anatomical classification, based on the specific anatomical\\nlocation of an abscess — which typically develops in one of the few\\nconstant potential spaces — has diminished in significance since the\\nadvent of readily available modern imaging and percutaneous drainage\\ntechniques.\\n\\n Note that abscesses signify an intermediate natural outcome of\\ncontamination/infection. At one end of the spectrum infection persists,\\nspreads and kills; at the other, the process is entirely cleared by host\\ndefenses — assisted by your therapy. Abscesses lie in no-man’s land,\\nwhere the peritoneal defenses are only partially effective — being\\ndisturbed by an overwhelming number of bacteria, micro-environmental\\nhypoxemia or acidosis, and adjuvants of infection such as necrotic\\ndebris, hemoglobin, fibrin and (if you are stupid enough) barium sulfate.\\nAn untreated abdominal abscess won’t kill your patient immediately,\\nbut if neglected and undrained, it will become gradually lethal,\\nunless spontaneous drainage occurs.',\n", " 'md': '```markdown\\n## Abscess Classification\\n\\nAbscesses can be classified based on their location and characteristics:\\n\\n1. **Non-visceral abscesses** arise following the resolution of diffuse peritonitis, during which loculated areas of infection and suppuration are ‘walled off’ and persist. They can also arise after a perforation of a viscus, which is effectively localized by peritoneal defenses.\\n\\n2. **Visceral abscesses** are usually caused by hematogenous or lymphatic dissemination of bacteria to a solid organ. Direct invasion is also possible, such as in:\\n- Hepatic abscess secondary to posterior wall perforation of a gallbladder.\\n- Splenic abscess in continuity with a splenic flexure perforation due to cancer or diverticulitis.\\n\\n3. **Retroperitoneal abscesses** may result from perforation of a hollow viscus into the retroperitoneum, as well as by hematogenous or lymphatic spread.\\n\\n### Types of Abscesses\\n\\n- **Postoperative abscesses**: Development of which surgeons feel responsible.\\n- **Spontaneous abscesses**: Unassociated with a previous operation.\\n\\n### Simple vs. Complex Abscesses\\n\\nA clinically significant separation exists between:\\n- **Simple abscesses**: Typically straightforward in nature.\\n- **Complex abscesses**: These may be multiple, multiloculated, or associated with tissue necrosis, enteric communication, or tumor, requiring more aggressive therapy and carrying a poorer prognosis.\\n\\n### Anatomical Classification\\n\\nThe anatomical classification, based on the specific anatomical location of an abscess, has diminished in significance since the advent of readily available modern imaging and percutaneous drainage techniques.\\n\\n### Clinical Significance\\n\\nAbscesses signify an intermediate natural outcome of contamination/infection. The spectrum includes:\\n- **Persistent infection**: Spreads and kills.\\n- **Complete clearance**: By host defenses, assisted by therapy.\\n\\nAbscesses lie in a state where peritoneal defenses are only partially effective, disturbed by an overwhelming number of bacteria, micro-environmental hypoxemia or acidosis, and adjuvants of infection such as necrotic debris, hemoglobin, fibrin, and potentially harmful substances like barium sulfate.\\n\\nAn untreated abdominal abscess won’t kill your patient immediately, but if neglected and undrained, it will gradually become lethal unless spontaneous drainage occurs.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Abscess Classification',\n", " 'md': '## Abscess Classification',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Abscesses can be classified based on their location and characteristics:\\n\\n1. **Non-visceral abscesses** arise following the resolution of diffuse peritonitis, during which loculated areas of infection and suppuration are ‘walled off’ and persist. They can also arise after a perforation of a viscus, which is effectively localized by peritoneal defenses.\\n\\n2. **Visceral abscesses** are usually caused by hematogenous or lymphatic dissemination of bacteria to a solid organ. Direct invasion is also possible, such as in:\\n- Hepatic abscess secondary to posterior wall perforation of a gallbladder.\\n- Splenic abscess in continuity with a splenic flexure perforation due to cancer or diverticulitis.\\n\\n3. **Retroperitoneal abscesses** may result from perforation of a hollow viscus into the retroperitoneum, as well as by hematogenous or lymphatic spread.',\n", " 'md': 'Abscesses can be classified based on their location and characteristics:\\n\\n1. **Non-visceral abscesses** arise following the resolution of diffuse peritonitis, during which loculated areas of infection and suppuration are ‘walled off’ and persist. They can also arise after a perforation of a viscus, which is effectively localized by peritoneal defenses.\\n\\n2. **Visceral abscesses** are usually caused by hematogenous or lymphatic dissemination of bacteria to a solid organ. Direct invasion is also possible, such as in:\\n- Hepatic abscess secondary to posterior wall perforation of a gallbladder.\\n- Splenic abscess in continuity with a splenic flexure perforation due to cancer or diverticulitis.\\n\\n3. **Retroperitoneal abscesses** may result from perforation of a hollow viscus into the retroperitoneum, as well as by hematogenous or lymphatic spread.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.33, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Types of Abscesses',\n", " 'md': '### Types of Abscesses',\n", " 'bBox': {'x': 169, 'y': 303, 'w': 16, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Postoperative abscesses**: Development of which surgeons feel responsible.\\n- **Spontaneous abscesses**: Unassociated with a previous operation.',\n", " 'md': '- **Postoperative abscesses**: Development of which surgeons feel responsible.\\n- **Spontaneous abscesses**: Unassociated with a previous operation.',\n", " 'bBox': {'x': 72, 'y': 303, 'w': 86.38, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Simple vs. Complex Abscesses',\n", " 'md': '### Simple vs. Complex Abscesses',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A clinically significant separation exists between:\\n- **Simple abscesses**: Typically straightforward in nature.\\n- **Complex abscesses**: These may be multiple, multiloculated, or associated with tissue necrosis, enteric communication, or tumor, requiring more aggressive therapy and carrying a poorer prognosis.',\n", " 'md': 'A clinically significant separation exists between:\\n- **Simple abscesses**: Typically straightforward in nature.\\n- **Complex abscesses**: These may be multiple, multiloculated, or associated with tissue necrosis, enteric communication, or tumor, requiring more aggressive therapy and carrying a poorer prognosis.',\n", " 'bBox': {'x': 516, 'y': 303, 'w': 24, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Anatomical Classification',\n", " 'md': '### Anatomical Classification',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The anatomical classification, based on the specific anatomical location of an abscess, has diminished in significance since the advent of readily available modern imaging and percutaneous drainage techniques.',\n", " 'md': 'The anatomical classification, based on the specific anatomical location of an abscess, has diminished in significance since the advent of readily available modern imaging and percutaneous drainage techniques.',\n", " 'bBox': {'x': 72, 'y': 303, 'w': 121, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Clinical Significance',\n", " 'md': '### Clinical Significance',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Abscesses signify an intermediate natural outcome of contamination/infection. The spectrum includes:\\n- **Persistent infection**: Spreads and kills.\\n- **Complete clearance**: By host defenses, assisted by therapy.\\n\\nAbscesses lie in a state where peritoneal defenses are only partially effective, disturbed by an overwhelming number of bacteria, micro-environmental hypoxemia or acidosis, and adjuvants of infection such as necrotic debris, hemoglobin, fibrin, and potentially harmful substances like barium sulfate.\\n\\nAn untreated abdominal abscess won’t kill your patient immediately, but if neglected and undrained, it will gradually become lethal unless spontaneous drainage occurs.\\n```',\n", " 'md': 'Abscesses signify an intermediate natural outcome of contamination/infection. The spectrum includes:\\n- **Persistent infection**: Spreads and kills.\\n- **Complete clearance**: By host defenses, assisted by therapy.\\n\\nAbscesses lie in a state where peritoneal defenses are only partially effective, disturbed by an overwhelming number of bacteria, micro-environmental hypoxemia or acidosis, and adjuvants of infection such as necrotic debris, hemoglobin, fibrin, and potentially harmful substances like barium sulfate.\\n\\nAn untreated abdominal abscess won’t kill your patient immediately, but if neglected and undrained, it will gradually become lethal unless spontaneous drainage occurs.\\n```',\n", " 'bBox': {'x': 72, 'y': 303, 'w': 467.33, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 786,\n", " 'text': ' Microbiology\\n\\n Generally speaking, abdominal abscesses are polymicrobial.\\nAbscesses that develop in the aftermath of secondary peritonitis (e.g.\\nappendiceal or diverticular abscess) possess the mixed aerobic-\\nanaerobic flora of secondary peritonitis ( Chapters 7 and 13). It appears\\nthat while endotoxin-generating facultative anaerobes, such as\\nEscherichia coli, are responsible for the phase of acute peritonitis, the\\nobligate anaerobes, such as Bacteroides fragilis, are responsible for late\\nabscess formation. These bacteria act in synergy; both are necessary to\\nproduce an abscess, and the obligate anaerobe can increase the lethality\\nof an otherwise non-lethal inoculum of the facultative micro-organisms.\\nThe vast majority of visceral abscesses (e.g. hepatic and splenic) are\\npolymicrobial — aerobic, anaerobic, Gram-negative and -positive. This is\\nalso true for retroperitoneal abscesses. Primary abscesses (e.g. psoas\\nabscess) are often monobacterial, with Staphylococci predominating.\\nPostoperative abscesses are often characterized by the flora typical\\nof tertiary peritonitis — representing superinfection with yeasts and\\nother opportunists ( Chapter 13). The low virulence of these\\norganisms, which are probably a marker rather than a cause of tertiary\\nperitonitis, reflects the global immunodepression of the affected patients.\\n\\n Clinical features\\n\\n The clinical presentation of abdominal abscesses is as heterogeneous\\nand multifaceted as the abscesses themselves. The spectrum is vast;\\nsystemic repercussions of the infection vary from frank septic\\nshock to nothing at all when suppressed by immunoparesis and\\nantibiotics. Locally, the abscess may be felt through the abdominal wall,\\nthe rectum or vagina; in most instances, however, it remains physically\\noccult. In our modern times, when any fever is an alleged indication for\\nantibiotics, most abscesses are initially partially treated or masked —\\npresenting as a SIRS with or without (multi-) organ dysfunction. Ileus is\\nanother notable presentation of abdominal abscess; in the\\npostoperative situation it is an “ileus that fails to resolve” ( Chapter 45).\\n\\n In this age of instant and repeated imaging, of obsessive wielding',\n", " 'md': '```markdown\\n# Microbiology\\n\\nGenerally speaking, abdominal abscesses are polymicrobial. Abscesses that develop in the aftermath of secondary peritonitis (e.g. appendiceal or diverticular abscess) possess the mixed aerobic-anaerobic flora of secondary peritonitis (Chapters 7 and 13). It appears that while endotoxin-generating facultative anaerobes, such as Escherichia coli, are responsible for the phase of acute peritonitis, the obligate anaerobes, such as Bacteroides fragilis, are responsible for late abscess formation. These bacteria act in synergy; both are necessary to produce an abscess, and the obligate anaerobe can increase the lethality of an otherwise non-lethal inoculum of the facultative microorganisms. The vast majority of visceral abscesses (e.g. hepatic and splenic) are polymicrobial — aerobic, anaerobic, Gram-negative and -positive. This is also true for retroperitoneal abscesses. Primary abscesses (e.g. psoas abscess) are often monobacterial, with Staphylococci predominating. Postoperative abscesses are often characterized by the flora typical of tertiary peritonitis — representing superinfection with yeasts and other opportunists (Chapter 13). The low virulence of these organisms, which are probably a marker rather than a cause of tertiary peritonitis, reflects the global immunodepression of the affected patients.\\n\\n## Clinical features\\n\\nThe clinical presentation of abdominal abscesses is as heterogeneous and multifaceted as the abscesses themselves. The spectrum is vast; systemic repercussions of the infection vary from frank septic shock to nothing at all when suppressed by immunoparesis and antibiotics. Locally, the abscess may be felt through the abdominal wall, the rectum or vagina; in most instances, however, it remains physically occult. In our modern times, when any fever is an alleged indication for antibiotics, most abscesses are initially partially treated or masked — presenting as a SIRS with or without (multi-) organ dysfunction. Ileus is another notable presentation of abdominal abscess; in the postoperative situation it is an “ileus that fails to resolve” (Chapter 45).\\n\\nIn this age of instant and repeated imaging, of obsessive wielding\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Microbiology',\n", " 'md': '# Microbiology',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 102.98, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Generally speaking, abdominal abscesses are polymicrobial. Abscesses that develop in the aftermath of secondary peritonitis (e.g. appendiceal or diverticular abscess) possess the mixed aerobic-anaerobic flora of secondary peritonitis (Chapters 7 and 13). It appears that while endotoxin-generating facultative anaerobes, such as Escherichia coli, are responsible for the phase of acute peritonitis, the obligate anaerobes, such as Bacteroides fragilis, are responsible for late abscess formation. These bacteria act in synergy; both are necessary to produce an abscess, and the obligate anaerobe can increase the lethality of an otherwise non-lethal inoculum of the facultative microorganisms. The vast majority of visceral abscesses (e.g. hepatic and splenic) are polymicrobial — aerobic, anaerobic, Gram-negative and -positive. This is also true for retroperitoneal abscesses. Primary abscesses (e.g. psoas abscess) are often monobacterial, with Staphylococci predominating. Postoperative abscesses are often characterized by the flora typical of tertiary peritonitis — representing superinfection with yeasts and other opportunists (Chapter 13). The low virulence of these organisms, which are probably a marker rather than a cause of tertiary peritonitis, reflects the global immunodepression of the affected patients.',\n", " 'md': 'Generally speaking, abdominal abscesses are polymicrobial. Abscesses that develop in the aftermath of secondary peritonitis (e.g. appendiceal or diverticular abscess) possess the mixed aerobic-anaerobic flora of secondary peritonitis (Chapters 7 and 13). It appears that while endotoxin-generating facultative anaerobes, such as Escherichia coli, are responsible for the phase of acute peritonitis, the obligate anaerobes, such as Bacteroides fragilis, are responsible for late abscess formation. These bacteria act in synergy; both are necessary to produce an abscess, and the obligate anaerobe can increase the lethality of an otherwise non-lethal inoculum of the facultative microorganisms. The vast majority of visceral abscesses (e.g. hepatic and splenic) are polymicrobial — aerobic, anaerobic, Gram-negative and -positive. This is also true for retroperitoneal abscesses. Primary abscesses (e.g. psoas abscess) are often monobacterial, with Staphylococci predominating. Postoperative abscesses are often characterized by the flora typical of tertiary peritonitis — representing superinfection with yeasts and other opportunists (Chapter 13). The low virulence of these organisms, which are probably a marker rather than a cause of tertiary peritonitis, reflects the global immunodepression of the affected patients.',\n", " 'bBox': {'x': 72, 'y': 173, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical features',\n", " 'md': '## Clinical features',\n", " 'bBox': {'x': 86, 'y': 465, 'w': 127.82, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The clinical presentation of abdominal abscesses is as heterogeneous and multifaceted as the abscesses themselves. The spectrum is vast; systemic repercussions of the infection vary from frank septic shock to nothing at all when suppressed by immunoparesis and antibiotics. Locally, the abscess may be felt through the abdominal wall, the rectum or vagina; in most instances, however, it remains physically occult. In our modern times, when any fever is an alleged indication for antibiotics, most abscesses are initially partially treated or masked — presenting as a SIRS with or without (multi-) organ dysfunction. Ileus is another notable presentation of abdominal abscess; in the postoperative situation it is an “ileus that fails to resolve” (Chapter 45).\\n\\nIn this age of instant and repeated imaging, of obsessive wielding\\n```',\n", " 'md': 'The clinical presentation of abdominal abscesses is as heterogeneous and multifaceted as the abscesses themselves. The spectrum is vast; systemic repercussions of the infection vary from frank septic shock to nothing at all when suppressed by immunoparesis and antibiotics. Locally, the abscess may be felt through the abdominal wall, the rectum or vagina; in most instances, however, it remains physically occult. In our modern times, when any fever is an alleged indication for antibiotics, most abscesses are initially partially treated or masked — presenting as a SIRS with or without (multi-) organ dysfunction. Ileus is another notable presentation of abdominal abscess; in the postoperative situation it is an “ileus that fails to resolve” (Chapter 45).\\n\\nIn this age of instant and repeated imaging, of obsessive wielding\\n```',\n", " 'bBox': {'x': 72, 'y': 190, 'w': 467.21, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the instructions, excluding any headers or footers.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 519, 'y': 190, 'w': 20.2, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'facultative '},\n", " {'text': 'anaerobes, '},\n", " {'text': 'organisms, which are probably a '},\n", " {'text': ''}]},\n", " {'page': 787,\n", " 'text': 'of needles and knives, we tend to forget the real natural history of\\nintra-abdominal abscesses. The following case will serve as an\\nexample.\\n\\n An 88-year-old lady presented with massive fecaluria. Imaging showed a phlegmon/abscess\\n involving the sigmoid colon with a large colovesical fistula. The family refused our\\n recommendation to proceed with an emergency sigmoidectomy, or a diverting colostomy plus\\n percutaneous drainage of the abscess. “Let her die in peace”, they pleaded and summoned\\n her Priest. The patient returned to her nursing home but refused to die. Instead she continued\\n to flourish while draining feces into her urine. Six months later she developed a subcutaneous\\n abscess on the lower abdominal wall. We drained it under local anesthesia — it produced\\n feces. A colostomy bag was placed on the drainage wound — voilà, a spontaneous colostomy.\\n The urine became clear. Now, two years later, the patient continues to thrive.\\n\\n Just makes you stop and ponder…\\n\\n Diagnosis\\n\\n Life has become simple! Modern abdominal imaging has\\nrevolutionized the diagnosis of abdominal abscesses. Yes, you still\\nneed to suspect the abscess and carefully examine your patient but the\\ndefinitive diagnosis (and usually the treatment) depends on imaging\\ntechniques. Computed tomography (CT), ultrasound (US) and various\\nradioisotope-scanning techniques are available. Which is the best?\\n\\n Radioisotope scanning, regardless of the isotope used, does not\\nprovide any anatomical data beyond vague localization of an\\ninflammatory site; it is not accurate enough to permit percutaneous (PC)\\ndrainage. The usefulness of these methods is limited therefore to the\\ncontinuous survival of nuclear medicine units and an excuse to publish\\npapers (nuclear medicine = unclear medicine). Practically, these tests\\nhave a very limited role (work-up of obscure fever), and some would say\\nno role at all.',\n", " 'md': '```markdown\\n## Case Study of Intra-Abdominal Abscesses\\n\\nAn 88-year-old lady presented with massive fecaluria. Imaging showed a phlegmon/abscess involving the sigmoid colon with a large colovesical fistula. The family refused our recommendation to proceed with an emergency sigmoidectomy, or a diverting colostomy plus percutaneous drainage of the abscess. “Let her die in peace,” they pleaded and summoned her Priest. The patient returned to her nursing home but refused to die. Instead, she continued to flourish while draining feces into her urine. Six months later, she developed a subcutaneous abscess on the lower abdominal wall. We drained it under local anesthesia — it produced feces. A colostomy bag was placed on the drainage wound — voilà, a spontaneous colostomy. The urine became clear. Now, two years later, the patient continues to thrive.\\n\\nJust makes you stop and ponder…\\n\\n### Diagnosis\\n\\nLife has become simple! Modern abdominal imaging has revolutionized the diagnosis of abdominal abscesses. Yes, you still need to suspect the abscess and carefully examine your patient, but the definitive diagnosis (and usually the treatment) depends on imaging techniques. Computed tomography (CT), ultrasound (US), and various radioisotope-scanning techniques are available. Which is the best?\\n\\nRadioisotope scanning, regardless of the isotope used, does not provide any anatomical data beyond vague localization of an inflammatory site; it is not accurate enough to permit percutaneous (PC) drainage. The usefulness of these methods is limited therefore to the continuous survival of nuclear medicine units and an excuse to publish papers (nuclear medicine = unclear medicine). Practically, these tests have a very limited role (work-up of obscure fever), and some would say no role at all.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Case Study of Intra-Abdominal Abscesses',\n", " 'md': '## Case Study of Intra-Abdominal Abscesses',\n", " 'bBox': {'x': 360, 'y': 451, 'w': 75.94, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'An 88-year-old lady presented with massive fecaluria. Imaging showed a phlegmon/abscess involving the sigmoid colon with a large colovesical fistula. The family refused our recommendation to proceed with an emergency sigmoidectomy, or a diverting colostomy plus percutaneous drainage of the abscess. “Let her die in peace,” they pleaded and summoned her Priest. The patient returned to her nursing home but refused to die. Instead, she continued to flourish while draining feces into her urine. Six months later, she developed a subcutaneous abscess on the lower abdominal wall. We drained it under local anesthesia — it produced feces. A colostomy bag was placed on the drainage wound — voilà, a spontaneous colostomy. The urine became clear. Now, two years later, the patient continues to thrive.\\n\\nJust makes you stop and ponder…',\n", " 'md': 'An 88-year-old lady presented with massive fecaluria. Imaging showed a phlegmon/abscess involving the sigmoid colon with a large colovesical fistula. The family refused our recommendation to proceed with an emergency sigmoidectomy, or a diverting colostomy plus percutaneous drainage of the abscess. “Let her die in peace,” they pleaded and summoned her Priest. The patient returned to her nursing home but refused to die. Instead, she continued to flourish while draining feces into her urine. Six months later, she developed a subcutaneous abscess on the lower abdominal wall. We drained it under local anesthesia — it produced feces. A colostomy bag was placed on the drainage wound — voilà, a spontaneous colostomy. The urine became clear. Now, two years later, the patient continues to thrive.\\n\\nJust makes you stop and ponder…',\n", " 'bBox': {'x': 79, 'y': 204, 'w': 453.21, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Diagnosis',\n", " 'md': '### Diagnosis',\n", " 'bBox': {'x': 86, 'y': 415, 'w': 79.09, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Life has become simple! Modern abdominal imaging has revolutionized the diagnosis of abdominal abscesses. Yes, you still need to suspect the abscess and carefully examine your patient, but the definitive diagnosis (and usually the treatment) depends on imaging techniques. Computed tomography (CT), ultrasound (US), and various radioisotope-scanning techniques are available. Which is the best?\\n\\nRadioisotope scanning, regardless of the isotope used, does not provide any anatomical data beyond vague localization of an inflammatory site; it is not accurate enough to permit percutaneous (PC) drainage. The usefulness of these methods is limited therefore to the continuous survival of nuclear medicine units and an excuse to publish papers (nuclear medicine = unclear medicine). Practically, these tests have a very limited role (work-up of obscure fever), and some would say no role at all.\\n```',\n", " 'md': 'Life has become simple! Modern abdominal imaging has revolutionized the diagnosis of abdominal abscesses. Yes, you still need to suspect the abscess and carefully examine your patient, but the definitive diagnosis (and usually the treatment) depends on imaging techniques. Computed tomography (CT), ultrasound (US), and various radioisotope-scanning techniques are available. Which is the best?\\n\\nRadioisotope scanning, regardless of the isotope used, does not provide any anatomical data beyond vague localization of an inflammatory site; it is not accurate enough to permit percutaneous (PC) drainage. The usefulness of these methods is limited therefore to the continuous survival of nuclear medicine units and an excuse to publish papers (nuclear medicine = unclear medicine). Practically, these tests have a very limited role (work-up of obscure fever), and some would say no role at all.\\n```',\n", " 'bBox': {'x': 72, 'y': 415, 'w': 467.6, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 788,\n", " 'text': ' Both US and CT provide good anatomical definition including the site\\nof the abscess, its size and structure ( Figure 46.1); both can guide PC\\ndrainage. US is portable, cheaper, and more accurate at detecting\\nabscesses in the right upper abdomen and pelvis. It is, however,\\nextremely operator-dependent. We surgeons are better trained to read\\nCT scans rather than US; hence, we prefer CT, which allows us to\\nvisualize the entire abdomen, independently assess the anatomy of\\nthe abscess, and plan its optimal management. CT — enhanced with\\nintravenous and intraluminal contrast — is also helpful in\\nclassifying the abscess either as simple or complex ( Table 46.1).\\n FeRA14\\n Figure 46.1. “You call that an abscess? THIS is an abscess!”\\n\\n Do understand that imaging during the first postoperative week\\ncannot distinguish between a sterile fluid collection (e.g. residual\\nlavage fluid) and an infected fluid collection before the development\\nof a frank, mature abscess. The only way to document the infective\\nnature of any visualized fluid is a diagnostic aspiration — subjecting the\\naspirate to a Gram stain and culture. CT features suggestive of a proper\\nabscess are a contrast-enhancing, well-defined rim, and the presence of\\ngas bubbles.',\n", " 'md': '```markdown\\n## Page Content\\n\\nBoth US and CT provide good anatomical definition including the site of the abscess, its size and structure (Figure 46.1); both can guide PC drainage. US is portable, cheaper, and more accurate at detecting abscesses in the right upper abdomen and pelvis. It is, however, extremely operator-dependent. We surgeons are better trained to read CT scans rather than US; hence, we prefer CT, which allows us to visualize the entire abdomen, independently assess the anatomy of the abscess, and plan its optimal management. CT — enhanced with intravenous and intraluminal contrast — is also helpful in classifying the abscess either as simple or complex (Table 46.1).\\n\\nFigure 46.1. “You call that an abscess? THIS is an abscess!”\\n\\nDo understand that imaging during the first postoperative week cannot distinguish between a sterile fluid collection (e.g. residual lavage fluid) and an infected fluid collection before the development of a frank, mature abscess. The only way to document the infective nature of any visualized fluid is a diagnostic aspiration — subjecting the aspirate to a Gram stain and culture. CT features suggestive of a proper abscess are a contrast-enhancing, well-defined rim, and the presence of gas bubbles.\\n\\n## Figures and Tables\\n\\n### Figure 46.1\\n- **Description**: This figure likely depicts a comparison of abscesses, emphasizing the difference between a typical abscess and a more severe case. The caption humorously suggests a significant difference in severity.\\n- **Summary**: The figure illustrates the anatomical features of an abscess, highlighting the importance of imaging in diagnosis.\\n\\n### Table 46.1\\n- **Description**: This table classifies abscesses as either simple or complex based on CT imaging features.\\n- **Summary**: The table provides a structured overview of the characteristics that differentiate simple abscesses from complex ones.\\n\\n```',\n", " 'images': [{'name': 'img_p787_2.png',\n", " 'height': 568,\n", " 'width': 806,\n", " 'x': 106.55999999999995,\n", " 'y': 248.39999999999992,\n", " 'original_width': 1386,\n", " 'original_height': 976}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Both US and CT provide good anatomical definition including the site of the abscess, its size and structure (Figure 46.1); both can guide PC drainage. US is portable, cheaper, and more accurate at detecting abscesses in the right upper abdomen and pelvis. It is, however, extremely operator-dependent. We surgeons are better trained to read CT scans rather than US; hence, we prefer CT, which allows us to visualize the entire abdomen, independently assess the anatomy of the abscess, and plan its optimal management. CT — enhanced with intravenous and intraluminal contrast — is also helpful in classifying the abscess either as simple or complex (Table 46.1).\\n\\nFigure 46.1. “You call that an abscess? THIS is an abscess!”\\n\\nDo understand that imaging during the first postoperative week cannot distinguish between a sterile fluid collection (e.g. residual lavage fluid) and an infected fluid collection before the development of a frank, mature abscess. The only way to document the infective nature of any visualized fluid is a diagnostic aspiration — subjecting the aspirate to a Gram stain and culture. CT features suggestive of a proper abscess are a contrast-enhancing, well-defined rim, and the presence of gas bubbles.',\n", " 'md': 'Both US and CT provide good anatomical definition including the site of the abscess, its size and structure (Figure 46.1); both can guide PC drainage. US is portable, cheaper, and more accurate at detecting abscesses in the right upper abdomen and pelvis. It is, however, extremely operator-dependent. We surgeons are better trained to read CT scans rather than US; hence, we prefer CT, which allows us to visualize the entire abdomen, independently assess the anatomy of the abscess, and plan its optimal management. CT — enhanced with intravenous and intraluminal contrast — is also helpful in classifying the abscess either as simple or complex (Table 46.1).\\n\\nFigure 46.1. “You call that an abscess? THIS is an abscess!”\\n\\nDo understand that imaging during the first postoperative week cannot distinguish between a sterile fluid collection (e.g. residual lavage fluid) and an infected fluid collection before the development of a frank, mature abscess. The only way to document the infective nature of any visualized fluid is a diagnostic aspiration — subjecting the aspirate to a Gram stain and culture. CT features suggestive of a proper abscess are a contrast-enhancing, well-defined rim, and the presence of gas bubbles.',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 468, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figures and Tables',\n", " 'md': '## Figures and Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 46.1',\n", " 'md': '### Figure 46.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure likely depicts a comparison of abscesses, emphasizing the difference between a typical abscess and a more severe case. The caption humorously suggests a significant difference in severity.\\n- **Summary**: The figure illustrates the anatomical features of an abscess, highlighting the importance of imaging in diagnosis.',\n", " 'md': '- **Description**: This figure likely depicts a comparison of abscesses, emphasizing the difference between a typical abscess and a more severe case. The caption humorously suggests a significant difference in severity.\\n- **Summary**: The figure illustrates the anatomical features of an abscess, highlighting the importance of imaging in diagnosis.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Table 46.1',\n", " 'md': '### Table 46.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This table classifies abscesses as either simple or complex based on CT imaging features.\\n- **Summary**: The table provides a structured overview of the characteristics that differentiate simple abscesses from complex ones.\\n\\n```',\n", " 'md': '- **Description**: This table classifies abscesses as either simple or complex based on CT imaging features.\\n- **Summary**: The table provides a structured overview of the characteristics that differentiate simple abscesses from complex ones.\\n\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'drainage. US is portable, cheaper, and more accurate at detecting'},\n", " {'text': ''}]},\n", " {'page': 789,\n", " 'text': ' Please bear in mind that not all fluid collections that are detected\\nin the postoperative abdomen require active management; be\\nguided by the patient’s clinical condition at all times. Be resistant to\\nthe offers of aggressive radiologists to drain all accessible\\ncollections, particularly in the early postop period.\\n\\n Antibiotics\\n\\n Abdominal abscesses should be drained. When an ‘active’ source\\nexists it should be dealt with. Antibiotic treatment is of secondary\\nimportance. The truth is that no real evidence exists to prove that\\nantimicrobial agents, which penetrate poorly into established abscesses\\nanyway, are necessary as an adjunct to the complete evacuation of pus.\\nThink about the good old days, not many years ago, when pelvic\\nabscesses were observed until reaching ‘maturity’ and then drained\\nthrough the rectum or the vagina; no antibiotics were used and the\\nrecovery was immediate and complete. But then again who cares about\\nthe ‘truth’ and ‘evidence’ — we follow the trends…\\n\\n The prevalent standard of care, although lacking evidence,\\nmaintains that when an abscess is strongly suspected or\\ndiagnosed, then antibiotic therapy should be initiated. The latter\\nshould initially be empirically targeted against the usual expected\\npolymicrobial spectrum of bacteria; when the causative bacteria are\\nidentified the coverage can be changed or reduced as indicated.\\n\\n How long to administer antibiotics? Again there are no scientific\\ndata to formulate logical guidelines. Common sense dictates that\\nprolonged administration after effective drainage is unnecessary.\\nTheoretically, antibiotics may combat bacteremia during drainage and\\neradicate locally spilled micro-organisms; but after the pus has been\\nevacuated, leading to a clinical response, antibiotics should be\\ndiscontinued. The presence of a drain is not an indication to continue\\nwith administration.\\n\\n Conservative treatment',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nPlease bear in mind that not all fluid collections that are detected in the postoperative abdomen require active management; be guided by the patient’s clinical condition at all times. Be resistant to the offers of aggressive radiologists to drain all accessible collections, particularly in the early postop period.\\n\\n### Antibiotics\\n\\nAbdominal abscesses should be drained. When an ‘active’ source exists it should be dealt with. Antibiotic treatment is of secondary importance. The truth is that no real evidence exists to prove that antimicrobial agents, which penetrate poorly into established abscesses anyway, are necessary as an adjunct to the complete evacuation of pus. Think about the good old days, not many years ago, when pelvic abscesses were observed until reaching ‘maturity’ and then drained through the rectum or the vagina; no antibiotics were used and the recovery was immediate and complete. But then again who cares about the ‘truth’ and ‘evidence’ — we follow the trends…\\n\\nThe prevalent standard of care, although lacking evidence, maintains that when an abscess is strongly suspected or diagnosed, then antibiotic therapy should be initiated. The latter should initially be empirically targeted against the usual expected polymicrobial spectrum of bacteria; when the causative bacteria are identified the coverage can be changed or reduced as indicated.\\n\\nHow long to administer antibiotics? Again there are no scientific data to formulate logical guidelines. Common sense dictates that prolonged administration after effective drainage is unnecessary. Theoretically, antibiotics may combat bacteremia during drainage and eradicate locally spilled micro-organisms; but after the pus has been evacuated, leading to a clinical response, antibiotics should be discontinued. The presence of a drain is not an indication to continue with administration.\\n\\n### Conservative treatment\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Please bear in mind that not all fluid collections that are detected in the postoperative abdomen require active management; be guided by the patient’s clinical condition at all times. Be resistant to the offers of aggressive radiologists to drain all accessible collections, particularly in the early postop period.',\n", " 'md': 'Please bear in mind that not all fluid collections that are detected in the postoperative abdomen require active management; be guided by the patient’s clinical condition at all times. Be resistant to the offers of aggressive radiologists to drain all accessible collections, particularly in the early postop period.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.03, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Antibiotics',\n", " 'md': '### Antibiotics',\n", " 'bBox': {'x': 86, 'y': 195, 'w': 85.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Abdominal abscesses should be drained. When an ‘active’ source exists it should be dealt with. Antibiotic treatment is of secondary importance. The truth is that no real evidence exists to prove that antimicrobial agents, which penetrate poorly into established abscesses anyway, are necessary as an adjunct to the complete evacuation of pus. Think about the good old days, not many years ago, when pelvic abscesses were observed until reaching ‘maturity’ and then drained through the rectum or the vagina; no antibiotics were used and the recovery was immediate and complete. But then again who cares about the ‘truth’ and ‘evidence’ — we follow the trends…\\n\\nThe prevalent standard of care, although lacking evidence, maintains that when an abscess is strongly suspected or diagnosed, then antibiotic therapy should be initiated. The latter should initially be empirically targeted against the usual expected polymicrobial spectrum of bacteria; when the causative bacteria are identified the coverage can be changed or reduced as indicated.\\n\\nHow long to administer antibiotics? Again there are no scientific data to formulate logical guidelines. Common sense dictates that prolonged administration after effective drainage is unnecessary. Theoretically, antibiotics may combat bacteremia during drainage and eradicate locally spilled micro-organisms; but after the pus has been evacuated, leading to a clinical response, antibiotics should be discontinued. The presence of a drain is not an indication to continue with administration.',\n", " 'md': 'Abdominal abscesses should be drained. When an ‘active’ source exists it should be dealt with. Antibiotic treatment is of secondary importance. The truth is that no real evidence exists to prove that antimicrobial agents, which penetrate poorly into established abscesses anyway, are necessary as an adjunct to the complete evacuation of pus. Think about the good old days, not many years ago, when pelvic abscesses were observed until reaching ‘maturity’ and then drained through the rectum or the vagina; no antibiotics were used and the recovery was immediate and complete. But then again who cares about the ‘truth’ and ‘evidence’ — we follow the trends…\\n\\nThe prevalent standard of care, although lacking evidence, maintains that when an abscess is strongly suspected or diagnosed, then antibiotic therapy should be initiated. The latter should initially be empirically targeted against the usual expected polymicrobial spectrum of bacteria; when the causative bacteria are identified the coverage can be changed or reduced as indicated.\\n\\nHow long to administer antibiotics? Again there are no scientific data to formulate logical guidelines. Common sense dictates that prolonged administration after effective drainage is unnecessary. Theoretically, antibiotics may combat bacteremia during drainage and eradicate locally spilled micro-organisms; but after the pus has been evacuated, leading to a clinical response, antibiotics should be discontinued. The presence of a drain is not an indication to continue with administration.',\n", " 'bBox': {'x': 72, 'y': 195, 'w': 467.38, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Conservative treatment',\n", " 'md': '### Conservative treatment',\n", " 'bBox': {'x': 86, 'y': 692, 'w': 183.94, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured according to the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and structured according to the requirements.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 790,\n", " 'text': ' Traditionally, multiple hepatic abscesses, as a consequence of portal\\npyemia, which are not amenable to drainage, are treated with antibiotics,\\nwith a variable response rate. There are those who claim that non-\\noperative treatment, with prolonged administration of antibiotics, is also\\neffective in children who develop abdominal abscesses following\\nappendectomy for acute appendicitis. The problem with such ‘success\\nstories’ is that the alleged ‘abscesses’, which were imaged on US or CT,\\nwere never proven as such. Instead, they probably represented sterile\\ncollections — the majority requiring no therapy at all — or early,\\nunwalled, infected fluid collections into which antibiotics do penetrate. In\\naddition, small (<5cm) pericolic ‘diverticular’ abscesses can resolve with\\nantibiotics only — without the need for drainage. Remember also that\\nperi-appendicular abscesses can (and should) be treated conservatively\\nas detailed in Chapter 23.\\n\\n Drainage\\n\\n With regard to the general philosophy and timing of drainage,\\npresently, the prevailing paradigm, when an abscess is suspected on a\\nCT or US, is to hit the patient with antibiotics and rush to drainage. In this\\nhysterical hurry to treat, clinical lessons learned over centuries are often\\nignored. Only a few generations ago, a patient who spiked a temperature\\nafter an appendectomy was patiently but carefully observed without\\nantibiotics (which did not exist); usually the temperature — signifying the\\nresidual SIRS, or local inflammatory response syndrome (LIRS) —\\nsubsided spontaneously. In a minority of patients, ‘septic’ fever persisted\\nreflecting maturing local suppuration. The latter was eventually drained\\nthrough the rectum when assessed as ‘mature’. Today, on the other\\nhand, antibiotics are immediately given to mask the clinical picture, and\\nimaging techniques are instantly ordered, only to diagnose ‘red herrings’,\\nwhich in turn promote unnecessary invasive procedures. Remember, in\\nan otherwise ‘well’ patient, fever is a symptom of effective host\\ndefenses — not an indication to be aggressively invasive.\\n\\n Practical approach\\n\\n When an abscess is suspected, a few dilemmas arise and should be',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nTraditionally, multiple hepatic abscesses, as a consequence of portal pyemia, which are not amenable to drainage, are treated with antibiotics, with a variable response rate. There are those who claim that non-operative treatment, with prolonged administration of antibiotics, is also effective in children who develop abdominal abscesses following appendectomy for acute appendicitis. The problem with such ‘success stories’ is that the alleged ‘abscesses’, which were imaged on US or CT, were never proven as such. Instead, they probably represented sterile collections — the majority requiring no therapy at all — or early, unwalled, infected fluid collections into which antibiotics do penetrate. In addition, small (<5cm) pericolic ‘diverticular’ abscesses can resolve with antibiotics only — without the need for drainage. Remember also that peri-appendicular abscesses can (and should) be treated conservatively as detailed in Chapter 23.\\n\\n### Drainage\\n\\nWith regard to the general philosophy and timing of drainage, presently, the prevailing paradigm, when an abscess is suspected on a CT or US, is to hit the patient with antibiotics and rush to drainage. In this hysterical hurry to treat, clinical lessons learned over centuries are often ignored. Only a few generations ago, a patient who spiked a temperature after an appendectomy was patiently but carefully observed without antibiotics (which did not exist); usually the temperature — signifying the residual SIRS, or local inflammatory response syndrome (LIRS) — subsided spontaneously. In a minority of patients, ‘septic’ fever persisted reflecting maturing local suppuration. The latter was eventually drained through the rectum when assessed as ‘mature’. Today, on the other hand, antibiotics are immediately given to mask the clinical picture, and imaging techniques are instantly ordered, only to diagnose ‘red herrings’, which in turn promote unnecessary invasive procedures. Remember, in an otherwise ‘well’ patient, fever is a symptom of effective host defenses — not an indication to be aggressively invasive.\\n\\n### Practical approach\\n\\nWhen an abscess is suspected, a few dilemmas arise and should be...\\n```\\n\\n## Image Identification and Description\\n\\n*No images, graphs, or tables were identified on this page.*',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Traditionally, multiple hepatic abscesses, as a consequence of portal pyemia, which are not amenable to drainage, are treated with antibiotics, with a variable response rate. There are those who claim that non-operative treatment, with prolonged administration of antibiotics, is also effective in children who develop abdominal abscesses following appendectomy for acute appendicitis. The problem with such ‘success stories’ is that the alleged ‘abscesses’, which were imaged on US or CT, were never proven as such. Instead, they probably represented sterile collections — the majority requiring no therapy at all — or early, unwalled, infected fluid collections into which antibiotics do penetrate. In addition, small (<5cm) pericolic ‘diverticular’ abscesses can resolve with antibiotics only — without the need for drainage. Remember also that peri-appendicular abscesses can (and should) be treated conservatively as detailed in Chapter 23.',\n", " 'md': 'Traditionally, multiple hepatic abscesses, as a consequence of portal pyemia, which are not amenable to drainage, are treated with antibiotics, with a variable response rate. There are those who claim that non-operative treatment, with prolonged administration of antibiotics, is also effective in children who develop abdominal abscesses following appendectomy for acute appendicitis. The problem with such ‘success stories’ is that the alleged ‘abscesses’, which were imaged on US or CT, were never proven as such. Instead, they probably represented sterile collections — the majority requiring no therapy at all — or early, unwalled, infected fluid collections into which antibiotics do penetrate. In addition, small (<5cm) pericolic ‘diverticular’ abscesses can resolve with antibiotics only — without the need for drainage. Remember also that peri-appendicular abscesses can (and should) be treated conservatively as detailed in Chapter 23.',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.9, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Drainage',\n", " 'md': '### Drainage',\n", " 'bBox': {'x': 86, 'y': 344, 'w': 70.82, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'With regard to the general philosophy and timing of drainage, presently, the prevailing paradigm, when an abscess is suspected on a CT or US, is to hit the patient with antibiotics and rush to drainage. In this hysterical hurry to treat, clinical lessons learned over centuries are often ignored. Only a few generations ago, a patient who spiked a temperature after an appendectomy was patiently but carefully observed without antibiotics (which did not exist); usually the temperature — signifying the residual SIRS, or local inflammatory response syndrome (LIRS) — subsided spontaneously. In a minority of patients, ‘septic’ fever persisted reflecting maturing local suppuration. The latter was eventually drained through the rectum when assessed as ‘mature’. Today, on the other hand, antibiotics are immediately given to mask the clinical picture, and imaging techniques are instantly ordered, only to diagnose ‘red herrings’, which in turn promote unnecessary invasive procedures. Remember, in an otherwise ‘well’ patient, fever is a symptom of effective host defenses — not an indication to be aggressively invasive.',\n", " 'md': 'With regard to the general philosophy and timing of drainage, presently, the prevailing paradigm, when an abscess is suspected on a CT or US, is to hit the patient with antibiotics and rush to drainage. In this hysterical hurry to treat, clinical lessons learned over centuries are often ignored. Only a few generations ago, a patient who spiked a temperature after an appendectomy was patiently but carefully observed without antibiotics (which did not exist); usually the temperature — signifying the residual SIRS, or local inflammatory response syndrome (LIRS) — subsided spontaneously. In a minority of patients, ‘septic’ fever persisted reflecting maturing local suppuration. The latter was eventually drained through the rectum when assessed as ‘mature’. Today, on the other hand, antibiotics are immediately given to mask the clinical picture, and imaging techniques are instantly ordered, only to diagnose ‘red herrings’, which in turn promote unnecessary invasive procedures. Remember, in an otherwise ‘well’ patient, fever is a symptom of effective host defenses — not an indication to be aggressively invasive.',\n", " 'bBox': {'x': 72, 'y': 344, 'w': 468, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Practical approach',\n", " 'md': '### Practical approach',\n", " 'bBox': {'x': 86, 'y': 672, 'w': 148.07, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'When an abscess is suspected, a few dilemmas arise and should be...\\n```',\n", " 'md': 'When an abscess is suspected, a few dilemmas arise and should be...\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images, graphs, or tables were identified on this page.*',\n", " 'md': '*No images, graphs, or tables were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 791,\n", " 'text': 'dealt with stepwise:\\n\\n • Is it an abscess or a sterile collection? The CT features\\n mentioned above may be helpful but the clinical scenario is as\\n important — especially where postoperative abscesses are\\n concerned. Abscesses are rarely ready for drainage in the first\\n postoperative week, and at 3 weeks after the operation the\\n cause of ‘sepsis’ is rarely within the abdomen. When in doubt\\n image-guided diagnostic aspiration is indicated.\\n • Percutaneous (PC) versus open surgical drainage? During the\\n 1980s multiple retrospective series suggested that the results of PC\\n drainage are at least as good as those achieved by an operation. It\\n was also said by some that, paradoxically, despite the attractiveness\\n of a PC technique for abscess drainage in the most ill patients, a\\n better chance of survival is achieved with surgical treatment, and\\n that surgical treatment should not be avoided because the patient is\\n considered to be too ill. Be that as it may, there is no clear evidence\\n to attribute lesser mortality or morbidity to PC drainage versus\\n surgical drainage. The former, however, is a minimal access\\n procedure that can spare the patient the unpleasantness and\\n obvious risks of yet another open abdominal operation.\\n • The concept of a complex abscess is clinically useful.\\n Abscesses that are multiple, multiloculated, associated with\\n tissue necrosis, enteric communication or tumor, are defined\\n as complex and are less likely to respond to PC drainage,\\n whereas most simple abscesses do. ħowever, in gravely ill patients\\n with complex abscesses, PC drainage may offer significant\\n temporizing therapeutic benefits — allowing a definitive semi-\\n elective laparotomy in better-stabilized patients.\\n • PC drainage and surgical drainage techniques should not be\\n considered competitive but rather complementary. If an abscess\\n is accessible by PC technique, it is reasonable to consider a non-\\n operative approach to the problem. You, the surgeon, should\\n consider each abscess individually together with the radiologist,\\n taking into consideration the pros and cons presented in Table\\n 46.2.\\n • Percutaneous aspiration only versus catheter drainage? A\\n single PC needle aspiration may successfully eradicate an abscess',\n", " 'md': '```markdown\\n## Clinical Considerations for Abscess Management\\n\\n- Is it an abscess or a sterile collection? The CT features mentioned above may be helpful but the clinical scenario is as important — especially where postoperative abscesses are concerned. Abscesses are rarely ready for drainage in the first postoperative week, and at 3 weeks after the operation the cause of ‘sepsis’ is rarely within the abdomen. When in doubt, image-guided diagnostic aspiration is indicated.\\n\\n- Percutaneous (PC) versus open surgical drainage? During the 1980s, multiple retrospective series suggested that the results of PC drainage are at least as good as those achieved by an operation. It was also said by some that, paradoxically, despite the attractiveness of a PC technique for abscess drainage in the most ill patients, a better chance of survival is achieved with surgical treatment, and that surgical treatment should not be avoided because the patient is considered to be too ill. Be that as it may, there is no clear evidence to attribute lesser mortality or morbidity to PC drainage versus surgical drainage. The former, however, is a minimal access procedure that can spare the patient the unpleasantness and obvious risks of yet another open abdominal operation.\\n\\n- The concept of a complex abscess is clinically useful. Abscesses that are multiple, multiloculated, associated with tissue necrosis, enteric communication, or tumor, are defined as complex and are less likely to respond to PC drainage, whereas most simple abscesses do. However, in gravely ill patients with complex abscesses, PC drainage may offer significant temporizing therapeutic benefits — allowing a definitive semi-elective laparotomy in better-stabilized patients.\\n\\n- PC drainage and surgical drainage techniques should not be considered competitive but rather complementary. If an abscess is accessible by PC technique, it is reasonable to consider a non-operative approach to the problem. You, the surgeon, should consider each abscess individually together with the radiologist, taking into consideration the pros and cons presented in Table 46.2.\\n\\n- Percutaneous aspiration only versus catheter drainage? A single PC needle aspiration may successfully eradicate an abscess.\\n```\\n\\n### Notes:\\n- No figures or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas or hyperlinks present in the extracted text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Considerations for Abscess Management',\n", " 'md': '## Clinical Considerations for Abscess Management',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Is it an abscess or a sterile collection? The CT features mentioned above may be helpful but the clinical scenario is as important — especially where postoperative abscesses are concerned. Abscesses are rarely ready for drainage in the first postoperative week, and at 3 weeks after the operation the cause of ‘sepsis’ is rarely within the abdomen. When in doubt, image-guided diagnostic aspiration is indicated.\\n\\n- Percutaneous (PC) versus open surgical drainage? During the 1980s, multiple retrospective series suggested that the results of PC drainage are at least as good as those achieved by an operation. It was also said by some that, paradoxically, despite the attractiveness of a PC technique for abscess drainage in the most ill patients, a better chance of survival is achieved with surgical treatment, and that surgical treatment should not be avoided because the patient is considered to be too ill. Be that as it may, there is no clear evidence to attribute lesser mortality or morbidity to PC drainage versus surgical drainage. The former, however, is a minimal access procedure that can spare the patient the unpleasantness and obvious risks of yet another open abdominal operation.\\n\\n- The concept of a complex abscess is clinically useful. Abscesses that are multiple, multiloculated, associated with tissue necrosis, enteric communication, or tumor, are defined as complex and are less likely to respond to PC drainage, whereas most simple abscesses do. However, in gravely ill patients with complex abscesses, PC drainage may offer significant temporizing therapeutic benefits — allowing a definitive semi-elective laparotomy in better-stabilized patients.\\n\\n- PC drainage and surgical drainage techniques should not be considered competitive but rather complementary. If an abscess is accessible by PC technique, it is reasonable to consider a non-operative approach to the problem. You, the surgeon, should consider each abscess individually together with the radiologist, taking into consideration the pros and cons presented in Table 46.2.\\n\\n- Percutaneous aspiration only versus catheter drainage? A single PC needle aspiration may successfully eradicate an abscess.\\n```',\n", " 'md': '- Is it an abscess or a sterile collection? The CT features mentioned above may be helpful but the clinical scenario is as important — especially where postoperative abscesses are concerned. Abscesses are rarely ready for drainage in the first postoperative week, and at 3 weeks after the operation the cause of ‘sepsis’ is rarely within the abdomen. When in doubt, image-guided diagnostic aspiration is indicated.\\n\\n- Percutaneous (PC) versus open surgical drainage? During the 1980s, multiple retrospective series suggested that the results of PC drainage are at least as good as those achieved by an operation. It was also said by some that, paradoxically, despite the attractiveness of a PC technique for abscess drainage in the most ill patients, a better chance of survival is achieved with surgical treatment, and that surgical treatment should not be avoided because the patient is considered to be too ill. Be that as it may, there is no clear evidence to attribute lesser mortality or morbidity to PC drainage versus surgical drainage. The former, however, is a minimal access procedure that can spare the patient the unpleasantness and obvious risks of yet another open abdominal operation.\\n\\n- The concept of a complex abscess is clinically useful. Abscesses that are multiple, multiloculated, associated with tissue necrosis, enteric communication, or tumor, are defined as complex and are less likely to respond to PC drainage, whereas most simple abscesses do. However, in gravely ill patients with complex abscesses, PC drainage may offer significant temporizing therapeutic benefits — allowing a definitive semi-elective laparotomy in better-stabilized patients.\\n\\n- PC drainage and surgical drainage techniques should not be considered competitive but rather complementary. If an abscess is accessible by PC technique, it is reasonable to consider a non-operative approach to the problem. You, the surgeon, should consider each abscess individually together with the radiologist, taking into consideration the pros and cons presented in Table 46.2.\\n\\n- Percutaneous aspiration only versus catheter drainage? A single PC needle aspiration may successfully eradicate an abscess.\\n```',\n", " 'bBox': {'x': 100, 'y': 221, 'w': 436.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No figures or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas or hyperlinks present in the extracted text.',\n", " 'md': '- No figures or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas or hyperlinks present in the extracted text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ' Table'}]},\n", " {'page': 792,\n", " 'text': ' — especially when it is small and contains low-viscosity fluid or\\n when it is located within a solid organ such as the liver or spleen.\\n There is good evidence, however, that PC catheter drainage is\\n more effective.\\n• Size of PC catheters/drains? Some claim advantage for large-bore\\n trocar catheters for PC drainage but the evidence indicates that size\\n 7Fr PC sump drains are as effective as size 14Fr. When needed, a\\n small size catheter can be changed into a bigger one with\\n percutaneous techniques.\\n• Management of PC drains. There is not much science here; these\\n are small tubes and should be regularly flushed with saline to remain\\n patent. The drain site should be regularly cleaned and observed:\\n there are single case reports of necrotizing fasciitis of the abdominal\\n wall around a PC drain site. PC drains are removed when clinical\\n SIRS has resolved and the daily output (minus the saline injected) is\\n below 25ml. On average, after PC drainage of a simple\\n abdominal abscess, the drain is removed after 5-7 days.\\n• Reimaging. Clinical improvement should be seen within 24 to 72\\n hours following PC drainage. Persistent fever and leukocytosis on\\n the fourth day after PC drainage correlates with management failure.\\n Non-responders should be reimaged with CT, combined with\\n water-soluble contrast injected through the drain. Depending on\\n the findings, a decision should be taken by you — the surgeon — in\\n consultation with the radiologist, as to the next appropriate course of\\n action: a repeat PC drain or an operation. Persistence of high-output\\n drainage in a patient who is clinically well can be better investigated\\n with a tube sinogram to delineate the size of the residual abscess\\n cavity. Abscess cavities which do not collapse tend to recur.',\n", " 'md': '```markdown\\n## Page Content\\n\\n- Especially when it is small and contains low-viscosity fluid or when it is located within a solid organ such as the liver or spleen. There is good evidence, however, that PC catheter drainage is more effective.\\n\\n- **Size of PC catheters/drains?** Some claim advantage for large-bore trocar catheters for PC drainage but the evidence indicates that size 7Fr PC sump drains are as effective as size 14Fr. When needed, a small size catheter can be changed into a bigger one with percutaneous techniques.\\n\\n- **Management of PC drains.** There is not much science here; these are small tubes and should be regularly flushed with saline to remain patent. The drain site should be regularly cleaned and observed: there are single case reports of necrotizing fasciitis of the abdominal wall around a PC drain site. PC drains are removed when clinical SIRS has resolved and the daily output (minus the saline injected) is below 25ml. On average, after PC drainage of a simple abdominal abscess, the drain is removed after 5-7 days.\\n\\n- **Reimaging.** Clinical improvement should be seen within 24 to 72 hours following PC drainage. Persistent fever and leukocytosis on the fourth day after PC drainage correlates with management failure. Non-responders should be reimaged with CT, combined with water-soluble contrast injected through the drain. Depending on the findings, a decision should be taken by you — the surgeon — in consultation with the radiologist, as to the next appropriate course of action: a repeat PC drain or an operation. Persistence of high-output drainage in a patient who is clinically well can be better investigated with a tube sinogram to delineate the size of the residual abscess cavity. Abscess cavities which do not collapse tend to recur.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Especially when it is small and contains low-viscosity fluid or when it is located within a solid organ such as the liver or spleen. There is good evidence, however, that PC catheter drainage is more effective.\\n\\n- **Size of PC catheters/drains?** Some claim advantage for large-bore trocar catheters for PC drainage but the evidence indicates that size 7Fr PC sump drains are as effective as size 14Fr. When needed, a small size catheter can be changed into a bigger one with percutaneous techniques.\\n\\n- **Management of PC drains.** There is not much science here; these are small tubes and should be regularly flushed with saline to remain patent. The drain site should be regularly cleaned and observed: there are single case reports of necrotizing fasciitis of the abdominal wall around a PC drain site. PC drains are removed when clinical SIRS has resolved and the daily output (minus the saline injected) is below 25ml. On average, after PC drainage of a simple abdominal abscess, the drain is removed after 5-7 days.\\n\\n- **Reimaging.** Clinical improvement should be seen within 24 to 72 hours following PC drainage. Persistent fever and leukocytosis on the fourth day after PC drainage correlates with management failure. Non-responders should be reimaged with CT, combined with water-soluble contrast injected through the drain. Depending on the findings, a decision should be taken by you — the surgeon — in consultation with the radiologist, as to the next appropriate course of action: a repeat PC drain or an operation. Persistence of high-output drainage in a patient who is clinically well can be better investigated with a tube sinogram to delineate the size of the residual abscess cavity. Abscess cavities which do not collapse tend to recur.\\n```',\n", " 'md': '- Especially when it is small and contains low-viscosity fluid or when it is located within a solid organ such as the liver or spleen. There is good evidence, however, that PC catheter drainage is more effective.\\n\\n- **Size of PC catheters/drains?** Some claim advantage for large-bore trocar catheters for PC drainage but the evidence indicates that size 7Fr PC sump drains are as effective as size 14Fr. When needed, a small size catheter can be changed into a bigger one with percutaneous techniques.\\n\\n- **Management of PC drains.** There is not much science here; these are small tubes and should be regularly flushed with saline to remain patent. The drain site should be regularly cleaned and observed: there are single case reports of necrotizing fasciitis of the abdominal wall around a PC drain site. PC drains are removed when clinical SIRS has resolved and the daily output (minus the saline injected) is below 25ml. On average, after PC drainage of a simple abdominal abscess, the drain is removed after 5-7 days.\\n\\n- **Reimaging.** Clinical improvement should be seen within 24 to 72 hours following PC drainage. Persistent fever and leukocytosis on the fourth day after PC drainage correlates with management failure. Non-responders should be reimaged with CT, combined with water-soluble contrast injected through the drain. Depending on the findings, a decision should be taken by you — the surgeon — in consultation with the radiologist, as to the next appropriate course of action: a repeat PC drain or an operation. Persistence of high-output drainage in a patient who is clinically well can be better investigated with a tube sinogram to delineate the size of the residual abscess cavity. Abscess cavities which do not collapse tend to recur.\\n```',\n", " 'bBox': {'x': 100, 'y': 119, 'w': 437.05, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 793,\n", " 'text': \" Table 46.2. Intra-abdominal abscesses: percutaneous (PC) versus\\n open surgical drainage: Considerations in selecting the approach* _\\n Prefer PC drainage] Prefer open drainage\\n Surgical accessibility Hostile abdomen Accessible\\n PC accessibility Yes No\\n Source controlled Yes No\\n Location Visceral Interloop\\n Number Single Multiple\\n Loculation No Yes\\n Communication with bowel No Yes\\n Associated necrosis No Yes\\n Associated malignancy No Yes\\n Viscosity Thin Thick debris\\n Invasive radiologist Available Not available\\n Severity of illness 'Stable' Critically ill cannot tolerate delay\\n Failed PC drainage No Yes\\n These factors are not 'written in stone' and should be considered together with the\\n specific clinical situation:\\nFailure of PC drainage: when to ‘switch over’ to surgical\\ndrainage?\",\n", " 'md': \"```markdown\\n## Table 46.2. Intra-abdominal abscesses: percutaneous (PC) versus open surgical drainage: Considerations in selecting the approach\\n\\n| Considerations | Prefer PC drainage | Prefer open drainage |\\n|------------------------------------|--------------------|----------------------|\\n| Surgical accessibility | Hostile abdomen | Accessible |\\n| PC accessibility | Yes | No |\\n| Source controlled | Yes | No |\\n| Location | Visceral | Interloop |\\n| Number | Single | Multiple |\\n| Loculation | No | Yes |\\n| Communication with bowel | No | Yes |\\n| Associated necrosis | No | Yes |\\n| Associated malignancy | No | Yes |\\n| Viscosity | Thin | Thick debris |\\n| Invasive radiologist | Available | Not available |\\n| Severity of illness | 'Stable' | Critically ill cannot tolerate delay |\\n| Failed PC drainage | No | Yes |\\n\\nThese factors are not 'written in stone' and should be considered together with the specific clinical situation:\\n**Failure of PC drainage: when to ‘switch over’ to surgical drainage?**\\n```\",\n", " 'images': [{'name': 'img_p792_1.png',\n", " 'height': 1116,\n", " 'width': 822,\n", " 'x': 102.96000000000004,\n", " 'y': 72,\n", " 'original_width': 1412,\n", " 'original_height': 1916}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table 46.2. Intra-abdominal abscesses: percutaneous (PC) versus open surgical drainage: Considerations in selecting the approach',\n", " 'md': '## Table 46.2. Intra-abdominal abscesses: percutaneous (PC) versus open surgical drainage: Considerations in selecting the approach',\n", " 'bBox': {'x': 106.92, 'y': 76.95, 'w': 398.39, 'h': 18.31}},\n", " {'type': 'table',\n", " 'rows': [['Considerations', 'Prefer PC drainage', 'Prefer open drainage'],\n", " ['Surgical accessibility', 'Hostile abdomen', 'Accessible'],\n", " ['PC accessibility', 'Yes', 'No'],\n", " ['Source controlled', 'Yes', 'No'],\n", " ['Location', 'Visceral', 'Interloop'],\n", " ['Number', 'Single', 'Multiple'],\n", " ['Loculation', 'No', 'Yes'],\n", " ['Communication with bowel', 'No', 'Yes'],\n", " ['Associated necrosis', 'No', 'Yes'],\n", " ['Associated malignancy', 'No', 'Yes'],\n", " ['Viscosity', 'Thin', 'Thick debris'],\n", " ['Invasive radiologist', 'Available', 'Not available'],\n", " ['Severity of illness',\n", " \"'Stable'\",\n", " 'Critically ill cannot tolerate delay'],\n", " ['Failed PC drainage', 'No', 'Yes']],\n", " 'md': \"| Considerations | Prefer PC drainage | Prefer open drainage |\\n|------------------------------------|--------------------|----------------------|\\n| Surgical accessibility | Hostile abdomen | Accessible |\\n| PC accessibility | Yes | No |\\n| Source controlled | Yes | No |\\n| Location | Visceral | Interloop |\\n| Number | Single | Multiple |\\n| Loculation | No | Yes |\\n| Communication with bowel | No | Yes |\\n| Associated necrosis | No | Yes |\\n| Associated malignancy | No | Yes |\\n| Viscosity | Thin | Thick debris |\\n| Invasive radiologist | Available | Not available |\\n| Severity of illness | 'Stable' | Critically ill cannot tolerate delay |\\n| Failed PC drainage | No | Yes |\",\n", " 'isPerfectTable': True,\n", " 'csv': '\"Considerations\",\"Prefer PC drainage\",\"Prefer open drainage\"\\n\"Surgical accessibility\",\"Hostile abdomen\",\"Accessible\"\\n\"PC accessibility\",\"Yes\",\"No\"\\n\"Source controlled\",\"Yes\",\"No\"\\n\"Location\",\"Visceral\",\"Interloop\"\\n\"Number\",\"Single\",\"Multiple\"\\n\"Loculation\",\"No\",\"Yes\"\\n\"Communication with bowel\",\"No\",\"Yes\"\\n\"Associated necrosis\",\"No\",\"Yes\"\\n\"Associated malignancy\",\"No\",\"Yes\"\\n\"Viscosity\",\"Thin\",\"Thick debris\"\\n\"Invasive radiologist\",\"Available\",\"Not available\"\\n\"Severity of illness\",\"\\'Stable\\'\",\"Critically ill cannot tolerate delay\"\\n\"Failed PC drainage\",\"No\",\"Yes\"',\n", " 'bBox': {'x': 107.41, 'y': 150.18, 'w': 128.67, 'h': 15.34}},\n", " {'type': 'text',\n", " 'value': \"These factors are not 'written in stone' and should be considered together with the specific clinical situation:\\n**Failure of PC drainage: when to ‘switch over’ to surgical drainage?**\\n```\",\n", " 'md': \"These factors are not 'written in stone' and should be considered together with the specific clinical situation:\\n**Failure of PC drainage: when to ‘switch over’ to surgical drainage?**\\n```\",\n", " 'bBox': {'x': 86, 'y': 185.81, 'w': 452.52, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 794,\n", " 'text': ' Patients who deteriorate after the initial attempts at PC drainage\\nshould be operated upon promptly; further procrastination may be\\ndisastrous.\\n\\n In stable non-responders to the initial PC drainage, a second attempt\\nmay be appropriate, according to the considerations mentioned in\\nTable 46.2. Inability to successfully effect the second PC drainage, or its\\nclinical failure, mandates an open procedure.\\n\\n Surgical management of intra-abdominal abscesses\\n\\n At least in modern environments it is unusual that an intra-abdominal\\nabscess is not suitable for PC drainage and requires an open operation.\\nBut if this does happen a few practical dilemmas exist:\\n\\n • Exploratory laparotomy vs. direct surgical approach. A ‘blind’\\n exploratory laparotomy to search for an abscess ‘somewhere’, so\\n common less than 30 years ago, is currently very rarely necessary.\\n A direct approach is obviously more ‘benign’, sparing the\\n previously uninvolved peritoneal spaces and avoiding bowel\\n injury and wound complications. It is almost always possible in\\n spontaneous abscesses, which are so well defined on CT. But those\\n are also the kind of abscesses that usually respond to PC drainage.\\n Nowadays, although postoperative abscesses are anatomically well\\n localized on CT, those that fail PC drainage are usually ‘complex’,\\n and therefore often not amenable to a direct approach (e.g. interloop\\n abscess) or they require additional procedures to control the\\n intestinal source. Criteria for choosing the correct approach are\\n summarized in Table 46.3.\\n\\n If you already have a PC drain in place but it does not drain sufficiently, open exploration is\\n easier when you ‘follow the drain’. Ari\\n\\n • Direct approach: extraperitoneal versus transperitoneal? There\\n are no significant differences in overall mortality and morbidly\\n between the two approaches; however, the transperitoneal route is',\n", " 'md': '```markdown\\n## Surgical Management of Intra-Abdominal Abscesses\\n\\nPatients who deteriorate after the initial attempts at PC drainage should be operated upon promptly; further procrastination may be disastrous.\\n\\nIn stable non-responders to the initial PC drainage, a second attempt may be appropriate, according to the considerations mentioned in Table 46.2. Inability to successfully effect the second PC drainage, or its clinical failure, mandates an open procedure.\\n\\n### Key Considerations\\n\\n- **Exploratory laparotomy vs. direct surgical approach**: A ‘blind’ exploratory laparotomy to search for an abscess ‘somewhere’, so common less than 30 years ago, is currently very rarely necessary. A direct approach is obviously more ‘benign’, sparing the previously uninvolved peritoneal spaces and avoiding bowel injury and wound complications. It is almost always possible in spontaneous abscesses, which are so well defined on CT. But those are also the kind of abscesses that usually respond to PC drainage. Nowadays, although postoperative abscesses are anatomically well localized on CT, those that fail PC drainage are usually ‘complex’, and therefore often not amenable to a direct approach (e.g. interloop abscess) or they require additional procedures to control the intestinal source. Criteria for choosing the correct approach are summarized in Table 46.3.\\n\\n- If you already have a PC drain in place but it does not drain sufficiently, open exploration is easier when you ‘follow the drain’.\\n\\n- **Direct approach: extraperitoneal versus transperitoneal?** There are no significant differences in overall mortality and morbidity between the two approaches; however, the transperitoneal route is...\\n```\\n\\n### Notes:\\n- The text has been structured into sections for clarity.\\n- Table references (Table 46.2 and Table 46.3) are mentioned but not extracted as tables since the content of the tables is not provided.\\n- The text has been cleaned of any headers, footers, or diagonal text as per the instructions.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Management of Intra-Abdominal Abscesses',\n", " 'md': '## Surgical Management of Intra-Abdominal Abscesses',\n", " 'bBox': {'x': 86, 'y': 247, 'w': 409.22, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Patients who deteriorate after the initial attempts at PC drainage should be operated upon promptly; further procrastination may be disastrous.\\n\\nIn stable non-responders to the initial PC drainage, a second attempt may be appropriate, according to the considerations mentioned in Table 46.2. Inability to successfully effect the second PC drainage, or its clinical failure, mandates an open procedure.',\n", " 'md': 'Patients who deteriorate after the initial attempts at PC drainage should be operated upon promptly; further procrastination may be disastrous.\\n\\nIn stable non-responders to the initial PC drainage, a second attempt may be appropriate, according to the considerations mentioned in Table 46.2. Inability to successfully effect the second PC drainage, or its clinical failure, mandates an open procedure.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.89, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key Considerations',\n", " 'md': '### Key Considerations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Exploratory laparotomy vs. direct surgical approach**: A ‘blind’ exploratory laparotomy to search for an abscess ‘somewhere’, so common less than 30 years ago, is currently very rarely necessary. A direct approach is obviously more ‘benign’, sparing the previously uninvolved peritoneal spaces and avoiding bowel injury and wound complications. It is almost always possible in spontaneous abscesses, which are so well defined on CT. But those are also the kind of abscesses that usually respond to PC drainage. Nowadays, although postoperative abscesses are anatomically well localized on CT, those that fail PC drainage are usually ‘complex’, and therefore often not amenable to a direct approach (e.g. interloop abscess) or they require additional procedures to control the intestinal source. Criteria for choosing the correct approach are summarized in Table 46.3.\\n\\n- If you already have a PC drain in place but it does not drain sufficiently, open exploration is easier when you ‘follow the drain’.\\n\\n- **Direct approach: extraperitoneal versus transperitoneal?** There are no significant differences in overall mortality and morbidity between the two approaches; however, the transperitoneal route is...\\n```',\n", " 'md': '- **Exploratory laparotomy vs. direct surgical approach**: A ‘blind’ exploratory laparotomy to search for an abscess ‘somewhere’, so common less than 30 years ago, is currently very rarely necessary. A direct approach is obviously more ‘benign’, sparing the previously uninvolved peritoneal spaces and avoiding bowel injury and wound complications. It is almost always possible in spontaneous abscesses, which are so well defined on CT. But those are also the kind of abscesses that usually respond to PC drainage. Nowadays, although postoperative abscesses are anatomically well localized on CT, those that fail PC drainage are usually ‘complex’, and therefore often not amenable to a direct approach (e.g. interloop abscess) or they require additional procedures to control the intestinal source. Criteria for choosing the correct approach are summarized in Table 46.3.\\n\\n- If you already have a PC drain in place but it does not drain sufficiently, open exploration is easier when you ‘follow the drain’.\\n\\n- **Direct approach: extraperitoneal versus transperitoneal?** There are no significant differences in overall mortality and morbidity between the two approaches; however, the transperitoneal route is...\\n```',\n", " 'bBox': {'x': 100, 'y': 385, 'w': 437.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text has been structured into sections for clarity.\\n- Table references (Table 46.2 and Table 46.3) are mentioned but not extracted as tables since the content of the tables is not provided.\\n- The text has been cleaned of any headers, footers, or diagonal text as per the instructions.',\n", " 'md': '- The text has been structured into sections for clarity.\\n- Table references (Table 46.2 and Table 46.3) are mentioned but not extracted as tables since the content of the tables is not provided.\\n- The text has been cleaned of any headers, footers, or diagonal text as per the instructions.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Table 46.2. Inability to successfully effect the second PC drainage, or its clinical failure, mandates an open procedure.'},\n", " {'text': ''}]},\n", " {'page': 795,\n", " 'text': \" associated with a higher incidence of injury to the bowel. It is logical\\n to suggest that the extraperitoneal approach should be used\\n whenever anatomically possible. Subphrenic and subhepatic\\n abscesses can be approached extraperitoneally through a subcostal\\n incision or — if posterior — through the bed of the 12th rib. Old-\\n timers are still familiar with these techniques, which are currently\\n rarely utilized — having been replaced by PC drainage. Pericolic,\\n appendicular and all sorts of retroperitoneal abscesses are best\\n approached through a loin incision. Late-appearing pancreatic\\n abscesses too can be drained extraperitoneally — through the flank\\n — but occasionally need a bilateral approach. Pelvic abscesses are\\n best drained through the rectum or vagina.\\n Table 46.3. Exploratory laparotomy vs. 'direct' open drainage of\\n abdominal abscesses:\\n Prefer exploratory Prefer direct open\\n laparotomy drainage\\n Abscess accurately localized on CT\\n Early postoperative phase\\n Interloop abscess\\n Single abscess\\n Late postoperative phase\\n Lesser sac abscess\\n Multiple abscesses 1\\n Source of infection uncontrolled\\n Subphrenic/subhepatic 1\\n Gutter abscess\\n Pelvic abscess\\n• Drains? Classically, at the end of the open procedure a drain was\\n placed within the abscess cavity — brought to the skin away from\\n the main incision. The type, size and number of drains used\\n depended more on local traditions and preferences than on science.\\n Similarly, the postoperative management of drains involved\",\n", " 'md': \"```markdown\\n## Text Extraction\\n\\nThe text discusses the extraperitoneal approach for draining various types of abdominal abscesses, suggesting that it should be used whenever anatomically possible. It mentions specific techniques for accessing subphrenic and subhepatic abscesses, as well as the preferred methods for draining pericolic, appendicular, retroperitoneal, and pelvic abscesses.\\n\\n### Key Points:\\n- The extraperitoneal approach is logical for certain abscesses.\\n- Techniques include subcostal incision and posterior access through the 12th rib.\\n- The text notes that these techniques are rarely utilized today, having been replaced by PC drainage.\\n- Specific approaches for different types of abscesses are highlighted.\\n\\n## Table Extraction\\n\\n### Table 46.3: Exploratory Laparotomy vs. 'Direct' Open Drainage of Abdominal Abscesses\\n\\n| Prefer Exploratory Laparotomy | Prefer Direct Open Drainage |\\n|-------------------------------|-----------------------------|\\n| Abscess accurately localized on CT | Early postoperative phase |\\n| Interloop abscess | Single abscess |\\n| Late postoperative phase | Lesser sac abscess |\\n| Multiple abscesses | Source of infection uncontrolled |\\n| Subphrenic/subhepatic | Gutter abscess |\\n| | Pelvic abscess |\\n\\n## Additional Notes\\n\\n- The text mentions that traditionally, a drain was placed within the abscess cavity at the end of the open procedure, with the type, size, and number of drains varying based on local traditions rather than scientific evidence.\\n- The postoperative management of drains is also noted but not elaborated upon in the provided text.\\n```\",\n", " 'images': [{'name': 'img_p794_1.png',\n", " 'height': 632,\n", " 'width': 812,\n", " 'x': 105.11999999999989,\n", " 'y': 290.16,\n", " 'original_width': 1394,\n", " 'original_height': 1084}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the extraperitoneal approach for draining various types of abdominal abscesses, suggesting that it should be used whenever anatomically possible. It mentions specific techniques for accessing subphrenic and subhepatic abscesses, as well as the preferred methods for draining pericolic, appendicular, retroperitoneal, and pelvic abscesses.',\n", " 'md': 'The text discusses the extraperitoneal approach for draining various types of abdominal abscesses, suggesting that it should be used whenever anatomically possible. It mentions specific techniques for accessing subphrenic and subhepatic abscesses, as well as the preferred methods for draining pericolic, appendicular, retroperitoneal, and pelvic abscesses.',\n", " 'bBox': {'x': 100, 'y': 119, 'w': 83.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Key Points:',\n", " 'md': '### Key Points:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The extraperitoneal approach is logical for certain abscesses.\\n- Techniques include subcostal incision and posterior access through the 12th rib.\\n- The text notes that these techniques are rarely utilized today, having been replaced by PC drainage.\\n- Specific approaches for different types of abscesses are highlighted.',\n", " 'md': '- The extraperitoneal approach is logical for certain abscesses.\\n- Techniques include subcostal incision and posterior access through the 12th rib.\\n- The text notes that these techniques are rarely utilized today, having been replaced by PC drainage.\\n- Specific approaches for different types of abscesses are highlighted.',\n", " 'bBox': {'x': 172, 'y': 119, 'w': 285, 'h': 111.74}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table Extraction',\n", " 'md': '## Table Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': \"Table 46.3: Exploratory Laparotomy vs. 'Direct' Open Drainage of Abdominal Abscesses\",\n", " 'md': \"### Table 46.3: Exploratory Laparotomy vs. 'Direct' Open Drainage of Abdominal Abscesses\",\n", " 'bBox': {'x': 283.24, 'y': 351.47, 'w': 67.78, 'h': 18.79}},\n", " {'type': 'table',\n", " 'rows': [['Prefer Exploratory Laparotomy', 'Prefer Direct Open Drainage'],\n", " ['Abscess accurately localized on CT', 'Early postoperative phase'],\n", " ['Interloop abscess', 'Single abscess'],\n", " ['Late postoperative phase', 'Lesser sac abscess'],\n", " ['Multiple abscesses', 'Source of infection uncontrolled'],\n", " ['Subphrenic/subhepatic', 'Gutter abscess'],\n", " ['', 'Pelvic abscess']],\n", " 'md': '| Prefer Exploratory Laparotomy | Prefer Direct Open Drainage |\\n|-------------------------------|-----------------------------|\\n| Abscess accurately localized on CT | Early postoperative phase |\\n| Interloop abscess | Single abscess |\\n| Late postoperative phase | Lesser sac abscess |\\n| Multiple abscesses | Source of infection uncontrolled |\\n| Subphrenic/subhepatic | Gutter abscess |\\n| | Pelvic abscess |',\n", " 'isPerfectTable': True,\n", " 'csv': '\"Prefer Exploratory Laparotomy\",\"Prefer Direct Open Drainage\"\\n\"Abscess accurately localized on CT\",\"Early postoperative phase\"\\n\"Interloop abscess\",\"Single abscess\"\\n\"Late postoperative phase\",\"Lesser sac abscess\"\\n\"Multiple abscesses\",\"Source of infection uncontrolled\"\\n\"Subphrenic/subhepatic\",\"Gutter abscess\"\\n\"\",\"Pelvic abscess\"',\n", " 'bBox': {'x': 108.58, 'y': 119, 'w': 278.56, 'h': 234.45}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Additional Notes',\n", " 'md': '## Additional Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text mentions that traditionally, a drain was placed within the abscess cavity at the end of the open procedure, with the type, size, and number of drains varying based on local traditions rather than scientific evidence.\\n- The postoperative management of drains is also noted but not elaborated upon in the provided text.\\n```',\n", " 'md': '- The text mentions that traditionally, a drain was placed within the abscess cavity at the end of the open procedure, with the type, size, and number of drains varying based on local traditions rather than scientific evidence.\\n- The postoperative management of drains is also noted but not elaborated upon in the provided text.\\n```',\n", " 'bBox': {'x': 172, 'y': 119, 'w': 285, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 796,\n", " 'text': ' cumbersome rituals with the drains sequentially shortened, based\\n on serial contrast sinograms, to ascertain the gradual collapse of the\\n cavities and drain-tracks. ħouse surgeons and nurses forever\\n changed dressings and irrigated the drains — again according to the\\n locally prevailing ritual. Our experience is that this elaborate\\n nonsense should belong to history. With adequate surgical\\n drainage, when the source of infection has been controlled,\\n when the abscess cavity is ‘filled’ with omentum or adjacent\\n structures, and peri-operative antibiotics are administered —\\n no drains are necessary. Trust the peritoneal cavity to deal with\\n the residual bacteria better in the absence of a foreign body — the\\n drain. We do not recall the last time we had to ‘shorten’ a drain or to\\n obtain a drain sinogram. Oh, the sweet memories of naïve youth.\\n (For a more detailed discussion on drains go to Chapter 39.)\\n\\n And to sum up…\\n\\n Tailor your approach to the anatomy of the abscess, the physiology of\\nthe patient, and the local facilities available to you. Do not procrastinate,\\ndo not forget to deal with the source, do not over-rely on antibiotics, and\\nget rid of the pus. Sepsis (i.e. the host-generated systemic inflammatory\\nresponse to the infection process) may persist, and progress to organ\\nfailure, even after the abscess has been adequately managed. Try not to\\nbe too late.\\n\\n “No drainage is better than the ignorant employment of\\n it… A drain invariably produces some necrosis of the\\n tissue with which it comes in contact, and enfeebles the\\n power of resistance of the tissues toward organisms.”\\n William Stewart Halsted',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nCumbersome rituals with the drains sequentially shortened, based on serial contrast sinograms, to ascertain the gradual collapse of the cavities and drain-tracks. House surgeons and nurses forever changed dressings and irrigated the drains — again according to the locally prevailing ritual. Our experience is that this elaborate nonsense should belong to history. With adequate surgical drainage, when the source of infection has been controlled, when the abscess cavity is ‘filled’ with omentum or adjacent structures, and peri-operative antibiotics are administered — no drains are necessary. Trust the peritoneal cavity to deal with the residual bacteria better in the absence of a foreign body — the drain. We do not recall the last time we had to ‘shorten’ a drain or to obtain a drain sinogram. Oh, the sweet memories of naïve youth. (For a more detailed discussion on drains go to [Chapter 39](#).)\\n\\nAnd to sum up…\\n\\nTailor your approach to the anatomy of the abscess, the physiology of the patient, and the local facilities available to you. Do not procrastinate, do not forget to deal with the source, do not over-rely on antibiotics, and get rid of the pus. Sepsis (i.e. the host-generated systemic inflammatory response to the infection process) may persist, and progress to organ failure, even after the abscess has been adequately managed. Try not to be too late.\\n\\n“No drainage is better than the ignorant employment of it… A drain invariably produces some necrosis of the tissue with which it comes in contact, and enfeebles the power of resistance of the tissues toward organisms.”\\n— William Stewart Halsted\\n```\\n\\n## Image Identification and Description\\n\\n*No images or figures were identified on this page.*\\n\\n## Formula Extraction\\n\\n*No formulas were identified on this page.*\\n\\n## Table Extraction\\n\\n*No tables were identified on this page.*\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Cumbersome rituals with the drains sequentially shortened, based on serial contrast sinograms, to ascertain the gradual collapse of the cavities and drain-tracks. House surgeons and nurses forever changed dressings and irrigated the drains — again according to the locally prevailing ritual. Our experience is that this elaborate nonsense should belong to history. With adequate surgical drainage, when the source of infection has been controlled, when the abscess cavity is ‘filled’ with omentum or adjacent structures, and peri-operative antibiotics are administered — no drains are necessary. Trust the peritoneal cavity to deal with the residual bacteria better in the absence of a foreign body — the drain. We do not recall the last time we had to ‘shorten’ a drain or to obtain a drain sinogram. Oh, the sweet memories of naïve youth. (For a more detailed discussion on drains go to [Chapter 39](#).)\\n\\nAnd to sum up…\\n\\nTailor your approach to the anatomy of the abscess, the physiology of the patient, and the local facilities available to you. Do not procrastinate, do not forget to deal with the source, do not over-rely on antibiotics, and get rid of the pus. Sepsis (i.e. the host-generated systemic inflammatory response to the infection process) may persist, and progress to organ failure, even after the abscess has been adequately managed. Try not to be too late.\\n\\n“No drainage is better than the ignorant employment of it… A drain invariably produces some necrosis of the tissue with which it comes in contact, and enfeebles the power of resistance of the tissues toward organisms.”\\n— William Stewart Halsted\\n```',\n", " 'md': 'Cumbersome rituals with the drains sequentially shortened, based on serial contrast sinograms, to ascertain the gradual collapse of the cavities and drain-tracks. House surgeons and nurses forever changed dressings and irrigated the drains — again according to the locally prevailing ritual. Our experience is that this elaborate nonsense should belong to history. With adequate surgical drainage, when the source of infection has been controlled, when the abscess cavity is ‘filled’ with omentum or adjacent structures, and peri-operative antibiotics are administered — no drains are necessary. Trust the peritoneal cavity to deal with the residual bacteria better in the absence of a foreign body — the drain. We do not recall the last time we had to ‘shorten’ a drain or to obtain a drain sinogram. Oh, the sweet memories of naïve youth. (For a more detailed discussion on drains go to [Chapter 39](#).)\\n\\nAnd to sum up…\\n\\nTailor your approach to the anatomy of the abscess, the physiology of the patient, and the local facilities available to you. Do not procrastinate, do not forget to deal with the source, do not over-rely on antibiotics, and get rid of the pus. Sepsis (i.e. the host-generated systemic inflammatory response to the infection process) may persist, and progress to organ failure, even after the abscess has been adequately managed. Try not to be too late.\\n\\n“No drainage is better than the ignorant employment of it… A drain invariably produces some necrosis of the tissue with which it comes in contact, and enfeebles the power of resistance of the tissues toward organisms.”\\n— William Stewart Halsted\\n```',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 467.42, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*',\n", " 'md': '*No images or figures were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formula Extraction',\n", " 'md': '## Formula Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No formulas were identified on this page.*',\n", " 'md': '*No formulas were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Table Extraction',\n", " 'md': '## Table Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No tables were identified on this page.*\\n```',\n", " 'md': '*No tables were identified on this page.*\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 797,\n", " 'text': 'Chapter 47\\nAnastomotic leaks and fistulas\\nMoshe Schein\\n\\n Anastomotic leakage is a completely avoidable\\n complication; providing you don’t perform an anastomosis.\\n Brendan Moran\\n\\n If there is a possibility of several things going wrong, the\\n one that will cause the most damage will be the one to go\\n wrong.\\n Murphy’s Law, Arthur Bloch\\n\\n And if things do go wrong, there is no limit to how bad they can get… Ari\\n\\n For a comprehensive treatise of this dreaded and touchy topic we\\nrecommend that you study Chapter 6 in Schein’s Common Sense\\nPrevention and Management of Surgical Complications where all types of\\n‘leaks’ — from the esophagus to the rectum — are discussed. ħere we\\noffer an abbreviated version, looking at the basics from a different\\nperspective.\\n\\n There are two chief clinical patterns of postoperative intestinal\\nleak:\\n\\n • The leak is obvious — you see intestinal contents draining from the\\n operative wound or from the drain site (if a drain was used).',\n", " 'md': '```markdown\\n# Chapter 47: Anastomotic Leaks and Fistulas\\n**Author:** Moshe Schein\\n\\n> \"Anastomotic leakage is a completely avoidable complication; providing you don’t perform an anastomosis.\"\\n> — Brendan Moran\\n\\n> \"If there is a possibility of several things going wrong, the one that will cause the most damage will be the one to go wrong.\"\\n> — Murphy’s Law, Arthur Bloch\\n\\n> \"And if things do go wrong, there is no limit to how bad they can get…\"\\n> — Ari\\n\\nFor a comprehensive treatise of this dreaded and touchy topic, we recommend that you study Chapter 6 in Schein’s *Common Sense Prevention and Management of Surgical Complications* where all types of ‘leaks’ — from the esophagus to the rectum — are discussed. Here we offer an abbreviated version, looking at the basics from a different perspective.\\n\\n## Clinical Patterns of Postoperative Intestinal Leak\\n\\nThere are two chief clinical patterns of postoperative intestinal leak:\\n\\n- The leak is obvious — you see intestinal contents draining from the operative wound or from the drain site (if a drain was used).\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 47: Anastomotic Leaks and Fistulas',\n", " 'md': '# Chapter 47: Anastomotic Leaks and Fistulas',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 271.01, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Author:** Moshe Schein\\n\\n> \"Anastomotic leakage is a completely avoidable complication; providing you don’t perform an anastomosis.\"\\n> — Brendan Moran\\n\\n> \"If there is a possibility of several things going wrong, the one that will cause the most damage will be the one to go wrong.\"\\n> — Murphy’s Law, Arthur Bloch\\n\\n> \"And if things do go wrong, there is no limit to how bad they can get…\"\\n> — Ari\\n\\nFor a comprehensive treatise of this dreaded and touchy topic, we recommend that you study Chapter 6 in Schein’s *Common Sense Prevention and Management of Surgical Complications* where all types of ‘leaks’ — from the esophagus to the rectum — are discussed. Here we offer an abbreviated version, looking at the basics from a different perspective.',\n", " 'md': '**Author:** Moshe Schein\\n\\n> \"Anastomotic leakage is a completely avoidable complication; providing you don’t perform an anastomosis.\"\\n> — Brendan Moran\\n\\n> \"If there is a possibility of several things going wrong, the one that will cause the most damage will be the one to go wrong.\"\\n> — Murphy’s Law, Arthur Bloch\\n\\n> \"And if things do go wrong, there is no limit to how bad they can get…\"\\n> — Ari\\n\\nFor a comprehensive treatise of this dreaded and touchy topic, we recommend that you study Chapter 6 in Schein’s *Common Sense Prevention and Management of Surgical Complications* where all types of ‘leaks’ — from the esophagus to the rectum — are discussed. Here we offer an abbreviated version, looking at the basics from a different perspective.',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 381.25, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Patterns of Postoperative Intestinal Leak',\n", " 'md': '## Clinical Patterns of Postoperative Intestinal Leak',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'There are two chief clinical patterns of postoperative intestinal leak:\\n\\n- The leak is obvious — you see intestinal contents draining from the operative wound or from the drain site (if a drain was used).\\n```',\n", " 'md': 'There are two chief clinical patterns of postoperative intestinal leak:\\n\\n- The leak is obvious — you see intestinal contents draining from the operative wound or from the drain site (if a drain was used).\\n```',\n", " 'bBox': {'x': 72, 'y': 309, 'w': 436.85, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Prevention and Management of Surgical Complications'}]},\n", " {'page': 798,\n", " 'text': ' • The leak is suspected — you do not see it…\\n\\n Scenario 1: the obvious leak\\n\\n It is postoperative day 6 after a laparotomy for small bowel obstruction ( Chapter 21). The\\n procedure was uneventful, except for two accidental enterotomies, which were closed with\\n interrupted Vicryl® 3-0 in one layer. During morning rounds the patient complains: “Look,\\n doctor, my bed is full of this green stuff.” You uncover the patient’s abdomen to see bile-stained\\n intestinal juice pouring through the incision! Now you are very upset — you feel like you want\\n to vanish — why did this happen to me?! I did a perfect operation… True, the patient’s\\n recovery was not smooth; he was running a fever and a high white cell count. And now this\\n terrible disaster! It is a disaster indeed, for the morbidity of this complication is horrendous and\\n the mortality significant.\\n\\nFigure 47.1. What’s in their mind? “Reoperate?” “Treat as fistula?” “Transfer?” “Why is\\nthis happening to me?”',\n", " 'md': \"```markdown\\n## Scenario 1: The Obvious Leak\\n\\nIt is postoperative day 6 after a laparotomy for small bowel obstruction (Chapter 21). The procedure was uneventful, except for two accidental enterotomies, which were closed with interrupted Vicryl® 3-0 in one layer. During morning rounds, the patient complains: “Look, doctor, my bed is full of this green stuff.” You uncover the patient’s abdomen to see bile-stained intestinal juice pouring through the incision! Now you are very upset — you feel like you want to vanish — why did this happen to me?! I did a perfect operation… True, the patient’s recovery was not smooth; he was running a fever and a high white cell count. And now this terrible disaster! It is a disaster indeed, for the morbidity of this complication is horrendous and the mortality significant.\\n\\n### Figure 47.1\\n**Caption:** What’s in their mind? “Reoperate?” “Treat as fistula?” “Transfer?” “Why is this happening to me?”\\n\\n**Description:** This figure likely depicts a thought bubble or a series of questions reflecting the concerns and thoughts of the medical team regarding the patient's condition post-surgery. The questions suggest a state of confusion and urgency about the next steps in management. The visual representation may include illustrations or icons that symbolize the different options being considered, such as reoperation, treatment as a fistula, or transfer to another facility.\\n```\",\n", " 'images': [{'name': 'img_p797_1.png',\n", " 'height': 18,\n", " 'width': 18,\n", " 'x': 432,\n", " 'y': 174.95999999999998},\n", " {'name': 'img_p797_2.png',\n", " 'height': 581,\n", " 'width': 811,\n", " 'x': 105.83999999999997,\n", " 'y': 370.79999999999995,\n", " 'original_width': 1392,\n", " 'original_height': 997}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Scenario 1: The Obvious Leak',\n", " 'md': '## Scenario 1: The Obvious Leak',\n", " 'bBox': {'x': 86, 'y': 138, 'w': 223.45, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'It is postoperative day 6 after a laparotomy for small bowel obstruction (Chapter 21). The procedure was uneventful, except for two accidental enterotomies, which were closed with interrupted Vicryl® 3-0 in one layer. During morning rounds, the patient complains: “Look, doctor, my bed is full of this green stuff.” You uncover the patient’s abdomen to see bile-stained intestinal juice pouring through the incision! Now you are very upset — you feel like you want to vanish — why did this happen to me?! I did a perfect operation… True, the patient’s recovery was not smooth; he was running a fever and a high white cell count. And now this terrible disaster! It is a disaster indeed, for the morbidity of this complication is horrendous and the mortality significant.',\n", " 'md': 'It is postoperative day 6 after a laparotomy for small bowel obstruction (Chapter 21). The procedure was uneventful, except for two accidental enterotomies, which were closed with interrupted Vicryl® 3-0 in one layer. During morning rounds, the patient complains: “Look, doctor, my bed is full of this green stuff.” You uncover the patient’s abdomen to see bile-stained intestinal juice pouring through the incision! Now you are very upset — you feel like you want to vanish — why did this happen to me?! I did a perfect operation… True, the patient’s recovery was not smooth; he was running a fever and a high white cell count. And now this terrible disaster! It is a disaster indeed, for the morbidity of this complication is horrendous and the mortality significant.',\n", " 'bBox': {'x': 79, 'y': 185, 'w': 453.21, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 47.1',\n", " 'md': '### Figure 47.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"**Caption:** What’s in their mind? “Reoperate?” “Treat as fistula?” “Transfer?” “Why is this happening to me?”\\n\\n**Description:** This figure likely depicts a thought bubble or a series of questions reflecting the concerns and thoughts of the medical team regarding the patient's condition post-surgery. The questions suggest a state of confusion and urgency about the next steps in management. The visual representation may include illustrations or icons that symbolize the different options being considered, such as reoperation, treatment as a fistula, or transfer to another facility.\\n```\",\n", " 'md': \"**Caption:** What’s in their mind? “Reoperate?” “Treat as fistula?” “Transfer?” “Why is this happening to me?”\\n\\n**Description:** This figure likely depicts a thought bubble or a series of questions reflecting the concerns and thoughts of the medical team regarding the patient's condition post-surgery. The questions suggest a state of confusion and urgency about the next steps in management. The visual representation may include illustrations or icons that symbolize the different options being considered, such as reoperation, treatment as a fistula, or transfer to another facility.\\n```\",\n", " 'bBox': {'x': 75, 'y': 690, 'w': 120.45, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 799,\n", " 'text': ' Your first reaction is: let’s get him immediately to the operating room\\nand fix this mess… Or perhaps treat conservatively? And what about\\nshipping him out — let the guys in the ivory tower deal with it…?\\n\\n What to do with such a nightmare ( Figure 47.1)?\\n\\n The controversy\\n\\n There is little controversy that established postoperative external\\nenterocutaneous fistulas, which usually result from leaking anastomoses\\nor incidental enterotomies, should initially be managed conservatively. As\\nnoted in previous chapters, there is also little controversy that acute\\ngastrointestinal perforation, be it spontaneous or traumatic, is an\\nindication for an emergency laparotomy to deal with the source of\\ncontamination/infection ( Chapter 13).\\n\\n So what about the early postoperative small bowel leakage? Is it\\nlike a ‘simple perforation’ requiring an immediate operation, or like a\\n‘fistula’ to be managed conservatively?\\n\\n We contend that this scenario represents both conditions and\\nshould therefore be managed selectively in the individual patient.\\n\\n The role of non-operative management\\n\\n With proper supportive management, and in the absence of distal\\nobstruction or loss of bowel continuity (i.e. it is a ‘side-fistula’, not an ‘end-\\nfistula’), about a third of postoperative small bowel fistulas will close\\nspontaneously within 6 weeks. Those which fail to close by this time will\\nrequire elective reoperation. This, when performed on an anabolic,\\nnon-SIRS patient, in a less hostile peritoneal environment, will\\nrestore the integrity of the gastrointestinal tract with an acceptable\\nrisk of complications.\\n\\n A crucial issue when deciding on a trial of conservative\\nmanagement is the presence or absence of significant peritonitis\\nand sepsis — their presence being an indication for an immediate',\n", " 'md': '```markdown\\n## Page Content\\n\\nYour first reaction is: let’s get him immediately to the operating room and fix this mess… Or perhaps treat conservatively? And what about shipping him out — let the guys in the ivory tower deal with it…?\\n\\nWhat to do with such a nightmare (Figure 47.1)?\\n\\n### The Controversy\\n\\nThere is little controversy that established postoperative external enterocutaneous fistulas, which usually result from leaking anastomoses or incidental enterotomies, should initially be managed conservatively. As noted in previous chapters, there is also little controversy that acute gastrointestinal perforation, be it spontaneous or traumatic, is an indication for an emergency laparotomy to deal with the source of contamination/infection (Chapter 13).\\n\\nSo what about the early postoperative small bowel leakage? Is it like a ‘simple perforation’ requiring an immediate operation, or like a ‘fistula’ to be managed conservatively?\\n\\nWe contend that this scenario represents both conditions and should therefore be managed selectively in the individual patient.\\n\\n### The Role of Non-Operative Management\\n\\nWith proper supportive management, and in the absence of distal obstruction or loss of bowel continuity (i.e. it is a ‘side-fistula’, not an ‘end-fistula’), about a third of postoperative small bowel fistulas will close spontaneously within 6 weeks. Those which fail to close by this time will require elective reoperation. This, when performed on an anabolic, non-SIRS patient, in a less hostile peritoneal environment, will restore the integrity of the gastrointestinal tract with an acceptable risk of complications.\\n\\nA crucial issue when deciding on a trial of conservative management is the presence or absence of significant peritonitis and sepsis — their presence being an indication for an immediate...\\n```\\n\\n### Figure Description\\n\\n**Figure 47.1**: The figure referenced in the text is not provided, but it likely illustrates a clinical scenario related to postoperative complications, possibly depicting a flowchart or decision tree regarding the management of enterocutaneous fistulas. The figure serves to visually summarize the decision-making process in handling such cases, emphasizing the need for selective management based on individual patient conditions.\\n\\n### Summary\\n\\nThe text discusses the management of postoperative complications, particularly focusing on enterocutaneous fistulas and the decision-making process involved in their treatment. It highlights the importance of conservative management in certain cases and the factors influencing the choice between immediate surgical intervention and non-operative management.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Your first reaction is: let’s get him immediately to the operating room and fix this mess… Or perhaps treat conservatively? And what about shipping him out — let the guys in the ivory tower deal with it…?\\n\\nWhat to do with such a nightmare (Figure 47.1)?',\n", " 'md': 'Your first reaction is: let’s get him immediately to the operating room and fix this mess… Or perhaps treat conservatively? And what about shipping him out — let the guys in the ivory tower deal with it…?\\n\\nWhat to do with such a nightmare (Figure 47.1)?',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 407.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Controversy',\n", " 'md': '### The Controversy',\n", " 'bBox': {'x': 86, 'y': 197, 'w': 128.76, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'There is little controversy that established postoperative external enterocutaneous fistulas, which usually result from leaking anastomoses or incidental enterotomies, should initially be managed conservatively. As noted in previous chapters, there is also little controversy that acute gastrointestinal perforation, be it spontaneous or traumatic, is an indication for an emergency laparotomy to deal with the source of contamination/infection (Chapter 13).\\n\\nSo what about the early postoperative small bowel leakage? Is it like a ‘simple perforation’ requiring an immediate operation, or like a ‘fistula’ to be managed conservatively?\\n\\nWe contend that this scenario represents both conditions and should therefore be managed selectively in the individual patient.',\n", " 'md': 'There is little controversy that established postoperative external enterocutaneous fistulas, which usually result from leaking anastomoses or incidental enterotomies, should initially be managed conservatively. As noted in previous chapters, there is also little controversy that acute gastrointestinal perforation, be it spontaneous or traumatic, is an indication for an emergency laparotomy to deal with the source of contamination/infection (Chapter 13).\\n\\nSo what about the early postoperative small bowel leakage? Is it like a ‘simple perforation’ requiring an immediate operation, or like a ‘fistula’ to be managed conservatively?\\n\\nWe contend that this scenario represents both conditions and should therefore be managed selectively in the individual patient.',\n", " 'bBox': {'x': 72, 'y': 250, 'w': 467.79, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Role of Non-Operative Management',\n", " 'md': '### The Role of Non-Operative Management',\n", " 'bBox': {'x': 86, 'y': 496, 'w': 305.28, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'With proper supportive management, and in the absence of distal obstruction or loss of bowel continuity (i.e. it is a ‘side-fistula’, not an ‘end-fistula’), about a third of postoperative small bowel fistulas will close spontaneously within 6 weeks. Those which fail to close by this time will require elective reoperation. This, when performed on an anabolic, non-SIRS patient, in a less hostile peritoneal environment, will restore the integrity of the gastrointestinal tract with an acceptable risk of complications.\\n\\nA crucial issue when deciding on a trial of conservative management is the presence or absence of significant peritonitis and sepsis — their presence being an indication for an immediate...\\n```',\n", " 'md': 'With proper supportive management, and in the absence of distal obstruction or loss of bowel continuity (i.e. it is a ‘side-fistula’, not an ‘end-fistula’), about a third of postoperative small bowel fistulas will close spontaneously within 6 weeks. Those which fail to close by this time will require elective reoperation. This, when performed on an anabolic, non-SIRS patient, in a less hostile peritoneal environment, will restore the integrity of the gastrointestinal tract with an acceptable risk of complications.\\n\\nA crucial issue when deciding on a trial of conservative management is the presence or absence of significant peritonitis and sepsis — their presence being an indication for an immediate...\\n```',\n", " 'bBox': {'x': 72, 'y': 548, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Description',\n", " 'md': '### Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 47.1**: The figure referenced in the text is not provided, but it likely illustrates a clinical scenario related to postoperative complications, possibly depicting a flowchart or decision tree regarding the management of enterocutaneous fistulas. The figure serves to visually summarize the decision-making process in handling such cases, emphasizing the need for selective management based on individual patient conditions.',\n", " 'md': '**Figure 47.1**: The figure referenced in the text is not provided, but it likely illustrates a clinical scenario related to postoperative complications, possibly depicting a flowchart or decision tree regarding the management of enterocutaneous fistulas. The figure serves to visually summarize the decision-making process in handling such cases, emphasizing the need for selective management based on individual patient conditions.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the management of postoperative complications, particularly focusing on enterocutaneous fistulas and the decision-making process involved in their treatment. It highlights the importance of conservative management in certain cases and the factors influencing the choice between immediate surgical intervention and non-operative management.',\n", " 'md': 'The text discusses the management of postoperative complications, particularly focusing on enterocutaneous fistulas and the decision-making process involved in their treatment. It highlights the importance of conservative management in certain cases and the factors influencing the choice between immediate surgical intervention and non-operative management.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 800,\n", " 'text': 'operation. Even when clinical peritonitis is not present, any evidence of\\nSIRS or sepsis should trigger an aggressive search for drainable intra-\\nabdominal pus. This is best done with a CT scan; associated abscesses\\nshould be drained, percutaneously (PC) or at laparotomy ( Chapter 46).\\n\\n Remember: The chief cause of death in patients who develop anastomotic leaks is\\n neglected intra-abdominal infection.\\n\\n The role of early operative management\\n\\n As stated above, diffuse peritonitis or a complex intra-abdominal\\nabscess not suitable for — or not responding to — PC drainage, are\\nindications for laparotomy (sometimes laparoscopy) to achieve source\\ncontrol. But why not operate on all such patients? Why not just\\nsurrender to the temptation buzzing in your brain: “I know where this leak\\nis coming from; let me just return to that abdomen and fix this frustrating\\nproblem with a few more sutures… and abort this bad dream?”\\n\\n Why not? Because — in the vast majority of cases — resuturing\\nthe leak won’t solve the problem!\\n\\n Primary closure of a disrupted intestinal suture line is doomed to fail.\\n\\n Each of us can remember an isolated success in closing an intestinal\\nleak (see below for specific indications to do so), but the collective\\nexperience points to an overwhelmingly high rate of failure. Attempts to\\nclose an intestinal leak, after only a few days, in an infected peritoneal\\ncavity are doomed to fail. Similarly, redoing an intestinal anastomosis in\\nthe presence of postoperative peritonitis is an exercise in futility.\\nObviously, if successful, the surgeon is a hero who either saves his\\npatient’s life, or at least prevents prolonged hospitalization and morbidity.\\nIf, however, a leak redevelops, as it usually does, it produces a\\ntremendous ‘second hit’ — added to the insult of the reoperation — which\\nstrikes an already primed, susceptible and compromised host. Sepsis\\nand death are then almost inevitable.',\n", " 'md': '```markdown\\n## The Role of Early Operative Management\\n\\nEven when clinical peritonitis is not present, any evidence of SIRS or sepsis should trigger an aggressive search for drainable intra-abdominal pus. This is best done with a CT scan; associated abscesses should be drained, percutaneously (PC) or at laparotomy.\\n\\n**Remember:** The chief cause of death in patients who develop anastomotic leaks is neglected intra-abdominal infection.\\n\\nAs stated above, diffuse peritonitis or a complex intra-abdominal abscess not suitable for — or not responding to — PC drainage, are indications for laparotomy (sometimes laparoscopy) to achieve source control. But why not operate on all such patients? Why not just surrender to the temptation buzzing in your brain: “I know where this leak is coming from; let me just return to that abdomen and fix this frustrating problem with a few more sutures… and abort this bad dream?”\\n\\n**Why not?** Because — in the vast majority of cases — resuturing the leak won’t solve the problem!\\n\\nPrimary closure of a disrupted intestinal suture line is doomed to fail.\\n\\nEach of us can remember an isolated success in closing an intestinal leak (see below for specific indications to do so), but the collective experience points to an overwhelmingly high rate of failure. Attempts to close an intestinal leak, after only a few days, in an infected peritoneal cavity are doomed to fail. Similarly, redoing an intestinal anastomosis in the presence of postoperative peritonitis is an exercise in futility. Obviously, if successful, the surgeon is a hero who either saves his patient’s life, or at least prevents prolonged hospitalization and morbidity. If, however, a leak redevelops, as it usually does, it produces a tremendous ‘second hit’ — added to the insult of the reoperation — which strikes an already primed, susceptible and compromised host. Sepsis and death are then almost inevitable.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Role of Early Operative Management',\n", " 'md': '## The Role of Early Operative Management',\n", " 'bBox': {'x': 86, 'y': 255, 'w': 312.65, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Even when clinical peritonitis is not present, any evidence of SIRS or sepsis should trigger an aggressive search for drainable intra-abdominal pus. This is best done with a CT scan; associated abscesses should be drained, percutaneously (PC) or at laparotomy.\\n\\n**Remember:** The chief cause of death in patients who develop anastomotic leaks is neglected intra-abdominal infection.\\n\\nAs stated above, diffuse peritonitis or a complex intra-abdominal abscess not suitable for — or not responding to — PC drainage, are indications for laparotomy (sometimes laparoscopy) to achieve source control. But why not operate on all such patients? Why not just surrender to the temptation buzzing in your brain: “I know where this leak is coming from; let me just return to that abdomen and fix this frustrating problem with a few more sutures… and abort this bad dream?”\\n\\n**Why not?** Because — in the vast majority of cases — resuturing the leak won’t solve the problem!\\n\\nPrimary closure of a disrupted intestinal suture line is doomed to fail.\\n\\nEach of us can remember an isolated success in closing an intestinal leak (see below for specific indications to do so), but the collective experience points to an overwhelmingly high rate of failure. Attempts to close an intestinal leak, after only a few days, in an infected peritoneal cavity are doomed to fail. Similarly, redoing an intestinal anastomosis in the presence of postoperative peritonitis is an exercise in futility. Obviously, if successful, the surgeon is a hero who either saves his patient’s life, or at least prevents prolonged hospitalization and morbidity. If, however, a leak redevelops, as it usually does, it produces a tremendous ‘second hit’ — added to the insult of the reoperation — which strikes an already primed, susceptible and compromised host. Sepsis and death are then almost inevitable.\\n```',\n", " 'md': 'Even when clinical peritonitis is not present, any evidence of SIRS or sepsis should trigger an aggressive search for drainable intra-abdominal pus. This is best done with a CT scan; associated abscesses should be drained, percutaneously (PC) or at laparotomy.\\n\\n**Remember:** The chief cause of death in patients who develop anastomotic leaks is neglected intra-abdominal infection.\\n\\nAs stated above, diffuse peritonitis or a complex intra-abdominal abscess not suitable for — or not responding to — PC drainage, are indications for laparotomy (sometimes laparoscopy) to achieve source control. But why not operate on all such patients? Why not just surrender to the temptation buzzing in your brain: “I know where this leak is coming from; let me just return to that abdomen and fix this frustrating problem with a few more sutures… and abort this bad dream?”\\n\\n**Why not?** Because — in the vast majority of cases — resuturing the leak won’t solve the problem!\\n\\nPrimary closure of a disrupted intestinal suture line is doomed to fail.\\n\\nEach of us can remember an isolated success in closing an intestinal leak (see below for specific indications to do so), but the collective experience points to an overwhelmingly high rate of failure. Attempts to close an intestinal leak, after only a few days, in an infected peritoneal cavity are doomed to fail. Similarly, redoing an intestinal anastomosis in the presence of postoperative peritonitis is an exercise in futility. Obviously, if successful, the surgeon is a hero who either saves his patient’s life, or at least prevents prolonged hospitalization and morbidity. If, however, a leak redevelops, as it usually does, it produces a tremendous ‘second hit’ — added to the insult of the reoperation — which strikes an already primed, susceptible and compromised host. Sepsis and death are then almost inevitable.\\n```',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.96, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 801,\n", " 'text': ' Suggested approach to early leaks/postoperative\\n intestinal fistulas\\n\\n A trial of conservative management is warranted when:\\n\\n • There is no clinical peritonitis.\\n • There are no associated abscesses on CT and you know the leak is\\n ‘controlled’.\\n\\n An immediate relaparotomy is warranted when:\\n\\n • There is evidence of clinical peritonitis.\\n • There is SIRS/sepsis with proven or suspected intraperitoneal\\n abscesses which cannot be drained percutaneously.\\n • The ‘index’ operation was performed by somebody you do not know\\n or trust, or you cannot obtain accurate information about what\\n exactly has been done. Bitter experience has taught us that in such\\n (transferred from elsewhere) patients ‘anything is possible’ and it is\\n better to reoperate — you never know what the findings will be.\\n\\n What to do during an emergency relaparotomy?\\n\\n There are three things to consider:\\n\\n • The condition of the bowel.\\n • The condition of the peritoneal cavity.\\n • The condition of the patient.\\n Very rarely — in a stable, minimally compromised patient, when\\nperitonitis appears minimal, when the bowel appears of ‘good quality’\\n(meaning the consistency of thick slices of prosciutto — not mortadella),\\nwhen the patient’s serum albumin levels are reasonable — we would\\nresect the involved segment of small bowel and reanastomose. Such a',\n", " 'md': '```markdown\\n# Suggested Approach to Early Leaks/Postoperative Intestinal Fistulas\\n\\nA trial of conservative management is warranted when:\\n\\n- There is no clinical peritonitis.\\n- There are no associated abscesses on CT and you know the leak is ‘controlled’.\\n\\nAn immediate relaparotomy is warranted when:\\n\\n- There is evidence of clinical peritonitis.\\n- There is SIRS/sepsis with proven or suspected intraperitoneal abscesses which cannot be drained percutaneously.\\n- The ‘index’ operation was performed by somebody you do not know or trust, or you cannot obtain accurate information about what exactly has been done. Bitter experience has taught us that in such (transferred from elsewhere) patients ‘anything is possible’ and it is better to reoperate — you never know what the findings will be.\\n\\n## What to do during an emergency relaparotomy?\\n\\nThere are three things to consider:\\n\\n- The condition of the bowel.\\n- The condition of the peritoneal cavity.\\n- The condition of the patient.\\n\\nVery rarely — in a stable, minimally compromised patient, when peritonitis appears minimal, when the bowel appears of ‘good quality’ (meaning the consistency of thick slices of prosciutto — not mortadella), when the patient’s serum albumin levels are reasonable — we would resect the involved segment of small bowel and reanastomose. Such a\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Suggested Approach to Early Leaks/Postoperative Intestinal Fistulas',\n", " 'md': '# Suggested Approach to Early Leaks/Postoperative Intestinal Fistulas',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 154.51, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'A trial of conservative management is warranted when:\\n\\n- There is no clinical peritonitis.\\n- There are no associated abscesses on CT and you know the leak is ‘controlled’.\\n\\nAn immediate relaparotomy is warranted when:\\n\\n- There is evidence of clinical peritonitis.\\n- There is SIRS/sepsis with proven or suspected intraperitoneal abscesses which cannot be drained percutaneously.\\n- The ‘index’ operation was performed by somebody you do not know or trust, or you cannot obtain accurate information about what exactly has been done. Bitter experience has taught us that in such (transferred from elsewhere) patients ‘anything is possible’ and it is better to reoperate — you never know what the findings will be.',\n", " 'md': 'A trial of conservative management is warranted when:\\n\\n- There is no clinical peritonitis.\\n- There are no associated abscesses on CT and you know the leak is ‘controlled’.\\n\\nAn immediate relaparotomy is warranted when:\\n\\n- There is evidence of clinical peritonitis.\\n- There is SIRS/sepsis with proven or suspected intraperitoneal abscesses which cannot be drained percutaneously.\\n- The ‘index’ operation was performed by somebody you do not know or trust, or you cannot obtain accurate information about what exactly has been done. Bitter experience has taught us that in such (transferred from elsewhere) patients ‘anything is possible’ and it is better to reoperate — you never know what the findings will be.',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 436.95, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'What to do during an emergency relaparotomy?',\n", " 'md': '## What to do during an emergency relaparotomy?',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 376.99, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'There are three things to consider:\\n\\n- The condition of the bowel.\\n- The condition of the peritoneal cavity.\\n- The condition of the patient.\\n\\nVery rarely — in a stable, minimally compromised patient, when peritonitis appears minimal, when the bowel appears of ‘good quality’ (meaning the consistency of thick slices of prosciutto — not mortadella), when the patient’s serum albumin levels are reasonable — we would resect the involved segment of small bowel and reanastomose. Such a\\n```',\n", " 'md': 'There are three things to consider:\\n\\n- The condition of the bowel.\\n- The condition of the peritoneal cavity.\\n- The condition of the patient.\\n\\nVery rarely — in a stable, minimally compromised patient, when peritonitis appears minimal, when the bowel appears of ‘good quality’ (meaning the consistency of thick slices of prosciutto — not mortadella), when the patient’s serum albumin levels are reasonable — we would resect the involved segment of small bowel and reanastomose. Such a\\n```',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 466.8, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 802,\n", " 'text': 'sequence of events is possible only when the leak presents within a\\nday or two after the operation (usually caused by a technical mishap).\\nAn immediate reoperation before local and systemic adverse\\nrepercussions develop may thus provide a definitive cure. Other\\ncircumstances when attemps at repair of the leak are reasonable would\\nbe during early reoperations for upper gastrointestinal leaks (e.g.\\nfollowing omentopexy for perforated peptic ulcer), where exteriorization of\\nthe leaking part is impossible. So one tries to patch and one leaves a\\ndrain; if the leak redevelops — and usually it does — one hopes at least\\nto establish a controlled fistula.\\n\\n In all other circumstances, the less heroic but logical and life-saving option of\\n exteriorization — if technically possible — of the leaking point as an enterostomy\\n should be carried out, and at any level — even just distal to the duodenojejunal flexure.\\n If this seems impossible just aim to achieve a controlled, external fistula — drain!\\n\\n Conservative management\\n\\n The principles of management are few and simple:\\n\\n • Provide aggressive supportive care.\\n • Restore fluid and electrolyte balance. All the fistula’s losses\\n should be measured and replaced.\\n • Exclude and treat associated infection. This has been mentioned\\n before and is repeated here only to emphasize that when your fistula\\n patient dies it is usually because you were not aggressive enough in\\n pursuing our advice. Try to do it percutaneously. If an operation is\\n needed, try to drain the abscess through a direct, local approach,\\n avoiding the risks of a ‘complete’ laparotomy ( Chapter 46).\\n • Protect the skin around the fistula from the corrosive intestinal\\n juice. A well-fitting colostomy bag around the fistula often does the\\n trick. Otherwise, place a tube connected to a continuous suction\\n source adjacent to the fistula, place Stomahesive® sheaths around\\n the defect, and cover the entire field with an adhesive transparent\\n dressing — similar to the ‘sandwich’ described in Chapter 48 (or',\n", " 'md': '```markdown\\n## Management of Leaks\\n\\nThe sequence of events is possible only when the leak presents within a day or two after the operation (usually caused by a technical mishap). An immediate reoperation before local and systemic adverse repercussions develop may thus provide a definitive cure. Other circumstances when attempts at repair of the leak are reasonable would be during early reoperations for upper gastrointestinal leaks (e.g. following omentopexy for perforated peptic ulcer), where exteriorization of the leaking part is impossible. So one tries to patch and one leaves a drain; if the leak redevelops — and usually it does — one hopes at least to establish a controlled fistula.\\n\\nIn all other circumstances, the less heroic but logical and life-saving option of exteriorization — if technically possible — of the leaking point as an enterostomy should be carried out, and at any level — even just distal to the duodenojejunal flexure. If this seems impossible just aim to achieve a controlled, external fistula — drain!\\n\\n### Conservative Management\\n\\nThe principles of management are few and simple:\\n\\n- Provide aggressive supportive care.\\n- Restore fluid and electrolyte balance. All the fistula’s losses should be measured and replaced.\\n- Exclude and treat associated infection. This has been mentioned before and is repeated here only to emphasize that when your fistula patient dies it is usually because you were not aggressive enough in pursuing our advice. Try to do it percutaneously. If an operation is needed, try to drain the abscess through a direct, local approach, avoiding the risks of a ‘complete’ laparotomy (Chapter 46).\\n- Protect the skin around the fistula from the corrosive intestinal juice. A well-fitting colostomy bag around the fistula often does the trick. Otherwise, place a tube connected to a continuous suction source adjacent to the fistula, place Stomahesive® sheaths around the defect, and cover the entire field with an adhesive transparent dressing — similar to the ‘sandwich’ described in Chapter 48.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Leaks',\n", " 'md': '## Management of Leaks',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The sequence of events is possible only when the leak presents within a day or two after the operation (usually caused by a technical mishap). An immediate reoperation before local and systemic adverse repercussions develop may thus provide a definitive cure. Other circumstances when attempts at repair of the leak are reasonable would be during early reoperations for upper gastrointestinal leaks (e.g. following omentopexy for perforated peptic ulcer), where exteriorization of the leaking part is impossible. So one tries to patch and one leaves a drain; if the leak redevelops — and usually it does — one hopes at least to establish a controlled fistula.\\n\\nIn all other circumstances, the less heroic but logical and life-saving option of exteriorization — if technically possible — of the leaking point as an enterostomy should be carried out, and at any level — even just distal to the duodenojejunal flexure. If this seems impossible just aim to achieve a controlled, external fistula — drain!',\n", " 'md': 'The sequence of events is possible only when the leak presents within a day or two after the operation (usually caused by a technical mishap). An immediate reoperation before local and systemic adverse repercussions develop may thus provide a definitive cure. Other circumstances when attempts at repair of the leak are reasonable would be during early reoperations for upper gastrointestinal leaks (e.g. following omentopexy for perforated peptic ulcer), where exteriorization of the leaking part is impossible. So one tries to patch and one leaves a drain; if the leak redevelops — and usually it does — one hopes at least to establish a controlled fistula.\\n\\nIn all other circumstances, the less heroic but logical and life-saving option of exteriorization — if technically possible — of the leaking point as an enterostomy should be carried out, and at any level — even just distal to the duodenojejunal flexure. If this seems impossible just aim to achieve a controlled, external fistula — drain!',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.74, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Conservative Management',\n", " 'md': '### Conservative Management',\n", " 'bBox': {'x': 86, 'y': 391, 'w': 210.62, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The principles of management are few and simple:\\n\\n- Provide aggressive supportive care.\\n- Restore fluid and electrolyte balance. All the fistula’s losses should be measured and replaced.\\n- Exclude and treat associated infection. This has been mentioned before and is repeated here only to emphasize that when your fistula patient dies it is usually because you were not aggressive enough in pursuing our advice. Try to do it percutaneously. If an operation is needed, try to drain the abscess through a direct, local approach, avoiding the risks of a ‘complete’ laparotomy (Chapter 46).\\n- Protect the skin around the fistula from the corrosive intestinal juice. A well-fitting colostomy bag around the fistula often does the trick. Otherwise, place a tube connected to a continuous suction source adjacent to the fistula, place Stomahesive® sheaths around the defect, and cover the entire field with an adhesive transparent dressing — similar to the ‘sandwich’ described in Chapter 48.\\n```',\n", " 'md': 'The principles of management are few and simple:\\n\\n- Provide aggressive supportive care.\\n- Restore fluid and electrolyte balance. All the fistula’s losses should be measured and replaced.\\n- Exclude and treat associated infection. This has been mentioned before and is repeated here only to emphasize that when your fistula patient dies it is usually because you were not aggressive enough in pursuing our advice. Try to do it percutaneously. If an operation is needed, try to drain the abscess through a direct, local approach, avoiding the risks of a ‘complete’ laparotomy (Chapter 46).\\n- Protect the skin around the fistula from the corrosive intestinal juice. A well-fitting colostomy bag around the fistula often does the trick. Otherwise, place a tube connected to a continuous suction source adjacent to the fistula, place Stomahesive® sheaths around the defect, and cover the entire field with an adhesive transparent dressing — similar to the ‘sandwich’ described in Chapter 48.\\n```',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 437.4, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 803,\n", " 'text': ' you may want to waste money on one of the commercially available\\n vacuum-assisted closure [VAC] systems). Make generous use of\\n karaya and/or zinc paste to protect the skin around difficult-to-\\n manage, complex fistulas. Although such wounds require lots of\\n effort and dedication, they are almost always manageable — but\\n only if you care. The way the abdominal wall of your fistula\\n patient looks is how you look!\\n• Provide nutrition. Proximal gastrointestinal fistulas require total\\n parenteral nutrition (TPN) initially until a nasal feeding tube is\\n inserted beyond the leak level. Most distal small bowel and colonic\\n fistulas will close spontaneously whether the patient is fed orally or\\n not. As emphasized in Chapter 43, using the intestine for feeding,\\n if possible, is better. In proximal fistulas it is often possible, and\\n beneficial, to collect the fistula’s output and reinfuse it, together with\\n the enteral diet, into the bowel below the fistula.\\n• Delineate anatomy. This is best done with a sinogram — injecting\\n water-soluble contrast into the fistula tract. This will document the\\n level of the bowel defect and, hopefully, the absence of distal\\n obstruction or loss of bowel continuity — the enemies of successful\\n conservative management.\\n• Strive to achieve spontaneous closure — the likelihood of which\\n depends on the site and anatomy of the fistula; this should be\\n possible in most cases provided the following factors are not\\n present: distal obstruction; loss of bowel continuity; undrained\\n infection; superficial fistula with no adjacent structures to cover it;\\n associated cancer, foreign body or necrotic tissue. Oops, we almost\\n forgot to mention tuberculosis, irradiated bowel or actinomycosis…\\n• Proceed with surgical closure when indicated, but delay it when\\n the patient and his abdominal wall and peritoneal cavity are not\\n ready. Certainly not within 6 weeks but in most cases much longer\\n — usually at least after 3 months. The longer you wait the easier\\n will be the reoperation.\\n• Refer the patient to a specialized center if your own set-up is\\n unable to cope with the demanding care of fistula patients.\\n\\n Gimmicks or no gimmicks',\n", " 'md': '```markdown\\n## Management of Fistulas\\n\\n- You may want to waste money on one of the commercially available vacuum-assisted closure (VAC) systems. Make generous use of karaya and/or zinc paste to protect the skin around difficult-to-manage, complex fistulas. Although such wounds require lots of effort and dedication, they are almost always manageable — but only if you care. The way the abdominal wall of your fistula patient looks is how you look!\\n\\n- **Provide nutrition.** Proximal gastrointestinal fistulas require total parenteral nutrition (TPN) initially until a nasal feeding tube is inserted beyond the leak level. Most distal small bowel and colonic fistulas will close spontaneously whether the patient is fed orally or not. As emphasized in Chapter 43, using the intestine for feeding, if possible, is better. In proximal fistulas, it is often possible, and beneficial, to collect the fistula’s output and reinfuse it, together with the enteral diet, into the bowel below the fistula.\\n\\n- **Delineate anatomy.** This is best done with a sinogram — injecting water-soluble contrast into the fistula tract. This will document the level of the bowel defect and, hopefully, the absence of distal obstruction or loss of bowel continuity — the enemies of successful conservative management.\\n\\n- **Strive to achieve spontaneous closure** — the likelihood of which depends on the site and anatomy of the fistula; this should be possible in most cases provided the following factors are not present: distal obstruction; loss of bowel continuity; undrained infection; superficial fistula with no adjacent structures to cover it; associated cancer, foreign body or necrotic tissue. Oops, we almost forgot to mention tuberculosis, irradiated bowel or actinomycosis…\\n\\n- **Proceed with surgical closure when indicated,** but delay it when the patient and his abdominal wall and peritoneal cavity are not ready. Certainly not within 6 weeks but in most cases much longer — usually at least after 3 months. The longer you wait the easier will be the reoperation.\\n\\n- **Refer the patient to a specialized center** if your own set-up is unable to cope with the demanding care of fistula patients.\\n\\n### Gimmicks or No Gimmicks\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management of Fistulas',\n", " 'md': '## Management of Fistulas',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- You may want to waste money on one of the commercially available vacuum-assisted closure (VAC) systems. Make generous use of karaya and/or zinc paste to protect the skin around difficult-to-manage, complex fistulas. Although such wounds require lots of effort and dedication, they are almost always manageable — but only if you care. The way the abdominal wall of your fistula patient looks is how you look!\\n\\n- **Provide nutrition.** Proximal gastrointestinal fistulas require total parenteral nutrition (TPN) initially until a nasal feeding tube is inserted beyond the leak level. Most distal small bowel and colonic fistulas will close spontaneously whether the patient is fed orally or not. As emphasized in Chapter 43, using the intestine for feeding, if possible, is better. In proximal fistulas, it is often possible, and beneficial, to collect the fistula’s output and reinfuse it, together with the enteral diet, into the bowel below the fistula.\\n\\n- **Delineate anatomy.** This is best done with a sinogram — injecting water-soluble contrast into the fistula tract. This will document the level of the bowel defect and, hopefully, the absence of distal obstruction or loss of bowel continuity — the enemies of successful conservative management.\\n\\n- **Strive to achieve spontaneous closure** — the likelihood of which depends on the site and anatomy of the fistula; this should be possible in most cases provided the following factors are not present: distal obstruction; loss of bowel continuity; undrained infection; superficial fistula with no adjacent structures to cover it; associated cancer, foreign body or necrotic tissue. Oops, we almost forgot to mention tuberculosis, irradiated bowel or actinomycosis…\\n\\n- **Proceed with surgical closure when indicated,** but delay it when the patient and his abdominal wall and peritoneal cavity are not ready. Certainly not within 6 weeks but in most cases much longer — usually at least after 3 months. The longer you wait the easier will be the reoperation.\\n\\n- **Refer the patient to a specialized center** if your own set-up is unable to cope with the demanding care of fistula patients.',\n", " 'md': '- You may want to waste money on one of the commercially available vacuum-assisted closure (VAC) systems. Make generous use of karaya and/or zinc paste to protect the skin around difficult-to-manage, complex fistulas. Although such wounds require lots of effort and dedication, they are almost always manageable — but only if you care. The way the abdominal wall of your fistula patient looks is how you look!\\n\\n- **Provide nutrition.** Proximal gastrointestinal fistulas require total parenteral nutrition (TPN) initially until a nasal feeding tube is inserted beyond the leak level. Most distal small bowel and colonic fistulas will close spontaneously whether the patient is fed orally or not. As emphasized in Chapter 43, using the intestine for feeding, if possible, is better. In proximal fistulas, it is often possible, and beneficial, to collect the fistula’s output and reinfuse it, together with the enteral diet, into the bowel below the fistula.\\n\\n- **Delineate anatomy.** This is best done with a sinogram — injecting water-soluble contrast into the fistula tract. This will document the level of the bowel defect and, hopefully, the absence of distal obstruction or loss of bowel continuity — the enemies of successful conservative management.\\n\\n- **Strive to achieve spontaneous closure** — the likelihood of which depends on the site and anatomy of the fistula; this should be possible in most cases provided the following factors are not present: distal obstruction; loss of bowel continuity; undrained infection; superficial fistula with no adjacent structures to cover it; associated cancer, foreign body or necrotic tissue. Oops, we almost forgot to mention tuberculosis, irradiated bowel or actinomycosis…\\n\\n- **Proceed with surgical closure when indicated,** but delay it when the patient and his abdominal wall and peritoneal cavity are not ready. Certainly not within 6 weeks but in most cases much longer — usually at least after 3 months. The longer you wait the easier will be the reoperation.\\n\\n- **Refer the patient to a specialized center** if your own set-up is unable to cope with the demanding care of fistula patients.',\n", " 'bBox': {'x': 100, 'y': 86, 'w': 436.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Gimmicks or No Gimmicks',\n", " 'md': '### Gimmicks or No Gimmicks',\n", " 'bBox': {'x': 86, 'y': 692, 'w': 205.97, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '```',\n", " 'md': '```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'if possible, is better. In proximal fistulas it is often possible, and'}]},\n", " {'page': 804,\n", " 'text': ' The initial output of a fistula has few prognostic implications. A fistula\\nwhich drains 1000ml/day during the first week has the same chance of\\nspontaneously sealing as one with an output of 500ml/day. Artificially\\ndecreasing a fistula’s output with total starvation and administration\\nof a somatostatin analogue is cosmetically appealing but not\\nproven to be beneficial.\\n\\n In patients with a well-established (and long) fistula tract (which\\ntakes a few weeks to develop), it is possible to hasten the resolution\\nof the fistula by blocking the tract. Many ‘innovative’ methods have\\nbeen reported as successful (usually in tiny series of patients), ranging\\nfrom the injection of fibrin glue (through a fiberscope) deep into the tract,\\nto plugging the tract’s orifice with chewing gum (chewed by the patient\\nnot by you…).\\n\\n Endoscopic attempts to seal the early leak with clips, glue and stents\\nare becoming increasingly popular among esophageal, bariatric and\\ncolorectal surgeons but, obviously, are not practical for small bowel leaks.\\n\\n Fistulas associated with a large abdominal wall defect\\n\\n Not uncommonly, the end result of intestinal leaks and reoperative\\nsurgery is an abdominal wall defect with multiple intestinal fistulas in its\\nbase. This so-called complex or type IV fistula is a catastrophe that\\ncarries a very high mortality rate. (According to our classification 1,\\ntype I are foregut fistulas, type II, small bowel, and type III, colonic.) With\\nthe widespread practice of open abdomen management techniques,\\nthese types of fistula are observed with increasing frequency. The\\ndistance of the fistulous opening in the intestine from the surface of\\nthe defect and the condition of the peritoneal cavity have a crucial\\nbearing on the treatment of this condition. It is practical to distinguish\\nbetween two situations ( Figure 47.2):',\n", " 'md': '```markdown\\n## Fistula Management and Prognosis\\n\\nThe initial output of a fistula has few prognostic implications. A fistula which drains 1000 ml/day during the first week has the same chance of spontaneously sealing as one with an output of 500 ml/day. Artificially decreasing a fistula’s output with total starvation and administration of a somatostatin analogue is cosmetically appealing but not proven to be beneficial.\\n\\nIn patients with a well-established (and long) fistula tract (which takes a few weeks to develop), it is possible to hasten the resolution of the fistula by blocking the tract. Many ‘innovative’ methods have been reported as successful (usually in tiny series of patients), ranging from the injection of fibrin glue (through a fiberscope) deep into the tract, to plugging the tract’s orifice with chewing gum (chewed by the patient not by you…).\\n\\nEndoscopic attempts to seal the early leak with clips, glue, and stents are becoming increasingly popular among esophageal, bariatric, and colorectal surgeons but, obviously, are not practical for small bowel leaks.\\n\\n### Fistulas Associated with a Large Abdominal Wall Defect\\n\\nNot uncommonly, the end result of intestinal leaks and reoperative surgery is an abdominal wall defect with multiple intestinal fistulas in its base. This so-called complex or type IV fistula is a catastrophe that carries a very high mortality rate. (According to our classification, type I are foregut fistulas, type II, small bowel, and type III, colonic.) With the widespread practice of open abdomen management techniques, these types of fistula are observed with increasing frequency. The distance of the fistulous opening in the intestine from the surface of the defect and the condition of the peritoneal cavity have a crucial bearing on the treatment of this condition. It is practical to distinguish between two situations (Figure 47.2):\\n```\\n\\n### Image Identification and Description\\n\\n- **Figure 47.2**: This figure likely illustrates the two situations regarding the distance of the fistulous opening in the intestine from the surface of the defect and the condition of the peritoneal cavity. The specific details of the image are not provided in the text, but it is essential for understanding the treatment implications of complex fistulas.\\n\\n**Summary**: The text discusses the management and prognosis of fistulas, particularly focusing on their outputs and treatment methods. It highlights the challenges associated with complex fistulas resulting from intestinal leaks and reoperative surgery, emphasizing the importance of understanding the anatomical and pathological context for effective treatment.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Fistula Management and Prognosis',\n", " 'md': '## Fistula Management and Prognosis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The initial output of a fistula has few prognostic implications. A fistula which drains 1000 ml/day during the first week has the same chance of spontaneously sealing as one with an output of 500 ml/day. Artificially decreasing a fistula’s output with total starvation and administration of a somatostatin analogue is cosmetically appealing but not proven to be beneficial.\\n\\nIn patients with a well-established (and long) fistula tract (which takes a few weeks to develop), it is possible to hasten the resolution of the fistula by blocking the tract. Many ‘innovative’ methods have been reported as successful (usually in tiny series of patients), ranging from the injection of fibrin glue (through a fiberscope) deep into the tract, to plugging the tract’s orifice with chewing gum (chewed by the patient not by you…).\\n\\nEndoscopic attempts to seal the early leak with clips, glue, and stents are becoming increasingly popular among esophageal, bariatric, and colorectal surgeons but, obviously, are not practical for small bowel leaks.',\n", " 'md': 'The initial output of a fistula has few prognostic implications. A fistula which drains 1000 ml/day during the first week has the same chance of spontaneously sealing as one with an output of 500 ml/day. Artificially decreasing a fistula’s output with total starvation and administration of a somatostatin analogue is cosmetically appealing but not proven to be beneficial.\\n\\nIn patients with a well-established (and long) fistula tract (which takes a few weeks to develop), it is possible to hasten the resolution of the fistula by blocking the tract. Many ‘innovative’ methods have been reported as successful (usually in tiny series of patients), ranging from the injection of fibrin glue (through a fiberscope) deep into the tract, to plugging the tract’s orifice with chewing gum (chewed by the patient not by you…).\\n\\nEndoscopic attempts to seal the early leak with clips, glue, and stents are becoming increasingly popular among esophageal, bariatric, and colorectal surgeons but, obviously, are not practical for small bowel leaks.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.74, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Fistulas Associated with a Large Abdominal Wall Defect',\n", " 'md': '### Fistulas Associated with a Large Abdominal Wall Defect',\n", " 'bBox': {'x': 86, 'y': 414, 'w': 424.79, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Not uncommonly, the end result of intestinal leaks and reoperative surgery is an abdominal wall defect with multiple intestinal fistulas in its base. This so-called complex or type IV fistula is a catastrophe that carries a very high mortality rate. (According to our classification, type I are foregut fistulas, type II, small bowel, and type III, colonic.) With the widespread practice of open abdomen management techniques, these types of fistula are observed with increasing frequency. The distance of the fistulous opening in the intestine from the surface of the defect and the condition of the peritoneal cavity have a crucial bearing on the treatment of this condition. It is practical to distinguish between two situations (Figure 47.2):\\n```',\n", " 'md': 'Not uncommonly, the end result of intestinal leaks and reoperative surgery is an abdominal wall defect with multiple intestinal fistulas in its base. This so-called complex or type IV fistula is a catastrophe that carries a very high mortality rate. (According to our classification, type I are foregut fistulas, type II, small bowel, and type III, colonic.) With the widespread practice of open abdomen management techniques, these types of fistula are observed with increasing frequency. The distance of the fistulous opening in the intestine from the surface of the defect and the condition of the peritoneal cavity have a crucial bearing on the treatment of this condition. It is practical to distinguish between two situations (Figure 47.2):\\n```',\n", " 'bBox': {'x': 72, 'y': 484, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 47.2**: This figure likely illustrates the two situations regarding the distance of the fistulous opening in the intestine from the surface of the defect and the condition of the peritoneal cavity. The specific details of the image are not provided in the text, but it is essential for understanding the treatment implications of complex fistulas.\\n\\n**Summary**: The text discusses the management and prognosis of fistulas, particularly focusing on their outputs and treatment methods. It highlights the challenges associated with complex fistulas resulting from intestinal leaks and reoperative surgery, emphasizing the importance of understanding the anatomical and pathological context for effective treatment.',\n", " 'md': '- **Figure 47.2**: This figure likely illustrates the two situations regarding the distance of the fistulous opening in the intestine from the surface of the defect and the condition of the peritoneal cavity. The specific details of the image are not provided in the text, but it is essential for understanding the treatment implications of complex fistulas.\\n\\n**Summary**: The text discusses the management and prognosis of fistulas, particularly focusing on their outputs and treatment methods. It highlights the challenges associated with complex fistulas resulting from intestinal leaks and reoperative surgery, emphasizing the importance of understanding the anatomical and pathological context for effective treatment.',\n", " 'bBox': {'x': 72, 'y': 569, 'w': 467.99, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 805,\n", " 'text': ' Type IV-B fistula\\n Colon Colon\\n Pus and gut contents\\n Type IV-A fistula\\nFigure 47.2. Type IV-A fistulas vs. Type IV-B fistulas.\\n\\n • Type IV-A fistulas. This is a scenario occuring early after the\\n development of the intestinal leak. ħere the fistula is located in\\n the depths of the abdominal wall defect, resulting in prolonged\\n contact of large peritoneal surfaces with gastrointestinal contents,\\n allowing increased absorption of toxic products, thus perpetuating\\n local and systemic inflammatory responses and organ dysfunction.\\n In such instances reoperation is necessary to exteriorize or\\n divert the intestinal leak away from the defect. Otherwise, the\\n patient is doomed, as more than half of patients with this type of\\n postoperative fistula die!\\n • Type IV-B fistulas. This is a late phenomenon in the natural\\n history of leakage. These are ‘exposed’ fistulas near the surface of\\n the defect. Also called ‘bud’ or ‘enteroatmospheric’ fistulas, they\\n result from damage to matted intestine which forms the ‘bed’ of the\\n defect (the so-called ‘central visceral block’). Because the peritoneal\\n cavity is usually clean and sealed away from intestinal contents, the\\n patient is free of SIRS or ‘sepsis’ but the management of such\\n fistulas needs a lot of your ingenuity.',\n", " 'md': '```markdown\\n# Type IV-A and Type IV-B Fistulas\\n\\n## Figure 47.2. Type IV-A Fistulas vs. Type IV-B Fistulas\\n\\n### Description\\nThis figure illustrates the differences between Type IV-A and Type IV-B fistulas. Type IV-A fistulas are depicted with a colon and indicate the presence of pus and gut contents, while Type IV-B fistulas are shown in a similar context but represent a different stage of the condition.\\n\\n### Text Content\\n- **Type IV-A Fistulas**: This scenario occurs early after the development of the intestinal leak. Here, the fistula is located in the depths of the abdominal wall defect, resulting in prolonged contact of large peritoneal surfaces with gastrointestinal contents. This allows increased absorption of toxic products, thus perpetuating local and systemic inflammatory responses and organ dysfunction. In such instances, reoperation is necessary to exteriorize or divert the intestinal leak away from the defect. Otherwise, the patient is doomed, as more than half of patients with this type of postoperative fistula die!\\n\\n- **Type IV-B Fistulas**: This is a late phenomenon in the natural history of leakage. These are ‘exposed’ fistulas near the surface of the defect. Also called ‘bud’ or ‘enteroatmospheric’ fistulas, they result from damage to matted intestine which forms the ‘bed’ of the defect (the so-called ‘central visceral block’). Because the peritoneal cavity is usually clean and sealed away from intestinal contents, the patient is free of SIRS or ‘sepsis’, but the management of such fistulas needs a lot of ingenuity.\\n```',\n", " 'images': [{'name': 'img_p804_1.png',\n", " 'height': 489,\n", " 'width': 818,\n", " 'x': 103.67999999999984,\n", " 'y': 82.79999999999998,\n", " 'original_width': 1404,\n", " 'original_height': 840}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Type IV-A and Type IV-B Fistulas',\n", " 'md': '# Type IV-A and Type IV-B Fistulas',\n", " 'bBox': {'x': 275.83, 'y': 88.24, 'w': 69.25, 'h': 13.36}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 47.2. Type IV-A Fistulas vs. Type IV-B Fistulas',\n", " 'md': '## Figure 47.2. Type IV-A Fistulas vs. Type IV-B Fistulas',\n", " 'bBox': {'x': 272.86, 'y': 88.24, 'w': 72.22, 'h': 13.36}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Description',\n", " 'md': '### Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'This figure illustrates the differences between Type IV-A and Type IV-B fistulas. Type IV-A fistulas are depicted with a colon and indicate the presence of pus and gut contents, while Type IV-B fistulas are shown in a similar context but represent a different stage of the condition.',\n", " 'md': 'This figure illustrates the differences between Type IV-A and Type IV-B fistulas. Type IV-A fistulas are depicted with a colon and indicate the presence of pus and gut contents, while Type IV-B fistulas are shown in a similar context but represent a different stage of the condition.',\n", " 'bBox': {'x': 139.3, 'y': 88.24, 'w': 205.78, 'h': 15.83}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text Content',\n", " 'md': '### Text Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Type IV-A Fistulas**: This scenario occurs early after the development of the intestinal leak. Here, the fistula is located in the depths of the abdominal wall defect, resulting in prolonged contact of large peritoneal surfaces with gastrointestinal contents. This allows increased absorption of toxic products, thus perpetuating local and systemic inflammatory responses and organ dysfunction. In such instances, reoperation is necessary to exteriorize or divert the intestinal leak away from the defect. Otherwise, the patient is doomed, as more than half of patients with this type of postoperative fistula die!\\n\\n- **Type IV-B Fistulas**: This is a late phenomenon in the natural history of leakage. These are ‘exposed’ fistulas near the surface of the defect. Also called ‘bud’ or ‘enteroatmospheric’ fistulas, they result from damage to matted intestine which forms the ‘bed’ of the defect (the so-called ‘central visceral block’). Because the peritoneal cavity is usually clean and sealed away from intestinal contents, the patient is free of SIRS or ‘sepsis’, but the management of such fistulas needs a lot of ingenuity.\\n```',\n", " 'md': '- **Type IV-A Fistulas**: This scenario occurs early after the development of the intestinal leak. Here, the fistula is located in the depths of the abdominal wall defect, resulting in prolonged contact of large peritoneal surfaces with gastrointestinal contents. This allows increased absorption of toxic products, thus perpetuating local and systemic inflammatory responses and organ dysfunction. In such instances, reoperation is necessary to exteriorize or divert the intestinal leak away from the defect. Otherwise, the patient is doomed, as more than half of patients with this type of postoperative fistula die!\\n\\n- **Type IV-B Fistulas**: This is a late phenomenon in the natural history of leakage. These are ‘exposed’ fistulas near the surface of the defect. Also called ‘bud’ or ‘enteroatmospheric’ fistulas, they result from damage to matted intestine which forms the ‘bed’ of the defect (the so-called ‘central visceral block’). Because the peritoneal cavity is usually clean and sealed away from intestinal contents, the patient is free of SIRS or ‘sepsis’, but the management of such fistulas needs a lot of ingenuity.\\n```',\n", " 'bBox': {'x': 100, 'y': 88.24, 'w': 437.03, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 806,\n", " 'text': ' Management\\n\\n• Again, with type IV-A fistulas, your aim is to exteriorize the leak\\n or divert it. Once the intestinal effluent stops pouring into the\\n general peritoneal cavity the situation is no longer immediately life-\\n threatening.\\n• With type IV-B fistulas, the immediate task is to control the\\n output of the fistula. Use your creative skills to construct a sealed\\n vacuum dressing of your choice to cover the whole defect —\\n sucking out the fistula’s effluent. We use a modification of our\\n ‘sandwich’ ( Chapter 48). Others would suture a large colostomy\\n bag all around the rim of the fistula (bag-enterostomy), placing a\\n suction tube into the bag. And there are all those commercial\\n products…\\n• A tiny ‘exposed-bud’ fistula may be dealt with temporarily (until\\n definitive reconstruction) using the following technique: define the\\n mucosal and submucosal layer of the pouting intestinal hole, and\\n close it with a fine monofilament suture. Immediately cover the\\n repaired bowel and the surrounding abdominal wall defect with a\\n split-thickness skin graft. This should be successful in half of your\\n attempts. Some would apply fibrin glue between the sutured\\n intestine and skin graft. Other surgeons try to patch such holes with\\n human acellular dermal matrix (AlloDerm®) and fibrin glue.\\n• Such simple measures are impossible when the exposed fistula is\\n large (as large as a colostomy). Such fistulas won’t heal if not\\n covered with well-vascularized tissue, be it skin flaps or\\n musculofascial flaps. (For a good discussion about ‘fancy’ options in\\n the management of exposed fistulas, look up this reference 2.)\\n• In most such patients, however, you will have to control the fistula,\\n support the patient, wait for the abdomial wall defect to contract, wait\\n for resolution of the peritoneal inflammation, wait for maturation of\\n intra-abdominal adhesions, and only then — after at least 6 months\\n and usually more than that — consider ‘take down’ of the fistula and\\n abdominal wall reconstruction. A simple rule of thumb is that the\\n condition of the abdominal wall defect reflects the condition of\\n the peritoneal cavity. A well-contracted abdominal wall defect,\\n and fistulas that look like surgical stomas are indicators that an',\n", " 'md': '```markdown\\n# Management\\n\\n- Again, with type IV-A fistulas, your aim is to exteriorize the leak or divert it. Once the intestinal effluent stops pouring into the general peritoneal cavity, the situation is no longer immediately life-threatening.\\n- With type IV-B fistulas, the immediate task is to control the output of the fistula. Use your creative skills to construct a sealed vacuum dressing of your choice to cover the whole defect — sucking out the fistula’s effluent. We use a modification of our ‘sandwich’ (see Chapter 48). Others would suture a large colostomy bag all around the rim of the fistula (bag-enterostomy), placing a suction tube into the bag. And there are all those commercial products…\\n- A tiny ‘exposed-bud’ fistula may be dealt with temporarily (until definitive reconstruction) using the following technique: define the mucosal and submucosal layer of the pouting intestinal hole, and close it with a fine monofilament suture. Immediately cover the repaired bowel and the surrounding abdominal wall defect with a split-thickness skin graft. This should be successful in half of your attempts. Some would apply fibrin glue between the sutured intestine and skin graft. Other surgeons try to patch such holes with human acellular dermal matrix (AlloDerm®) and fibrin glue.\\n- Such simple measures are impossible when the exposed fistula is large (as large as a colostomy). Such fistulas won’t heal if not covered with well-vascularized tissue, be it skin flaps or musculofascial flaps. (For a good discussion about ‘fancy’ options in the management of exposed fistulas, look up this reference 2.)\\n- In most such patients, however, you will have to control the fistula, support the patient, wait for the abdominal wall defect to contract, wait for resolution of the peritoneal inflammation, wait for maturation of intra-abdominal adhesions, and only then — after at least 6 months and usually more than that — consider ‘take down’ of the fistula and abdominal wall reconstruction. A simple rule of thumb is that the condition of the abdominal wall defect reflects the condition of the peritoneal cavity. A well-contracted abdominal wall defect, and fistulas that look like surgical stomas are indicators that an...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management',\n", " 'md': '# Management',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Again, with type IV-A fistulas, your aim is to exteriorize the leak or divert it. Once the intestinal effluent stops pouring into the general peritoneal cavity, the situation is no longer immediately life-threatening.\\n- With type IV-B fistulas, the immediate task is to control the output of the fistula. Use your creative skills to construct a sealed vacuum dressing of your choice to cover the whole defect — sucking out the fistula’s effluent. We use a modification of our ‘sandwich’ (see Chapter 48). Others would suture a large colostomy bag all around the rim of the fistula (bag-enterostomy), placing a suction tube into the bag. And there are all those commercial products…\\n- A tiny ‘exposed-bud’ fistula may be dealt with temporarily (until definitive reconstruction) using the following technique: define the mucosal and submucosal layer of the pouting intestinal hole, and close it with a fine monofilament suture. Immediately cover the repaired bowel and the surrounding abdominal wall defect with a split-thickness skin graft. This should be successful in half of your attempts. Some would apply fibrin glue between the sutured intestine and skin graft. Other surgeons try to patch such holes with human acellular dermal matrix (AlloDerm®) and fibrin glue.\\n- Such simple measures are impossible when the exposed fistula is large (as large as a colostomy). Such fistulas won’t heal if not covered with well-vascularized tissue, be it skin flaps or musculofascial flaps. (For a good discussion about ‘fancy’ options in the management of exposed fistulas, look up this reference 2.)\\n- In most such patients, however, you will have to control the fistula, support the patient, wait for the abdominal wall defect to contract, wait for resolution of the peritoneal inflammation, wait for maturation of intra-abdominal adhesions, and only then — after at least 6 months and usually more than that — consider ‘take down’ of the fistula and abdominal wall reconstruction. A simple rule of thumb is that the condition of the abdominal wall defect reflects the condition of the peritoneal cavity. A well-contracted abdominal wall defect, and fistulas that look like surgical stomas are indicators that an...\\n```',\n", " 'md': '- Again, with type IV-A fistulas, your aim is to exteriorize the leak or divert it. Once the intestinal effluent stops pouring into the general peritoneal cavity, the situation is no longer immediately life-threatening.\\n- With type IV-B fistulas, the immediate task is to control the output of the fistula. Use your creative skills to construct a sealed vacuum dressing of your choice to cover the whole defect — sucking out the fistula’s effluent. We use a modification of our ‘sandwich’ (see Chapter 48). Others would suture a large colostomy bag all around the rim of the fistula (bag-enterostomy), placing a suction tube into the bag. And there are all those commercial products…\\n- A tiny ‘exposed-bud’ fistula may be dealt with temporarily (until definitive reconstruction) using the following technique: define the mucosal and submucosal layer of the pouting intestinal hole, and close it with a fine monofilament suture. Immediately cover the repaired bowel and the surrounding abdominal wall defect with a split-thickness skin graft. This should be successful in half of your attempts. Some would apply fibrin glue between the sutured intestine and skin graft. Other surgeons try to patch such holes with human acellular dermal matrix (AlloDerm®) and fibrin glue.\\n- Such simple measures are impossible when the exposed fistula is large (as large as a colostomy). Such fistulas won’t heal if not covered with well-vascularized tissue, be it skin flaps or musculofascial flaps. (For a good discussion about ‘fancy’ options in the management of exposed fistulas, look up this reference 2.)\\n- In most such patients, however, you will have to control the fistula, support the patient, wait for the abdominal wall defect to contract, wait for resolution of the peritoneal inflammation, wait for maturation of intra-abdominal adhesions, and only then — after at least 6 months and usually more than that — consider ‘take down’ of the fistula and abdominal wall reconstruction. A simple rule of thumb is that the condition of the abdominal wall defect reflects the condition of the peritoneal cavity. A well-contracted abdominal wall defect, and fistulas that look like surgical stomas are indicators that an...\\n```',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 437.01, 'h': 17.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'bag all around the rim of the fistula (bag-enterostomy), placing a'},\n", " {'text': 'the management of exposed fistulas, look up this reference '}]},\n", " {'page': 807,\n", " 'text': ' elective intervention is possible and safe ( Chapter 48).\\n\\n Remember: the key term in such patients is W.W.W. — wait, wait\\nand wait!\\n\\n Scenario 2: you suspect a leak but do not see one\\n\\n Your patient is now a week after an uneventful right hemicolectomy for a carcinoma of the\\n cecum. She is already at home, and eating, when a new pain develops on the right side of her\\n abdomen, accompanied by vomiting. The patient returns to the emergency room. She is\\n febrile, her right abdomen is tender with a questionable mass, the abdominal X-ray suggests\\n an ileus or partial small bowel obstruction, the white cell count is elevated. You suspect an\\n anastomotic leak.\\n\\n From a clinical standpoint there are three types of intestinal leaks\\nthat ‘you cannot see’:\\n\\n • Free leak. The anastomosis is disrupted and the leak is not\\n contained by adjacent structures. The patients usually appear ‘sick’,\\n exhibiting signs of diffuse peritonitis. An immediate laparotomy is\\n indicated as outlined above.\\n • Contained leak. The leak is partially contained by peri-anastomotic\\n adhesions to the omentum and adjacent viscera. The clinical\\n abdominal manifestations are localized. A peri-anastomotic abscess\\n is a natural sequela.\\n • A mini-leak. This is a ‘minute’ anastomotic leak — usually occurring\\n late after the operation when the anastomosis is well-sealed off.\\n Abdominal manifestations are localized and the patient is not ‘toxic’.\\n A mini-leak is actually a ‘peri-anastomositis’ — an inflammatory\\n phlegmon around the anastomosis. Usually it is not associated with\\n a drainable pus-containing abscess.\\n\\n In the absence of diffuse peritonitis you should document the leak and\\ngrade it, which is best done by combining a contrast study with a CT —',\n", " 'md': '```markdown\\n## Clinical Scenarios of Intestinal Leaks\\n\\n### Scenario 2: You suspect a leak but do not see one\\n\\nYour patient is now a week after an uneventful right hemicolectomy for a carcinoma of the cecum. She is already at home and eating when a new pain develops on the right side of her abdomen, accompanied by vomiting. The patient returns to the emergency room. She is febrile, her right abdomen is tender with a questionable mass, the abdominal X-ray suggests an ileus or partial small bowel obstruction, and the white cell count is elevated. You suspect an anastomotic leak.\\n\\nFrom a clinical standpoint, there are three types of intestinal leaks that ‘you cannot see’:\\n\\n1. **Free leak**: The anastomosis is disrupted, and the leak is not contained by adjacent structures. The patients usually appear ‘sick’, exhibiting signs of diffuse peritonitis. An immediate laparotomy is indicated as outlined above.\\n\\n2. **Contained leak**: The leak is partially contained by peri-anastomotic adhesions to the omentum and adjacent viscera. The clinical abdominal manifestations are localized. A peri-anastomotic abscess is a natural sequela.\\n\\n3. **Mini-leak**: This is a ‘minute’ anastomotic leak — usually occurring late after the operation when the anastomosis is well-sealed off. Abdominal manifestations are localized, and the patient is not ‘toxic’. A mini-leak is actually a ‘peri-anastomositis’ — an inflammatory phlegmon around the anastomosis. Usually, it is not associated with a drainable pus-containing abscess.\\n\\nIn the absence of diffuse peritonitis, you should document the leak and grade it, which is best done by combining a contrast study with a CT.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Clinical Scenarios of Intestinal Leaks',\n", " 'md': '## Clinical Scenarios of Intestinal Leaks',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Scenario 2: You suspect a leak but do not see one',\n", " 'md': '### Scenario 2: You suspect a leak but do not see one',\n", " 'bBox': {'x': 86, 'y': 183, 'w': 392.64, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Your patient is now a week after an uneventful right hemicolectomy for a carcinoma of the cecum. She is already at home and eating when a new pain develops on the right side of her abdomen, accompanied by vomiting. The patient returns to the emergency room. She is febrile, her right abdomen is tender with a questionable mass, the abdominal X-ray suggests an ileus or partial small bowel obstruction, and the white cell count is elevated. You suspect an anastomotic leak.\\n\\nFrom a clinical standpoint, there are three types of intestinal leaks that ‘you cannot see’:\\n\\n1. **Free leak**: The anastomosis is disrupted, and the leak is not contained by adjacent structures. The patients usually appear ‘sick’, exhibiting signs of diffuse peritonitis. An immediate laparotomy is indicated as outlined above.\\n\\n2. **Contained leak**: The leak is partially contained by peri-anastomotic adhesions to the omentum and adjacent viscera. The clinical abdominal manifestations are localized. A peri-anastomotic abscess is a natural sequela.\\n\\n3. **Mini-leak**: This is a ‘minute’ anastomotic leak — usually occurring late after the operation when the anastomosis is well-sealed off. Abdominal manifestations are localized, and the patient is not ‘toxic’. A mini-leak is actually a ‘peri-anastomositis’ — an inflammatory phlegmon around the anastomosis. Usually, it is not associated with a drainable pus-containing abscess.\\n\\nIn the absence of diffuse peritonitis, you should document the leak and grade it, which is best done by combining a contrast study with a CT.\\n```',\n", " 'md': 'Your patient is now a week after an uneventful right hemicolectomy for a carcinoma of the cecum. She is already at home and eating when a new pain develops on the right side of her abdomen, accompanied by vomiting. The patient returns to the emergency room. She is febrile, her right abdomen is tender with a questionable mass, the abdominal X-ray suggests an ileus or partial small bowel obstruction, and the white cell count is elevated. You suspect an anastomotic leak.\\n\\nFrom a clinical standpoint, there are three types of intestinal leaks that ‘you cannot see’:\\n\\n1. **Free leak**: The anastomosis is disrupted, and the leak is not contained by adjacent structures. The patients usually appear ‘sick’, exhibiting signs of diffuse peritonitis. An immediate laparotomy is indicated as outlined above.\\n\\n2. **Contained leak**: The leak is partially contained by peri-anastomotic adhesions to the omentum and adjacent viscera. The clinical abdominal manifestations are localized. A peri-anastomotic abscess is a natural sequela.\\n\\n3. **Mini-leak**: This is a ‘minute’ anastomotic leak — usually occurring late after the operation when the anastomosis is well-sealed off. Abdominal manifestations are localized, and the patient is not ‘toxic’. A mini-leak is actually a ‘peri-anastomositis’ — an inflammatory phlegmon around the anastomosis. Usually, it is not associated with a drainable pus-containing abscess.\\n\\nIn the absence of diffuse peritonitis, you should document the leak and grade it, which is best done by combining a contrast study with a CT.\\n```',\n", " 'bBox': {'x': 72, 'y': 288, 'w': 459.9, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 808,\n", " 'text': 'searching for free intraperitoneal contrast or abscesses. There are a few\\npossibilities:\\n\\n • Free leak of contrast into the peritoneal cavity (a lot of free contrast\\n and fluid on CT). You have to reoperate. We have previously\\n discussed what to do: it’s best to take down the anastomosis, if\\n technically feasible.\\n • Contained localized leak (a local collection or abscess on CT). The\\n rest of the peritoneal cavity is ‘dry’. This is initially treated with\\n antibiotics and PC drainage.\\n • No leak on contrast study (a peri-anastomotic phlegmon on CT).\\n This represents a mini-leak or ‘peri-anastomositis’ and usually\\n resolves after a few days of antibiotic therapy.\\n\\n Note that a contained leak or a mini-leak may be associated with\\nan obstruction at the anastomosis — a result of local inflammation.\\nSuch obstruction usually resolves spontaneously (within a week or so)\\nafter the pus has been drained and the inflammation has subsided.\\n\\n We have tried to persuade you that an anastomotic leak is not one disease but a variety of\\n conditions requiring customized approaches. To keep morbidity at bay, tailor your treatment to\\n the specific leak, its severity and the condition of the affected patient. Above all — remember\\n that non-drained intraperitoneal bowel contents and pus are killers — often silent ones.\\n\\n “We tend to remember best those patients we almost\\n killed; we never forget those we actually managed to\\n kill.”\\n “Good surgeons operate well; great surgeons know how\\n to manage their own complications.”\\n\\n 1 Schein M, Decker GAG. Postoperative external alimentary tract fistulas. Am J Surg 1991;\\n 161: 435-8.',\n", " 'md': '```markdown\\n## Page Content\\n\\nSearching for free intraperitoneal contrast or abscesses. There are a few possibilities:\\n\\n- Free leak of contrast into the peritoneal cavity (a lot of free contrast and fluid on CT). You have to reoperate. We have previously discussed what to do: it’s best to take down the anastomosis, if technically feasible.\\n- Contained localized leak (a local collection or abscess on CT). The rest of the peritoneal cavity is ‘dry’. This is initially treated with antibiotics and PC drainage.\\n- No leak on contrast study (a peri-anastomotic phlegmon on CT). This represents a mini-leak or ‘peri-anastomositis’ and usually resolves after a few days of antibiotic therapy.\\n\\nNote that a contained leak or a mini-leak may be associated with an obstruction at the anastomosis — a result of local inflammation. Such obstruction usually resolves spontaneously (within a week or so) after the pus has been drained and the inflammation has subsided.\\n\\nWe have tried to persuade you that an anastomotic leak is not one disease but a variety of conditions requiring customized approaches. To keep morbidity at bay, tailor your treatment to the specific leak, its severity and the condition of the affected patient. Above all — remember that non-drained intraperitoneal bowel contents and pus are killers — often silent ones.\\n\\n> “We tend to remember best those patients we almost killed; we never forget those we actually managed to kill.”\\n> “Good surgeons operate well; great surgeons know how to manage their own complications.”\\n\\n1. Schein M, Decker GAG. Postoperative external alimentary tract fistulas. Am J Surg 1991; 161: 435-8.\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted, and no formulas were present.\\n- The quoted text has been preserved as is.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Searching for free intraperitoneal contrast or abscesses. There are a few possibilities:\\n\\n- Free leak of contrast into the peritoneal cavity (a lot of free contrast and fluid on CT). You have to reoperate. We have previously discussed what to do: it’s best to take down the anastomosis, if technically feasible.\\n- Contained localized leak (a local collection or abscess on CT). The rest of the peritoneal cavity is ‘dry’. This is initially treated with antibiotics and PC drainage.\\n- No leak on contrast study (a peri-anastomotic phlegmon on CT). This represents a mini-leak or ‘peri-anastomositis’ and usually resolves after a few days of antibiotic therapy.\\n\\nNote that a contained leak or a mini-leak may be associated with an obstruction at the anastomosis — a result of local inflammation. Such obstruction usually resolves spontaneously (within a week or so) after the pus has been drained and the inflammation has subsided.\\n\\nWe have tried to persuade you that an anastomotic leak is not one disease but a variety of conditions requiring customized approaches. To keep morbidity at bay, tailor your treatment to the specific leak, its severity and the condition of the affected patient. Above all — remember that non-drained intraperitoneal bowel contents and pus are killers — often silent ones.\\n\\n> “We tend to remember best those patients we almost killed; we never forget those we actually managed to kill.”\\n> “Good surgeons operate well; great surgeons know how to manage their own complications.”\\n\\n1. Schein M, Decker GAG. Postoperative external alimentary tract fistulas. Am J Surg 1991; 161: 435-8.\\n```',\n", " 'md': 'Searching for free intraperitoneal contrast or abscesses. There are a few possibilities:\\n\\n- Free leak of contrast into the peritoneal cavity (a lot of free contrast and fluid on CT). You have to reoperate. We have previously discussed what to do: it’s best to take down the anastomosis, if technically feasible.\\n- Contained localized leak (a local collection or abscess on CT). The rest of the peritoneal cavity is ‘dry’. This is initially treated with antibiotics and PC drainage.\\n- No leak on contrast study (a peri-anastomotic phlegmon on CT). This represents a mini-leak or ‘peri-anastomositis’ and usually resolves after a few days of antibiotic therapy.\\n\\nNote that a contained leak or a mini-leak may be associated with an obstruction at the anastomosis — a result of local inflammation. Such obstruction usually resolves spontaneously (within a week or so) after the pus has been drained and the inflammation has subsided.\\n\\nWe have tried to persuade you that an anastomotic leak is not one disease but a variety of conditions requiring customized approaches. To keep morbidity at bay, tailor your treatment to the specific leak, its severity and the condition of the affected patient. Above all — remember that non-drained intraperitoneal bowel contents and pus are killers — often silent ones.\\n\\n> “We tend to remember best those patients we almost killed; we never forget those we actually managed to kill.”\\n> “Good surgeons operate well; great surgeons know how to manage their own complications.”\\n\\n1. Schein M, Decker GAG. Postoperative external alimentary tract fistulas. Am J Surg 1991; 161: 435-8.\\n```',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.65, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted, and no formulas were present.\\n- The quoted text has been preserved as is.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted, and no formulas were present.\\n- The quoted text has been preserved as is.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 809,\n", " 'text': '2 Jamshidi R, Schecter WP. Biological dressings for the management of enteric fistulas in the\\n open abdomen. Arch Surg 2007; 142: 793-6.',\n", " 'md': '```markdown\\n## References\\n\\n1. Jamshidi R, Schecter WP. Biological dressings for the management of enteric fistulas in the open abdomen. Arch Surg 2007; 142: 793-6.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'References',\n", " 'md': '## References',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '1. Jamshidi R, Schecter WP. Biological dressings for the management of enteric fistulas in the open abdomen. Arch Surg 2007; 142: 793-6.\\n```',\n", " 'md': '1. Jamshidi R, Schecter WP. Biological dressings for the management of enteric fistulas in the open abdomen. Arch Surg 2007; 142: 793-6.\\n```',\n", " 'bBox': {'x': 73, 'y': 80, 'w': 440.73, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '2'}]},\n", " {'page': 810,\n", " 'text': 'Chapter 48\\nRelaparotomy and laparostomy for infection\\nRoger Saadia, Moshe Schein and Danny Rosin\\n\\n This chapter has been subdivided into the following three\\n sections:\\n\\n 1. Relaparotomy.\\n 2. Laparostomy.\\n 3. Laparoscopic abdominal re-exploration.\\n\\n It’s just that as an old general surgeon, I usually reserve\\n optimism until the day after discharge, or often until the first\\n post-op visit. Until then I plan for the next worst potential\\n problem.\\n Jerry Kaplan\\n\\n Remember, we discussed earlier the principles of management of\\nintra-abdominal infection (IAI) ( Chapter 13)? We told you that to\\nimprove survival, in some patients, source control and peritoneal\\ntoilet must be pushed a little further; some patients need a\\nrelaparotomy and in many of these the abdomen is left open\\n(laparostomy). These modalities will now be discussed in greater detail.\\nAt the end of the chapter, Danny discusses laparoscopic abdominal re-\\nexploration after open surgery.',\n", " 'md': '```markdown\\n# Chapter 48: Relaparotomy and Laparostomy for Infection\\n\\n**Authors:** Roger Saadia, Moshe Schein, and Danny Rosin\\n\\nThis chapter has been subdivided into the following three sections:\\n\\n1. Relaparotomy.\\n2. Laparostomy.\\n3. Laparoscopic abdominal re-exploration.\\n\\n> “It’s just that as an old general surgeon, I usually reserve optimism until the day after discharge, or often until the first post-op visit. Until then I plan for the next worst potential problem.”\\n> — Jerry Kaplan\\n\\nRemember, we discussed earlier the principles of management of intra-abdominal infection (IAI) (Chapter 13)? We told you that to improve survival, in some patients, source control and peritoneal toilet must be pushed a little further; some patients need a relaparotomy and in many of these the abdomen is left open (laparostomy). These modalities will now be discussed in greater detail. At the end of the chapter, Danny discusses laparoscopic abdominal re-exploration after open surgery.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 48: Relaparotomy and Laparostomy for Infection',\n", " 'md': '# Chapter 48: Relaparotomy and Laparostomy for Infection',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 389.69, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '**Authors:** Roger Saadia, Moshe Schein, and Danny Rosin\\n\\nThis chapter has been subdivided into the following three sections:\\n\\n1. Relaparotomy.\\n2. Laparostomy.\\n3. Laparoscopic abdominal re-exploration.\\n\\n> “It’s just that as an old general surgeon, I usually reserve optimism until the day after discharge, or often until the first post-op visit. Until then I plan for the next worst potential problem.”\\n> — Jerry Kaplan\\n\\nRemember, we discussed earlier the principles of management of intra-abdominal infection (IAI) (Chapter 13)? We told you that to improve survival, in some patients, source control and peritoneal toilet must be pushed a little further; some patients need a relaparotomy and in many of these the abdomen is left open (laparostomy). These modalities will now be discussed in greater detail. At the end of the chapter, Danny discusses laparoscopic abdominal re-exploration after open surgery.\\n```',\n", " 'md': '**Authors:** Roger Saadia, Moshe Schein, and Danny Rosin\\n\\nThis chapter has been subdivided into the following three sections:\\n\\n1. Relaparotomy.\\n2. Laparostomy.\\n3. Laparoscopic abdominal re-exploration.\\n\\n> “It’s just that as an old general surgeon, I usually reserve optimism until the day after discharge, or often until the first post-op visit. Until then I plan for the next worst potential problem.”\\n> — Jerry Kaplan\\n\\nRemember, we discussed earlier the principles of management of intra-abdominal infection (IAI) (Chapter 13)? We told you that to improve survival, in some patients, source control and peritoneal toilet must be pushed a little further; some patients need a relaparotomy and in many of these the abdomen is left open (laparostomy). These modalities will now be discussed in greater detail. At the end of the chapter, Danny discusses laparoscopic abdominal re-exploration after open surgery.\\n```',\n", " 'bBox': {'x': 72, 'y': 319, 'w': 467.68, 'h': 18.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'improve survival, in some patients, source control and peritoneal'}]},\n", " {'page': 811,\n", " 'text': ' Relaparotomy\\n1 Roger Saadia and Moshe Schein\\n Definitions\\n\\n Before we continue you should be reintroduced to some definitions.\\n\\n ‘On-demand’ versus ‘planned’ relaparotomy:\\n\\n ‘On-demand’: in the aftermath of an initial laparotomy, clinical or radiological\\n evidence of an intra-abdominal complication forces the surgeon to reoperate.\\n ‘Planned’ (or ‘electively staged’): at the initial laparotomy, the surgeon makes the\\n decision to reoperate within 1-3 days, irrespective of the patient’s immediate\\n postoperative course.\\n\\n Both these types of relaparotomy have a place in the postoperative\\nmanagement of the patient following a laparotomy, but they apply in\\ndifferent clinical contexts.\\n\\n Relaparotomy ‘on demand’\\n\\n The classic indication for emergency relaparotomy is generalized\\nperitonitis due to an anastomotic leak. Leaks take place typically between\\nthe fifth and eighth postoperative days, but may occur earlier or later. If\\nnot ‘controlled’, or if not ‘contained’ and thus amenable to percutaneous\\ndrainage, the abdomen may have to be re-explored ( Chapters 46 and\\n47).\\n\\n There are many other situations calling for a reoperation:\\naccidental intestinal injury (duodenum during lap cholecystectomy);\\nstrangulated intestinal obstruction (within a port site); ischemic bowel\\n(people do ligate the SMA by mistake…); complete abdominal wall\\ndehiscence (embarrassing); abdominal compartment syndrome (why did\\nI close?); necrotizing fasciitis of the abdominal wall; retained sponge,',\n", " 'md': '```markdown\\n# Relaparotomy\\n## Roger Saadia and Moshe Schein\\n\\n### Definitions\\n\\nBefore we continue, you should be reintroduced to some definitions.\\n\\n**‘On-demand’ versus ‘planned’ relaparotomy:**\\n\\n- **‘On-demand’**: In the aftermath of an initial laparotomy, clinical or radiological evidence of an intra-abdominal complication forces the surgeon to reoperate.\\n- **‘Planned’ (or ‘electively staged’)**: At the initial laparotomy, the surgeon makes the decision to reoperate within 1-3 days, irrespective of the patient’s immediate postoperative course.\\n\\nBoth these types of relaparotomy have a place in the postoperative management of the patient following a laparotomy, but they apply in different clinical contexts.\\n\\n### Relaparotomy ‘on demand’\\n\\nThe classic indication for emergency relaparotomy is generalized peritonitis due to an anastomotic leak. Leaks take place typically between the fifth and eighth postoperative days, but may occur earlier or later. If not ‘controlled’, or if not ‘contained’ and thus amenable to percutaneous drainage, the abdomen may have to be re-explored (Chapters 46 and 47).\\n\\nThere are many other situations calling for a reoperation: accidental intestinal injury (duodenum during lap cholecystectomy); strangulated intestinal obstruction (within a port site); ischemic bowel (people do ligate the SMA by mistake…); complete abdominal wall dehiscence (embarrassing); abdominal compartment syndrome (why did I close?); necrotizing fasciitis of the abdominal wall; retained sponge.\\n```',\n", " 'images': [{'name': 'img_p810_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999997,\n", " 'y': 258.47999999999996},\n", " {'name': 'img_p810_1.png',\n", " 'height': 19,\n", " 'width': 13,\n", " 'x': 92.15999999999997,\n", " 'y': 298.79999999999995}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Relaparotomy',\n", " 'md': '# Relaparotomy',\n", " 'bBox': {'x': 100, 'y': 90, 'w': 110.37, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Roger Saadia and Moshe Schein',\n", " 'md': '## Roger Saadia and Moshe Schein',\n", " 'bBox': {'x': 100, 'y': 109, 'w': 242.86, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Definitions',\n", " 'md': '### Definitions',\n", " 'bBox': {'x': 86, 'y': 155, 'w': 85.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Before we continue, you should be reintroduced to some definitions.\\n\\n**‘On-demand’ versus ‘planned’ relaparotomy:**\\n\\n- **‘On-demand’**: In the aftermath of an initial laparotomy, clinical or radiological evidence of an intra-abdominal complication forces the surgeon to reoperate.\\n- **‘Planned’ (or ‘electively staged’)**: At the initial laparotomy, the surgeon makes the decision to reoperate within 1-3 days, irrespective of the patient’s immediate postoperative course.\\n\\nBoth these types of relaparotomy have a place in the postoperative management of the patient following a laparotomy, but they apply in different clinical contexts.',\n", " 'md': 'Before we continue, you should be reintroduced to some definitions.\\n\\n**‘On-demand’ versus ‘planned’ relaparotomy:**\\n\\n- **‘On-demand’**: In the aftermath of an initial laparotomy, clinical or radiological evidence of an intra-abdominal complication forces the surgeon to reoperate.\\n- **‘Planned’ (or ‘electively staged’)**: At the initial laparotomy, the surgeon makes the decision to reoperate within 1-3 days, irrespective of the patient’s immediate postoperative course.\\n\\nBoth these types of relaparotomy have a place in the postoperative management of the patient following a laparotomy, but they apply in different clinical contexts.',\n", " 'bBox': {'x': 72, 'y': 90, 'w': 367.83, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Relaparotomy ‘on demand’',\n", " 'md': '### Relaparotomy ‘on demand’',\n", " 'bBox': {'x': 86, 'y': 90, 'w': 212.42, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The classic indication for emergency relaparotomy is generalized peritonitis due to an anastomotic leak. Leaks take place typically between the fifth and eighth postoperative days, but may occur earlier or later. If not ‘controlled’, or if not ‘contained’ and thus amenable to percutaneous drainage, the abdomen may have to be re-explored (Chapters 46 and 47).\\n\\nThere are many other situations calling for a reoperation: accidental intestinal injury (duodenum during lap cholecystectomy); strangulated intestinal obstruction (within a port site); ischemic bowel (people do ligate the SMA by mistake…); complete abdominal wall dehiscence (embarrassing); abdominal compartment syndrome (why did I close?); necrotizing fasciitis of the abdominal wall; retained sponge.\\n```',\n", " 'md': 'The classic indication for emergency relaparotomy is generalized peritonitis due to an anastomotic leak. Leaks take place typically between the fifth and eighth postoperative days, but may occur earlier or later. If not ‘controlled’, or if not ‘contained’ and thus amenable to percutaneous drainage, the abdomen may have to be re-explored (Chapters 46 and 47).\\n\\nThere are many other situations calling for a reoperation: accidental intestinal injury (duodenum during lap cholecystectomy); strangulated intestinal obstruction (within a port site); ischemic bowel (people do ligate the SMA by mistake…); complete abdominal wall dehiscence (embarrassing); abdominal compartment syndrome (why did I close?); necrotizing fasciitis of the abdominal wall; retained sponge.\\n```',\n", " 'bBox': {'x': 72, 'y': 90, 'w': 467.79, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': '47).'}]},\n", " {'page': 812,\n", " 'text': 'instrument or drain (oy vey); retracted or necrotic stoma (why didn’t I do it\\nbetter?); missed diagnosis (mainly in penetrating trauma) — the list is\\nlong, use your imagination. All such situations are discussed within\\nthe specific chapters; here we will focus on the common\\ndenominator — postoperative peritonitis.\\n\\n Postoperative peritonitis\\n\\n Peritonitis complicating a laparotomy is termed ‘postoperative\\nperitonitis’. This is one of the most lethal types of peritonitis — killing\\nat least a third of sufferers — for the following three reasons:\\n\\n • The diagnosis is usually delayed, because the abdominal and\\n systemic signs are initially masked by the expected similar signs of\\n the normal postoperative abdomen.\\n • It occurs in the postoperative phase, when the patient is\\n catabolic, with associated inflammation (SIRS) and\\n immunodepression — CARS (compensatory anti-inflammatory\\n response syndrome).\\n • This is a case of nosocomial secondary peritonitis where the\\n microbiology is less predictable and more noxious due to previous\\n antibiotic administration and the prevailing hospital flora.\\n\\n There are several possible clinical presentations developing\\nwithin days of a laparotomy as outlined below.\\n\\n Generalized peritonitis\\n\\n The abdominal findings are out of proportion to the normal\\npostoperative state (severe abdominal pain and tenderness, massive or\\nprolonged ileus). There may be associated systemic repercussions\\n(fever, leukocytosis) that are uncharacteristic of the expected\\npostoperative recovery. Sometimes, the diagnosis is made easier by the\\nadditional presence of an enterocutaneous fistula ( Chapter 47), deep\\nwound infection ( Chapter 49), or abdominal wall dehiscence.\\nObviously, any clinical feature which promotes early abdominal imaging,',\n", " 'md': \"```markdown\\n## Postoperative Peritonitis\\n\\nPostoperative peritonitis is a serious complication that can arise following a laparotomy. It is one of the most lethal forms of peritonitis, with a mortality rate of at least one-third of those affected. The high mortality rate can be attributed to three main factors:\\n\\n- The diagnosis is often delayed because the abdominal and systemic signs are initially masked by the expected signs of a normal postoperative abdomen.\\n- It occurs during the postoperative phase when the patient is in a catabolic state, accompanied by inflammation (SIRS - Systemic Inflammatory Response Syndrome) and immunodepression (CARS - Compensatory Anti-Inflammatory Response Syndrome).\\n- This type of peritonitis is nosocomial and secondary, where the microbiology is less predictable and more harmful due to prior antibiotic use and the hospital's prevailing flora.\\n\\n### Clinical Presentations\\n\\nSeveral clinical presentations can develop within days of a laparotomy, including:\\n\\n#### Generalized Peritonitis\\n\\nIn cases of generalized peritonitis, the abdominal findings are disproportionate to the normal postoperative state, characterized by:\\n\\n- Severe abdominal pain and tenderness\\n- Massive or prolonged ileus\\n\\nThere may also be systemic repercussions such as fever and leukocytosis, which are not typical of expected postoperative recovery. The diagnosis can sometimes be facilitated by the presence of additional complications such as:\\n\\n- Enterocutaneous fistula (refer to Chapter 47)\\n- Deep wound infection (refer to Chapter 49)\\n- Abdominal wall dehiscence\\n\\nAny clinical feature that encourages early abdominal imaging is crucial for diagnosis.\\n```\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Postoperative Peritonitis',\n", " 'md': '## Postoperative Peritonitis',\n", " 'bBox': {'x': 86, 'y': 195, 'w': 194.01, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': \"Postoperative peritonitis is a serious complication that can arise following a laparotomy. It is one of the most lethal forms of peritonitis, with a mortality rate of at least one-third of those affected. The high mortality rate can be attributed to three main factors:\\n\\n- The diagnosis is often delayed because the abdominal and systemic signs are initially masked by the expected signs of a normal postoperative abdomen.\\n- It occurs during the postoperative phase when the patient is in a catabolic state, accompanied by inflammation (SIRS - Systemic Inflammatory Response Syndrome) and immunodepression (CARS - Compensatory Anti-Inflammatory Response Syndrome).\\n- This type of peritonitis is nosocomial and secondary, where the microbiology is less predictable and more harmful due to prior antibiotic use and the hospital's prevailing flora.\",\n", " 'md': \"Postoperative peritonitis is a serious complication that can arise following a laparotomy. It is one of the most lethal forms of peritonitis, with a mortality rate of at least one-third of those affected. The high mortality rate can be attributed to three main factors:\\n\\n- The diagnosis is often delayed because the abdominal and systemic signs are initially masked by the expected signs of a normal postoperative abdomen.\\n- It occurs during the postoperative phase when the patient is in a catabolic state, accompanied by inflammation (SIRS - Systemic Inflammatory Response Syndrome) and immunodepression (CARS - Compensatory Anti-Inflammatory Response Syndrome).\\n- This type of peritonitis is nosocomial and secondary, where the microbiology is less predictable and more harmful due to prior antibiotic use and the hospital's prevailing flora.\",\n", " 'bBox': {'x': 86, 'y': 195, 'w': 194.01, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Clinical Presentations',\n", " 'md': '### Clinical Presentations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Several clinical presentations can develop within days of a laparotomy, including:',\n", " 'md': 'Several clinical presentations can develop within days of a laparotomy, including:',\n", " 'bBox': {'x': 418, 'y': 638, 'w': 16, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 4,\n", " 'value': 'Generalized Peritonitis',\n", " 'md': '#### Generalized Peritonitis',\n", " 'bBox': {'x': 86, 'y': 552, 'w': 178.37, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In cases of generalized peritonitis, the abdominal findings are disproportionate to the normal postoperative state, characterized by:\\n\\n- Severe abdominal pain and tenderness\\n- Massive or prolonged ileus\\n\\nThere may also be systemic repercussions such as fever and leukocytosis, which are not typical of expected postoperative recovery. The diagnosis can sometimes be facilitated by the presence of additional complications such as:\\n\\n- Enterocutaneous fistula (refer to Chapter 47)\\n- Deep wound infection (refer to Chapter 49)\\n- Abdominal wall dehiscence\\n\\nAny clinical feature that encourages early abdominal imaging is crucial for diagnosis.\\n```',\n", " 'md': 'In cases of generalized peritonitis, the abdominal findings are disproportionate to the normal postoperative state, characterized by:\\n\\n- Severe abdominal pain and tenderness\\n- Massive or prolonged ileus\\n\\nThere may also be systemic repercussions such as fever and leukocytosis, which are not typical of expected postoperative recovery. The diagnosis can sometimes be facilitated by the presence of additional complications such as:\\n\\n- Enterocutaneous fistula (refer to Chapter 47)\\n- Deep wound infection (refer to Chapter 49)\\n- Abdominal wall dehiscence\\n\\nAny clinical feature that encourages early abdominal imaging is crucial for diagnosis.\\n```',\n", " 'bBox': {'x': 86, 'y': 369, 'w': 451, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ' Chapter 49), or abdominal wall dehiscence.'},\n", " {'text': 'Obviously, any clinical feature which promotes early abdominal imaging,'}]},\n", " {'page': 813,\n", " 'text': 'like persistent postoperative ileus ( Chapter 45), would aid in the\\ndiagnosis.\\n\\n Organ dysfunction\\n\\n Renal failure could be confused with dehydration and incipient acute\\nrespiratory distress syndrome (ARDS) could be attributed to atelectasis\\nor pneumonia. Not infrequently, the surgeon seeks expert advice from\\nmedical colleagues (nephrologist, chest physician, infectious disease\\nspecialist or intensivist). Of course, renal failure or pneumonia may well\\noccur in a postoperative patient for a variety of reasons that are unrelated\\nto an intra-abdominal complication. However, persistent or recurrent\\nintra-abdominal infection may present initially as a single system\\ndysfunction and progress, in time, to multiple organ failure (MOF). It\\nis essential, firstly, to be aware of the relationship between intra-\\nabdominal infection and organ dysfunction and secondly, to be humble\\nenough to consider the possibility of a surgical complication in one’s\\npatient ( Chapter 42). The diagnosis is established by careful\\nclinical evaluation of the patient — nowadays typically\\nsupplemented with abdominal imaging — mainly CT.\\n\\n The intensive care setting\\n\\n In the intensive care setting, the possibility of intra-abdominal infection\\nis raised because of the need for prolonged ventilation or aggravation of\\nmultiple organ dysfunction in a critically ill postoperative patient, for\\nexample, after massive trauma or major abdominal surgery. Intensivists\\nare usually quick to point to the abdomen as the culprit and eager to spur\\non the surgeon to re-explore. In a ventilated, paralyzed patient, the\\nabdomen cannot be evaluated clinically. There is therefore a real\\ndilemma in differentiating between, on the one hand, the presence of an\\nabdominal focus of infection and, on the other hand, SIRS (with no\\ninfectious focus) or an infection elsewhere. Abdominal CT scanning is\\nvery useful but, unfortunately, less so in the first few postoperative\\ndays. After any laparotomy, tissue planes are distorted and potential\\nspaces may contain fluid; even the best radiologist cannot tell you — on\\npostoperative day 3 — whether the fluid is blood, serous fluid, leaking',\n", " 'md': '```markdown\\n## Organ Dysfunction\\n\\nRenal failure could be confused with dehydration, and incipient acute respiratory distress syndrome (ARDS) could be attributed to atelectasis or pneumonia. Not infrequently, the surgeon seeks expert advice from medical colleagues (nephrologist, chest physician, infectious disease specialist, or intensivist). Of course, renal failure or pneumonia may well occur in a postoperative patient for a variety of reasons that are unrelated to an intra-abdominal complication. However, persistent or recurrent intra-abdominal infection may present initially as a single system dysfunction and progress, in time, to multiple organ failure (MOF). It is essential, firstly, to be aware of the relationship between intra-abdominal infection and organ dysfunction and secondly, to be humble enough to consider the possibility of a surgical complication in one’s patient (Chapter 42). The diagnosis is established by careful clinical evaluation of the patient — nowadays typically supplemented with abdominal imaging — mainly CT.\\n\\n## The Intensive Care Setting\\n\\nIn the intensive care setting, the possibility of intra-abdominal infection is raised because of the need for prolonged ventilation or aggravation of multiple organ dysfunction in a critically ill postoperative patient, for example, after massive trauma or major abdominal surgery. Intensivists are usually quick to point to the abdomen as the culprit and eager to spur on the surgeon to re-explore. In a ventilated, paralyzed patient, the abdomen cannot be evaluated clinically. There is therefore a real dilemma in differentiating between, on the one hand, the presence of an abdominal focus of infection and, on the other hand, SIRS (with no infectious focus) or an infection elsewhere. Abdominal CT scanning is very useful but, unfortunately, less so in the first few postoperative days. After any laparotomy, tissue planes are distorted and potential spaces may contain fluid; even the best radiologist cannot tell you — on postoperative day 3 — whether the fluid is blood, serous fluid, leaking .\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Organ Dysfunction',\n", " 'md': '## Organ Dysfunction',\n", " 'bBox': {'x': 86, 'y': 145, 'w': 147.12, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Renal failure could be confused with dehydration, and incipient acute respiratory distress syndrome (ARDS) could be attributed to atelectasis or pneumonia. Not infrequently, the surgeon seeks expert advice from medical colleagues (nephrologist, chest physician, infectious disease specialist, or intensivist). Of course, renal failure or pneumonia may well occur in a postoperative patient for a variety of reasons that are unrelated to an intra-abdominal complication. However, persistent or recurrent intra-abdominal infection may present initially as a single system dysfunction and progress, in time, to multiple organ failure (MOF). It is essential, firstly, to be aware of the relationship between intra-abdominal infection and organ dysfunction and secondly, to be humble enough to consider the possibility of a surgical complication in one’s patient (Chapter 42). The diagnosis is established by careful clinical evaluation of the patient — nowadays typically supplemented with abdominal imaging — mainly CT.',\n", " 'md': 'Renal failure could be confused with dehydration, and incipient acute respiratory distress syndrome (ARDS) could be attributed to atelectasis or pneumonia. Not infrequently, the surgeon seeks expert advice from medical colleagues (nephrologist, chest physician, infectious disease specialist, or intensivist). Of course, renal failure or pneumonia may well occur in a postoperative patient for a variety of reasons that are unrelated to an intra-abdominal complication. However, persistent or recurrent intra-abdominal infection may present initially as a single system dysfunction and progress, in time, to multiple organ failure (MOF). It is essential, firstly, to be aware of the relationship between intra-abdominal infection and organ dysfunction and secondly, to be humble enough to consider the possibility of a surgical complication in one’s patient (Chapter 42). The diagnosis is established by careful clinical evaluation of the patient — nowadays typically supplemented with abdominal imaging — mainly CT.',\n", " 'bBox': {'x': 72, 'y': 145, 'w': 467.7, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Intensive Care Setting',\n", " 'md': '## The Intensive Care Setting',\n", " 'bBox': {'x': 86, 'y': 396, 'w': 203.22, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'In the intensive care setting, the possibility of intra-abdominal infection is raised because of the need for prolonged ventilation or aggravation of multiple organ dysfunction in a critically ill postoperative patient, for example, after massive trauma or major abdominal surgery. Intensivists are usually quick to point to the abdomen as the culprit and eager to spur on the surgeon to re-explore. In a ventilated, paralyzed patient, the abdomen cannot be evaluated clinically. There is therefore a real dilemma in differentiating between, on the one hand, the presence of an abdominal focus of infection and, on the other hand, SIRS (with no infectious focus) or an infection elsewhere. Abdominal CT scanning is very useful but, unfortunately, less so in the first few postoperative days. After any laparotomy, tissue planes are distorted and potential spaces may contain fluid; even the best radiologist cannot tell you — on postoperative day 3 — whether the fluid is blood, serous fluid, leaking .\\n```',\n", " 'md': 'In the intensive care setting, the possibility of intra-abdominal infection is raised because of the need for prolonged ventilation or aggravation of multiple organ dysfunction in a critically ill postoperative patient, for example, after massive trauma or major abdominal surgery. Intensivists are usually quick to point to the abdomen as the culprit and eager to spur on the surgeon to re-explore. In a ventilated, paralyzed patient, the abdomen cannot be evaluated clinically. There is therefore a real dilemma in differentiating between, on the one hand, the presence of an abdominal focus of infection and, on the other hand, SIRS (with no infectious focus) or an infection elsewhere. Abdominal CT scanning is very useful but, unfortunately, less so in the first few postoperative days. After any laparotomy, tissue planes are distorted and potential spaces may contain fluid; even the best radiologist cannot tell you — on postoperative day 3 — whether the fluid is blood, serous fluid, leaking .\\n```',\n", " 'bBox': {'x': 72, 'y': 145, 'w': 467.95, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': 'evaluation '}]},\n", " {'page': 814,\n", " 'text': 'bowel contents or pus; or whether the quantity of free air is inappropriate\\nto the index operation. In addition, transporting a critically ill patient on\\nmaximal organ support to the CT suite is not an innocuous undertaking.\\nThus, the decision to reoperate during the first postoperative week\\ncan be extremely vexing and requires good cooperation between\\nsurgeons, intensivists and radiologists.\\n\\n Intra-abdominal abscesses ( Chapter 46)\\n\\n Remember: The diagnosis of postoperative intra-abdominal ‘septic’ complications is\\n extremely difficult. Denial is a major culprit in ‘missed’ cases! Surgeons hate\\n to admit to their own failures and confront them. Consider, for a moment, your past experience:\\n haven’t you seen patients fading away while their deterioration is blamed on a bad bout of\\n pneumonia? Autopsy would have revealed unsuspected intra-abdominal complications in a\\n good proportion of them.\\n\\n Mark M. Ravitch reminds us wisely: “The last man to see the necessity\\nfor reoperation is the man who performed the operation.”\\n\\n The following admonition should be deeply imprinted in your\\nsurgical soul: “Look for pneumonia inside the abdomen.”\\n\\n ‘Planned’ (electively staged) relaparotomy\\n A negative relaparotomy is better than a positive autopsy\\n but is not, nevertheless, a benign procedure.\\n\\n The policy of planned relaparotomies is decided upon during, or\\nimmediately after, the initial, index operation for peritonitis, when\\nthe surgeon decides to reoperate within 1-3 days, irrespective of the\\npatient’s immediate postoperative course. The decision to re-explore\\nthe abdomen is part of the initial management plan. ħistorically,\\nmesenteric ischemia ( Chapter 24) was probably the first instance\\nwhen a planned relook laparotomy was advocated. In the context of intra-\\nabdominal infection, the main justification for a relook is to deal with',\n", " 'md': '```markdown\\n## Page Content\\n\\nBowel contents or pus; or whether the quantity of free air is inappropriate to the index operation. In addition, transporting a critically ill patient on maximal organ support to the CT suite is not an innocuous undertaking. Thus, the decision to reoperate during the first postoperative week can be extremely vexing and requires good cooperation between surgeons, intensivists, and radiologists.\\n\\n### Intra-abdominal Abscesses (Chapter 46)\\n\\nRemember: The diagnosis of postoperative intra-abdominal ‘septic’ complications is extremely difficult. Denial is a major culprit in ‘missed’ cases! Surgeons hate to admit to their own failures and confront them. Consider, for a moment, your past experience: haven’t you seen patients fading away while their deterioration is blamed on a bad bout of pneumonia? Autopsy would have revealed unsuspected intra-abdominal complications in a good proportion of them.\\n\\nMark M. Ravitch reminds us wisely: “The last man to see the necessity for reoperation is the man who performed the operation.”\\n\\nThe following admonition should be deeply imprinted in your surgical soul: “Look for pneumonia inside the abdomen.”\\n\\n### ‘Planned’ (Electively Staged) Relaparotomy\\n\\n- A negative relaparotomy is better than a positive autopsy but is not, nevertheless, a benign procedure.\\n\\nThe policy of planned relaparotomies is decided upon during, or immediately after, the initial, index operation for peritonitis, when the surgeon decides to reoperate within 1-3 days, irrespective of the patient’s immediate postoperative course. The decision to re-explore the abdomen is part of the initial management plan. Historically, mesenteric ischemia (Chapter 24) was probably the first instance when a planned relook laparotomy was advocated. In the context of intra-abdominal infection, the main justification for a relook is to deal with...\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Bowel contents or pus; or whether the quantity of free air is inappropriate to the index operation. In addition, transporting a critically ill patient on maximal organ support to the CT suite is not an innocuous undertaking. Thus, the decision to reoperate during the first postoperative week can be extremely vexing and requires good cooperation between surgeons, intensivists, and radiologists.',\n", " 'md': 'Bowel contents or pus; or whether the quantity of free air is inappropriate to the index operation. In addition, transporting a critically ill patient on maximal organ support to the CT suite is not an innocuous undertaking. Thus, the decision to reoperate during the first postoperative week can be extremely vexing and requires good cooperation between surgeons, intensivists, and radiologists.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.88, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Intra-abdominal Abscesses (Chapter 46)',\n", " 'md': '### Intra-abdominal Abscesses (Chapter 46)',\n", " 'bBox': {'x': 86, 'y': 211, 'w': 222.55, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Remember: The diagnosis of postoperative intra-abdominal ‘septic’ complications is extremely difficult. Denial is a major culprit in ‘missed’ cases! Surgeons hate to admit to their own failures and confront them. Consider, for a moment, your past experience: haven’t you seen patients fading away while their deterioration is blamed on a bad bout of pneumonia? Autopsy would have revealed unsuspected intra-abdominal complications in a good proportion of them.\\n\\nMark M. Ravitch reminds us wisely: “The last man to see the necessity for reoperation is the man who performed the operation.”\\n\\nThe following admonition should be deeply imprinted in your surgical soul: “Look for pneumonia inside the abdomen.”',\n", " 'md': 'Remember: The diagnosis of postoperative intra-abdominal ‘septic’ complications is extremely difficult. Denial is a major culprit in ‘missed’ cases! Surgeons hate to admit to their own failures and confront them. Consider, for a moment, your past experience: haven’t you seen patients fading away while their deterioration is blamed on a bad bout of pneumonia? Autopsy would have revealed unsuspected intra-abdominal complications in a good proportion of them.\\n\\nMark M. Ravitch reminds us wisely: “The last man to see the necessity for reoperation is the man who performed the operation.”\\n\\nThe following admonition should be deeply imprinted in your surgical soul: “Look for pneumonia inside the abdomen.”',\n", " 'bBox': {'x': 72, 'y': 280, 'w': 460.59, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': '‘Planned’ (Electively Staged) Relaparotomy',\n", " 'md': '### ‘Planned’ (Electively Staged) Relaparotomy',\n", " 'bBox': {'x': 86, 'y': 514, 'w': 330.12, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- A negative relaparotomy is better than a positive autopsy but is not, nevertheless, a benign procedure.\\n\\nThe policy of planned relaparotomies is decided upon during, or immediately after, the initial, index operation for peritonitis, when the surgeon decides to reoperate within 1-3 days, irrespective of the patient’s immediate postoperative course. The decision to re-explore the abdomen is part of the initial management plan. Historically, mesenteric ischemia (Chapter 24) was probably the first instance when a planned relook laparotomy was advocated. In the context of intra-abdominal infection, the main justification for a relook is to deal with...\\n\\n```',\n", " 'md': '- A negative relaparotomy is better than a positive autopsy but is not, nevertheless, a benign procedure.\\n\\nThe policy of planned relaparotomies is decided upon during, or immediately after, the initial, index operation for peritonitis, when the surgeon decides to reoperate within 1-3 days, irrespective of the patient’s immediate postoperative course. The decision to re-explore the abdomen is part of the initial management plan. Historically, mesenteric ischemia (Chapter 24) was probably the first instance when a planned relook laparotomy was advocated. In the context of intra-abdominal infection, the main justification for a relook is to deal with...\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 562, 'w': 467.69, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'when a planned relook laparotomy was advocated. In the context of intra-'}]},\n", " {'page': 815,\n", " 'text': 'persisting infected collections or to anticipate the formation of new ones\\nbefore they have had the time to amplify the existing SIRS and to tip the\\npatient into irreversible multiple organ failure.\\n\\n Indications for planned relaparotomies\\n\\n These need to be better defined and restricted to well-selected\\npatients. A relaparotomy is best undertaken during the first few\\npostoperative days, a period when abdominal CT findings are ‘non-\\nspecific’ and CT-directed percutaneous procedures are not an option.\\n\\n So in the following situations we may consider a planned reoperation:\\n\\n • The most appropriate indication is failure to obtain adequate\\n source control during the initial operation. A classic example is\\n infected pancreatic necrosis ( Chapter 19). Another example is an\\n intestinal leak which cannot be safely repaired or exteriorized (e.g. a\\n neglected leak from the retroperitoneal duodenum) — a scenario\\n commonly associated with postoperative peritonitis.\\n • The necessity to redebride or redrain poorly localized,\\n ‘stubborn’ infected tissues; for example, in diffuse retroperitoneal\\n necrotizing infection (some call it ‘retroperitoneal fasciitis’) due to\\n retroperitoneal perforation of the duodenum or colon.\\n • As in the massive trauma situation ( Chapter 32), the poor shape\\n of the patient during the initial operation may occasionally lead to an\\n abbreviated ‘damage control’ procedure, with an obligatory\\n subsequent planned relaparotomy to complete source control\\n and peritoneal toilet. In brief, the reoperation is to ‘complete the\\n job’ (e.g. a deferred anastomosis) — the first operation is for\\n physiology, the second is for anatomy. Obviously, when\\n hemostatic packs have to be left in situ, a relaparotomy is needed to\\n remove them.\\n • In the past, diffuse fecal peritonitis was considered a relative\\n indication, with the rationale that in the face of massive fecal\\n contamination another laparotomy is necessary to achieve an\\n adequate peritoneal toilet. Nowadays, we believe, most such\\n patients can be treated with a ‘single’ operation — supplemented, if',\n", " 'md': '```markdown\\n## Indications for Planned Relaparotomies\\n\\nThese need to be better defined and restricted to well-selected patients. A relaparotomy is best undertaken during the first few postoperative days, a period when abdominal CT findings are ‘non-specific’ and CT-directed percutaneous procedures are not an option.\\n\\nSo in the following situations we may consider a planned reoperation:\\n\\n- The most appropriate indication is failure to obtain adequate source control during the initial operation. A classic example is infected pancreatic necrosis (Chapter 19). Another example is an intestinal leak which cannot be safely repaired or exteriorized (e.g. a neglected leak from the retroperitoneal duodenum) — a scenario commonly associated with postoperative peritonitis.\\n- The necessity to redebride or redrain poorly localized, ‘stubborn’ infected tissues; for example, in diffuse retroperitoneal necrotizing infection (some call it ‘retroperitoneal fasciitis’) due to retroperitoneal perforation of the duodenum or colon.\\n- As in the massive trauma situation (Chapter 32), the poor shape of the patient during the initial operation may occasionally lead to an abbreviated ‘damage control’ procedure, with an obligatory subsequent planned relaparotomy to complete source control and peritoneal toilet. In brief, the reoperation is to ‘complete the job’ (e.g. a deferred anastomosis) — the first operation is for physiology, the second is for anatomy. Obviously, when hemostatic packs have to be left in situ, a relaparotomy is needed to remove them.\\n- In the past, diffuse fecal peritonitis was considered a relative indication, with the rationale that in the face of massive fecal contamination another laparotomy is necessary to achieve an adequate peritoneal toilet. Nowadays, we believe, most such patients can be treated with a ‘single’ operation — supplemented, if necessary, by further interventions.\\n\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Indications for Planned Relaparotomies',\n", " 'md': '## Indications for Planned Relaparotomies',\n", " 'bBox': {'x': 86, 'y': 162, 'w': 305.26, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'These need to be better defined and restricted to well-selected patients. A relaparotomy is best undertaken during the first few postoperative days, a period when abdominal CT findings are ‘non-specific’ and CT-directed percutaneous procedures are not an option.\\n\\nSo in the following situations we may consider a planned reoperation:\\n\\n- The most appropriate indication is failure to obtain adequate source control during the initial operation. A classic example is infected pancreatic necrosis (Chapter 19). Another example is an intestinal leak which cannot be safely repaired or exteriorized (e.g. a neglected leak from the retroperitoneal duodenum) — a scenario commonly associated with postoperative peritonitis.\\n- The necessity to redebride or redrain poorly localized, ‘stubborn’ infected tissues; for example, in diffuse retroperitoneal necrotizing infection (some call it ‘retroperitoneal fasciitis’) due to retroperitoneal perforation of the duodenum or colon.\\n- As in the massive trauma situation (Chapter 32), the poor shape of the patient during the initial operation may occasionally lead to an abbreviated ‘damage control’ procedure, with an obligatory subsequent planned relaparotomy to complete source control and peritoneal toilet. In brief, the reoperation is to ‘complete the job’ (e.g. a deferred anastomosis) — the first operation is for physiology, the second is for anatomy. Obviously, when hemostatic packs have to be left in situ, a relaparotomy is needed to remove them.\\n- In the past, diffuse fecal peritonitis was considered a relative indication, with the rationale that in the face of massive fecal contamination another laparotomy is necessary to achieve an adequate peritoneal toilet. Nowadays, we believe, most such patients can be treated with a ‘single’ operation — supplemented, if necessary, by further interventions.\\n\\n```',\n", " 'md': 'These need to be better defined and restricted to well-selected patients. A relaparotomy is best undertaken during the first few postoperative days, a period when abdominal CT findings are ‘non-specific’ and CT-directed percutaneous procedures are not an option.\\n\\nSo in the following situations we may consider a planned reoperation:\\n\\n- The most appropriate indication is failure to obtain adequate source control during the initial operation. A classic example is infected pancreatic necrosis (Chapter 19). Another example is an intestinal leak which cannot be safely repaired or exteriorized (e.g. a neglected leak from the retroperitoneal duodenum) — a scenario commonly associated with postoperative peritonitis.\\n- The necessity to redebride or redrain poorly localized, ‘stubborn’ infected tissues; for example, in diffuse retroperitoneal necrotizing infection (some call it ‘retroperitoneal fasciitis’) due to retroperitoneal perforation of the duodenum or colon.\\n- As in the massive trauma situation (Chapter 32), the poor shape of the patient during the initial operation may occasionally lead to an abbreviated ‘damage control’ procedure, with an obligatory subsequent planned relaparotomy to complete source control and peritoneal toilet. In brief, the reoperation is to ‘complete the job’ (e.g. a deferred anastomosis) — the first operation is for physiology, the second is for anatomy. Obviously, when hemostatic packs have to be left in situ, a relaparotomy is needed to remove them.\\n- In the past, diffuse fecal peritonitis was considered a relative indication, with the rationale that in the face of massive fecal contamination another laparotomy is necessary to achieve an adequate peritoneal toilet. Nowadays, we believe, most such patients can be treated with a ‘single’ operation — supplemented, if necessary, by further interventions.\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 247, 'w': 441.38, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'intestinal leak which cannot be safely repaired or exteriorized (e.g. a'},\n", " {'text': 'of the patient during the initial operation may occasionally lead to an'}]},\n", " {'page': 816,\n", " 'text': ' necessary, with percutaneous drainage or an ‘on-demand’\\n reoperation.\\n\\n The conduct of a relaparotomy\\n\\n The key piece of advice for the surgeon who plans to re-enter a\\nrecently opened abdomen is to be gentle! The peritoneal surfaces are\\nedematous, friable and vascular, and so is the bowel. Reoperative\\nabdominal surgery is a situation where the dictum “first do no harm” has\\nparticular relevance. Do not perforate the bowel, do not cause\\nbleeding — such mishaps in an already compromised patient are\\noften a death sentence.\\n\\n Another important tip: know your way around. Ideally, the\\nsurgeon who has performed the original procedure should either be\\nthe one to reoperate or at least be a member of the reoperating\\nteam. Think about the infected postoperative abdomen as a thick jungle;\\na previous journey through it renders a return easier. You will remember,\\nfor example, that the colon was ‘stuck’ to the lower end of the incision;\\nyour partner who did not accompany you on your first trip may instead\\nenter the lumen of the colon, with horrendous consequences. Even in\\nthis glorious era of ‘surgical hospitalists’ and ‘shift mentality’ we\\nfeel it is neglectful for a surgeon to expect others to fix his patients\\nwithout being directly involved!\\n\\n The abdominal relook itself aims at draining all infected\\ncollections and controlling, if necessary, persistent sources of\\ncontamination. ħow thorough the exploration should be depends on the\\nindividual case. Sometimes there are several inter-loop abscesses that\\nneed to be drained and the whole bowel must be carefully unravelled.\\nParticularly later in the natural course of peritonitis, the intestines\\nbecome matted together, forming a ‘central visceral block’; it is then\\nprudent to explore the spaces around the matted bowel —\\nsubphrenic spaces, paracolic gutters, pelvis. The decision on the\\nextent of exploration is important because the more extensive it is, the\\nmore dangerous it is to the viscera. As you have been told here again\\nand again, the more you do, the more local and systemic inflammation',\n", " 'md': '```markdown\\n## Conduct of a Relaparotomy\\n\\nThe key piece of advice for the surgeon who plans to re-enter a recently opened abdomen is to be gentle! The peritoneal surfaces are edematous, friable, and vascular, and so is the bowel. Reoperative abdominal surgery is a situation where the dictum “first do no harm” has particular relevance. Do not perforate the bowel, do not cause bleeding — such mishaps in an already compromised patient are often a death sentence.\\n\\nAnother important tip: know your way around. Ideally, the surgeon who has performed the original procedure should either be the one to reoperate or at least be a member of the reoperating team. Think about the infected postoperative abdomen as a thick jungle; a previous journey through it renders a return easier. You will remember, for example, that the colon was ‘stuck’ to the lower end of the incision; your partner who did not accompany you on your first trip may instead enter the lumen of the colon, with horrendous consequences. Even in this glorious era of ‘surgical hospitalists’ and ‘shift mentality’ we feel it is neglectful for a surgeon to expect others to fix his patients without being directly involved!\\n\\nThe abdominal relook itself aims at draining all infected collections and controlling, if necessary, persistent sources of contamination. How thorough the exploration should be depends on the individual case. Sometimes there are several inter-loop abscesses that need to be drained and the whole bowel must be carefully unravelled. Particularly later in the natural course of peritonitis, the intestines become matted together, forming a ‘central visceral block’; it is then prudent to explore the spaces around the matted bowel — subphrenic spaces, paracolic gutters, pelvis. The decision on the extent of exploration is important because the more extensive it is, the more dangerous it is to the viscera. As you have been told here again and again, the more you do, the more local and systemic inflammation.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Conduct of a Relaparotomy',\n", " 'md': '## Conduct of a Relaparotomy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The key piece of advice for the surgeon who plans to re-enter a recently opened abdomen is to be gentle! The peritoneal surfaces are edematous, friable, and vascular, and so is the bowel. Reoperative abdominal surgery is a situation where the dictum “first do no harm” has particular relevance. Do not perforate the bowel, do not cause bleeding — such mishaps in an already compromised patient are often a death sentence.\\n\\nAnother important tip: know your way around. Ideally, the surgeon who has performed the original procedure should either be the one to reoperate or at least be a member of the reoperating team. Think about the infected postoperative abdomen as a thick jungle; a previous journey through it renders a return easier. You will remember, for example, that the colon was ‘stuck’ to the lower end of the incision; your partner who did not accompany you on your first trip may instead enter the lumen of the colon, with horrendous consequences. Even in this glorious era of ‘surgical hospitalists’ and ‘shift mentality’ we feel it is neglectful for a surgeon to expect others to fix his patients without being directly involved!\\n\\nThe abdominal relook itself aims at draining all infected collections and controlling, if necessary, persistent sources of contamination. How thorough the exploration should be depends on the individual case. Sometimes there are several inter-loop abscesses that need to be drained and the whole bowel must be carefully unravelled. Particularly later in the natural course of peritonitis, the intestines become matted together, forming a ‘central visceral block’; it is then prudent to explore the spaces around the matted bowel — subphrenic spaces, paracolic gutters, pelvis. The decision on the extent of exploration is important because the more extensive it is, the more dangerous it is to the viscera. As you have been told here again and again, the more you do, the more local and systemic inflammation.\\n```',\n", " 'md': 'The key piece of advice for the surgeon who plans to re-enter a recently opened abdomen is to be gentle! The peritoneal surfaces are edematous, friable, and vascular, and so is the bowel. Reoperative abdominal surgery is a situation where the dictum “first do no harm” has particular relevance. Do not perforate the bowel, do not cause bleeding — such mishaps in an already compromised patient are often a death sentence.\\n\\nAnother important tip: know your way around. Ideally, the surgeon who has performed the original procedure should either be the one to reoperate or at least be a member of the reoperating team. Think about the infected postoperative abdomen as a thick jungle; a previous journey through it renders a return easier. You will remember, for example, that the colon was ‘stuck’ to the lower end of the incision; your partner who did not accompany you on your first trip may instead enter the lumen of the colon, with horrendous consequences. Even in this glorious era of ‘surgical hospitalists’ and ‘shift mentality’ we feel it is neglectful for a surgeon to expect others to fix his patients without being directly involved!\\n\\nThe abdominal relook itself aims at draining all infected collections and controlling, if necessary, persistent sources of contamination. How thorough the exploration should be depends on the individual case. Sometimes there are several inter-loop abscesses that need to be drained and the whole bowel must be carefully unravelled. Particularly later in the natural course of peritonitis, the intestines become matted together, forming a ‘central visceral block’; it is then prudent to explore the spaces around the matted bowel — subphrenic spaces, paracolic gutters, pelvis. The decision on the extent of exploration is important because the more extensive it is, the more dangerous it is to the viscera. As you have been told here again and again, the more you do, the more local and systemic inflammation.\\n```',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.95, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 817,\n", " 'text': 'you trigger. The extent of the exploration depends not only on\\nwhether your operation is ‘directed’ or ‘non-directed’ but also on its\\ntiming.\\n\\n ‘Directed’ versus ‘non-directed’ relook\\n\\n Let the CT scan be your guide. A ‘directed’ reoperation implies\\nthat you know exactly where you want to go. The CT scan identifies a\\nright subhepatic collection, with the rest of the abdomen appearing clean.\\nYou can proceed directly to where the trouble is, sparing the rest of the\\nabdomen the potentially damaging effects of your manipulations.\\nConversely, a ‘non-directed’ relook is a blind re-exploration when you are\\nnot sure where the problem lies, for example, when the CT scan shows\\ndiffuse collections; in this instance, a thorough search is required.\\n\\n Timing of the relook\\n\\n When you re-explore the abdomen 24-72 hours after the index\\noperation, the adhesions between viscera and peritoneal surfaces give\\nway easily; you can enter any space with atraumatic dissection. At this\\nstage total abdominal exploration is readily feasible. However, as time\\ngoes by, the intra-abdominal structures become progressively\\ncemented to each other, with dense, vascular, immature adhesions\\nthat are troublesome to divide. Clearly, abdominal re-entry between 1-\\n4 weeks after the index operation may be hazardous, and will remain so\\nuntil the eventual maturation of the adhesions several weeks (or even\\nmonths) later.\\n\\n Consequently, during an early relook operation, you may unravel the\\nwhole bowel and drain all inter-loop collections. In contrast, you will\\nfind, at late reoperations, a central mass of matted small bowel.\\nLeave it alone! Again: dissection of the individual loops at this stage is\\ndangerous and non-productive because significant collections are to be\\nfound only at the periphery — above (under the diaphragms or under the\\nliver), below (in the pelvis), and on the sides (in the gutters).',\n", " 'md': '```markdown\\n## Directed versus Non-Directed Relook\\n\\nThe extent of the exploration depends not only on whether your operation is ‘directed’ or ‘non-directed’ but also on its timing.\\n\\n### Directed versus Non-Directed Relook\\n\\nLet the CT scan be your guide. A ‘directed’ reoperation implies that you know exactly where you want to go. The CT scan identifies a right subhepatic collection, with the rest of the abdomen appearing clean. You can proceed directly to where the trouble is, sparing the rest of the abdomen the potentially damaging effects of your manipulations. Conversely, a ‘non-directed’ relook is a blind re-exploration when you are not sure where the problem lies, for example, when the CT scan shows diffuse collections; in this instance, a thorough search is required.\\n\\n### Timing of the Relook\\n\\nWhen you re-explore the abdomen 24-72 hours after the index operation, the adhesions between viscera and peritoneal surfaces give way easily; you can enter any space with atraumatic dissection. At this stage, total abdominal exploration is readily feasible. However, as time goes by, the intra-abdominal structures become progressively cemented to each other, with dense, vascular, immature adhesions that are troublesome to divide. Clearly, abdominal re-entry between 1-4 weeks after the index operation may be hazardous, and will remain so until the eventual maturation of the adhesions several weeks (or even months) later.\\n\\nConsequently, during an early relook operation, you may unravel the whole bowel and drain all inter-loop collections. In contrast, you will find, at late reoperations, a central mass of matted small bowel. Leave it alone! Again: dissection of the individual loops at this stage is dangerous and non-productive because significant collections are to be found only at the periphery — above (under the diaphragms or under the liver), below (in the pelvis), and on the sides (in the gutters).\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Directed versus Non-Directed Relook',\n", " 'md': '## Directed versus Non-Directed Relook',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The extent of the exploration depends not only on whether your operation is ‘directed’ or ‘non-directed’ but also on its timing.',\n", " 'md': 'The extent of the exploration depends not only on whether your operation is ‘directed’ or ‘non-directed’ but also on its timing.',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.61, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Directed versus Non-Directed Relook',\n", " 'md': '### Directed versus Non-Directed Relook',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Let the CT scan be your guide. A ‘directed’ reoperation implies that you know exactly where you want to go. The CT scan identifies a right subhepatic collection, with the rest of the abdomen appearing clean. You can proceed directly to where the trouble is, sparing the rest of the abdomen the potentially damaging effects of your manipulations. Conversely, a ‘non-directed’ relook is a blind re-exploration when you are not sure where the problem lies, for example, when the CT scan shows diffuse collections; in this instance, a thorough search is required.',\n", " 'md': 'Let the CT scan be your guide. A ‘directed’ reoperation implies that you know exactly where you want to go. The CT scan identifies a right subhepatic collection, with the rest of the abdomen appearing clean. You can proceed directly to where the trouble is, sparing the rest of the abdomen the potentially damaging effects of your manipulations. Conversely, a ‘non-directed’ relook is a blind re-exploration when you are not sure where the problem lies, for example, when the CT scan shows diffuse collections; in this instance, a thorough search is required.',\n", " 'bBox': {'x': 72, 'y': 214, 'w': 468.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Timing of the Relook',\n", " 'md': '### Timing of the Relook',\n", " 'bBox': {'x': 86, 'y': 357, 'w': 157.82, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'When you re-explore the abdomen 24-72 hours after the index operation, the adhesions between viscera and peritoneal surfaces give way easily; you can enter any space with atraumatic dissection. At this stage, total abdominal exploration is readily feasible. However, as time goes by, the intra-abdominal structures become progressively cemented to each other, with dense, vascular, immature adhesions that are troublesome to divide. Clearly, abdominal re-entry between 1-4 weeks after the index operation may be hazardous, and will remain so until the eventual maturation of the adhesions several weeks (or even months) later.\\n\\nConsequently, during an early relook operation, you may unravel the whole bowel and drain all inter-loop collections. In contrast, you will find, at late reoperations, a central mass of matted small bowel. Leave it alone! Again: dissection of the individual loops at this stage is dangerous and non-productive because significant collections are to be found only at the periphery — above (under the diaphragms or under the liver), below (in the pelvis), and on the sides (in the gutters).\\n```',\n", " 'md': 'When you re-explore the abdomen 24-72 hours after the index operation, the adhesions between viscera and peritoneal surfaces give way easily; you can enter any space with atraumatic dissection. At this stage, total abdominal exploration is readily feasible. However, as time goes by, the intra-abdominal structures become progressively cemented to each other, with dense, vascular, immature adhesions that are troublesome to divide. Clearly, abdominal re-entry between 1-4 weeks after the index operation may be hazardous, and will remain so until the eventual maturation of the adhesions several weeks (or even months) later.\\n\\nConsequently, during an early relook operation, you may unravel the whole bowel and drain all inter-loop collections. In contrast, you will find, at late reoperations, a central mass of matted small bowel. Leave it alone! Again: dissection of the individual loops at this stage is dangerous and non-productive because significant collections are to be found only at the periphery — above (under the diaphragms or under the liver), below (in the pelvis), and on the sides (in the gutters).\\n```',\n", " 'bBox': {'x': 72, 'y': 476, 'w': 467.97, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 818,\n", " 'text': ' During re-exploration sharp tools are rarely needed. Your fingers are the safest dissecting\\n instrument. Remember: where tissue planes are fused, forbidding admission to your gently\\n pinching fingers, nothing is to be found. So follow your fingers to where the\\n pus lies. Remember the old jingle about the Yellow Pages? “Let your fingers do the\\n walking.”\\n\\n Dissection is the key to successful surgery. Knowledge of anatomy is the key to dissection. In a\\n situation where normal anatomy is distorted by inflammation and previous operations, start by\\n restoring original anatomy through careful dissection using your fingers and tips of scissors. A\\n well-known Finnish surgeon Arto Sivula used to say that “a good surgeon grows nerves to the\\n tips of the scissors”. In a scarred operative field, never cut anything\\n unless you can see through it. Ari\\n\\n The leaking intestine\\n\\n Dehisced suture lines and anastomoses must be defunctioned, ideally\\nby the fashioning of appropriate stomas or, if this is not possible, by tube\\ndrainage. Resuturing leaking bowel in an infected peritoneal cavity\\nis doomed to failure and carries a prohibitive mortality. No, we will\\nnever tire of driving home this point! — see Chapter 47.\\n\\n Drains\\n\\n The use of intraperitoneal drains is controversial in this setting. They\\nare certainly not required as long as planned relaparotomies continue.\\nThe placement of a drain at the final laparotomy is another matter; the\\nadvantages need to be weighed against the risk of damage to viscera\\nthat are extremely friable as a result of recent re-explorations. The use of\\ndrains in our practice is strictly limited to specific situations as\\ndiscussed elsewhere ( Chapter 39).\\n\\n When to stop ‘planned’ relaparotomies ( Figure 48.1)?',\n", " 'md': '```markdown\\n## Surgical Techniques and Considerations\\n\\nDuring re-exploration, sharp tools are rarely needed. Your fingers are the safest dissecting instrument. Remember: where tissue planes are fused, forbidding admission to your gently pinching fingers, nothing is to be found. So follow your fingers to where the pus lies. Remember the old jingle about the Yellow Pages? “Let your fingers do the walking.”\\n\\nDissection is the key to successful surgery. Knowledge of anatomy is the key to dissection. In a situation where normal anatomy is distorted by inflammation and previous operations, start by restoring original anatomy through careful dissection using your fingers and tips of scissors. A well-known Finnish surgeon, Arto Sivula, used to say that “a good surgeon grows nerves to the tips of the scissors.” In a scarred operative field, never cut anything unless you can see through it.\\n\\n### The Leaking Intestine\\n\\nDehisced suture lines and anastomoses must be defunctioned, ideally by the fashioning of appropriate stomas or, if this is not possible, by tube drainage. Resuturing leaking bowel in an infected peritoneal cavity is doomed to failure and carries a prohibitive mortality. No, we will never tire of driving home this point! — see Chapter 47.\\n\\n### Drains\\n\\nThe use of intraperitoneal drains is controversial in this setting. They are certainly not required as long as planned relaparotomies continue. The placement of a drain at the final laparotomy is another matter; the advantages need to be weighed against the risk of damage to viscera that are extremely friable as a result of recent re-explorations. The use of drains in our practice is strictly limited to specific situations as discussed elsewhere (Chapter 39).\\n\\n### When to Stop ‘Planned’ Relaparotomies\\n\\n![Figure 48.1]()\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Surgical Techniques and Considerations',\n", " 'md': '## Surgical Techniques and Considerations',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'During re-exploration, sharp tools are rarely needed. Your fingers are the safest dissecting instrument. Remember: where tissue planes are fused, forbidding admission to your gently pinching fingers, nothing is to be found. So follow your fingers to where the pus lies. Remember the old jingle about the Yellow Pages? “Let your fingers do the walking.”\\n\\nDissection is the key to successful surgery. Knowledge of anatomy is the key to dissection. In a situation where normal anatomy is distorted by inflammation and previous operations, start by restoring original anatomy through careful dissection using your fingers and tips of scissors. A well-known Finnish surgeon, Arto Sivula, used to say that “a good surgeon grows nerves to the tips of the scissors.” In a scarred operative field, never cut anything unless you can see through it.',\n", " 'md': 'During re-exploration, sharp tools are rarely needed. Your fingers are the safest dissecting instrument. Remember: where tissue planes are fused, forbidding admission to your gently pinching fingers, nothing is to be found. So follow your fingers to where the pus lies. Remember the old jingle about the Yellow Pages? “Let your fingers do the walking.”\\n\\nDissection is the key to successful surgery. Knowledge of anatomy is the key to dissection. In a situation where normal anatomy is distorted by inflammation and previous operations, start by restoring original anatomy through careful dissection using your fingers and tips of scissors. A well-known Finnish surgeon, Arto Sivula, used to say that “a good surgeon grows nerves to the tips of the scissors.” In a scarred operative field, never cut anything unless you can see through it.',\n", " 'bBox': {'x': 77, 'y': 173, 'w': 457.47, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Leaking Intestine',\n", " 'md': '### The Leaking Intestine',\n", " 'bBox': {'x': 86, 'y': 371, 'w': 163.67, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Dehisced suture lines and anastomoses must be defunctioned, ideally by the fashioning of appropriate stomas or, if this is not possible, by tube drainage. Resuturing leaking bowel in an infected peritoneal cavity is doomed to failure and carries a prohibitive mortality. No, we will never tire of driving home this point! — see Chapter 47.',\n", " 'md': 'Dehisced suture lines and anastomoses must be defunctioned, ideally by the fashioning of appropriate stomas or, if this is not possible, by tube drainage. Resuturing leaking bowel in an infected peritoneal cavity is doomed to failure and carries a prohibitive mortality. No, we will never tire of driving home this point! — see Chapter 47.',\n", " 'bBox': {'x': 72, 'y': 407, 'w': 467.67, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Drains',\n", " 'md': '### Drains',\n", " 'bBox': {'x': 86, 'y': 517, 'w': 51.51, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The use of intraperitoneal drains is controversial in this setting. They are certainly not required as long as planned relaparotomies continue. The placement of a drain at the final laparotomy is another matter; the advantages need to be weighed against the risk of damage to viscera that are extremely friable as a result of recent re-explorations. The use of drains in our practice is strictly limited to specific situations as discussed elsewhere (Chapter 39).',\n", " 'md': 'The use of intraperitoneal drains is controversial in this setting. They are certainly not required as long as planned relaparotomies continue. The placement of a drain at the final laparotomy is another matter; the advantages need to be weighed against the risk of damage to viscera that are extremely friable as a result of recent re-explorations. The use of drains in our practice is strictly limited to specific situations as discussed elsewhere (Chapter 39).',\n", " 'bBox': {'x': 72, 'y': 517, 'w': 466.95, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'When to Stop ‘Planned’ Relaparotomies',\n", " 'md': '### When to Stop ‘Planned’ Relaparotomies',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '![Figure 48.1]()\\n```',\n", " 'md': '![Figure 48.1]()\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}, {'text': ''}]},\n", " {'page': 819,\n", " 'text': ' As in most vital aspects of life, too much of anything is not good,\\nand too many planned relaparotomies are harmful. When to stop? In\\nsuch a management program, the decision to quit must be based on the\\nfinding of a macroscopically clean peritoneal cavity and evidence that\\nsources of contamination have been controlled definitively. Whether the\\nsource is controlled or not is obvious but estimation of whether the\\nperitoneal cavity is ‘clean’ or not requires experience and judgment.\\nThus, do not send your junior partner or senior resident to re-\\nexplore it alone. (We bet you are familiar with this scenario: the\\ninternationally famous master of laparoscopic surgery does a beautiful\\noperation. Two days later he sends his Fellow to fix the disaster. The\\noutcome is predictable… while the globetrotting ‘master’ sips sake in\\nTokyo...).\\n M\\n 3\\n ReRyA Jol4\\n Figure 48.1. Junior surgeon to Professor: “Sir, this morning the patient underwent\\n relaparotomy number 21. When should we stop re-exploring?” Professor: “When his C-\\n reactive protein normalizes…”\\n\\n Frequent dilemma: “take your spouse for dinner or the patient back to\\nthe OR?” (you may lose even if you make the correct choice!).\\n\\n When peritonitis persists, despite apparently adequate source control\\nand repeated reoperations, think about tertiary peritonitis ( Chapter\\n13).',\n", " 'md': \"```markdown\\nAs in most vital aspects of life, too much of anything is not good, and too many planned relaparotomies are harmful. When to stop? In such a management program, the decision to quit must be based on the finding of a macroscopically clean peritoneal cavity and evidence that sources of contamination have been controlled definitively. Whether the source is controlled or not is obvious but estimation of whether the peritoneal cavity is ‘clean’ or not requires experience and judgment. Thus, do not send your junior partner or senior resident to re-explore it alone. (We bet you are familiar with this scenario: the internationally famous master of laparoscopic surgery does a beautiful operation. Two days later he sends his Fellow to fix the disaster. The outcome is predictable… while the globetrotting ‘master’ sips sake in Tokyo…).\\n\\nFigure 48.1. Junior surgeon to Professor: “Sir, this morning the patient underwent relaparotomy number 21. When should we stop re-exploring?” Professor: “When his C-reactive protein normalizes…”\\n\\nFrequent dilemma: “take your spouse for dinner or the patient back to the OR?” (you may lose even if you make the correct choice!).\\n\\nWhen peritonitis persists, despite apparently adequate source control and repeated reoperations, think about tertiary peritonitis (Chapter 13).\\n```\\n\\n### Image Description\\n- **Figure 48.1**: This image likely depicts a conversation between a junior surgeon and a professor regarding the management of a patient who has undergone multiple relaparotomies. The dialogue highlights the dilemma of when to stop re-exploring the patient, with the professor suggesting that the decision should be based on the normalization of the patient's C-reactive protein levels. The image captures the essence of surgical decision-making and the challenges faced by junior surgeons in clinical practice.\\n\\n### Summary\\nThe text discusses the complexities of managing relaparotomies and emphasizes the importance of experience in determining when to cease surgical interventions. It also touches on the emotional and ethical dilemmas faced by surgeons in balancing personal life with professional responsibilities.\",\n", " 'images': [{'name': 'img_p818_1.png',\n", " 'height': 472,\n", " 'width': 822,\n", " 'x': 102.96000000000004,\n", " 'y': 298.08000000000004,\n", " 'original_width': 1413,\n", " 'original_height': 811}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\nAs in most vital aspects of life, too much of anything is not good, and too many planned relaparotomies are harmful. When to stop? In such a management program, the decision to quit must be based on the finding of a macroscopically clean peritoneal cavity and evidence that sources of contamination have been controlled definitively. Whether the source is controlled or not is obvious but estimation of whether the peritoneal cavity is ‘clean’ or not requires experience and judgment. Thus, do not send your junior partner or senior resident to re-explore it alone. (We bet you are familiar with this scenario: the internationally famous master of laparoscopic surgery does a beautiful operation. Two days later he sends his Fellow to fix the disaster. The outcome is predictable… while the globetrotting ‘master’ sips sake in Tokyo…).\\n\\nFigure 48.1. Junior surgeon to Professor: “Sir, this morning the patient underwent relaparotomy number 21. When should we stop re-exploring?” Professor: “When his C-reactive protein normalizes…”\\n\\nFrequent dilemma: “take your spouse for dinner or the patient back to the OR?” (you may lose even if you make the correct choice!).\\n\\nWhen peritonitis persists, despite apparently adequate source control and repeated reoperations, think about tertiary peritonitis (Chapter 13).\\n```',\n", " 'md': '```markdown\\nAs in most vital aspects of life, too much of anything is not good, and too many planned relaparotomies are harmful. When to stop? In such a management program, the decision to quit must be based on the finding of a macroscopically clean peritoneal cavity and evidence that sources of contamination have been controlled definitively. Whether the source is controlled or not is obvious but estimation of whether the peritoneal cavity is ‘clean’ or not requires experience and judgment. Thus, do not send your junior partner or senior resident to re-explore it alone. (We bet you are familiar with this scenario: the internationally famous master of laparoscopic surgery does a beautiful operation. Two days later he sends his Fellow to fix the disaster. The outcome is predictable… while the globetrotting ‘master’ sips sake in Tokyo…).\\n\\nFigure 48.1. Junior surgeon to Professor: “Sir, this morning the patient underwent relaparotomy number 21. When should we stop re-exploring?” Professor: “When his C-reactive protein normalizes…”\\n\\nFrequent dilemma: “take your spouse for dinner or the patient back to the OR?” (you may lose even if you make the correct choice!).\\n\\nWhen peritonitis persists, despite apparently adequate source control and repeated reoperations, think about tertiary peritonitis (Chapter 13).\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.55, 'h': 29.65}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 126.22, 'y': 408.29, 'w': 33.65, 'h': 29.65}},\n", " {'type': 'text',\n", " 'value': \"- **Figure 48.1**: This image likely depicts a conversation between a junior surgeon and a professor regarding the management of a patient who has undergone multiple relaparotomies. The dialogue highlights the dilemma of when to stop re-exploring the patient, with the professor suggesting that the decision should be based on the normalization of the patient's C-reactive protein levels. The image captures the essence of surgical decision-making and the challenges faced by junior surgeons in clinical practice.\",\n", " 'md': \"- **Figure 48.1**: This image likely depicts a conversation between a junior surgeon and a professor regarding the management of a patient who has undergone multiple relaparotomies. The dialogue highlights the dilemma of when to stop re-exploring the patient, with the professor suggesting that the decision should be based on the normalization of the patient's C-reactive protein levels. The image captures the essence of surgical decision-making and the challenges faced by junior surgeons in clinical practice.\",\n", " 'bBox': {'x': 126.22, 'y': 408.29, 'w': 33.65, 'h': 29.65}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 126.22, 'y': 408.29, 'w': 33.65, 'h': 29.65}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the complexities of managing relaparotomies and emphasizes the importance of experience in determining when to cease surgical interventions. It also touches on the emotional and ethical dilemmas faced by surgeons in balancing personal life with professional responsibilities.',\n", " 'md': 'The text discusses the complexities of managing relaparotomies and emphasizes the importance of experience in determining when to cease surgical interventions. It also touches on the emotional and ethical dilemmas faced by surgeons in balancing personal life with professional responsibilities.',\n", " 'bBox': {'x': 126.22, 'y': 408.29, 'w': 33.65, 'h': 29.65}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'and repeated reoperations, think about tertiary peritonitis ( Chapter 13).'}]},\n", " {'page': 820,\n", " 'text': ' Are ‘planned’ relaparotomies beneficial?\\n\\n What is the verdict? Do planned relaparotomies reverse, prevent\\nor aggravate SIRS and multi-organ dysfunction? Is the benefit/risk\\nratio favorable? There it is, at the risk of being repetitive.\\n\\n Any surgical maneuver that successfully eliminates the source of\\ninfection and evacuates contaminants and pus has to be beneficial; this\\nis axiomatic. The problem is that planned relaparotomies are a\\ndouble-edged sword — they may achieve the above goal but may also\\ninjure the host. Indeed, strict adherence to the policy of planned\\nrelaparotomies is a definite overkill. If one operates until the abdomen\\nis clean then — in retrospect — the last operation was unnecessary.\\nMultiple relaparotomies are attended by a high morbidity accounted for\\nby destabilizing an ICU patient during repeated trips to the OR, iatrogenic\\nbowel injuries and possibly the stimulation of an exaggerated\\ninflammatory response. We believe that, in the long run, we serve our\\npatients better with a low-threshold policy of postoperative on-\\ndemand percutaneous CT-guided drainage procedures or on-\\ndemand CT-directed laparotomies. This will appease the advocates of\\nplanned relaparotomies whose main fear is to miss the boat. One or two\\nplanned relaparotomies may still have a place in the indications\\nlisted above and only in the first postoperative week when both the\\nimaging is less reliable and the abdomen safer to re-enter. It is our\\nopinion that at a later stage of a critically ill patient’s course, ‘on demand’\\nis the way to go, based on the patient’s clinical condition and convincing\\nimaging. Common sense and experience must prevail when high-\\nlevel evidence is lacking.\\n\\n Laparostomy\\n2 Roger Saadia and Moshe Schein\\n P. Fagniez of Paris has coined the term ‘laparostomie’\\n(laparostomy) which entails leaving the abdomen open. Open\\nmanagement of the infected abdomen was instituted in the belief that the\\ninfected peritoneal cavity should be left open like an abscess cavity. It\\nsoon became clear, however, that sometimes there was still a need for',\n", " 'md': '```markdown\\n# Are ‘planned’ relaparotomies beneficial?\\n\\n## What is the verdict?\\nDo planned relaparotomies reverse, prevent, or aggravate SIRS and multi-organ dysfunction? Is the benefit/risk ratio favorable? There it is, at the risk of being repetitive.\\n\\nAny surgical maneuver that successfully eliminates the source of infection and evacuates contaminants and pus has to be beneficial; this is axiomatic. The problem is that planned relaparotomies are a double-edged sword — they may achieve the above goal but may also injure the host. Indeed, strict adherence to the policy of planned relaparotomies is a definite overkill. If one operates until the abdomen is clean then — in retrospect — the last operation was unnecessary.\\n\\nMultiple relaparotomies are attended by a high morbidity accounted for by destabilizing an ICU patient during repeated trips to the OR, iatrogenic bowel injuries, and possibly the stimulation of an exaggerated inflammatory response. We believe that, in the long run, we serve our patients better with a low-threshold policy of postoperative on-demand percutaneous CT-guided drainage procedures or on-demand CT-directed laparotomies. This will appease the advocates of planned relaparotomies whose main fear is to miss the boat.\\n\\nOne or two planned relaparotomies may still have a place in the indications listed above and only in the first postoperative week when both the imaging is less reliable and the abdomen safer to re-enter. It is our opinion that at a later stage of a critically ill patient’s course, ‘on demand’ is the way to go, based on the patient’s clinical condition and convincing imaging. Common sense and experience must prevail when high-level evidence is lacking.\\n\\n## Laparostomy\\nRoger Saadia and Moshe Schein\\nP. Fagniez of Paris has coined the term ‘laparostomie’ (laparostomy) which entails leaving the abdomen open. Open management of the infected abdomen was instituted in the belief that the infected peritoneal cavity should be left open like an abscess cavity. It soon became clear, however, that sometimes there was still a need for .\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Are ‘planned’ relaparotomies beneficial?',\n", " 'md': '# Are ‘planned’ relaparotomies beneficial?',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 318.15, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'What is the verdict?',\n", " 'md': '## What is the verdict?',\n", " 'bBox': {'x': 359, 'y': 640, 'w': 25.58, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'Do planned relaparotomies reverse, prevent, or aggravate SIRS and multi-organ dysfunction? Is the benefit/risk ratio favorable? There it is, at the risk of being repetitive.\\n\\nAny surgical maneuver that successfully eliminates the source of infection and evacuates contaminants and pus has to be beneficial; this is axiomatic. The problem is that planned relaparotomies are a double-edged sword — they may achieve the above goal but may also injure the host. Indeed, strict adherence to the policy of planned relaparotomies is a definite overkill. If one operates until the abdomen is clean then — in retrospect — the last operation was unnecessary.\\n\\nMultiple relaparotomies are attended by a high morbidity accounted for by destabilizing an ICU patient during repeated trips to the OR, iatrogenic bowel injuries, and possibly the stimulation of an exaggerated inflammatory response. We believe that, in the long run, we serve our patients better with a low-threshold policy of postoperative on-demand percutaneous CT-guided drainage procedures or on-demand CT-directed laparotomies. This will appease the advocates of planned relaparotomies whose main fear is to miss the boat.\\n\\nOne or two planned relaparotomies may still have a place in the indications listed above and only in the first postoperative week when both the imaging is less reliable and the abdomen safer to re-enter. It is our opinion that at a later stage of a critically ill patient’s course, ‘on demand’ is the way to go, based on the patient’s clinical condition and convincing imaging. Common sense and experience must prevail when high-level evidence is lacking.',\n", " 'md': 'Do planned relaparotomies reverse, prevent, or aggravate SIRS and multi-organ dysfunction? Is the benefit/risk ratio favorable? There it is, at the risk of being repetitive.\\n\\nAny surgical maneuver that successfully eliminates the source of infection and evacuates contaminants and pus has to be beneficial; this is axiomatic. The problem is that planned relaparotomies are a double-edged sword — they may achieve the above goal but may also injure the host. Indeed, strict adherence to the policy of planned relaparotomies is a definite overkill. If one operates until the abdomen is clean then — in retrospect — the last operation was unnecessary.\\n\\nMultiple relaparotomies are attended by a high morbidity accounted for by destabilizing an ICU patient during repeated trips to the OR, iatrogenic bowel injuries, and possibly the stimulation of an exaggerated inflammatory response. We believe that, in the long run, we serve our patients better with a low-threshold policy of postoperative on-demand percutaneous CT-guided drainage procedures or on-demand CT-directed laparotomies. This will appease the advocates of planned relaparotomies whose main fear is to miss the boat.\\n\\nOne or two planned relaparotomies may still have a place in the indications listed above and only in the first postoperative week when both the imaging is less reliable and the abdomen safer to re-enter. It is our opinion that at a later stage of a critically ill patient’s course, ‘on demand’ is the way to go, based on the patient’s clinical condition and convincing imaging. Common sense and experience must prevail when high-level evidence is lacking.',\n", " 'bBox': {'x': 72, 'y': 157, 'w': 467.93, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Laparostomy',\n", " 'md': '## Laparostomy',\n", " 'bBox': {'x': 100, 'y': 582, 'w': 103.93, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Roger Saadia and Moshe Schein\\nP. Fagniez of Paris has coined the term ‘laparostomie’ (laparostomy) which entails leaving the abdomen open. Open management of the infected abdomen was instituted in the belief that the infected peritoneal cavity should be left open like an abscess cavity. It soon became clear, however, that sometimes there was still a need for .\\n```',\n", " 'md': 'Roger Saadia and Moshe Schein\\nP. Fagniez of Paris has coined the term ‘laparostomie’ (laparostomy) which entails leaving the abdomen open. Open management of the infected abdomen was instituted in the belief that the infected peritoneal cavity should be left open like an abscess cavity. It soon became clear, however, that sometimes there was still a need for .\\n```',\n", " 'bBox': {'x': 72, 'y': 582, 'w': 467.99, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 821,\n", " 'text': 'thorough abdominal re-exploration in search of deep pockets of infection.\\nLaparostomy has become an adjunct to the policy of repeated\\nlaparotomies; indeed, if the abdomen is to be reopened 48 hours\\nlater, why close it at all?\\n\\n The notion that peritonitis and its operative treatment often result in\\nincreased intra-abdominal pressure (IAP) has been raised sporadically\\nthroughout the 20th century. However, only over the last 10-20 years\\nhave clinicians accepted the concept that the prevention or\\ntreatment of intra-abdominal hypertension with laparostomy is\\nbeneficial.\\n\\n The potential advantages of laparostomy are substantial: necrosis\\nof the macerated abdominal midline incision closed forcefully and\\nrepeatedly in the presence of an edematous and distended bowel is\\navoided; better diaphragmatic excursion may be expected; and the\\nabdominal compartment syndrome with its renal, respiratory and\\nhemodynamic repercussions is prevented ( Chapter 33).\\n\\n Indications\\n\\n For practical purposes, consider laparostomy either when the abdomen\\ncannot be closed or should not be closed ( Figure 48.2).',\n", " 'md': '```markdown\\n# Laparostomy and Intra-Abdominal Pressure\\n\\nThorough abdominal re-exploration in search of deep pockets of infection. Laparostomy has become an adjunct to the policy of repeated laparotomies; indeed, if the abdomen is to be reopened 48 hours later, why close it at all?\\n\\nThe notion that peritonitis and its operative treatment often result in increased intra-abdominal pressure (IAP) has been raised sporadically throughout the 20th century. However, only over the last 10-20 years have clinicians accepted the concept that the prevention or treatment of intra-abdominal hypertension with laparostomy is beneficial.\\n\\nThe potential advantages of laparostomy are substantial: necrosis of the macerated abdominal midline incision closed forcefully and repeatedly in the presence of an edematous and distended bowel is avoided; better diaphragmatic excursion may be expected; and the abdominal compartment syndrome with its renal, respiratory, and hemodynamic repercussions is prevented (Chapter 33).\\n\\n## Indications\\n\\nFor practical purposes, consider laparostomy either when the abdomen cannot be closed or should not be closed (Figure 48.2).\\n\\n----\\n\\n### Figure 48.2\\n**Description:** This figure likely illustrates the indications for laparostomy, showing scenarios where the abdomen cannot or should not be closed. The specific content of the figure is not provided in the text, but it is referenced as a visual aid to support the discussion on laparostomy.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Laparostomy and Intra-Abdominal Pressure',\n", " 'md': '# Laparostomy and Intra-Abdominal Pressure',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Thorough abdominal re-exploration in search of deep pockets of infection. Laparostomy has become an adjunct to the policy of repeated laparotomies; indeed, if the abdomen is to be reopened 48 hours later, why close it at all?\\n\\nThe notion that peritonitis and its operative treatment often result in increased intra-abdominal pressure (IAP) has been raised sporadically throughout the 20th century. However, only over the last 10-20 years have clinicians accepted the concept that the prevention or treatment of intra-abdominal hypertension with laparostomy is beneficial.\\n\\nThe potential advantages of laparostomy are substantial: necrosis of the macerated abdominal midline incision closed forcefully and repeatedly in the presence of an edematous and distended bowel is avoided; better diaphragmatic excursion may be expected; and the abdominal compartment syndrome with its renal, respiratory, and hemodynamic repercussions is prevented (Chapter 33).',\n", " 'md': 'Thorough abdominal re-exploration in search of deep pockets of infection. Laparostomy has become an adjunct to the policy of repeated laparotomies; indeed, if the abdomen is to be reopened 48 hours later, why close it at all?\\n\\nThe notion that peritonitis and its operative treatment often result in increased intra-abdominal pressure (IAP) has been raised sporadically throughout the 20th century. However, only over the last 10-20 years have clinicians accepted the concept that the prevention or treatment of intra-abdominal hypertension with laparostomy is beneficial.\\n\\nThe potential advantages of laparostomy are substantial: necrosis of the macerated abdominal midline incision closed forcefully and repeatedly in the presence of an edematous and distended bowel is avoided; better diaphragmatic excursion may be expected; and the abdominal compartment syndrome with its renal, respiratory, and hemodynamic repercussions is prevented (Chapter 33).',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.46, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Indications',\n", " 'md': '## Indications',\n", " 'bBox': {'x': 86, 'y': 414, 'w': 87.35, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'For practical purposes, consider laparostomy either when the abdomen cannot be closed or should not be closed (Figure 48.2).\\n\\n----',\n", " 'md': 'For practical purposes, consider laparostomy either when the abdomen cannot be closed or should not be closed (Figure 48.2).\\n\\n----',\n", " 'bBox': {'x': 86, 'y': 450, 'w': 453.38, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 48.2',\n", " 'md': '### Figure 48.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** This figure likely illustrates the indications for laparostomy, showing scenarios where the abdomen cannot or should not be closed. The specific content of the figure is not provided in the text, but it is referenced as a visual aid to support the discussion on laparostomy.\\n```',\n", " 'md': '**Description:** This figure likely illustrates the indications for laparostomy, showing scenarios where the abdomen cannot or should not be closed. The specific content of the figure is not provided in the text, but it is referenced as a visual aid to support the discussion on laparostomy.\\n```',\n", " 'bBox': {'x': 86, 'y': 414, 'w': 87.35, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}, {'text': ''}]},\n", " {'page': 822,\n", " 'text': ' siesc LiRs\"\\n 5iRS eies\\n PERr474\\nFigure 48.2. “I told you that laparostomy would make him better: let the SIRS and LIRS\\nout…”\\n\\n The abdomen cannot be closed:\\n\\n After major loss of abdominal wall tissue following trauma or debridement for\\n necrotizing fasciitis.\\n Extreme visceral or retroperitoneal swelling after major trauma, resuscitation or\\n major surgery (e.g. ruptured abdominal aortic aneurysm).\\n Poor condition of fascia after multiple laparotomies.\\n Burst abdomen’ with elevated intra-abdominal pressure and/or necrotic fascial\\n edges.\\n\\n\\n The abdomen should not be closed:\\n Planned reoperation within a day or two — why lock the gate through which you\\n are to re-enter very soon?',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\nThe abdomen cannot be closed:\\n- After major loss of abdominal wall tissue following trauma or debridement for necrotizing fasciitis.\\n- Extreme visceral or retroperitoneal swelling after major trauma, resuscitation or major surgery (e.g. ruptured abdominal aortic aneurysm).\\n- Poor condition of fascia after multiple laparotomies.\\n- Burst abdomen with elevated intra-abdominal pressure and/or necrotic fascial edges.\\n\\nThe abdomen should not be closed:\\n- Planned reoperation within a day or two — why lock the gate through which you are to re-enter very soon?\\n\\n## Images\\n### Figure 48.2\\n**Description**: This figure appears to depict a clinical scenario related to laparostomy, with a quote stating, \"I told you that laparostomy would make him better: let the SIRS and LIRS out…\". The context suggests a discussion on the management of abdominal conditions where closure is not feasible.\\n\\n**Summary**: The image likely illustrates the concept of laparostomy in the context of severe abdominal conditions, emphasizing the importance of leaving the abdomen open under certain circumstances.\\n\\n\\n```',\n", " 'images': [{'name': 'img_p821_1.png',\n", " 'height': 558,\n", " 'width': 812,\n", " 'x': 105.11999999999989,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1395,\n", " 'original_height': 958}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The abdomen cannot be closed:\\n- After major loss of abdominal wall tissue following trauma or debridement for necrotizing fasciitis.\\n- Extreme visceral or retroperitoneal swelling after major trauma, resuscitation or major surgery (e.g. ruptured abdominal aortic aneurysm).\\n- Poor condition of fascia after multiple laparotomies.\\n- Burst abdomen with elevated intra-abdominal pressure and/or necrotic fascial edges.\\n\\nThe abdomen should not be closed:\\n- Planned reoperation within a day or two — why lock the gate through which you are to re-enter very soon?',\n", " 'md': 'The abdomen cannot be closed:\\n- After major loss of abdominal wall tissue following trauma or debridement for necrotizing fasciitis.\\n- Extreme visceral or retroperitoneal swelling after major trauma, resuscitation or major surgery (e.g. ruptured abdominal aortic aneurysm).\\n- Poor condition of fascia after multiple laparotomies.\\n- Burst abdomen with elevated intra-abdominal pressure and/or necrotic fascial edges.\\n\\nThe abdomen should not be closed:\\n- Planned reoperation within a day or two — why lock the gate through which you are to re-enter very soon?',\n", " 'bBox': {'x': 79, 'y': 449, 'w': 272.69, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 48.2',\n", " 'md': '### Figure 48.2',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description**: This figure appears to depict a clinical scenario related to laparostomy, with a quote stating, \"I told you that laparostomy would make him better: let the SIRS and LIRS out…\". The context suggests a discussion on the management of abdominal conditions where closure is not feasible.\\n\\n**Summary**: The image likely illustrates the concept of laparostomy in the context of severe abdominal conditions, emphasizing the importance of leaving the abdomen open under certain circumstances.\\n\\n\\n```',\n", " 'md': '**Description**: This figure appears to depict a clinical scenario related to laparostomy, with a quote stating, \"I told you that laparostomy would make him better: let the SIRS and LIRS out…\". The context suggests a discussion on the management of abdominal conditions where closure is not feasible.\\n\\n**Summary**: The image likely illustrates the concept of laparostomy in the context of severe abdominal conditions, emphasizing the importance of leaving the abdomen open under certain circumstances.\\n\\n\\n```',\n", " 'bBox': {'x': 286.21, 'y': 154.46, 'w': 32.16, 'h': 12.85}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 823,\n", " 'text': ' Closure possible only under extreme tension, compromising the fascia and creating\\n intra-abdominal hypertension (IAħ).\\n\\n Technical considerations of laparostomy\\n\\n Now that you have decided not to close the abdomen, how should\\nyou manage it? The option of simply covering the exposed viscera with\\nmoist gauze packs has been practiced for generations but is inadvisable:\\nintestine, if not matted together, can eviscerate; it is also messy, requiring\\nintensive work to keep the patient and his bed clean and dry. More\\nimportantly, it carries a significant risk of creating spontaneous,\\n‘atmospheric’ (i.e. exposed to the open air and without a track) intestinal\\nfistulas ( Chapter 47). A friable, dilated bowel wall does not weather\\nwell the trauma of exposure and repeated dressing change, and is likely\\nat some point to break down. Temporary abdominal closure (TAC)\\ndevices to cover the laparostomy wound are therefore highly\\nrecommended.\\n\\n Temporary abdominal closure (TAC)\\n\\n The ideal method (still to be invented) has to:\\n\\n • Allow re-exploration, offering easy access for relaparotomies, if\\n needed.\\n • Offer drainage to the peritoneal exudate and later for possible\\n fistulas.\\n • Preserve fascia for future abdominal closure.\\n • Avoid ‘loss of domain’: when the fascial edges retract, the viscera\\n bulge out and cannot be returned to the peritoneal cavity.\\n • Be kind to the underlying bowel especially in the absence of an\\n interposed omentum.\\n\\n Your local guru has probably his own preferred method of TAC be it a\\n‘Bogota bag’ made of a large sterile intravenous-fluid bag, a ready-to-use\\ntransparent ‘bowel bag’, a synthetic mesh (absorbable or non-',\n", " 'md': '```markdown\\n## Technical Considerations of Laparostomy\\n\\nClosure is possible only under extreme tension, compromising the fascia and creating intra-abdominal hypertension (IAħ).\\n\\nNow that you have decided not to close the abdomen, how should you manage it? The option of simply covering the exposed viscera with moist gauze packs has been practiced for generations but is inadvisable: intestine, if not matted together, can eviscerate; it is also messy, requiring intensive work to keep the patient and his bed clean and dry. More importantly, it carries a significant risk of creating spontaneous, ‘atmospheric’ (i.e. exposed to the open air and without a track) intestinal fistulas (Chapter 47). A friable, dilated bowel wall does not weather well the trauma of exposure and repeated dressing change, and is likely at some point to break down. Temporary abdominal closure (TAC) devices to cover the laparostomy wound are therefore highly recommended.\\n\\n### Temporary Abdominal Closure (TAC)\\n\\nThe ideal method (still to be invented) has to:\\n\\n- Allow re-exploration, offering easy access for relaparotomies, if needed.\\n- Offer drainage to the peritoneal exudate and later for possible fistulas.\\n- Preserve fascia for future abdominal closure.\\n- Avoid ‘loss of domain’: when the fascial edges retract, the viscera bulge out and cannot be returned to the peritoneal cavity.\\n- Be kind to the underlying bowel especially in the absence of an interposed omentum.\\n\\nYour local guru has probably his own preferred method of TAC be it a ‘Bogota bag’ made of a large sterile intravenous-fluid bag, a ready-to-use transparent ‘bowel bag’, a synthetic mesh (absorbable or non-).\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Technical Considerations of Laparostomy',\n", " 'md': '## Technical Considerations of Laparostomy',\n", " 'bBox': {'x': 86, 'y': 159, 'w': 320.62, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Closure is possible only under extreme tension, compromising the fascia and creating intra-abdominal hypertension (IAħ).\\n\\nNow that you have decided not to close the abdomen, how should you manage it? The option of simply covering the exposed viscera with moist gauze packs has been practiced for generations but is inadvisable: intestine, if not matted together, can eviscerate; it is also messy, requiring intensive work to keep the patient and his bed clean and dry. More importantly, it carries a significant risk of creating spontaneous, ‘atmospheric’ (i.e. exposed to the open air and without a track) intestinal fistulas (Chapter 47). A friable, dilated bowel wall does not weather well the trauma of exposure and repeated dressing change, and is likely at some point to break down. Temporary abdominal closure (TAC) devices to cover the laparostomy wound are therefore highly recommended.',\n", " 'md': 'Closure is possible only under extreme tension, compromising the fascia and creating intra-abdominal hypertension (IAħ).\\n\\nNow that you have decided not to close the abdomen, how should you manage it? The option of simply covering the exposed viscera with moist gauze packs has been practiced for generations but is inadvisable: intestine, if not matted together, can eviscerate; it is also messy, requiring intensive work to keep the patient and his bed clean and dry. More importantly, it carries a significant risk of creating spontaneous, ‘atmospheric’ (i.e. exposed to the open air and without a track) intestinal fistulas (Chapter 47). A friable, dilated bowel wall does not weather well the trauma of exposure and repeated dressing change, and is likely at some point to break down. Temporary abdominal closure (TAC) devices to cover the laparostomy wound are therefore highly recommended.',\n", " 'bBox': {'x': 72, 'y': 104, 'w': 467.61, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Temporary Abdominal Closure (TAC)',\n", " 'md': '### Temporary Abdominal Closure (TAC)',\n", " 'bBox': {'x': 86, 'y': 420, 'w': 283.52, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The ideal method (still to be invented) has to:\\n\\n- Allow re-exploration, offering easy access for relaparotomies, if needed.\\n- Offer drainage to the peritoneal exudate and later for possible fistulas.\\n- Preserve fascia for future abdominal closure.\\n- Avoid ‘loss of domain’: when the fascial edges retract, the viscera bulge out and cannot be returned to the peritoneal cavity.\\n- Be kind to the underlying bowel especially in the absence of an interposed omentum.\\n\\nYour local guru has probably his own preferred method of TAC be it a ‘Bogota bag’ made of a large sterile intravenous-fluid bag, a ready-to-use transparent ‘bowel bag’, a synthetic mesh (absorbable or non-).\\n```',\n", " 'md': 'The ideal method (still to be invented) has to:\\n\\n- Allow re-exploration, offering easy access for relaparotomies, if needed.\\n- Offer drainage to the peritoneal exudate and later for possible fistulas.\\n- Preserve fascia for future abdominal closure.\\n- Avoid ‘loss of domain’: when the fascial edges retract, the viscera bulge out and cannot be returned to the peritoneal cavity.\\n- Be kind to the underlying bowel especially in the absence of an interposed omentum.\\n\\nYour local guru has probably his own preferred method of TAC be it a ‘Bogota bag’ made of a large sterile intravenous-fluid bag, a ready-to-use transparent ‘bowel bag’, a synthetic mesh (absorbable or non-).\\n```',\n", " 'bBox': {'x': 72, 'y': 456, 'w': 467.63, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'well the trauma of exposure and repeated dressing change, and is likely'}]},\n", " {'page': 824,\n", " 'text': 'absorbable), a Velcro®-type material, which can be tightened like your\\ntennis shoe (‘Wittmann patch’) or some ‘innovation’ featured in Figure\\n48.3. We even know a guy in South America who uses discarded nylon\\nhose for this purpose. Nowadays, there is a whole line of home-made or\\nlucrative commercial products based on the vacuum concept.\\n 5\\n F2RYA2814\\nFigure 48.3. Surgeon to visitors: “This is our new temporary closure device. It allows us\\nto apply negative pressure to the whole patient…”\\n\\n In fact, we (MS and RS) were the first authors to recommend and use\\na vacuum-suction system for TAC (British Journal of Surgery, 1986). We\\ndubbed our system the ‘sandwich technique’. It consisted then of:\\n\\n • A non-absorbable, porous synthetic mesh (Marlex® — polypropylene\\n [these days we would use one of the ‘bowel-friendly’ meshes])\\n sutured to the fascial edges.\\n • Two suction drains placed over the mesh in the edges of the\\n abdominal defect and brought out through the skin to collect the\\n abdominal effluent.\\n Sheets of Stomahesive® applied to the healthy skin bordering the',\n", " 'md': \"```markdown\\n## Page Content\\n\\nIn this section, we discuss a Velcro®-type material that can be tightened like your tennis shoe, referred to as the ‘Wittmann patch’, or some ‘innovation’ featured in **Figure 48.3**. There is also mention of a person in South America who uses discarded nylon hose for this purpose. Nowadays, there is a whole line of home-made or lucrative commercial products based on the vacuum concept.\\n\\n**Figure 48.3**: Surgeon to visitors: “This is our new temporary closure device. It allows us to apply negative pressure to the whole patient…”\\n\\nIn fact, we (MS and RS) were the first authors to recommend and use a vacuum-suction system for TAC (British Journal of Surgery, 1986). We dubbed our system the ‘sandwich technique’. It consisted then of:\\n\\n- A non-absorbable, porous synthetic mesh (Marlex® — polypropylene [these days we would use one of the ‘bowel-friendly’ meshes]) sutured to the fascial edges.\\n- Two suction drains placed over the mesh in the edges of the abdominal defect and brought out through the skin to collect the abdominal effluent.\\n- Sheets of Stomahesive® applied to the healthy skin bordering the...\\n\\n## Image Identification and Description\\n\\n**Figure 48.3**: This image depicts a temporary closure device used in surgical procedures. The device is designed to apply negative pressure to the entire patient, which is a critical aspect of the vacuum-suction system discussed in the text. The image likely shows the device in use or its components, but specific details are not provided in the text.\\n\\n### Summary\\nThe text discusses innovative surgical techniques involving a vacuum-suction system, highlighting the use of a temporary closure device that applies negative pressure. The 'sandwich technique' is introduced, which utilizes a synthetic mesh and suction drains to manage abdominal defects.\\n```\",\n", " 'images': [{'name': 'img_p823_1.png',\n", " 'height': 585,\n", " 'width': 830,\n", " 'x': 100.80000000000018,\n", " 'y': 167.76,\n", " 'original_width': 1424,\n", " 'original_height': 1004}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'In this section, we discuss a Velcro®-type material that can be tightened like your tennis shoe, referred to as the ‘Wittmann patch’, or some ‘innovation’ featured in **Figure 48.3**. There is also mention of a person in South America who uses discarded nylon hose for this purpose. Nowadays, there is a whole line of home-made or lucrative commercial products based on the vacuum concept.\\n\\n**Figure 48.3**: Surgeon to visitors: “This is our new temporary closure device. It allows us to apply negative pressure to the whole patient…”\\n\\nIn fact, we (MS and RS) were the first authors to recommend and use a vacuum-suction system for TAC (British Journal of Surgery, 1986). We dubbed our system the ‘sandwich technique’. It consisted then of:\\n\\n- A non-absorbable, porous synthetic mesh (Marlex® — polypropylene [these days we would use one of the ‘bowel-friendly’ meshes]) sutured to the fascial edges.\\n- Two suction drains placed over the mesh in the edges of the abdominal defect and brought out through the skin to collect the abdominal effluent.\\n- Sheets of Stomahesive® applied to the healthy skin bordering the...',\n", " 'md': 'In this section, we discuss a Velcro®-type material that can be tightened like your tennis shoe, referred to as the ‘Wittmann patch’, or some ‘innovation’ featured in **Figure 48.3**. There is also mention of a person in South America who uses discarded nylon hose for this purpose. Nowadays, there is a whole line of home-made or lucrative commercial products based on the vacuum concept.\\n\\n**Figure 48.3**: Surgeon to visitors: “This is our new temporary closure device. It allows us to apply negative pressure to the whole patient…”\\n\\nIn fact, we (MS and RS) were the first authors to recommend and use a vacuum-suction system for TAC (British Journal of Surgery, 1986). We dubbed our system the ‘sandwich technique’. It consisted then of:\\n\\n- A non-absorbable, porous synthetic mesh (Marlex® — polypropylene [these days we would use one of the ‘bowel-friendly’ meshes]) sutured to the fascial edges.\\n- Two suction drains placed over the mesh in the edges of the abdominal defect and brought out through the skin to collect the abdominal effluent.\\n- Sheets of Stomahesive® applied to the healthy skin bordering the...',\n", " 'bBox': {'x': 72, 'y': 138, 'w': 467.52, 'h': 17.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 48.3**: This image depicts a temporary closure device used in surgical procedures. The device is designed to apply negative pressure to the entire patient, which is a critical aspect of the vacuum-suction system discussed in the text. The image likely shows the device in use or its components, but specific details are not provided in the text.',\n", " 'md': '**Figure 48.3**: This image depicts a temporary closure device used in surgical procedures. The device is designed to apply negative pressure to the entire patient, which is a critical aspect of the vacuum-suction system discussed in the text. The image likely shows the device in use or its components, but specific details are not provided in the text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"The text discusses innovative surgical techniques involving a vacuum-suction system, highlighting the use of a temporary closure device that applies negative pressure. The 'sandwich technique' is introduced, which utilizes a synthetic mesh and suction drains to manage abdominal defects.\\n```\",\n", " 'md': \"The text discusses innovative surgical techniques involving a vacuum-suction system, highlighting the use of a temporary closure device that applies negative pressure. The 'sandwich technique' is introduced, which utilizes a synthetic mesh and suction drains to manage abdominal defects.\\n```\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'tennis shoe (‘Wittmann patch’) or some ‘innovation’ featured in Figure 48.3. We even know a guy in South America who uses discarded nylon hose for this purpose. Nowadays, there is a whole line of home-made or'}]},\n", " {'page': 825,\n", " 'text': \" • defect.\\n • A large, adhesive, transparent sheet (Steri-Drape™ or Opsite™)\\n stuck on top to cover the entire abdomen.\\n\\n This arrangement is beneficial since the viscera are protected, the\\nlaparostomy’s output is measurable, the patient remains clean and\\ndry, and the demands on nursing are minimized ( Figure 48.4).\\nNowadays, we recommend replacing the suction drains with a vacuum-\\nassisted closure (VAC) sponge applied directly onto the mesh and\\nconnected to an electric suction pump. This refinement is beneficial:\\n Transparent adhesive drape Non-absorbable mesh\\n Suction tubes sutured to defect's edge\\n Fascial edge\\n Exposed bowel at the base of an abdominal wall defect\\n Figure 48.4. The ‘sandwich technique’ in the management of laparostomy (when neither\\n further laparotomy nor ‘early’ abdominal closure is planned).\\n\\n • The suction effect is more efficient and reliable.\\n • The VAC sponge can be changed every few days at the bedside\\n when it gets ‘mucky’.\\n • The strong suction effect has the added effect of drawing together\\n the defect edges and minimizing the fascial retraction.\\n\\n The ‘sandwich’ can be modified depending on the circumstances. If, for\\nexample, an early relaparotomy or closure is contemplated, the mesh is\\nnot used ( Figure 48.5). Instead, a perforated plastic bowel bag (much\",\n", " 'md': \"```markdown\\n## Page Content\\n\\n- A large, adhesive, transparent sheet (Steri-Drape™ or Opsite™) stuck on top to cover the entire abdomen.\\n\\nThis arrangement is beneficial since the viscera are protected, the laparostomy’s output is measurable, the patient remains clean and dry, and the demands on nursing are minimized (Figure 48.4). Nowadays, we recommend replacing the suction drains with a vacuum-assisted closure (VAC) sponge applied directly onto the mesh and connected to an electric suction pump. This refinement is beneficial:\\n- The suction effect is more efficient and reliable.\\n- The VAC sponge can be changed every few days at the bedside when it gets ‘mucky’.\\n- The strong suction effect has the added effect of drawing together the defect edges and minimizing the fascial retraction.\\n\\nThe ‘sandwich’ can be modified depending on the circumstances. If, for example, an early relaparotomy or closure is contemplated, the mesh is not used (Figure 48.5). Instead, a perforated plastic bowel bag (much ).\\n\\n## Figure Descriptions\\n\\n### Figure 48.4\\n**Description:** The image illustrates the ‘sandwich technique’ in the management of laparostomy, where a transparent adhesive drape is placed over a non-absorbable mesh that is sutured to the defect's edge. The image shows the exposed bowel at the base of an abdominal wall defect.\\n\\n**Summary:** This figure demonstrates the arrangement of the VAC sponge and the transparent adhesive drape, highlighting the protective measures for the viscera and the management of laparostomy.\\n\\n### Figure 48.5\\n**Description:** \\n\\n**Summary:** This figure likely depicts an alternative arrangement for managing laparostomy when an early relaparotomy or closure is planned, but the details are not clearly identifiable.\\n```\",\n", " 'images': [{'name': 'img_p824_1.png',\n", " 'height': 444,\n", " 'width': 770,\n", " 'x': 115.92000000000007,\n", " 'y': 264.96000000000004,\n", " 'original_width': 1323,\n", " 'original_height': 764}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- A large, adhesive, transparent sheet (Steri-Drape™ or Opsite™) stuck on top to cover the entire abdomen.\\n\\nThis arrangement is beneficial since the viscera are protected, the laparostomy’s output is measurable, the patient remains clean and dry, and the demands on nursing are minimized (Figure 48.4). Nowadays, we recommend replacing the suction drains with a vacuum-assisted closure (VAC) sponge applied directly onto the mesh and connected to an electric suction pump. This refinement is beneficial:\\n- The suction effect is more efficient and reliable.\\n- The VAC sponge can be changed every few days at the bedside when it gets ‘mucky’.\\n- The strong suction effect has the added effect of drawing together the defect edges and minimizing the fascial retraction.\\n\\nThe ‘sandwich’ can be modified depending on the circumstances. If, for example, an early relaparotomy or closure is contemplated, the mesh is not used (Figure 48.5). Instead, a perforated plastic bowel bag (much ).',\n", " 'md': '- A large, adhesive, transparent sheet (Steri-Drape™ or Opsite™) stuck on top to cover the entire abdomen.\\n\\nThis arrangement is beneficial since the viscera are protected, the laparostomy’s output is measurable, the patient remains clean and dry, and the demands on nursing are minimized (Figure 48.4). Nowadays, we recommend replacing the suction drains with a vacuum-assisted closure (VAC) sponge applied directly onto the mesh and connected to an electric suction pump. This refinement is beneficial:\\n- The suction effect is more efficient and reliable.\\n- The VAC sponge can be changed every few days at the bedside when it gets ‘mucky’.\\n- The strong suction effect has the added effect of drawing together the defect edges and minimizing the fascial retraction.\\n\\nThe ‘sandwich’ can be modified depending on the circumstances. If, for example, an early relaparotomy or closure is contemplated, the mesh is not used (Figure 48.5). Instead, a perforated plastic bowel bag (much ).',\n", " 'bBox': {'x': 72, 'y': 131, 'w': 467.91, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure Descriptions',\n", " 'md': '## Figure Descriptions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 48.4',\n", " 'md': '### Figure 48.4',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"**Description:** The image illustrates the ‘sandwich technique’ in the management of laparostomy, where a transparent adhesive drape is placed over a non-absorbable mesh that is sutured to the defect's edge. The image shows the exposed bowel at the base of an abdominal wall defect.\\n\\n**Summary:** This figure demonstrates the arrangement of the VAC sponge and the transparent adhesive drape, highlighting the protective measures for the viscera and the management of laparostomy.\",\n", " 'md': \"**Description:** The image illustrates the ‘sandwich technique’ in the management of laparostomy, where a transparent adhesive drape is placed over a non-absorbable mesh that is sutured to the defect's edge. The image shows the exposed bowel at the base of an abdominal wall defect.\\n\\n**Summary:** This figure demonstrates the arrangement of the VAC sponge and the transparent adhesive drape, highlighting the protective measures for the viscera and the management of laparostomy.\",\n", " 'bBox': {'x': 100, 'y': 85, 'w': 231.5, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 48.5',\n", " 'md': '### Figure 48.5',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Description:** \\n\\n**Summary:** This figure likely depicts an alternative arrangement for managing laparostomy when an early relaparotomy or closure is planned, but the details are not clearly identifiable.\\n```',\n", " 'md': '**Description:** \\n\\n**Summary:** This figure likely depicts an alternative arrangement for managing laparostomy when an early relaparotomy or closure is planned, but the details are not clearly identifiable.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Nowadays, we recommend replacing the suction drains with a '},\n", " {'text': ''}]},\n", " {'page': 826,\n", " 'text': 'wider than the abdominal defect) is applied over the viscera; its edges\\nare tucked in under the abdominal wall bordering the defect. Early\\nadhesions between intestine and abdominal wall are thus prevented. A\\nprotective, absorbent, layer of gauze (or a ‘green towel’) is held in place\\nover this plastic sheet by a large Opsite™ dressing. Suction is\\nunnecessary if the patient is returned to the OR the next day.\\n Transparent occlusive-\\n adhesive drape Suction tubes Gauze or towel\\n Fascial edge\\n Perforated bowelbag\\n Exposed bowel at the base of an abdominal wall defect\\nFigure 48.5. Temporary vacuum abdominal closure (when additional reoperations or\\n‘early’ abdominal closure are planned).\\n\\n The most dreaded complication of TAC devices is the development of spontaneous intestinal\\n fistulas resulting from the intimate contact between the artificial cover and the intestinal wall.\\n The best prevention is to interpose the omentum, whenever possible, between the TAC\\n prosthesis and intestine.\\n\\n Terminating the laparostomy\\n\\n Once the laparostomy has outlived its usefulness, it is time to plan for\\nabdominal closure. Two options exist, depending on both the surgeon’s\\npreference and local abdominal conditions: early abdominal closure or\\ndelayed abdominal wall reconstruction.',\n", " 'md': '```markdown\\n### Text\\nA protective, absorbent layer of gauze (or a ‘green towel’) is held in place over this plastic sheet by a large Opsite™ dressing. Suction is unnecessary if the patient is returned to the OR the next day.\\n\\nThe most dreaded complication of TAC devices is the development of spontaneous intestinal fistulas resulting from the intimate contact between the artificial cover and the intestinal wall. The best prevention is to interpose the omentum, whenever possible, between the TAC prosthesis and intestine.\\n\\nTerminating the laparostomy\\n\\nOnce the laparostomy has outlived its usefulness, it is time to plan for abdominal closure. Two options exist, depending on both the surgeon’s preference and local abdominal conditions: early abdominal closure or delayed abdominal wall reconstruction.\\n\\n### Figure\\n**Figure 48.5**: Temporary vacuum abdominal closure (when additional reoperations or ‘early’ abdominal closure are planned).\\n\\n**Description**: The image illustrates a temporary vacuum abdominal closure setup. It includes a transparent occlusive-adhesive drape, suction tubes, and a gauze or towel placed over the exposed bowel at the base of an abdominal wall defect. The perforated bowel bag is also visible, indicating the management of the exposed bowel.\\n\\n**Summary**: This figure depicts a clinical setup for managing abdominal wall defects using a temporary vacuum closure method, highlighting the components involved in preventing complications during the healing process.\\n\\n```',\n", " 'images': [{'name': 'img_p825_1.png',\n", " 'height': 444,\n", " 'width': 835,\n", " 'x': 99.35999999999967,\n", " 'y': 182.16,\n", " 'original_width': 1436,\n", " 'original_height': 764}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Text',\n", " 'md': '### Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'A protective, absorbent layer of gauze (or a ‘green towel’) is held in place over this plastic sheet by a large Opsite™ dressing. Suction is unnecessary if the patient is returned to the OR the next day.\\n\\nThe most dreaded complication of TAC devices is the development of spontaneous intestinal fistulas resulting from the intimate contact between the artificial cover and the intestinal wall. The best prevention is to interpose the omentum, whenever possible, between the TAC prosthesis and intestine.\\n\\nTerminating the laparostomy\\n\\nOnce the laparostomy has outlived its usefulness, it is time to plan for abdominal closure. Two options exist, depending on both the surgeon’s preference and local abdominal conditions: early abdominal closure or delayed abdominal wall reconstruction.',\n", " 'md': 'A protective, absorbent layer of gauze (or a ‘green towel’) is held in place over this plastic sheet by a large Opsite™ dressing. Suction is unnecessary if the patient is returned to the OR the next day.\\n\\nThe most dreaded complication of TAC devices is the development of spontaneous intestinal fistulas resulting from the intimate contact between the artificial cover and the intestinal wall. The best prevention is to interpose the omentum, whenever possible, between the TAC prosthesis and intestine.\\n\\nTerminating the laparostomy\\n\\nOnce the laparostomy has outlived its usefulness, it is time to plan for abdominal closure. Two options exist, depending on both the surgeon’s preference and local abdominal conditions: early abdominal closure or delayed abdominal wall reconstruction.',\n", " 'bBox': {'x': 72, 'y': 168, 'w': 466.93, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure',\n", " 'md': '### Figure',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 48.5**: Temporary vacuum abdominal closure (when additional reoperations or ‘early’ abdominal closure are planned).\\n\\n**Description**: The image illustrates a temporary vacuum abdominal closure setup. It includes a transparent occlusive-adhesive drape, suction tubes, and a gauze or towel placed over the exposed bowel at the base of an abdominal wall defect. The perforated bowel bag is also visible, indicating the management of the exposed bowel.\\n\\n**Summary**: This figure depicts a clinical setup for managing abdominal wall defects using a temporary vacuum closure method, highlighting the components involved in preventing complications during the healing process.\\n\\n```',\n", " 'md': '**Figure 48.5**: Temporary vacuum abdominal closure (when additional reoperations or ‘early’ abdominal closure are planned).\\n\\n**Description**: The image illustrates a temporary vacuum abdominal closure setup. It includes a transparent occlusive-adhesive drape, suction tubes, and a gauze or towel placed over the exposed bowel at the base of an abdominal wall defect. The perforated bowel bag is also visible, indicating the management of the exposed bowel.\\n\\n**Summary**: This figure depicts a clinical setup for managing abdominal wall defects using a temporary vacuum closure method, highlighting the components involved in preventing complications during the healing process.\\n\\n```',\n", " 'bBox': {'x': 75, 'y': 185.62, 'w': 259.46, 'h': 14.84}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 827,\n", " 'text': ' Early abdominal closure\\n\\n The optimal time window is quite narrow, about a week from the\\nlast abdominal exploration. Beyond that, the fascia retracts laterally\\nand adhesions form between intestine and abdominal wall. You will then\\nfind it impossible to mobilize and push the bulging viscera back into the\\nabdominal cavity (‘loss of domain’), to say nothing of the stubborn refusal\\nof the fascial edges to meet in the midline. Even within the first week, the\\nlonger the delay, the more difficult and risky this endeavor becomes. It\\ngoes without saying that feasibility of early closure is predicated on a\\nnumber of factors, including defect size, resolution of the ileus, and\\nabsence of fistulas, and negative fluid balance ( Chapter 47). In rare\\ncases, the defect is so small that the fascial edges lend themselves to\\nmidline suturing without tension (one wonders, in such cases, whether a\\nlaparostomy was indicated in the first place!). More commonly, in small-\\nsize defects, the fascia is left open, but primary cutaneous closure is\\npossible after undermining the skin edges. The patient is left with a\\nventral hernia, but skin cover is superior to any prosthetic material (\\n Chapter 40\\n\\n Most laparostomy wounds in the aftermath of a real abdominal\\ndisaster are large and present with fixed, retracted edges, and with\\nloss of domain for the abdominal viscera. Recently developed\\nbiomaterials are being aggressively marketed (a new such product is\\nbeing alleged as ‘superior’ almost every month…) for this setting. They\\nare claimed to be superior to synthetic meshes in resisting infection in\\nthese frequently heavily contaminated wounds. It turns out that they are\\nnot totally immune to infection. While providing a temporary bridge, their\\nother claim to fame is their purported ability to stimulate growth of site-\\nspecific cells to replace the prosthesis with new fascia (not scar). In\\npractice, the majority of patients undergoing early abdominal\\nclosure with these ‘wunderbioprostheses’ are found, on brief follow-\\nup, to have large ventral hernias. It seems therefore that, in many\\ninstances, these biomaterials are no more than a tremendously\\nexpensive TAC.\\n\\n Some surgeons advocate early reconstruction using ‘component\\nseparation techniques’ to approximate the fascia, occasionally',\n", " 'md': '```markdown\\n# Early Abdominal Closure\\n\\nThe optimal time window is quite narrow, about a week from the last abdominal exploration. Beyond that, the fascia retracts laterally and adhesions form between the intestine and abdominal wall. You will then find it impossible to mobilize and push the bulging viscera back into the abdominal cavity (‘loss of domain’), to say nothing of the stubborn refusal of the fascial edges to meet in the midline. Even within the first week, the longer the delay, the more difficult and risky this endeavor becomes.\\n\\nIt goes without saying that the feasibility of early closure is predicated on a number of factors, including defect size, resolution of the ileus, absence of fistulas, and negative fluid balance (Chapter 47). In rare cases, the defect is so small that the fascial edges lend themselves to midline suturing without tension (one wonders, in such cases, whether a laparostomy was indicated in the first place!). More commonly, in small-size defects, the fascia is left open, but primary cutaneous closure is possible after undermining the skin edges. The patient is left with a ventral hernia, but skin cover is superior to any prosthetic material (Chapter 40).\\n\\nMost laparostomy wounds in the aftermath of a real abdominal disaster are large and present with fixed, retracted edges, and with loss of domain for the abdominal viscera. Recently developed biomaterials are being aggressively marketed (a new such product is being alleged as ‘superior’ almost every month…) for this setting. They are claimed to be superior to synthetic meshes in resisting infection in these frequently heavily contaminated wounds. It turns out that they are not totally immune to infection. While providing a temporary bridge, their other claim to fame is their purported ability to stimulate growth of site-specific cells to replace the prosthesis with new fascia (not scar). In practice, the majority of patients undergoing early abdominal closure with these ‘wunderbioprostheses’ are found, on brief follow-up, to have large ventral hernias. It seems therefore that, in many instances, these biomaterials are no more than a tremendously expensive TAC.\\n\\nSome surgeons advocate early reconstruction using ‘component separation techniques’ to approximate the fascia, occasionally.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Early Abdominal Closure',\n", " 'md': '# Early Abdominal Closure',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 191.27, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The optimal time window is quite narrow, about a week from the last abdominal exploration. Beyond that, the fascia retracts laterally and adhesions form between the intestine and abdominal wall. You will then find it impossible to mobilize and push the bulging viscera back into the abdominal cavity (‘loss of domain’), to say nothing of the stubborn refusal of the fascial edges to meet in the midline. Even within the first week, the longer the delay, the more difficult and risky this endeavor becomes.\\n\\nIt goes without saying that the feasibility of early closure is predicated on a number of factors, including defect size, resolution of the ileus, absence of fistulas, and negative fluid balance (Chapter 47). In rare cases, the defect is so small that the fascial edges lend themselves to midline suturing without tension (one wonders, in such cases, whether a laparostomy was indicated in the first place!). More commonly, in small-size defects, the fascia is left open, but primary cutaneous closure is possible after undermining the skin edges. The patient is left with a ventral hernia, but skin cover is superior to any prosthetic material (Chapter 40).\\n\\nMost laparostomy wounds in the aftermath of a real abdominal disaster are large and present with fixed, retracted edges, and with loss of domain for the abdominal viscera. Recently developed biomaterials are being aggressively marketed (a new such product is being alleged as ‘superior’ almost every month…) for this setting. They are claimed to be superior to synthetic meshes in resisting infection in these frequently heavily contaminated wounds. It turns out that they are not totally immune to infection. While providing a temporary bridge, their other claim to fame is their purported ability to stimulate growth of site-specific cells to replace the prosthesis with new fascia (not scar). In practice, the majority of patients undergoing early abdominal closure with these ‘wunderbioprostheses’ are found, on brief follow-up, to have large ventral hernias. It seems therefore that, in many instances, these biomaterials are no more than a tremendously expensive TAC.\\n\\nSome surgeons advocate early reconstruction using ‘component separation techniques’ to approximate the fascia, occasionally.\\n```',\n", " 'md': 'The optimal time window is quite narrow, about a week from the last abdominal exploration. Beyond that, the fascia retracts laterally and adhesions form between the intestine and abdominal wall. You will then find it impossible to mobilize and push the bulging viscera back into the abdominal cavity (‘loss of domain’), to say nothing of the stubborn refusal of the fascial edges to meet in the midline. Even within the first week, the longer the delay, the more difficult and risky this endeavor becomes.\\n\\nIt goes without saying that the feasibility of early closure is predicated on a number of factors, including defect size, resolution of the ileus, absence of fistulas, and negative fluid balance (Chapter 47). In rare cases, the defect is so small that the fascial edges lend themselves to midline suturing without tension (one wonders, in such cases, whether a laparostomy was indicated in the first place!). More commonly, in small-size defects, the fascia is left open, but primary cutaneous closure is possible after undermining the skin edges. The patient is left with a ventral hernia, but skin cover is superior to any prosthetic material (Chapter 40).\\n\\nMost laparostomy wounds in the aftermath of a real abdominal disaster are large and present with fixed, retracted edges, and with loss of domain for the abdominal viscera. Recently developed biomaterials are being aggressively marketed (a new such product is being alleged as ‘superior’ almost every month…) for this setting. They are claimed to be superior to synthetic meshes in resisting infection in these frequently heavily contaminated wounds. It turns out that they are not totally immune to infection. While providing a temporary bridge, their other claim to fame is their purported ability to stimulate growth of site-specific cells to replace the prosthesis with new fascia (not scar). In practice, the majority of patients undergoing early abdominal closure with these ‘wunderbioprostheses’ are found, on brief follow-up, to have large ventral hernias. It seems therefore that, in many instances, these biomaterials are no more than a tremendously expensive TAC.\\n\\nSome surgeons advocate early reconstruction using ‘component separation techniques’ to approximate the fascia, occasionally.\\n```',\n", " 'bBox': {'x': 72, 'y': 88, 'w': 467.96, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'cases, the defect is so small that the fascial edges lend themselves to'},\n", " {'text': ''}]},\n", " {'page': 828,\n", " 'text': 'buttressing the midline with an underlay of bioprosthesis.\\nExperimentation with these novel techniques is inadvisable for the\\nuninitiated. In our practice, most patients are treated with delayed\\nabdominal reconstruction.\\n\\n There is some evidence that negative pressure dressing actually sucks out cytokines and other\\n bad stuff — as depicted in Figure 48.2 — thus alleviating the inflammatory attack. Besides,\\n recent literature has shown that by combining negative pressure therapy with a temporary mesh\\n providing mechanical traction increased at every dressing change, the delayed fascial closure\\n rates are higher and enteric fistula rates lower than with any other temporary abdominal closure\\n method. Ari\\n\\n However you manage the abdominal wall defect, remember that\\nyour patient has just recovered from the immense stress of severe\\nperitonitis and multiple operations — he cannot take much more at\\nthis stage.\\n\\n Delayed abdominal wall reconstruction\\n\\n Consider the following scenario:\\n\\n An obese patient develops a breakdown of his colorectal anastomosis with severe fecal\\n peritonitis. The patient is now grossly distended, ‘septic’ and in respiratory failure. He\\n undergoes a Hartmann’s; and, obviously, his abdomen cannot be closed — so he is managed\\n with a laparostomy. In your judgment, he does not require planned reoperations. Early closure\\n is not a realistic option. How to proceed?\\n\\n At this juncture, we would have used our sandwich technique. A more\\nfancy (but more expensive) VAC system over the mesh also works well at\\nthis stage. A couple of weeks later, a healthy layer of granulation tissue\\nappears over the disintegrating absorbable mesh (we don’t use Marlex®\\nfor temporary closure nowadays). A split-skin graft can now be applied\\nonto the defect. The resulting ventral hernia is usually wide-necked and',\n", " 'md': '```markdown\\n## Delayed Abdominal Reconstruction\\n\\nButtressing the midline with an underlay of bioprosthesis. Experimentation with these novel techniques is inadvisable for the uninitiated. In our practice, most patients are treated with delayed abdominal reconstruction.\\n\\nThere is some evidence that negative pressure dressing actually sucks out cytokines and other bad stuff — as depicted in **Figure 48.2** — thus alleviating the inflammatory attack. Besides, recent literature has shown that by combining negative pressure therapy with a temporary mesh providing mechanical traction increased at every dressing change, the delayed fascial closure rates are higher and enteric fistula rates lower than with any other temporary abdominal closure method.\\n\\nHowever, you manage the abdominal wall defect, remember that your patient has just recovered from the immense stress of severe peritonitis and multiple operations — he cannot take much more at this stage.\\n\\n### Consider the Following Scenario:\\n\\nAn obese patient develops a breakdown of his colorectal anastomosis with severe fecal peritonitis. The patient is now grossly distended, ‘septic’ and in respiratory failure. He undergoes a Hartmann’s; and, obviously, his abdomen cannot be closed — so he is managed with a laparostomy. In your judgment, he does not require planned reoperations. Early closure is not a realistic option. How to proceed?\\n\\nAt this juncture, we would have used our sandwich technique. A more fancy (but more expensive) VAC system over the mesh also works well at this stage. A couple of weeks later, a healthy layer of granulation tissue appears over the disintegrating absorbable mesh (we don’t use Marlex® for temporary closure nowadays). A split-skin graft can now be applied onto the defect. The resulting ventral hernia is usually wide-necked and .\\n```\\n\\n### Figure Description\\n- **Figure 48.2**: This figure illustrates the concept of negative pressure dressing and its effect on cytokines and inflammation. The graphical representation likely shows the mechanism by which negative pressure therapy alleviates inflammatory responses in patients with abdominal wall defects. The details of the graph are not provided in the text, but it is referenced as a significant part of the discussion on delayed abdominal reconstruction.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Delayed Abdominal Reconstruction',\n", " 'md': '## Delayed Abdominal Reconstruction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Buttressing the midline with an underlay of bioprosthesis. Experimentation with these novel techniques is inadvisable for the uninitiated. In our practice, most patients are treated with delayed abdominal reconstruction.\\n\\nThere is some evidence that negative pressure dressing actually sucks out cytokines and other bad stuff — as depicted in **Figure 48.2** — thus alleviating the inflammatory attack. Besides, recent literature has shown that by combining negative pressure therapy with a temporary mesh providing mechanical traction increased at every dressing change, the delayed fascial closure rates are higher and enteric fistula rates lower than with any other temporary abdominal closure method.\\n\\nHowever, you manage the abdominal wall defect, remember that your patient has just recovered from the immense stress of severe peritonitis and multiple operations — he cannot take much more at this stage.',\n", " 'md': 'Buttressing the midline with an underlay of bioprosthesis. Experimentation with these novel techniques is inadvisable for the uninitiated. In our practice, most patients are treated with delayed abdominal reconstruction.\\n\\nThere is some evidence that negative pressure dressing actually sucks out cytokines and other bad stuff — as depicted in **Figure 48.2** — thus alleviating the inflammatory attack. Besides, recent literature has shown that by combining negative pressure therapy with a temporary mesh providing mechanical traction increased at every dressing change, the delayed fascial closure rates are higher and enteric fistula rates lower than with any other temporary abdominal closure method.\\n\\nHowever, you manage the abdominal wall defect, remember that your patient has just recovered from the immense stress of severe peritonitis and multiple operations — he cannot take much more at this stage.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.99, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Consider the Following Scenario:',\n", " 'md': '### Consider the Following Scenario:',\n", " 'bBox': {'x': 86, 'y': 85, 'w': 222, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'An obese patient develops a breakdown of his colorectal anastomosis with severe fecal peritonitis. The patient is now grossly distended, ‘septic’ and in respiratory failure. He undergoes a Hartmann’s; and, obviously, his abdomen cannot be closed — so he is managed with a laparostomy. In your judgment, he does not require planned reoperations. Early closure is not a realistic option. How to proceed?\\n\\nAt this juncture, we would have used our sandwich technique. A more fancy (but more expensive) VAC system over the mesh also works well at this stage. A couple of weeks later, a healthy layer of granulation tissue appears over the disintegrating absorbable mesh (we don’t use Marlex® for temporary closure nowadays). A split-skin graft can now be applied onto the defect. The resulting ventral hernia is usually wide-necked and .\\n```',\n", " 'md': 'An obese patient develops a breakdown of his colorectal anastomosis with severe fecal peritonitis. The patient is now grossly distended, ‘septic’ and in respiratory failure. He undergoes a Hartmann’s; and, obviously, his abdomen cannot be closed — so he is managed with a laparostomy. In your judgment, he does not require planned reoperations. Early closure is not a realistic option. How to proceed?\\n\\nAt this juncture, we would have used our sandwich technique. A more fancy (but more expensive) VAC system over the mesh also works well at this stage. A couple of weeks later, a healthy layer of granulation tissue appears over the disintegrating absorbable mesh (we don’t use Marlex® for temporary closure nowadays). A split-skin graft can now be applied onto the defect. The resulting ventral hernia is usually wide-necked and .\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 467.51, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Description',\n", " 'md': '### Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 48.2**: This figure illustrates the concept of negative pressure dressing and its effect on cytokines and inflammation. The graphical representation likely shows the mechanism by which negative pressure therapy alleviates inflammatory responses in patients with abdominal wall defects. The details of the graph are not provided in the text, but it is referenced as a significant part of the discussion on delayed abdominal reconstruction.',\n", " 'md': '- **Figure 48.2**: This figure illustrates the concept of negative pressure dressing and its effect on cytokines and inflammation. The graphical representation likely shows the mechanism by which negative pressure therapy alleviates inflammatory responses in patients with abdominal wall defects. The details of the graph are not provided in the text, but it is referenced as a significant part of the discussion on delayed abdominal reconstruction.',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 180, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''}]},\n", " {'page': 829,\n", " 'text': 'well tolerated except for its cosmetic appearance. Many patients feel\\nfortunate enough to have survived their ‘surgical saga’ and find the end-\\nresult acceptable with the added support from an abdominal Velcro®\\nbinder.\\n Rectus muscle\\n 1Ocm\\n 3cm\\n 13cm\\nFigure 48.6. Component separation technique.\\n\\nThe same maneuvers are performed on both sides:\\n\\na. Arrow — skin-flap elevation off the anterior abdominal wall.\\nb. Arrow — incision at the junction of external oblique fascia with the rectus abdominis.\\nThe external oblique is then dissected off the internal oblique laterally. These two steps\\nwould allow the myofascial unit to slide medially up to 10cm1.\\nc. Arrow — incision of the posterior rectus sheath, which is then dissected off the rectus\\nmuscle to allow additional medial mobilization for 3cm. This step is optional.\\nd. The completed procedure.\\n\\nLaparoscopic modifications of the procedure have been described and used for\\nabdominal wall decompression in abdominal compartment syndrome without violating\\nthe peritoneal cavity.\\n\\n A detailed discussion of the delayed elective abdominal reconstruction\\nof the laparostomy defect is beyond the scope of this book. ħowever,',\n", " 'md': \"```markdown\\n## Page Content\\n\\nMany patients feel fortunate enough to have survived their ‘surgical saga’ and find the end result acceptable with the added support from an abdominal Velcro® binder.\\n\\n### Figure 48.6: Component Separation Technique\\n\\nThe same maneuvers are performed on both sides:\\n\\n1. **Arrow** — skin-flap elevation off the anterior abdominal wall.\\n2. **Arrow** — incision at the junction of external oblique fascia with the rectus abdominis. The external oblique is then dissected off the internal oblique laterally. These two steps would allow the myofascial unit to slide medially up to \\\\(10 \\\\, \\\\text{cm}\\\\).\\n3. **Arrow** — incision of the posterior rectus sheath, which is then dissected off the rectus muscle to allow additional medial mobilization for \\\\(3 \\\\, \\\\text{cm}\\\\). This step is optional.\\n4. The completed procedure.\\n\\nLaparoscopic modifications of the procedure have been described and used for abdominal wall decompression in abdominal compartment syndrome without violating the peritoneal cavity.\\n\\nA detailed discussion of the delayed elective abdominal reconstruction of the laparostomy defect is beyond the scope of this book. However, \\n```\\n\\n### Image Description\\n- **Figure 48.6**: This figure illustrates the component separation technique used in abdominal surgery. It shows the steps involved in the procedure, including skin-flap elevation, incisions at specific anatomical junctions, and the dissection of muscles to allow for medial mobilization. The arrows indicate the areas of focus for each step. The figure provides a visual representation of the surgical technique, which is crucial for understanding the procedure's execution.\",\n", " 'images': [{'name': 'img_p828_1.png',\n", " 'height': 613,\n", " 'width': 784,\n", " 'x': 112.31999999999971,\n", " 'y': 151.2,\n", " 'original_width': 1348,\n", " 'original_height': 1052}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Many patients feel fortunate enough to have survived their ‘surgical saga’ and find the end result acceptable with the added support from an abdominal Velcro® binder.',\n", " 'md': 'Many patients feel fortunate enough to have survived their ‘surgical saga’ and find the end result acceptable with the added support from an abdominal Velcro® binder.',\n", " 'bBox': {'x': 72, 'y': 137, 'w': 43.19, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 48.6: Component Separation Technique',\n", " 'md': '### Figure 48.6: Component Separation Technique',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The same maneuvers are performed on both sides:\\n\\n1. **Arrow** — skin-flap elevation off the anterior abdominal wall.\\n2. **Arrow** — incision at the junction of external oblique fascia with the rectus abdominis. The external oblique is then dissected off the internal oblique laterally. These two steps would allow the myofascial unit to slide medially up to \\\\(10 \\\\, \\\\text{cm}\\\\).\\n3. **Arrow** — incision of the posterior rectus sheath, which is then dissected off the rectus muscle to allow additional medial mobilization for \\\\(3 \\\\, \\\\text{cm}\\\\). This step is optional.\\n4. The completed procedure.\\n\\nLaparoscopic modifications of the procedure have been described and used for abdominal wall decompression in abdominal compartment syndrome without violating the peritoneal cavity.\\n\\nA detailed discussion of the delayed elective abdominal reconstruction of the laparostomy defect is beyond the scope of this book. However, \\n```',\n", " 'md': 'The same maneuvers are performed on both sides:\\n\\n1. **Arrow** — skin-flap elevation off the anterior abdominal wall.\\n2. **Arrow** — incision at the junction of external oblique fascia with the rectus abdominis. The external oblique is then dissected off the internal oblique laterally. These two steps would allow the myofascial unit to slide medially up to \\\\(10 \\\\, \\\\text{cm}\\\\).\\n3. **Arrow** — incision of the posterior rectus sheath, which is then dissected off the rectus muscle to allow additional medial mobilization for \\\\(3 \\\\, \\\\text{cm}\\\\). This step is optional.\\n4. The completed procedure.\\n\\nLaparoscopic modifications of the procedure have been described and used for abdominal wall decompression in abdominal compartment syndrome without violating the peritoneal cavity.\\n\\nA detailed discussion of the delayed elective abdominal reconstruction of the laparostomy defect is beyond the scope of this book. However, \\n```',\n", " 'bBox': {'x': 75, 'y': 253.06, 'w': 460.65, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Description',\n", " 'md': '### Image Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"- **Figure 48.6**: This figure illustrates the component separation technique used in abdominal surgery. It shows the steps involved in the procedure, including skin-flap elevation, incisions at specific anatomical junctions, and the dissection of muscles to allow for medial mobilization. The arrows indicate the areas of focus for each step. The figure provides a visual representation of the surgical technique, which is crucial for understanding the procedure's execution.\",\n", " 'md': \"- **Figure 48.6**: This figure illustrates the component separation technique used in abdominal surgery. It shows the steps involved in the procedure, including skin-flap elevation, incisions at specific anatomical junctions, and the dissection of muscles to allow for medial mobilization. The arrows indicate the areas of focus for each step. The figure provides a visual representation of the surgical technique, which is crucial for understanding the procedure's execution.\",\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ' 1'}]},\n", " {'page': 830,\n", " 'text': 'here are the principles involved:\\n\\n • Delay reconstruction for up to 12 months, or even more, until\\n the abdomen looks and feels like ‘jelly’: the skin graft is ‘loose’ and\\n ‘pinchable’ away from underlying structures, the scar is soft, the\\n stomas or fistulas, if present, are prolapsing.\\n • At operation, excise the skin graft, lyse all adhesions and use the\\n component separation technique ( Figure 48.6) to close the fascial\\n defect, combined, if necessary, with synthetic mesh. Avoid the use\\n of synthetic mesh in contaminated fields; for example, when the\\n operation involves the resection of an intestinal fistula or take down\\n of a stoma.\\n\\n Antibiotics\\n\\n Prolonged courses of postoperative antibiotics may be justified, in\\npatients with severe intra-abdominal infection who require reoperations\\nand/or laparostomy for additional source control and peritoneal toilet (\\nChapter 44). Antibiotics should be continued as long as the source,\\nand residual infection, are ‘active’. Evidence suggests that, in this\\nsubgroup of patients, anti-fungal prophylaxis with fluconazole may\\ndecrease the incidence of intra-abdominal superinfection with Candida\\nspecies.\\n\\n Is laparostomy beneficial?\\n\\n Complications do occur with laparostomy, the most morbid being\\nspontaneous enteric fistulas ( Chapter 47), and there is always the\\nneed for subsequent reconstruction of the abdominal wall. How\\nfavorable is the risk/benefit ratio of laparostomy in these patients?\\n\\n The physiological benefits of a decompressing laparostomy for\\nsignificant IAħ/abdominal compartment syndrome are well proven in\\ntrauma and general surgical patients ( Chapter 33). There is also a\\nlarge body of experimental evidence suggesting that elevated intra-\\nabdominal pressure promotes systemic absorption/translocation of',\n", " 'md': '```markdown\\n## Principles Involved\\n\\n- Delay reconstruction for up to 12 months, or even more, until the abdomen looks and feels like ‘jelly’: the skin graft is ‘loose’ and ‘pinchable’ away from underlying structures, the scar is soft, and the stomas or fistulas, if present, are prolapsing.\\n- At operation, excise the skin graft, lyse all adhesions, and use the component separation technique (Figure 48.6) to close the fascial defect, combined, if necessary, with synthetic mesh. Avoid the use of synthetic mesh in contaminated fields; for example, when the operation involves the resection of an intestinal fistula or take down of a stoma.\\n\\n### Antibiotics\\n\\nProlonged courses of postoperative antibiotics may be justified in patients with severe intra-abdominal infection who require reoperations and/or laparostomy for additional source control and peritoneal toilet (Chapter 44). Antibiotics should be continued as long as the source and residual infection are ‘active’. Evidence suggests that, in this subgroup of patients, anti-fungal prophylaxis with fluconazole may decrease the incidence of intra-abdominal superinfection with Candida species.\\n\\n### Is Laparostomy Beneficial?\\n\\nComplications do occur with laparostomy, the most morbid being spontaneous enteric fistulas (Chapter 47), and there is always the need for subsequent reconstruction of the abdominal wall. How favorable is the risk/benefit ratio of laparostomy in these patients?\\n\\nThe physiological benefits of a decompressing laparostomy for significant intra-abdominal hypertension/abdominal compartment syndrome are well proven in trauma and general surgical patients (Chapter 33). There is also a large body of experimental evidence suggesting that elevated intra-abdominal pressure promotes systemic absorption/translocation of...\\n```\\n\\n### Image Identification and Description\\n\\n- **Figure 48.6**: This figure illustrates the component separation technique used in surgical procedures. The image likely depicts the anatomical layers involved in the technique, showing how the skin graft is excised and the fascial defect is closed. The caption may provide additional context about the surgical approach and its applications.\\n\\n(Note: The actual image is not provided, so a detailed description of the visual content cannot be included.)',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Principles Involved',\n", " 'md': '## Principles Involved',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Delay reconstruction for up to 12 months, or even more, until the abdomen looks and feels like ‘jelly’: the skin graft is ‘loose’ and ‘pinchable’ away from underlying structures, the scar is soft, and the stomas or fistulas, if present, are prolapsing.\\n- At operation, excise the skin graft, lyse all adhesions, and use the component separation technique (Figure 48.6) to close the fascial defect, combined, if necessary, with synthetic mesh. Avoid the use of synthetic mesh in contaminated fields; for example, when the operation involves the resection of an intestinal fistula or take down of a stoma.',\n", " 'md': '- Delay reconstruction for up to 12 months, or even more, until the abdomen looks and feels like ‘jelly’: the skin graft is ‘loose’ and ‘pinchable’ away from underlying structures, the scar is soft, and the stomas or fistulas, if present, are prolapsing.\\n- At operation, excise the skin graft, lyse all adhesions, and use the component separation technique (Figure 48.6) to close the fascial defect, combined, if necessary, with synthetic mesh. Avoid the use of synthetic mesh in contaminated fields; for example, when the operation involves the resection of an intestinal fistula or take down of a stoma.',\n", " 'bBox': {'x': 100, 'y': 138, 'w': 436.77, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Antibiotics',\n", " 'md': '### Antibiotics',\n", " 'bBox': {'x': 86, 'y': 319, 'w': 85.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Prolonged courses of postoperative antibiotics may be justified in patients with severe intra-abdominal infection who require reoperations and/or laparostomy for additional source control and peritoneal toilet (Chapter 44). Antibiotics should be continued as long as the source and residual infection are ‘active’. Evidence suggests that, in this subgroup of patients, anti-fungal prophylaxis with fluconazole may decrease the incidence of intra-abdominal superinfection with Candida species.',\n", " 'md': 'Prolonged courses of postoperative antibiotics may be justified in patients with severe intra-abdominal infection who require reoperations and/or laparostomy for additional source control and peritoneal toilet (Chapter 44). Antibiotics should be continued as long as the source and residual infection are ‘active’. Evidence suggests that, in this subgroup of patients, anti-fungal prophylaxis with fluconazole may decrease the incidence of intra-abdominal superinfection with Candida species.',\n", " 'bBox': {'x': 72, 'y': 319, 'w': 454.39, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Is Laparostomy Beneficial?',\n", " 'md': '### Is Laparostomy Beneficial?',\n", " 'bBox': {'x': 86, 'y': 514, 'w': 207.81, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Complications do occur with laparostomy, the most morbid being spontaneous enteric fistulas (Chapter 47), and there is always the need for subsequent reconstruction of the abdominal wall. How favorable is the risk/benefit ratio of laparostomy in these patients?\\n\\nThe physiological benefits of a decompressing laparostomy for significant intra-abdominal hypertension/abdominal compartment syndrome are well proven in trauma and general surgical patients (Chapter 33). There is also a large body of experimental evidence suggesting that elevated intra-abdominal pressure promotes systemic absorption/translocation of...\\n```',\n", " 'md': 'Complications do occur with laparostomy, the most morbid being spontaneous enteric fistulas (Chapter 47), and there is always the need for subsequent reconstruction of the abdominal wall. How favorable is the risk/benefit ratio of laparostomy in these patients?\\n\\nThe physiological benefits of a decompressing laparostomy for significant intra-abdominal hypertension/abdominal compartment syndrome are well proven in trauma and general surgical patients (Chapter 33). There is also a large body of experimental evidence suggesting that elevated intra-abdominal pressure promotes systemic absorption/translocation of...\\n```',\n", " 'bBox': {'x': 72, 'y': 600, 'w': 454.8, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 48.6**: This figure illustrates the component separation technique used in surgical procedures. The image likely depicts the anatomical layers involved in the technique, showing how the skin graft is excised and the fascial defect is closed. The caption may provide additional context about the surgical approach and its applications.\\n\\n(Note: The actual image is not provided, so a detailed description of the visual content cannot be included.)',\n", " 'md': '- **Figure 48.6**: This figure illustrates the component separation technique used in surgical procedures. The image likely depicts the anatomical layers involved in the technique, showing how the skin graft is excised and the fascial defect is closed. The caption may provide additional context about the surgical approach and its applications.\\n\\n(Note: The actual image is not provided, so a detailed description of the visual content cannot be included.)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'defect, combined, if necessary, with synthetic mesh. Avoid the use'},\n", " {'text': 'Chapter 44). and residual infection, are ‘active’'},\n", " {'text': 'need for subsequent reconstruction of the abdominal wall. '},\n", " {'text': 'large body of experimental evidence suggesting that elevated intra-'}]},\n", " {'page': 831,\n", " 'text': 'peritoneal endotoxins and bacteria, thus increasing the mortality rate of\\nperitonitis in small and large animals. Although the issue of raised intra-\\nabdominal pressure and its treatment with laparostomy has not been\\nstudied specifically in the setting of peritonitis, it is probably true that\\ntreating IAħ is beneficial. The risk/benefit ratio of prophylactic\\nlaparostomy in borderline IAħ is not clear as yet.\\n\\n In our practice, therefore, we reserve laparostomy for patients with severe IAH, those\\n who ‘cannot be closed’ and those whom we plan to re-explore.\\n\\n In sum…\\n\\n Relaparotomy and laparostomy are therapeutic measures that are\\nindicated in a small minority of patients. They represent, for the time\\nbeing, the heaviest weaponry in the surgeon’s mechanical\\narmamentarium for the treatment of severe intra-abdominal infection and\\nother post-laparotomy abdominal catastrophes. Remember that\\nunnecessary relaparotomies carry significant morbidity in these\\npatients. An aggressive but selective policy of directed, ‘on-demand’\\nrelooks, supplemented sparingly by laparostomy is probably superior to\\nthe indiscriminate use of ‘blind’ planned relaparotomies with routine\\nlaparostomy.\\n\\n He who operates and runs away, may get to reoperate on\\n the same patient another day.\\n\\n Laparoscopic abdominal re-\\n3 exploration\\n Danny Rosin\\n\\n No surgeon likes to face a postoperative complication, but the need to\\ntreat such a complication by repeated surgery is even more distressing.\\nSuch complications include intestinal obstruction, intra-abdominal\\nbleeding, hollow viscus perforation and inadvertent bowel injury resulting\\nin intra-abdominal infection. In some cases, such as mesenteric\\nischemia, a repeat operation is a planned ‘second-look’ procedure (',\n", " 'md': '```markdown\\n## Page Content\\n\\nPeritoneal endotoxins and bacteria, thus increasing the mortality rate of peritonitis in small and large animals. Although the issue of raised intra-abdominal pressure and its treatment with laparostomy has not been studied specifically in the setting of peritonitis, it is probably true that treating intra-abdominal hypertension (IAH) is beneficial. The risk/benefit ratio of prophylactic laparostomy in borderline IAH is not clear as yet.\\n\\nIn our practice, therefore, we reserve laparostomy for patients with severe IAH, those who ‘cannot be closed’ and those whom we plan to re-explore.\\n\\nIn sum…\\n\\nRelaparotomy and laparostomy are therapeutic measures that are indicated in a small minority of patients. They represent, for the time being, the heaviest weaponry in the surgeon’s mechanical armamentarium for the treatment of severe intra-abdominal infection and other post-laparotomy abdominal catastrophes. Remember that unnecessary relaparotomies carry significant morbidity in these patients. An aggressive but selective policy of directed, ‘on-demand’ relooks, supplemented sparingly by laparostomy is probably superior to the indiscriminate use of ‘blind’ planned relaparotomies with routine laparostomy.\\n\\n> He who operates and runs away, may get to reoperate on the same patient another day.\\n\\n### Laparoscopic Abdominal Re-exploration\\n**Danny Rosin**\\n\\nNo surgeon likes to face a postoperative complication, but the need to treat such a complication by repeated surgery is even more distressing. Such complications include intestinal obstruction, intra-abdominal bleeding, hollow viscus perforation, and inadvertent bowel injury resulting in intra-abdominal infection. In some cases, such as mesenteric ischemia, a repeat operation is a planned ‘second-look’ procedure.\\n\\n----\\n\\n### Summary of Content\\n- The text discusses the implications of intra-abdominal hypertension (IAH) and the use of laparostomy in treating severe cases.\\n- It emphasizes the selective use of relaparotomy and laparostomy, cautioning against unnecessary procedures due to potential morbidity.\\n- The section concludes with a quote about the realities of surgical practice and the challenges of postoperative complications.\\n\\n### Figures and Images\\n- **Figure 3**: The title \"Laparoscopic Abdominal Re-exploration\" is mentioned, but no graphical elements or images are identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Peritoneal endotoxins and bacteria, thus increasing the mortality rate of peritonitis in small and large animals. Although the issue of raised intra-abdominal pressure and its treatment with laparostomy has not been studied specifically in the setting of peritonitis, it is probably true that treating intra-abdominal hypertension (IAH) is beneficial. The risk/benefit ratio of prophylactic laparostomy in borderline IAH is not clear as yet.\\n\\nIn our practice, therefore, we reserve laparostomy for patients with severe IAH, those who ‘cannot be closed’ and those whom we plan to re-explore.\\n\\nIn sum…\\n\\nRelaparotomy and laparostomy are therapeutic measures that are indicated in a small minority of patients. They represent, for the time being, the heaviest weaponry in the surgeon’s mechanical armamentarium for the treatment of severe intra-abdominal infection and other post-laparotomy abdominal catastrophes. Remember that unnecessary relaparotomies carry significant morbidity in these patients. An aggressive but selective policy of directed, ‘on-demand’ relooks, supplemented sparingly by laparostomy is probably superior to the indiscriminate use of ‘blind’ planned relaparotomies with routine laparostomy.\\n\\n> He who operates and runs away, may get to reoperate on the same patient another day.',\n", " 'md': 'Peritoneal endotoxins and bacteria, thus increasing the mortality rate of peritonitis in small and large animals. Although the issue of raised intra-abdominal pressure and its treatment with laparostomy has not been studied specifically in the setting of peritonitis, it is probably true that treating intra-abdominal hypertension (IAH) is beneficial. The risk/benefit ratio of prophylactic laparostomy in borderline IAH is not clear as yet.\\n\\nIn our practice, therefore, we reserve laparostomy for patients with severe IAH, those who ‘cannot be closed’ and those whom we plan to re-explore.\\n\\nIn sum…\\n\\nRelaparotomy and laparostomy are therapeutic measures that are indicated in a small minority of patients. They represent, for the time being, the heaviest weaponry in the surgeon’s mechanical armamentarium for the treatment of severe intra-abdominal infection and other post-laparotomy abdominal catastrophes. Remember that unnecessary relaparotomies carry significant morbidity in these patients. An aggressive but selective policy of directed, ‘on-demand’ relooks, supplemented sparingly by laparostomy is probably superior to the indiscriminate use of ‘blind’ planned relaparotomies with routine laparostomy.\\n\\n> He who operates and runs away, may get to reoperate on the same patient another day.',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 467.9, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Laparoscopic Abdominal Re-exploration',\n", " 'md': '### Laparoscopic Abdominal Re-exploration',\n", " 'bBox': {'x': 103, 'y': 389, 'w': 206.38, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '**Danny Rosin**\\n\\nNo surgeon likes to face a postoperative complication, but the need to treat such a complication by repeated surgery is even more distressing. Such complications include intestinal obstruction, intra-abdominal bleeding, hollow viscus perforation, and inadvertent bowel injury resulting in intra-abdominal infection. In some cases, such as mesenteric ischemia, a repeat operation is a planned ‘second-look’ procedure.\\n\\n----',\n", " 'md': '**Danny Rosin**\\n\\nNo surgeon likes to face a postoperative complication, but the need to treat such a complication by repeated surgery is even more distressing. Such complications include intestinal obstruction, intra-abdominal bleeding, hollow viscus perforation, and inadvertent bowel injury resulting in intra-abdominal infection. In some cases, such as mesenteric ischemia, a repeat operation is a planned ‘second-look’ procedure.\\n\\n----',\n", " 'bBox': {'x': 72, 'y': 355, 'w': 467.86, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary of Content',\n", " 'md': '### Summary of Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text discusses the implications of intra-abdominal hypertension (IAH) and the use of laparostomy in treating severe cases.\\n- It emphasizes the selective use of relaparotomy and laparostomy, cautioning against unnecessary procedures due to potential morbidity.\\n- The section concludes with a quote about the realities of surgical practice and the challenges of postoperative complications.',\n", " 'md': '- The text discusses the implications of intra-abdominal hypertension (IAH) and the use of laparostomy in treating severe cases.\\n- It emphasizes the selective use of relaparotomy and laparostomy, cautioning against unnecessary procedures due to potential morbidity.\\n- The section concludes with a quote about the realities of surgical practice and the challenges of postoperative complications.',\n", " 'bBox': {'x': 129, 'y': 355, 'w': 99.16, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figures and Images',\n", " 'md': '### Figures and Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 3**: The title \"Laparoscopic Abdominal Re-exploration\" is mentioned, but no graphical elements or images are identified on this page.\\n```',\n", " 'md': '- **Figure 3**: The title \"Laparoscopic Abdominal Re-exploration\" is mentioned, but no graphical elements or images are identified on this page.\\n```',\n", " 'bBox': {'x': 73, 'y': 355, 'w': 142.21, 'h': 28.8}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 832,\n", " 'text': 'Chapter 24).\\n\\n The presence of a fresh abdominal wound makes it rational to re-\\nexplore through this same incision. ħowever, reopening of a recent\\nincision and re-exploration by laparotomy may increase short- and long-\\nterm morbidity. Relaparotomy is associated with pain, ileus and increased\\nrisk of abdominal infection. It may increase the risk of wound infection,\\nand eventual wound dehiscence or later development of an incisional\\nhernia. Overall, it may extend the recovery period of the patient, on top of\\nthe condition that prompted it, serving as a ‘second hit’.\\n\\n Treatment of complications after laparoscopic surgery is\\nfrequently attempted by a repeat laparoscopy — trying to avoid a\\nformal laparotomy (see also Chapter 12). Indeed, complications such\\nas bleeding or bile leak after laparoscopic cholecystectomy can be\\nsuccessfully approached by a second laparoscopy ( Chapter 20).\\nLaparoscopy is also a valid treatment option in various acute surgical\\nconditions ( Chapter 12).\\n\\n Laparoscopy is frequently performed in the presence of abdominal\\nscars and previous operations and, thus, adhesions and moderately\\ndistended bowel are no longer considered to be contraindications for\\nlaparoscopic intervention. Given the morbidity associated with\\nrelaparotomy, and the ability of trained laparoscopic surgeons to deal\\nwith acute abdominal conditions, it naturally follows that acute\\nsurgical complications may be optimally handled by a minimal\\naccess approach.\\n\\n Postoperative conditions treated by laparoscopy\\n\\n Mesenteric ischemia ( Chapter 24)\\n\\n One of the earliest applications of laparoscopy after a recent\\nlaparotomy was to perform a ‘second-look’ operation after treating acute\\nmesenteric ischemia. The purpose of this procedure is to ascertain the\\nviability of potentially ischemic segments of bowel, for example, around\\nthe anastomosis after resection of gangrenous bowel. As the secondary',\n", " 'md': '```markdown\\n# Chapter 24\\n\\nThe presence of a fresh abdominal wound makes it rational to re-explore through this same incision. However, reopening of a recent incision and re-exploration by laparotomy may increase short- and long-term morbidity. Relaparotomy is associated with pain, ileus, and increased risk of abdominal infection. It may increase the risk of wound infection, and eventual wound dehiscence or later development of an incisional hernia. Overall, it may extend the recovery period of the patient, on top of the condition that prompted it, serving as a ‘second hit’.\\n\\nTreatment of complications after laparoscopic surgery is frequently attempted by a repeat laparoscopy — trying to avoid a formal laparotomy (see also Chapter 12). Indeed, complications such as bleeding or bile leak after laparoscopic cholecystectomy can be successfully approached by a second laparoscopy (Chapter 20). Laparoscopy is also a valid treatment option in various acute surgical conditions (Chapter 12).\\n\\nLaparoscopy is frequently performed in the presence of abdominal scars and previous operations and, thus, adhesions and moderately distended bowel are no longer considered to be contraindications for laparoscopic intervention. Given the morbidity associated with relaparotomy, and the ability of trained laparoscopic surgeons to deal with acute abdominal conditions, it naturally follows that acute surgical complications may be optimally handled by a minimal access approach.\\n\\n## Postoperative conditions treated by laparoscopy\\n\\n- **Mesenteric ischemia** (Chapter 24)\\n\\nOne of the earliest applications of laparoscopy after a recent laparotomy was to perform a ‘second-look’ operation after treating acute mesenteric ischemia. The purpose of this procedure is to ascertain the viability of potentially ischemic segments of bowel, for example, around the anastomosis after resection of gangrenous bowel. As the secondary\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 24',\n", " 'md': '# Chapter 24',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The presence of a fresh abdominal wound makes it rational to re-explore through this same incision. However, reopening of a recent incision and re-exploration by laparotomy may increase short- and long-term morbidity. Relaparotomy is associated with pain, ileus, and increased risk of abdominal infection. It may increase the risk of wound infection, and eventual wound dehiscence or later development of an incisional hernia. Overall, it may extend the recovery period of the patient, on top of the condition that prompted it, serving as a ‘second hit’.\\n\\nTreatment of complications after laparoscopic surgery is frequently attempted by a repeat laparoscopy — trying to avoid a formal laparotomy (see also Chapter 12). Indeed, complications such as bleeding or bile leak after laparoscopic cholecystectomy can be successfully approached by a second laparoscopy (Chapter 20). Laparoscopy is also a valid treatment option in various acute surgical conditions (Chapter 12).\\n\\nLaparoscopy is frequently performed in the presence of abdominal scars and previous operations and, thus, adhesions and moderately distended bowel are no longer considered to be contraindications for laparoscopic intervention. Given the morbidity associated with relaparotomy, and the ability of trained laparoscopic surgeons to deal with acute abdominal conditions, it naturally follows that acute surgical complications may be optimally handled by a minimal access approach.',\n", " 'md': 'The presence of a fresh abdominal wound makes it rational to re-explore through this same incision. However, reopening of a recent incision and re-exploration by laparotomy may increase short- and long-term morbidity. Relaparotomy is associated with pain, ileus, and increased risk of abdominal infection. It may increase the risk of wound infection, and eventual wound dehiscence or later development of an incisional hernia. Overall, it may extend the recovery period of the patient, on top of the condition that prompted it, serving as a ‘second hit’.\\n\\nTreatment of complications after laparoscopic surgery is frequently attempted by a repeat laparoscopy — trying to avoid a formal laparotomy (see also Chapter 12). Indeed, complications such as bleeding or bile leak after laparoscopic cholecystectomy can be successfully approached by a second laparoscopy (Chapter 20). Laparoscopy is also a valid treatment option in various acute surgical conditions (Chapter 12).\\n\\nLaparoscopy is frequently performed in the presence of abdominal scars and previous operations and, thus, adhesions and moderately distended bowel are no longer considered to be contraindications for laparoscopic intervention. Given the morbidity associated with relaparotomy, and the ability of trained laparoscopic surgeons to deal with acute abdominal conditions, it naturally follows that acute surgical complications may be optimally handled by a minimal access approach.',\n", " 'bBox': {'x': 72, 'y': 154, 'w': 467.49, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Postoperative conditions treated by laparoscopy',\n", " 'md': '## Postoperative conditions treated by laparoscopy',\n", " 'bBox': {'x': 86, 'y': 566, 'w': 383.46, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- **Mesenteric ischemia** (Chapter 24)\\n\\nOne of the earliest applications of laparoscopy after a recent laparotomy was to perform a ‘second-look’ operation after treating acute mesenteric ischemia. The purpose of this procedure is to ascertain the viability of potentially ischemic segments of bowel, for example, around the anastomosis after resection of gangrenous bowel. As the secondary\\n```',\n", " 'md': '- **Mesenteric ischemia** (Chapter 24)\\n\\nOne of the earliest applications of laparoscopy after a recent laparotomy was to perform a ‘second-look’ operation after treating acute mesenteric ischemia. The purpose of this procedure is to ascertain the viability of potentially ischemic segments of bowel, for example, around the anastomosis after resection of gangrenous bowel. As the secondary\\n```',\n", " 'bBox': {'x': 72, 'y': 272, 'w': 467.69, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the requirements.',\n", " 'bBox': {'x': 317, 'y': 272, 'w': 222, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 24).'},\n", " {'text': 'as bleeding or bile leak after laparoscopic cholecystectomy can be'},\n", " {'text': 'Laparoscopy is also a valid treatment option in various acute surgical'},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 833,\n", " 'text': 'intervention is a simple diagnostic procedure (unless further resection is\\nnecessary), it can readily be accomplished via laparoscopy. It has even\\nbeen suggested that laparoscopic ports should be left in place at the end\\nof the first operation to facilitate access at the second look, but we\\nconsider this approach unnecessary and risky. Possible injury can be\\ncaused by the port itself, which may also serve as a port of entry to\\nbacteria, and reinsertion of new ports is simple enough.\\n\\n Early postoperative small bowel obstruction\\n\\n Early postoperative small bowel obstruction ( Chapter 45) is a\\nrelatively infrequent condition, as opposed to the more common\\npostoperative ileus. At times, it will require a second intervention.\\nLaparoscopic management of bowel obstruction is an established\\nprocedure and we have successfully applied this approach in several\\ncases of early postoperative obstruction after appendectomy, colectomy\\nand laparotomy for trauma.\\n\\n Peptic ulcer perforation\\n\\n Peptic ulcer perforation ( Chapter 18) is another rare postoperative\\ncomplication, not directly related to the specific procedure performed but\\npossibly related to the postoperative stress response or to ulcerogenic\\nmedications. We have treated such a case by laparoscopic omentopexy,\\njust as in our standard approach to ‘primary’ duodenal peptic\\nperforations.\\n\\n Intra-abdominal infections\\n\\n Intra-abdominal infections ( Chapters 13, 46, and earlier in this\\nchapter) may include established abdominal abscesses, and septic\\nconditions associated with recent anastomoses. Most postoperative\\nabscesses are amenable to percutaneous CT-guided drainage, but a few\\nare not accessible and mandate surgical drainage. Unless treating a\\npatient in extreme conditions of septic shock, laparoscopy can be used to\\naccess the abscess cavity, drain and irrigate it, and leave suction',\n", " 'md': '```markdown\\n## Early Postoperative Complications\\n\\n### Intervention\\nIntervention is a simple diagnostic procedure (unless further resection is necessary); it can readily be accomplished via laparoscopy. It has even been suggested that laparoscopic ports should be left in place at the end of the first operation to facilitate access at the second look, but we consider this approach unnecessary and risky. Possible injury can be caused by the port itself, which may also serve as a port of entry to bacteria, and reinsertion of new ports is simple enough.\\n\\n### Early Postoperative Small Bowel Obstruction\\nEarly postoperative small bowel obstruction (Chapter 45) is a relatively infrequent condition, as opposed to the more common postoperative ileus. At times, it will require a second intervention. Laparoscopic management of bowel obstruction is an established procedure, and we have successfully applied this approach in several cases of early postoperative obstruction after appendectomy, colectomy, and laparotomy for trauma.\\n\\n### Peptic Ulcer Perforation\\nPeptic ulcer perforation (Chapter 18) is another rare postoperative complication, not directly related to the specific procedure performed but possibly related to the postoperative stress response or to ulcerogenic medications. We have treated such a case by laparoscopic omentopexy, just as in our standard approach to ‘primary’ duodenal peptic perforations.\\n\\n### Intra-abdominal Infections\\nIntra-abdominal infections (Chapters 13, 46, and earlier in this chapter) may include established abdominal abscesses and septic conditions associated with recent anastomoses. Most postoperative abscesses are amenable to percutaneous CT-guided drainage, but a few are not accessible and mandate surgical drainage. Unless treating a patient in extreme conditions of septic shock, laparoscopy can be used to access the abscess cavity, drain and irrigate it, and leave suction.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Early Postoperative Complications',\n", " 'md': '## Early Postoperative Complications',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Intervention',\n", " 'md': '### Intervention',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Intervention is a simple diagnostic procedure (unless further resection is necessary); it can readily be accomplished via laparoscopy. It has even been suggested that laparoscopic ports should be left in place at the end of the first operation to facilitate access at the second look, but we consider this approach unnecessary and risky. Possible injury can be caused by the port itself, which may also serve as a port of entry to bacteria, and reinsertion of new ports is simple enough.',\n", " 'md': 'Intervention is a simple diagnostic procedure (unless further resection is necessary); it can readily be accomplished via laparoscopy. It has even been suggested that laparoscopic ports should be left in place at the end of the first operation to facilitate access at the second look, but we consider this approach unnecessary and risky. Possible injury can be caused by the port itself, which may also serve as a port of entry to bacteria, and reinsertion of new ports is simple enough.',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.95, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Early Postoperative Small Bowel Obstruction',\n", " 'md': '### Early Postoperative Small Bowel Obstruction',\n", " 'bBox': {'x': 86, 'y': 228, 'w': 347.56, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Early postoperative small bowel obstruction (Chapter 45) is a relatively infrequent condition, as opposed to the more common postoperative ileus. At times, it will require a second intervention. Laparoscopic management of bowel obstruction is an established procedure, and we have successfully applied this approach in several cases of early postoperative obstruction after appendectomy, colectomy, and laparotomy for trauma.',\n", " 'md': 'Early postoperative small bowel obstruction (Chapter 45) is a relatively infrequent condition, as opposed to the more common postoperative ileus. At times, it will require a second intervention. Laparoscopic management of bowel obstruction is an established procedure, and we have successfully applied this approach in several cases of early postoperative obstruction after appendectomy, colectomy, and laparotomy for trauma.',\n", " 'bBox': {'x': 72, 'y': 228, 'w': 361.56, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Peptic Ulcer Perforation',\n", " 'md': '### Peptic Ulcer Perforation',\n", " 'bBox': {'x': 86, 'y': 407, 'w': 185.73, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Peptic ulcer perforation (Chapter 18) is another rare postoperative complication, not directly related to the specific procedure performed but possibly related to the postoperative stress response or to ulcerogenic medications. We have treated such a case by laparoscopic omentopexy, just as in our standard approach to ‘primary’ duodenal peptic perforations.',\n", " 'md': 'Peptic ulcer perforation (Chapter 18) is another rare postoperative complication, not directly related to the specific procedure performed but possibly related to the postoperative stress response or to ulcerogenic medications. We have treated such a case by laparoscopic omentopexy, just as in our standard approach to ‘primary’ duodenal peptic perforations.',\n", " 'bBox': {'x': 72, 'y': 407, 'w': 468.01, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Intra-abdominal Infections',\n", " 'md': '### Intra-abdominal Infections',\n", " 'bBox': {'x': 86, 'y': 568, 'w': 206.87, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Intra-abdominal infections (Chapters 13, 46, and earlier in this chapter) may include established abdominal abscesses and septic conditions associated with recent anastomoses. Most postoperative abscesses are amenable to percutaneous CT-guided drainage, but a few are not accessible and mandate surgical drainage. Unless treating a patient in extreme conditions of septic shock, laparoscopy can be used to access the abscess cavity, drain and irrigate it, and leave suction.\\n```',\n", " 'md': 'Intra-abdominal infections (Chapters 13, 46, and earlier in this chapter) may include established abdominal abscesses and septic conditions associated with recent anastomoses. Most postoperative abscesses are amenable to percutaneous CT-guided drainage, but a few are not accessible and mandate surgical drainage. Unless treating a patient in extreme conditions of septic shock, laparoscopy can be used to access the abscess cavity, drain and irrigate it, and leave suction.\\n```',\n", " 'bBox': {'x': 72, 'y': 568, 'w': 467.63, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'relatively infrequent condition, as opposed to the more common'},\n", " {'text': 'complication, not directly related to the specific procedure performed but'},\n", " {'text': 'chapter) may include established abdominal abscesses, and septic'},\n", " {'text': 'chapter) may include established abdominal abscesses, and septic'}]},\n", " {'page': 834,\n", " 'text': 'drainage in the area.\\n\\n Anastomotic leak\\n\\n Anastomotic leak ( Chapter 47) is another dreaded postoperative\\ncomplication. It may manifest as a free intestinal leak, or as an\\ninflammatory condition (‘peri-anastomositis’). Exteriorization and stoma\\ncreation is the usual treatment of the first condition, but the peritonitis\\nleads to a high rate of wound infection, abdominal wall edema, and a risk\\nof increased intra-abdominal pressure. The need for temporary\\nabdominal closure is frequent. Laparoscopy may permit bowel\\nexteriorization and abdominal toilet, without disturbing the original\\nlaparotomy wound. In addition, peri-anastomositis, although usually\\nresponding to antibiotic treatment, may be associated with the presence\\nof free abdominal gas but without actual spillage of bowel contents. This\\nis frequently treated by anastomotic take-down or a proximal diversion.\\nWe have limited experience with several patients in whom laparoscopy\\nrevealed a localized inflammatory process, without actual spillage or\\ngeneralized peritonitis, and drainage alone led to full recovery.\\n\\n Technique\\n\\n Access to the abdominal cavity must be established by the open\\ntechnique, using a Hasson cannula, as the bowel may be distended\\nand adherent to the abdominal wall. The port is placed away from\\nthe previous incision, usually laterally in the abdominal wall, to\\navoid the inevitable adhesions to the fresh scar.\\n\\n Some of the adhesions can be separated bluntly by careful movements\\nof the camera, as the bowel may be edematous and friable. Further\\ntrocars are placed as necessary, when enough space is established, to\\ncomplete the space creation and permit abdominal exploration. Non-\\ntraumatic instruments should be used, and bowel handling should be\\nkept to a minimum, preferably manipulating the bowel by grasping its\\nmesentery to avoid serosal tears and perforations. Although at times the\\npathology is evident, it is frequently hidden by adhesions of omentum and\\nbowel loops. The abdomen may initially appear ‘benign’, but a',\n", " 'md': '```markdown\\n## Anastomotic Leak\\n\\nAnastomotic leak (Chapter 47) is another dreaded postoperative complication. It may manifest as a free intestinal leak, or as an inflammatory condition (‘peri-anastomositis’). Exteriorization and stoma creation is the usual treatment of the first condition, but the peritonitis leads to a high rate of wound infection, abdominal wall edema, and a risk of increased intra-abdominal pressure. The need for temporary abdominal closure is frequent. Laparoscopy may permit bowel exteriorization and abdominal toilet, without disturbing the original laparotomy wound. In addition, peri-anastomositis, although usually responding to antibiotic treatment, may be associated with the presence of free abdominal gas but without actual spillage of bowel contents. This is frequently treated by anastomotic take-down or a proximal diversion. We have limited experience with several patients in whom laparoscopy revealed a localized inflammatory process, without actual spillage or generalized peritonitis, and drainage alone led to full recovery.\\n\\n## Technique\\n\\nAccess to the abdominal cavity must be established by the open technique, using a Hasson cannula, as the bowel may be distended and adherent to the abdominal wall. The port is placed away from the previous incision, usually laterally in the abdominal wall, to avoid the inevitable adhesions to the fresh scar.\\n\\nSome of the adhesions can be separated bluntly by careful movements of the camera, as the bowel may be edematous and friable. Further trocars are placed as necessary, when enough space is established, to complete the space creation and permit abdominal exploration. Non-traumatic instruments should be used, and bowel handling should be kept to a minimum, preferably manipulating the bowel by grasping its mesentery to avoid serosal tears and perforations. Although at times the pathology is evident, it is frequently hidden by adhesions of omentum and bowel loops. The abdomen may initially appear ‘benign’, but a...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Anastomotic Leak',\n", " 'md': '## Anastomotic Leak',\n", " 'bBox': {'x': 86, 'y': 129, 'w': 137.03, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Anastomotic leak (Chapter 47) is another dreaded postoperative complication. It may manifest as a free intestinal leak, or as an inflammatory condition (‘peri-anastomositis’). Exteriorization and stoma creation is the usual treatment of the first condition, but the peritonitis leads to a high rate of wound infection, abdominal wall edema, and a risk of increased intra-abdominal pressure. The need for temporary abdominal closure is frequent. Laparoscopy may permit bowel exteriorization and abdominal toilet, without disturbing the original laparotomy wound. In addition, peri-anastomositis, although usually responding to antibiotic treatment, may be associated with the presence of free abdominal gas but without actual spillage of bowel contents. This is frequently treated by anastomotic take-down or a proximal diversion. We have limited experience with several patients in whom laparoscopy revealed a localized inflammatory process, without actual spillage or generalized peritonitis, and drainage alone led to full recovery.',\n", " 'md': 'Anastomotic leak (Chapter 47) is another dreaded postoperative complication. It may manifest as a free intestinal leak, or as an inflammatory condition (‘peri-anastomositis’). Exteriorization and stoma creation is the usual treatment of the first condition, but the peritonitis leads to a high rate of wound infection, abdominal wall edema, and a risk of increased intra-abdominal pressure. The need for temporary abdominal closure is frequent. Laparoscopy may permit bowel exteriorization and abdominal toilet, without disturbing the original laparotomy wound. In addition, peri-anastomositis, although usually responding to antibiotic treatment, may be associated with the presence of free abdominal gas but without actual spillage of bowel contents. This is frequently treated by anastomotic take-down or a proximal diversion. We have limited experience with several patients in whom laparoscopy revealed a localized inflammatory process, without actual spillage or generalized peritonitis, and drainage alone led to full recovery.',\n", " 'bBox': {'x': 72, 'y': 129, 'w': 467.51, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Technique',\n", " 'md': '## Technique',\n", " 'bBox': {'x': 86, 'y': 440, 'w': 81.54, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Access to the abdominal cavity must be established by the open technique, using a Hasson cannula, as the bowel may be distended and adherent to the abdominal wall. The port is placed away from the previous incision, usually laterally in the abdominal wall, to avoid the inevitable adhesions to the fresh scar.\\n\\nSome of the adhesions can be separated bluntly by careful movements of the camera, as the bowel may be edematous and friable. Further trocars are placed as necessary, when enough space is established, to complete the space creation and permit abdominal exploration. Non-traumatic instruments should be used, and bowel handling should be kept to a minimum, preferably manipulating the bowel by grasping its mesentery to avoid serosal tears and perforations. Although at times the pathology is evident, it is frequently hidden by adhesions of omentum and bowel loops. The abdomen may initially appear ‘benign’, but a...\\n```',\n", " 'md': 'Access to the abdominal cavity must be established by the open technique, using a Hasson cannula, as the bowel may be distended and adherent to the abdominal wall. The port is placed away from the previous incision, usually laterally in the abdominal wall, to avoid the inevitable adhesions to the fresh scar.\\n\\nSome of the adhesions can be separated bluntly by careful movements of the camera, as the bowel may be edematous and friable. Further trocars are placed as necessary, when enough space is established, to complete the space creation and permit abdominal exploration. Non-traumatic instruments should be used, and bowel handling should be kept to a minimum, preferably manipulating the bowel by grasping its mesentery to avoid serosal tears and perforations. Although at times the pathology is evident, it is frequently hidden by adhesions of omentum and bowel loops. The abdomen may initially appear ‘benign’, but a...\\n```',\n", " 'bBox': {'x': 72, 'y': 264, 'w': 467.78, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'bBox': {'x': 213, 'y': 264, 'w': 14.4, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'complication. It may manifest as a free intestinal leak, or as an'}]},\n", " {'page': 835,\n", " 'text': 'thorough search in spaces such as the pelvis, subphrenic areas or\\nretroperitoneum may reveal a compartmentalized process. Previous\\ndata obtained by a CT scan should help you direct the exploration\\nand prevent false-negative explorations and missed pathologies.\\n\\n In summary, laparoscopic abdominal re-exploration has a role in:\\n\\n • Persistent early postoperative intestinal obstruction.\\n • Second look’ for mesenteric ischemia.\\n • Perforated peptic ulcers.\\n • Drainage of abscesses and collections (when percutaneous\\n attempts fail).\\n • Drainage (with or without exteriorization) for anastomotic leaks.\\n\\n I agree that laparoscopic re-exploration in the hands of well-trained and experienced\\n laparoscopic surgeons may, occasionally, be advantageous compared with relaparotomy. At the\\n same time I’m skeptical — for example — about the rationale of applying laparoscopy in a\\n relook (24-36 hours later) to check for intestinal ischemia: why would one want to create new\\n holes in the abdominal wall? What’s wrong with taking the Mayo scissors and cutting the fascial\\n stitch, letting the fresh incisional wound fall open? Is it not more of a ‘second-hit’ to create\\n additional port holes?\\n\\n Furthermore, the patients must be well selected in terms of their physiology (you do not want to\\n pump lots of gas into the distended belly of a moribund patient) and intra-abdominal pathology.\\n In fact, in most instances the procedure would be ‘CT-guided\\n laparoscopy’ to compensate for the lack of manual exploration of\\n blind spots. And what is true with any laparoscopic procedure should be crucial here: “Do\\n not f**k around, do not damage anything — and for God’s sake — know when to stop and open\\n up!” Moshe\\n\\n “A surgeon… is like the skipper of an ocean-going racing',\n", " 'md': \"```markdown\\n## Summary of Laparoscopic Abdominal Re-exploration\\n\\nA thorough search in spaces such as the pelvis, subphrenic areas, or retroperitoneum may reveal a compartmentalized process. Previous data obtained by a CT scan should help direct the exploration and prevent false-negative explorations and missed pathologies.\\n\\n### Indications for Laparoscopic Abdominal Re-exploration\\n\\nIn summary, laparoscopic abdominal re-exploration has a role in:\\n\\n- Persistent early postoperative intestinal obstruction.\\n- 'Second look' for mesenteric ischemia.\\n- Perforated peptic ulcers.\\n- Drainage of abscesses and collections (when percutaneous attempts fail).\\n- Drainage (with or without exteriorization) for anastomotic leaks.\\n\\nI agree that laparoscopic re-exploration in the hands of well-trained and experienced laparoscopic surgeons may, occasionally, be advantageous compared with relaparotomy. At the same time, I’m skeptical — for example — about the rationale of applying laparoscopy in a relook (24-36 hours later) to check for intestinal ischemia: why would one want to create new holes in the abdominal wall? What’s wrong with taking the Mayo scissors and cutting the fascial stitch, letting the fresh incisional wound fall open? Is it not more of a ‘second-hit’ to create additional port holes?\\n\\nFurthermore, the patients must be well selected in terms of their physiology (you do not want to pump lots of gas into the distended belly of a moribund patient) and intra-abdominal pathology. In fact, in most instances, the procedure would be ‘CT-guided laparoscopy’ to compensate for the lack of manual exploration of blind spots. And what is true with any laparoscopic procedure should be crucial here: “Do not f**k around, do not damage anything — and for God’s sake — know when to stop and open up!” Moshe\\n\\n“A surgeon… is like the skipper of an ocean-going racing\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\",\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Summary of Laparoscopic Abdominal Re-exploration',\n", " 'md': '## Summary of Laparoscopic Abdominal Re-exploration',\n", " 'bBox': {'x': 172, 'y': 291, 'w': 16, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': 'A thorough search in spaces such as the pelvis, subphrenic areas, or retroperitoneum may reveal a compartmentalized process. Previous data obtained by a CT scan should help direct the exploration and prevent false-negative explorations and missed pathologies.',\n", " 'md': 'A thorough search in spaces such as the pelvis, subphrenic areas, or retroperitoneum may reveal a compartmentalized process. Previous data obtained by a CT scan should help direct the exploration and prevent false-negative explorations and missed pathologies.',\n", " 'bBox': {'x': 72, 'y': 103, 'w': 466.77, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Indications for Laparoscopic Abdominal Re-exploration',\n", " 'md': '### Indications for Laparoscopic Abdominal Re-exploration',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': \"In summary, laparoscopic abdominal re-exploration has a role in:\\n\\n- Persistent early postoperative intestinal obstruction.\\n- 'Second look' for mesenteric ischemia.\\n- Perforated peptic ulcers.\\n- Drainage of abscesses and collections (when percutaneous attempts fail).\\n- Drainage (with or without exteriorization) for anastomotic leaks.\\n\\nI agree that laparoscopic re-exploration in the hands of well-trained and experienced laparoscopic surgeons may, occasionally, be advantageous compared with relaparotomy. At the same time, I’m skeptical — for example — about the rationale of applying laparoscopy in a relook (24-36 hours later) to check for intestinal ischemia: why would one want to create new holes in the abdominal wall? What’s wrong with taking the Mayo scissors and cutting the fascial stitch, letting the fresh incisional wound fall open? Is it not more of a ‘second-hit’ to create additional port holes?\\n\\nFurthermore, the patients must be well selected in terms of their physiology (you do not want to pump lots of gas into the distended belly of a moribund patient) and intra-abdominal pathology. In fact, in most instances, the procedure would be ‘CT-guided laparoscopy’ to compensate for the lack of manual exploration of blind spots. And what is true with any laparoscopic procedure should be crucial here: “Do not f**k around, do not damage anything — and for God’s sake — know when to stop and open up!” Moshe\\n\\n“A surgeon… is like the skipper of an ocean-going racing\\n```\",\n", " 'md': \"In summary, laparoscopic abdominal re-exploration has a role in:\\n\\n- Persistent early postoperative intestinal obstruction.\\n- 'Second look' for mesenteric ischemia.\\n- Perforated peptic ulcers.\\n- Drainage of abscesses and collections (when percutaneous attempts fail).\\n- Drainage (with or without exteriorization) for anastomotic leaks.\\n\\nI agree that laparoscopic re-exploration in the hands of well-trained and experienced laparoscopic surgeons may, occasionally, be advantageous compared with relaparotomy. At the same time, I’m skeptical — for example — about the rationale of applying laparoscopy in a relook (24-36 hours later) to check for intestinal ischemia: why would one want to create new holes in the abdominal wall? What’s wrong with taking the Mayo scissors and cutting the fascial stitch, letting the fresh incisional wound fall open? Is it not more of a ‘second-hit’ to create additional port holes?\\n\\nFurthermore, the patients must be well selected in terms of their physiology (you do not want to pump lots of gas into the distended belly of a moribund patient) and intra-abdominal pathology. In fact, in most instances, the procedure would be ‘CT-guided laparoscopy’ to compensate for the lack of manual exploration of blind spots. And what is true with any laparoscopic procedure should be crucial here: “Do not f**k around, do not damage anything — and for God’s sake — know when to stop and open up!” Moshe\\n\\n“A surgeon… is like the skipper of an ocean-going racing\\n```\",\n", " 'bBox': {'x': 77, 'y': 170, 'w': 457.78, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 836,\n", " 'text': ' yacht. He knows the port he must make, but he cannot\\n foresee the course of the journey. At every stage he must\\n have a plan, based on a working knowledge of his\\n present position, that will allow him to make for the best\\n of several available harbours should things go wrong, or\\n if none is suitable he must know where to find temporary\\n refuge under the lee of the land till he can resume his\\n journey.”\\n William Heneage Ogilvie\\n\\n1 We actually place the incision on the external oblique aponeurosis 2cm lateral from the\\n rectus-externus oblique junction to avoid creating a weak point. In this area the aponeurosis\\n still has no muscle, so it does not bleed, but it avoids making the incision at the thinnest part\\n of the fascial structures. Ari',\n", " 'md': '```markdown\\n> \"A yacht. He knows the port he must make, but he cannot foresee the course of the journey. At every stage he must have a plan, based on a working knowledge of his present position, that will allow him to make for the best of several available harbours should things go wrong, or if none is suitable he must know where to find temporary refuge under the lee of the land till he can resume his journey.”\\n> — William Heneage Ogilvie\\n\\n1. We actually place the incision on the external oblique aponeurosis 2cm lateral from the rectus-externus oblique junction to avoid creating a weak point. In this area, the aponeurosis still has no muscle, so it does not bleed, but it avoids making the incision at the thinnest part of the fascial structures.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown\\n> \"A yacht. He knows the port he must make, but he cannot foresee the course of the journey. At every stage he must have a plan, based on a working knowledge of his present position, that will allow him to make for the best of several available harbours should things go wrong, or if none is suitable he must know where to find temporary refuge under the lee of the land till he can resume his journey.”\\n> — William Heneage Ogilvie\\n\\n1. We actually place the incision on the external oblique aponeurosis 2cm lateral from the rectus-externus oblique junction to avoid creating a weak point. In this area, the aponeurosis still has no muscle, so it does not bleed, but it avoids making the incision at the thinnest part of the fascial structures.\\n```',\n", " 'md': '```markdown\\n> \"A yacht. He knows the port he must make, but he cannot foresee the course of the journey. At every stage he must have a plan, based on a working knowledge of his present position, that will allow him to make for the best of several available harbours should things go wrong, or if none is suitable he must know where to find temporary refuge under the lee of the land till he can resume his journey.”\\n> — William Heneage Ogilvie\\n\\n1. We actually place the incision on the external oblique aponeurosis 2cm lateral from the rectus-externus oblique junction to avoid creating a weak point. In this area, the aponeurosis still has no muscle, so it does not bleed, but it avoids making the incision at the thinnest part of the fascial structures.\\n```',\n", " 'bBox': {'x': 73, 'y': 88, 'w': 459.5, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 837,\n", " 'text': 'Chapter 49\\nWound management\\nMoshe Schein\\n\\n The fate of the surgical wound is sealed during the\\n operation; almost nothing can be done after the operation to\\n modify the wound’s outcome.\\n\\n A minor complication is one that happens to somebody\\n else.\\n RRAl\\nFigure 49.1. “I hope you are satisfied with the beautiful wound, eh?”',\n", " 'md': \"```markdown\\n# Chapter 49: Wound Management\\n**Author:** Moshe Schein\\n\\nThe fate of the surgical wound is sealed during the operation; almost nothing can be done after the operation to modify the wound’s outcome.\\n\\nA minor complication is one that happens to somebody else.\\n\\n----\\n\\n**Figure 49.1**: “I hope you are satisfied with the beautiful wound, eh?”\\n- **Description**: This figure likely depicts a humorous or ironic commentary on surgical wounds, possibly featuring an image of a wound or a surgical scene. The caption suggests a light-hearted approach to the topic of wound management.\\n- **Summary**: The figure emphasizes the importance of perception in surgical outcomes, hinting at the disconnect between the surgeon's perspective and the patient's experience.\\n```\",\n", " 'images': [{'name': 'img_p836_1.png',\n", " 'height': 531,\n", " 'width': 803,\n", " 'x': 107.28,\n", " 'y': 411.11999999999995,\n", " 'original_width': 1380,\n", " 'original_height': 913}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 49: Wound Management',\n", " 'md': '# Chapter 49: Wound Management',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 186.68, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': \"**Author:** Moshe Schein\\n\\nThe fate of the surgical wound is sealed during the operation; almost nothing can be done after the operation to modify the wound’s outcome.\\n\\nA minor complication is one that happens to somebody else.\\n\\n----\\n\\n**Figure 49.1**: “I hope you are satisfied with the beautiful wound, eh?”\\n- **Description**: This figure likely depicts a humorous or ironic commentary on surgical wounds, possibly featuring an image of a wound or a surgical scene. The caption suggests a light-hearted approach to the topic of wound management.\\n- **Summary**: The figure emphasizes the importance of perception in surgical outcomes, hinting at the disconnect between the surgeon's perspective and the patient's experience.\\n```\",\n", " 'md': \"**Author:** Moshe Schein\\n\\nThe fate of the surgical wound is sealed during the operation; almost nothing can be done after the operation to modify the wound’s outcome.\\n\\nA minor complication is one that happens to somebody else.\\n\\n----\\n\\n**Figure 49.1**: “I hope you are satisfied with the beautiful wound, eh?”\\n- **Description**: This figure likely depicts a humorous or ironic commentary on surgical wounds, possibly featuring an image of a wound or a surgical scene. The caption suggests a light-hearted approach to the topic of wound management.\\n- **Summary**: The figure emphasizes the importance of perception in surgical outcomes, hinting at the disconnect between the surgeon's perspective and the patient's experience.\\n```\",\n", " 'bBox': {'x': 72, 'y': 198, 'w': 381.41, 'h': 20.16}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 838,\n", " 'text': ' All that is visible to the patient of your wonderful, life-saving,\\nemergency abdominal operation is the surgical wound ( Figure 49.1).\\nWound complications, although not life-threatening, are an irritating\\nsource of painful, and often prolonged, morbidity, which bothers the\\npatient and his surgeon alike. It is no wonder then that throughout\\ngenerations, surgeons have developed elaborate rituals to prevent and\\ntreat wound complications. Now that you are reading one of the last\\nchapters of this book you are, we hope, sufficiently brain-washed to\\ndeplore elaborate gimmicks, and to demand pragmatic solutions instead.\\n\\n Definitions and the spectrum\\n\\n For practical purposes you do not need complicated definitions used by\\nepidemiologists or infection-control nurses — the usually humorless and\\ndogmatic individuals who tell you not to walk out of the operating room\\nwith your scrubs on…\\n\\n Wounds are either uncomplicated or complicated. An\\nuncomplicated wound is a sutured wound that heals uneventfully by\\nprimary intention. Note that following emergency abdominal surgery, an\\nentirely uncomplicated wound is an exception! You don’t believe us?\\nStart to document from now on all your wounds and see for yourself the\\nnumber of weeping or red and swollen wounds your patients have.\\n\\n Complicated wounds are extremely common after emergency surgery\\nwhen prospectively assessed by independent observers. Conversely,\\nwhen ‘reported’ by surgeons they become ‘rare’ or ‘minor’ due to our\\nnatural tendency to suppress or ignore adverse outcomes. Besides,\\nmost of these wound problems manifest after the patient has been\\ndischarged. Do you know any surgeon who would run after the infection\\ncontrol Tzar in his hospital begging her to advertise his wound infection\\nrate? Thus, in real life the rate of wound infections is grossly under-\\nreported and underestimated, and the corresponding hospital statistics\\nbiased!\\n\\n The spectrum of wound complications is wide and encompasses\\ninfective and non-infective complications, minor and major.',\n", " 'md': '```markdown\\n## Wound Complications in Emergency Abdominal Surgery\\n\\nAll that is visible to the patient of your wonderful, life-saving, emergency abdominal operation is the surgical wound (Figure 49.1). Wound complications, although not life-threatening, are an irritating source of painful, and often prolonged, morbidity, which bothers the patient and his surgeon alike. It is no wonder then that throughout generations, surgeons have developed elaborate rituals to prevent and treat wound complications. Now that you are reading one of the last chapters of this book you are, we hope, sufficiently brain-washed to deplore elaborate gimmicks, and to demand pragmatic solutions instead.\\n\\n### Definitions and the Spectrum\\n\\nFor practical purposes you do not need complicated definitions used by epidemiologists or infection-control nurses — the usually humorless and dogmatic individuals who tell you not to walk out of the operating room with your scrubs on…\\n\\nWounds are either uncomplicated or complicated. An uncomplicated wound is a sutured wound that heals uneventfully by primary intention. Note that following emergency abdominal surgery, an entirely uncomplicated wound is an exception! You don’t believe us? Start to document from now on all your wounds and see for yourself the number of weeping or red and swollen wounds your patients have.\\n\\nComplicated wounds are extremely common after emergency surgery when prospectively assessed by independent observers. Conversely, when ‘reported’ by surgeons they become ‘rare’ or ‘minor’ due to our natural tendency to suppress or ignore adverse outcomes. Besides, most of these wound problems manifest after the patient has been discharged. Do you know any surgeon who would run after the infection control Tzar in his hospital begging her to advertise his wound infection rate? Thus, in real life the rate of wound infections is grossly under-reported and underestimated, and the corresponding hospital statistics biased!\\n\\nThe spectrum of wound complications is wide and encompasses infective and non-infective complications, minor and major.\\n\\n### Figure 49.1\\n- **Description**: This figure likely depicts a surgical wound from an emergency abdominal operation. The details of the image are not provided in the text, but it serves as a visual reference for the discussion on wound complications.\\n- **Summary**: The figure illustrates the visible aspect of surgical wounds, which are the primary concern for both patients and surgeons post-operation.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Wound Complications in Emergency Abdominal Surgery',\n", " 'md': '## Wound Complications in Emergency Abdominal Surgery',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'All that is visible to the patient of your wonderful, life-saving, emergency abdominal operation is the surgical wound (Figure 49.1). Wound complications, although not life-threatening, are an irritating source of painful, and often prolonged, morbidity, which bothers the patient and his surgeon alike. It is no wonder then that throughout generations, surgeons have developed elaborate rituals to prevent and treat wound complications. Now that you are reading one of the last chapters of this book you are, we hope, sufficiently brain-washed to deplore elaborate gimmicks, and to demand pragmatic solutions instead.',\n", " 'md': 'All that is visible to the patient of your wonderful, life-saving, emergency abdominal operation is the surgical wound (Figure 49.1). Wound complications, although not life-threatening, are an irritating source of painful, and often prolonged, morbidity, which bothers the patient and his surgeon alike. It is no wonder then that throughout generations, surgeons have developed elaborate rituals to prevent and treat wound complications. Now that you are reading one of the last chapters of this book you are, we hope, sufficiently brain-washed to deplore elaborate gimmicks, and to demand pragmatic solutions instead.',\n", " 'bBox': {'x': 72, 'y': 218, 'w': 462.18, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Definitions and the Spectrum',\n", " 'md': '### Definitions and the Spectrum',\n", " 'bBox': {'x': 86, 'y': 261, 'w': 228.03, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'For practical purposes you do not need complicated definitions used by epidemiologists or infection-control nurses — the usually humorless and dogmatic individuals who tell you not to walk out of the operating room with your scrubs on…\\n\\nWounds are either uncomplicated or complicated. An uncomplicated wound is a sutured wound that heals uneventfully by primary intention. Note that following emergency abdominal surgery, an entirely uncomplicated wound is an exception! You don’t believe us? Start to document from now on all your wounds and see for yourself the number of weeping or red and swollen wounds your patients have.\\n\\nComplicated wounds are extremely common after emergency surgery when prospectively assessed by independent observers. Conversely, when ‘reported’ by surgeons they become ‘rare’ or ‘minor’ due to our natural tendency to suppress or ignore adverse outcomes. Besides, most of these wound problems manifest after the patient has been discharged. Do you know any surgeon who would run after the infection control Tzar in his hospital begging her to advertise his wound infection rate? Thus, in real life the rate of wound infections is grossly under-reported and underestimated, and the corresponding hospital statistics biased!\\n\\nThe spectrum of wound complications is wide and encompasses infective and non-infective complications, minor and major.',\n", " 'md': 'For practical purposes you do not need complicated definitions used by epidemiologists or infection-control nurses — the usually humorless and dogmatic individuals who tell you not to walk out of the operating room with your scrubs on…\\n\\nWounds are either uncomplicated or complicated. An uncomplicated wound is a sutured wound that heals uneventfully by primary intention. Note that following emergency abdominal surgery, an entirely uncomplicated wound is an exception! You don’t believe us? Start to document from now on all your wounds and see for yourself the number of weeping or red and swollen wounds your patients have.\\n\\nComplicated wounds are extremely common after emergency surgery when prospectively assessed by independent observers. Conversely, when ‘reported’ by surgeons they become ‘rare’ or ‘minor’ due to our natural tendency to suppress or ignore adverse outcomes. Besides, most of these wound problems manifest after the patient has been discharged. Do you know any surgeon who would run after the infection control Tzar in his hospital begging her to advertise his wound infection rate? Thus, in real life the rate of wound infections is grossly under-reported and underestimated, and the corresponding hospital statistics biased!\\n\\nThe spectrum of wound complications is wide and encompasses infective and non-infective complications, minor and major.',\n", " 'bBox': {'x': 72, 'y': 297, 'w': 467.92, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure 49.1',\n", " 'md': '### Figure 49.1',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Description**: This figure likely depicts a surgical wound from an emergency abdominal operation. The details of the image are not provided in the text, but it serves as a visual reference for the discussion on wound complications.\\n- **Summary**: The figure illustrates the visible aspect of surgical wounds, which are the primary concern for both patients and surgeons post-operation.\\n```',\n", " 'md': '- **Description**: This figure likely depicts a surgical wound from an emergency abdominal operation. The details of the image are not provided in the text, but it serves as a visual reference for the discussion on wound complications.\\n- **Summary**: The figure illustrates the visible aspect of surgical wounds, which are the primary concern for both patients and surgeons post-operation.\\n```',\n", " 'bBox': {'x': 161, 'y': 382, 'w': 25.6, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Wound complications, although not life-threatening, are an irritating'}]},\n", " {'page': 839,\n", " 'text': ' Minor complications are those irritating aberrations in the process of\\n healing that, however, do not impede primary healing of the wound: a small\\n hematoma, a little erythema, some serous discharge. The distinction between an\\n infectious and non-infectious process is difficult and also unnecessary; why take\\n swab cultures from such a wound if it will not affect therapy?\\n Major complications are those that interfere with the process of primary\\n healing and require your intervention: a large hematoma or a wound abscess in\\n need of drainage.\\n\\n Wound infection — for practical purposes this is a wound\\n that contains pus and requires drainage. Usually such an\\n infection represents a ‘walled-off’ wound abscess, with minimal involvement of\\n adjacent soft tissues or underlying fascia. Rarely, there may be significant\\n surrounding cellulitis or involvement of the deep fascia, denoting a (deep-space)\\n invasive infection.\\n\\n Prevention\\n\\n Surgical technique and overall patient care are of great importance in\\nminimizing the incidence of wound infection. Rarely is one aspect of\\nmanagement of singular importance, rather it is the sum of the parts\\nthat yields favorable results. Emergency surgery is particularly\\nassociated with wound problems for several reasons. Contamination of\\nthe wound may arise from intestinal bacteria released at the time of\\nbowel resection or from the organisms present in the established\\ninfection that the surgery was performed to treat ( Chapter 13).\\nAdditionally, there is insufficient time pre-operatively to reverse all\\nconditions which may adversely affect wound healing such as shock,\\ndiabetes and malnutrition ( Chapter 6).\\n\\n Evidence suggests that tissue hypoxia, hypothermia and poorly controlled blood sugar\\n predispose to wound complications. So try — the best you can in the few hours you have (if\\n any at all) before the operation — to oxygenate the patient better (yes, give him that oxygen\\n mask!), warm him up and administer insulin if necessary.',\n", " 'md': '```markdown\\n## Minor and Major Complications of Wound Healing\\n\\nMinor complications are those irritating aberrations in the process of healing that, however, do not impede primary healing of the wound: a small hematoma, a little erythema, some serous discharge. The distinction between an infectious and non-infectious process is difficult and also unnecessary; why take swab cultures from such a wound if it will not affect therapy?\\n\\nMajor complications are those that interfere with the process of primary healing and require your intervention: a large hematoma or a wound abscess in need of drainage.\\n\\n### Wound Infection\\n\\nWound infection — for practical purposes this is a wound that contains pus and requires drainage. Usually, such an infection represents a ‘walled-off’ wound abscess, with minimal involvement of adjacent soft tissues or underlying fascia. Rarely, there may be significant surrounding cellulitis or involvement of the deep fascia, denoting a (deep-space) invasive infection.\\n\\n### Prevention\\n\\nSurgical technique and overall patient care are of great importance in minimizing the incidence of wound infection. Rarely is one aspect of management of singular importance; rather, it is the sum of the parts that yields favorable results. Emergency surgery is particularly associated with wound problems for several reasons. Contamination of the wound may arise from intestinal bacteria released at the time of bowel resection or from the organisms present in the established infection that the surgery was performed to treat (Chapter 13). Additionally, there is insufficient time pre-operatively to reverse all conditions which may adversely affect wound healing such as shock, diabetes, and malnutrition (Chapter 6).\\n\\nEvidence suggests that tissue hypoxia, hypothermia, and poorly controlled blood sugar predispose to wound complications. So try — the best you can in the few hours you have (if any at all) before the operation — to oxygenate the patient better (yes, give him that oxygen mask!), warm him up, and administer insulin if necessary.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Minor and Major Complications of Wound Healing',\n", " 'md': '## Minor and Major Complications of Wound Healing',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Minor complications are those irritating aberrations in the process of healing that, however, do not impede primary healing of the wound: a small hematoma, a little erythema, some serous discharge. The distinction between an infectious and non-infectious process is difficult and also unnecessary; why take swab cultures from such a wound if it will not affect therapy?\\n\\nMajor complications are those that interfere with the process of primary healing and require your intervention: a large hematoma or a wound abscess in need of drainage.',\n", " 'md': 'Minor complications are those irritating aberrations in the process of healing that, however, do not impede primary healing of the wound: a small hematoma, a little erythema, some serous discharge. The distinction between an infectious and non-infectious process is difficult and also unnecessary; why take swab cultures from such a wound if it will not affect therapy?\\n\\nMajor complications are those that interfere with the process of primary healing and require your intervention: a large hematoma or a wound abscess in need of drainage.',\n", " 'bBox': {'x': 133, 'y': 171, 'w': 286.91, 'h': 10.8}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Wound Infection',\n", " 'md': '### Wound Infection',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Wound infection — for practical purposes this is a wound that contains pus and requires drainage. Usually, such an infection represents a ‘walled-off’ wound abscess, with minimal involvement of adjacent soft tissues or underlying fascia. Rarely, there may be significant surrounding cellulitis or involvement of the deep fascia, denoting a (deep-space) invasive infection.',\n", " 'md': 'Wound infection — for practical purposes this is a wound that contains pus and requires drainage. Usually, such an infection represents a ‘walled-off’ wound abscess, with minimal involvement of adjacent soft tissues or underlying fascia. Rarely, there may be significant surrounding cellulitis or involvement of the deep fascia, denoting a (deep-space) invasive infection.',\n", " 'bBox': {'x': 133, 'y': 255, 'w': 397.34, 'h': 16.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Prevention',\n", " 'md': '### Prevention',\n", " 'bBox': {'x': 86, 'y': 404, 'w': 85.53, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Surgical technique and overall patient care are of great importance in minimizing the incidence of wound infection. Rarely is one aspect of management of singular importance; rather, it is the sum of the parts that yields favorable results. Emergency surgery is particularly associated with wound problems for several reasons. Contamination of the wound may arise from intestinal bacteria released at the time of bowel resection or from the organisms present in the established infection that the surgery was performed to treat (Chapter 13). Additionally, there is insufficient time pre-operatively to reverse all conditions which may adversely affect wound healing such as shock, diabetes, and malnutrition (Chapter 6).\\n\\nEvidence suggests that tissue hypoxia, hypothermia, and poorly controlled blood sugar predispose to wound complications. So try — the best you can in the few hours you have (if any at all) before the operation — to oxygenate the patient better (yes, give him that oxygen mask!), warm him up, and administer insulin if necessary.\\n```',\n", " 'md': 'Surgical technique and overall patient care are of great importance in minimizing the incidence of wound infection. Rarely is one aspect of management of singular importance; rather, it is the sum of the parts that yields favorable results. Emergency surgery is particularly associated with wound problems for several reasons. Contamination of the wound may arise from intestinal bacteria released at the time of bowel resection or from the organisms present in the established infection that the surgery was performed to treat (Chapter 13). Additionally, there is insufficient time pre-operatively to reverse all conditions which may adversely affect wound healing such as shock, diabetes, and malnutrition (Chapter 6).\\n\\nEvidence suggests that tissue hypoxia, hypothermia, and poorly controlled blood sugar predispose to wound complications. So try — the best you can in the few hours you have (if any at all) before the operation — to oxygenate the patient better (yes, give him that oxygen mask!), warm him up, and administer insulin if necessary.\\n```',\n", " 'bBox': {'x': 79, 'y': 440, 'w': 460.45, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Additionally, there is insufficient time pre-operatively to reverse all'},\n", " {'text': ''}]},\n", " {'page': 840,\n", " 'text': ' When you deal with complicated wounds you get wound\\n complications.\\n\\n Yes, this aphorism is true, and a certain rate of wound complications is\\nobligatory and inherent in the nature of this type of surgery.\\nNevertheless, you should strive to keep it as low as possible. How?\\n\\n Let us reiterate here the above-mentioned aphorism: “The fate of the\\nsurgical wound is sealed during the operation; almost nothing can\\nbe done after the operation to modify the wound’s outcome.”\\nWhether your patient develops a wound hematoma or infection depends\\non your patient and on you, and is determined during the operation — not\\nafterwards. We quote Mark Ravitch again: “The likelihood of wound\\ninfections has been determined by the time the last stitch is\\ninserted in the wound.”\\n\\n Meticulous technique as described in Chapter 40 is paramount.\\nħere, a few preventive points are re-emphasized:\\n\\n • Operate efficiently and carefully; avoid ‘masturbating’ the tissues.\\n • Do not strangulate the fascia with interrupted figure-of-eight sutures\\n of wire, Ethibond® or Vicryl®; instead, use low-tension continuous\\n spring-like monofilament closure — letting the abdominal wall\\n breathe ( Chapter 40).\\n • Do not ‘barbecue’ the skin and underlying tissues with excessive use\\n of diathermy.\\n • Do not bury tons of highly irritating chromic (or anything else) in the\\n subcutaneous fat.\\n • Do not close the skin with the even more noxious silk.\\n • Do not place contaminating colostomies in the main abdominal\\n wound.\\n • Do not leave useless drains (unless absolutely necessary) in the\\n wound. And if you insert a drain then remove it ASAP. Don’t forget\\n that drains increase the risk of wound infections.',\n", " 'md': '```markdown\\n## Wound Complications\\n\\nWhen you deal with complicated wounds you get wound complications.\\n\\nYes, this aphorism is true, and a certain rate of wound complications is obligatory and inherent in the nature of this type of surgery. Nevertheless, you should strive to keep it as low as possible. How?\\n\\nLet us reiterate here the above-mentioned aphorism: “The fate of the surgical wound is sealed during the operation; almost nothing can be done after the operation to modify the wound’s outcome.” Whether your patient develops a wound hematoma or infection depends on your patient and on you, and is determined during the operation — not afterwards. We quote Mark Ravitch again: “The likelihood of wound infections has been determined by the time the last stitch is inserted in the wound.”\\n\\nMeticulous technique as described in Chapter 40 is paramount. Here, a few preventive points are re-emphasized:\\n\\n- Operate efficiently and carefully; avoid ‘masturbating’ the tissues.\\n- Do not strangulate the fascia with interrupted figure-of-eight sutures of wire, Ethibond® or Vicryl®; instead, use low-tension continuous spring-like monofilament closure — letting the abdominal wall breathe (Chapter 40).\\n- Do not ‘barbecue’ the skin and underlying tissues with excessive use of diathermy.\\n- Do not bury tons of highly irritating chromic (or anything else) in the subcutaneous fat.\\n- Do not close the skin with the even more noxious silk.\\n- Do not place contaminating colostomies in the main abdominal wound.\\n- Do not leave useless drains (unless absolutely necessary) in the wound. And if you insert a drain then remove it ASAP. Don’t forget that drains increase the risk of wound infections.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Wound Complications',\n", " 'md': '## Wound Complications',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'When you deal with complicated wounds you get wound complications.\\n\\nYes, this aphorism is true, and a certain rate of wound complications is obligatory and inherent in the nature of this type of surgery. Nevertheless, you should strive to keep it as low as possible. How?\\n\\nLet us reiterate here the above-mentioned aphorism: “The fate of the surgical wound is sealed during the operation; almost nothing can be done after the operation to modify the wound’s outcome.” Whether your patient develops a wound hematoma or infection depends on your patient and on you, and is determined during the operation — not afterwards. We quote Mark Ravitch again: “The likelihood of wound infections has been determined by the time the last stitch is inserted in the wound.”\\n\\nMeticulous technique as described in Chapter 40 is paramount. Here, a few preventive points are re-emphasized:\\n\\n- Operate efficiently and carefully; avoid ‘masturbating’ the tissues.\\n- Do not strangulate the fascia with interrupted figure-of-eight sutures of wire, Ethibond® or Vicryl®; instead, use low-tension continuous spring-like monofilament closure — letting the abdominal wall breathe (Chapter 40).\\n- Do not ‘barbecue’ the skin and underlying tissues with excessive use of diathermy.\\n- Do not bury tons of highly irritating chromic (or anything else) in the subcutaneous fat.\\n- Do not close the skin with the even more noxious silk.\\n- Do not place contaminating colostomies in the main abdominal wound.\\n- Do not leave useless drains (unless absolutely necessary) in the wound. And if you insert a drain then remove it ASAP. Don’t forget that drains increase the risk of wound infections.\\n```',\n", " 'md': 'When you deal with complicated wounds you get wound complications.\\n\\nYes, this aphorism is true, and a certain rate of wound complications is obligatory and inherent in the nature of this type of surgery. Nevertheless, you should strive to keep it as low as possible. How?\\n\\nLet us reiterate here the above-mentioned aphorism: “The fate of the surgical wound is sealed during the operation; almost nothing can be done after the operation to modify the wound’s outcome.” Whether your patient develops a wound hematoma or infection depends on your patient and on you, and is determined during the operation — not afterwards. We quote Mark Ravitch again: “The likelihood of wound infections has been determined by the time the last stitch is inserted in the wound.”\\n\\nMeticulous technique as described in Chapter 40 is paramount. Here, a few preventive points are re-emphasized:\\n\\n- Operate efficiently and carefully; avoid ‘masturbating’ the tissues.\\n- Do not strangulate the fascia with interrupted figure-of-eight sutures of wire, Ethibond® or Vicryl®; instead, use low-tension continuous spring-like monofilament closure — letting the abdominal wall breathe (Chapter 40).\\n- Do not ‘barbecue’ the skin and underlying tissues with excessive use of diathermy.\\n- Do not bury tons of highly irritating chromic (or anything else) in the subcutaneous fat.\\n- Do not close the skin with the even more noxious silk.\\n- Do not place contaminating colostomies in the main abdominal wound.\\n- Do not leave useless drains (unless absolutely necessary) in the wound. And if you insert a drain then remove it ASAP. Don’t forget that drains increase the risk of wound infections.\\n```',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.69, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'ħere, a few preventive points are re-emphasized:'},\n", " {'text': ''}]},\n", " {'page': 841,\n", " 'text': ' Transfer your meticulous technique to the ward also. Nosocomial\\n(hospital-acquired) infection is a menace to our patients. We have\\nalready mentioned the contribution that indiscriminate use of non-\\nindicated antibiotics makes to the emergence of resistant organisms. The\\nprevalence of these germs as colonizers of our patients is increasing,\\nand spread from patient to patient is a big problem. Doctors are a major\\nvector in this spread. Wash your hands every time you touch a patient. It\\nseems astonishing that this message has to be repeated nowadays, but\\nstudies have shown time and again that nurses are much more\\nmeticulous in their approach to this issue than MDs. This act of\\nhandwashing after each patient contact should be so ingrained that\\nyou have a sense of incompleteness until it is performed.\\n\\n Antibiotics\\n\\n Antibiotic prophylaxis reduces the wound infection rate; its anti-\\ninfective effects are in fact more pronounced in the surgical wound than\\nwithin the peritoneal cavity ( Chapter 7). Intra-incisional antibiotics — I\\nbelieve but others do not — have an additional preventive role; this\\nmakes sense if you consider that the wound’s defense mechanisms are\\nmuch weaker than those of the peritoneal cavity. Many years ago it was\\nshown that systemic antibiotics are effective in preventing wound\\ninfections only if given within 3 hours of bacterial contamination — the\\n‘effective period’. Postoperative antibiotics cannot change the fate of\\nthe wound, as they won’t penetrate the area. Despite what you have\\nbeen told hitherto by your local infectious disease specialists or surgical\\ngurus, brief peri-operative antibiotic coverage is as effective in preventing\\nwound infection as 7 days of post-op administration ( Chapter 44).\\n\\n Non-closure or delayed closure of the wound\\n\\n Leaving the skin and subcutis completely or partially open following\\ncontaminated or dirty procedures is still advocated by some ‘authorities’.\\nTrue, it may prevent wound infection in the minority of patients who are\\nbound to develop one but not every severely contaminated wound will\\nbecome infected (indeed, you can even smear s**t on an open wound\\nwithout getting an infection!). At the same time leaving these wounds',\n", " 'md': '```markdown\\n## Page Content\\n\\nTransfer your meticulous technique to the ward also. Nosocomial (hospital-acquired) infection is a menace to our patients. We have already mentioned the contribution that indiscriminate use of non-indicated antibiotics makes to the emergence of resistant organisms. The prevalence of these germs as colonizers of our patients is increasing, and spread from patient to patient is a big problem. Doctors are a major vector in this spread. Wash your hands every time you touch a patient. It seems astonishing that this message has to be repeated nowadays, but studies have shown time and again that nurses are much more meticulous in their approach to this issue than MDs. This act of handwashing after each patient contact should be so ingrained that you have a sense of incompleteness until it is performed.\\n\\n### Antibiotics\\n\\nAntibiotic prophylaxis reduces the wound infection rate; its anti-infective effects are in fact more pronounced in the surgical wound than within the peritoneal cavity (Chapter 7). Intra-incisional antibiotics — I believe but others do not — have an additional preventive role; this makes sense if you consider that the wound’s defense mechanisms are much weaker than those of the peritoneal cavity. Many years ago it was shown that systemic antibiotics are effective in preventing wound infections only if given within 3 hours of bacterial contamination — the ‘effective period’. Postoperative antibiotics cannot change the fate of the wound, as they won’t penetrate the area. Despite what you have been told hitherto by your local infectious disease specialists or surgical gurus, brief peri-operative antibiotic coverage is as effective in preventing wound infection as 7 days of post-op administration (Chapter 44).\\n\\n### Non-closure or delayed closure of the wound\\n\\nLeaving the skin and subcutis completely or partially open following contaminated or dirty procedures is still advocated by some ‘authorities’. True, it may prevent wound infection in the minority of patients who are bound to develop one but not every severely contaminated wound will become infected (indeed, you can even smear s**t on an open wound without getting an infection!). At the same time leaving these wounds...\\n\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Page Content',\n", " 'md': '## Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Transfer your meticulous technique to the ward also. Nosocomial (hospital-acquired) infection is a menace to our patients. We have already mentioned the contribution that indiscriminate use of non-indicated antibiotics makes to the emergence of resistant organisms. The prevalence of these germs as colonizers of our patients is increasing, and spread from patient to patient is a big problem. Doctors are a major vector in this spread. Wash your hands every time you touch a patient. It seems astonishing that this message has to be repeated nowadays, but studies have shown time and again that nurses are much more meticulous in their approach to this issue than MDs. This act of handwashing after each patient contact should be so ingrained that you have a sense of incompleteness until it is performed.',\n", " 'md': 'Transfer your meticulous technique to the ward also. Nosocomial (hospital-acquired) infection is a menace to our patients. We have already mentioned the contribution that indiscriminate use of non-indicated antibiotics makes to the emergence of resistant organisms. The prevalence of these germs as colonizers of our patients is increasing, and spread from patient to patient is a big problem. Doctors are a major vector in this spread. Wash your hands every time you touch a patient. It seems astonishing that this message has to be repeated nowadays, but studies have shown time and again that nurses are much more meticulous in their approach to this issue than MDs. This act of handwashing after each patient contact should be so ingrained that you have a sense of incompleteness until it is performed.',\n", " 'bBox': {'x': 72, 'y': 135, 'w': 467.94, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Antibiotics',\n", " 'md': '### Antibiotics',\n", " 'bBox': {'x': 86, 'y': 311, 'w': 85.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Antibiotic prophylaxis reduces the wound infection rate; its anti-infective effects are in fact more pronounced in the surgical wound than within the peritoneal cavity (Chapter 7). Intra-incisional antibiotics — I believe but others do not — have an additional preventive role; this makes sense if you consider that the wound’s defense mechanisms are much weaker than those of the peritoneal cavity. Many years ago it was shown that systemic antibiotics are effective in preventing wound infections only if given within 3 hours of bacterial contamination — the ‘effective period’. Postoperative antibiotics cannot change the fate of the wound, as they won’t penetrate the area. Despite what you have been told hitherto by your local infectious disease specialists or surgical gurus, brief peri-operative antibiotic coverage is as effective in preventing wound infection as 7 days of post-op administration (Chapter 44).',\n", " 'md': 'Antibiotic prophylaxis reduces the wound infection rate; its anti-infective effects are in fact more pronounced in the surgical wound than within the peritoneal cavity (Chapter 7). Intra-incisional antibiotics — I believe but others do not — have an additional preventive role; this makes sense if you consider that the wound’s defense mechanisms are much weaker than those of the peritoneal cavity. Many years ago it was shown that systemic antibiotics are effective in preventing wound infections only if given within 3 hours of bacterial contamination — the ‘effective period’. Postoperative antibiotics cannot change the fate of the wound, as they won’t penetrate the area. Despite what you have been told hitherto by your local infectious disease specialists or surgical gurus, brief peri-operative antibiotic coverage is as effective in preventing wound infection as 7 days of post-op administration (Chapter 44).',\n", " 'bBox': {'x': 72, 'y': 311, 'w': 467.97, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Non-closure or delayed closure of the wound',\n", " 'md': '### Non-closure or delayed closure of the wound',\n", " 'bBox': {'x': 86, 'y': 589, 'w': 354.92, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Leaving the skin and subcutis completely or partially open following contaminated or dirty procedures is still advocated by some ‘authorities’. True, it may prevent wound infection in the minority of patients who are bound to develop one but not every severely contaminated wound will become infected (indeed, you can even smear s**t on an open wound without getting an infection!). At the same time leaving these wounds...\\n\\n```',\n", " 'md': 'Leaving the skin and subcutis completely or partially open following contaminated or dirty procedures is still advocated by some ‘authorities’. True, it may prevent wound infection in the minority of patients who are bound to develop one but not every severely contaminated wound will become infected (indeed, you can even smear s**t on an open wound without getting an infection!). At the same time leaving these wounds...\\n\\n```',\n", " 'bBox': {'x': 72, 'y': 641, 'w': 467.68, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.\\n- There are no formulas to convert into LaTeX MathJax notation.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'believe but others do not — have an additional preventive role; this'},\n", " {'text': ''}]},\n", " {'page': 842,\n", " 'text': 'open condemns the majority, whose wounds are destined to heal more or\\nless uneventfully, to the morbidity of open wounds, the associated\\nproblems of management, and the risk of superinfection. Look at\\nChapter 40 for more details on this controversial issue.\\n\\n Management\\n\\n The uncomplicated wound\\n\\n Throughout history surgeons have been fascinated with the treatment\\nof wounds because all they could do was to manage external post-\\ntraumatic wounds. For hundreds of years surgical leaders have\\nadvocated simplicity in the management of wounds:\\n\\n • Felix Wurtz wrote in the 14th century: “Keep them as neat and\\n clean as possible, and disturb them as little as you can; so far\\n as may be practicable, exclude the air; favor healing under the\\n scab; and… feed it as you would a women recovering from her\\n confinement.”\\n • The great Joseph Lister said in the 19th century: “Skin is the best\\n dressing.”\\n • The renowned physician William Osler maintained: “Soap and\\n water and common sense are the best disinfectants.”\\n\\n But most surgeons took literally the famous adage by war surgeon\\n(14th century) Ambroise Paré: “I dressed him and God healed him,”\\nand practiced unnecessarily elaborate wound-management policies.\\n\\n The uncomplicated primarily closed surgical wound needs almost\\nno care. A day after the operation it is well sealed away from the external\\nenvironment by a layer of fibrin. It can be left exposed. Isn’t it ridiculous to\\nsee gloved and masked nurses changing sterile dressings on routine\\nsurgical wounds?\\n\\n However, I guess it is also dependent on the closure method. It seems to me that a careful\\n layered closure with sutures is not equivalent to stapler closure, the latter being more',\n", " 'md': '```markdown\\n## Management\\n\\n### The Uncomplicated Wound\\n\\nThroughout history, surgeons have been fascinated with the treatment of wounds because all they could do was to manage external post-traumatic wounds. For hundreds of years, surgical leaders have advocated simplicity in the management of wounds:\\n\\n- Felix Wurtz wrote in the 14th century: “Keep them as neat and clean as possible, and disturb them as little as you can; so far as may be practicable, exclude the air; favor healing under the scab; and… feed it as you would a woman recovering from her confinement.”\\n- The great Joseph Lister said in the 19th century: “Skin is the best dressing.”\\n- The renowned physician William Osler maintained: “Soap and water and common sense are the best disinfectants.”\\n\\nBut most surgeons took literally the famous adage by war surgeon (14th century) Ambroise Paré: “I dressed him and God healed him,” and practiced unnecessarily elaborate wound-management policies.\\n\\nThe uncomplicated primarily closed surgical wound needs almost no care. A day after the operation, it is well sealed away from the external environment by a layer of fibrin. It can be left exposed. Isn’t it ridiculous to see gloved and masked nurses changing sterile dressings on routine surgical wounds?\\n\\nHowever, I guess it is also dependent on the closure method. It seems to me that a careful layered closure with sutures is not equivalent to stapler closure, the latter being more...\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Management',\n", " 'md': '## Management',\n", " 'bBox': {'x': 86, 'y': 178, 'w': 101.17, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Uncomplicated Wound',\n", " 'md': '### The Uncomplicated Wound',\n", " 'bBox': {'x': 86, 'y': 222, 'w': 208.73, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Throughout history, surgeons have been fascinated with the treatment of wounds because all they could do was to manage external post-traumatic wounds. For hundreds of years, surgical leaders have advocated simplicity in the management of wounds:\\n\\n- Felix Wurtz wrote in the 14th century: “Keep them as neat and clean as possible, and disturb them as little as you can; so far as may be practicable, exclude the air; favor healing under the scab; and… feed it as you would a woman recovering from her confinement.”\\n- The great Joseph Lister said in the 19th century: “Skin is the best dressing.”\\n- The renowned physician William Osler maintained: “Soap and water and common sense are the best disinfectants.”\\n\\nBut most surgeons took literally the famous adage by war surgeon (14th century) Ambroise Paré: “I dressed him and God healed him,” and practiced unnecessarily elaborate wound-management policies.\\n\\nThe uncomplicated primarily closed surgical wound needs almost no care. A day after the operation, it is well sealed away from the external environment by a layer of fibrin. It can be left exposed. Isn’t it ridiculous to see gloved and masked nurses changing sterile dressings on routine surgical wounds?\\n\\nHowever, I guess it is also dependent on the closure method. It seems to me that a careful layered closure with sutures is not equivalent to stapler closure, the latter being more...\\n```',\n", " 'md': 'Throughout history, surgeons have been fascinated with the treatment of wounds because all they could do was to manage external post-traumatic wounds. For hundreds of years, surgical leaders have advocated simplicity in the management of wounds:\\n\\n- Felix Wurtz wrote in the 14th century: “Keep them as neat and clean as possible, and disturb them as little as you can; so far as may be practicable, exclude the air; favor healing under the scab; and… feed it as you would a woman recovering from her confinement.”\\n- The great Joseph Lister said in the 19th century: “Skin is the best dressing.”\\n- The renowned physician William Osler maintained: “Soap and water and common sense are the best disinfectants.”\\n\\nBut most surgeons took literally the famous adage by war surgeon (14th century) Ambroise Paré: “I dressed him and God healed him,” and practiced unnecessarily elaborate wound-management policies.\\n\\nThe uncomplicated primarily closed surgical wound needs almost no care. A day after the operation, it is well sealed away from the external environment by a layer of fibrin. It can be left exposed. Isn’t it ridiculous to see gloved and masked nurses changing sterile dressings on routine surgical wounds?\\n\\nHowever, I guess it is also dependent on the closure method. It seems to me that a careful layered closure with sutures is not equivalent to stapler closure, the latter being more...\\n```',\n", " 'bBox': {'x': 72, 'y': 178, 'w': 467.72, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Chapter 40 for more details on this controversial issue.'}]},\n", " {'page': 843,\n", " 'text': ' susceptible to contamination from the ouside during the first few postop days. Danny\\n\\n Sunshine and fresh air is what the patient — and wound — needs. Ari\\n\\n Some patients demand their wounds be covered; cheap dry gauze is\\nmore than adequate for this purpose — but in our modern commercial\\nenvironment it is more likely that your nurses would like to use fancy\\nexpensive products. The main achievement of elaborate ‘modern’\\ndressing materials, impregnated with antibiotics, silver or whatever,\\nis the enrichment of the medical-industrial complex. We try to avoid\\nthem. Patients with uncomplicated wounds can shower or bathe any\\ntime.\\n\\n The complicated wound\\n\\n Here the punishment should fit the crime. Minor non-specific\\ncomplications should be observed — the majority will resolve\\nspontaneously. Again, starting antibiotics because a wound weeps a little\\nserous discharge is not going to change anything; if the wound is\\ndestined to develop an infection it will, with or without antibiotics! Major\\nwound hematomas require evacuation but this is rare following\\nabdominal surgery.\\n\\n Wound infections\\n\\n Wound infection following an emergency abdominal operation is\\nusually caused by endogenous bacteria — the resident bacteria of the\\nabdominal organs breached during the operation or the bacteria which\\ncaused the intra-abdominal infection in the first place. Following non-\\ncontaminated operations (e.g. blunt splenic trauma), the bugs causing\\nwound infections are exogenous — skin residents, usually a\\nStaphylococcus. Carriers of MRSA (methicillin-resistant Staphylococcus\\naureus) are prone to wound infections caused by this bug but this is\\nanother story. The same goes for Streptococcal wound cellulitis which\\nmay develop a day (nay, even hours) after the operation with local pain\\n(severe pain at the operative site is typical) and unexplained systemic\\ntoxicity. Early on in this infection the wound itself is a little erythematous',\n", " 'md': '```markdown\\n# Wound Care and Complications\\n\\n## Text\\n\\n- Patients are susceptible to contamination from the outside during the first few postoperative days.\\n- Sunshine and fresh air is what the patient — and wound — needs.\\n- Some patients demand their wounds be covered; cheap dry gauze is more than adequate for this purpose — but in our modern commercial environment it is more likely that your nurses would like to use fancy expensive products. The main achievement of elaborate ‘modern’ dressing materials, impregnated with antibiotics, silver or whatever, is the enrichment of the medical-industrial complex. We try to avoid them. Patients with uncomplicated wounds can shower or bathe any time.\\n\\n### The Complicated Wound\\n\\n- Here the punishment should fit the crime. Minor non-specific complications should be observed — the majority will resolve spontaneously. Again, starting antibiotics because a wound weeps a little serous discharge is not going to change anything; if the wound is destined to develop an infection it will, with or without antibiotics! Major wound hematomas require evacuation but this is rare following abdominal surgery.\\n\\n### Wound Infections\\n\\n- Wound infection following an emergency abdominal operation is usually caused by endogenous bacteria — the resident bacteria of the abdominal organs breached during the operation or the bacteria which caused the intra-abdominal infection in the first place. Following non-contaminated operations (e.g. blunt splenic trauma), the bugs causing wound infections are exogenous — skin residents, usually a Staphylococcus. Carriers of MRSA (methicillin-resistant Staphylococcus aureus) are prone to wound infections caused by this bug but this is another story. The same goes for Streptococcal wound cellulitis which may develop a day (nay, even hours) after the operation with local pain (severe pain at the operative site is typical) and unexplained systemic toxicity. Early on in this infection the wound itself is a little erythematous.\\n\\n## Images\\n\\n- No images or graphs were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 531, 'y': 617, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Wound Care and Complications',\n", " 'md': '# Wound Care and Complications',\n", " 'bBox': {'x': 72, 'y': 617, 'w': 46.39, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Patients are susceptible to contamination from the outside during the first few postoperative days.\\n- Sunshine and fresh air is what the patient — and wound — needs.\\n- Some patients demand their wounds be covered; cheap dry gauze is more than adequate for this purpose — but in our modern commercial environment it is more likely that your nurses would like to use fancy expensive products. The main achievement of elaborate ‘modern’ dressing materials, impregnated with antibiotics, silver or whatever, is the enrichment of the medical-industrial complex. We try to avoid them. Patients with uncomplicated wounds can shower or bathe any time.',\n", " 'md': '- Patients are susceptible to contamination from the outside during the first few postoperative days.\\n- Sunshine and fresh air is what the patient — and wound — needs.\\n- Some patients demand their wounds be covered; cheap dry gauze is more than adequate for this purpose — but in our modern commercial environment it is more likely that your nurses would like to use fancy expensive products. The main achievement of elaborate ‘modern’ dressing materials, impregnated with antibiotics, silver or whatever, is the enrichment of the medical-industrial complex. We try to avoid them. Patients with uncomplicated wounds can shower or bathe any time.',\n", " 'bBox': {'x': 72, 'y': 227, 'w': 467.96, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Complicated Wound',\n", " 'md': '### The Complicated Wound',\n", " 'bBox': {'x': 86, 'y': 319, 'w': 188.5, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Here the punishment should fit the crime. Minor non-specific complications should be observed — the majority will resolve spontaneously. Again, starting antibiotics because a wound weeps a little serous discharge is not going to change anything; if the wound is destined to develop an infection it will, with or without antibiotics! Major wound hematomas require evacuation but this is rare following abdominal surgery.',\n", " 'md': '- Here the punishment should fit the crime. Minor non-specific complications should be observed — the majority will resolve spontaneously. Again, starting antibiotics because a wound weeps a little serous discharge is not going to change anything; if the wound is destined to develop an infection it will, with or without antibiotics! Major wound hematomas require evacuation but this is rare following abdominal surgery.',\n", " 'bBox': {'x': 72, 'y': 389, 'w': 467.84, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Wound Infections',\n", " 'md': '### Wound Infections',\n", " 'bBox': {'x': 72, 'y': 498, 'w': 152.53, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': '- Wound infection following an emergency abdominal operation is usually caused by endogenous bacteria — the resident bacteria of the abdominal organs breached during the operation or the bacteria which caused the intra-abdominal infection in the first place. Following non-contaminated operations (e.g. blunt splenic trauma), the bugs causing wound infections are exogenous — skin residents, usually a Staphylococcus. Carriers of MRSA (methicillin-resistant Staphylococcus aureus) are prone to wound infections caused by this bug but this is another story. The same goes for Streptococcal wound cellulitis which may develop a day (nay, even hours) after the operation with local pain (severe pain at the operative site is typical) and unexplained systemic toxicity. Early on in this infection the wound itself is a little erythematous.',\n", " 'md': '- Wound infection following an emergency abdominal operation is usually caused by endogenous bacteria — the resident bacteria of the abdominal organs breached during the operation or the bacteria which caused the intra-abdominal infection in the first place. Following non-contaminated operations (e.g. blunt splenic trauma), the bugs causing wound infections are exogenous — skin residents, usually a Staphylococcus. Carriers of MRSA (methicillin-resistant Staphylococcus aureus) are prone to wound infections caused by this bug but this is another story. The same goes for Streptococcal wound cellulitis which may develop a day (nay, even hours) after the operation with local pain (severe pain at the operative site is typical) and unexplained systemic toxicity. Early on in this infection the wound itself is a little erythematous.',\n", " 'bBox': {'x': 72, 'y': 498, 'w': 467.99, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 531, 'y': 617, 'w': 8.01, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.\\n```',\n", " 'md': '- No images or graphs were identified on this page.\\n```',\n", " 'bBox': {'x': 531, 'y': 617, 'w': 8.01, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 844,\n", " 'text': '— the typically thin exudate lies in the deeper layers. This is a rare but\\nlife-threatening complication — if you don’t think about the\\ntreatment (wide drainage of the wound — including the deep layers\\nand removal of mesh, if present — and appropriate antibiotics), it\\nmay arrive too late with bitter consequences1.\\n\\n As alluded to above, wound infections also may present in your private\\noffice even weeks after the operation, skewing — underestimating —\\nyour hospital infection-control data (which seem to be collected only to\\nservice the administration’s need to produce statistics).\\n\\n When in doubt, do not rush to poke in or open the wound — creating\\ncomplications in wounds that would otherwise heal. Instead, be patient,\\nwait a day or two, let the infection mature and declare itself.\\n\\n Remember: A ‘hot red’ surgical wound with surrounding erythema does not mean\\n ‘cellulitis’. It means that there is pus within the wound that has to be drained. As a rule,\\n removing a few skin sutures and draining the pus treats most wound infections. There is no\\n need to lay the whole wound open if only part of it is infected. You do not need a CT scan to\\n diagnose a wound infection (this is not a joke… this is what ‘modern medicine’ is educating\\n people to do). All you need do is to remove a few sutures or staples and probe the wound. If\\n the cavity does not extend further up — or downwards — stop there and leave just that part\\n open.\\n\\n Aftercare\\n\\n Aftercare should be simple. Open shallow wounds are covered with dry\\nnon-adherent gauze and cleaned once or twice daily with water and\\nsoap. There is nothing better for an open wound than a shower or bath!\\nDeeper wounds are loosely — loosely, not plugged! — packed with\\ngauze to afford drainage and prevent premature closure of the superficial\\nlayers. Antibiotics are usually not necessary. Do you give antibiotics after\\nthe incision and drainage of a peri-anal abscess? Of course not. So why\\ntreat wound infections with antibiotics? A short course of antimicrobials is\\nindicated when severe cellulitis is present or the abdominal fascia is',\n", " 'md': '```markdown\\n# Wound Infections and Aftercare\\n\\nThe typically thin exudate lies in the deeper layers. This is a rare but life-threatening complication — if you don’t think about the treatment (wide drainage of the wound — including the deep layers and removal of mesh, if present — and appropriate antibiotics), it may arrive too late with bitter consequences.\\n\\nAs alluded to above, wound infections also may present in your private office even weeks after the operation, skewing — underestimating — your hospital infection-control data (which seem to be collected only to service the administration’s need to produce statistics).\\n\\nWhen in doubt, do not rush to poke in or open the wound — creating complications in wounds that would otherwise heal. Instead, be patient, wait a day or two, let the infection mature and declare itself.\\n\\nRemember: A ‘hot red’ surgical wound with surrounding erythema does not mean ‘cellulitis’. It means that there is pus within the wound that has to be drained. As a rule, removing a few skin sutures and draining the pus treats most wound infections. There is no need to lay the whole wound open if only part of it is infected. You do not need a CT scan to diagnose a wound infection (this is not a joke… this is what ‘modern medicine’ is educating people to do). All you need do is to remove a few sutures or staples and probe the wound. If the cavity does not extend further up — or downwards — stop there and leave just that part open.\\n\\n## Aftercare\\n\\nAftercare should be simple. Open shallow wounds are covered with dry non-adherent gauze and cleaned once or twice daily with water and soap. There is nothing better for an open wound than a shower or bath! Deeper wounds are loosely — loosely, not plugged! — packed with gauze to afford drainage and prevent premature closure of the superficial layers. Antibiotics are usually not necessary. Do you give antibiotics after the incision and drainage of a peri-anal abscess? Of course not. So why treat wound infections with antibiotics? A short course of antimicrobials is indicated when severe cellulitis is present or the abdominal fascia is...\\n```\\n\\n### Notes:\\n- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Wound Infections and Aftercare',\n", " 'md': '# Wound Infections and Aftercare',\n", " 'bBox': {'x': 86, 'y': 543, 'w': 72.67, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'The typically thin exudate lies in the deeper layers. This is a rare but life-threatening complication — if you don’t think about the treatment (wide drainage of the wound — including the deep layers and removal of mesh, if present — and appropriate antibiotics), it may arrive too late with bitter consequences.\\n\\nAs alluded to above, wound infections also may present in your private office even weeks after the operation, skewing — underestimating — your hospital infection-control data (which seem to be collected only to service the administration’s need to produce statistics).\\n\\nWhen in doubt, do not rush to poke in or open the wound — creating complications in wounds that would otherwise heal. Instead, be patient, wait a day or two, let the infection mature and declare itself.\\n\\nRemember: A ‘hot red’ surgical wound with surrounding erythema does not mean ‘cellulitis’. It means that there is pus within the wound that has to be drained. As a rule, removing a few skin sutures and draining the pus treats most wound infections. There is no need to lay the whole wound open if only part of it is infected. You do not need a CT scan to diagnose a wound infection (this is not a joke… this is what ‘modern medicine’ is educating people to do). All you need do is to remove a few sutures or staples and probe the wound. If the cavity does not extend further up — or downwards — stop there and leave just that part open.',\n", " 'md': 'The typically thin exudate lies in the deeper layers. This is a rare but life-threatening complication — if you don’t think about the treatment (wide drainage of the wound — including the deep layers and removal of mesh, if present — and appropriate antibiotics), it may arrive too late with bitter consequences.\\n\\nAs alluded to above, wound infections also may present in your private office even weeks after the operation, skewing — underestimating — your hospital infection-control data (which seem to be collected only to service the administration’s need to produce statistics).\\n\\nWhen in doubt, do not rush to poke in or open the wound — creating complications in wounds that would otherwise heal. Instead, be patient, wait a day or two, let the infection mature and declare itself.\\n\\nRemember: A ‘hot red’ surgical wound with surrounding erythema does not mean ‘cellulitis’. It means that there is pus within the wound that has to be drained. As a rule, removing a few skin sutures and draining the pus treats most wound infections. There is no need to lay the whole wound open if only part of it is infected. You do not need a CT scan to diagnose a wound infection (this is not a joke… this is what ‘modern medicine’ is educating people to do). All you need do is to remove a few sutures or staples and probe the wound. If the cavity does not extend further up — or downwards — stop there and leave just that part open.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.41, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Aftercare',\n", " 'md': '## Aftercare',\n", " 'bBox': {'x': 86, 'y': 543, 'w': 72.67, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Aftercare should be simple. Open shallow wounds are covered with dry non-adherent gauze and cleaned once or twice daily with water and soap. There is nothing better for an open wound than a shower or bath! Deeper wounds are loosely — loosely, not plugged! — packed with gauze to afford drainage and prevent premature closure of the superficial layers. Antibiotics are usually not necessary. Do you give antibiotics after the incision and drainage of a peri-anal abscess? Of course not. So why treat wound infections with antibiotics? A short course of antimicrobials is indicated when severe cellulitis is present or the abdominal fascia is...\\n```',\n", " 'md': 'Aftercare should be simple. Open shallow wounds are covered with dry non-adherent gauze and cleaned once or twice daily with water and soap. There is nothing better for an open wound than a shower or bath! Deeper wounds are loosely — loosely, not plugged! — packed with gauze to afford drainage and prevent premature closure of the superficial layers. Antibiotics are usually not necessary. Do you give antibiotics after the incision and drainage of a peri-anal abscess? Of course not. So why treat wound infections with antibiotics? A short course of antimicrobials is indicated when severe cellulitis is present or the abdominal fascia is...\\n```',\n", " 'bBox': {'x': 72, 'y': 543, 'w': 467.9, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'md': '- No figures, tables, or images were identified on this page.\\n- The text has been transcribed accurately, excluding any headers, footers, or diagonal text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ' 1'}]},\n", " {'page': 845,\n", " 'text': 'involved, indicating invasive infection.\\n\\n Wound swabs? Wound cultures? Gram stains? What for? As you\\nknow by now, the causative bacteria are mostly predictable ( Chapter\\n13) and, besides, how could the microbiological results change the\\ntherapy outlined above? The answer of course is that they don’t. But\\nsome wounds will become problematic and it is then valuable to know the\\nnature of the organism involved. Then the correct antibiotic can be\\nadministered without having to guess sensitivities or wait for the result of\\ncultures. MRSA is currently endemic in the United States and elsewhere\\nin the world, and is increasingly responsible for our postoperative wound\\ninfections. Early treatment of complications from these wound infections\\nis obviously desirable. Early cultures from leaking wounds do therefore\\nhave some role to play, but be sure to prevent your junior colleagues\\nfrom prescribing antibiotics just because a positive culture appears.\\nExplain to them that even cultures taken from their own hands will grow a\\nzoo…\\n\\n Nurses and for-profit home-care agencies push elaborate and\\nexpensive wound care methods in order to justify their continued\\ninvolvement. Local application of solutions or ointments of antiseptics or\\nantibiotics destroy micro-organisms and human cells alike, induce allergy\\nand encourage bacterial resistance.\\n\\n Simple is beautiful. Use soap, water; and for our problematic\\nwounds we are enthusiastic users of honey. Try it!\\n\\n ħowever, in selected situations the application of a negative pressure\\n(vacuum) wound system can facilitate management and hasten wound\\nclosure. We would use it for deep, productive wounds — never for the\\nsimple ones.\\n\\n (For a more elaborate discussion on wound complications and their\\nmanagement — including the use of honey, as depicted in Figure 49.2\\n— we advise you to read the chapter referred to in the earlier footnote.)',\n", " 'md': '```markdown\\n## Wound Management and Infection\\n\\nWound swabs? Wound cultures? Gram stains? What for? As you know by now, the causative bacteria are mostly predictable (Chapter 13) and, besides, how could the microbiological results change the therapy outlined above? The answer of course is that they don’t. But some wounds will become problematic and it is then valuable to know the nature of the organism involved. Then the correct antibiotic can be administered without having to guess sensitivities or wait for the result of cultures. MRSA is currently endemic in the United States and elsewhere in the world, and is increasingly responsible for our postoperative wound infections. Early treatment of complications from these wound infections is obviously desirable. Early cultures from leaking wounds do therefore have some role to play, but be sure to prevent your junior colleagues from prescribing antibiotics just because a positive culture appears. Explain to them that even cultures taken from their own hands will grow a zoo…\\n\\nNurses and for-profit home-care agencies push elaborate and expensive wound care methods in order to justify their continued involvement. Local application of solutions or ointments of antiseptics or antibiotics destroy micro-organisms and human cells alike, induce allergy and encourage bacterial resistance.\\n\\nSimple is beautiful. Use soap, water; and for our problematic wounds we are enthusiastic users of honey. Try it!\\n\\nHowever, in selected situations the application of a negative pressure (vacuum) wound system can facilitate management and hasten wound closure. We would use it for deep, productive wounds — never for the simple ones.\\n\\n(For a more elaborate discussion on wound complications and their management — including the use of honey, as depicted in Figure 49.2 — we advise you to read the chapter referred to in the earlier footnote.)\\n```\\n\\n### Image Identification and Description\\n- **Figure 49.2**: This figure is referenced in the text but not provided in the current page. It likely depicts the use of honey in wound management, which is mentioned as a beneficial treatment for problematic wounds. The description of the figure is not available, but it is suggested to be informative regarding the application of honey in wound care.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Wound Management and Infection',\n", " 'md': '## Wound Management and Infection',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Wound swabs? Wound cultures? Gram stains? What for? As you know by now, the causative bacteria are mostly predictable (Chapter 13) and, besides, how could the microbiological results change the therapy outlined above? The answer of course is that they don’t. But some wounds will become problematic and it is then valuable to know the nature of the organism involved. Then the correct antibiotic can be administered without having to guess sensitivities or wait for the result of cultures. MRSA is currently endemic in the United States and elsewhere in the world, and is increasingly responsible for our postoperative wound infections. Early treatment of complications from these wound infections is obviously desirable. Early cultures from leaking wounds do therefore have some role to play, but be sure to prevent your junior colleagues from prescribing antibiotics just because a positive culture appears. Explain to them that even cultures taken from their own hands will grow a zoo…\\n\\nNurses and for-profit home-care agencies push elaborate and expensive wound care methods in order to justify their continued involvement. Local application of solutions or ointments of antiseptics or antibiotics destroy micro-organisms and human cells alike, induce allergy and encourage bacterial resistance.\\n\\nSimple is beautiful. Use soap, water; and for our problematic wounds we are enthusiastic users of honey. Try it!\\n\\nHowever, in selected situations the application of a negative pressure (vacuum) wound system can facilitate management and hasten wound closure. We would use it for deep, productive wounds — never for the simple ones.\\n\\n(For a more elaborate discussion on wound complications and their management — including the use of honey, as depicted in Figure 49.2 — we advise you to read the chapter referred to in the earlier footnote.)\\n```',\n", " 'md': 'Wound swabs? Wound cultures? Gram stains? What for? As you know by now, the causative bacteria are mostly predictable (Chapter 13) and, besides, how could the microbiological results change the therapy outlined above? The answer of course is that they don’t. But some wounds will become problematic and it is then valuable to know the nature of the organism involved. Then the correct antibiotic can be administered without having to guess sensitivities or wait for the result of cultures. MRSA is currently endemic in the United States and elsewhere in the world, and is increasingly responsible for our postoperative wound infections. Early treatment of complications from these wound infections is obviously desirable. Early cultures from leaking wounds do therefore have some role to play, but be sure to prevent your junior colleagues from prescribing antibiotics just because a positive culture appears. Explain to them that even cultures taken from their own hands will grow a zoo…\\n\\nNurses and for-profit home-care agencies push elaborate and expensive wound care methods in order to justify their continued involvement. Local application of solutions or ointments of antiseptics or antibiotics destroy micro-organisms and human cells alike, induce allergy and encourage bacterial resistance.\\n\\nSimple is beautiful. Use soap, water; and for our problematic wounds we are enthusiastic users of honey. Try it!\\n\\nHowever, in selected situations the application of a negative pressure (vacuum) wound system can facilitate management and hasten wound closure. We would use it for deep, productive wounds — never for the simple ones.\\n\\n(For a more elaborate discussion on wound complications and their management — including the use of honey, as depicted in Figure 49.2 — we advise you to read the chapter referred to in the earlier footnote.)\\n```',\n", " 'bBox': {'x': 72, 'y': 137, 'w': 467.74, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Image Identification and Description',\n", " 'md': '### Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 49.2**: This figure is referenced in the text but not provided in the current page. It likely depicts the use of honey in wound management, which is mentioned as a beneficial treatment for problematic wounds. The description of the figure is not available, but it is suggested to be informative regarding the application of honey in wound care.',\n", " 'md': '- **Figure 49.2**: This figure is referenced in the text but not provided in the current page. It likely depicts the use of honey in wound management, which is mentioned as a beneficial treatment for problematic wounds. The description of the figure is not available, but it is suggested to be informative regarding the application of honey in wound care.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'know by now, the causative bacteria are mostly predictable ( Chapter 13) and, besides, how could the microbiological results change the therapy outlined above? The answer of course is that they don’t. But'},\n", " {'text': '— we advise you to read the chapter referred to in the earlier footnote.)'}]},\n", " {'page': 846,\n", " 'text': ' PeRY42o14\\nFigure 49.2. “Welcome to my honey management wound center.”\\n\\n Our friend Barry Alexander of Australia (also known as Baz) has\\nsummarized wound management very elegantly:\\n\\n “I describe to my students what an injured animal does: it lies\\nunder a shady bush (rest, splint) by a water source (fluids,\\nnutrition), licks the wound frequently (dressing changes) until it is\\nclean and healing (time and patience) — and hope it makes them\\nthink past the gorgeous dressing promoted by manufacturers’\\nreps.”\\n\\n “Dressings on undrained wounds serve only to hide the\\n wound, interfere with examination, and to invite adhesive\\n tape dermatitis.”\\n Mark M. Ravitch',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\nFigure 49.2. “Welcome to my honey management wound center.”\\n\\nOur friend Barry Alexander of Australia (also known as Baz) has summarized wound management very elegantly:\\n\\n“I describe to my students what an injured animal does: it lies under a shady bush (rest, splint) by a water source (fluids, nutrition), licks the wound frequently (dressing changes) until it is clean and healing (time and patience) — and hope it makes them think past the gorgeous dressing promoted by manufacturers’ reps.”\\n\\n“Dressings on undrained wounds serve only to hide the wound, interfere with examination, and to invite adhesive tape dermatitis.”\\n— Mark M. Ravitch\\n\\n## Image Identification and Description\\n**Figure 49.2**: The image titled \"Welcome to my honey management wound center\" likely depicts a conceptual or illustrative representation related to wound management. The content may include visual elements that symbolize the principles of wound care as described by Barry Alexander.\\n\\n### Summary\\nThe figure emphasizes the natural process of wound healing, drawing parallels between animal behavior and human wound management practices. It serves as a reminder to consider the underlying principles of care rather than just the superficial aspects promoted by commercial products.\\n```',\n", " 'images': [{'name': 'img_p845_1.png',\n", " 'height': 575,\n", " 'width': 803,\n", " 'x': 107.27999999999975,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1380,\n", " 'original_height': 988}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 49.2. “Welcome to my honey management wound center.”\\n\\nOur friend Barry Alexander of Australia (also known as Baz) has summarized wound management very elegantly:\\n\\n“I describe to my students what an injured animal does: it lies under a shady bush (rest, splint) by a water source (fluids, nutrition), licks the wound frequently (dressing changes) until it is clean and healing (time and patience) — and hope it makes them think past the gorgeous dressing promoted by manufacturers’ reps.”\\n\\n“Dressings on undrained wounds serve only to hide the wound, interfere with examination, and to invite adhesive tape dermatitis.”\\n— Mark M. Ravitch',\n", " 'md': 'Figure 49.2. “Welcome to my honey management wound center.”\\n\\nOur friend Barry Alexander of Australia (also known as Baz) has summarized wound management very elegantly:\\n\\n“I describe to my students what an injured animal does: it lies under a shady bush (rest, splint) by a water source (fluids, nutrition), licks the wound frequently (dressing changes) until it is clean and healing (time and patience) — and hope it makes them think past the gorgeous dressing promoted by manufacturers’ reps.”\\n\\n“Dressings on undrained wounds serve only to hide the wound, interfere with examination, and to invite adhesive tape dermatitis.”\\n— Mark M. Ravitch',\n", " 'bBox': {'x': 72, 'y': 387, 'w': 453.2, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 49.2**: The image titled \"Welcome to my honey management wound center\" likely depicts a conceptual or illustrative representation related to wound management. The content may include visual elements that symbolize the principles of wound care as described by Barry Alexander.',\n", " 'md': '**Figure 49.2**: The image titled \"Welcome to my honey management wound center\" likely depicts a conceptual or illustrative representation related to wound management. The content may include visual elements that symbolize the principles of wound care as described by Barry Alexander.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The figure emphasizes the natural process of wound healing, drawing parallels between animal behavior and human wound management practices. It serves as a reminder to consider the underlying principles of care rather than just the superficial aspects promoted by commercial products.\\n```',\n", " 'md': 'The figure emphasizes the natural process of wound healing, drawing parallels between animal behavior and human wound management practices. It serves as a reminder to consider the underlying principles of care rather than just the superficial aspects promoted by commercial products.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 847,\n", " 'text': '1 Look at Chapter 5 on wound complications in Schein’s Common Sense Prevention and\\n Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013.',\n", " 'md': '```markdown\\n# Page Content\\n\\nLook at Chapter 5 on wound complications in Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Look at Chapter 5 on wound complications in Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013.\\n```',\n", " 'md': 'Look at Chapter 5 on wound complications in Schein’s Common Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm publishing, 2013.\\n```',\n", " 'bBox': {'x': 73, 'y': 97, 'w': 376.62, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 848,\n", " 'text': 'Chapter 50\\nIn the aftermath and the M & M meeting\\nMoshe Schein\\n\\n Again and again I find that there are few things so quickly\\n forgotten by the surgical system as a dead patient.\\n P. O. Nyström\\n\\n A ‘big’ operation in a fit patient may be ‘small’.\\n A ‘small’ operation in a sick patient may be ‘big’.\\n A ‘big’ surgeon knows to tailor the operation and its trauma\\n to the patient and his disease.\\n\\n Let us hope that your patient survives his emergency abdominal\\noperation and his postoperative course is uneventful. Unfortunately, the\\noverall mortality of such procedures is still far from negligible and the\\nmorbidity rate is generally high. As somebody said: “you can’t make a\\nchicken salad out of chicken shit” — shit happens!\\n\\n Now, after the storm has abated, it is the time to sit down and reflect on\\nwhat went wrong. As Francis D. Moore said: “You want a surgical team\\nthat faces each error, each mishap, straight up, names it, and takes\\nsteps to prevent its recurrence.”\\n\\n The morbidity & mortality meeting\\n\\n At any place where a group of surgeons is working, it is crucial to',\n", " 'md': '```markdown\\n# Chapter 50\\n## In the Aftermath and the M & M Meeting\\n### Moshe Schein\\n\\n> Again and again I find that there are few things so quickly forgotten by the surgical system as a dead patient.\\n> — P. O. Nyström\\n\\nA ‘big’ operation in a fit patient may be ‘small’.\\nA ‘small’ operation in a sick patient may be ‘big’.\\nA ‘big’ surgeon knows to tailor the operation and its trauma to the patient and his disease.\\n\\nLet us hope that your patient survives his emergency abdominal operation and his postoperative course is uneventful. Unfortunately, the overall mortality of such procedures is still far from negligible and the morbidity rate is generally high. As somebody said: “you can’t make a chicken salad out of chicken shit” — shit happens!\\n\\nNow, after the storm has abated, it is the time to sit down and reflect on what went wrong. As Francis D. Moore said: “You want a surgical team that faces each error, each mishap, straight up, names it, and takes steps to prevent its recurrence.”\\n\\n## The Morbidity & Mortality Meeting\\n\\nAt any place where a group of surgeons is working, it is crucial to\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and formatted according to the requirements.\\n- All formulas and hyperlinks were checked, but none were found in the provided text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Chapter 50',\n", " 'md': '# Chapter 50',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 148.79, 'h': 28.8}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'In the Aftermath and the M & M Meeting',\n", " 'md': '## In the Aftermath and the M & M Meeting',\n", " 'bBox': {'x': 72, 'y': 198, 'w': 354.92, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Moshe Schein',\n", " 'md': '### Moshe Schein',\n", " 'bBox': {'x': 72, 'y': 239, 'w': 91.18, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '> Again and again I find that there are few things so quickly forgotten by the surgical system as a dead patient.\\n> — P. O. Nyström\\n\\nA ‘big’ operation in a fit patient may be ‘small’.\\nA ‘small’ operation in a sick patient may be ‘big’.\\nA ‘big’ surgeon knows to tailor the operation and its trauma to the patient and his disease.\\n\\nLet us hope that your patient survives his emergency abdominal operation and his postoperative course is uneventful. Unfortunately, the overall mortality of such procedures is still far from negligible and the morbidity rate is generally high. As somebody said: “you can’t make a chicken salad out of chicken shit” — shit happens!\\n\\nNow, after the storm has abated, it is the time to sit down and reflect on what went wrong. As Francis D. Moore said: “You want a surgical team that faces each error, each mishap, straight up, names it, and takes steps to prevent its recurrence.”',\n", " 'md': '> Again and again I find that there are few things so quickly forgotten by the surgical system as a dead patient.\\n> — P. O. Nyström\\n\\nA ‘big’ operation in a fit patient may be ‘small’.\\nA ‘small’ operation in a sick patient may be ‘big’.\\nA ‘big’ surgeon knows to tailor the operation and its trauma to the patient and his disease.\\n\\nLet us hope that your patient survives his emergency abdominal operation and his postoperative course is uneventful. Unfortunately, the overall mortality of such procedures is still far from negligible and the morbidity rate is generally high. As somebody said: “you can’t make a chicken salad out of chicken shit” — shit happens!\\n\\nNow, after the storm has abated, it is the time to sit down and reflect on what went wrong. As Francis D. Moore said: “You want a surgical team that faces each error, each mishap, straight up, names it, and takes steps to prevent its recurrence.”',\n", " 'bBox': {'x': 72, 'y': 326, 'w': 467.48, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'The Morbidity & Mortality Meeting',\n", " 'md': '## The Morbidity & Mortality Meeting',\n", " 'bBox': {'x': 86, 'y': 674, 'w': 268.46, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'At any place where a group of surgeons is working, it is crucial to\\n```',\n", " 'md': 'At any place where a group of surgeons is working, it is crucial to\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and formatted according to the requirements.\\n- All formulas and hyperlinks were checked, but none were found in the provided text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been extracted and formatted according to the requirements.\\n- All formulas and hyperlinks were checked, but none were found in the provided text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 849,\n", " 'text': 'conduct a regular M & M meeting (MMM). This is the venue where you\\nand your colleagues should objectively analyze and discuss — in\\nretrospect — all the recent mortalities and complications. You are\\nfamiliar with the cliché that “some surgeons learn from their own\\nmistakes, some learn from those of others, and some never learn”.\\nThe aim of the MMM is to abolish the last entity.\\n\\n Do you have a regular M & M meeting in your department? If you are\\nassociated, as a resident or a qualified surgeon, with a teaching\\ndepartment in the USA, you must have a weekly MMM, because without\\na routine MMM the department’s residency program cannot be\\naccredited. We know that in many corners around the world MMMs are\\nnot conducted; all blunders and failures are swept under the carpet.\\nElsewhere still, MMMs are conducted in name only, being used to\\npresent ‘interesting cases’ or the latest ‘success stories’. This is wrong!\\nThe MMM exists to analyze objectively your mistakes and complications\\n— not to punish or humiliate anyone, but to educate and improve results.\\nYou do not want to repeat the same error twice. So see to it that proper\\nMMMs are conducted wherever you provide surgical care. And if you, like\\nme, are a ‘solo’ small town surgeon — then conduct your own MMM!\\n\\n The optimal format for the MMM:\\n\\n A routine hour should be dedicated to the MMM each week.\\n ALL interns, residents and surgeons should attend — regularly.\\n ALL complications and deaths that occurred in any patient treated by any member\\n of the department should be presented.\\n ‘A complication is a complication’ — irrespective of whether the outcome was a\\n triumph or tragedy. All must be presented.\\n The MMM is a democratic forum. The boss’s blunder or that goof by the ‘local giant’\\n are as ‘interesting’, if not more, as that caused by a junior resident.\\n\\n The resident-team that was involved with the case should present it.\\nThey should know all the details and rehearse the presentation in\\nadvance. The patient’s chart and X-rays should be readily available. If',\n", " 'md': '# Markdown Copy of the Page\\n\\n## Regular M & M Meetings (MMM)\\n\\nConduct a regular M & M meeting (MMM). This is the venue where you and your colleagues should objectively analyze and discuss — in retrospect — all the recent mortalities and complications. You are familiar with the cliché that “some surgeons learn from their own mistakes, some learn from those of others, and some never learn”. The aim of the MMM is to abolish the last entity.\\n\\nDo you have a regular M & M meeting in your department? If you are associated, as a resident or a qualified surgeon, with a teaching department in the USA, you must have a weekly MMM, because without a routine MMM the department’s residency program cannot be accredited. We know that in many corners around the world MMMs are not conducted; all blunders and failures are swept under the carpet. Elsewhere still, MMMs are conducted in name only, being used to present ‘interesting cases’ or the latest ‘success stories’. This is wrong! The MMM exists to analyze objectively your mistakes and complications — not to punish or humiliate anyone, but to educate and improve results. You do not want to repeat the same error twice. So see to it that proper MMMs are conducted wherever you provide surgical care. And if you, like me, are a ‘solo’ small town surgeon — then conduct your own MMM!\\n\\n### The Optimal Format for the MMM:\\n\\n- A routine hour should be dedicated to the MMM each week.\\n- ALL interns, residents, and surgeons should attend — regularly.\\n- ALL complications and deaths that occurred in any patient treated by any member of the department should be presented.\\n- ‘A complication is a complication’ — irrespective of whether the outcome was a triumph or tragedy. All must be presented.\\n- The MMM is a democratic forum. The boss’s blunder or that goof by the ‘local giant’ are as ‘interesting’, if not more, as that caused by a junior resident.\\n\\nThe resident team that was involved with the case should present it. They should know all the details and rehearse the presentation in advance. The patient’s chart and X-rays should be readily available.',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Markdown Copy of the Page',\n", " 'md': '# Markdown Copy of the Page',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Regular M & M Meetings (MMM)',\n", " 'md': '## Regular M & M Meetings (MMM)',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Conduct a regular M & M meeting (MMM). This is the venue where you and your colleagues should objectively analyze and discuss — in retrospect — all the recent mortalities and complications. You are familiar with the cliché that “some surgeons learn from their own mistakes, some learn from those of others, and some never learn”. The aim of the MMM is to abolish the last entity.\\n\\nDo you have a regular M & M meeting in your department? If you are associated, as a resident or a qualified surgeon, with a teaching department in the USA, you must have a weekly MMM, because without a routine MMM the department’s residency program cannot be accredited. We know that in many corners around the world MMMs are not conducted; all blunders and failures are swept under the carpet. Elsewhere still, MMMs are conducted in name only, being used to present ‘interesting cases’ or the latest ‘success stories’. This is wrong! The MMM exists to analyze objectively your mistakes and complications — not to punish or humiliate anyone, but to educate and improve results. You do not want to repeat the same error twice. So see to it that proper MMMs are conducted wherever you provide surgical care. And if you, like me, are a ‘solo’ small town surgeon — then conduct your own MMM!',\n", " 'md': 'Conduct a regular M & M meeting (MMM). This is the venue where you and your colleagues should objectively analyze and discuss — in retrospect — all the recent mortalities and complications. You are familiar with the cliché that “some surgeons learn from their own mistakes, some learn from those of others, and some never learn”. The aim of the MMM is to abolish the last entity.\\n\\nDo you have a regular M & M meeting in your department? If you are associated, as a resident or a qualified surgeon, with a teaching department in the USA, you must have a weekly MMM, because without a routine MMM the department’s residency program cannot be accredited. We know that in many corners around the world MMMs are not conducted; all blunders and failures are swept under the carpet. Elsewhere still, MMMs are conducted in name only, being used to present ‘interesting cases’ or the latest ‘success stories’. This is wrong! The MMM exists to analyze objectively your mistakes and complications — not to punish or humiliate anyone, but to educate and improve results. You do not want to repeat the same error twice. So see to it that proper MMMs are conducted wherever you provide surgical care. And if you, like me, are a ‘solo’ small town surgeon — then conduct your own MMM!',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 468.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'The Optimal Format for the MMM:',\n", " 'md': '### The Optimal Format for the MMM:',\n", " 'bBox': {'x': 79, 'y': 449, 'w': 223, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- A routine hour should be dedicated to the MMM each week.\\n- ALL interns, residents, and surgeons should attend — regularly.\\n- ALL complications and deaths that occurred in any patient treated by any member of the department should be presented.\\n- ‘A complication is a complication’ — irrespective of whether the outcome was a triumph or tragedy. All must be presented.\\n- The MMM is a democratic forum. The boss’s blunder or that goof by the ‘local giant’ are as ‘interesting’, if not more, as that caused by a junior resident.\\n\\nThe resident team that was involved with the case should present it. They should know all the details and rehearse the presentation in advance. The patient’s chart and X-rays should be readily available.',\n", " 'md': '- A routine hour should be dedicated to the MMM each week.\\n- ALL interns, residents, and surgeons should attend — regularly.\\n- ALL complications and deaths that occurred in any patient treated by any member of the department should be presented.\\n- ‘A complication is a complication’ — irrespective of whether the outcome was a triumph or tragedy. All must be presented.\\n- The MMM is a democratic forum. The boss’s blunder or that goof by the ‘local giant’ are as ‘interesting’, if not more, as that caused by a junior resident.\\n\\nThe resident team that was involved with the case should present it. They should know all the details and rehearse the presentation in advance. The patient’s chart and X-rays should be readily available.',\n", " 'bBox': {'x': 132, 'y': 482, 'w': 397.77, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 850,\n", " 'text': 'you are the presenting resident, be objective and neutral. Your task is to\\nlearn and facilitate the learning of others, not to defend or cover up for\\nthe involved surgeon; you are not his or her lawyer. Understand that the\\nmajority of those who are present are not stupid — they sense\\nimmediately when the truth is deserted.\\n\\n The assessment of complications\\n\\n After the case has been presented, the person who presides over the\\nmeeting has to initiate and generate a discussion with the intent of\\narriving at a consensus. An easy way to break the commonly prevailing\\nand embarrassing silence is to point at one of the senior surgeons and\\nask “Dr. X, please tell us, had this patient been under your care from the\\nbeginning, would the outcome be the same?” This technique usually\\nmanages to break the ice, prompting a sincere and complete response.\\n\\n The questions to be answered during the discussion are:\\n\\n • Was it a ‘real’ complication? Some surgeons may argue that blood\\n loss, which required transfusion, is not a complication but a technical\\n mishap, which simply can ‘happen’.\\n • Assess the cause: was it an error of judgment or a technical\\n error? Operating on a dying terminal cancer patient reflects poor\\n judgment; having to reoperate for hemorrhage from the gallbladder\\n bed marks a technical error — poor hemostasis at the first\\n operation. The two types of errors are often combined and\\n inseparable: the patient with acute bowel ischemia died because\\n his operation was ‘too late’ (poor judgment) and the stoma, which\\n was performed, has retracted, leaking into the peritoneal cavity\\n (poor technique). Often it is impossible to define whether a technical\\n complication (e.g. anastomotic leak) is caused by poor technique\\n (technical error) or patient-related factors, such as malnutrition or\\n chronic steroid intake.\\n • Another possibility is to look at the error as either an error of\\n commission or omission. One either operates too late or not at all\\n (omission) or operates too early or unnecessarily (commission).\\n One either misses the injury or resects too little (omission) or does',\n", " 'md': '```markdown\\n## Assessment of Complications\\n\\nYou are the presenting resident; be objective and neutral. Your task is to learn and facilitate the learning of others, not to defend or cover up for the involved surgeon; you are not his or her lawyer. Understand that the majority of those who are present are not stupid — they sense immediately when the truth is deserted.\\n\\n### Discussion Initiation\\n\\nAfter the case has been presented, the person who presides over the meeting has to initiate and generate a discussion with the intent of arriving at a consensus. An easy way to break the commonly prevailing and embarrassing silence is to point at one of the senior surgeons and ask, “Dr. X, please tell us, had this patient been under your care from the beginning, would the outcome be the same?” This technique usually manages to break the ice, prompting a sincere and complete response.\\n\\n### Questions to be Answered During the Discussion\\n\\n- **Was it a ‘real’ complication?** Some surgeons may argue that blood loss, which required transfusion, is not a complication but a technical mishap, which simply can ‘happen’.\\n\\n- **Assess the cause:** Was it an error of judgment or a technical error? Operating on a dying terminal cancer patient reflects poor judgment; having to reoperate for hemorrhage from the gallbladder bed marks a technical error — poor hemostasis at the first operation. The two types of errors are often combined and inseparable: the patient with acute bowel ischemia died because his operation was ‘too late’ (poor judgment) and the stoma, which was performed, has retracted, leaking into the peritoneal cavity (poor technique). Often it is impossible to define whether a technical complication (e.g., anastomotic leak) is caused by poor technique (technical error) or patient-related factors, such as malnutrition or chronic steroid intake.\\n\\n- **Error Classification:** Another possibility is to look at the error as either an error of commission or omission. One either operates too late or not at all (omission) or operates too early or unnecessarily (commission). One either misses the injury or resects too little (omission) or does...\\n```\\n\\n### Notes:\\n- No images, graphs, or tables were identified on this page.\\n- The text has been structured into sections for clarity.\\n- All formulas and mathematical expressions were not present in the extracted text.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Assessment of Complications',\n", " 'md': '## Assessment of Complications',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'You are the presenting resident; be objective and neutral. Your task is to learn and facilitate the learning of others, not to defend or cover up for the involved surgeon; you are not his or her lawyer. Understand that the majority of those who are present are not stupid — they sense immediately when the truth is deserted.',\n", " 'md': 'You are the presenting resident; be objective and neutral. Your task is to learn and facilitate the learning of others, not to defend or cover up for the involved surgeon; you are not his or her lawyer. Understand that the majority of those who are present are not stupid — they sense immediately when the truth is deserted.',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 468.01, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Discussion Initiation',\n", " 'md': '### Discussion Initiation',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'After the case has been presented, the person who presides over the meeting has to initiate and generate a discussion with the intent of arriving at a consensus. An easy way to break the commonly prevailing and embarrassing silence is to point at one of the senior surgeons and ask, “Dr. X, please tell us, had this patient been under your care from the beginning, would the outcome be the same?” This technique usually manages to break the ice, prompting a sincere and complete response.',\n", " 'md': 'After the case has been presented, the person who presides over the meeting has to initiate and generate a discussion with the intent of arriving at a consensus. An easy way to break the commonly prevailing and embarrassing silence is to point at one of the senior surgeons and ask, “Dr. X, please tell us, had this patient been under your care from the beginning, would the outcome be the same?” This technique usually manages to break the ice, prompting a sincere and complete response.',\n", " 'bBox': {'x': 72, 'y': 231, 'w': 467.72, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Questions to be Answered During the Discussion',\n", " 'md': '### Questions to be Answered During the Discussion',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Was it a ‘real’ complication?** Some surgeons may argue that blood loss, which required transfusion, is not a complication but a technical mishap, which simply can ‘happen’.\\n\\n- **Assess the cause:** Was it an error of judgment or a technical error? Operating on a dying terminal cancer patient reflects poor judgment; having to reoperate for hemorrhage from the gallbladder bed marks a technical error — poor hemostasis at the first operation. The two types of errors are often combined and inseparable: the patient with acute bowel ischemia died because his operation was ‘too late’ (poor judgment) and the stoma, which was performed, has retracted, leaking into the peritoneal cavity (poor technique). Often it is impossible to define whether a technical complication (e.g., anastomotic leak) is caused by poor technique (technical error) or patient-related factors, such as malnutrition or chronic steroid intake.\\n\\n- **Error Classification:** Another possibility is to look at the error as either an error of commission or omission. One either operates too late or not at all (omission) or operates too early or unnecessarily (commission). One either misses the injury or resects too little (omission) or does...\\n```',\n", " 'md': '- **Was it a ‘real’ complication?** Some surgeons may argue that blood loss, which required transfusion, is not a complication but a technical mishap, which simply can ‘happen’.\\n\\n- **Assess the cause:** Was it an error of judgment or a technical error? Operating on a dying terminal cancer patient reflects poor judgment; having to reoperate for hemorrhage from the gallbladder bed marks a technical error — poor hemostasis at the first operation. The two types of errors are often combined and inseparable: the patient with acute bowel ischemia died because his operation was ‘too late’ (poor judgment) and the stoma, which was performed, has retracted, leaking into the peritoneal cavity (poor technique). Often it is impossible to define whether a technical complication (e.g., anastomotic leak) is caused by poor technique (technical error) or patient-related factors, such as malnutrition or chronic steroid intake.\\n\\n- **Error Classification:** Another possibility is to look at the error as either an error of commission or omission. One either operates too late or not at all (omission) or operates too early or unnecessarily (commission). One either misses the injury or resects too little (omission) or does...\\n```',\n", " 'bBox': {'x': 100, 'y': 418, 'w': 436.87, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- The text has been structured into sections for clarity.\\n- All formulas and mathematical expressions were not present in the extracted text.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- The text has been structured into sections for clarity.\\n- All formulas and mathematical expressions were not present in the extracted text.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 851,\n", " 'text': ' too much (commission). After the operation one either fails to\\n reoperate for the abscess (omission) or operates unnecessarily\\n when percutaneous drainage was possible (commission). Note\\n that the surgical community considers errors of omission more\\n gravely that those of commission; the latter are looked at with\\n understanding: “we did all we could but we failed.”\\n• Was there negligence? A certain rate of mistakes (hopefully\\n low) is an integral part of any surgical practice as only those\\n who never operate commit no errors — but negligence is\\n deplorable. The operation was delayed because the responsible\\n surgeon did not want to be disturbed over the weekend or the\\n surgeon operated under the influence of alcohol: this is clearly\\n ‘negligence’. When an individual surgeon repeats errors over and\\n over again, a pattern is exhibited, which in itself may constitute\\n negligence.\\n• Was the complication/death preventable or potentially\\n preventable? Each case is different and has to be analyzed\\n individually.\\n• Who was responsible? The MMM is not a court ( Figure 50.1).\\n Culpability is not the issue, but at the end of the presentation it\\n should be clear to all present how things might have been done\\n better. Blame is to be avoided at all costs (except in the most\\n extreme cases, and then the MMM is not the forum to deal with\\n them) because any system that aims to apportion blame as part of\\n the quality control processes will fail; the truth will be hidden and\\n confrontation avoided. Such is human nature. The sad truth,\\n however, is that in many instances complications and mortality\\n are caused by ‘system failure’ — which in purely surgical terms\\n means that the hospital is a cesspit with a malfunctioning chain\\n of command, organization, supervision, education and morals.',\n", " 'md': '```markdown\\n### Page Content\\n\\n- Too much (commission). After the operation one either fails to reoperate for the abscess (omission) or operates unnecessarily when percutaneous drainage was possible (commission). Note that the surgical community considers errors of omission more gravely than those of commission; the latter are looked at with understanding: “we did all we could but we failed.”\\n\\n- Was there negligence? A certain rate of mistakes (hopefully low) is an integral part of any surgical practice as only those who never operate commit no errors — but negligence is deplorable. The operation was delayed because the responsible surgeon did not want to be disturbed over the weekend or the surgeon operated under the influence of alcohol: this is clearly ‘negligence’. When an individual surgeon repeats errors over and over again, a pattern is exhibited, which in itself may constitute negligence.\\n\\n- Was the complication/death preventable or potentially preventable? Each case is different and has to be analyzed individually.\\n\\n- Who was responsible? The MMM is not a court (Figure 50.1). Culpability is not the issue, but at the end of the presentation it should be clear to all present how things might have been done better. Blame is to be avoided at all costs (except in the most extreme cases, and then the MMM is not the forum to deal with them) because any system that aims to apportion blame as part of the quality control processes will fail; the truth will be hidden and confrontation avoided. Such is human nature. The sad truth, however, is that in many instances complications and mortality are caused by ‘system failure’ — which in purely surgical terms means that the hospital is a cesspit with a malfunctioning chain of command, organization, supervision, education and morals.\\n\\n### Figure Description\\n\\n- **Figure 50.1**: This figure is referenced in the text but is not described in the provided content. It likely illustrates a concept related to the responsibilities in surgical practice or the structure of the MMM (Morbidity and Mortality Meeting). Without the actual image, a detailed description cannot be provided.\\n\\n### Summary\\n\\nThe text discusses the complexities of surgical errors, distinguishing between errors of omission and commission, and emphasizes the importance of analyzing negligence and preventability in surgical complications. It highlights the need for a constructive approach in discussions about surgical outcomes, avoiding blame and focusing on systemic issues that may contribute to failures in patient care.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Page Content',\n", " 'md': '### Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Too much (commission). After the operation one either fails to reoperate for the abscess (omission) or operates unnecessarily when percutaneous drainage was possible (commission). Note that the surgical community considers errors of omission more gravely than those of commission; the latter are looked at with understanding: “we did all we could but we failed.”\\n\\n- Was there negligence? A certain rate of mistakes (hopefully low) is an integral part of any surgical practice as only those who never operate commit no errors — but negligence is deplorable. The operation was delayed because the responsible surgeon did not want to be disturbed over the weekend or the surgeon operated under the influence of alcohol: this is clearly ‘negligence’. When an individual surgeon repeats errors over and over again, a pattern is exhibited, which in itself may constitute negligence.\\n\\n- Was the complication/death preventable or potentially preventable? Each case is different and has to be analyzed individually.\\n\\n- Who was responsible? The MMM is not a court (Figure 50.1). Culpability is not the issue, but at the end of the presentation it should be clear to all present how things might have been done better. Blame is to be avoided at all costs (except in the most extreme cases, and then the MMM is not the forum to deal with them) because any system that aims to apportion blame as part of the quality control processes will fail; the truth will be hidden and confrontation avoided. Such is human nature. The sad truth, however, is that in many instances complications and mortality are caused by ‘system failure’ — which in purely surgical terms means that the hospital is a cesspit with a malfunctioning chain of command, organization, supervision, education and morals.',\n", " 'md': '- Too much (commission). After the operation one either fails to reoperate for the abscess (omission) or operates unnecessarily when percutaneous drainage was possible (commission). Note that the surgical community considers errors of omission more gravely than those of commission; the latter are looked at with understanding: “we did all we could but we failed.”\\n\\n- Was there negligence? A certain rate of mistakes (hopefully low) is an integral part of any surgical practice as only those who never operate commit no errors — but negligence is deplorable. The operation was delayed because the responsible surgeon did not want to be disturbed over the weekend or the surgeon operated under the influence of alcohol: this is clearly ‘negligence’. When an individual surgeon repeats errors over and over again, a pattern is exhibited, which in itself may constitute negligence.\\n\\n- Was the complication/death preventable or potentially preventable? Each case is different and has to be analyzed individually.\\n\\n- Who was responsible? The MMM is not a court (Figure 50.1). Culpability is not the issue, but at the end of the presentation it should be clear to all present how things might have been done better. Blame is to be avoided at all costs (except in the most extreme cases, and then the MMM is not the forum to deal with them) because any system that aims to apportion blame as part of the quality control processes will fail; the truth will be hidden and confrontation avoided. Such is human nature. The sad truth, however, is that in many instances complications and mortality are caused by ‘system failure’ — which in purely surgical terms means that the hospital is a cesspit with a malfunctioning chain of command, organization, supervision, education and morals.',\n", " 'bBox': {'x': 100, 'y': 135, 'w': 437.03, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Figure Description',\n", " 'md': '### Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Figure 50.1**: This figure is referenced in the text but is not described in the provided content. It likely illustrates a concept related to the responsibilities in surgical practice or the structure of the MMM (Morbidity and Mortality Meeting). Without the actual image, a detailed description cannot be provided.',\n", " 'md': '- **Figure 50.1**: This figure is referenced in the text but is not described in the provided content. It likely illustrates a concept related to the responsibilities in surgical practice or the structure of the MMM (Morbidity and Mortality Meeting). Without the actual image, a detailed description cannot be provided.',\n", " 'bBox': {'x': 147, 'y': 340, 'w': 25.58, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The text discusses the complexities of surgical errors, distinguishing between errors of omission and commission, and emphasizes the importance of analyzing negligence and preventability in surgical complications. It highlights the need for a constructive approach in discussions about surgical outcomes, avoiding blame and focusing on systemic issues that may contribute to failures in patient care.\\n```',\n", " 'md': 'The text discusses the complexities of surgical errors, distinguishing between errors of omission and commission, and emphasizes the importance of analyzing negligence and preventability in surgical complications. It highlights the need for a constructive approach in discussions about surgical outcomes, avoiding blame and focusing on systemic issues that may contribute to failures in patient care.\\n```',\n", " 'bBox': {'x': 147, 'y': 340, 'w': 25.58, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Culpability is not the issue, but at the end of the presentation it'}]},\n", " {'page': 852,\n", " 'text': ' Mw\\n KRAY\\nFigure 50.1. “You killed the patient!”\\n\\n Here is an example…\\n The old man was gasping unattended for 6 hours in the emergency room before you were\\n called to assess his acute abdomen. You decided on an emergency laparotomy but no\\n operating room was available for 2 hours. Because the orderlies went for dinner another half-\\n an-hour was lost until you decided to fetch the patient yourself. Only then did you realize that\\n the antibiotics and intravenous fluids you ordered had not been given. A clueless anesthetist\\n then struggles with the intubation producing prolonged hypoxia… and so on and so on… how\\n much damage can an old man take? System failures are much more\\n common than you think, just look around your own\\n environment…\\n\\n • Was the standard of care met? As you surely know, the ‘standard\\n of care’ means different things to different people. (“The good thing\\n about a standard of care is that there are so many to choose',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\nFigure 50.1. “You killed the patient!”\\n\\nHere is an example…\\nThe old man was gasping unattended for 6 hours in the emergency room before you were called to assess his acute abdomen. You decided on an emergency laparotomy but no operating room was available for 2 hours. Because the orderlies went for dinner another half-an-hour was lost until you decided to fetch the patient yourself. Only then did you realize that the antibiotics and intravenous fluids you ordered had not been given. A clueless anesthetist then struggles with the intubation producing prolonged hypoxia… and so on and so on… how much damage can an old man take? System failures are much more common than you think, just look around your own environment…\\n\\n- Was the standard of care met? As you surely know, the ‘standard of care’ means different things to different people. (“The good thing about a standard of care is that there are so many to choose...\\n\\n## Image Identification and Description\\n**Figure 50**: The image depicts a dramatic scene in a medical emergency context, illustrating the consequences of systemic failures in patient care. The caption suggests a critical moment where the patient is in distress, highlighting the urgency and chaos often present in emergency medical situations.\\n\\n### Summary\\nThe image serves as a stark reminder of the importance of timely and effective medical intervention, emphasizing the potential repercussions of delays and miscommunication in healthcare settings.\\n```',\n", " 'images': [{'name': 'img_p851_1.png',\n", " 'height': 556,\n", " 'width': 802,\n", " 'x': 108,\n", " 'y': 82.80000000000001,\n", " 'original_width': 1377,\n", " 'original_height': 955}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 503, 'y': 603, 'w': 28.78, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Figure 50.1. “You killed the patient!”\\n\\nHere is an example…\\nThe old man was gasping unattended for 6 hours in the emergency room before you were called to assess his acute abdomen. You decided on an emergency laparotomy but no operating room was available for 2 hours. Because the orderlies went for dinner another half-an-hour was lost until you decided to fetch the patient yourself. Only then did you realize that the antibiotics and intravenous fluids you ordered had not been given. A clueless anesthetist then struggles with the intubation producing prolonged hypoxia… and so on and so on… how much damage can an old man take? System failures are much more common than you think, just look around your own environment…\\n\\n- Was the standard of care met? As you surely know, the ‘standard of care’ means different things to different people. (“The good thing about a standard of care is that there are so many to choose...',\n", " 'md': 'Figure 50.1. “You killed the patient!”\\n\\nHere is an example…\\nThe old man was gasping unattended for 6 hours in the emergency room before you were called to assess his acute abdomen. You decided on an emergency laparotomy but no operating room was available for 2 hours. Because the orderlies went for dinner another half-an-hour was lost until you decided to fetch the patient yourself. Only then did you realize that the antibiotics and intravenous fluids you ordered had not been given. A clueless anesthetist then struggles with the intubation producing prolonged hypoxia… and so on and so on… how much damage can an old man take? System failures are much more common than you think, just look around your own environment…\\n\\n- Was the standard of care met? As you surely know, the ‘standard of care’ means different things to different people. (“The good thing about a standard of care is that there are so many to choose...',\n", " 'bBox': {'x': 75, 'y': 378, 'w': 453.57, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 50**: The image depicts a dramatic scene in a medical emergency context, illustrating the consequences of systemic failures in patient care. The caption suggests a critical moment where the patient is in distress, highlighting the urgency and chaos often present in emergency medical situations.',\n", " 'md': '**Figure 50**: The image depicts a dramatic scene in a medical emergency context, illustrating the consequences of systemic failures in patient care. The caption suggests a critical moment where the patient is in distress, highlighting the urgency and chaos often present in emergency medical situations.',\n", " 'bBox': {'x': 357, 'y': 583, 'w': 51.17, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Summary',\n", " 'md': '### Summary',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The image serves as a stark reminder of the importance of timely and effective medical intervention, emphasizing the potential repercussions of delays and miscommunication in healthcare settings.\\n```',\n", " 'md': 'The image serves as a stark reminder of the importance of timely and effective medical intervention, emphasizing the potential repercussions of delays and miscommunication in healthcare settings.\\n```',\n", " 'bBox': {'x': 418, 'y': 583, 'w': 21.61, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 853,\n", " 'text': ' from.”) It has a spectrum, which should be well represented and\\n assessed by a group of well-informed practicing surgeons. Take, for\\n example, a case of perforated sigmoid diverticulitis with local\\n peritonitis: any operation ranging from a ħartmann’s procedure (the\\n conservative surgeon) to a sigmoid resection with anastomosis (the\\n modern surgeon) would fall within the accepted standard of care (oh\\n well, the ultra-modern surgeon may have elected to treat such a\\n patient with laparoscopic lavage only…). Primary closure of the\\n perforation would not. This would be easy to assess: “anyone who\\n would attempt closing the perforation please raise your hand.” No\\n hand is raised; the responsible surgeon is left lonely to understand\\n that what he did is not acceptable and is outside the practiced\\n standard in his community. The responsible surgeon may,\\n however, present published literature to support that what he did is\\n acceptable elsewhere. And, obviously, local surgeons can be\\n dogmatic and wrong!\\n• Evidence-based surgery. At the end of the presentation the\\n resident should present the literature to pinpoint the ‘state of the art’\\n and associated controversies, emphasizing what could have been\\n done, and should be done when we see a similar case in the future.\\n• The surgeon in whose patient the complication arose. At the\\n end of the discussion the most senior surgeon involved in the care\\n of the concerned patient should offer a statement. ħe or she may\\n choose to present additional evidence from the published literature\\n to show that what was done is acceptable elsewhere. The most\\n graceful way to deal with the situation is to discuss the case\\n scenario frankly, and humbly admit any mistakes one may have\\n made. If you had another chance with the same patient how\\n would you manage him? By standing up and confessing, you gain\\n the respect of all present. When you lie, cover up and refuse to\\n accept the verdict of the gathering, you evoke silent contempt and\\n disdain (or perhaps sympathy from other obsessive liars). So stand\\n up and fess up!\\n\\n Conclusions and corrective measures\\n\\n Finally, the person in the chair has to conclude — was there an',\n", " 'md': '```markdown\\n## Text Extraction\\n\\nIt has a spectrum, which should be well represented and assessed by a group of well-informed practicing surgeons. Take, for example, a case of perforated sigmoid diverticulitis with local peritonitis: any operation ranging from a Hartmann’s procedure (the conservative surgeon) to a sigmoid resection with anastomosis (the modern surgeon) would fall within the accepted standard of care (oh well, the ultra-modern surgeon may have elected to treat such a patient with laparoscopic lavage only…). Primary closure of the perforation would not. This would be easy to assess: “anyone who would attempt closing the perforation please raise your hand.” No hand is raised; the responsible surgeon is left lonely to understand that what he did is not acceptable and is outside the practiced standard in his community. The responsible surgeon may, however, present published literature to support that what he did is acceptable elsewhere. And, obviously, local surgeons can be dogmatic and wrong!\\n\\n- Evidence-based surgery. At the end of the presentation the resident should present the literature to pinpoint the ‘state of the art’ and associated controversies, emphasizing what could have been done, and should be done when we see a similar case in the future.\\n\\n- The surgeon in whose patient the complication arose. At the end of the discussion the most senior surgeon involved in the care of the concerned patient should offer a statement. He or she may choose to present additional evidence from the published literature to show that what was done is acceptable elsewhere. The most graceful way to deal with the situation is to discuss the case scenario frankly, and humbly admit any mistakes one may have made. If you had another chance with the same patient how would you manage him? By standing up and confessing, you gain the respect of all present. When you lie, cover up and refuse to accept the verdict of the gathering, you evoke silent contempt and disdain (or perhaps sympathy from other obsessive liars). So stand up and fess up!\\n\\n## Conclusions and Corrective Measures\\n\\nFinally, the person in the chair has to conclude — was there an...\\n```\\n\\n### Notes:\\n- The text has been extracted without any headers or footers.\\n- There are no formulas or images identified in the provided text.\\n- The text has been structured into sections for clarity.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'It has a spectrum, which should be well represented and assessed by a group of well-informed practicing surgeons. Take, for example, a case of perforated sigmoid diverticulitis with local peritonitis: any operation ranging from a Hartmann’s procedure (the conservative surgeon) to a sigmoid resection with anastomosis (the modern surgeon) would fall within the accepted standard of care (oh well, the ultra-modern surgeon may have elected to treat such a patient with laparoscopic lavage only…). Primary closure of the perforation would not. This would be easy to assess: “anyone who would attempt closing the perforation please raise your hand.” No hand is raised; the responsible surgeon is left lonely to understand that what he did is not acceptable and is outside the practiced standard in his community. The responsible surgeon may, however, present published literature to support that what he did is acceptable elsewhere. And, obviously, local surgeons can be dogmatic and wrong!\\n\\n- Evidence-based surgery. At the end of the presentation the resident should present the literature to pinpoint the ‘state of the art’ and associated controversies, emphasizing what could have been done, and should be done when we see a similar case in the future.\\n\\n- The surgeon in whose patient the complication arose. At the end of the discussion the most senior surgeon involved in the care of the concerned patient should offer a statement. He or she may choose to present additional evidence from the published literature to show that what was done is acceptable elsewhere. The most graceful way to deal with the situation is to discuss the case scenario frankly, and humbly admit any mistakes one may have made. If you had another chance with the same patient how would you manage him? By standing up and confessing, you gain the respect of all present. When you lie, cover up and refuse to accept the verdict of the gathering, you evoke silent contempt and disdain (or perhaps sympathy from other obsessive liars). So stand up and fess up!',\n", " 'md': 'It has a spectrum, which should be well represented and assessed by a group of well-informed practicing surgeons. Take, for example, a case of perforated sigmoid diverticulitis with local peritonitis: any operation ranging from a Hartmann’s procedure (the conservative surgeon) to a sigmoid resection with anastomosis (the modern surgeon) would fall within the accepted standard of care (oh well, the ultra-modern surgeon may have elected to treat such a patient with laparoscopic lavage only…). Primary closure of the perforation would not. This would be easy to assess: “anyone who would attempt closing the perforation please raise your hand.” No hand is raised; the responsible surgeon is left lonely to understand that what he did is not acceptable and is outside the practiced standard in his community. The responsible surgeon may, however, present published literature to support that what he did is acceptable elsewhere. And, obviously, local surgeons can be dogmatic and wrong!\\n\\n- Evidence-based surgery. At the end of the presentation the resident should present the literature to pinpoint the ‘state of the art’ and associated controversies, emphasizing what could have been done, and should be done when we see a similar case in the future.\\n\\n- The surgeon in whose patient the complication arose. At the end of the discussion the most senior surgeon involved in the care of the concerned patient should offer a statement. He or she may choose to present additional evidence from the published literature to show that what was done is acceptable elsewhere. The most graceful way to deal with the situation is to discuss the case scenario frankly, and humbly admit any mistakes one may have made. If you had another chance with the same patient how would you manage him? By standing up and confessing, you gain the respect of all present. When you lie, cover up and refuse to accept the verdict of the gathering, you evoke silent contempt and disdain (or perhaps sympathy from other obsessive liars). So stand up and fess up!',\n", " 'bBox': {'x': 100, 'y': 102, 'w': 437.34, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Conclusions and Corrective Measures',\n", " 'md': '## Conclusions and Corrective Measures',\n", " 'bBox': {'x': 86, 'y': 666, 'w': 298.89, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Finally, the person in the chair has to conclude — was there an...\\n```',\n", " 'md': 'Finally, the person in the chair has to conclude — was there an...\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes:',\n", " 'md': '### Notes:',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text has been extracted without any headers or footers.\\n- There are no formulas or images identified in the provided text.\\n- The text has been structured into sections for clarity.',\n", " 'md': '- The text has been extracted without any headers or footers.\\n- There are no formulas or images identified in the provided text.\\n- The text has been structured into sections for clarity.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 854,\n", " 'text': 'error? Was the standard of care met? And what are the future\\nrecommendations and the corrective measures? If you are that\\nchairman, and you may be some day, don’t be wishy-washy. Be objective\\nand definitive, for the audience is not stupid. Essentially, in any\\ndepartment of surgery, the face of the MMM, its objectivity and\\npractical value, reflects the face and ethical standards of the\\ndepartment’s chairman or director.\\n\\n Most ‘avoidable’ surgical disasters and mortalities are not caused by one sentinel —\\n horrendous, clearly evident — error which cries “I am negligent”. Instead, most such avoidable\\n catastrophes result from a chain of allegedly ‘minor’ hesitations, confusions, ignorance, greed,\\n inattention, overconfidence, arrogance, stupidity — which together drive the nails into the coffin.\\n Taken together they may whisper: “we are negligent!” Moshe\\n\\n We hope that after reading this little book you will want to look at\\nour other book dedicated to COMPLICATIONS 1, from which we\\nwant to cite here this:\\n\\n As you see, definitions are not clear cut and a wide gray area exists.\\nBut let us offer a unifying concept — a practical one.\\n\\n “S**t happens/s**t should not have happened.”\\n\\n Please forgive the coarse language but this is how weathered trench-\\ndwelling surgeons tend to consider the recurring dilemma, how they look\\nat and analyze complications — whether their own or produced by their\\ncolleagues. Any complication is either a known/potential consequence of\\nthe procedure and/or was unpreventable (“s**t happens”) or the opposite\\nis true: “s**t should not have happened.” Each case should be analyzed\\nindividually and in some cases the answer remains unknown.\\n\\n In some cases, even if it is hard to admit that “s**t has happened”\\n— it still stinks!\\n\\n So now go and read our Schein’s Common Sense Prevention and',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\n- Error? Was the standard of care met? And what are the future recommendations and the corrective measures? If you are that chairman, and you may be some day, don’t be wishy-washy. Be objective and definitive, for the audience is not stupid. Essentially, in any department of surgery, the face of the MMM, its objectivity and practical value, reflects the face and ethical standards of the department’s chairman or director.\\n\\n- Most ‘avoidable’ surgical disasters and mortalities are not caused by one sentinel — horrendous, clearly evident — error which cries “I am negligent”. Instead, most such avoidable catastrophes result from a chain of allegedly ‘minor’ hesitations, confusions, ignorance, greed, inattention, overconfidence, arrogance, stupidity — which together drive the nails into the coffin. Taken together they may whisper: “we are negligent!” Moshe\\n\\n- We hope that after reading this little book you will want to look at our other book dedicated to COMPLICATIONS 1, from which we want to cite here this:\\n\\n- As you see, definitions are not clear cut and a wide gray area exists. But let us offer a unifying concept — a practical one.\\n\\n- “S**t happens/s**t should not have happened.”\\n\\n- Please forgive the coarse language but this is how weathered trench-dwelling surgeons tend to consider the recurring dilemma, how they look at and analyze complications — whether their own or produced by their colleagues. Any complication is either a known/potential consequence of the procedure and/or was unpreventable (“s**t happens”) or the opposite is true: “s**t should not have happened.” Each case should be analyzed individually and in some cases the answer remains unknown.\\n\\n- In some cases, even if it is hard to admit that “s**t has happened” — it still stinks!\\n\\n- So now go and read our Schein’s Common Sense Prevention and\\n\\n## Images\\n- No images or graphs were identified on this page.\\n\\n## Tables\\n- No tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Error? Was the standard of care met? And what are the future recommendations and the corrective measures? If you are that chairman, and you may be some day, don’t be wishy-washy. Be objective and definitive, for the audience is not stupid. Essentially, in any department of surgery, the face of the MMM, its objectivity and practical value, reflects the face and ethical standards of the department’s chairman or director.\\n\\n- Most ‘avoidable’ surgical disasters and mortalities are not caused by one sentinel — horrendous, clearly evident — error which cries “I am negligent”. Instead, most such avoidable catastrophes result from a chain of allegedly ‘minor’ hesitations, confusions, ignorance, greed, inattention, overconfidence, arrogance, stupidity — which together drive the nails into the coffin. Taken together they may whisper: “we are negligent!” Moshe\\n\\n- We hope that after reading this little book you will want to look at our other book dedicated to COMPLICATIONS 1, from which we want to cite here this:\\n\\n- As you see, definitions are not clear cut and a wide gray area exists. But let us offer a unifying concept — a practical one.\\n\\n- “S**t happens/s**t should not have happened.”\\n\\n- Please forgive the coarse language but this is how weathered trench-dwelling surgeons tend to consider the recurring dilemma, how they look at and analyze complications — whether their own or produced by their colleagues. Any complication is either a known/potential consequence of the procedure and/or was unpreventable (“s**t happens”) or the opposite is true: “s**t should not have happened.” Each case should be analyzed individually and in some cases the answer remains unknown.\\n\\n- In some cases, even if it is hard to admit that “s**t has happened” — it still stinks!\\n\\n- So now go and read our Schein’s Common Sense Prevention and',\n", " 'md': '- Error? Was the standard of care met? And what are the future recommendations and the corrective measures? If you are that chairman, and you may be some day, don’t be wishy-washy. Be objective and definitive, for the audience is not stupid. Essentially, in any department of surgery, the face of the MMM, its objectivity and practical value, reflects the face and ethical standards of the department’s chairman or director.\\n\\n- Most ‘avoidable’ surgical disasters and mortalities are not caused by one sentinel — horrendous, clearly evident — error which cries “I am negligent”. Instead, most such avoidable catastrophes result from a chain of allegedly ‘minor’ hesitations, confusions, ignorance, greed, inattention, overconfidence, arrogance, stupidity — which together drive the nails into the coffin. Taken together they may whisper: “we are negligent!” Moshe\\n\\n- We hope that after reading this little book you will want to look at our other book dedicated to COMPLICATIONS 1, from which we want to cite here this:\\n\\n- As you see, definitions are not clear cut and a wide gray area exists. But let us offer a unifying concept — a practical one.\\n\\n- “S**t happens/s**t should not have happened.”\\n\\n- Please forgive the coarse language but this is how weathered trench-dwelling surgeons tend to consider the recurring dilemma, how they look at and analyze complications — whether their own or produced by their colleagues. Any complication is either a known/potential consequence of the procedure and/or was unpreventable (“s**t happens”) or the opposite is true: “s**t should not have happened.” Each case should be analyzed individually and in some cases the answer remains unknown.\\n\\n- In some cases, even if it is hard to admit that “s**t has happened” — it still stinks!\\n\\n- So now go and read our Schein’s Common Sense Prevention and',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 467.95, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No tables were identified on this page.\\n```',\n", " 'md': '- No tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 855,\n", " 'text': 'Management of Surgical Complications, which will help you to reduce the\\nincidence of **** happening and to deal with it when it does occur.\\n\\n Financial morbidity\\n PERYA1l4\\n Figure 50.2. “How much money can he bill for sending this guy to his grave?”\\n\\n In this day and age of growing costs and limited resources we must not\\nignore the financial morbidity — the excessive spending on unnecessary\\nprocedures, even if they are not associated with an immediately visible\\nphysical morbidity ( Figure 50.2). When discussing the case, ask the\\npresenter to justify why he used the frickin’ ROBOT to repair a banal\\numbilical hernia, or the reason antibiotics were continued for 7 days, or\\nwhy the patient was ‘observed’ in the SICU after an uneventful\\nlaparotomy? A useful educational exercise is to randomly present a\\ndetailed summary of the hospital bill of a presented patient. If you are\\nconfronted with what your patient’s care, your superfluous acts, and the\\ncomplications you created actually cost in dollars or euros, you may\\nbecome a more careful surgeon.',\n", " 'md': '```markdown\\n# Management of Surgical Complications\\n\\nThe management of surgical complications is crucial in reducing the incidence of adverse events and effectively addressing them when they occur.\\n\\n## Financial Morbidity\\n\\nFigure 50.2. “How much money can he bill for sending this guy to his grave?”\\n\\nIn this day and age of growing costs and limited resources, we must not ignore the financial morbidity — the excessive spending on unnecessary procedures, even if they are not associated with an immediately visible physical morbidity (Figure 50.2).\\n\\nWhen discussing the case, ask the presenter to justify why he used the frickin’ ROBOT to repair a banal umbilical hernia, or the reason antibiotics were continued for 7 days, or why the patient was ‘observed’ in the SICU after an uneventful laparotomy?\\n\\nA useful educational exercise is to randomly present a detailed summary of the hospital bill of a presented patient. If you are confronted with what your patient’s care, your superfluous acts, and the complications you created actually cost in dollars or euros, you may become a more careful surgeon.\\n\\n## Figure Description\\n\\n**Figure 50.2**: This figure likely depicts a humorous or critical commentary on the financial implications of surgical decisions, possibly illustrating the costs associated with unnecessary procedures. The caption suggests a provocative question regarding the financial burden of surgical errors or excessive interventions.\\n\\n**Summary**: The figure serves to highlight the importance of considering financial morbidity in surgical practice, encouraging surgeons to reflect on the costs of their decisions and the implications for patient care.\\n```',\n", " 'images': [{'name': 'img_p854_1.png',\n", " 'height': 581,\n", " 'width': 799,\n", " 'x': 108.7199999999998,\n", " 'y': 159.84000000000003,\n", " 'original_width': 1372,\n", " 'original_height': 996}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Management of Surgical Complications',\n", " 'md': '# Management of Surgical Complications',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'The management of surgical complications is crucial in reducing the incidence of adverse events and effectively addressing them when they occur.',\n", " 'md': 'The management of surgical complications is crucial in reducing the incidence of adverse events and effectively addressing them when they occur.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Financial Morbidity',\n", " 'md': '## Financial Morbidity',\n", " 'bBox': {'x': 86, 'y': 145, 'w': 151.7, 'h': 16.56}},\n", " {'type': 'text',\n", " 'value': 'Figure 50.2. “How much money can he bill for sending this guy to his grave?”\\n\\nIn this day and age of growing costs and limited resources, we must not ignore the financial morbidity — the excessive spending on unnecessary procedures, even if they are not associated with an immediately visible physical morbidity (Figure 50.2).\\n\\nWhen discussing the case, ask the presenter to justify why he used the frickin’ ROBOT to repair a banal umbilical hernia, or the reason antibiotics were continued for 7 days, or why the patient was ‘observed’ in the SICU after an uneventful laparotomy?\\n\\nA useful educational exercise is to randomly present a detailed summary of the hospital bill of a presented patient. If you are confronted with what your patient’s care, your superfluous acts, and the complications you created actually cost in dollars or euros, you may become a more careful surgeon.',\n", " 'md': 'Figure 50.2. “How much money can he bill for sending this guy to his grave?”\\n\\nIn this day and age of growing costs and limited resources, we must not ignore the financial morbidity — the excessive spending on unnecessary procedures, even if they are not associated with an immediately visible physical morbidity (Figure 50.2).\\n\\nWhen discussing the case, ask the presenter to justify why he used the frickin’ ROBOT to repair a banal umbilical hernia, or the reason antibiotics were continued for 7 days, or why the patient was ‘observed’ in the SICU after an uneventful laparotomy?\\n\\nA useful educational exercise is to randomly present a detailed summary of the hospital bill of a presented patient. If you are confronted with what your patient’s care, your superfluous acts, and the complications you created actually cost in dollars or euros, you may become a more careful surgeon.',\n", " 'bBox': {'x': 72, 'y': 145, 'w': 467.59, 'h': 16.56}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure Description',\n", " 'md': '## Figure Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 50.2**: This figure likely depicts a humorous or critical commentary on the financial implications of surgical decisions, possibly illustrating the costs associated with unnecessary procedures. The caption suggests a provocative question regarding the financial burden of surgical errors or excessive interventions.\\n\\n**Summary**: The figure serves to highlight the importance of considering financial morbidity in surgical practice, encouraging surgeons to reflect on the costs of their decisions and the implications for patient care.\\n```',\n", " 'md': '**Figure 50.2**: This figure likely depicts a humorous or critical commentary on the financial implications of surgical decisions, possibly illustrating the costs associated with unnecessary procedures. The caption suggests a provocative question regarding the financial burden of surgical errors or excessive interventions.\\n\\n**Summary**: The figure serves to highlight the importance of considering financial morbidity in surgical practice, encouraging surgeons to reflect on the costs of their decisions and the implications for patient care.\\n```',\n", " 'bBox': {'x': 86, 'y': 145, 'w': 151.7, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'presenter to justify why he used the frickin’ ROBOT to repair a banal'}]},\n", " {'page': 856,\n", " 'text': ' The SURGINET\\n Pery4l4\\nFigure 50.3. “SURGINET — please help me!”\\n\\n An ideal and objective MMM as featured above is not conducted in\\nmany places because of local sociopolitical constraints. If this is the case\\nin your neck of the woods, it may be damaging to your own surgical\\neducation; how would you know what is right or wrong? Books and\\njournals are useful but cannot replace a thorough analysis of specific\\ncases by a group of learned surgeons. Well, if you have a PC and email\\naccess, you can subscribe to SURGINET, an international forum of\\nsurgeons, who would openly and objectively discuss any case or\\ncomplication you present to them ( Figure 50.3). Should you want to\\ntake part in this ‘international MMM’ send an email message to Dr. Tom\\nGilas of Toronto (tgilas@sympatico.ca), or to Danny (drosin@mac.com),\\nor to me (mosheschein@gmail.com).\\n\\n Before we close…\\n\\n As you know, there are many ways to skin a cat, and it is easy to be a',\n", " 'md': '```markdown\\n# Page Content\\n\\nAn ideal and objective MMM as featured above is not conducted in many places because of local sociopolitical constraints. If this is the case in your neck of the woods, it may be damaging to your own surgical education; how would you know what is right or wrong? Books and journals are useful but cannot replace a thorough analysis of specific cases by a group of learned surgeons. Well, if you have a PC and email access, you can subscribe to SURGINET, an international forum of surgeons, who would openly and objectively discuss any case or complication you present to them (Figure 50.3). Should you want to take part in this ‘international MMM’ send an email message to Dr. Tom Gilas of Toronto ([tgilas@sympatico.ca](mailto:tgilas@sympatico.ca)), or to Danny ([drosin@mac.com](mailto:drosin@mac.com)), or to me ([mosheschein@gmail.com](mailto:mosheschein@gmail.com)).\\n\\n## Figure 50.3 Description\\n\\n**Figure 50.3**: “SURGINET — please help me!”\\n\\n- **Summary**: This figure likely represents a visual element related to the SURGINET forum, possibly including a call for assistance or collaboration among surgeons. The exact content of the image is not provided in the text, but it is implied to be relevant to the discussion of surgical education and case analysis.\\n```',\n", " 'images': [{'name': 'img_p855_1.png',\n", " 'height': 575,\n", " 'width': 800,\n", " 'x': 108,\n", " 'y': 102.24000000000001,\n", " 'original_width': 1374,\n", " 'original_height': 988}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'An ideal and objective MMM as featured above is not conducted in many places because of local sociopolitical constraints. If this is the case in your neck of the woods, it may be damaging to your own surgical education; how would you know what is right or wrong? Books and journals are useful but cannot replace a thorough analysis of specific cases by a group of learned surgeons. Well, if you have a PC and email access, you can subscribe to SURGINET, an international forum of surgeons, who would openly and objectively discuss any case or complication you present to them (Figure 50.3). Should you want to take part in this ‘international MMM’ send an email message to Dr. Tom Gilas of Toronto ([tgilas@sympatico.ca](mailto:tgilas@sympatico.ca)), or to Danny ([drosin@mac.com](mailto:drosin@mac.com)), or to me ([mosheschein@gmail.com](mailto:mosheschein@gmail.com)).',\n", " 'md': 'An ideal and objective MMM as featured above is not conducted in many places because of local sociopolitical constraints. If this is the case in your neck of the woods, it may be damaging to your own surgical education; how would you know what is right or wrong? Books and journals are useful but cannot replace a thorough analysis of specific cases by a group of learned surgeons. Well, if you have a PC and email access, you can subscribe to SURGINET, an international forum of surgeons, who would openly and objectively discuss any case or complication you present to them (Figure 50.3). Should you want to take part in this ‘international MMM’ send an email message to Dr. Tom Gilas of Toronto ([tgilas@sympatico.ca](mailto:tgilas@sympatico.ca)), or to Danny ([drosin@mac.com](mailto:drosin@mac.com)), or to me ([mosheschein@gmail.com](mailto:mosheschein@gmail.com)).',\n", " 'bBox': {'x': 72, 'y': 470, 'w': 467.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Figure 50.3 Description',\n", " 'md': '## Figure 50.3 Description',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Figure 50.3**: “SURGINET — please help me!”\\n\\n- **Summary**: This figure likely represents a visual element related to the SURGINET forum, possibly including a call for assistance or collaboration among surgeons. The exact content of the image is not provided in the text, but it is implied to be relevant to the discussion of surgical education and case analysis.\\n```',\n", " 'md': '**Figure 50.3**: “SURGINET — please help me!”\\n\\n- **Summary**: This figure likely represents a visual element related to the SURGINET forum, possibly including a call for assistance or collaboration among surgeons. The exact content of the image is not provided in the text, but it is implied to be relevant to the discussion of surgical education and case analysis.\\n```',\n", " 'bBox': {'x': 86, 'y': 88, 'w': 119.55, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'take part in this ‘international MMM’ send an email message to Dr. Tom'},\n", " {'url': 'mailto:tgilas@sympatico.ca',\n", " 'text': 'or to me (mosheschein@gmail.com).'},\n", " {'url': 'mailto:drosin@mac.com', 'text': ''},\n", " {'url': 'mailto:mosheschein@gmail.com', 'text': ''}]},\n", " {'page': 857,\n", " 'text': 'smart ass looking at things through the retrospectoscope.\\n\\n “The blinding light of the retrospectoscope”, as Professor Eero Kivilaakso used to say. Ari\\n\\n Our sick patients and the events leading to the MMM are very complex.\\nBut behind this chaos there is always an instructive truth which should be\\nand can be disclosed and announced. As Winston Churchill said,\\nsuccess is “the ability to go from failure to failure without losing your\\nenthusiasm.”\\n\\n “It is usually the second mistake in response to the first\\n mistake that does the patient in.”\\n Clifford K. Meador\\n “The two unforgivable sins of surgery. The first great\\n error in surgery is to — operate unnecessarily; the\\n second, to undertake an operation for which the surgeon\\n is not sufficiently skilled technically.”\\n Max Thorek\\n\\n Thanks for reading and farewell\\n We hope you enjoyed our humble book. Let us wish you farewell using this memorable\\n quotation from Winston Churchill’s broadcast (1941) to the people of conquered Europe:\\n\\n “Good night then: sleep to gather strength for the morning. For the\\n morning will come. Brightly will it shine on the brave and the true,\\n kindly on all who suffer for the cause, glorious upon the tombs of\\n heroes. Thus will shine the dawn.”\\n You — the emergency surgeons — are the heroes of medicine. For you the dawn will shine!\\n The Editors',\n", " 'md': '```markdown\\n# Page Content\\n\\n\"Smart ass looking at things through the retrospectoscope.\"\\n\\n“The blinding light of the retrospectoscope,” as Professor Eero Kivilaakso used to say. Ari\\n\\nOur sick patients and the events leading to the MMM are very complex. But behind this chaos there is always an instructive truth which should be and can be disclosed and announced. As Winston Churchill said, success is “the ability to go from failure to failure without losing your enthusiasm.”\\n\\n“It is usually the second mistake in response to the first mistake that does the patient in.”\\n— Clifford K. Meador\\n\\n“The two unforgivable sins of surgery. The first great error in surgery is to — operate unnecessarily; the second, to undertake an operation for which the surgeon is not sufficiently skilled technically.”\\n— Max Thorek\\n\\nThanks for reading and farewell. We hope you enjoyed our humble book. Let us wish you farewell using this memorable quotation from Winston Churchill’s broadcast (1941) to the people of conquered Europe:\\n\\n“Good night then: sleep to gather strength for the morning. For the morning will come. Brightly will it shine on the brave and the true, kindly on all who suffer for the cause, glorious upon the tombs of heroes. Thus will shine the dawn.”\\n\\nYou — the emergency surgeons — are the heroes of medicine. For you the dawn will shine!\\n— The Editors\\n```\\n\\n### Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '\"Smart ass looking at things through the retrospectoscope.\"\\n\\n“The blinding light of the retrospectoscope,” as Professor Eero Kivilaakso used to say. Ari\\n\\nOur sick patients and the events leading to the MMM are very complex. But behind this chaos there is always an instructive truth which should be and can be disclosed and announced. As Winston Churchill said, success is “the ability to go from failure to failure without losing your enthusiasm.”\\n\\n“It is usually the second mistake in response to the first mistake that does the patient in.”\\n— Clifford K. Meador\\n\\n“The two unforgivable sins of surgery. The first great error in surgery is to — operate unnecessarily; the second, to undertake an operation for which the surgeon is not sufficiently skilled technically.”\\n— Max Thorek\\n\\nThanks for reading and farewell. We hope you enjoyed our humble book. Let us wish you farewell using this memorable quotation from Winston Churchill’s broadcast (1941) to the people of conquered Europe:\\n\\n“Good night then: sleep to gather strength for the morning. For the morning will come. Brightly will it shine on the brave and the true, kindly on all who suffer for the cause, glorious upon the tombs of heroes. Thus will shine the dawn.”\\n\\nYou — the emergency surgeons — are the heroes of medicine. For you the dawn will shine!\\n— The Editors\\n```',\n", " 'md': '\"Smart ass looking at things through the retrospectoscope.\"\\n\\n“The blinding light of the retrospectoscope,” as Professor Eero Kivilaakso used to say. Ari\\n\\nOur sick patients and the events leading to the MMM are very complex. But behind this chaos there is always an instructive truth which should be and can be disclosed and announced. As Winston Churchill said, success is “the ability to go from failure to failure without losing your enthusiasm.”\\n\\n“It is usually the second mistake in response to the first mistake that does the patient in.”\\n— Clifford K. Meador\\n\\n“The two unforgivable sins of surgery. The first great error in surgery is to — operate unnecessarily; the second, to undertake an operation for which the surgeon is not sufficiently skilled technically.”\\n— Max Thorek\\n\\nThanks for reading and farewell. We hope you enjoyed our humble book. Let us wish you farewell using this memorable quotation from Winston Churchill’s broadcast (1941) to the people of conquered Europe:\\n\\n“Good night then: sleep to gather strength for the morning. For the morning will come. Brightly will it shine on the brave and the true, kindly on all who suffer for the cause, glorious upon the tombs of heroes. Thus will shine the dawn.”\\n\\nYou — the emergency surgeons — are the heroes of medicine. For you the dawn will shine!\\n— The Editors\\n```',\n", " 'bBox': {'x': 72, 'y': 86, 'w': 467.54, 'h': 20.16}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted and formatted according to the instructions.',\n", " 'bBox': {'x': 129, 'y': 376, 'w': 24.83, 'h': 16.56}}],\n", " 'status': 'OK',\n", " 'links': []},\n", " {'page': 858,\n", " 'text': '1 Schein’s Common Sense Prevention and Management of Surgical Complications.\\n Shrewsbury, UK: tfm publishing, 2013.',\n", " 'md': '# Schein’s Common Sense Prevention and Management of Surgical Complications\\n\\n**Reference:**\\n- Shrewsbury, UK: tfm publishing, 2013.\\n\\n*Note: No images, graphs, or tables were identified on this page.*',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Schein’s Common Sense Prevention and Management of Surgical Complications',\n", " 'md': '# Schein’s Common Sense Prevention and Management of Surgical Complications',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '**Reference:**\\n- Shrewsbury, UK: tfm publishing, 2013.\\n\\n*Note: No images, graphs, or tables were identified on this page.*',\n", " 'md': '**Reference:**\\n- Shrewsbury, UK: tfm publishing, 2013.\\n\\n*Note: No images, graphs, or tables were identified on this page.*',\n", " 'bBox': {'x': 73, 'y': 97, 'w': 182.63, 'h': 10.8}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '1'}]},\n", " {'page': 859,\n", " 'text': 'Index\\nabdominal aorta see aorta\\nabdominal apoplexy 26, 107-9, 525-6\\nabdominal binders 620\\nabdominal compartment syndrome (ACS) 229, 238, 503-13\\n delayed closure 511, 524, 698, 707\\n in pregnancy 538\\nabdominal X-rays (AXR) 38, 46-50\\n calculi 49, 560\\n colonic obstruction/volvulus 48, 381, 395, 397\\n colonic perforation 469-70\\n gastric volvulus 182\\n SBO 48, 270, 274\\nabscesses\\n amoebic 578-80\\n appendiceal 305, 320-1\\n hepatic 358-9, 578-80\\n imaging 62, 579, 580, 669-70\\n perianal 373, 438, 444-8\\n pericolic 408-11\\n postoperative (intra-abdominal) 128, 605, 665-76, 692, 709-10\\nacidosis 30, 67, 72\\nadhesions 17, 29, 265-80, 283, 290, 545\\n early 657, 661\\nadolescent girls 554, 555\\nAfrica, abdominal emergencies 586-96\\nair gun pellet injuries 483-4\\nalbumin 37, 640\\n hypoalbuminemic enteropathy 659\\nalcohol consumption 223\\nalvimopan 658\\namoebiasis 578-81\\namylase 27, 36, 224',\n", " 'md': '```markdown\\n# Index\\n\\n- abdominal aorta see aorta\\n- abdominal apoplexy 26, 107-9, 525-6\\n- abdominal binders 620\\n- abdominal compartment syndrome (ACS) 229, 238, 503-13\\n- delayed closure 511, 524, 698, 707\\n- in pregnancy 538\\n- abdominal X-rays (AXR) 38, 46-50\\n- calculi 49, 560\\n- colonic obstruction/volvulus 48, 381, 395, 397\\n- colonic perforation 469-70\\n- gastric volvulus 182\\n- SBO 48, 270, 274\\n- abscesses\\n- amoebic 578-80\\n- appendiceal 305, 320-1\\n- hepatic 358-9, 578-80\\n- imaging 62, 579, 580, 669-70\\n- perianal 373, 438, 444-8\\n- pericolic 408-11\\n- postoperative (intra-abdominal) 128, 605, 665-76, 692, 709-10\\n- acidosis 30, 67, 72\\n- adhesions 17, 29, 265-80, 283, 290, 545\\n- early 657, 661\\n- adolescent girls 554, 555\\n- Africa, abdominal emergencies 586-96\\n- air gun pellet injuries 483-4\\n- albumin 37, 640\\n- hypoalbuminemic enteropathy 659\\n- alcohol consumption 223\\n- alvimopan 658\\n- amoebiasis 578-81\\n- amylase 27, 36, 224\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Index',\n", " 'md': '# Index',\n", " 'bBox': {'x': 72, 'y': 143, 'w': 75.19, 'h': 28.8}},\n", " {'type': 'text',\n", " 'value': '- abdominal aorta see aorta\\n- abdominal apoplexy 26, 107-9, 525-6\\n- abdominal binders 620\\n- abdominal compartment syndrome (ACS) 229, 238, 503-13\\n- delayed closure 511, 524, 698, 707\\n- in pregnancy 538\\n- abdominal X-rays (AXR) 38, 46-50\\n- calculi 49, 560\\n- colonic obstruction/volvulus 48, 381, 395, 397\\n- colonic perforation 469-70\\n- gastric volvulus 182\\n- SBO 48, 270, 274\\n- abscesses\\n- amoebic 578-80\\n- appendiceal 305, 320-1\\n- hepatic 358-9, 578-80\\n- imaging 62, 579, 580, 669-70\\n- perianal 373, 438, 444-8\\n- pericolic 408-11\\n- postoperative (intra-abdominal) 128, 605, 665-76, 692, 709-10\\n- acidosis 30, 67, 72\\n- adhesions 17, 29, 265-80, 283, 290, 545\\n- early 657, 661\\n- adolescent girls 554, 555\\n- Africa, abdominal emergencies 586-96\\n- air gun pellet injuries 483-4\\n- albumin 37, 640\\n- hypoalbuminemic enteropathy 659\\n- alcohol consumption 223\\n- alvimopan 658\\n- amoebiasis 578-81\\n- amylase 27, 36, 224\\n```',\n", " 'md': '- abdominal aorta see aorta\\n- abdominal apoplexy 26, 107-9, 525-6\\n- abdominal binders 620\\n- abdominal compartment syndrome (ACS) 229, 238, 503-13\\n- delayed closure 511, 524, 698, 707\\n- in pregnancy 538\\n- abdominal X-rays (AXR) 38, 46-50\\n- calculi 49, 560\\n- colonic obstruction/volvulus 48, 381, 395, 397\\n- colonic perforation 469-70\\n- gastric volvulus 182\\n- SBO 48, 270, 274\\n- abscesses\\n- amoebic 578-80\\n- appendiceal 305, 320-1\\n- hepatic 358-9, 578-80\\n- imaging 62, 579, 580, 669-70\\n- perianal 373, 438, 444-8\\n- pericolic 408-11\\n- postoperative (intra-abdominal) 128, 605, 665-76, 692, 709-10\\n- acidosis 30, 67, 72\\n- adhesions 17, 29, 265-80, 283, 290, 545\\n- early 657, 661\\n- adolescent girls 554, 555\\n- Africa, abdominal emergencies 586-96\\n- air gun pellet injuries 483-4\\n- albumin 37, 640\\n- hypoalbuminemic enteropathy 659\\n- alcohol consumption 223\\n- alvimopan 658\\n- amoebiasis 578-81\\n- amylase 27, 36, 224\\n```',\n", " 'bBox': {'x': 72, 'y': 192, 'w': 396.6, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'abdominal binders 620'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'abdominal compartment syndrome (ACS) 229, 238, 503-13'},\n", " {'text': 'delayed closure 511, 524, 698, 707'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'in pregnancy 538'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'abdominal X-rays (AXR) 38, 46-50'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'colonic obstruction/volvulus 48, 381, 395, 397'},\n", " {'text': 'colonic obstruction/volvulus 48, 381, 395, 397'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'gastric volvulus 182'},\n", " {'text': 'SBO 48, 270, 274'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'appendiceal 305, 320-1'},\n", " {'text': 'hepatic 358-9, 578-80'},\n", " {'text': 'hepatic 358-9, 578-80'},\n", " {'text': 'imaging 62, 579, 580, 669-70'},\n", " {'text': 'imaging 62, 579, 580, 669-70'},\n", " {'text': 'perianal 373, 438, 444-8'},\n", " {'text': 'perianal 373, 438, 444-8'},\n", " {'text': 'perianal 373, 438, 444-8'},\n", " {'text': 'perianal 373, 438, 444-8'},\n", " {'text': 'pericolic 408-11'},\n", " {'text': 'pericolic 408-11'},\n", " {'text': ''},\n", " {'text': 'postoperative (intra-abdominal) 128, 605, 665-76, 692, 709-10'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'adhesions 17, 29, 265-80, 283, 290, 545'},\n", " {'text': 'adhesions 17, 29, 265-80, 283, 290, 545'},\n", " {'text': 'adhesions 17, 29, 265-80, 283, 290, 545'},\n", " {'text': 'early 657, 661'},\n", " {'text': 'early 657, 661'},\n", " {'text': 'early 657, 661'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'adolescent girls 554, 555'},\n", " {'text': 'adolescent girls 554, 555'},\n", " {'text': 'Africa, abdominal emergencies 586-96'},\n", " {'text': 'Africa, abdominal emergencies 586-96'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'hypoalbuminemic enteropathy 659'},\n", " {'text': 'hypoalbuminemic enteropathy 659'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'amoebiasis 578-81'},\n", " {'text': 'amylase 27, 36, 224'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 860,\n", " 'text': 'anal conditions 437-40\\n anal canal trauma 454\\n anal fissure 438, 440-2\\n bleeding 424-5, 431, 434\\n postoperative 448-50\\n Crohn’s disease 373\\n healing 450\\n hemorrhoids 424, 438, 442-4\\n perianal abscesses 373, 438, 444-8\\n surgical practice 450-1\\nanalgesia 28, 293, 628, 658\\nanastomosis 139-48\\n aortic 522-3\\n bleeding 435-6\\n in colonic obstruction 393-4\\n in Crohn’s disease 371\\n leaks 140, 143, 146, 662, 677-87, 696, 710\\n in liver patients 349\\n obstruction of 662, 687\\n after small bowel resection 336-7\\n stomal ulcers 206-7\\nangiography\\n embolization 201, 360-1, 430\\n lower GI bleeds 429-30, 435\\n mesenteric ischemia 40, 332-3\\nAnisakis simplex (nematode) 585\\nantibiotics\\n abscesses 448, 670-1\\n appendicitis 309, 314-15, 320\\n C. difficile colitis 374\\n cholangitis 259\\n cholecystitis 254\\n diverticulitis 404\\n esophageal perforation 165\\n pancreatitis 229\\n perforated ulcers 213\\n PID 535\\n postoperative 79, 275, 314, 633, 649-54, 707, 717\\n pre-operative 77-82, 213',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Extracted Text\\n- anal conditions 437-40\\n- anal canal trauma 454\\n- anal fissure 438, 440-2\\n- bleeding 424-5, 431, 434\\n- postoperative 448-50\\n- Crohn’s disease 373\\n- healing 450\\n- hemorrhoids 424, 438, 442-4\\n- perianal abscesses 373, 438, 444-8\\n- surgical practice 450-1\\n- analgesia 28, 293, 628, 658\\n- anastomosis 139-48\\n- aortic 522-3\\n- bleeding 435-6\\n- in colonic obstruction 393-4\\n- in Crohn’s disease 371\\n- leaks 140, 143, 146, 662, 677-87, 696, 710\\n- in liver patients 349\\n- obstruction of 662, 687\\n- after small bowel resection 336-7\\n- stomal ulcers 206-7\\n- angiography\\n- embolization 201, 360-1, 430\\n- lower GI bleeds 429-30, 435\\n- mesenteric ischemia 40, 332-3\\n- Anisakis simplex (nematode) 585\\n- antibiotics\\n- abscesses 448, 670-1\\n- appendicitis 309, 314-15, 320\\n- C. difficile colitis 374\\n- cholangitis 259\\n- cholecystitis 254\\n- diverticulitis 404\\n- esophageal perforation 165\\n- pancreatitis 229\\n- perforated ulcers 213\\n- PID 535\\n- postoperative 79, 275, 314, 633, 649-54, 707, 717\\n- pre-operative 77-82, 213\\n\\n## Notes\\n- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers or footers.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- anal conditions 437-40\\n- anal canal trauma 454\\n- anal fissure 438, 440-2\\n- bleeding 424-5, 431, 434\\n- postoperative 448-50\\n- Crohn’s disease 373\\n- healing 450\\n- hemorrhoids 424, 438, 442-4\\n- perianal abscesses 373, 438, 444-8\\n- surgical practice 450-1\\n- analgesia 28, 293, 628, 658\\n- anastomosis 139-48\\n- aortic 522-3\\n- bleeding 435-6\\n- in colonic obstruction 393-4\\n- in Crohn’s disease 371\\n- leaks 140, 143, 146, 662, 677-87, 696, 710\\n- in liver patients 349\\n- obstruction of 662, 687\\n- after small bowel resection 336-7\\n- stomal ulcers 206-7\\n- angiography\\n- embolization 201, 360-1, 430\\n- lower GI bleeds 429-30, 435\\n- mesenteric ischemia 40, 332-3\\n- Anisakis simplex (nematode) 585\\n- antibiotics\\n- abscesses 448, 670-1\\n- appendicitis 309, 314-15, 320\\n- C. difficile colitis 374\\n- cholangitis 259\\n- cholecystitis 254\\n- diverticulitis 404\\n- esophageal perforation 165\\n- pancreatitis 229\\n- perforated ulcers 213\\n- PID 535\\n- postoperative 79, 275, 314, 633, 649-54, 707, 717\\n- pre-operative 77-82, 213',\n", " 'md': '- anal conditions 437-40\\n- anal canal trauma 454\\n- anal fissure 438, 440-2\\n- bleeding 424-5, 431, 434\\n- postoperative 448-50\\n- Crohn’s disease 373\\n- healing 450\\n- hemorrhoids 424, 438, 442-4\\n- perianal abscesses 373, 438, 444-8\\n- surgical practice 450-1\\n- analgesia 28, 293, 628, 658\\n- anastomosis 139-48\\n- aortic 522-3\\n- bleeding 435-6\\n- in colonic obstruction 393-4\\n- in Crohn’s disease 371\\n- leaks 140, 143, 146, 662, 677-87, 696, 710\\n- in liver patients 349\\n- obstruction of 662, 687\\n- after small bowel resection 336-7\\n- stomal ulcers 206-7\\n- angiography\\n- embolization 201, 360-1, 430\\n- lower GI bleeds 429-30, 435\\n- mesenteric ischemia 40, 332-3\\n- Anisakis simplex (nematode) 585\\n- antibiotics\\n- abscesses 448, 670-1\\n- appendicitis 309, 314-15, 320\\n- C. difficile colitis 374\\n- cholangitis 259\\n- cholecystitis 254\\n- diverticulitis 404\\n- esophageal perforation 165\\n- pancreatitis 229\\n- perforated ulcers 213\\n- PID 535\\n- postoperative 79, 275, 314, 633, 649-54, 707, 717\\n- pre-operative 77-82, 213',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 319.06, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Notes',\n", " 'md': '## Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers or footers.\\n```',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers or footers.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'anal canal trauma 454'},\n", " {'text': 'anal fissure 438, 440-2'},\n", " {'text': 'bleeding 424-5, 431, 434'},\n", " {'text': 'bleeding 424-5, 431, 434'},\n", " {'text': 'postoperative 448-50'},\n", " {'text': 'postoperative 448-50'},\n", " {'text': 'postoperative 448-50'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'hemorrhoids 424, 438, 442-4'},\n", " {'text': 'perianal abscesses 373, 438, 444-8'},\n", " {'text': 'perianal abscesses 373, 438, 444-8'},\n", " {'text': 'perianal abscesses 373, 438, 444-8'},\n", " {'text': 'surgical practice 450-1'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'analgesia 28, 293, 628, 658'},\n", " {'text': 'anastomosis 139-48'},\n", " {'text': 'anastomosis 139-48'},\n", " {'text': 'anastomosis 139-48'},\n", " {'text': ''},\n", " {'text': 'aortic 522-3'},\n", " {'text': 'bleeding 435-6'},\n", " {'text': 'in colonic obstruction 393-4'},\n", " {'text': 'in Crohn’s disease 371'},\n", " {'text': 'leaks 140, 143, 146, 662, 677-87, 696, 710'},\n", " {'text': 'in liver patients 349'},\n", " {'text': 'in liver patients 349'},\n", " {'text': 'in liver patients 349'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'obstruction of 662, 687'},\n", " {'text': 'after small bowel resection 336-7'},\n", " {'text': 'after small bowel resection 336-7'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'lower GI bleeds 429-30, 435'},\n", " {'text': 'lower GI bleeds 429-30, 435'},\n", " {'text': 'lower GI bleeds 429-30, 435'},\n", " {'text': 'mesenteric ischemia 40, 332-3'},\n", " {'text': 'mesenteric ischemia 40, 332-3'},\n", " {'text': ' (nematode) 585'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'appendicitis 309, 314-15, 320'},\n", " {'text': 'appendicitis 309, 314-15, 320'},\n", " {'text': 'C. difficile colitis 374'},\n", " {'text': 'C. difficile colitis 374'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'cholecystitis 254'},\n", " {'text': 'diverticulitis 404'},\n", " {'text': 'esophageal perforation 165'},\n", " {'text': ''},\n", " {'text': 'perforated ulcers 213'},\n", " {'text': ''},\n", " {'text': 'postoperative 79, 275, 314, 633, 649-54, 707, 717'},\n", " {'text': 'pre-operative 77-82, 213'},\n", " {'text': 'pre-operative 77-82, 213'},\n", " {'text': 'pre-operative 77-82, 213'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 861,\n", " 'text': ' SBO 275\\nantifungal agents 165\\nanti-TNF agents 364-5\\nantrectomy 205\\nanus see anal conditions\\naorta\\n aneurysm (AAA) 40, 517-25\\n dissection 526, 527\\n occlusion 526-7\\n trauma 498\\nAPACHE II score 67, 192, 225, 640-1\\nappendagitis epiploica 60, 321-2\\nappendicitis 6, 301-22\\n in children 544, 546-8\\n Crohn’s disease 372-3\\n drainage 599-600\\n in history 15-16\\n imaging 38, 55-6, 309-10, 312-13\\n fecaliths 50\\n laparoscopy 124, 311, 317, 321, 322-7, 539, 547-8\\n perforation 303-4, 589\\n phlegmon/abscess 305, 320-1\\n in pregnancy 538-9\\nAppendicitis Inflammatory Response (AIR) score 302, 303, 306-7, 313\\narteriovenous malformations, bleeding 428, 432\\nascariasis 285, 581-3, 589-90\\nascending cholangitis 258-60\\nascites 50, 55, 62, 130, 348, 349\\nAsia, abdominal emergencies 573-86\\nautopsies under anesthesia (AUA) 88\\nAXR see abdominal X-rays\\n\\nBacteriodes fragilis 80, 667\\nballoon tamponade of bleeding varices 343-4\\nbariatric surgery 207\\nbarium contrast studies 40-1\\nbase excess 67, 72\\nbatteries, swallowed 177\\nbehavior',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Extracted Text\\n- SBO 275\\n- antifungal agents 165\\n- anti-TNF agents 364-5\\n- antrectomy 205\\n- anus see anal conditions\\n- aorta\\n- aneurysm (AAA) 40, 517-25\\n- dissection 526, 527\\n- occlusion 526-7\\n- trauma 498\\n- APACHE II score 67, 192, 225, 640-1\\n- appendagitis epiploica 60, 321-2\\n- appendicitis 6, 301-22\\n- in children 544, 546-8\\n- Crohn’s disease 372-3\\n- drainage 599-600\\n- in history 15-16\\n- imaging 38, 55-6, 309-10, 312-13\\n- fecaliths 50\\n- laparoscopy 124, 311, 317, 321, 322-7, 539, 547-8\\n- perforation 303-4, 589\\n- phlegmon/abscess 305, 320-1\\n- in pregnancy 538-9\\n- Appendicitis Inflammatory Response (AIR) score 302, 303, 306-7, 313\\n- arteriovenous malformations, bleeding 428, 432\\n- ascariasis 285, 581-3, 589-90\\n- ascending cholangitis 258-60\\n- ascites 50, 55, 62, 130, 348, 349\\n- Asia, abdominal emergencies 573-86\\n- autopsies under anesthesia (AUA) 88\\n- AXR see abdominal X-rays\\n- Bacteriodes fragilis 80, 667\\n- balloon tamponade of bleeding varices 343-4\\n- bariatric surgery 207\\n- barium contrast studies 40-1\\n- base excess 67, 72\\n- batteries, swallowed 177\\n- behavior\\n\\n## Notes\\n- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- SBO 275\\n- antifungal agents 165\\n- anti-TNF agents 364-5\\n- antrectomy 205\\n- anus see anal conditions\\n- aorta\\n- aneurysm (AAA) 40, 517-25\\n- dissection 526, 527\\n- occlusion 526-7\\n- trauma 498\\n- APACHE II score 67, 192, 225, 640-1\\n- appendagitis epiploica 60, 321-2\\n- appendicitis 6, 301-22\\n- in children 544, 546-8\\n- Crohn’s disease 372-3\\n- drainage 599-600\\n- in history 15-16\\n- imaging 38, 55-6, 309-10, 312-13\\n- fecaliths 50\\n- laparoscopy 124, 311, 317, 321, 322-7, 539, 547-8\\n- perforation 303-4, 589\\n- phlegmon/abscess 305, 320-1\\n- in pregnancy 538-9\\n- Appendicitis Inflammatory Response (AIR) score 302, 303, 306-7, 313\\n- arteriovenous malformations, bleeding 428, 432\\n- ascariasis 285, 581-3, 589-90\\n- ascending cholangitis 258-60\\n- ascites 50, 55, 62, 130, 348, 349\\n- Asia, abdominal emergencies 573-86\\n- autopsies under anesthesia (AUA) 88\\n- AXR see abdominal X-rays\\n- Bacteriodes fragilis 80, 667\\n- balloon tamponade of bleeding varices 343-4\\n- bariatric surgery 207\\n- barium contrast studies 40-1\\n- base excess 67, 72\\n- batteries, swallowed 177\\n- behavior',\n", " 'md': '- SBO 275\\n- antifungal agents 165\\n- anti-TNF agents 364-5\\n- antrectomy 205\\n- anus see anal conditions\\n- aorta\\n- aneurysm (AAA) 40, 517-25\\n- dissection 526, 527\\n- occlusion 526-7\\n- trauma 498\\n- APACHE II score 67, 192, 225, 640-1\\n- appendagitis epiploica 60, 321-2\\n- appendicitis 6, 301-22\\n- in children 544, 546-8\\n- Crohn’s disease 372-3\\n- drainage 599-600\\n- in history 15-16\\n- imaging 38, 55-6, 309-10, 312-13\\n- fecaliths 50\\n- laparoscopy 124, 311, 317, 321, 322-7, 539, 547-8\\n- perforation 303-4, 589\\n- phlegmon/abscess 305, 320-1\\n- in pregnancy 538-9\\n- Appendicitis Inflammatory Response (AIR) score 302, 303, 306-7, 313\\n- arteriovenous malformations, bleeding 428, 432\\n- ascariasis 285, 581-3, 589-90\\n- ascending cholangitis 258-60\\n- ascites 50, 55, 62, 130, 348, 349\\n- Asia, abdominal emergencies 573-86\\n- autopsies under anesthesia (AUA) 88\\n- AXR see abdominal X-rays\\n- Bacteriodes fragilis 80, 667\\n- balloon tamponade of bleeding varices 343-4\\n- bariatric surgery 207\\n- barium contrast studies 40-1\\n- base excess 67, 72\\n- batteries, swallowed 177\\n- behavior',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 446.98, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Notes',\n", " 'md': '## Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'antifungal agents 165'},\n", " {'text': 'anti-TNF agents 364-5'},\n", " {'text': ''},\n", " {'text': ' anal conditions'},\n", " {'text': 'dissection 526, 527'},\n", " {'text': ''},\n", " {'text': 'occlusion 526-7'},\n", " {'text': 'occlusion 526-7'},\n", " {'text': 'trauma 498'},\n", " {'text': 'APACHE II score 67, 192, 225, 640-1'},\n", " {'text': 'appendagitis epiploica 60, 321-2'},\n", " {'text': 'appendagitis epiploica 60, 321-2'},\n", " {'text': 'appendagitis epiploica 60, 321-2'},\n", " {'text': 'appendagitis epiploica 60, 321-2'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'in children 544, 546-8'},\n", " {'text': 'in children 544, 546-8'},\n", " {'text': 'Crohn’s disease 372-3'},\n", " {'text': 'Crohn’s disease 372-3'},\n", " {'text': 'drainage 599-600'},\n", " {'text': 'in history 15-16'},\n", " {'text': 'imaging 38, 55-6, 309-10, 312-13'},\n", " {'text': 'fecaliths 50'},\n", " {'text': 'fecaliths 50'},\n", " {'text': 'fecaliths 50'},\n", " {'text': ''},\n", " {'text': 'laparoscopy 124, 311, 317, 321, 322-7, 539, 547-8'},\n", " {'text': 'perforation 303-4, 589'},\n", " {'text': 'perforation 303-4, 589'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'phlegmon/abscess 305, 320-1'},\n", " {'text': 'phlegmon/abscess 305, 320-1'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'Appendicitis Inflammatory Response (AIR) score 302, 303, 306-7, 313'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'ascending cholangitis 258-60'},\n", " {'text': 'ascending cholangitis 258-60'},\n", " {'text': 'ascending cholangitis 258-60'},\n", " {'text': 'ascites 50, 55, 62, 130, 348, 349'},\n", " {'text': 'Asia, abdominal emergencies 573-86'},\n", " {'text': 'Asia, abdominal emergencies 573-86'},\n", " {'text': 'Asia, abdominal emergencies 573-86'},\n", " {'text': 'Asia, abdominal emergencies 573-86'},\n", " {'text': 'Asia, abdominal emergencies 573-86'},\n", " {'text': 'Asia, abdominal emergencies 573-86'},\n", " {'text': 'autopsies under anesthesia (AUA) 88'},\n", " {'text': ''},\n", " {'text': 'balloon tamponade of bleeding varices 343-4'},\n", " {'text': 'balloon tamponade of bleeding varices 343-4'},\n", " {'text': ''},\n", " {'text': 'barium contrast studies 40-1'},\n", " {'text': ''},\n", " {'text': 'batteries, swallowed 177'},\n", " {'text': 'batteries, swallowed 177'},\n", " {'text': ''}]},\n", " {'page': 862,\n", " 'text': ' in the OR 95\\n towards the patient/family 83-6, 88-9\\nbest practice 3-12\\n pre-operative 31-3, 41-2, 57, 93\\n pre-closure 621-3\\n postoperative 628, 716, 723-9\\nbezoars 284-5\\nbile, intraperitoneal 110\\nbiliary colic 242\\nbiliary tract 241-2\\n complications of ERCP 463-7\\n drainage 245, 605\\n gallstones in 255-60\\n pancreatitis 223, 224-5, 260-3\\n hemobilia 359-60\\n imaging 46-7, 58-9, 253-4, 257, 284\\n parasitic infestations 583, 585\\n trauma 494\\n see also cholecystitis\\nbladder, urinary\\n cystostomy tubes 564-5\\n fistulas 403, 418\\n should be empty 94, 325\\n trauma 496, 570\\nblood tests 36-7\\n hypovolemia 67, 72\\n inflammatory markers 36, 309\\n mesenteric ischemia 40, 332\\n pancreatitis 27, 36, 224, 225\\n SBO 269\\nblood/blood product transfusions 72-3, 76, 475, 633\\n‘blow-hole’ colostomy and cecostomy 156-7, 386\\nBochdalek hernia 180\\nBoerhaave’s syndrome 37, 163\\n see also esophagus, perforation\\nbotulinum toxin 442\\n\\nC-reactive protein (CRP) 36, 309\\ncalculi 49, 560',\n", " 'md': '```markdown\\n# Extracted Content from Current Page\\n\\n## Text\\n- in the OR 95\\n- towards the patient/family 83-6, 88-9\\n- best practice 3-12\\n- pre-operative 31-3, 41-2, 57, 93\\n- pre-closure 621-3\\n- postoperative 628, 716, 723-9\\n- bezoars 284-5\\n- bile, intraperitoneal 110\\n- biliary colic 242\\n- biliary tract 241-2\\n- complications of ERCP 463-7\\n- drainage 245, 605\\n- gallstones in 255-60\\n- pancreatitis 223, 224-5, 260-3\\n- hemobilia 359-60\\n- imaging 46-7, 58-9, 253-4, 257, 284\\n- parasitic infestations 583, 585\\n- trauma 494\\n- see also cholecystitis\\n- bladder, urinary\\n- cystostomy tubes 564-5\\n- fistulas 403, 418\\n- should be empty 94, 325\\n- trauma 496, 570\\n- blood tests 36-7\\n- hypovolemia 67, 72\\n- inflammatory markers 36, 309\\n- mesenteric ischemia 40, 332\\n- pancreatitis 27, 36, 224, 225\\n- SBO 269\\n- blood/blood product transfusions 72-3, 76, 475, 633\\n- ‘blow-hole’ colostomy and cecostomy 156-7, 386\\n- Bochdalek hernia 180\\n- Boerhaave’s syndrome 37, 163\\n- see also esophagus, perforation\\n- botulinum toxin 442\\n- C-reactive protein (CRP) 36, 309\\n- calculi 49, 560\\n\\n## Hyperlinks\\n- None identified.\\n\\n## Formulas\\n- None identified.\\n\\n## Images\\n- None identified.\\n\\n## Tables\\n- None identified.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Extracted Content from Current Page',\n", " 'md': '# Extracted Content from Current Page',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- in the OR 95\\n- towards the patient/family 83-6, 88-9\\n- best practice 3-12\\n- pre-operative 31-3, 41-2, 57, 93\\n- pre-closure 621-3\\n- postoperative 628, 716, 723-9\\n- bezoars 284-5\\n- bile, intraperitoneal 110\\n- biliary colic 242\\n- biliary tract 241-2\\n- complications of ERCP 463-7\\n- drainage 245, 605\\n- gallstones in 255-60\\n- pancreatitis 223, 224-5, 260-3\\n- hemobilia 359-60\\n- imaging 46-7, 58-9, 253-4, 257, 284\\n- parasitic infestations 583, 585\\n- trauma 494\\n- see also cholecystitis\\n- bladder, urinary\\n- cystostomy tubes 564-5\\n- fistulas 403, 418\\n- should be empty 94, 325\\n- trauma 496, 570\\n- blood tests 36-7\\n- hypovolemia 67, 72\\n- inflammatory markers 36, 309\\n- mesenteric ischemia 40, 332\\n- pancreatitis 27, 36, 224, 225\\n- SBO 269\\n- blood/blood product transfusions 72-3, 76, 475, 633\\n- ‘blow-hole’ colostomy and cecostomy 156-7, 386\\n- Bochdalek hernia 180\\n- Boerhaave’s syndrome 37, 163\\n- see also esophagus, perforation\\n- botulinum toxin 442\\n- C-reactive protein (CRP) 36, 309\\n- calculi 49, 560',\n", " 'md': '- in the OR 95\\n- towards the patient/family 83-6, 88-9\\n- best practice 3-12\\n- pre-operative 31-3, 41-2, 57, 93\\n- pre-closure 621-3\\n- postoperative 628, 716, 723-9\\n- bezoars 284-5\\n- bile, intraperitoneal 110\\n- biliary colic 242\\n- biliary tract 241-2\\n- complications of ERCP 463-7\\n- drainage 245, 605\\n- gallstones in 255-60\\n- pancreatitis 223, 224-5, 260-3\\n- hemobilia 359-60\\n- imaging 46-7, 58-9, 253-4, 257, 284\\n- parasitic infestations 583, 585\\n- trauma 494\\n- see also cholecystitis\\n- bladder, urinary\\n- cystostomy tubes 564-5\\n- fistulas 403, 418\\n- should be empty 94, 325\\n- trauma 496, 570\\n- blood tests 36-7\\n- hypovolemia 67, 72\\n- inflammatory markers 36, 309\\n- mesenteric ischemia 40, 332\\n- pancreatitis 27, 36, 224, 225\\n- SBO 269\\n- blood/blood product transfusions 72-3, 76, 475, 633\\n- ‘blow-hole’ colostomy and cecostomy 156-7, 386\\n- Bochdalek hernia 180\\n- Boerhaave’s syndrome 37, 163\\n- see also esophagus, perforation\\n- botulinum toxin 442\\n- C-reactive protein (CRP) 36, 309\\n- calculi 49, 560',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 328.65, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Hyperlinks',\n", " 'md': '## Hyperlinks',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.',\n", " 'md': '- None identified.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formulas',\n", " 'md': '## Formulas',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.',\n", " 'md': '- None identified.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.',\n", " 'md': '- None identified.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.\\n```',\n", " 'md': '- None identified.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'towards the patient/family 83-6, 88-9'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'pre-operative 31-3, 41-2, 57, 93'},\n", " {'text': 'pre-closure 621-3'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'postoperative 628, 716, 723-9'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'bile, intraperitoneal 110'},\n", " {'text': ''},\n", " {'text': 'biliary tract 241-2'},\n", " {'text': 'complications of ERCP 463-7'},\n", " {'text': ''},\n", " {'text': 'gallstones in 255-60'},\n", " {'text': 'gallstones in 255-60'},\n", " {'text': 'pancreatitis 223, 224-5, 260-3'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'imaging 46-7, 58-9, 253-4, 257, 284'},\n", " {'text': 'parasitic infestations 583, 585'},\n", " {'text': 'parasitic infestations 583, 585'},\n", " {'text': 'parasitic infestations 583, 585'},\n", " {'text': 'parasitic infestations 583, 585'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'see also'},\n", " {'text': ''},\n", " {'text': 'should be empty 94, 325'},\n", " {'text': 'should be empty 94, 325'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'blood tests 36-7'},\n", " {'text': ''},\n", " {'text': 'hypovolemia 67, 72'},\n", " {'text': 'inflammatory markers 36, 309'},\n", " {'text': 'inflammatory markers 36, 309'},\n", " {'text': 'mesenteric ischemia 40, 332'},\n", " {'text': 'mesenteric ischemia 40, 332'},\n", " {'text': 'pancreatitis 27, 36, 224, 225'},\n", " {'text': 'pancreatitis 27, 36, 224, 225'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'blood/blood product transfusions 72-3, 76, 475, 633'},\n", " {'text': '‘blow-hole’ colostomy and cecostomy 156-7, 386'},\n", " {'text': '‘blow-hole’ colostomy and cecostomy 156-7, 386'},\n", " {'text': '‘blow-hole’ colostomy and cecostomy 156-7, 386'},\n", " {'text': '‘blow-hole’ colostomy and cecostomy 156-7, 386'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'Boerhaave’s syndrome 37, 163'},\n", " {'text': ' esophagus, perforation'},\n", " {'text': ' esophagus, perforation'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 863,\n", " 'text': ' see also gallstones\\ncameras, laparoscopic 121, 325\\ncapillary refill time 70\\ncardiac function, pre-operative 71-2, 73\\nCattell-Braasch maneuver 357\\ncaustic ingestion 163, 174-5\\ncecum\\n cancer 29\\n cecostomy 157, 386-7, 398, 400\\n in colonic pseudo-obstruction 399-400\\n dilation 367-8\\n diverticulitis 419\\n volvulus 397-8\\nceliac artery 499\\ncellulitis 719\\ncentral venous pressure (CVP) 71\\nCharcot’s triad 258\\nchest X-rays (CXR) 37-8, 164, 184\\nChilaiditi sign 38\\nchild abuse 555\\nChild-Pugh score 346-7\\nchildren see pediatrics\\ncholangiography 253-4\\ncholangitis 258-60\\ncholecystectomy\\n for acute cholecystitis see under cholecystitis\\n for other conditions 257, 261, 284\\ncholecystitis 37, 59, 242-54\\n acalculous 254-5\\n cholecystectomy 245, 246-52, 255, 257, 281\\n drainage 600-1\\n laparoscopic 123-4, 246-8, 251, 539\\n in pregnancy 539\\ncholecystostomy 253\\ncholedocholithiasis 255-60\\ncirrhotic patients 130, 341-53\\nClostridium difficile colitis 36, 365, 366, 373-4\\nclosure 611-20, 716\\n after appendectomy 318',\n", " 'md': '```markdown\\n# Current Page Content\\n\\n## Extracted Text\\n- see also gallstones\\n- cameras, laparoscopic 121, 325\\n- capillary refill time 70\\n- cardiac function, pre-operative 71-2, 73\\n- Cattell-Braasch maneuver 357\\n- caustic ingestion 163, 174-5\\n- cecum\\n- cancer 29\\n- cecostomy 157, 386-7, 398, 400\\n- in colonic pseudo-obstruction 399-400\\n- dilation 367-8\\n- diverticulitis 419\\n- volvulus 397-8\\n- celiac artery 499\\n- cellulitis 719\\n- central venous pressure (CVP) 71\\n- Charcot’s triad 258\\n- chest X-rays (CXR) 37-8, 164, 184\\n- Chilaiditi sign 38\\n- child abuse 555\\n- Child-Pugh score 346-7\\n- children see pediatrics\\n- cholangiography 253-4\\n- cholangitis 258-60\\n- cholecystectomy\\n- for acute cholecystitis see under cholecystitis\\n- for other conditions 257, 261, 284\\n- cholecystitis 37, 59, 242-54\\n- acalculous 254-5\\n- cholecystectomy 245, 246-52, 255, 257, 281\\n- drainage 600-1\\n- laparoscopic 123-4, 246-8, 251, 539\\n- in pregnancy 539\\n- cholecystostomy 253\\n- choledocholithiasis 255-60\\n- cirrhotic patients 130, 341-53\\n- Clostridium difficile colitis 36, 365, 366, 373-4\\n- closure 611-20, 716\\n- after appendectomy 318\\n\\n## Notes\\n- No images, graphs, or tables were identified on this page.\\n- All extracted text has been presented without headers, footers, or diagonal text.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Current Page Content',\n", " 'md': '# Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- see also gallstones\\n- cameras, laparoscopic 121, 325\\n- capillary refill time 70\\n- cardiac function, pre-operative 71-2, 73\\n- Cattell-Braasch maneuver 357\\n- caustic ingestion 163, 174-5\\n- cecum\\n- cancer 29\\n- cecostomy 157, 386-7, 398, 400\\n- in colonic pseudo-obstruction 399-400\\n- dilation 367-8\\n- diverticulitis 419\\n- volvulus 397-8\\n- celiac artery 499\\n- cellulitis 719\\n- central venous pressure (CVP) 71\\n- Charcot’s triad 258\\n- chest X-rays (CXR) 37-8, 164, 184\\n- Chilaiditi sign 38\\n- child abuse 555\\n- Child-Pugh score 346-7\\n- children see pediatrics\\n- cholangiography 253-4\\n- cholangitis 258-60\\n- cholecystectomy\\n- for acute cholecystitis see under cholecystitis\\n- for other conditions 257, 261, 284\\n- cholecystitis 37, 59, 242-54\\n- acalculous 254-5\\n- cholecystectomy 245, 246-52, 255, 257, 281\\n- drainage 600-1\\n- laparoscopic 123-4, 246-8, 251, 539\\n- in pregnancy 539\\n- cholecystostomy 253\\n- choledocholithiasis 255-60\\n- cirrhotic patients 130, 341-53\\n- Clostridium difficile colitis 36, 365, 366, 373-4\\n- closure 611-20, 716\\n- after appendectomy 318',\n", " 'md': '- see also gallstones\\n- cameras, laparoscopic 121, 325\\n- capillary refill time 70\\n- cardiac function, pre-operative 71-2, 73\\n- Cattell-Braasch maneuver 357\\n- caustic ingestion 163, 174-5\\n- cecum\\n- cancer 29\\n- cecostomy 157, 386-7, 398, 400\\n- in colonic pseudo-obstruction 399-400\\n- dilation 367-8\\n- diverticulitis 419\\n- volvulus 397-8\\n- celiac artery 499\\n- cellulitis 719\\n- central venous pressure (CVP) 71\\n- Charcot’s triad 258\\n- chest X-rays (CXR) 37-8, 164, 184\\n- Chilaiditi sign 38\\n- child abuse 555\\n- Child-Pugh score 346-7\\n- children see pediatrics\\n- cholangiography 253-4\\n- cholangitis 258-60\\n- cholecystectomy\\n- for acute cholecystitis see under cholecystitis\\n- for other conditions 257, 261, 284\\n- cholecystitis 37, 59, 242-54\\n- acalculous 254-5\\n- cholecystectomy 245, 246-52, 255, 257, 281\\n- drainage 600-1\\n- laparoscopic 123-4, 246-8, 251, 539\\n- in pregnancy 539\\n- cholecystostomy 253\\n- choledocholithiasis 255-60\\n- cirrhotic patients 130, 341-53\\n- Clostridium difficile colitis 36, 365, 366, 373-4\\n- closure 611-20, 716\\n- after appendectomy 318',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 287.71, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Notes',\n", " 'md': '## Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All extracted text has been presented without headers, footers, or diagonal text.\\n```',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All extracted text has been presented without headers, footers, or diagonal text.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': 'cardiac function, pre-operative 71-2, 73'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'caustic ingestion 163, 174-5'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'cecostomy 157, 386-7, 398, 400'},\n", " {'text': 'in colonic pseudo-obstruction 399-400'},\n", " {'text': 'in colonic pseudo-obstruction 399-400'},\n", " {'text': 'in colonic pseudo-obstruction 399-400'},\n", " {'text': 'in colonic pseudo-obstruction 399-400'},\n", " {'text': ''},\n", " {'text': 'diverticulitis 419'},\n", " {'text': 'volvulus 397-8'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'central venous pressure (CVP) 71'},\n", " {'text': ''},\n", " {'text': 'chest X-rays (CXR) 37-8, 164, 184'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'child abuse 555'},\n", " {'text': 'Child-Pugh score 346-7'},\n", " {'text': ' pediatrics'},\n", " {'text': 'cholangitis 258-60'},\n", " {'text': 'cholecystectomy'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'acalculous 254-5'},\n", " {'text': 'acalculous 254-5'},\n", " {'text': 'acalculous 254-5'},\n", " {'text': 'cholecystectomy 245, 246-52, 255, 257, 281'},\n", " {'text': 'drainage 600-1'},\n", " {'text': 'drainage 600-1'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'laparoscopic 123-4, 246-8, 251, 539'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'choledocholithiasis 255-60'},\n", " {'text': 'cirrhotic patients 130, 341-53'},\n", " {'text': 'Clostridium difficile'},\n", " {'text': ' colitis 36, 365, 366, 373-4'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'after appendectomy 318'},\n", " {'text': ''}]},\n", " {'page': 864,\n", " 'text': ' delayed/temporary see laparostomy\\n after laparoscopy 618-20\\n after laparostomy 703-5\\n pre-closure checklist 623\\ncoagulopathy 348\\ncolloids 69\\ncolon\\n anastomosis 139-48, 349, 371, 393-4\\n see also anastomosis, leaks\\n cancer 379-93, 432-3\\n colitis 363, 377\\n amoebic 581\\n C. difficile 36, 365, 366, 373-4\\n diverticular-associated 419-20\\n IBD 154-5, 363-71, 433\\n ischemic 329, 376-7, 434\\n neutropenic 375-6\\n colonoscopy\\n complications 468-72\\n hemorrhage 425-8, 435\\n obstruction 395, 399\\n colostomy 148-52, 152-4, 156-8, 350-1, 384, 386-7\\n ileocolostomy 155\\n decompression 389, 399\\n diverticulitis 60, 125, 401-21\\n drainage after resection 602-3, 607\\n imaging 37, 48, 56, 60, 381-2, 395, 397, 469-70\\n intra-operative lavage 391-3, 394\\n intussusception 548-51, 587-9\\n ischemia 294, 329, 430\\n necrosis 376\\n in acute pancreatitis 230-1\\n obstruction 16-17, 28, 29-30, 119, 379-400\\n in pregnancy 539-40\\n perforation 37, 367-8, 370-1\\n amoebiasis 581\\n after colonoscopy 469-72\\n in diverticulitis 403, 411-17\\n by a PEG tube 463',\n", " 'md': '```markdown\\n# Extracted Content from Current Page\\n\\n## Text\\n- delayed/temporary see laparostomy\\n- after laparoscopy 618-20\\n- after laparostomy 703-5\\n- pre-closure checklist 623\\n- coagulopathy 348\\n- colloids 69\\n- colon\\n- anastomosis 139-48, 349, 371, 393-4\\n- see also anastomosis, leaks\\n- cancer 379-93, 432-3\\n- colitis 363, 377\\n- amoebic 581\\n- C. difficile 36, 365, 366, 373-4\\n- diverticular-associated 419-20\\n- IBD 154-5, 363-71, 433\\n- ischemic 329, 376-7, 434\\n- neutropenic 375-6\\n- colonoscopy\\n- complications 468-72\\n- hemorrhage 425-8, 435\\n- obstruction 395, 399\\n- colostomy 148-52, 152-4, 156-8, 350-1, 384, 386-7\\n- ileocolostomy 155\\n- decompression 389, 399\\n- diverticulitis 60, 125, 401-21\\n- drainage after resection 602-3, 607\\n- imaging 37, 48, 56, 60, 381-2, 395, 397, 469-70\\n- intra-operative lavage 391-3, 394\\n- intussusception 548-51, 587-9\\n- ischemia 294, 329, 430\\n- necrosis 376\\n- in acute pancreatitis 230-1\\n- obstruction 16-17, 28, 29-30, 119, 379-400\\n- in pregnancy 539-40\\n- perforation 37, 367-8, 370-1\\n- amoebiasis 581\\n- after colonoscopy 469-72\\n- in diverticulitis 403, 411-17\\n- by a PEG tube 463\\n```\\n\\n### Notes\\n- The text has been extracted without any headers, footers, or diagonal text.\\n- There are no images, graphs, or tables present on this page to describe or convert.',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Extracted Content from Current Page',\n", " 'md': '# Extracted Content from Current Page',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- delayed/temporary see laparostomy\\n- after laparoscopy 618-20\\n- after laparostomy 703-5\\n- pre-closure checklist 623\\n- coagulopathy 348\\n- colloids 69\\n- colon\\n- anastomosis 139-48, 349, 371, 393-4\\n- see also anastomosis, leaks\\n- cancer 379-93, 432-3\\n- colitis 363, 377\\n- amoebic 581\\n- C. difficile 36, 365, 366, 373-4\\n- diverticular-associated 419-20\\n- IBD 154-5, 363-71, 433\\n- ischemic 329, 376-7, 434\\n- neutropenic 375-6\\n- colonoscopy\\n- complications 468-72\\n- hemorrhage 425-8, 435\\n- obstruction 395, 399\\n- colostomy 148-52, 152-4, 156-8, 350-1, 384, 386-7\\n- ileocolostomy 155\\n- decompression 389, 399\\n- diverticulitis 60, 125, 401-21\\n- drainage after resection 602-3, 607\\n- imaging 37, 48, 56, 60, 381-2, 395, 397, 469-70\\n- intra-operative lavage 391-3, 394\\n- intussusception 548-51, 587-9\\n- ischemia 294, 329, 430\\n- necrosis 376\\n- in acute pancreatitis 230-1\\n- obstruction 16-17, 28, 29-30, 119, 379-400\\n- in pregnancy 539-40\\n- perforation 37, 367-8, 370-1\\n- amoebiasis 581\\n- after colonoscopy 469-72\\n- in diverticulitis 403, 411-17\\n- by a PEG tube 463\\n```',\n", " 'md': '- delayed/temporary see laparostomy\\n- after laparoscopy 618-20\\n- after laparostomy 703-5\\n- pre-closure checklist 623\\n- coagulopathy 348\\n- colloids 69\\n- colon\\n- anastomosis 139-48, 349, 371, 393-4\\n- see also anastomosis, leaks\\n- cancer 379-93, 432-3\\n- colitis 363, 377\\n- amoebic 581\\n- C. difficile 36, 365, 366, 373-4\\n- diverticular-associated 419-20\\n- IBD 154-5, 363-71, 433\\n- ischemic 329, 376-7, 434\\n- neutropenic 375-6\\n- colonoscopy\\n- complications 468-72\\n- hemorrhage 425-8, 435\\n- obstruction 395, 399\\n- colostomy 148-52, 152-4, 156-8, 350-1, 384, 386-7\\n- ileocolostomy 155\\n- decompression 389, 399\\n- diverticulitis 60, 125, 401-21\\n- drainage after resection 602-3, 607\\n- imaging 37, 48, 56, 60, 381-2, 395, 397, 469-70\\n- intra-operative lavage 391-3, 394\\n- intussusception 548-51, 587-9\\n- ischemia 294, 329, 430\\n- necrosis 376\\n- in acute pancreatitis 230-1\\n- obstruction 16-17, 28, 29-30, 119, 379-400\\n- in pregnancy 539-40\\n- perforation 37, 367-8, 370-1\\n- amoebiasis 581\\n- after colonoscopy 469-72\\n- in diverticulitis 403, 411-17\\n- by a PEG tube 463\\n```',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 324.65, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 3,\n", " 'value': 'Notes',\n", " 'md': '### Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- The text has been extracted without any headers, footers, or diagonal text.\\n- There are no images, graphs, or tables present on this page to describe or convert.',\n", " 'md': '- The text has been extracted without any headers, footers, or diagonal text.\\n- There are no images, graphs, or tables present on this page to describe or convert.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'after laparostomy 703-5'},\n", " {'text': 'pre-closure checklist 623'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'see also'},\n", " {'text': ' anastomosis, leaks'},\n", " {'text': ' anastomosis, leaks'},\n", " {'text': ' anastomosis, leaks'},\n", " {'text': 'colitis 363, 377'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'amoebic 581'},\n", " {'text': 'C. difficile'},\n", " {'text': 'diverticular-associated 419-20'},\n", " {'text': 'diverticular-associated 419-20'},\n", " {'text': 'diverticular-associated 419-20'},\n", " {'text': 'diverticular-associated 419-20'},\n", " {'text': 'IBD 154-5, 363-71, 433'},\n", " {'text': 'ischemic 329, 376-7, 434'},\n", " {'text': 'ischemic 329, 376-7, 434'},\n", " {'text': 'ischemic 329, 376-7, 434'},\n", " {'text': 'neutropenic 375-6'},\n", " {'text': 'neutropenic 375-6'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'hemorrhage 425-8, 435'},\n", " {'text': 'obstruction 395, 399'},\n", " {'text': 'obstruction 395, 399'},\n", " {'text': 'colostomy 148-52, 152-4, 156-8, 350-1, 384, 386-7'},\n", " {'text': 'colostomy 148-52, 152-4, 156-8, 350-1, 384, 386-7'},\n", " {'text': 'ileocolostomy 155'},\n", " {'text': 'ileocolostomy 155'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'decompression 389, 399'},\n", " {'text': 'diverticulitis 60, 125, 401-21'},\n", " {'text': 'diverticulitis 60, 125, 401-21'},\n", " {'text': 'drainage after resection 602-3, 607'},\n", " {'text': 'drainage after resection 602-3, 607'},\n", " {'text': 'drainage after resection 602-3, 607'},\n", " {'text': 'imaging 37, 48, 56, 60, 381-2, 395, 397, 469-70'},\n", " {'text': 'imaging 37, 48, 56, 60, 381-2, 395, 397, 469-70'},\n", " {'text': 'intra-operative lavage 391-3, 394'},\n", " {'text': 'intra-operative lavage 391-3, 394'},\n", " {'text': 'intra-operative lavage 391-3, 394'},\n", " {'text': 'intra-operative lavage 391-3, 394'},\n", " {'text': 'intra-operative lavage 391-3, 394'},\n", " {'text': 'intra-operative lavage 391-3, 394'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'intussusception 548-51, 587-9'},\n", " {'text': 'intussusception 548-51, 587-9'},\n", " {'text': 'ischemia 294, 329, 430'},\n", " {'text': ''},\n", " {'text': 'necrosis 376'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'in acute pancreatitis 230-1'},\n", " {'text': 'obstruction 16-17, 28, 29-30, 119, 379-400'},\n", " {'text': 'in pregnancy 539-40'},\n", " {'text': 'in pregnancy 539-40'},\n", " {'text': 'in pregnancy 539-40'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'perforation 37, 367-8, 370-1'},\n", " {'text': 'amoebiasis 581'},\n", " {'text': 'amoebiasis 581'},\n", " {'text': 'amoebiasis 581'},\n", " {'text': 'after colonoscopy 469-72'},\n", " {'text': 'in diverticulitis 403, 411-17'},\n", " {'text': 'by a PEG tube 463'},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 865,\n", " 'text': ' pseudo-obstruction 383, 398-400\\n trauma 497\\n volvulus 394-8, 593-4\\n see also lower GI bleeding\\ncommunication, with the patient/family 83-9\\ncompensatory anti-inflammatory response syndrome (CARS) 9\\ncomponent separation technique 705-6\\ncomputed tomography see CT scans\\nconsent 83-5, 87-8\\nconstipation 28, 545\\ncontamination 109, 110, 128\\n antibiotics 651, 652\\ncontinuity of care 31-3, 628\\ncontrast studies 40-2, 52, 57see also Gastrografin®\\ncritical view of safety (CVS) 248\\nCrohn’s disease (CD) 60, 363, 369, 370-3, 433\\nCRP (C-reactive protein) 36, 309\\ncrystalloids 69-70, 73\\nCT scans 31, 39-40, 51-64, 101\\n abscesses 62, 579, 580, 670\\n appendicitis 55-6, 310, 312-13\\n biliary tract 58-9, 243\\n in children 547\\n colon 56, 60, 381-2, 395, 470\\n esophageal perforation 164, 166, 167\\n gastric volvulus 184-5\\n kidney 60, 566-7\\n liver 58, 353, 579, 580\\n lower GI bleeds 429\\n mesenteric ischemia 40, 332-3, 338-9\\n pancreas 59-60, 224, 231, 232-3\\n small bowel 60, 270-2, 275, 289\\n trauma 55, 353, 477, 478-9, 488-9, 566\\n ulcer perforation 211-12\\nCXR (chest X-rays) 37-8, 164, 184\\ncystostomy tubes 564-5\\ncysts\\n hepatic 358, 584-5',\n", " 'md': '```markdown\\n# Current Page Content\\n\\n## Extracted Text\\n- pseudo-obstruction 383, 398-400\\n- trauma 497\\n- volvulus 394-8, 593-4\\n- see also lower GI bleeding\\n- communication, with the patient/family 83-9\\n- compensatory anti-inflammatory response syndrome (CARS) 9\\n- component separation technique 705-6\\n- computed tomography see CT scans\\n- consent 83-5, 87-8\\n- constipation 28, 545\\n- contamination 109, 110, 128\\n- antibiotics 651, 652\\n- continuity of care 31-3, 628\\n- contrast studies 40-2, 52, 57 see also Gastrografin®\\n- critical view of safety (CVS) 248\\n- Crohn’s disease (CD) 60, 363, 369, 370-3, 433\\n- CRP (C-reactive protein) 36, 309\\n- crystalloids 69-70, 73\\n- CT scans 31, 39-40, 51-64, 101\\n- abscesses 62, 579, 580, 670\\n- appendicitis 55-6, 310, 312-13\\n- biliary tract 58-9, 243\\n- in children 547\\n- colon 56, 60, 381-2, 395, 470\\n- esophageal perforation 164, 166, 167\\n- gastric volvulus 184-5\\n- kidney 60, 566-7\\n- liver 58, 353, 579, 580\\n- lower GI bleeds 429\\n- mesenteric ischemia 40, 332-3, 338-9\\n- pancreas 59-60, 224, 231, 232-3\\n- small bowel 60, 270-2, 275, 289\\n- trauma 55, 353, 477, 478-9, 488-9, 566\\n- ulcer perforation 211-12\\n- CXR (chest X-rays) 37-8, 164, 184\\n- cystostomy tubes 564-5\\n- cysts\\n- hepatic 358, 584-5\\n\\n## Notes\\n- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Current Page Content',\n", " 'md': '# Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- pseudo-obstruction 383, 398-400\\n- trauma 497\\n- volvulus 394-8, 593-4\\n- see also lower GI bleeding\\n- communication, with the patient/family 83-9\\n- compensatory anti-inflammatory response syndrome (CARS) 9\\n- component separation technique 705-6\\n- computed tomography see CT scans\\n- consent 83-5, 87-8\\n- constipation 28, 545\\n- contamination 109, 110, 128\\n- antibiotics 651, 652\\n- continuity of care 31-3, 628\\n- contrast studies 40-2, 52, 57 see also Gastrografin®\\n- critical view of safety (CVS) 248\\n- Crohn’s disease (CD) 60, 363, 369, 370-3, 433\\n- CRP (C-reactive protein) 36, 309\\n- crystalloids 69-70, 73\\n- CT scans 31, 39-40, 51-64, 101\\n- abscesses 62, 579, 580, 670\\n- appendicitis 55-6, 310, 312-13\\n- biliary tract 58-9, 243\\n- in children 547\\n- colon 56, 60, 381-2, 395, 470\\n- esophageal perforation 164, 166, 167\\n- gastric volvulus 184-5\\n- kidney 60, 566-7\\n- liver 58, 353, 579, 580\\n- lower GI bleeds 429\\n- mesenteric ischemia 40, 332-3, 338-9\\n- pancreas 59-60, 224, 231, 232-3\\n- small bowel 60, 270-2, 275, 289\\n- trauma 55, 353, 477, 478-9, 488-9, 566\\n- ulcer perforation 211-12\\n- CXR (chest X-rays) 37-8, 164, 184\\n- cystostomy tubes 564-5\\n- cysts\\n- hepatic 358, 584-5',\n", " 'md': '- pseudo-obstruction 383, 398-400\\n- trauma 497\\n- volvulus 394-8, 593-4\\n- see also lower GI bleeding\\n- communication, with the patient/family 83-9\\n- compensatory anti-inflammatory response syndrome (CARS) 9\\n- component separation technique 705-6\\n- computed tomography see CT scans\\n- consent 83-5, 87-8\\n- constipation 28, 545\\n- contamination 109, 110, 128\\n- antibiotics 651, 652\\n- continuity of care 31-3, 628\\n- contrast studies 40-2, 52, 57 see also Gastrografin®\\n- critical view of safety (CVS) 248\\n- Crohn’s disease (CD) 60, 363, 369, 370-3, 433\\n- CRP (C-reactive protein) 36, 309\\n- crystalloids 69-70, 73\\n- CT scans 31, 39-40, 51-64, 101\\n- abscesses 62, 579, 580, 670\\n- appendicitis 55-6, 310, 312-13\\n- biliary tract 58-9, 243\\n- in children 547\\n- colon 56, 60, 381-2, 395, 470\\n- esophageal perforation 164, 166, 167\\n- gastric volvulus 184-5\\n- kidney 60, 566-7\\n- liver 58, 353, 579, 580\\n- lower GI bleeds 429\\n- mesenteric ischemia 40, 332-3, 338-9\\n- pancreas 59-60, 224, 231, 232-3\\n- small bowel 60, 270-2, 275, 289\\n- trauma 55, 353, 477, 478-9, 488-9, 566\\n- ulcer perforation 211-12\\n- CXR (chest X-rays) 37-8, 164, 184\\n- cystostomy tubes 564-5\\n- cysts\\n- hepatic 358, 584-5',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 400.61, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Notes',\n", " 'md': '## Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': 'volvulus 394-8, 593-4'},\n", " {'text': ' lower GI bleeding'},\n", " {'text': ' lower GI bleeding'},\n", " {'text': 'compensatory anti-inflammatory response syndrome (CARS) 9'},\n", " {'text': ''},\n", " {'text': ' CT scans'},\n", " {'text': 'constipation 28, 545'},\n", " {'text': 'constipation 28, 545'},\n", " {'text': 'contamination 109, 110, 128'},\n", " {'text': 'contamination 109, 110, 128'},\n", " {'text': 'antibiotics 651, 652'},\n", " {'text': 'antibiotics 651, 652'},\n", " {'text': 'antibiotics 651, 652'},\n", " {'text': 'continuity of care 31-3, 628'},\n", " {'text': 'continuity of care 31-3, 628'},\n", " {'text': 'contrast studies 40-2, 52, 57'},\n", " {'text': 'contrast studies 40-2, 52, 57'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'Crohn’s disease (CD) 60, 363, 369, 370-3, 433'},\n", " {'text': 'CRP (C-reactive protein) 36, 309'},\n", " {'text': 'CRP (C-reactive protein) 36, 309'},\n", " {'text': 'CRP (C-reactive protein) 36, 309'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'CT scans 31, 39-40, 51-64, 101'},\n", " {'text': 'CT scans 31, 39-40, 51-64, 101'},\n", " {'text': 'abscesses 62, 579, 580, 670'},\n", " {'text': 'abscesses 62, 579, 580, 670'},\n", " {'text': 'abscesses 62, 579, 580, 670'},\n", " {'text': 'abscesses 62, 579, 580, 670'},\n", " {'text': 'appendicitis 55-6, 310, 312-13'},\n", " {'text': 'appendicitis 55-6, 310, 312-13'},\n", " {'text': 'appendicitis 55-6, 310, 312-13'},\n", " {'text': 'appendicitis 55-6, 310, 312-13'},\n", " {'text': 'biliary tract 58-9, 243'},\n", " {'text': 'biliary tract 58-9, 243'},\n", " {'text': ''},\n", " {'text': 'in children 547'},\n", " {'text': ''},\n", " {'text': 'colon 56, 60, 381-2, 395, 470'},\n", " {'text': 'esophageal perforation 164, 166, 167'},\n", " {'text': 'esophageal perforation 164, 166, 167'},\n", " {'text': 'esophageal perforation 164, 166, 167'},\n", " {'text': 'esophageal perforation 164, 166, 167'},\n", " {'text': 'esophageal perforation 164, 166, 167'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'kidney 60, 566-7'},\n", " {'text': 'liver 58, 353, 579, 580'},\n", " {'text': 'liver 58, 353, 579, 580'},\n", " {'text': 'lower GI bleeds 429'},\n", " {'text': 'lower GI bleeds 429'},\n", " {'text': 'lower GI bleeds 429'},\n", " {'text': 'lower GI bleeds 429'},\n", " {'text': 'mesenteric ischemia 40, 332-3, 338-9'},\n", " {'text': 'pancreas 59-60, 224, 231, 232-3'},\n", " {'text': 'pancreas 59-60, 224, 231, 232-3'},\n", " {'text': 'pancreas 59-60, 224, 231, 232-3'},\n", " {'text': 'small bowel 60, 270-2, 275, 289'},\n", " {'text': 'small bowel 60, 270-2, 275, 289'},\n", " {'text': 'small bowel 60, 270-2, 275, 289'},\n", " {'text': 'small bowel 60, 270-2, 275, 289'},\n", " {'text': 'trauma 55, 353, 477, 478-9, 488-9, 566'},\n", " {'text': 'trauma 55, 353, 477, 478-9, 488-9, 566'},\n", " {'text': 'trauma 55, 353, 477, 478-9, 488-9, 566'},\n", " {'text': 'trauma 55, 353, 477, 478-9, 488-9, 566'},\n", " {'text': 'ulcer perforation 211-12'},\n", " {'text': 'ulcer perforation 211-12'},\n", " {'text': 'ulcer perforation 211-12'},\n", " {'text': 'ulcer perforation 211-12'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'CXR (chest X-rays) 37-8, 164, 184'},\n", " {'text': 'cystostomy tubes 564-5'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 866,\n", " 'text': ' ovarian 534-5\\nCytomegalovirus enteritis 591\\n\\ndamage control operations 501-2, 693-4\\ndecompression\\n GI tract 186, 277-8, 389, 399, 630\\n in IAH 513-14\\ndeep vein thrombosis (DVT) 94, 634\\ndiabetic ketoacidosis 30\\ndiagnosis 35-44\\n in children 543-6, 555-6\\n differential 23-31\\n exploratory surgery 105-15, 118, 202\\n laparoscopy 44, 118\\n peritoneal lavage 486-7\\n physical examination 26, 99, 544\\n unnecessary tests 42-3, 51, 631\\n see also blood tests; imaging\\ndiaphragm 179-87\\n hernias 180, 181-7\\n incisions 102\\n trauma 126, 181, 479, 492-3\\ndiathermy 102-3\\ndiet see nutrition\\nDieulafoy’s lesion 191, 207\\ndigital rectal examination 380, 441, 479, 544\\ndiverticular bleeding 402, 427, 432\\ndiverticulitis 60, 125, 401-21\\ndiverticulosis 401\\ndocumentation, pre-operative 88, 91-4\\ndrains/drainage 597-610, 631\\n abscesses 605, 671-4, 676, 709-10\\n perianal 373, 446, 447, 448\\n pericolic 410-11\\n gallbladder 245\\n perforated ulcer repair 216, 601-2\\n in peritonitis 134-5, 603-4, 607, 696\\n subcutaneous 615\\nduodenum',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Extracted Text\\n- Ovarian 534-5\\n- Cytomegalovirus enteritis 591\\n- Damage control operations 501-2, 693-4\\n- Decompression\\n- GI tract 186, 277-8, 389, 399, 630\\n- In IAH 513-14\\n- Deep vein thrombosis (DVT) 94, 634\\n- Diabetic ketoacidosis 30\\n- Diagnosis 35-44\\n- In children 543-6, 555-6\\n- Differential 23-31\\n- Exploratory surgery 105-15, 118, 202\\n- Laparoscopy 44, 118\\n- Peritoneal lavage 486-7\\n- Physical examination 26, 99, 544\\n- Unnecessary tests 42-3, 51, 631\\n- See also blood tests; imaging\\n- Diaphragm 179-87\\n- Hernias 180, 181-7\\n- Incisions 102\\n- Trauma 126, 181, 479, 492-3\\n- Diathermy 102-3\\n- Diet see nutrition\\n- Dieulafoy’s lesion 191, 207\\n- Digital rectal examination 380, 441, 479, 544\\n- Diverticular bleeding 402, 427, 432\\n- Diverticulitis 60, 125, 401-21\\n- Diverticulosis 401\\n- Documentation, pre-operative 88, 91-4\\n- Drains/drainage 597-610, 631\\n- Abscesses 605, 671-4, 676, 709-10\\n- Perianal 373, 446, 447, 448\\n- Pericolic 410-11\\n- Gallbladder 245\\n- Perforated ulcer repair 216, 601-2\\n- In peritonitis 134-5, 603-4, 607, 696\\n- Subcutaneous 615\\n- Duodenum\\n\\n## Notes\\n- No images, graphs, or tables were identified on this page.\\n- All extracted text has been presented without headers, footers, or diagonal text.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Ovarian 534-5\\n- Cytomegalovirus enteritis 591\\n- Damage control operations 501-2, 693-4\\n- Decompression\\n- GI tract 186, 277-8, 389, 399, 630\\n- In IAH 513-14\\n- Deep vein thrombosis (DVT) 94, 634\\n- Diabetic ketoacidosis 30\\n- Diagnosis 35-44\\n- In children 543-6, 555-6\\n- Differential 23-31\\n- Exploratory surgery 105-15, 118, 202\\n- Laparoscopy 44, 118\\n- Peritoneal lavage 486-7\\n- Physical examination 26, 99, 544\\n- Unnecessary tests 42-3, 51, 631\\n- See also blood tests; imaging\\n- Diaphragm 179-87\\n- Hernias 180, 181-7\\n- Incisions 102\\n- Trauma 126, 181, 479, 492-3\\n- Diathermy 102-3\\n- Diet see nutrition\\n- Dieulafoy’s lesion 191, 207\\n- Digital rectal examination 380, 441, 479, 544\\n- Diverticular bleeding 402, 427, 432\\n- Diverticulitis 60, 125, 401-21\\n- Diverticulosis 401\\n- Documentation, pre-operative 88, 91-4\\n- Drains/drainage 597-610, 631\\n- Abscesses 605, 671-4, 676, 709-10\\n- Perianal 373, 446, 447, 448\\n- Pericolic 410-11\\n- Gallbladder 245\\n- Perforated ulcer repair 216, 601-2\\n- In peritonitis 134-5, 603-4, 607, 696\\n- Subcutaneous 615\\n- Duodenum',\n", " 'md': '- Ovarian 534-5\\n- Cytomegalovirus enteritis 591\\n- Damage control operations 501-2, 693-4\\n- Decompression\\n- GI tract 186, 277-8, 389, 399, 630\\n- In IAH 513-14\\n- Deep vein thrombosis (DVT) 94, 634\\n- Diabetic ketoacidosis 30\\n- Diagnosis 35-44\\n- In children 543-6, 555-6\\n- Differential 23-31\\n- Exploratory surgery 105-15, 118, 202\\n- Laparoscopy 44, 118\\n- Peritoneal lavage 486-7\\n- Physical examination 26, 99, 544\\n- Unnecessary tests 42-3, 51, 631\\n- See also blood tests; imaging\\n- Diaphragm 179-87\\n- Hernias 180, 181-7\\n- Incisions 102\\n- Trauma 126, 181, 479, 492-3\\n- Diathermy 102-3\\n- Diet see nutrition\\n- Dieulafoy’s lesion 191, 207\\n- Digital rectal examination 380, 441, 479, 544\\n- Diverticular bleeding 402, 427, 432\\n- Diverticulitis 60, 125, 401-21\\n- Diverticulosis 401\\n- Documentation, pre-operative 88, 91-4\\n- Drains/drainage 597-610, 631\\n- Abscesses 605, 671-4, 676, 709-10\\n- Perianal 373, 446, 447, 448\\n- Pericolic 410-11\\n- Gallbladder 245\\n- Perforated ulcer repair 216, 601-2\\n- In peritonitis 134-5, 603-4, 607, 696\\n- Subcutaneous 615\\n- Duodenum',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 282.26, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Notes',\n", " 'md': '## Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All extracted text has been presented without headers, footers, or diagonal text.\\n```',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All extracted text has been presented without headers, footers, or diagonal text.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Cytomegalovirus'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'in IAH 513-14'},\n", " {'text': 'in IAH 513-14'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'deep vein thrombosis (DVT) 94, 634'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'in children 543-6, 555-6'},\n", " {'text': 'differential 23-31'},\n", " {'text': ''},\n", " {'text': 'exploratory surgery 105-15, 118, 202'},\n", " {'text': 'laparoscopy 44, 118'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'peritoneal lavage 486-7'},\n", " {'text': 'peritoneal lavage 486-7'},\n", " {'text': 'physical examination 26, 99, 544'},\n", " {'text': 'unnecessary tests 42-3, 51, 631'},\n", " {'text': 'unnecessary tests 42-3, 51, 631'},\n", " {'text': 'unnecessary tests 42-3, 51, 631'},\n", " {'text': ' blood tests; imaging'},\n", " {'text': ' blood tests; imaging'},\n", " {'text': ' blood tests; imaging'},\n", " {'text': 'hernias 180, 181-7'},\n", " {'text': 'incisions 102'},\n", " {'text': 'incisions 102'},\n", " {'text': 'trauma 126, 181, 479, 492-3'},\n", " {'text': 'diathermy 102-3'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ' nutrition'},\n", " {'text': 'digital rectal examination 380, 441, 479, 544'},\n", " {'text': 'digital rectal examination 380, 441, 479, 544'},\n", " {'text': 'diverticular bleeding 402, 427, 432'},\n", " {'text': 'diverticular bleeding 402, 427, 432'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'diverticulitis 60, 125, 401-21'},\n", " {'text': 'diverticulitis 60, 125, 401-21'},\n", " {'text': ''},\n", " {'text': 'diverticulosis 401'},\n", " {'text': 'diverticulosis 401'},\n", " {'text': ''},\n", " {'text': 'documentation, pre-operative 88, 91-4'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'abscesses 605, 671-4, 676, 709-10'},\n", " {'text': 'abscesses 605, 671-4, 676, 709-10'},\n", " {'text': 'perianal 373, 446, 447, 448'},\n", " {'text': 'perianal 373, 446, 447, 448'},\n", " {'text': 'perianal 373, 446, 447, 448'},\n", " {'text': 'perianal 373, 446, 447, 448'},\n", " {'text': 'pericolic 410-11'},\n", " {'text': 'pericolic 410-11'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'perforated ulcer repair 216, 601-2'},\n", " {'text': 'in peritonitis 134-5, 603-4, 607, 696'},\n", " {'text': 'in peritonitis 134-5, 603-4, 607, 696'},\n", " {'text': 'subcutaneous 615'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 867,\n", " 'text': ' complications of ERCP 464-7\\n fistulas 216, 237\\n suture drainage 605\\n trauma 496-7\\n ulcers (DU)\\n bleeding 191, 195, 202, 204-5, 206, 424\\n perforated 124-5, 209-20, 574, 601-2, 709\\n see also upper GI bleeding\\n\\nechinococcosis 358, 584-5\\nectopic pregnancy 18-19, 532-3\\nedema 75, 143, 633\\nelectrolytes 67, 272\\nembolization therapy 201, 360-1, 430\\nend colostomy 153, 602-3\\nend ileostomy 154\\nendoscopy\\n colonic 395, 399, 425-8, 435, 468-72\\n complications 459-72\\n ERCP 257, 259-60, 262, 463-7, 583\\n esophageal\\n complications 460-1\\n foreign body removal 175, 176-7\\n perforations 164, 171-2, 175, 460-1\\n gastric volvulus 186\\n lower GI bleeding 425-8, 431, 435\\n upper GI bleeding 195, 196-8, 200, 201, 202-3\\nendovascular repair, aortic 525\\nenhanced recovery after surgery (ERAS) 636\\nenteral nutrition 228, 634, 642-5\\n complications of PEG 461-3\\nEnterococcus 80\\nenterocolitis\\n C. difficile 36, 365, 366, 373-4\\n IBD 154-5, 363-71, 433\\n neutropenic 375-6\\nepigastric hernias 297\\nepigastric vessels 104, 537\\nEPSBO (early postoperative small bowel obstruction) 656-8, 659, 660-2,',\n", " 'md': '```markdown\\n# Complications and Conditions\\n\\n## Text Extraction\\n- Complications of ERCP: 464-7\\n- Fistulas: 216, 237\\n- Suture drainage: 605\\n- Trauma: 496-7\\n- Ulcers (DU):\\n- Bleeding: 191, 195, 202, 204-5, 206, 424\\n- Perforated: 124-5, 209-20, 574, 601-2, 709\\n- See also upper GI bleeding\\n- Echinococcosis: 358, 584-5\\n- Ectopic pregnancy: 18-19, 532-3\\n- Edema: 75, 143, 633\\n- Electrolytes: 67, 272\\n- Embolization therapy: 201, 360-1, 430\\n- End colostomy: 153, 602-3\\n- End ileostomy: 154\\n- Endoscopy:\\n- Colonic: 395, 399, 425-8, 435, 468-72\\n- Complications: 459-72\\n- ERCP: 257, 259-60, 262, 463-7, 583\\n- Esophageal:\\n- Complications: 460-1\\n- Foreign body removal: 175, 176-7\\n- Perforations: 164, 171-2, 175, 460-1\\n- Gastric volvulus: 186\\n- Lower GI bleeding: 425-8, 431, 435\\n- Upper GI bleeding: 195, 196-8, 200, 201, 202-3\\n- Endovascular repair, aortic: 525\\n- Enhanced recovery after surgery (ERAS): 636\\n- Enteral nutrition: 228, 634, 642-5\\n- Complications of PEG: 461-3\\n- Enterococcus: 80\\n- Enterocolitis:\\n- C. difficile: 36, 365, 366, 373-4\\n- IBD: 154-5, 363-71, 433\\n- Neutropenic: 375-6\\n- Epigastric hernias: 297\\n- Epigastric vessels: 104, 537\\n- EPSBO (early postoperative small bowel obstruction): 656-8, 659, 660-2\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Complications and Conditions',\n", " 'md': '# Complications and Conditions',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- Complications of ERCP: 464-7\\n- Fistulas: 216, 237\\n- Suture drainage: 605\\n- Trauma: 496-7\\n- Ulcers (DU):\\n- Bleeding: 191, 195, 202, 204-5, 206, 424\\n- Perforated: 124-5, 209-20, 574, 601-2, 709\\n- See also upper GI bleeding\\n- Echinococcosis: 358, 584-5\\n- Ectopic pregnancy: 18-19, 532-3\\n- Edema: 75, 143, 633\\n- Electrolytes: 67, 272\\n- Embolization therapy: 201, 360-1, 430\\n- End colostomy: 153, 602-3\\n- End ileostomy: 154\\n- Endoscopy:\\n- Colonic: 395, 399, 425-8, 435, 468-72\\n- Complications: 459-72\\n- ERCP: 257, 259-60, 262, 463-7, 583\\n- Esophageal:\\n- Complications: 460-1\\n- Foreign body removal: 175, 176-7\\n- Perforations: 164, 171-2, 175, 460-1\\n- Gastric volvulus: 186\\n- Lower GI bleeding: 425-8, 431, 435\\n- Upper GI bleeding: 195, 196-8, 200, 201, 202-3\\n- Endovascular repair, aortic: 525\\n- Enhanced recovery after surgery (ERAS): 636\\n- Enteral nutrition: 228, 634, 642-5\\n- Complications of PEG: 461-3\\n- Enterococcus: 80\\n- Enterocolitis:\\n- C. difficile: 36, 365, 366, 373-4\\n- IBD: 154-5, 363-71, 433\\n- Neutropenic: 375-6\\n- Epigastric hernias: 297\\n- Epigastric vessels: 104, 537\\n- EPSBO (early postoperative small bowel obstruction): 656-8, 659, 660-2\\n```',\n", " 'md': '- Complications of ERCP: 464-7\\n- Fistulas: 216, 237\\n- Suture drainage: 605\\n- Trauma: 496-7\\n- Ulcers (DU):\\n- Bleeding: 191, 195, 202, 204-5, 206, 424\\n- Perforated: 124-5, 209-20, 574, 601-2, 709\\n- See also upper GI bleeding\\n- Echinococcosis: 358, 584-5\\n- Ectopic pregnancy: 18-19, 532-3\\n- Edema: 75, 143, 633\\n- Electrolytes: 67, 272\\n- Embolization therapy: 201, 360-1, 430\\n- End colostomy: 153, 602-3\\n- End ileostomy: 154\\n- Endoscopy:\\n- Colonic: 395, 399, 425-8, 435, 468-72\\n- Complications: 459-72\\n- ERCP: 257, 259-60, 262, 463-7, 583\\n- Esophageal:\\n- Complications: 460-1\\n- Foreign body removal: 175, 176-7\\n- Perforations: 164, 171-2, 175, 460-1\\n- Gastric volvulus: 186\\n- Lower GI bleeding: 425-8, 431, 435\\n- Upper GI bleeding: 195, 196-8, 200, 201, 202-3\\n- Endovascular repair, aortic: 525\\n- Enhanced recovery after surgery (ERAS): 636\\n- Enteral nutrition: 228, 634, 642-5\\n- Complications of PEG: 461-3\\n- Enterococcus: 80\\n- Enterocolitis:\\n- C. difficile: 36, 365, 366, 373-4\\n- IBD: 154-5, 363-71, 433\\n- Neutropenic: 375-6\\n- Epigastric hernias: 297\\n- Epigastric vessels: 104, 537\\n- EPSBO (early postoperative small bowel obstruction): 656-8, 659, 660-2\\n```',\n", " 'bBox': {'x': 72, 'y': 152, 'w': 225.35, 'h': 14.4}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'suture drainage 605'},\n", " {'text': 'suture drainage 605'},\n", " {'text': ''},\n", " {'text': 'ulcers (DU)'},\n", " {'text': 'perforated 124-5, 209-20, 574, 601-2, 709'},\n", " {'text': 'perforated 124-5, 209-20, 574, 601-2, 709'},\n", " {'text': 'perforated 124-5, 209-20, 574, 601-2, 709'},\n", " {'text': 'perforated 124-5, 209-20, 574, 601-2, 709'},\n", " {'text': 'perforated 124-5, 209-20, 574, 601-2, 709'},\n", " {'text': 'perforated 124-5, 209-20, 574, 601-2, 709'},\n", " {'text': ' upper GI bleeding'},\n", " {'text': ' upper GI bleeding'},\n", " {'text': ' upper GI bleeding'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'ectopic pregnancy 18-19, 532-3'},\n", " {'text': 'ectopic pregnancy 18-19, 532-3'},\n", " {'text': 'edema 75, 143, 633'},\n", " {'text': ''},\n", " {'text': 'electrolytes 67, 272'},\n", " {'text': 'electrolytes 67, 272'},\n", " {'text': 'electrolytes 67, 272'},\n", " {'text': 'embolization therapy 201, 360-1, 430'},\n", " {'text': 'embolization therapy 201, 360-1, 430'},\n", " {'text': 'end colostomy 153, 602-3'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'end ileostomy 154'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'complications 459-72'},\n", " {'text': 'complications 459-72'},\n", " {'text': 'complications 459-72'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'ERCP 257, 259-60, 262, 463-7, 583'},\n", " {'text': 'esophageal'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'foreign body removal 175, 176-7'},\n", " {'text': 'perforations 164, 171-2, 175, 460-1'},\n", " {'text': 'perforations 164, 171-2, 175, 460-1'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'lower GI bleeding 425-8, 431, 435'},\n", " {'text': 'upper GI bleeding 195, 196-8, 200, 201, 202-3'},\n", " {'text': 'upper GI bleeding 195, 196-8, 200, 201, 202-3'},\n", " {'text': 'upper GI bleeding 195, 196-8, 200, 201, 202-3'},\n", " {'text': 'endovascular repair, aortic 525'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'enhanced recovery after surgery (ERAS) 636'},\n", " {'text': ''},\n", " {'text': 'complications of PEG 461-3'},\n", " {'text': 'complications of PEG 461-3'},\n", " {'text': 'complications of PEG 461-3'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'IBD 154-5, 363-71, 433'},\n", " {'text': 'IBD 154-5, 363-71, 433'},\n", " {'text': 'IBD 154-5, 363-71, 433'},\n", " {'text': ''},\n", " {'text': 'neutropenic 375-6'},\n", " {'text': 'neutropenic 375-6'},\n", " {'text': ''},\n", " {'text': 'epigastric hernias 297'},\n", " {'text': 'epigastric vessels 104, 537'},\n", " {'text': 'EPSBO (early postoperative small bowel obstruction) 656-8, 659, 660-2,'},\n", " {'text': 'EPSBO (early postoperative small bowel obstruction) 656-8, 659, 660-2,'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 868,\n", " 'text': '663-4, 709\\nERCP (endoscopic retrograde cholangiopancreatography) 257, 259-60,\\n262, 583\\n complications 463-7\\nEscherichia coli 80, 667\\nesophagus 161-78\\n cancer 174\\n caustic ingestion 163, 174-5\\n complications of EGD 460-1\\n foreign body ingestion 162, 175-6\\n motility disorders 174\\n perforation 161-2\\n abdominal 162-3, 171\\n cervical 162, 163, 164, 168\\n diagnosis 37, 163-4, 175\\n following endoscopy 460-1\\n management 165-74, 175\\n thoracic 37, 162-3, 169-71\\n strictures 173-4\\n variceal bleeding 190, 195, 196, 342-5, 461\\nethics 86, 88\\n treatment of pregnant women 538\\nevidence-based medicine 9-11, 727\\nexamination of the abdomen 26, 99, 544, 628\\nexploratory surgery 105-15, 118, 202\\n abscesses 674-5\\n\\nfalciform ligament 104\\nfallopian tubes, salpingectomy 18-19, 533\\nfamily, talking to 85-6, 87, 88-9\\nFAST scans 38, 479-80, 487-8\\nfeces\\n imaging 49\\n transplants 374\\n vomiting 267-8\\nfemoral hernias 29, 293, 295-6\\nfetus 538, 540\\nfever 632\\nfinancial considerations 315, 324, 729-30',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Extracted Text\\n- ERCP (endoscopic retrograde cholangiopancreatography) 257, 259-60, 262, 583\\n- complications 463-7\\n- Escherichia coli 80, 667\\n- esophagus 161-78\\n- cancer 174\\n- caustic ingestion 163, 174-5\\n- complications of EGD 460-1\\n- foreign body ingestion 162, 175-6\\n- motility disorders 174\\n- perforation 161-2\\n- abdominal 162-3, 171\\n- cervical 162, 163, 164, 168\\n- diagnosis 37, 163-4, 175\\n- following endoscopy 460-1\\n- management 165-74, 175\\n- thoracic 37, 162-3, 169-71\\n- strictures 173-4\\n- variceal bleeding 190, 195, 196, 342-5, 461\\n- ethics 86, 88\\n- treatment of pregnant women 538\\n- evidence-based medicine 9-11, 727\\n- examination of the abdomen 26, 99, 544, 628\\n- exploratory surgery 105-15, 118, 202\\n- abscesses 674-5\\n- falciform ligament 104\\n- fallopian tubes, salpingectomy 18-19, 533\\n- family, talking to 85-6, 87, 88-9\\n- FAST scans 38, 479-80, 487-8\\n- feces\\n- imaging 49\\n- transplants 374\\n- vomiting 267-8\\n- femoral hernias 29, 293, 295-6\\n- fetus 538, 540\\n- fever 632\\n- financial considerations 315, 324, 729-30\\n\\n## Images and Graphs\\n- No images or graphs were identified on this page.\\n\\n## Tables\\n- No tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- ERCP (endoscopic retrograde cholangiopancreatography) 257, 259-60, 262, 583\\n- complications 463-7\\n- Escherichia coli 80, 667\\n- esophagus 161-78\\n- cancer 174\\n- caustic ingestion 163, 174-5\\n- complications of EGD 460-1\\n- foreign body ingestion 162, 175-6\\n- motility disorders 174\\n- perforation 161-2\\n- abdominal 162-3, 171\\n- cervical 162, 163, 164, 168\\n- diagnosis 37, 163-4, 175\\n- following endoscopy 460-1\\n- management 165-74, 175\\n- thoracic 37, 162-3, 169-71\\n- strictures 173-4\\n- variceal bleeding 190, 195, 196, 342-5, 461\\n- ethics 86, 88\\n- treatment of pregnant women 538\\n- evidence-based medicine 9-11, 727\\n- examination of the abdomen 26, 99, 544, 628\\n- exploratory surgery 105-15, 118, 202\\n- abscesses 674-5\\n- falciform ligament 104\\n- fallopian tubes, salpingectomy 18-19, 533\\n- family, talking to 85-6, 87, 88-9\\n- FAST scans 38, 479-80, 487-8\\n- feces\\n- imaging 49\\n- transplants 374\\n- vomiting 267-8\\n- femoral hernias 29, 293, 295-6\\n- fetus 538, 540\\n- fever 632\\n- financial considerations 315, 324, 729-30',\n", " 'md': '- ERCP (endoscopic retrograde cholangiopancreatography) 257, 259-60, 262, 583\\n- complications 463-7\\n- Escherichia coli 80, 667\\n- esophagus 161-78\\n- cancer 174\\n- caustic ingestion 163, 174-5\\n- complications of EGD 460-1\\n- foreign body ingestion 162, 175-6\\n- motility disorders 174\\n- perforation 161-2\\n- abdominal 162-3, 171\\n- cervical 162, 163, 164, 168\\n- diagnosis 37, 163-4, 175\\n- following endoscopy 460-1\\n- management 165-74, 175\\n- thoracic 37, 162-3, 169-71\\n- strictures 173-4\\n- variceal bleeding 190, 195, 196, 342-5, 461\\n- ethics 86, 88\\n- treatment of pregnant women 538\\n- evidence-based medicine 9-11, 727\\n- examination of the abdomen 26, 99, 544, 628\\n- exploratory surgery 105-15, 118, 202\\n- abscesses 674-5\\n- falciform ligament 104\\n- fallopian tubes, salpingectomy 18-19, 533\\n- family, talking to 85-6, 87, 88-9\\n- FAST scans 38, 479-80, 487-8\\n- feces\\n- imaging 49\\n- transplants 374\\n- vomiting 267-8\\n- femoral hernias 29, 293, 295-6\\n- fetus 538, 540\\n- fever 632\\n- financial considerations 315, 324, 729-30',\n", " 'bBox': {'x': 72, 'y': 119, 'w': 289.47, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images and Graphs',\n", " 'md': '## Images and Graphs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No tables were identified on this page.\\n```',\n", " 'md': '- No tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': '663-4, 709 ERCP (endoscopic retrograde cholangiopancreatography) 257, 259-60,'},\n", " {'text': 'ERCP (endoscopic retrograde cholangiopancreatography) 257, 259-60,'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': '262, 583'},\n", " {'text': ''},\n", " {'text': ' 80, 667'},\n", " {'text': 'esophagus 161-78'},\n", " {'text': ''},\n", " {'text': 'cancer 174'},\n", " {'text': 'caustic ingestion 163, 174-5'},\n", " {'text': 'complications of EGD 460-1'},\n", " {'text': 'complications of EGD 460-1'},\n", " {'text': 'foreign body ingestion 162, 175-6'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'abdominal 162-3, 171'},\n", " {'text': 'cervical 162, 163, 164, 168'},\n", " {'text': 'cervical 162, 163, 164, 168'},\n", " {'text': 'diagnosis 37, 163-4, 175'},\n", " {'text': 'diagnosis 37, 163-4, 175'},\n", " {'text': 'diagnosis 37, 163-4, 175'},\n", " {'text': 'diagnosis 37, 163-4, 175'},\n", " {'text': 'following endoscopy 460-1'},\n", " {'text': 'following endoscopy 460-1'},\n", " {'text': 'following endoscopy 460-1'},\n", " {'text': 'management 165-74, 175'},\n", " {'text': 'thoracic 37, 162-3, 169-71'},\n", " {'text': 'thoracic 37, 162-3, 169-71'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'variceal bleeding 190, 195, 196, 342-5, 461'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'treatment of pregnant women 538'},\n", " {'text': ''},\n", " {'text': 'examination of the abdomen 26, 99, 544, 628'},\n", " {'text': 'examination of the abdomen 26, 99, 544, 628'},\n", " {'text': 'exploratory surgery 105-15, 118, 202'},\n", " {'text': 'exploratory surgery 105-15, 118, 202'},\n", " {'text': 'exploratory surgery 105-15, 118, 202'},\n", " {'text': ''},\n", " {'text': 'abscesses 674-5'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'fallopian tubes, salpingectomy 18-19, 533'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'FAST scans 38, 479-80, 487-8'},\n", " {'text': 'FAST scans 38, 479-80, 487-8'},\n", " {'text': 'FAST scans 38, 479-80, 487-8'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'transplants 374'},\n", " {'text': 'vomiting 267-8'},\n", " {'text': 'femoral hernias 29, 293, 295-6'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'fever 632'},\n", " {'text': ''},\n", " {'text': 'financial considerations 315, 324, 729-30'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 869,\n", " 'text': 'fistulas\\n abdominal wall defects 683-5\\n anal 373, 446\\n anastomotic leaks 679-87\\n diverticulitis 403, 418\\n duodenal ulcers 216\\n pancreatic 237\\nFitz-Hugh-Curtis syndrome 536\\nflank, stab wounds 479\\nfluid management\\n IAH 504, 512\\n liver patients 348\\n massive hemorrhage 107\\n pancreatitis 227\\n postoperative 633-4\\n pre-operative 69-76, 194, 272, 475\\n SBO 272\\n trauma patients 475\\n upper GI bleeding 194\\nforeign bodies\\n esophageal 162, 175-6\\n rectal 454-5\\nFournier’s gangrene 456-7\\nfree air (pneumoperitoneum) 37, 38, 46, 53-5, 58, 211, 469-70\\nfree fluid 55, 62\\n see also ascites\\nfulminant colitis 366, 367, 368\\n\\ngallbladder 241-2\\n cholecystitis see cholecystitis\\n imaging 59, 243-4, 253-4\\ngallstones\\n in the bile duct 255-60\\n causing pancreatitis 223, 224-5, 260-3\\n gallstone ileus 29, 283-4\\ngangrene see necrosis\\ngas\\n on CT 53-5, 57-8\\n escapes on opening peritoneum 110',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text Extracted\\n- fistulas\\n- abdominal wall defects 683-5\\n- anal 373, 446\\n- anastomotic leaks 679-87\\n- diverticulitis 403, 418\\n- duodenal ulcers 216\\n- pancreatic 237\\n- Fitz-Hugh-Curtis syndrome 536\\n- flank, stab wounds 479\\n- fluid management\\n- IAH 504, 512\\n- liver patients 348\\n- massive hemorrhage 107\\n- pancreatitis 227\\n- postoperative 633-4\\n- pre-operative 69-76, 194, 272, 475\\n- SBO 272\\n- trauma patients 475\\n- upper GI bleeding 194\\n- foreign bodies\\n- esophageal 162, 175-6\\n- rectal 454-5\\n- Fournier’s gangrene 456-7\\n- free air (pneumoperitoneum) 37, 38, 46, 53-5, 58, 211, 469-70\\n- free fluid 55, 62\\n- see also ascites\\n- fulminant colitis 366, 367, 368\\n- gallbladder 241-2\\n- cholecystitis see cholecystitis\\n- imaging 59, 243-4, 253-4\\n- gallstones\\n- in the bile duct 255-60\\n- causing pancreatitis 223, 224-5, 260-3\\n- gallstone ileus 29, 283-4\\n- gangrene see necrosis\\n- gas\\n- on CT 53-5, 57-8\\n- escapes on opening peritoneum 110\\n\\n## Hyperlinks\\n- None identified.\\n\\n## Formulas\\n- None identified.\\n\\n## Images and Graphs\\n- None identified.\\n\\n## Tables\\n- None identified.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extracted',\n", " 'md': '## Text Extracted',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- fistulas\\n- abdominal wall defects 683-5\\n- anal 373, 446\\n- anastomotic leaks 679-87\\n- diverticulitis 403, 418\\n- duodenal ulcers 216\\n- pancreatic 237\\n- Fitz-Hugh-Curtis syndrome 536\\n- flank, stab wounds 479\\n- fluid management\\n- IAH 504, 512\\n- liver patients 348\\n- massive hemorrhage 107\\n- pancreatitis 227\\n- postoperative 633-4\\n- pre-operative 69-76, 194, 272, 475\\n- SBO 272\\n- trauma patients 475\\n- upper GI bleeding 194\\n- foreign bodies\\n- esophageal 162, 175-6\\n- rectal 454-5\\n- Fournier’s gangrene 456-7\\n- free air (pneumoperitoneum) 37, 38, 46, 53-5, 58, 211, 469-70\\n- free fluid 55, 62\\n- see also ascites\\n- fulminant colitis 366, 367, 368\\n- gallbladder 241-2\\n- cholecystitis see cholecystitis\\n- imaging 59, 243-4, 253-4\\n- gallstones\\n- in the bile duct 255-60\\n- causing pancreatitis 223, 224-5, 260-3\\n- gallstone ileus 29, 283-4\\n- gangrene see necrosis\\n- gas\\n- on CT 53-5, 57-8\\n- escapes on opening peritoneum 110',\n", " 'md': '- fistulas\\n- abdominal wall defects 683-5\\n- anal 373, 446\\n- anastomotic leaks 679-87\\n- diverticulitis 403, 418\\n- duodenal ulcers 216\\n- pancreatic 237\\n- Fitz-Hugh-Curtis syndrome 536\\n- flank, stab wounds 479\\n- fluid management\\n- IAH 504, 512\\n- liver patients 348\\n- massive hemorrhage 107\\n- pancreatitis 227\\n- postoperative 633-4\\n- pre-operative 69-76, 194, 272, 475\\n- SBO 272\\n- trauma patients 475\\n- upper GI bleeding 194\\n- foreign bodies\\n- esophageal 162, 175-6\\n- rectal 454-5\\n- Fournier’s gangrene 456-7\\n- free air (pneumoperitoneum) 37, 38, 46, 53-5, 58, 211, 469-70\\n- free fluid 55, 62\\n- see also ascites\\n- fulminant colitis 366, 367, 368\\n- gallbladder 241-2\\n- cholecystitis see cholecystitis\\n- imaging 59, 243-4, 253-4\\n- gallstones\\n- in the bile duct 255-60\\n- causing pancreatitis 223, 224-5, 260-3\\n- gallstone ileus 29, 283-4\\n- gangrene see necrosis\\n- gas\\n- on CT 53-5, 57-8\\n- escapes on opening peritoneum 110',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 394.71, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Hyperlinks',\n", " 'md': '## Hyperlinks',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.',\n", " 'md': '- None identified.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formulas',\n", " 'md': '## Formulas',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.',\n", " 'md': '- None identified.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images and Graphs',\n", " 'md': '## Images and Graphs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.',\n", " 'md': '- None identified.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.\\n```',\n", " 'md': '- None identified.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'anastomotic leaks 679-87'},\n", " {'text': 'anastomotic leaks 679-87'},\n", " {'text': 'diverticulitis 403, 418'},\n", " {'text': 'duodenal ulcers 216'},\n", " {'text': 'duodenal ulcers 216'},\n", " {'text': ''},\n", " {'text': 'Fitz-Hugh-Curtis syndrome 536'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'liver patients 348'},\n", " {'text': 'liver patients 348'},\n", " {'text': 'massive hemorrhage 107'},\n", " {'text': ''},\n", " {'text': 'postoperative 633-4'},\n", " {'text': 'pre-operative 69-76, 194, 272, 475'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'trauma patients 475'},\n", " {'text': 'upper GI bleeding 194'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'Fournier’s gangrene 456-7'},\n", " {'text': 'free air (pneumoperitoneum) 37, 38, 46, 53-5, 58, 211, 469-70'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'see also'},\n", " {'text': 'see also'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'cholecystitis '},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'causing pancreatitis 223, 224-5, 260-3'},\n", " {'text': 'gallstone ileus 29, 283-4'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'escapes on opening peritoneum 110'},\n", " {'text': 'escapes on opening peritoneum 110'},\n", " {'text': ''}]},\n", " {'page': 870,\n", " 'text': ' on X-ray 37, 38, 46-8, 211, 469-70\\ngastrectomy\\n for bleeding ulcers 203, 206\\n for perforated ulcers 218\\n postoperative SBO/ileus 285-6, 662\\ngastric bypass 207\\ngastric dilatation, acute 662-3\\ngastric mucosal lesions, acute 191, 208\\ngastric trauma 496\\ngastric ulcers (GU)\\n bleeding 191, 206\\n see also upper GI bleeding\\n perforated 18, 124-5, 209, 218\\ngastric volvulus 181-7\\ngastroduodenal artery ligation 204\\ngastroduodenostomy 205, 218\\ngastroenteritis 546\\ngastroenterostomy 204\\nGastrografin® 41, 57, 274-5, 381-2, 660\\ngastrointestinal tract\\n lower GI bleeding 350-1, 402, 423-36, 448-50, 468\\n upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595\\n see also colon; esophagus; rectum; small bowel; stomach\\ngastrojejunostomy 145\\ngastroparesis 642, 662\\ngastrostomy, complications of PEG 461-3\\nglucose 639-40, 645, 646\\ngood practice see best practice\\ngroin\\n hernias 291-3\\n femoral 29, 293, 295-6\\n inguinal 29, 293-5, 552\\n see also testis\\ngunshot wounds 356, 453, 478, 483-4\\ngynecological emergencies 28, 529-32\\n abdominal emergencies during pregnancy 315, 536-40\\n ectopic pregnancy 18-19, 532-3\\n imaging 57, 60, 531, 534\\n ovarian cysts 534-5',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Extracted Text\\n- on X-ray 37, 38, 46-8, 211, 469-70\\n- gastrectomy for bleeding ulcers 203, 206\\n- gastrectomy for perforated ulcers 218\\n- postoperative SBO/ileus 285-6, 662\\n- gastric bypass 207\\n- gastric dilatation, acute 662-3\\n- gastric mucosal lesions, acute 191, 208\\n- gastric trauma 496\\n- gastric ulcers (GU)\\n- bleeding 191, 206\\n- see also upper GI bleeding\\n- perforated 18, 124-5, 209, 218\\n- gastric volvulus 181-7\\n- gastroduodenal artery ligation 204\\n- gastroduodenostomy 205, 218\\n- gastroenteritis 546\\n- gastroenterostomy 204\\n- Gastrografin® 41, 57, 274-5, 381-2, 660\\n- gastrointestinal tract\\n- lower GI bleeding 350-1, 402, 423-36, 448-50, 468\\n- upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595\\n- see also colon; esophagus; rectum; small bowel; stomach\\n- gastrojejunostomy 145\\n- gastroparesis 642, 662\\n- gastrostomy, complications of PEG 461-3\\n- glucose 639-40, 645, 646\\n- good practice see best practice\\n- groin\\n- hernias 291-3\\n- femoral 29, 293, 295-6\\n- inguinal 29, 293-5, 552\\n- see also testis\\n- gunshot wounds 356, 453, 478, 483-4\\n- gynecological emergencies 28, 529-32\\n- abdominal emergencies during pregnancy 315, 536-40\\n- ectopic pregnancy 18-19, 532-3\\n- imaging 57, 60, 531, 534\\n- ovarian cysts 534-5\\n\\n## Hyperlinks\\n- None identified.\\n\\n## Formulas\\n- None identified.\\n\\n## Images and Graphs\\n- None identified.\\n\\n## Tables\\n- None identified.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- on X-ray 37, 38, 46-8, 211, 469-70\\n- gastrectomy for bleeding ulcers 203, 206\\n- gastrectomy for perforated ulcers 218\\n- postoperative SBO/ileus 285-6, 662\\n- gastric bypass 207\\n- gastric dilatation, acute 662-3\\n- gastric mucosal lesions, acute 191, 208\\n- gastric trauma 496\\n- gastric ulcers (GU)\\n- bleeding 191, 206\\n- see also upper GI bleeding\\n- perforated 18, 124-5, 209, 218\\n- gastric volvulus 181-7\\n- gastroduodenal artery ligation 204\\n- gastroduodenostomy 205, 218\\n- gastroenteritis 546\\n- gastroenterostomy 204\\n- Gastrografin® 41, 57, 274-5, 381-2, 660\\n- gastrointestinal tract\\n- lower GI bleeding 350-1, 402, 423-36, 448-50, 468\\n- upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595\\n- see also colon; esophagus; rectum; small bowel; stomach\\n- gastrojejunostomy 145\\n- gastroparesis 642, 662\\n- gastrostomy, complications of PEG 461-3\\n- glucose 639-40, 645, 646\\n- good practice see best practice\\n- groin\\n- hernias 291-3\\n- femoral 29, 293, 295-6\\n- inguinal 29, 293-5, 552\\n- see also testis\\n- gunshot wounds 356, 453, 478, 483-4\\n- gynecological emergencies 28, 529-32\\n- abdominal emergencies during pregnancy 315, 536-40\\n- ectopic pregnancy 18-19, 532-3\\n- imaging 57, 60, 531, 534\\n- ovarian cysts 534-5',\n", " 'md': '- on X-ray 37, 38, 46-8, 211, 469-70\\n- gastrectomy for bleeding ulcers 203, 206\\n- gastrectomy for perforated ulcers 218\\n- postoperative SBO/ileus 285-6, 662\\n- gastric bypass 207\\n- gastric dilatation, acute 662-3\\n- gastric mucosal lesions, acute 191, 208\\n- gastric trauma 496\\n- gastric ulcers (GU)\\n- bleeding 191, 206\\n- see also upper GI bleeding\\n- perforated 18, 124-5, 209, 218\\n- gastric volvulus 181-7\\n- gastroduodenal artery ligation 204\\n- gastroduodenostomy 205, 218\\n- gastroenteritis 546\\n- gastroenterostomy 204\\n- Gastrografin® 41, 57, 274-5, 381-2, 660\\n- gastrointestinal tract\\n- lower GI bleeding 350-1, 402, 423-36, 448-50, 468\\n- upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595\\n- see also colon; esophagus; rectum; small bowel; stomach\\n- gastrojejunostomy 145\\n- gastroparesis 642, 662\\n- gastrostomy, complications of PEG 461-3\\n- glucose 639-40, 645, 646\\n- good practice see best practice\\n- groin\\n- hernias 291-3\\n- femoral 29, 293, 295-6\\n- inguinal 29, 293-5, 552\\n- see also testis\\n- gunshot wounds 356, 453, 478, 483-4\\n- gynecological emergencies 28, 529-32\\n- abdominal emergencies during pregnancy 315, 536-40\\n- ectopic pregnancy 18-19, 532-3\\n- imaging 57, 60, 531, 534\\n- ovarian cysts 534-5',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 367.25, 'h': 19.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Hyperlinks',\n", " 'md': '## Hyperlinks',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.',\n", " 'md': '- None identified.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formulas',\n", " 'md': '## Formulas',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.',\n", " 'md': '- None identified.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images and Graphs',\n", " 'md': '## Images and Graphs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.',\n", " 'md': '- None identified.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.\\n```',\n", " 'md': '- None identified.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'for perforated ulcers 218'},\n", " {'text': 'for perforated ulcers 218'},\n", " {'text': 'postoperative SBO/ileus 285-6, 662'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'gastric dilatation, acute 662-3'},\n", " {'text': 'gastric mucosal lesions, acute 191, 208'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'gastric ulcers (GU)'},\n", " {'text': 'see also'},\n", " {'text': 'see also'},\n", " {'text': 'gastric volvulus 181-7'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'gastroduodenal artery ligation 204'},\n", " {'text': 'gastroduodenostomy 205, 218'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'gastroenterostomy 204'},\n", " {'text': ''},\n", " {'text': 'gastrointestinal tract'},\n", " {'text': 'gastrointestinal tract'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595'},\n", " {'text': 'upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595'},\n", " {'text': 'upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595'},\n", " {'text': 'upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595'},\n", " {'text': 'upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595'},\n", " {'text': ' colon; esophagus; rectum; small bowel; stomach'},\n", " {'text': ' colon; esophagus; rectum; small bowel; stomach'},\n", " {'text': ' colon; esophagus; rectum; small bowel; stomach'},\n", " {'text': ' colon; esophagus; rectum; small bowel; stomach'},\n", " {'text': ' colon; esophagus; rectum; small bowel; stomach'},\n", " {'text': ' colon; esophagus; rectum; small bowel; stomach'},\n", " {'text': 'gastroparesis 642, 662'},\n", " {'text': 'gastrostomy, complications of PEG 461-3'},\n", " {'text': 'gastrostomy, complications of PEG 461-3'},\n", " {'text': ''},\n", " {'text': 'good practice '},\n", " {'text': 'see'},\n", " {'text': ' best practice'},\n", " {'text': 'femoral 29, 293, 295-6'},\n", " {'text': 'inguinal 29, 293-5, 552'},\n", " {'text': 'inguinal 29, 293-5, 552'},\n", " {'text': 'inguinal 29, 293-5, 552'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'gynecological emergencies 28, 529-32'},\n", " {'text': 'gynecological emergencies 28, 529-32'},\n", " {'text': 'gynecological emergencies 28, 529-32'},\n", " {'text': 'gynecological emergencies 28, 529-32'},\n", " {'text': 'abdominal emergencies during pregnancy 315, 536-40'},\n", " {'text': 'abdominal emergencies during pregnancy 315, 536-40'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'imaging 57, 60, 531, 534'},\n", " {'text': ''},\n", " {'text': 'ovarian cysts 534-5'},\n", " {'text': 'ovarian cysts 534-5'},\n", " {'text': 'ovarian cysts 534-5'},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 871,\n", " 'text': ' ovarian torsion 554\\n pelvic abscesses 410\\n PID 535-6\\n postpartum 540-1\\n vaginal tears 536\\n\\nHamman sign 163\\nhandwashing 716\\nHardman criteria (AAA rupture) 519\\nHartmann’s procedure 153, 602-3\\nHeaney maneuver 357\\nHELLP syndrome 539\\nhematemesis 191\\nhematochezia 191\\nhematocrit 36, 67\\nhematoma\\n on CT 55\\n rectus abdominis 537-8\\n traumatic 499-501\\nhematuria 566\\nhemobilia 359-60\\nhemorrhage\\n AAA rupture 517-25\\n abdominal apoplexy 26, 107-9, 525-6\\n gynecological causes 532-3\\n liver trauma 354-7, 493-4\\n liver tumors 360-1\\n lower GI tract 350-1, 402, 423-36, 448-50, 468\\n in pancreatitis 229-30, 237\\n resuscitation 66, 72-3, 75-6, 194, 495\\n upper GI tract 189-208, 342-5, 424, 461, 464-5, 595\\nhemorrhoids 424, 438, 442-4, 448-9\\nhemostasis\\n at incision 102-3\\n massive hemoperitoneum 107-9, 520-2\\n upper GI bleeding 197-8, 343-5\\nheparin 524, 634\\nhepatic artery trauma 355, 356\\nhepatic conditions see liver',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Extracted Text\\n- ovarian torsion 554\\n- pelvic abscesses 410\\n- PID 535-6\\n- postpartum 540-1\\n- vaginal tears 536\\n- Hamman sign 163\\n- handwashing 716\\n- Hardman criteria (AAA rupture) 519\\n- Hartmann’s procedure 153, 602-3\\n- Heaney maneuver 357\\n- HELLP syndrome 539\\n- hematemesis 191\\n- hematochezia 191\\n- hematocrit 36, 67\\n- hematoma\\n- on CT 55\\n- rectus abdominis 537-8\\n- traumatic 499-501\\n- hematuria 566\\n- hemobilia 359-60\\n- hemorrhage\\n- AAA rupture 517-25\\n- abdominal apoplexy 26, 107-9, 525-6\\n- gynecological causes 532-3\\n- liver trauma 354-7, 493-4\\n- liver tumors 360-1\\n- lower GI tract 350-1, 402, 423-36, 448-50, 468\\n- in pancreatitis 229-30, 237\\n- resuscitation 66, 72-3, 75-6, 194, 495\\n- upper GI tract 189-208, 342-5, 424, 461, 464-5, 595\\n- hemorrhoids 424, 438, 442-4, 448-9\\n- hemostasis\\n- at incision 102-3\\n- massive hemoperitoneum 107-9, 520-2\\n- upper GI bleeding 197-8, 343-5\\n- heparin 524, 634\\n- hepatic artery trauma 355, 356\\n- hepatic conditions see liver\\n\\n## Images and Graphs\\n- No images or graphs were identified on this page.\\n\\n## Tables\\n- No tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- ovarian torsion 554\\n- pelvic abscesses 410\\n- PID 535-6\\n- postpartum 540-1\\n- vaginal tears 536\\n- Hamman sign 163\\n- handwashing 716\\n- Hardman criteria (AAA rupture) 519\\n- Hartmann’s procedure 153, 602-3\\n- Heaney maneuver 357\\n- HELLP syndrome 539\\n- hematemesis 191\\n- hematochezia 191\\n- hematocrit 36, 67\\n- hematoma\\n- on CT 55\\n- rectus abdominis 537-8\\n- traumatic 499-501\\n- hematuria 566\\n- hemobilia 359-60\\n- hemorrhage\\n- AAA rupture 517-25\\n- abdominal apoplexy 26, 107-9, 525-6\\n- gynecological causes 532-3\\n- liver trauma 354-7, 493-4\\n- liver tumors 360-1\\n- lower GI tract 350-1, 402, 423-36, 448-50, 468\\n- in pancreatitis 229-30, 237\\n- resuscitation 66, 72-3, 75-6, 194, 495\\n- upper GI tract 189-208, 342-5, 424, 461, 464-5, 595\\n- hemorrhoids 424, 438, 442-4, 448-9\\n- hemostasis\\n- at incision 102-3\\n- massive hemoperitoneum 107-9, 520-2\\n- upper GI bleeding 197-8, 343-5\\n- heparin 524, 634\\n- hepatic artery trauma 355, 356\\n- hepatic conditions see liver',\n", " 'md': '- ovarian torsion 554\\n- pelvic abscesses 410\\n- PID 535-6\\n- postpartum 540-1\\n- vaginal tears 536\\n- Hamman sign 163\\n- handwashing 716\\n- Hardman criteria (AAA rupture) 519\\n- Hartmann’s procedure 153, 602-3\\n- Heaney maneuver 357\\n- HELLP syndrome 539\\n- hematemesis 191\\n- hematochezia 191\\n- hematocrit 36, 67\\n- hematoma\\n- on CT 55\\n- rectus abdominis 537-8\\n- traumatic 499-501\\n- hematuria 566\\n- hemobilia 359-60\\n- hemorrhage\\n- AAA rupture 517-25\\n- abdominal apoplexy 26, 107-9, 525-6\\n- gynecological causes 532-3\\n- liver trauma 354-7, 493-4\\n- liver tumors 360-1\\n- lower GI tract 350-1, 402, 423-36, 448-50, 468\\n- in pancreatitis 229-30, 237\\n- resuscitation 66, 72-3, 75-6, 194, 495\\n- upper GI tract 189-208, 342-5, 424, 461, 464-5, 595\\n- hemorrhoids 424, 438, 442-4, 448-9\\n- hemostasis\\n- at incision 102-3\\n- massive hemoperitoneum 107-9, 520-2\\n- upper GI bleeding 197-8, 343-5\\n- heparin 524, 634\\n- hepatic artery trauma 355, 356\\n- hepatic conditions see liver',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 330.23, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images and Graphs',\n", " 'md': '## Images and Graphs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No tables were identified on this page.\\n```',\n", " 'md': '- No tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'pelvic abscesses 410'},\n", " {'text': ''},\n", " {'text': 'postpartum 540-1'},\n", " {'text': 'vaginal tears 536'},\n", " {'text': ''},\n", " {'text': 'handwashing 716'},\n", " {'text': 'Hardman criteria (AAA rupture) 519'},\n", " {'text': 'Hartmann’s procedure 153, 602-3'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'HELLP syndrome 539'},\n", " {'text': ''},\n", " {'text': 'hematochezia 191'},\n", " {'text': 'hematocrit 36, 67'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'rectus abdominis 537-8'},\n", " {'text': 'traumatic 499-501'},\n", " {'text': ''},\n", " {'text': 'hemobilia 359-60'},\n", " {'text': 'hemorrhage'},\n", " {'text': 'abdominal apoplexy 26, 107-9, 525-6'},\n", " {'text': 'gynecological causes 532-3'},\n", " {'text': 'gynecological causes 532-3'},\n", " {'text': ''},\n", " {'text': 'liver trauma 354-7, 493-4'},\n", " {'text': 'liver tumors 360-1'},\n", " {'text': ''},\n", " {'text': 'lower GI tract 350-1, 402, 423-36, 448-50, 468'},\n", " {'text': 'in pancreatitis 229-30, 237'},\n", " {'text': 'in pancreatitis 229-30, 237'},\n", " {'text': 'in pancreatitis 229-30, 237'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'resuscitation 66, 72-3, 75-6, 194, 495'},\n", " {'text': 'resuscitation 66, 72-3, 75-6, 194, 495'},\n", " {'text': 'upper GI tract 189-208, 342-5, 424, 461, 464-5, 595'},\n", " {'text': 'upper GI tract 189-208, 342-5, 424, 461, 464-5, 595'},\n", " {'text': 'upper GI tract 189-208, 342-5, 424, 461, 464-5, 595'},\n", " {'text': 'upper GI tract 189-208, 342-5, 424, 461, 464-5, 595'},\n", " {'text': 'upper GI tract 189-208, 342-5, 424, 461, 464-5, 595'},\n", " {'text': 'hemorrhoids 424, 438, 442-4, 448-9'},\n", " {'text': 'hemorrhoids 424, 438, 442-4, 448-9'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'massive hemoperitoneum 107-9, 520-2'},\n", " {'text': 'upper GI bleeding 197-8, 343-5'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'hepatic artery trauma 355, 356'},\n", " {'text': 'hepatic artery trauma 355, 356'},\n", " {'text': 'see'},\n", " {'text': ' liver'}]},\n", " {'page': 872,\n", " 'text': 'hernias 14, 291-3\\n diaphragmatic 180, 181-7\\n femoral 29, 293, 295-6\\n incisional 296-8, 618\\n inguinal 29, 293-5, 552\\n laparoscopy 126, 299\\n SBO 29, 269, 292-3, 296, 657, 660-1\\n umbilical 297, 348-9\\nhiatus hernias 180\\nHIDA scans 243-4\\nhierarchy of evidence 9-11\\nHinchey classification (diverticulitis) 406, 408-13\\nhistory of abdominal surgery 13-20, 717-18\\nHIV-related emergencies 591\\nhorseshoe abscesses 447\\nHounsfield Units (HU) 54\\nhydatid cysts 358, 584-5\\nhyperbaric oxygen 457\\nhypothermia, intra-operative 94\\nhypovolemia\\n intra-operative 107\\n pre-operative optimization 65-76, 194, 227, 272, 475\\n in pregnancy 540\\n\\nIAH (intra-abdominal hypertension) see abdominal compartment\\nsyndrome\\nIBD see inflammatory bowel disease\\nileocecal valve 381\\nileocolostomy (double-barrel) 155\\nileosigmoid knotting 287, 594\\nileostomy 152, 154, 158-9, 394\\nileus 271, 647, 655-6, 657-60, 663-4, 668\\niliac arteries\\n in AAA repair 522, 523\\n trauma 498\\niliac veins 499\\nimaging 45-64, 93\\n abdominal X-rays 38, 46-50\\n abscesses 62, 579, 580, 669-70',\n", " 'md': '```markdown\\n# Current Page Content\\n\\n## Extracted Text\\n- hernias 14, 291-3\\n- diaphragmatic 180, 181-7\\n- femoral 29, 293, 295-6\\n- incisional 296-8, 618\\n- inguinal 29, 293-5, 552\\n- laparoscopy 126, 299\\n- SBO 29, 269, 292-3, 296, 657, 660-1\\n- umbilical 297, 348-9\\n- hiatus hernias 180\\n- HIDA scans 243-4\\n- hierarchy of evidence 9-11\\n- Hinchey classification (diverticulitis) 406, 408-13\\n- history of abdominal surgery 13-20, 717-18\\n- HIV-related emergencies 591\\n- horseshoe abscesses 447\\n- Hounsfield Units (HU) 54\\n- hydatid cysts 358, 584-5\\n- hyperbaric oxygen 457\\n- hypothermia, intra-operative 94\\n- hypovolemia\\n- intra-operative 107\\n- pre-operative optimization 65-76, 194, 227, 272, 475\\n- in pregnancy 540\\n- IAH (intra-abdominal hypertension) see abdominal compartment syndrome\\n- IBD see inflammatory bowel disease\\n- ileocecal valve 381\\n- ileocolostomy (double-barrel) 155\\n- ileosigmoid knotting 287, 594\\n- ileostomy 152, 154, 158-9, 394\\n- ileus 271, 647, 655-6, 657-60, 663-4, 668\\n- iliac arteries\\n- in AAA repair 522, 523\\n- trauma 498\\n- iliac veins 499\\n- imaging 45-64, 93\\n- abdominal X-rays 38, 46-50\\n- abscesses 62, 579, 580, 669-70\\n\\n## Notes\\n- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Current Page Content',\n", " 'md': '# Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- hernias 14, 291-3\\n- diaphragmatic 180, 181-7\\n- femoral 29, 293, 295-6\\n- incisional 296-8, 618\\n- inguinal 29, 293-5, 552\\n- laparoscopy 126, 299\\n- SBO 29, 269, 292-3, 296, 657, 660-1\\n- umbilical 297, 348-9\\n- hiatus hernias 180\\n- HIDA scans 243-4\\n- hierarchy of evidence 9-11\\n- Hinchey classification (diverticulitis) 406, 408-13\\n- history of abdominal surgery 13-20, 717-18\\n- HIV-related emergencies 591\\n- horseshoe abscesses 447\\n- Hounsfield Units (HU) 54\\n- hydatid cysts 358, 584-5\\n- hyperbaric oxygen 457\\n- hypothermia, intra-operative 94\\n- hypovolemia\\n- intra-operative 107\\n- pre-operative optimization 65-76, 194, 227, 272, 475\\n- in pregnancy 540\\n- IAH (intra-abdominal hypertension) see abdominal compartment syndrome\\n- IBD see inflammatory bowel disease\\n- ileocecal valve 381\\n- ileocolostomy (double-barrel) 155\\n- ileosigmoid knotting 287, 594\\n- ileostomy 152, 154, 158-9, 394\\n- ileus 271, 647, 655-6, 657-60, 663-4, 668\\n- iliac arteries\\n- in AAA repair 522, 523\\n- trauma 498\\n- iliac veins 499\\n- imaging 45-64, 93\\n- abdominal X-rays 38, 46-50\\n- abscesses 62, 579, 580, 669-70',\n", " 'md': '- hernias 14, 291-3\\n- diaphragmatic 180, 181-7\\n- femoral 29, 293, 295-6\\n- incisional 296-8, 618\\n- inguinal 29, 293-5, 552\\n- laparoscopy 126, 299\\n- SBO 29, 269, 292-3, 296, 657, 660-1\\n- umbilical 297, 348-9\\n- hiatus hernias 180\\n- HIDA scans 243-4\\n- hierarchy of evidence 9-11\\n- Hinchey classification (diverticulitis) 406, 408-13\\n- history of abdominal surgery 13-20, 717-18\\n- HIV-related emergencies 591\\n- horseshoe abscesses 447\\n- Hounsfield Units (HU) 54\\n- hydatid cysts 358, 584-5\\n- hyperbaric oxygen 457\\n- hypothermia, intra-operative 94\\n- hypovolemia\\n- intra-operative 107\\n- pre-operative optimization 65-76, 194, 227, 272, 475\\n- in pregnancy 540\\n- IAH (intra-abdominal hypertension) see abdominal compartment syndrome\\n- IBD see inflammatory bowel disease\\n- ileocecal valve 381\\n- ileocolostomy (double-barrel) 155\\n- ileosigmoid knotting 287, 594\\n- ileostomy 152, 154, 158-9, 394\\n- ileus 271, 647, 655-6, 657-60, 663-4, 668\\n- iliac arteries\\n- in AAA repair 522, 523\\n- trauma 498\\n- iliac veins 499\\n- imaging 45-64, 93\\n- abdominal X-rays 38, 46-50\\n- abscesses 62, 579, 580, 669-70',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 334.23, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Notes',\n", " 'md': '## Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'diaphragmatic 180, 181-7'},\n", " {'text': 'femoral 29, 293, 295-6'},\n", " {'text': 'femoral 29, 293, 295-6'},\n", " {'text': 'incisional 296-8, 618'},\n", " {'text': 'incisional 296-8, 618'},\n", " {'text': 'incisional 296-8, 618'},\n", " {'text': 'inguinal 29, 293-5, 552'},\n", " {'text': 'inguinal 29, 293-5, 552'},\n", " {'text': 'laparoscopy 126, 299'},\n", " {'text': 'laparoscopy 126, 299'},\n", " {'text': 'laparoscopy 126, 299'},\n", " {'text': 'SBO 29, 269, 292-3, 296, 657, 660-1'},\n", " {'text': 'SBO 29, 269, 292-3, 296, 657, 660-1'},\n", " {'text': 'umbilical 297, 348-9'},\n", " {'text': 'umbilical 297, 348-9'},\n", " {'text': 'umbilical 297, 348-9'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'hiatus hernias 180'},\n", " {'text': ''},\n", " {'text': 'HIDA scans 243-4'},\n", " {'text': 'hierarchy of evidence 9-11'},\n", " {'text': 'Hinchey classification (diverticulitis) 406, 408-13'},\n", " {'text': 'history of abdominal surgery 13-20, 717-18'},\n", " {'text': 'history of abdominal surgery 13-20, 717-18'},\n", " {'text': 'HIV-related emergencies 591'},\n", " {'text': ''},\n", " {'text': 'horseshoe abscesses 447'},\n", " {'text': 'Hounsfield Units (HU) 54'},\n", " {'text': 'hydatid cysts 358, 584-5'},\n", " {'text': 'hyperbaric oxygen 457'},\n", " {'text': 'hyperbaric oxygen 457'},\n", " {'text': 'hypothermia, intra-operative 94'},\n", " {'text': ''},\n", " {'text': 'pre-operative optimization 65-76, 194, 227, 272, 475'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'ileocolostomy (double-barrel) 155'},\n", " {'text': ''},\n", " {'text': 'ileostomy 152, 154, 158-9, 394'},\n", " {'text': 'ileostomy 152, 154, 158-9, 394'},\n", " {'text': 'ileus 271, 647, 655-6, 657-60, 663-4, 668'},\n", " {'text': 'ileus 271, 647, 655-6, 657-60, 663-4, 668'},\n", " {'text': 'ileus 271, 647, 655-6, 657-60, 663-4, 668'},\n", " {'text': 'ileus 271, 647, 655-6, 657-60, 663-4, 668'},\n", " {'text': 'iliac arteries'},\n", " {'text': 'iliac arteries'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'imaging 45-64, 93'},\n", " {'text': 'abdominal X-rays 38, 46-50'},\n", " {'text': 'abdominal X-rays 38, 46-50'},\n", " {'text': 'abscesses 62, 579, 580, 669-70'},\n", " {'text': 'abscesses 62, 579, 580, 669-70'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 873,\n", " 'text': ' appendicitis 38, 50, 55-6, 309-10, 312-13\\n biliary tract 46-7, 58-9, 243-4, 253-4, 257, 284\\n calculi 49, 257, 560\\n chest X-rays 37-8, 164, 184\\n children 547, 549\\n colon 48, 56, 60\\n obstruction 381-2, 395, 397\\n perforation 37, 469-70\\n contrast 40-2, 52, 57\\n CT scans 31, 39-40, 51-64, 101\\n esophageal perforation 37, 164, 166, 167, 175, 461\\n foreign bodies 176\\n gastric volvulus 182, 184-5\\n gynecological conditions 57, 60, 531, 534\\n ischemic colitis 377\\n kidney 60, 566-7\\n liver 58, 353, 579, 580\\n lower GI bleeds 429\\n mesenteric ischemia 40, 332-3, 338-9\\n pancreas 59-60, 224-5, 231, 232-3\\n in pregnancy 538-9\\n small bowel 48, 60, 267, 270-2, 274-5, 289\\n trauma 37, 55, 353, 477, 478-9, 487-9, 566-7\\n ulcer perforation 211-12\\n ultrasound 38-9\\nimmunosuppressed patients 364-5, 405, 416, 447-8, 555, 591\\nimpalement injuries 455, 481-2\\nincisional hernias 296-8, 618\\nincisions 99-104\\n AAA rupture 520\\n appendectomy 317\\n hernia repair 293-4, 295\\n laparoscopy 121\\ninfants 544, 546, 548-51, 552\\ninferior mesenteric artery (IMA) 499\\ninferior mesenteric vein (IMV) 55, 499\\ninflammation 8-9, 128, 651, 653\\n blood markers 36, 309\\n see also peritonitis',\n", " 'md': '```markdown\\n# Current Page Content\\n\\n## Extracted Text\\n- appendicitis 38, 50, 55-6, 309-10, 312-13\\n- biliary tract 46-7, 58-9, 243-4, 253-4, 257, 284\\n- calculi 49, 257, 560\\n- chest X-rays 37-8, 164, 184\\n- children 547, 549\\n- colon 48, 56, 60\\n- obstruction 381-2, 395, 397\\n- perforation 37, 469-70\\n- contrast 40-2, 52, 57\\n- CT scans 31, 39-40, 51-64, 101\\n- esophageal perforation 37, 164, 166, 167, 175, 461\\n- foreign bodies 176\\n- gastric volvulus 182, 184-5\\n- gynecological conditions 57, 60, 531, 534\\n- ischemic colitis 377\\n- kidney 60, 566-7\\n- liver 58, 353, 579, 580\\n- lower GI bleeds 429\\n- mesenteric ischemia 40, 332-3, 338-9\\n- pancreas 59-60, 224-5, 231, 232-3\\n- in pregnancy 538-9\\n- small bowel 48, 60, 267, 270-2, 274-5, 289\\n- trauma 37, 55, 353, 477, 478-9, 487-9, 566-7\\n- ulcer perforation 211-12\\n- ultrasound 38-9\\n- immunosuppressed patients 364-5, 405, 416, 447-8, 555, 591\\n- impalement injuries 455, 481-2\\n- incisional hernias 296-8, 618\\n- incisions 99-104\\n- AAA rupture 520\\n- appendectomy 317\\n- hernia repair 293-4, 295\\n- laparoscopy 121\\n- infants 544, 546, 548-51, 552\\n- inferior mesenteric artery (IMA) 499\\n- inferior mesenteric vein (IMV) 55, 499\\n- inflammation 8-9, 128, 651, 653\\n- blood markers 36, 309\\n- see also peritonitis\\n\\n## Notes\\n- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Current Page Content',\n", " 'md': '# Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- appendicitis 38, 50, 55-6, 309-10, 312-13\\n- biliary tract 46-7, 58-9, 243-4, 253-4, 257, 284\\n- calculi 49, 257, 560\\n- chest X-rays 37-8, 164, 184\\n- children 547, 549\\n- colon 48, 56, 60\\n- obstruction 381-2, 395, 397\\n- perforation 37, 469-70\\n- contrast 40-2, 52, 57\\n- CT scans 31, 39-40, 51-64, 101\\n- esophageal perforation 37, 164, 166, 167, 175, 461\\n- foreign bodies 176\\n- gastric volvulus 182, 184-5\\n- gynecological conditions 57, 60, 531, 534\\n- ischemic colitis 377\\n- kidney 60, 566-7\\n- liver 58, 353, 579, 580\\n- lower GI bleeds 429\\n- mesenteric ischemia 40, 332-3, 338-9\\n- pancreas 59-60, 224-5, 231, 232-3\\n- in pregnancy 538-9\\n- small bowel 48, 60, 267, 270-2, 274-5, 289\\n- trauma 37, 55, 353, 477, 478-9, 487-9, 566-7\\n- ulcer perforation 211-12\\n- ultrasound 38-9\\n- immunosuppressed patients 364-5, 405, 416, 447-8, 555, 591\\n- impalement injuries 455, 481-2\\n- incisional hernias 296-8, 618\\n- incisions 99-104\\n- AAA rupture 520\\n- appendectomy 317\\n- hernia repair 293-4, 295\\n- laparoscopy 121\\n- infants 544, 546, 548-51, 552\\n- inferior mesenteric artery (IMA) 499\\n- inferior mesenteric vein (IMV) 55, 499\\n- inflammation 8-9, 128, 651, 653\\n- blood markers 36, 309\\n- see also peritonitis',\n", " 'md': '- appendicitis 38, 50, 55-6, 309-10, 312-13\\n- biliary tract 46-7, 58-9, 243-4, 253-4, 257, 284\\n- calculi 49, 257, 560\\n- chest X-rays 37-8, 164, 184\\n- children 547, 549\\n- colon 48, 56, 60\\n- obstruction 381-2, 395, 397\\n- perforation 37, 469-70\\n- contrast 40-2, 52, 57\\n- CT scans 31, 39-40, 51-64, 101\\n- esophageal perforation 37, 164, 166, 167, 175, 461\\n- foreign bodies 176\\n- gastric volvulus 182, 184-5\\n- gynecological conditions 57, 60, 531, 534\\n- ischemic colitis 377\\n- kidney 60, 566-7\\n- liver 58, 353, 579, 580\\n- lower GI bleeds 429\\n- mesenteric ischemia 40, 332-3, 338-9\\n- pancreas 59-60, 224-5, 231, 232-3\\n- in pregnancy 538-9\\n- small bowel 48, 60, 267, 270-2, 274-5, 289\\n- trauma 37, 55, 353, 477, 478-9, 487-9, 566-7\\n- ulcer perforation 211-12\\n- ultrasound 38-9\\n- immunosuppressed patients 364-5, 405, 416, 447-8, 555, 591\\n- impalement injuries 455, 481-2\\n- incisional hernias 296-8, 618\\n- incisions 99-104\\n- AAA rupture 520\\n- appendectomy 317\\n- hernia repair 293-4, 295\\n- laparoscopy 121\\n- infants 544, 546, 548-51, 552\\n- inferior mesenteric artery (IMA) 499\\n- inferior mesenteric vein (IMV) 55, 499\\n- inflammation 8-9, 128, 651, 653\\n- blood markers 36, 309\\n- see also peritonitis',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 393.43, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Notes',\n", " 'md': '## Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'biliary tract 46-7, 58-9, 243-4, 253-4, 257, 284'},\n", " {'text': 'biliary tract 46-7, 58-9, 243-4, 253-4, 257, 284'},\n", " {'text': 'biliary tract 46-7, 58-9, 243-4, 253-4, 257, 284'},\n", " {'text': 'biliary tract 46-7, 58-9, 243-4, 253-4, 257, 284'},\n", " {'text': 'biliary tract 46-7, 58-9, 243-4, 253-4, 257, 284'},\n", " {'text': 'calculi 49, 257, 560'},\n", " {'text': 'calculi 49, 257, 560'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'chest X-rays 37-8, 164, 184'},\n", " {'text': 'chest X-rays 37-8, 164, 184'},\n", " {'text': 'chest X-rays 37-8, 164, 184'},\n", " {'text': 'children 547, 549'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'colon 48, 56, 60'},\n", " {'text': 'colon 48, 56, 60'},\n", " {'text': ''},\n", " {'text': 'obstruction 381-2, 395, 397'},\n", " {'text': 'obstruction 381-2, 395, 397'},\n", " {'text': 'perforation 37, 469-70'},\n", " {'text': 'perforation 37, 469-70'},\n", " {'text': ''},\n", " {'text': 'contrast 40-2, 52, 57'},\n", " {'text': ''},\n", " {'text': 'CT scans 31, 39-40, 51-64, 101'},\n", " {'text': 'CT scans 31, 39-40, 51-64, 101'},\n", " {'text': 'CT scans 31, 39-40, 51-64, 101'},\n", " {'text': 'esophageal perforation 37, 164, 166, 167, 175, 461'},\n", " {'text': 'esophageal perforation 37, 164, 166, 167, 175, 461'},\n", " {'text': 'esophageal perforation 37, 164, 166, 167, 175, 461'},\n", " {'text': 'esophageal perforation 37, 164, 166, 167, 175, 461'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'gastric volvulus 182, 184-5'},\n", " {'text': 'gynecological conditions 57, 60, 531, 534'},\n", " {'text': 'gynecological conditions 57, 60, 531, 534'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'kidney 60, 566-7'},\n", " {'text': 'liver 58, 353, 579, 580'},\n", " {'text': 'liver 58, 353, 579, 580'},\n", " {'text': 'lower GI bleeds 429'},\n", " {'text': 'lower GI bleeds 429'},\n", " {'text': 'lower GI bleeds 429'},\n", " {'text': 'lower GI bleeds 429'},\n", " {'text': 'mesenteric ischemia 40, 332-3, 338-9'},\n", " {'text': 'pancreas 59-60, 224-5, 231, 232-3'},\n", " {'text': 'pancreas 59-60, 224-5, 231, 232-3'},\n", " {'text': 'pancreas 59-60, 224-5, 231, 232-3'},\n", " {'text': 'in pregnancy 538-9'},\n", " {'text': 'in pregnancy 538-9'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'small bowel 48, 60, 267, 270-2, 274-5, 289'},\n", " {'text': 'trauma 37, 55, 353, 477, 478-9, 487-9, 566-7'},\n", " {'text': 'trauma 37, 55, 353, 477, 478-9, 487-9, 566-7'},\n", " {'text': 'trauma 37, 55, 353, 477, 478-9, 487-9, 566-7'},\n", " {'text': 'trauma 37, 55, 353, 477, 478-9, 487-9, 566-7'},\n", " {'text': 'trauma 37, 55, 353, 477, 478-9, 487-9, 566-7'},\n", " {'text': 'trauma 37, 55, 353, 477, 478-9, 487-9, 566-7'},\n", " {'text': 'ulcer perforation 211-12'},\n", " {'text': 'ulcer perforation 211-12'},\n", " {'text': 'ulcer perforation 211-12'},\n", " {'text': 'ulcer perforation 211-12'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'immunosuppressed patients 364-5, 405, 416, 447-8, 555, 591'},\n", " {'text': 'impalement injuries 455, 481-2'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'incisional hernias 296-8, 618'},\n", " {'text': 'incisional hernias 296-8, 618'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'AAA rupture 520'},\n", " {'text': 'appendectomy 317'},\n", " {'text': 'hernia repair 293-4, 295'},\n", " {'text': 'laparoscopy 121'},\n", " {'text': ''},\n", " {'text': 'infants 544, 546, 548-51, 552'},\n", " {'text': 'inferior mesenteric artery (IMA) 499'},\n", " {'text': 'inferior mesenteric artery (IMA) 499'},\n", " {'text': 'inferior mesenteric artery (IMA) 499'},\n", " {'text': 'inferior mesenteric artery (IMA) 499'},\n", " {'text': 'inferior mesenteric vein (IMV) 55, 499'},\n", " {'text': 'inflammation 8-9, 128, 651, 653'},\n", " {'text': ''},\n", " {'text': 'blood markers 36, 309'},\n", " {'text': 'blood markers 36, 309'},\n", " {'text': 'blood markers 36, 309'},\n", " {'text': 'blood markers 36, 309'},\n", " {'text': ' peritonitis'},\n", " {'text': ' peritonitis'}]},\n", " {'page': 874,\n", " 'text': 'inflammatory bowel disease (IBD)\\n colitis 154-5, 363-70, 433\\n Crohn’s disease 60, 363, 369, 370-3, 433\\ninformed consent 83-5, 87-8\\ninfracolic compartment 111\\ninguinal hernias 29, 293-5, 552\\nintercostal muscle flaps 171\\nintestines see colon; small bowel; small bowel obstruction\\nintra-abdominal hypertension (IAH) see abdominal compartment\\nsyndrome\\nintra-abdominal infection see peritonitis\\nintravenous pyelogram 566-7\\nintubation 69\\nintussusception 17, 281, 286, 545, 548-51, 587-9\\nischemia\\n colon 294, 329, 430\\n mesenteric 39-40, 55, 329-40, 709\\n small bowel 269, 294\\n stoma 158\\nischemic colitis 329, 376-7, 434\\n\\njaundice, obstructive 256-8\\njejunal diverticulosis 419\\njejunal feeding tubes 642-5\\njejunostomy 155-6, 643-4\\n\\nkidney\\n imaging 60, 556-7\\n trauma 495-6, 565-8\\nkissing ulcers 205, 218\\nknife wounds 475-7, 479-81\\nKocher’s maneuver 111-12\\n\\nLa Rocque’s maneuver 294-5\\nlaparoscopy 117-26\\n appendicitis 124, 311, 317, 321, 322-7, 539, 547-8\\n cholecystectomy 123-4, 246-8, 251, 539\\n colonic perforation 472\\n complications of 266, 660-1',\n", " 'md': '```markdown\\n# Inflammatory Bowel Disease (IBD)\\n\\n- **Colitis**: 154-5, 363-70, 433\\n- **Crohn’s Disease**: 60, 363, 369, 370-3, 433\\n\\n## Informed Consent\\n- 83-5, 87-8\\n\\n## Infracolic Compartment\\n- 111\\n\\n## Inguinal Hernias\\n- 29, 293-5, 552\\n\\n## Intercostal Muscle Flaps\\n- 171\\n\\n## Intestines\\n- See colon; small bowel; small bowel obstruction\\n\\n## Intra-abdominal Hypertension (IAH)\\n- See abdominal compartment syndrome\\n\\n## Intra-abdominal Infection\\n- See peritonitis\\n\\n## Intravenous Pyelogram\\n- 566-7\\n\\n## Intubation\\n- 69\\n\\n## Intussusception\\n- 17, 281, 286, 545, 548-51, 587-9\\n\\n## Ischemia\\n- **Colon**: 294, 329, 430\\n- **Mesenteric**: 39-40, 55, 329-40, 709\\n- **Small Bowel**: 269, 294\\n- **Stoma**: 158\\n\\n## Ischemic Colitis\\n- 329, 376-7, 434\\n\\n## Jaundice, Obstructive\\n- 256-8\\n\\n## Jejunal Diverticulosis\\n- 419\\n\\n## Jejunal Feeding Tubes\\n- 642-5\\n\\n## Jejunostomy\\n- 155-6, 643-4\\n\\n## Kidney\\n- **Imaging**: 60, 556-7\\n- **Trauma**: 495-6, 565-8\\n\\n## Kissing Ulcers\\n- 205, 218\\n\\n## Knife Wounds\\n- 475-7, 479-81\\n\\n## Kocher’s Maneuver\\n- 111-12\\n\\n## La Rocque’s Maneuver\\n- 294-5\\n\\n## Laparoscopy\\n- 117-26\\n- **Appendicitis**: 124, 311, 317, 321, 322-7, 539, 547-8\\n- **Cholecystectomy**: 123-4, 246-8, 251, 539\\n- **Colonic Perforation**: 472\\n- **Complications of**: 266, 660-1\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Inflammatory Bowel Disease (IBD)',\n", " 'md': '# Inflammatory Bowel Disease (IBD)',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 215.08, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Colitis**: 154-5, 363-70, 433\\n- **Crohn’s Disease**: 60, 363, 369, 370-3, 433',\n", " 'md': '- **Colitis**: 154-5, 363-70, 433\\n- **Crohn’s Disease**: 60, 363, 369, 370-3, 433',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Informed Consent',\n", " 'md': '## Informed Consent',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 83-5, 87-8',\n", " 'md': '- 83-5, 87-8',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Infracolic Compartment',\n", " 'md': '## Infracolic Compartment',\n", " 'bBox': {'x': 455, 'y': 218, 'w': 83.97, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- 111',\n", " 'md': '- 111',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Inguinal Hernias',\n", " 'md': '## Inguinal Hernias',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 29, 293-5, 552',\n", " 'md': '- 29, 293-5, 552',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Intercostal Muscle Flaps',\n", " 'md': '## Intercostal Muscle Flaps',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 171',\n", " 'md': '- 171',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Intestines',\n", " 'md': '## Intestines',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- See colon; small bowel; small bowel obstruction',\n", " 'md': '- See colon; small bowel; small bowel obstruction',\n", " 'bBox': {'x': 334, 'y': 218, 'w': 27, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Intra-abdominal Hypertension (IAH)',\n", " 'md': '## Intra-abdominal Hypertension (IAH)',\n", " 'bBox': {'x': 72, 'y': 218, 'w': 103.15, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- See abdominal compartment syndrome',\n", " 'md': '- See abdominal compartment syndrome',\n", " 'bBox': {'x': 72, 'y': 218, 'w': 345.97, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Intra-abdominal Infection',\n", " 'md': '## Intra-abdominal Infection',\n", " 'bBox': {'x': 72, 'y': 218, 'w': 103.15, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- See peritonitis',\n", " 'md': '- See peritonitis',\n", " 'bBox': {'x': 334, 'y': 218, 'w': 27, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Intravenous Pyelogram',\n", " 'md': '## Intravenous Pyelogram',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 566-7',\n", " 'md': '- 566-7',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Intubation',\n", " 'md': '## Intubation',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 69',\n", " 'md': '- 69',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Intussusception',\n", " 'md': '## Intussusception',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 17, 281, 286, 545, 548-51, 587-9',\n", " 'md': '- 17, 281, 286, 545, 548-51, 587-9',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Ischemia',\n", " 'md': '## Ischemia',\n", " 'bBox': {'x': 72, 'y': 317, 'w': 56.79, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Colon**: 294, 329, 430\\n- **Mesenteric**: 39-40, 55, 329-40, 709\\n- **Small Bowel**: 269, 294\\n- **Stoma**: 158',\n", " 'md': '- **Colon**: 294, 329, 430\\n- **Mesenteric**: 39-40, 55, 329-40, 709\\n- **Small Bowel**: 269, 294\\n- **Stoma**: 158',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Ischemic Colitis',\n", " 'md': '## Ischemic Colitis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 329, 376-7, 434',\n", " 'md': '- 329, 376-7, 434',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Jaundice, Obstructive',\n", " 'md': '## Jaundice, Obstructive',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 256-8',\n", " 'md': '- 256-8',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Jejunal Diverticulosis',\n", " 'md': '## Jejunal Diverticulosis',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 419',\n", " 'md': '- 419',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Jejunal Feeding Tubes',\n", " 'md': '## Jejunal Feeding Tubes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 642-5',\n", " 'md': '- 642-5',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Jejunostomy',\n", " 'md': '## Jejunostomy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 155-6, 643-4',\n", " 'md': '- 155-6, 643-4',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Kidney',\n", " 'md': '## Kidney',\n", " 'bBox': {'x': 72, 'y': 512, 'w': 41.59, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Imaging**: 60, 556-7\\n- **Trauma**: 495-6, 565-8',\n", " 'md': '- **Imaging**: 60, 556-7\\n- **Trauma**: 495-6, 565-8',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Kissing Ulcers',\n", " 'md': '## Kissing Ulcers',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 205, 218',\n", " 'md': '- 205, 218',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Knife Wounds',\n", " 'md': '## Knife Wounds',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 475-7, 479-81',\n", " 'md': '- 475-7, 479-81',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Kocher’s Maneuver',\n", " 'md': '## Kocher’s Maneuver',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 111-12',\n", " 'md': '- 111-12',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'La Rocque’s Maneuver',\n", " 'md': '## La Rocque’s Maneuver',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 294-5',\n", " 'md': '- 294-5',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Laparoscopy',\n", " 'md': '## Laparoscopy',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- 117-26\\n- **Appendicitis**: 124, 311, 317, 321, 322-7, 539, 547-8\\n- **Cholecystectomy**: 123-4, 246-8, 251, 539\\n- **Colonic Perforation**: 472\\n- **Complications of**: 266, 660-1\\n```',\n", " 'md': '- 117-26\\n- **Appendicitis**: 124, 311, 317, 321, 322-7, 539, 547-8\\n- **Cholecystectomy**: 123-4, 246-8, 251, 539\\n- **Colonic Perforation**: 472\\n- **Complications of**: 266, 660-1\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'Crohn’s disease 60, 363, 369, 370-3, 433'},\n", " {'text': 'Crohn’s disease 60, 363, 369, 370-3, 433'},\n", " {'text': 'Crohn’s disease 60, 363, 369, 370-3, 433'},\n", " {'text': 'informed consent 83-5, 87-8'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'infracolic compartment 111'},\n", " {'text': 'infracolic compartment 111'},\n", " {'text': 'inguinal hernias 29, 293-5, 552'},\n", " {'text': 'intercostal muscle flaps 171'},\n", " {'text': 'intercostal muscle flaps 171'},\n", " {'text': 'intercostal muscle flaps 171'},\n", " {'text': ' colon; small bowel; small bowel obstruction'},\n", " {'text': ''},\n", " {'text': 'intussusception 17, 281, 286, 545, 548-51, 587-9'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'mesenteric 39-40, 55, 329-40, 709'},\n", " {'text': 'mesenteric 39-40, 55, 329-40, 709'},\n", " {'text': 'mesenteric 39-40, 55, 329-40, 709'},\n", " {'text': 'small bowel 269, 294'},\n", " {'text': 'small bowel 269, 294'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'ischemic colitis 329, 376-7, 434'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'jejunal diverticulosis 419'},\n", " {'text': 'jejunal feeding tubes 642-5'},\n", " {'text': 'jejunostomy 155-6, 643-4'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'trauma 495-6, 565-8'},\n", " {'text': 'trauma 495-6, 565-8'},\n", " {'text': 'kissing ulcers 205, 218'},\n", " {'text': ''},\n", " {'text': 'knife wounds 475-7, 479-81'},\n", " {'text': 'knife wounds 475-7, 479-81'},\n", " {'text': 'Kocher’s maneuver 111-12'},\n", " {'text': 'Kocher’s maneuver 111-12'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'appendicitis 124, 311, 317, 321, 322-7, 539, 547-8'},\n", " {'text': 'cholecystectomy 123-4, 246-8, 251, 539'},\n", " {'text': 'cholecystectomy 123-4, 246-8, 251, 539'},\n", " {'text': 'cholecystectomy 123-4, 246-8, 251, 539'},\n", " {'text': 'cholecystectomy 123-4, 246-8, 251, 539'},\n", " {'text': 'cholecystectomy 123-4, 246-8, 251, 539'},\n", " {'text': 'cholecystectomy 123-4, 246-8, 251, 539'},\n", " {'text': ''},\n", " {'text': 'colonic perforation 472'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'complications of 266, 660-1'},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 875,\n", " 'text': ' diagnostic 44, 118\\n diverticulitis 125, 414-16\\n hernia repair 126, 299\\n port closure 618-20\\n for postoperative complications 708-11\\n for SBO 119, 125, 278-80, 709\\n SBO following 266, 660-1\\n for trauma 126, 476\\nlaparostomy 136, 236-7, 511, 524, 615-16, 698-708, 717\\nlarge bowel see colon\\nleft-sided Kocher’s maneuver 112\\nleiomyopathy 590-1\\nlipase 27, 224\\nliver\\n abscesses 358-9, 578-80\\n anatomical position 104\\n cysts 358, 584-5\\n emergencies in patients with chronic disease 130, 341-53\\n hemobilia 359-60\\n imaging 58, 353, 579, 580\\n transplant patients 341-2, 350\\n trauma 353-7, 491, 493-4\\n tumors 360-1\\nliver flukes 585\\nliver function tests 36-7, 244, 256\\nloop colostomy 153-4, 386\\nloop ileostomy 152, 154\\nlower GI bleeding 350-1, 402, 423-36, 448-50, 468\\nlung 37, 53\\n\\nmagnetic resonance angiography (MRA) 333\\nmalrotation, midgut 287-90, 545\\nMcEvedy’s incision 295\\nMeckel’s diverticulum 60, 551-2\\nmedial visceral rotation 112\\nmediastinitis 161, 163\\nmedical notes 88\\nmedicolegal issues 86-8, 725-6\\nMELD score 347',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Extracted Text\\n- diagnostic 44, 118\\n- diverticulitis 125, 414-16\\n- hernia repair 126, 299\\n- port closure 618-20\\n- for postoperative complications 708-11\\n- for SBO 119, 125, 278-80, 709\\n- SBO following 266, 660-1\\n- for trauma 126, 476\\n- laparostomy 136, 236-7, 511, 524, 615-16, 698-708, 717\\n- large bowel see colon\\n- left-sided Kocher’s maneuver 112\\n- leiomyopathy 590-1\\n- lipase 27, 224\\n- liver\\n- abscesses 358-9, 578-80\\n- anatomical position 104\\n- cysts 358, 584-5\\n- emergencies in patients with chronic disease 130, 341-53\\n- hemobilia 359-60\\n- imaging 58, 353, 579, 580\\n- transplant patients 341-2, 350\\n- trauma 353-7, 491, 493-4\\n- tumors 360-1\\n- liver flukes 585\\n- liver function tests 36-7, 244, 256\\n- loop colostomy 153-4, 386\\n- loop ileostomy 152, 154\\n- lower GI bleeding 350-1, 402, 423-36, 448-50, 468\\n- lung 37, 53\\n- magnetic resonance angiography (MRA) 333\\n- malrotation, midgut 287-90, 545\\n- McEvedy’s incision 295\\n- Meckel’s diverticulum 60, 551-2\\n- medial visceral rotation 112\\n- mediastinitis 161, 163\\n- medical notes 88\\n- medicolegal issues 86-8, 725-6\\n- MELD score 347\\n\\n## Images and Graphs\\n- No images or graphs were identified on this page.\\n\\n## Tables\\n- No tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- diagnostic 44, 118\\n- diverticulitis 125, 414-16\\n- hernia repair 126, 299\\n- port closure 618-20\\n- for postoperative complications 708-11\\n- for SBO 119, 125, 278-80, 709\\n- SBO following 266, 660-1\\n- for trauma 126, 476\\n- laparostomy 136, 236-7, 511, 524, 615-16, 698-708, 717\\n- large bowel see colon\\n- left-sided Kocher’s maneuver 112\\n- leiomyopathy 590-1\\n- lipase 27, 224\\n- liver\\n- abscesses 358-9, 578-80\\n- anatomical position 104\\n- cysts 358, 584-5\\n- emergencies in patients with chronic disease 130, 341-53\\n- hemobilia 359-60\\n- imaging 58, 353, 579, 580\\n- transplant patients 341-2, 350\\n- trauma 353-7, 491, 493-4\\n- tumors 360-1\\n- liver flukes 585\\n- liver function tests 36-7, 244, 256\\n- loop colostomy 153-4, 386\\n- loop ileostomy 152, 154\\n- lower GI bleeding 350-1, 402, 423-36, 448-50, 468\\n- lung 37, 53\\n- magnetic resonance angiography (MRA) 333\\n- malrotation, midgut 287-90, 545\\n- McEvedy’s incision 295\\n- Meckel’s diverticulum 60, 551-2\\n- medial visceral rotation 112\\n- mediastinitis 161, 163\\n- medical notes 88\\n- medicolegal issues 86-8, 725-6\\n- MELD score 347',\n", " 'md': '- diagnostic 44, 118\\n- diverticulitis 125, 414-16\\n- hernia repair 126, 299\\n- port closure 618-20\\n- for postoperative complications 708-11\\n- for SBO 119, 125, 278-80, 709\\n- SBO following 266, 660-1\\n- for trauma 126, 476\\n- laparostomy 136, 236-7, 511, 524, 615-16, 698-708, 717\\n- large bowel see colon\\n- left-sided Kocher’s maneuver 112\\n- leiomyopathy 590-1\\n- lipase 27, 224\\n- liver\\n- abscesses 358-9, 578-80\\n- anatomical position 104\\n- cysts 358, 584-5\\n- emergencies in patients with chronic disease 130, 341-53\\n- hemobilia 359-60\\n- imaging 58, 353, 579, 580\\n- transplant patients 341-2, 350\\n- trauma 353-7, 491, 493-4\\n- tumors 360-1\\n- liver flukes 585\\n- liver function tests 36-7, 244, 256\\n- loop colostomy 153-4, 386\\n- loop ileostomy 152, 154\\n- lower GI bleeding 350-1, 402, 423-36, 448-50, 468\\n- lung 37, 53\\n- magnetic resonance angiography (MRA) 333\\n- malrotation, midgut 287-90, 545\\n- McEvedy’s incision 295\\n- Meckel’s diverticulum 60, 551-2\\n- medial visceral rotation 112\\n- mediastinitis 161, 163\\n- medical notes 88\\n- medicolegal issues 86-8, 725-6\\n- MELD score 347',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 366.24, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images and Graphs',\n", " 'md': '## Images and Graphs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No tables were identified on this page.\\n```',\n", " 'md': '- No tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'diverticulitis 125, 414-16'},\n", " {'text': 'diverticulitis 125, 414-16'},\n", " {'text': 'hernia repair 126, 299'},\n", " {'text': 'hernia repair 126, 299'},\n", " {'text': 'port closure 618-20'},\n", " {'text': 'port closure 618-20'},\n", " {'text': 'for postoperative complications 708-11'},\n", " {'text': ''},\n", " {'text': 'SBO following 266, 660-1'},\n", " {'text': 'SBO following 266, 660-1'},\n", " {'text': 'SBO following 266, 660-1'},\n", " {'text': ''},\n", " {'text': 'for trauma 126, 476'},\n", " {'text': ''},\n", " {'text': 'laparostomy 136, 236-7, 511, 524, 615-16, 698-708, 717'},\n", " {'text': 'laparostomy 136, 236-7, 511, 524, 615-16, 698-708, 717'},\n", " {'text': 'see'},\n", " {'text': ' colon'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'lipase 27, 224'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'anatomical position 104'},\n", " {'text': 'anatomical position 104'},\n", " {'text': ''},\n", " {'text': 'emergencies in patients with chronic disease 130, 341-53'},\n", " {'text': 'emergencies in patients with chronic disease 130, 341-53'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'imaging 58, 353, 579, 580'},\n", " {'text': 'transplant patients 341-2, 350'},\n", " {'text': 'transplant patients 341-2, 350'},\n", " {'text': 'transplant patients 341-2, 350'},\n", " {'text': 'transplant patients 341-2, 350'},\n", " {'text': 'trauma 353-7, 491, 493-4'},\n", " {'text': ''},\n", " {'text': 'tumors 360-1'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'liver function tests 36-7, 244, 256'},\n", " {'text': 'loop colostomy 153-4, 386'},\n", " {'text': 'loop colostomy 153-4, 386'},\n", " {'text': ''},\n", " {'text': 'loop ileostomy 152, 154'},\n", " {'text': 'loop ileostomy 152, 154'},\n", " {'text': 'lower GI bleeding 350-1, 402, 423-36, 448-50, 468'},\n", " {'text': 'lower GI bleeding 350-1, 402, 423-36, 448-50, 468'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'McEvedy’s incision 295'},\n", " {'text': ''},\n", " {'text': 'Meckel’s diverticulum 60, 551-2'},\n", " {'text': 'medial visceral rotation 112'},\n", " {'text': 'medial visceral rotation 112'},\n", " {'text': ''},\n", " {'text': 'medical notes 88'},\n", " {'text': ''},\n", " {'text': 'medicolegal issues 86-8, 725-6'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 876,\n", " 'text': 'melena 191, 595\\nmenstruation 531\\nmesenteric ischemia 39-40, 55, 329-40, 709\\nmesenteric vessel trauma 499\\nmeshes, surgical 277, 295, 298\\nmetabolic acidosis 30, 67, 72\\nmicrobiology\\n abscesses 667-8\\n peritonitis 80-1, 129, 130, 137-8\\n wound infections 719, 720\\nmidline incisions 100, 101-2, 104\\nmobilization of the patient, postoperative 629\\nmonitoring\\n fluid resuscitation 70-2\\n postoperative 629-30\\nmorbidity & mortality meeting (MMM) 723-8\\nMorgagni hernias 180\\nmucous fistulas 154-5, 337, 369\\nmultiple organ failure (MOF) 227, 691-2\\nmuti enemas 590, 591-3\\nmyocardial infarction 30\\n\\nnasoenteric feeding 228, 642, 644-5\\nnasogastric (NG) tubes\\n enteral feeding 228, 642\\n GI tract decompression 186, 272-3, 630\\n insertion 273\\n before intubation 69\\nnecrosis\\n colon 230, 593\\n pancreas 110, 222, 224, 231-8\\n perineal infections 456-7\\n small bowel 334\\n stomach 187\\nnegligence 725-6\\nneostigmine 399\\nnephrectomy 568\\nneutropenic enterocolitis 375-6\\nNG tubes see nasogastric (NG) tubes',\n", " 'md': '```markdown\\n# Current Page Content\\n\\n## Extracted Text\\n- melena 191, 595\\n- menstruation 531\\n- mesenteric ischemia 39-40, 55, 329-40, 709\\n- mesenteric vessel trauma 499\\n- meshes, surgical 277, 295, 298\\n- metabolic acidosis 30, 67, 72\\n- microbiology\\n- abscesses 667-8\\n- peritonitis 80-1, 129, 130, 137-8\\n- wound infections 719, 720\\n- midline incisions 100, 101-2, 104\\n- mobilization of the patient, postoperative 629\\n- monitoring\\n- fluid resuscitation 70-2\\n- postoperative 629-30\\n- morbidity & mortality meeting (MMM) 723-8\\n- Morgagni hernias 180\\n- mucous fistulas 154-5, 337, 369\\n- multiple organ failure (MOF) 227, 691-2\\n- muti enemas 590, 591-3\\n- myocardial infarction 30\\n- nasoenteric feeding 228, 642, 644-5\\n- nasogastric (NG) tubes\\n- enteral feeding 228, 642\\n- GI tract decompression 186, 272-3, 630\\n- insertion 273\\n- before intubation 69\\n- necrosis\\n- colon 230, 593\\n- pancreas 110, 222, 224, 231-8\\n- perineal infections 456-7\\n- small bowel 334\\n- stomach 187\\n- negligence 725-6\\n- neostigmine 399\\n- nephrectomy 568\\n- neutropenic enterocolitis 375-6\\n- NG tubes see nasogastric (NG) tubes\\n\\n## Images and Graphs\\n- No images or graphs were identified on this page.\\n\\n## Tables\\n- No tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Current Page Content',\n", " 'md': '# Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- melena 191, 595\\n- menstruation 531\\n- mesenteric ischemia 39-40, 55, 329-40, 709\\n- mesenteric vessel trauma 499\\n- meshes, surgical 277, 295, 298\\n- metabolic acidosis 30, 67, 72\\n- microbiology\\n- abscesses 667-8\\n- peritonitis 80-1, 129, 130, 137-8\\n- wound infections 719, 720\\n- midline incisions 100, 101-2, 104\\n- mobilization of the patient, postoperative 629\\n- monitoring\\n- fluid resuscitation 70-2\\n- postoperative 629-30\\n- morbidity & mortality meeting (MMM) 723-8\\n- Morgagni hernias 180\\n- mucous fistulas 154-5, 337, 369\\n- multiple organ failure (MOF) 227, 691-2\\n- muti enemas 590, 591-3\\n- myocardial infarction 30\\n- nasoenteric feeding 228, 642, 644-5\\n- nasogastric (NG) tubes\\n- enteral feeding 228, 642\\n- GI tract decompression 186, 272-3, 630\\n- insertion 273\\n- before intubation 69\\n- necrosis\\n- colon 230, 593\\n- pancreas 110, 222, 224, 231-8\\n- perineal infections 456-7\\n- small bowel 334\\n- stomach 187\\n- negligence 725-6\\n- neostigmine 399\\n- nephrectomy 568\\n- neutropenic enterocolitis 375-6\\n- NG tubes see nasogastric (NG) tubes',\n", " 'md': '- melena 191, 595\\n- menstruation 531\\n- mesenteric ischemia 39-40, 55, 329-40, 709\\n- mesenteric vessel trauma 499\\n- meshes, surgical 277, 295, 298\\n- metabolic acidosis 30, 67, 72\\n- microbiology\\n- abscesses 667-8\\n- peritonitis 80-1, 129, 130, 137-8\\n- wound infections 719, 720\\n- midline incisions 100, 101-2, 104\\n- mobilization of the patient, postoperative 629\\n- monitoring\\n- fluid resuscitation 70-2\\n- postoperative 629-30\\n- morbidity & mortality meeting (MMM) 723-8\\n- Morgagni hernias 180\\n- mucous fistulas 154-5, 337, 369\\n- multiple organ failure (MOF) 227, 691-2\\n- muti enemas 590, 591-3\\n- myocardial infarction 30\\n- nasoenteric feeding 228, 642, 644-5\\n- nasogastric (NG) tubes\\n- enteral feeding 228, 642\\n- GI tract decompression 186, 272-3, 630\\n- insertion 273\\n- before intubation 69\\n- necrosis\\n- colon 230, 593\\n- pancreas 110, 222, 224, 231-8\\n- perineal infections 456-7\\n- small bowel 334\\n- stomach 187\\n- negligence 725-6\\n- neostigmine 399\\n- nephrectomy 568\\n- neutropenic enterocolitis 375-6\\n- NG tubes see nasogastric (NG) tubes',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 285.45, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images and Graphs',\n", " 'md': '## Images and Graphs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No tables were identified on this page.\\n```',\n", " 'md': '- No tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'menstruation 531'},\n", " {'text': 'menstruation 531'},\n", " {'text': 'mesenteric ischemia 39-40, 55, 329-40, 709'},\n", " {'text': 'mesenteric vessel trauma 499'},\n", " {'text': 'mesenteric vessel trauma 499'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'meshes, surgical 277, 295, 298'},\n", " {'text': 'metabolic acidosis 30, 67, 72'},\n", " {'text': 'metabolic acidosis 30, 67, 72'},\n", " {'text': 'metabolic acidosis 30, 67, 72'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'peritonitis 80-1, 129, 130, 137-8'},\n", " {'text': 'wound infections 719, 720'},\n", " {'text': 'wound infections 719, 720'},\n", " {'text': 'wound infections 719, 720'},\n", " {'text': 'wound infections 719, 720'},\n", " {'text': 'midline incisions 100, 101-2, 104'},\n", " {'text': 'midline incisions 100, 101-2, 104'},\n", " {'text': 'mobilization of the patient, postoperative 629'},\n", " {'text': 'mobilization of the patient, postoperative 629'},\n", " {'text': 'mobilization of the patient, postoperative 629'},\n", " {'text': ''},\n", " {'text': 'postoperative 629-30'},\n", " {'text': 'morbidity & mortality meeting (MMM) 723-8'},\n", " {'text': ''},\n", " {'text': 'mucous fistulas 154-5, 337, 369'},\n", " {'text': 'multiple organ failure (MOF) 227, 691-2'},\n", " {'text': 'multiple organ failure (MOF) 227, 691-2'},\n", " {'text': 'multiple organ failure (MOF) 227, 691-2'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'myocardial infarction 30'},\n", " {'text': 'myocardial infarction 30'},\n", " {'text': ''},\n", " {'text': 'nasogastric (NG) tubes'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'GI tract decompression 186, 272-3, 630'},\n", " {'text': 'GI tract decompression 186, 272-3, 630'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'before intubation 69'},\n", " {'text': ''},\n", " {'text': 'pancreas 110, 222, 224, 231-8'},\n", " {'text': 'pancreas 110, 222, 224, 231-8'},\n", " {'text': 'perineal infections 456-7'},\n", " {'text': 'perineal infections 456-7'},\n", " {'text': 'perineal infections 456-7'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'stomach 187'},\n", " {'text': ''},\n", " {'text': 'neostigmine 399'},\n", " {'text': 'nephrectomy 568'},\n", " {'text': 'neutropenic enterocolitis 375-6'},\n", " {'text': ' nasogastric (NG) tubes'}]},\n", " {'page': 877,\n", " 'text': 'nitrogen balance 646\\nnon-specific abdominal pain 30\\nnosocomial secondary peritonitis 129, 138, 679-81, 690-8\\nNSQIP Risk Calculator 67-8, 84\\nnuclear medicine scans 429, 669\\nnutrition 639-48\\n complications of PEG 461-3\\n enteral 228, 634, 642-5\\n in GI fistulas 682\\n malnourished patients 587\\n parenteral 334, 641, 645, 682\\n\\nobese patients 104, 324\\n stomata 154, 157\\nobstetric emergencies 537\\n ectopic pregnancy 18-19, 532-3\\nobstructive jaundice 256-8\\nOgilvie’s syndrome (pseudo-obstruction of the bowel) 383, 398-400\\nomentopexy 214-16, 601-2\\nopiates 293, 658\\noral feeding 642, 647\\norchidopexy 554\\novary\\n cysts 534-5\\n imaging 57, 60\\n torsion 554\\noxygen\\n hyperbaric 457\\n pre-operative 69\\n\\npain, non-specific 30\\npain relief 28, 293, 628, 658\\npancreas\\n acute pancreatitis 27, 36, 221-39\\n biliary pancreatitis 223, 224-5, 260-3\\n imaging 59-60, 224-5, 231, 232-3\\n necrosis 110, 222, 224, 231-8\\n post-ERCP pancreatitis 464\\n trauma 494-5',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Extracted Text\\n- nitrogen balance 646\\n- non-specific abdominal pain 30\\n- nosocomial secondary peritonitis 129, 138, 679-81, 690-8\\n- NSQIP Risk Calculator 67-8, 84\\n- nuclear medicine scans 429, 669\\n- nutrition 639-48\\n- complications of PEG 461-3\\n- enteral 228, 634, 642-5\\n- in GI fistulas 682\\n- malnourished patients 587\\n- parenteral 334, 641, 645, 682\\n- obese patients 104, 324\\n- stomata 154, 157\\n- obstetric emergencies 537\\n- ectopic pregnancy 18-19, 532-3\\n- obstructive jaundice 256-8\\n- Ogilvie’s syndrome (pseudo-obstruction of the bowel) 383, 398-400\\n- omentopexy 214-16, 601-2\\n- opiates 293, 658\\n- oral feeding 642, 647\\n- orchidopexy 554\\n- ovary\\n- cysts 534-5\\n- imaging 57, 60\\n- torsion 554\\n- oxygen\\n- hyperbaric 457\\n- pre-operative 69\\n- pain, non-specific 30\\n- pain relief 28, 293, 628, 658\\n- pancreas\\n- acute pancreatitis 27, 36, 221-39\\n- biliary pancreatitis 223, 224-5, 260-3\\n- imaging 59-60, 224-5, 231, 232-3\\n- necrosis 110, 222, 224, 231-8\\n- post-ERCP pancreatitis 464\\n- trauma 494-5\\n\\n## Notes\\n- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the guidelines.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- nitrogen balance 646\\n- non-specific abdominal pain 30\\n- nosocomial secondary peritonitis 129, 138, 679-81, 690-8\\n- NSQIP Risk Calculator 67-8, 84\\n- nuclear medicine scans 429, 669\\n- nutrition 639-48\\n- complications of PEG 461-3\\n- enteral 228, 634, 642-5\\n- in GI fistulas 682\\n- malnourished patients 587\\n- parenteral 334, 641, 645, 682\\n- obese patients 104, 324\\n- stomata 154, 157\\n- obstetric emergencies 537\\n- ectopic pregnancy 18-19, 532-3\\n- obstructive jaundice 256-8\\n- Ogilvie’s syndrome (pseudo-obstruction of the bowel) 383, 398-400\\n- omentopexy 214-16, 601-2\\n- opiates 293, 658\\n- oral feeding 642, 647\\n- orchidopexy 554\\n- ovary\\n- cysts 534-5\\n- imaging 57, 60\\n- torsion 554\\n- oxygen\\n- hyperbaric 457\\n- pre-operative 69\\n- pain, non-specific 30\\n- pain relief 28, 293, 628, 658\\n- pancreas\\n- acute pancreatitis 27, 36, 221-39\\n- biliary pancreatitis 223, 224-5, 260-3\\n- imaging 59-60, 224-5, 231, 232-3\\n- necrosis 110, 222, 224, 231-8\\n- post-ERCP pancreatitis 464\\n- trauma 494-5',\n", " 'md': '- nitrogen balance 646\\n- non-specific abdominal pain 30\\n- nosocomial secondary peritonitis 129, 138, 679-81, 690-8\\n- NSQIP Risk Calculator 67-8, 84\\n- nuclear medicine scans 429, 669\\n- nutrition 639-48\\n- complications of PEG 461-3\\n- enteral 228, 634, 642-5\\n- in GI fistulas 682\\n- malnourished patients 587\\n- parenteral 334, 641, 645, 682\\n- obese patients 104, 324\\n- stomata 154, 157\\n- obstetric emergencies 537\\n- ectopic pregnancy 18-19, 532-3\\n- obstructive jaundice 256-8\\n- Ogilvie’s syndrome (pseudo-obstruction of the bowel) 383, 398-400\\n- omentopexy 214-16, 601-2\\n- opiates 293, 658\\n- oral feeding 642, 647\\n- orchidopexy 554\\n- ovary\\n- cysts 534-5\\n- imaging 57, 60\\n- torsion 554\\n- oxygen\\n- hyperbaric 457\\n- pre-operative 69\\n- pain, non-specific 30\\n- pain relief 28, 293, 628, 658\\n- pancreas\\n- acute pancreatitis 27, 36, 221-39\\n- biliary pancreatitis 223, 224-5, 260-3\\n- imaging 59-60, 224-5, 231, 232-3\\n- necrosis 110, 222, 224, 231-8\\n- post-ERCP pancreatitis 464\\n- trauma 494-5',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 427.54, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Notes',\n", " 'md': '## Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the guidelines.\\n```',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All text has been extracted as per the guidelines.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'non-specific abdominal pain 30'},\n", " {'text': 'nosocomial secondary peritonitis 129, 138, 679-81, 690-8'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'nuclear medicine scans 429, 669'},\n", " {'text': 'nuclear medicine scans 429, 669'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'complications of PEG 461-3'},\n", " {'text': 'enteral 228, 634, 642-5'},\n", " {'text': 'in GI fistulas 682'},\n", " {'text': 'in GI fistulas 682'},\n", " {'text': ''},\n", " {'text': 'malnourished patients 587'},\n", " {'text': 'parenteral 334, 641, 645, 682'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'stomata 154, 157'},\n", " {'text': 'stomata 154, 157'},\n", " {'text': 'obstetric emergencies 537'},\n", " {'text': 'obstetric emergencies 537'},\n", " {'text': 'ectopic pregnancy 18-19, 532-3'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'Ogilvie’s syndrome (pseudo-obstruction of the bowel) 383, 398-400'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'opiates 293, 658'},\n", " {'text': ''},\n", " {'text': 'oral feeding 642, 647'},\n", " {'text': 'oral feeding 642, 647'},\n", " {'text': 'orchidopexy 554'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'imaging 57, 60'},\n", " {'text': 'torsion 554'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'pre-operative 69'},\n", " {'text': ''},\n", " {'text': 'pain relief 28, 293, 628, 658'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'biliary pancreatitis 223, 224-5, 260-3'},\n", " {'text': 'biliary pancreatitis 223, 224-5, 260-3'},\n", " {'text': 'biliary pancreatitis 223, 224-5, 260-3'},\n", " {'text': 'imaging 59-60, 224-5, 231, 232-3'},\n", " {'text': 'imaging 59-60, 224-5, 231, 232-3'},\n", " {'text': 'imaging 59-60, 224-5, 231, 232-3'},\n", " {'text': 'necrosis 110, 222, 224, 231-8'},\n", " {'text': 'necrosis 110, 222, 224, 231-8'},\n", " {'text': 'necrosis 110, 222, 224, 231-8'},\n", " {'text': 'necrosis 110, 222, 224, 231-8'},\n", " {'text': 'post-ERCP pancreatitis 464'},\n", " {'text': 'post-ERCP pancreatitis 464'},\n", " {'text': 'post-ERCP pancreatitis 464'},\n", " {'text': 'post-ERCP pancreatitis 464'},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 878,\n", " 'text': 'pancreatic fistulas 237\\npandiverticulosis 418-19\\npapaverine 333-4\\nparaesophageal hernias 180, 181-7\\nparalytic ileus 271, 647, 655-6, 657-60, 663-4, 668\\nparasitic infestations 285, 358, 581-6, 589-90\\nparastomal hernias 298\\nparenteral nutrition 334, 641, 645, 682\\npediatrics\\n appendicitis 544, 546-8\\n congenital diaphragmatic hernias 180\\n diagnosis 543-6, 555-6\\n inguinal hernias 552\\n intussusception 17, 545, 548-51, 587-9\\n malrotation 287-90, 545\\n Meckel’s diverticulum 60, 551-2\\n ovarian torsion 554\\n testicular torsion 544, 553-4, 561-4\\n trauma 545, 554-5\\npelvic emergencies see gynecological emergencies\\npelvic inflammatory disease (PID) 535-6\\npelvis, trauma 500-1\\npeptic ulcers\\n bleeding 189-208, 424\\n perforated 18, 124-5, 209-20, 574, 601-2, 709\\npercutaneous abscess drainage 410, 672-4\\npercutaneous endoscopic gastrostomy (PEG), complications 461-3\\nperianal abscesses 373, 438, 444-8\\nperianal blocks 451\\npericardium 102\\npericolic abscesses 408-11\\nperihepatitis 536\\nperineal Crohn’s disease 373\\nperineal infections, necrotizing 456-7\\nperineal trauma 479\\nperipheral parenteral nutrition (PPN) 645\\nperitoneal lavage, diagnostic 486-7\\nperitoneal toilet 133-5, 318\\nperitonitis 15, 127-38',\n", " 'md': '```markdown\\n# Extracted Content from Current Page\\n\\n## Text\\n- pancreatic fistulas 237\\n- pandiverticulosis 418-19\\n- papaverine 333-4\\n- paraesophageal hernias 180, 181-7\\n- paralytic ileus 271, 647, 655-6, 657-60, 663-4, 668\\n- parasitic infestations 285, 358, 581-6, 589-90\\n- parastomal hernias 298\\n- parenteral nutrition 334, 641, 645, 682\\n- pediatrics\\n- appendicitis 544, 546-8\\n- congenital diaphragmatic hernias 180\\n- diagnosis 543-6, 555-6\\n- inguinal hernias 552\\n- intussusception 17, 545, 548-51, 587-9\\n- malrotation 287-90, 545\\n- Meckel’s diverticulum 60, 551-2\\n- ovarian torsion 554\\n- testicular torsion 544, 553-4, 561-4\\n- trauma 545, 554-5\\n- pelvic emergencies see gynecological emergencies\\n- pelvic inflammatory disease (PID) 535-6\\n- pelvis, trauma 500-1\\n- peptic ulcers\\n- bleeding 189-208, 424\\n- perforated 18, 124-5, 209-20, 574, 601-2, 709\\n- percutaneous abscess drainage 410, 672-4\\n- percutaneous endoscopic gastrostomy (PEG), complications 461-3\\n- perianal abscesses 373, 438, 444-8\\n- perianal blocks 451\\n- pericardium 102\\n- pericolic abscesses 408-11\\n- perihepatitis 536\\n- perineal Crohn’s disease 373\\n- perineal infections, necrotizing 456-7\\n- perineal trauma 479\\n- peripheral parenteral nutrition (PPN) 645\\n- peritoneal lavage, diagnostic 486-7\\n- peritoneal toilet 133-5, 318\\n- peritonitis 15, 127-38\\n\\n## Images\\n- No images or graphs were identified on this page.\\n\\n## Tables\\n- No tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Extracted Content from Current Page',\n", " 'md': '# Extracted Content from Current Page',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- pancreatic fistulas 237\\n- pandiverticulosis 418-19\\n- papaverine 333-4\\n- paraesophageal hernias 180, 181-7\\n- paralytic ileus 271, 647, 655-6, 657-60, 663-4, 668\\n- parasitic infestations 285, 358, 581-6, 589-90\\n- parastomal hernias 298\\n- parenteral nutrition 334, 641, 645, 682\\n- pediatrics\\n- appendicitis 544, 546-8\\n- congenital diaphragmatic hernias 180\\n- diagnosis 543-6, 555-6\\n- inguinal hernias 552\\n- intussusception 17, 545, 548-51, 587-9\\n- malrotation 287-90, 545\\n- Meckel’s diverticulum 60, 551-2\\n- ovarian torsion 554\\n- testicular torsion 544, 553-4, 561-4\\n- trauma 545, 554-5\\n- pelvic emergencies see gynecological emergencies\\n- pelvic inflammatory disease (PID) 535-6\\n- pelvis, trauma 500-1\\n- peptic ulcers\\n- bleeding 189-208, 424\\n- perforated 18, 124-5, 209-20, 574, 601-2, 709\\n- percutaneous abscess drainage 410, 672-4\\n- percutaneous endoscopic gastrostomy (PEG), complications 461-3\\n- perianal abscesses 373, 438, 444-8\\n- perianal blocks 451\\n- pericardium 102\\n- pericolic abscesses 408-11\\n- perihepatitis 536\\n- perineal Crohn’s disease 373\\n- perineal infections, necrotizing 456-7\\n- perineal trauma 479\\n- peripheral parenteral nutrition (PPN) 645\\n- peritoneal lavage, diagnostic 486-7\\n- peritoneal toilet 133-5, 318\\n- peritonitis 15, 127-38',\n", " 'md': '- pancreatic fistulas 237\\n- pandiverticulosis 418-19\\n- papaverine 333-4\\n- paraesophageal hernias 180, 181-7\\n- paralytic ileus 271, 647, 655-6, 657-60, 663-4, 668\\n- parasitic infestations 285, 358, 581-6, 589-90\\n- parastomal hernias 298\\n- parenteral nutrition 334, 641, 645, 682\\n- pediatrics\\n- appendicitis 544, 546-8\\n- congenital diaphragmatic hernias 180\\n- diagnosis 543-6, 555-6\\n- inguinal hernias 552\\n- intussusception 17, 545, 548-51, 587-9\\n- malrotation 287-90, 545\\n- Meckel’s diverticulum 60, 551-2\\n- ovarian torsion 554\\n- testicular torsion 544, 553-4, 561-4\\n- trauma 545, 554-5\\n- pelvic emergencies see gynecological emergencies\\n- pelvic inflammatory disease (PID) 535-6\\n- pelvis, trauma 500-1\\n- peptic ulcers\\n- bleeding 189-208, 424\\n- perforated 18, 124-5, 209-20, 574, 601-2, 709\\n- percutaneous abscess drainage 410, 672-4\\n- percutaneous endoscopic gastrostomy (PEG), complications 461-3\\n- perianal abscesses 373, 438, 444-8\\n- perianal blocks 451\\n- pericardium 102\\n- pericolic abscesses 408-11\\n- perihepatitis 536\\n- perineal Crohn’s disease 373\\n- perineal infections, necrotizing 456-7\\n- perineal trauma 479\\n- peripheral parenteral nutrition (PPN) 645\\n- peritoneal lavage, diagnostic 486-7\\n- peritoneal toilet 133-5, 318\\n- peritonitis 15, 127-38',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 426.23, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No tables were identified on this page.\\n```',\n", " 'md': '- No tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'pandiverticulosis 418-19'},\n", " {'text': 'papaverine 333-4'},\n", " {'text': 'paraesophageal hernias 180, 181-7'},\n", " {'text': 'paralytic ileus 271, 647, 655-6, 657-60, 663-4, 668'},\n", " {'text': 'paralytic ileus 271, 647, 655-6, 657-60, 663-4, 668'},\n", " {'text': 'parasitic infestations 285, 358, 581-6, 589-90'},\n", " {'text': 'parasitic infestations 285, 358, 581-6, 589-90'},\n", " {'text': 'parasitic infestations 285, 358, 581-6, 589-90'},\n", " {'text': 'parasitic infestations 285, 358, 581-6, 589-90'},\n", " {'text': 'parasitic infestations 285, 358, 581-6, 589-90'},\n", " {'text': ''},\n", " {'text': 'parastomal hernias 298'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'parenteral nutrition 334, 641, 645, 682'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'congenital diaphragmatic hernias 180'},\n", " {'text': 'congenital diaphragmatic hernias 180'},\n", " {'text': ''},\n", " {'text': 'inguinal hernias 552'},\n", " {'text': 'inguinal hernias 552'},\n", " {'text': 'intussusception 17, 545, 548-51, 587-9'},\n", " {'text': 'malrotation 287-90, 545'},\n", " {'text': 'malrotation 287-90, 545'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'Meckel’s diverticulum 60, 551-2'},\n", " {'text': 'Meckel’s diverticulum 60, 551-2'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'testicular torsion 544, 553-4, 561-4'},\n", " {'text': 'trauma 545, 554-5'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'pelvic emergencies '},\n", " {'text': 'see'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'perforated 18, 124-5, 209-20, 574, 601-2, 709'},\n", " {'text': 'perforated 18, 124-5, 209-20, 574, 601-2, 709'},\n", " {'text': 'percutaneous abscess drainage 410, 672-4'},\n", " {'text': 'percutaneous abscess drainage 410, 672-4'},\n", " {'text': 'percutaneous abscess drainage 410, 672-4'},\n", " {'text': 'percutaneous abscess drainage 410, 672-4'},\n", " {'text': 'percutaneous abscess drainage 410, 672-4'},\n", " {'text': ''},\n", " {'text': 'percutaneous endoscopic gastrostomy (PEG), complications 461-3'},\n", " {'text': 'percutaneous endoscopic gastrostomy (PEG), complications 461-3'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'pericardium 102'},\n", " {'text': 'pericolic abscesses 408-11'},\n", " {'text': ''},\n", " {'text': 'perineal Crohn’s disease 373'},\n", " {'text': 'perineal infections, necrotizing 456-7'},\n", " {'text': ''},\n", " {'text': 'peripheral parenteral nutrition (PPN) 645'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'peritonitis 15, 127-38'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 879,\n", " 'text': ' in children 545\\n diverticulitis 411-17\\n drainage 134-5, 603-4, 607, 696\\n generalized 26-7, 545, 603-4, 690\\n laparoscopy 124-5\\n localized 27-8, 545\\n management 132-7\\n microbiology 80-1, 129, 130, 137-8\\n perforated ulcers 210-11\\n primary 110, 129-30, 137\\n secondary 129, 132-8\\n postoperative 138, 679-81, 690-8\\n tertiary 130-2, 138, 668, 697\\n in trauma patients 475\\nphytobezoars 284\\npiles (hemorrhoids) 424, 438, 442-4, 448-9\\npneumatosis intestinalis 47, 55\\npneumobilia 29, 46-7, 284\\npneumoperitoneum 37, 38, 46, 53-5, 58, 211, 469-70\\npneumothorax 37\\npolypectomy 428, 471\\nporta hepatis 494\\nportal hypertension, emergencies in patients with 341-53\\nportal vein\\n gas in 47\\n trauma 355, 356-7\\npositioning a patient 93-4, 325, 414\\n anorectal surgery 93, 450-1\\n avoiding IAH 512\\npost-hepatic jaundice 256-8\\npostoperative period\\n abscesses 128, 605, 665-76, 692, 709-10\\n anal surgery 448-50\\n anastomotic complications 143, 435-6, 662, 677-87, 696, 710\\n antibiotics 79, 275, 314, 633, 649-54, 707, 717\\n drains see drains/drainage\\n DVT 94, 634\\n general management 627-38\\n ileus/EPSBO 655-64, 668, 709',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Extracted Text\\n- diverticulitis 411-17\\n- drainage 134-5, 603-4, 607, 696\\n- generalized 26-7, 545, 603-4, 690\\n- laparoscopy 124-5\\n- localized 27-8, 545\\n- management 132-7\\n- microbiology 80-1, 129, 130, 137-8\\n- perforated ulcers 210-11\\n- primary 110, 129-30, 137\\n- secondary 129, 132-8\\n- postoperative 138, 679-81, 690-8\\n- tertiary 130-2, 138, 668, 697\\n- in trauma patients 475\\n- phytobezoars 284\\n- piles (hemorrhoids) 424, 438, 442-4, 448-9\\n- pneumatosis intestinalis 47, 55\\n- pneumobilia 29, 46-7, 284\\n- pneumoperitoneum 37, 38, 46, 53-5, 58, 211, 469-70\\n- pneumothorax 37\\n- polypectomy 428, 471\\n- porta hepatis 494\\n- portal hypertension, emergencies in patients with 341-53\\n- portal vein gas in 47\\n- portal vein trauma 355, 356-7\\n- positioning a patient 93-4, 325, 414\\n- anorectal surgery 93, 450-1\\n- avoiding IAH 512\\n- post-hepatic jaundice 256-8\\n- postoperative period\\n- abscesses 128, 605, 665-76, 692, 709-10\\n- anal surgery 448-50\\n- anastomotic complications 143, 435-6, 662, 677-87, 696, 710\\n- antibiotics 79, 275, 314, 633, 649-54, 707, 717\\n- drains see drains/drainage\\n- DVT 94, 634\\n- general management 627-38\\n- ileus/EPSBO 655-64, 668, 709\\n\\n## Images and Graphs\\n- No images or graphs were identified on this page.\\n\\n## Tables\\n- No tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- diverticulitis 411-17\\n- drainage 134-5, 603-4, 607, 696\\n- generalized 26-7, 545, 603-4, 690\\n- laparoscopy 124-5\\n- localized 27-8, 545\\n- management 132-7\\n- microbiology 80-1, 129, 130, 137-8\\n- perforated ulcers 210-11\\n- primary 110, 129-30, 137\\n- secondary 129, 132-8\\n- postoperative 138, 679-81, 690-8\\n- tertiary 130-2, 138, 668, 697\\n- in trauma patients 475\\n- phytobezoars 284\\n- piles (hemorrhoids) 424, 438, 442-4, 448-9\\n- pneumatosis intestinalis 47, 55\\n- pneumobilia 29, 46-7, 284\\n- pneumoperitoneum 37, 38, 46, 53-5, 58, 211, 469-70\\n- pneumothorax 37\\n- polypectomy 428, 471\\n- porta hepatis 494\\n- portal hypertension, emergencies in patients with 341-53\\n- portal vein gas in 47\\n- portal vein trauma 355, 356-7\\n- positioning a patient 93-4, 325, 414\\n- anorectal surgery 93, 450-1\\n- avoiding IAH 512\\n- post-hepatic jaundice 256-8\\n- postoperative period\\n- abscesses 128, 605, 665-76, 692, 709-10\\n- anal surgery 448-50\\n- anastomotic complications 143, 435-6, 662, 677-87, 696, 710\\n- antibiotics 79, 275, 314, 633, 649-54, 707, 717\\n- drains see drains/drainage\\n- DVT 94, 634\\n- general management 627-38\\n- ileus/EPSBO 655-64, 668, 709',\n", " 'md': '- diverticulitis 411-17\\n- drainage 134-5, 603-4, 607, 696\\n- generalized 26-7, 545, 603-4, 690\\n- laparoscopy 124-5\\n- localized 27-8, 545\\n- management 132-7\\n- microbiology 80-1, 129, 130, 137-8\\n- perforated ulcers 210-11\\n- primary 110, 129-30, 137\\n- secondary 129, 132-8\\n- postoperative 138, 679-81, 690-8\\n- tertiary 130-2, 138, 668, 697\\n- in trauma patients 475\\n- phytobezoars 284\\n- piles (hemorrhoids) 424, 438, 442-4, 448-9\\n- pneumatosis intestinalis 47, 55\\n- pneumobilia 29, 46-7, 284\\n- pneumoperitoneum 37, 38, 46, 53-5, 58, 211, 469-70\\n- pneumothorax 37\\n- polypectomy 428, 471\\n- porta hepatis 494\\n- portal hypertension, emergencies in patients with 341-53\\n- portal vein gas in 47\\n- portal vein trauma 355, 356-7\\n- positioning a patient 93-4, 325, 414\\n- anorectal surgery 93, 450-1\\n- avoiding IAH 512\\n- post-hepatic jaundice 256-8\\n- postoperative period\\n- abscesses 128, 605, 665-76, 692, 709-10\\n- anal surgery 448-50\\n- anastomotic complications 143, 435-6, 662, 677-87, 696, 710\\n- antibiotics 79, 275, 314, 633, 649-54, 707, 717\\n- drains see drains/drainage\\n- DVT 94, 634\\n- general management 627-38\\n- ileus/EPSBO 655-64, 668, 709',\n", " 'bBox': {'x': 72, 'y': 102, 'w': 390.22, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images and Graphs',\n", " 'md': '## Images and Graphs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No tables were identified on this page.\\n```',\n", " 'md': '- No tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'diverticulitis 411-17'},\n", " {'text': 'drainage 134-5, 603-4, 607, 696'},\n", " {'text': 'generalized 26-7, 545, 603-4, 690'},\n", " {'text': 'generalized 26-7, 545, 603-4, 690'},\n", " {'text': 'generalized 26-7, 545, 603-4, 690'},\n", " {'text': 'generalized 26-7, 545, 603-4, 690'},\n", " {'text': 'laparoscopy 124-5'},\n", " {'text': 'laparoscopy 124-5'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'localized 27-8, 545'},\n", " {'text': 'management 132-7'},\n", " {'text': 'management 132-7'},\n", " {'text': 'microbiology 80-1, 129, 130, 137-8'},\n", " {'text': 'perforated ulcers 210-11'},\n", " {'text': 'perforated ulcers 210-11'},\n", " {'text': 'perforated ulcers 210-11'},\n", " {'text': ''},\n", " {'text': 'primary 110, 129-30, 137'},\n", " {'text': 'secondary 129, 132-8'},\n", " {'text': 'secondary 129, 132-8'},\n", " {'text': 'secondary 129, 132-8'},\n", " {'text': 'postoperative 138, 679-81, 690-8'},\n", " {'text': 'postoperative 138, 679-81, 690-8'},\n", " {'text': 'tertiary 130-2, 138, 668, 697'},\n", " {'text': 'tertiary 130-2, 138, 668, 697'},\n", " {'text': ''},\n", " {'text': 'in trauma patients 475'},\n", " {'text': 'in trauma patients 475'},\n", " {'text': 'in trauma patients 475'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'piles (hemorrhoids) 424, 438, 442-4, 448-9'},\n", " {'text': 'pneumatosis intestinalis 47, 55'},\n", " {'text': 'pneumatosis intestinalis 47, 55'},\n", " {'text': 'pneumatosis intestinalis 47, 55'},\n", " {'text': ''},\n", " {'text': 'pneumobilia 29, 46-7, 284'},\n", " {'text': ''},\n", " {'text': 'pneumoperitoneum 37, 38, 46, 53-5, 58, 211, 469-70'},\n", " {'text': 'pneumoperitoneum 37, 38, 46, 53-5, 58, 211, 469-70'},\n", " {'text': 'pneumoperitoneum 37, 38, 46, 53-5, 58, 211, 469-70'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'polypectomy 428, 471'},\n", " {'text': 'porta hepatis 494'},\n", " {'text': ''},\n", " {'text': 'portal hypertension, emergencies in patients with 341-53'},\n", " {'text': ''},\n", " {'text': 'trauma 355, 356-7'},\n", " {'text': 'positioning a patient 93-4, 325, 414'},\n", " {'text': 'positioning a patient 93-4, 325, 414'},\n", " {'text': 'anorectal surgery 93, 450-1'},\n", " {'text': 'anorectal surgery 93, 450-1'},\n", " {'text': 'anorectal surgery 93, 450-1'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'post-hepatic jaundice 256-8'},\n", " {'text': ''},\n", " {'text': 'anal surgery 448-50'},\n", " {'text': 'anal surgery 448-50'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'anastomotic complications 143, 435-6, 662, 677-87, 696, 710'},\n", " {'text': 'antibiotics 79, 275, 314, 633, 649-54, 707, 717'},\n", " {'text': 'antibiotics 79, 275, 314, 633, 649-54, 707, 717'},\n", " {'text': 'antibiotics 79, 275, 314, 633, 649-54, 707, 717'},\n", " {'text': 'antibiotics 79, 275, 314, 633, 649-54, 707, 717'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ' drains/drainage'},\n", " {'text': ' drains/drainage'},\n", " {'text': ' drains/drainage'},\n", " {'text': ' drains/drainage'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'general management 627-38'},\n", " {'text': 'general management 627-38'},\n", " {'text': 'ileus/EPSBO 655-64, 668, 709'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 880,\n", " 'text': ' nutrition 334, 634, 639-48, 682\\n stoma care 158-9\\n wound care 450, 713-21\\n see also relaparotomy\\npostpartum period 540-1\\npostural hypotension 70\\npre-closure checklist 623\\npre-operative period\\n antibiotics 77-82, 213\\n checklist 91-4\\n patient optimization 65-76, 194, 272, 475\\n surgeon’s role 31-3, 57, 61-2\\n talking to the patient and family 83-6, 88-9\\n see also diagnosis\\npregnancy\\n acute abdomen during 315, 536-40\\n ectopic 18-19, 532-3\\nprimary survey 109\\nPringle maneuver 356, 493\\nproctectomy 371\\nproctoscopy 431, 435\\nproton pump inhibitors 199, 220\\npseudocyst, pancreatic 231, 233\\npseudomembranous colitis (C. difficile) 36, 365, 366, 373-4\\npseudo-obstruction of the bowel (Ogilvie’s syndrome) 383, 398-400\\npulmonary capillary wedge pressure 71-2\\npulmonary embolism 634\\npyloric obstruction/stenosis 218\\npyrexia 632\\n\\nradiation enteritis 282-3, 661\\nradiation proctitis 434\\nradiography see abdominal X-rays; chest X-rays; CT scans\\nradioisotope scans 429, 669\\nrectum\\n bleeding 424, 431, 432-3, 434\\n see also lower GI bleeding\\n digital examination 380, 441, 479, 544\\n IBD 368, 369-70, 371',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Extracted Text\\n- nutrition 334, 634, 639-48, 682\\n- stoma care 158-9\\n- wound care 450, 713-21\\n- see also relaparotomy\\n- postpartum period 540-1\\n- postural hypotension 70\\n- pre-closure checklist 623\\n- pre-operative period\\n- antibiotics 77-82, 213\\n- checklist 91-4\\n- patient optimization 65-76, 194, 272, 475\\n- surgeon’s role 31-3, 57, 61-2\\n- talking to the patient and family 83-6, 88-9\\n- see also diagnosis\\n- pregnancy\\n- acute abdomen during 315, 536-40\\n- ectopic 18-19, 532-3\\n- primary survey 109\\n- Pringle maneuver 356, 493\\n- proctectomy 371\\n- proctoscopy 431, 435\\n- proton pump inhibitors 199, 220\\n- pseudocyst, pancreatic 231, 233\\n- pseudomembranous colitis (C. difficile) 36, 365, 366, 373-4\\n- pseudo-obstruction of the bowel (Ogilvie’s syndrome) 383, 398-400\\n- pulmonary capillary wedge pressure 71-2\\n- pulmonary embolism 634\\n- pyloric obstruction/stenosis 218\\n- pyrexia 632\\n- radiation enteritis 282-3, 661\\n- radiation proctitis 434\\n- radiography see abdominal X-rays; chest X-rays; CT scans\\n- radioisotope scans 429, 669\\n- rectum\\n- bleeding 424, 431, 432-3, 434\\n- see also lower GI bleeding\\n- digital examination 380, 441, 479, 544\\n- IBD 368, 369-70, 371\\n\\n## Notes\\n- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- nutrition 334, 634, 639-48, 682\\n- stoma care 158-9\\n- wound care 450, 713-21\\n- see also relaparotomy\\n- postpartum period 540-1\\n- postural hypotension 70\\n- pre-closure checklist 623\\n- pre-operative period\\n- antibiotics 77-82, 213\\n- checklist 91-4\\n- patient optimization 65-76, 194, 272, 475\\n- surgeon’s role 31-3, 57, 61-2\\n- talking to the patient and family 83-6, 88-9\\n- see also diagnosis\\n- pregnancy\\n- acute abdomen during 315, 536-40\\n- ectopic 18-19, 532-3\\n- primary survey 109\\n- Pringle maneuver 356, 493\\n- proctectomy 371\\n- proctoscopy 431, 435\\n- proton pump inhibitors 199, 220\\n- pseudocyst, pancreatic 231, 233\\n- pseudomembranous colitis (C. difficile) 36, 365, 366, 373-4\\n- pseudo-obstruction of the bowel (Ogilvie’s syndrome) 383, 398-400\\n- pulmonary capillary wedge pressure 71-2\\n- pulmonary embolism 634\\n- pyloric obstruction/stenosis 218\\n- pyrexia 632\\n- radiation enteritis 282-3, 661\\n- radiation proctitis 434\\n- radiography see abdominal X-rays; chest X-rays; CT scans\\n- radioisotope scans 429, 669\\n- rectum\\n- bleeding 424, 431, 432-3, 434\\n- see also lower GI bleeding\\n- digital examination 380, 441, 479, 544\\n- IBD 368, 369-70, 371',\n", " 'md': '- nutrition 334, 634, 639-48, 682\\n- stoma care 158-9\\n- wound care 450, 713-21\\n- see also relaparotomy\\n- postpartum period 540-1\\n- postural hypotension 70\\n- pre-closure checklist 623\\n- pre-operative period\\n- antibiotics 77-82, 213\\n- checklist 91-4\\n- patient optimization 65-76, 194, 272, 475\\n- surgeon’s role 31-3, 57, 61-2\\n- talking to the patient and family 83-6, 88-9\\n- see also diagnosis\\n- pregnancy\\n- acute abdomen during 315, 536-40\\n- ectopic 18-19, 532-3\\n- primary survey 109\\n- Pringle maneuver 356, 493\\n- proctectomy 371\\n- proctoscopy 431, 435\\n- proton pump inhibitors 199, 220\\n- pseudocyst, pancreatic 231, 233\\n- pseudomembranous colitis (C. difficile) 36, 365, 366, 373-4\\n- pseudo-obstruction of the bowel (Ogilvie’s syndrome) 383, 398-400\\n- pulmonary capillary wedge pressure 71-2\\n- pulmonary embolism 634\\n- pyloric obstruction/stenosis 218\\n- pyrexia 632\\n- radiation enteritis 282-3, 661\\n- radiation proctitis 434\\n- radiography see abdominal X-rays; chest X-rays; CT scans\\n- radioisotope scans 429, 669\\n- rectum\\n- bleeding 424, 431, 432-3, 434\\n- see also lower GI bleeding\\n- digital examination 380, 441, 479, 544\\n- IBD 368, 369-70, 371',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 427.54, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Notes',\n", " 'md': '## Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented without headers, footers, or diagonal text.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'stoma care 158-9'},\n", " {'text': 'stoma care 158-9'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'wound care 450, 713-21'},\n", " {'text': ' relaparotomy'},\n", " {'text': ' relaparotomy'},\n", " {'text': 'postural hypotension 70'},\n", " {'text': 'pre-closure checklist 623'},\n", " {'text': ''},\n", " {'text': 'checklist 91-4'},\n", " {'text': ''},\n", " {'text': 'patient optimization 65-76, 194, 272, 475'},\n", " {'text': 'surgeon’s role 31-3, 57, 61-2'},\n", " {'text': 'surgeon’s role 31-3, 57, 61-2'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'talking to the patient and family 83-6, 88-9'},\n", " {'text': 'talking to the patient and family 83-6, 88-9'},\n", " {'text': 'talking to the patient and family 83-6, 88-9'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'primary survey 109'},\n", " {'text': ''},\n", " {'text': 'Pringle maneuver 356, 493'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'proctoscopy 431, 435'},\n", " {'text': 'proton pump inhibitors 199, 220'},\n", " {'text': 'proton pump inhibitors 199, 220'},\n", " {'text': 'pseudocyst, pancreatic 231, 233'},\n", " {'text': 'pseudocyst, pancreatic 231, 233'},\n", " {'text': 'pseudomembranous colitis ('},\n", " {'text': 'C. difficile'},\n", " {'text': 'pseudo-obstruction of the bowel (Ogilvie’s syndrome) 383, 398-400'},\n", " {'text': 'pseudo-obstruction of the bowel (Ogilvie’s syndrome) 383, 398-400'},\n", " {'text': 'pseudo-obstruction of the bowel (Ogilvie’s syndrome) 383, 398-400'},\n", " {'text': 'pseudo-obstruction of the bowel (Ogilvie’s syndrome) 383, 398-400'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'pyloric obstruction/stenosis 218'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'radiation proctitis 434'},\n", " {'text': ''},\n", " {'text': ' abdominal X-rays; chest X-rays; CT scans'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'see also'},\n", " {'text': 'see also'},\n", " {'text': ' lower GI bleeding'},\n", " {'text': ' lower GI bleeding'},\n", " {'text': 'IBD 368, 369-70, 371'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 881,\n", " 'text': ' prolapse 452\\n stents 384-5\\n trauma 452-5, 479, 498\\nrectus abdominis hematoma 537-8\\nrefeeding syndrome 645\\nrelaparotomy 84-5, 690\\n ‘on demand’ 690-3\\n anastomotic leaks 680-1, 696\\n planned 136-7, 693-4, 696-8\\n mesenteric ischemia 337-8\\n techniques 103, 694-6\\nrenal artery 567\\nrenal colic 57, 559-61\\nrenal imaging 60, 566-7\\nrenal trauma 495-6, 565-8\\nrenal vein 521\\nresuscitation\\n hemorrhage 66, 72-3, 75-6, 194, 475\\n over-resuscitation 75-6, 194\\n pancreatitis 227\\n pre-operative 65-76, 194, 272, 475\\n SBO 272\\n trauma patients 475\\nretractors 113\\nretroperitoneum\\n exploration 111-12\\n hematoma 499-500, 522\\n imaging 47-8, 56, 62\\nReynold’s pentad 258\\nRichter’s hernia 293\\nround hepatic ligament 104\\n\\nsafeguarding 555\\nsalpingectomy 18-19, 533\\nsandwich technique for temporary closure 700-2\\nSBO see small bowel obstruction\\nscrotum 544\\n testicular torsion 553-4, 561-4\\n trauma 570-1',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Extracted Text\\n- prolapse 452\\n- stents 384-5\\n- trauma 452-5, 479, 498\\n- rectus abdominis hematoma 537-8\\n- refeeding syndrome 645\\n- relaparotomy 84-5, 690\\n- ‘on demand’ 690-3\\n- anastomotic leaks 680-1, 696\\n- planned 136-7, 693-4, 696-8\\n- mesenteric ischemia 337-8\\n- techniques 103, 694-6\\n- renal artery 567\\n- renal colic 57, 559-61\\n- renal imaging 60, 566-7\\n- renal trauma 495-6, 565-8\\n- renal vein 521\\n- resuscitation\\n- hemorrhage 66, 72-3, 75-6, 194, 475\\n- over-resuscitation 75-6, 194\\n- pancreatitis 227\\n- pre-operative 65-76, 194, 272, 475\\n- SBO 272\\n- trauma patients 475\\n- retractors 113\\n- retroperitoneum\\n- exploration 111-12\\n- hematoma 499-500, 522\\n- imaging 47-8, 56, 62\\n- Reynold’s pentad 258\\n- Richter’s hernia 293\\n- round hepatic ligament 104\\n- safeguarding 555\\n- salpingectomy 18-19, 533\\n- sandwich technique for temporary closure 700-2\\n- SBO see small bowel obstruction\\n- scrotum 544\\n- testicular torsion 553-4, 561-4\\n- trauma 570-1\\n\\n## Hyperlinks\\n- None identified.\\n\\n## Formulas\\n- None identified.\\n\\n## Images and Graphs\\n- None identified.\\n\\n## Tables\\n- None identified.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- prolapse 452\\n- stents 384-5\\n- trauma 452-5, 479, 498\\n- rectus abdominis hematoma 537-8\\n- refeeding syndrome 645\\n- relaparotomy 84-5, 690\\n- ‘on demand’ 690-3\\n- anastomotic leaks 680-1, 696\\n- planned 136-7, 693-4, 696-8\\n- mesenteric ischemia 337-8\\n- techniques 103, 694-6\\n- renal artery 567\\n- renal colic 57, 559-61\\n- renal imaging 60, 566-7\\n- renal trauma 495-6, 565-8\\n- renal vein 521\\n- resuscitation\\n- hemorrhage 66, 72-3, 75-6, 194, 475\\n- over-resuscitation 75-6, 194\\n- pancreatitis 227\\n- pre-operative 65-76, 194, 272, 475\\n- SBO 272\\n- trauma patients 475\\n- retractors 113\\n- retroperitoneum\\n- exploration 111-12\\n- hematoma 499-500, 522\\n- imaging 47-8, 56, 62\\n- Reynold’s pentad 258\\n- Richter’s hernia 293\\n- round hepatic ligament 104\\n- safeguarding 555\\n- salpingectomy 18-19, 533\\n- sandwich technique for temporary closure 700-2\\n- SBO see small bowel obstruction\\n- scrotum 544\\n- testicular torsion 553-4, 561-4\\n- trauma 570-1',\n", " 'md': '- prolapse 452\\n- stents 384-5\\n- trauma 452-5, 479, 498\\n- rectus abdominis hematoma 537-8\\n- refeeding syndrome 645\\n- relaparotomy 84-5, 690\\n- ‘on demand’ 690-3\\n- anastomotic leaks 680-1, 696\\n- planned 136-7, 693-4, 696-8\\n- mesenteric ischemia 337-8\\n- techniques 103, 694-6\\n- renal artery 567\\n- renal colic 57, 559-61\\n- renal imaging 60, 566-7\\n- renal trauma 495-6, 565-8\\n- renal vein 521\\n- resuscitation\\n- hemorrhage 66, 72-3, 75-6, 194, 475\\n- over-resuscitation 75-6, 194\\n- pancreatitis 227\\n- pre-operative 65-76, 194, 272, 475\\n- SBO 272\\n- trauma patients 475\\n- retractors 113\\n- retroperitoneum\\n- exploration 111-12\\n- hematoma 499-500, 522\\n- imaging 47-8, 56, 62\\n- Reynold’s pentad 258\\n- Richter’s hernia 293\\n- round hepatic ligament 104\\n- safeguarding 555\\n- salpingectomy 18-19, 533\\n- sandwich technique for temporary closure 700-2\\n- SBO see small bowel obstruction\\n- scrotum 544\\n- testicular torsion 553-4, 561-4\\n- trauma 570-1',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 307.07, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Hyperlinks',\n", " 'md': '## Hyperlinks',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.',\n", " 'md': '- None identified.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formulas',\n", " 'md': '## Formulas',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.',\n", " 'md': '- None identified.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images and Graphs',\n", " 'md': '## Images and Graphs',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.',\n", " 'md': '- None identified.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- None identified.\\n```',\n", " 'md': '- None identified.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'stents 384-5'},\n", " {'text': 'trauma 452-5, 479, 498'},\n", " {'text': 'rectus abdominis hematoma 537-8'},\n", " {'text': 'rectus abdominis hematoma 537-8'},\n", " {'text': 'rectus abdominis hematoma 537-8'},\n", " {'text': ''},\n", " {'text': 'relaparotomy 84-5, 690'},\n", " {'text': '‘on demand’ 690-3'},\n", " {'text': '‘on demand’ 690-3'},\n", " {'text': 'anastomotic leaks 680-1, 696'},\n", " {'text': 'planned 136-7, 693-4, 696-8'},\n", " {'text': ''},\n", " {'text': 'mesenteric ischemia 337-8'},\n", " {'text': 'mesenteric ischemia 337-8'},\n", " {'text': 'mesenteric ischemia 337-8'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'renal colic 57, 559-61'},\n", " {'text': 'renal imaging 60, 566-7'},\n", " {'text': 'renal imaging 60, 566-7'},\n", " {'text': 'renal trauma 495-6, 565-8'},\n", " {'text': 'renal trauma 495-6, 565-8'},\n", " {'text': 'renal vein 521'},\n", " {'text': ''},\n", " {'text': 'resuscitation'},\n", " {'text': 'over-resuscitation 75-6, 194'},\n", " {'text': 'over-resuscitation 75-6, 194'},\n", " {'text': 'over-resuscitation 75-6, 194'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'pre-operative 65-76, 194, 272, 475'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'trauma patients 475'},\n", " {'text': ''},\n", " {'text': 'retroperitoneum'},\n", " {'text': 'hematoma 499-500, 522'},\n", " {'text': 'imaging 47-8, 56, 62'},\n", " {'text': ''},\n", " {'text': 'Reynold’s pentad 258'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'Richter’s hernia 293'},\n", " {'text': 'round hepatic ligament 104'},\n", " {'text': ''},\n", " {'text': 'salpingectomy 18-19, 533'},\n", " {'text': 'sandwich technique for temporary closure 700-2'},\n", " {'text': 'sandwich technique for temporary closure 700-2'},\n", " {'text': ''},\n", " {'text': 'testicular torsion 553-4, 561-4'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 882,\n", " 'text': 'secondary survey 109-13\\nsepsis 128\\nshock 26, 69-70, 107-9, 194, 475, 540\\nshotgun injuries 483\\nsickle cell disease 595-6\\nsigmoid diverticulitis 60, 125, 401-18, 420\\nsigmoid volvulus 395-7, 593-4\\n ileosigmoid knotting 287, 594\\nSIRS (systemic inflammatory response syndrome) 8-9, 128, 653\\nsmall bowel\\n anastomosis 139-48, 336-7, 371\\n see also anastomosis, leaks\\n bleeding duodenal ulcers 191, 195, 202, 204-5, 206, 424\\n Crohn’s disease 60, 363, 370-1\\n imaging 48, 60, 211-12, 267, 270-2, 274-5, 289\\n ischemia 269, 294\\n mesenteric 39-40, 55, 329-40, 709\\n Meckel’s diverticulum 60, 551-2\\n obstruction see small bowel obstruction\\n perforation\\n Crohn’s disease 370-1\\n duodenal ulcers 124-5, 209-20, 574, 601-2, 709\\n after ERCP 465-7\\n infections/infestations 576-8, 583, 594-5\\n in the Third World 574-5\\n stomata 147, 148-52, 154, 155-6, 157-9, 337, 643-4\\n trauma 496-7\\nsmall bowel obstruction (SBO) 28-9, 265-90\\n adhesions 17, 29, 265-80, 283, 290, 545\\n early 657, 661\\n bezoars 284-5\\n cancer 29, 271, 282, 661\\n in children 545\\n Crohn’s disease 372\\n decompression 277-8\\n gallstone ileus 29, 283-4\\n after gastrectomy 285-6, 662\\n hernias 29, 269, 292-3, 296, 657, 660-1\\n ileosigmoid knotting 287, 594',\n", " 'md': '```markdown\\n# Current Page Content\\n\\n## Text\\n- secondary survey 109-13\\n- sepsis 128\\n- shock 26, 69-70, 107-9, 194, 475, 540\\n- shotgun injuries 483\\n- sickle cell disease 595-6\\n- sigmoid diverticulitis 60, 125, 401-18, 420\\n- sigmoid volvulus 395-7, 593-4\\n- ileosigmoid knotting 287, 594\\n- SIRS (systemic inflammatory response syndrome) 8-9, 128, 653\\n- small bowel\\n- anastomosis 139-48, 336-7, 371\\n- see also anastomosis, leaks\\n- bleeding duodenal ulcers 191, 195, 202, 204-5, 206, 424\\n- Crohn’s disease 60, 363, 370-1\\n- imaging 48, 60, 211-12, 267, 270-2, 274-5, 289\\n- ischemia 269, 294\\n- mesenteric 39-40, 55, 329-40, 709\\n- Meckel’s diverticulum 60, 551-2\\n- obstruction see small bowel obstruction\\n- perforation\\n- Crohn’s disease 370-1\\n- duodenal ulcers 124-5, 209-20, 574, 601-2, 709\\n- after ERCP 465-7\\n- infections/infestations 576-8, 583, 594-5\\n- in the Third World 574-5\\n- stomata 147, 148-52, 154, 155-6, 157-9, 337, 643-4\\n- trauma 496-7\\n- small bowel obstruction (SBO) 28-9, 265-90\\n- adhesions 17, 29, 265-80, 283, 290, 545\\n- early 657, 661\\n- bezoars 284-5\\n- cancer 29, 271, 282, 661\\n- in children 545\\n- Crohn’s disease 372\\n- decompression 277-8\\n- gallstone ileus 29, 283-4\\n- after gastrectomy 285-6, 662\\n- hernias 29, 269, 292-3, 296, 657, 660-1\\n- ileosigmoid knotting 287, 594\\n\\n## Images\\n- No images or graphs were identified on this page.\\n\\n## Tables\\n- No tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Current Page Content',\n", " 'md': '# Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- secondary survey 109-13\\n- sepsis 128\\n- shock 26, 69-70, 107-9, 194, 475, 540\\n- shotgun injuries 483\\n- sickle cell disease 595-6\\n- sigmoid diverticulitis 60, 125, 401-18, 420\\n- sigmoid volvulus 395-7, 593-4\\n- ileosigmoid knotting 287, 594\\n- SIRS (systemic inflammatory response syndrome) 8-9, 128, 653\\n- small bowel\\n- anastomosis 139-48, 336-7, 371\\n- see also anastomosis, leaks\\n- bleeding duodenal ulcers 191, 195, 202, 204-5, 206, 424\\n- Crohn’s disease 60, 363, 370-1\\n- imaging 48, 60, 211-12, 267, 270-2, 274-5, 289\\n- ischemia 269, 294\\n- mesenteric 39-40, 55, 329-40, 709\\n- Meckel’s diverticulum 60, 551-2\\n- obstruction see small bowel obstruction\\n- perforation\\n- Crohn’s disease 370-1\\n- duodenal ulcers 124-5, 209-20, 574, 601-2, 709\\n- after ERCP 465-7\\n- infections/infestations 576-8, 583, 594-5\\n- in the Third World 574-5\\n- stomata 147, 148-52, 154, 155-6, 157-9, 337, 643-4\\n- trauma 496-7\\n- small bowel obstruction (SBO) 28-9, 265-90\\n- adhesions 17, 29, 265-80, 283, 290, 545\\n- early 657, 661\\n- bezoars 284-5\\n- cancer 29, 271, 282, 661\\n- in children 545\\n- Crohn’s disease 372\\n- decompression 277-8\\n- gallstone ileus 29, 283-4\\n- after gastrectomy 285-6, 662\\n- hernias 29, 269, 292-3, 296, 657, 660-1\\n- ileosigmoid knotting 287, 594',\n", " 'md': '- secondary survey 109-13\\n- sepsis 128\\n- shock 26, 69-70, 107-9, 194, 475, 540\\n- shotgun injuries 483\\n- sickle cell disease 595-6\\n- sigmoid diverticulitis 60, 125, 401-18, 420\\n- sigmoid volvulus 395-7, 593-4\\n- ileosigmoid knotting 287, 594\\n- SIRS (systemic inflammatory response syndrome) 8-9, 128, 653\\n- small bowel\\n- anastomosis 139-48, 336-7, 371\\n- see also anastomosis, leaks\\n- bleeding duodenal ulcers 191, 195, 202, 204-5, 206, 424\\n- Crohn’s disease 60, 363, 370-1\\n- imaging 48, 60, 211-12, 267, 270-2, 274-5, 289\\n- ischemia 269, 294\\n- mesenteric 39-40, 55, 329-40, 709\\n- Meckel’s diverticulum 60, 551-2\\n- obstruction see small bowel obstruction\\n- perforation\\n- Crohn’s disease 370-1\\n- duodenal ulcers 124-5, 209-20, 574, 601-2, 709\\n- after ERCP 465-7\\n- infections/infestations 576-8, 583, 594-5\\n- in the Third World 574-5\\n- stomata 147, 148-52, 154, 155-6, 157-9, 337, 643-4\\n- trauma 496-7\\n- small bowel obstruction (SBO) 28-9, 265-90\\n- adhesions 17, 29, 265-80, 283, 290, 545\\n- early 657, 661\\n- bezoars 284-5\\n- cancer 29, 271, 282, 661\\n- in children 545\\n- Crohn’s disease 372\\n- decompression 277-8\\n- gallstone ileus 29, 283-4\\n- after gastrectomy 285-6, 662\\n- hernias 29, 269, 292-3, 296, 657, 660-1\\n- ileosigmoid knotting 287, 594',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 408.6, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No tables were identified on this page.\\n```',\n", " 'md': '- No tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': 'shock 26, 69-70, 107-9, 194, 475, 540'},\n", " {'text': 'shotgun injuries 483'},\n", " {'text': 'shotgun injuries 483'},\n", " {'text': 'shotgun injuries 483'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'sickle cell disease 595-6'},\n", " {'text': 'sigmoid diverticulitis 60, 125, 401-18, 420'},\n", " {'text': 'sigmoid volvulus 395-7, 593-4'},\n", " {'text': 'sigmoid volvulus 395-7, 593-4'},\n", " {'text': 'sigmoid volvulus 395-7, 593-4'},\n", " {'text': ''},\n", " {'text': 'ileosigmoid knotting 287, 594'},\n", " {'text': 'ileosigmoid knotting 287, 594'},\n", " {'text': 'SIRS (systemic inflammatory response syndrome) 8-9, 128, 653'},\n", " {'text': 'SIRS (systemic inflammatory response syndrome) 8-9, 128, 653'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'see also'},\n", " {'text': ' anastomosis, leaks'},\n", " {'text': ' anastomosis, leaks'},\n", " {'text': 'Crohn’s disease 60, 363, 370-1'},\n", " {'text': 'Crohn’s disease 60, 363, 370-1'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'imaging 48, 60, 211-12, 267, 270-2, 274-5, 289'},\n", " {'text': 'imaging 48, 60, 211-12, 267, 270-2, 274-5, 289'},\n", " {'text': 'imaging 48, 60, 211-12, 267, 270-2, 274-5, 289'},\n", " {'text': 'ischemia 269, 294'},\n", " {'text': 'ischemia 269, 294'},\n", " {'text': 'ischemia 269, 294'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'mesenteric 39-40, 55, 329-40, 709'},\n", " {'text': 'mesenteric 39-40, 55, 329-40, 709'},\n", " {'text': 'Meckel’s diverticulum 60, 551-2'},\n", " {'text': 'Meckel’s diverticulum 60, 551-2'},\n", " {'text': 'Meckel’s diverticulum 60, 551-2'},\n", " {'text': ''},\n", " {'text': ' small bowel obstruction'},\n", " {'text': ' small bowel obstruction'},\n", " {'text': 'duodenal ulcers 124-5, 209-20, 574, 601-2, 709'},\n", " {'text': 'after ERCP 465-7'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'infections/infestations 576-8, 583, 594-5'},\n", " {'text': 'in the Third World 574-5'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'stomata 147, 148-52, 154, 155-6, 157-9, 337, 643-4'},\n", " {'text': 'trauma 496-7'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'small bowel obstruction (SBO) 28-9, 265-90'},\n", " {'text': 'adhesions 17, 29, 265-80, 283, 290, 545'},\n", " {'text': 'adhesions 17, 29, 265-80, 283, 290, 545'},\n", " {'text': 'early 657, 661'},\n", " {'text': 'early 657, 661'},\n", " {'text': 'early 657, 661'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'bezoars 284-5'},\n", " {'text': ''},\n", " {'text': 'cancer 29, 271, 282, 661'},\n", " {'text': 'in children 545'},\n", " {'text': 'in children 545'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'Crohn’s disease 372'},\n", " {'text': 'decompression 277-8'},\n", " {'text': 'gallstone ileus 29, 283-4'},\n", " {'text': 'after gastrectomy 285-6, 662'},\n", " {'text': 'after gastrectomy 285-6, 662'},\n", " {'text': 'hernias 29, 269, 292-3, 296, 657, 660-1'},\n", " {'text': 'hernias 29, 269, 292-3, 296, 657, 660-1'},\n", " {'text': 'ileosigmoid knotting 287, 594'},\n", " {'text': 'ileosigmoid knotting 287, 594'},\n", " {'text': 'ileosigmoid knotting 287, 594'},\n", " {'text': 'ileosigmoid knotting 287, 594'},\n", " {'text': 'ileosigmoid knotting 287, 594'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 883,\n", " 'text': ' imaging 48, 267, 270-2, 274-5, 289\\n intussusception 281, 286, 545, 548-51, 587-9\\n laparoscopy\\n SBO following 266, 660-1\\n treatment of SBO 119, 125, 278-80, 709\\n management 145, 272-9, 709\\n parasites 285, 582-3, 589-90\\n postoperative (EPSBO) 656-8, 659, 660-2, 663-4, 709\\n in pregnancy 539-40\\n radiation enteritis 282-3, 661\\n recurrent 270, 283, 290\\n strangulation 267, 268, 273\\n tubercular 575-6\\n virgin abdomen 29, 280-1, 545\\n volvulus 267, 269, 287-90, 545\\nSOFA score 225\\nspleen 14, 59\\n trauma 16, 490, 494\\nsplenic artery aneurysm 526\\nstab wounds 475-7, 479-81\\nstandard of care 727\\nstaplers 141, 142, 145\\nstarvation 639-40\\nstents\\n colonic/rectal 383-5\\n esophageal 171-2, 174, 344-5, 461\\nsteroids, in IBD 364, 365, 368\\nstomach\\n acute dilatation 662-3\\n causes of upper GI bleeding 191, 206, 207\\n gastrectomy 203, 206, 218\\n postoperative SBO/ileus 285-6, 662\\n gastroparesis 642, 662\\n trauma 496\\n ulcers\\n bleeding 191, 206\\n perforated 18, 124-5, 209, 218\\n volvulus 181-7\\nstomata 148-53',\n", " 'md': '```markdown\\n# Current Page Content\\n\\n## Extracted Text\\n- imaging 48, 267, 270-2, 274-5, 289\\n- intussusception 281, 286, 545, 548-51, 587-9\\n- laparoscopy\\n- SBO following 266, 660-1\\n- treatment of SBO 119, 125, 278-80, 709\\n- management 145, 272-9, 709\\n- parasites 285, 582-3, 589-90\\n- postoperative (EPSBO) 656-8, 659, 660-2, 663-4, 709\\n- in pregnancy 539-40\\n- radiation enteritis 282-3, 661\\n- recurrent 270, 283, 290\\n- strangulation 267, 268, 273\\n- tubercular 575-6\\n- virgin abdomen 29, 280-1, 545\\n- volvulus 267, 269, 287-90, 545\\n- SOFA score 225\\n- spleen 14, 59\\n- trauma 16, 490, 494\\n- splenic artery aneurysm 526\\n- stab wounds 475-7, 479-81\\n- standard of care 727\\n- staplers 141, 142, 145\\n- starvation 639-40\\n- stents\\n- colonic/rectal 383-5\\n- esophageal 171-2, 174, 344-5, 461\\n- steroids, in IBD 364, 365, 368\\n- stomach\\n- acute dilatation 662-3\\n- causes of upper GI bleeding 191, 206, 207\\n- gastrectomy 203, 206, 218\\n- postoperative SBO/ileus 285-6, 662\\n- gastroparesis 642, 662\\n- trauma 496\\n- ulcers\\n- bleeding 191, 206\\n- perforated 18, 124-5, 209, 218\\n- volvulus 181-7\\n- stomata 148-53\\n\\n## Notes\\n- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented in a structured format.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Current Page Content',\n", " 'md': '# Current Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- imaging 48, 267, 270-2, 274-5, 289\\n- intussusception 281, 286, 545, 548-51, 587-9\\n- laparoscopy\\n- SBO following 266, 660-1\\n- treatment of SBO 119, 125, 278-80, 709\\n- management 145, 272-9, 709\\n- parasites 285, 582-3, 589-90\\n- postoperative (EPSBO) 656-8, 659, 660-2, 663-4, 709\\n- in pregnancy 539-40\\n- radiation enteritis 282-3, 661\\n- recurrent 270, 283, 290\\n- strangulation 267, 268, 273\\n- tubercular 575-6\\n- virgin abdomen 29, 280-1, 545\\n- volvulus 267, 269, 287-90, 545\\n- SOFA score 225\\n- spleen 14, 59\\n- trauma 16, 490, 494\\n- splenic artery aneurysm 526\\n- stab wounds 475-7, 479-81\\n- standard of care 727\\n- staplers 141, 142, 145\\n- starvation 639-40\\n- stents\\n- colonic/rectal 383-5\\n- esophageal 171-2, 174, 344-5, 461\\n- steroids, in IBD 364, 365, 368\\n- stomach\\n- acute dilatation 662-3\\n- causes of upper GI bleeding 191, 206, 207\\n- gastrectomy 203, 206, 218\\n- postoperative SBO/ileus 285-6, 662\\n- gastroparesis 642, 662\\n- trauma 496\\n- ulcers\\n- bleeding 191, 206\\n- perforated 18, 124-5, 209, 218\\n- volvulus 181-7\\n- stomata 148-53',\n", " 'md': '- imaging 48, 267, 270-2, 274-5, 289\\n- intussusception 281, 286, 545, 548-51, 587-9\\n- laparoscopy\\n- SBO following 266, 660-1\\n- treatment of SBO 119, 125, 278-80, 709\\n- management 145, 272-9, 709\\n- parasites 285, 582-3, 589-90\\n- postoperative (EPSBO) 656-8, 659, 660-2, 663-4, 709\\n- in pregnancy 539-40\\n- radiation enteritis 282-3, 661\\n- recurrent 270, 283, 290\\n- strangulation 267, 268, 273\\n- tubercular 575-6\\n- virgin abdomen 29, 280-1, 545\\n- volvulus 267, 269, 287-90, 545\\n- SOFA score 225\\n- spleen 14, 59\\n- trauma 16, 490, 494\\n- splenic artery aneurysm 526\\n- stab wounds 475-7, 479-81\\n- standard of care 727\\n- staplers 141, 142, 145\\n- starvation 639-40\\n- stents\\n- colonic/rectal 383-5\\n- esophageal 171-2, 174, 344-5, 461\\n- steroids, in IBD 364, 365, 368\\n- stomach\\n- acute dilatation 662-3\\n- causes of upper GI bleeding 191, 206, 207\\n- gastrectomy 203, 206, 218\\n- postoperative SBO/ileus 285-6, 662\\n- gastroparesis 642, 662\\n- trauma 496\\n- ulcers\\n- bleeding 191, 206\\n- perforated 18, 124-5, 209, 218\\n- volvulus 181-7\\n- stomata 148-53',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 396.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Notes',\n", " 'md': '## Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented in a structured format.\\n```',\n", " 'md': '- No images, graphs, or tables were identified on this page.\\n- All extracted text is presented in a structured format.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'intussusception 281, 286, 545, 548-51, 587-9'},\n", " {'text': 'intussusception 281, 286, 545, 548-51, 587-9'},\n", " {'text': 'intussusception 281, 286, 545, 548-51, 587-9'},\n", " {'text': 'intussusception 281, 286, 545, 548-51, 587-9'},\n", " {'text': 'intussusception 281, 286, 545, 548-51, 587-9'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'treatment of SBO 119, 125, 278-80, 709'},\n", " {'text': 'treatment of SBO 119, 125, 278-80, 709'},\n", " {'text': 'management 145, 272-9, 709'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'parasites 285, 582-3, 589-90'},\n", " {'text': 'parasites 285, 582-3, 589-90'},\n", " {'text': 'parasites 285, 582-3, 589-90'},\n", " {'text': 'postoperative (EPSBO) 656-8, 659, 660-2, 663-4, 709'},\n", " {'text': 'postoperative (EPSBO) 656-8, 659, 660-2, 663-4, 709'},\n", " {'text': 'postoperative (EPSBO) 656-8, 659, 660-2, 663-4, 709'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'radiation enteritis 282-3, 661'},\n", " {'text': 'recurrent 270, 283, 290'},\n", " {'text': ''},\n", " {'text': 'strangulation 267, 268, 273'},\n", " {'text': 'strangulation 267, 268, 273'},\n", " {'text': 'strangulation 267, 268, 273'},\n", " {'text': 'tubercular 575-6'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'virgin abdomen 29, 280-1, 545'},\n", " {'text': 'volvulus 267, 269, 287-90, 545'},\n", " {'text': 'volvulus 267, 269, 287-90, 545'},\n", " {'text': 'volvulus 267, 269, 287-90, 545'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'spleen 14, 59'},\n", " {'text': ''},\n", " {'text': 'trauma 16, 490, 494'},\n", " {'text': 'splenic artery aneurysm 526'},\n", " {'text': 'splenic artery aneurysm 526'},\n", " {'text': 'splenic artery aneurysm 526'},\n", " {'text': 'stab wounds 475-7, 479-81'},\n", " {'text': 'standard of care 727'},\n", " {'text': 'standard of care 727'},\n", " {'text': 'staplers 141, 142, 145'},\n", " {'text': 'starvation 639-40'},\n", " {'text': 'starvation 639-40'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'esophageal 171-2, 174, 344-5, 461'},\n", " {'text': 'steroids, in IBD 364, 365, 368'},\n", " {'text': 'steroids, in IBD 364, 365, 368'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'causes of upper GI bleeding 191, 206, 207'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'postoperative SBO/ileus 285-6, 662'},\n", " {'text': 'postoperative SBO/ileus 285-6, 662'},\n", " {'text': 'postoperative SBO/ileus 285-6, 662'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'perforated 18, 124-5, 209, 218'},\n", " {'text': 'perforated 18, 124-5, 209, 218'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 884,\n", " 'text': ' cecostomy 157, 386-7, 398, 400\\n cholecystostomy 253\\n colostomy 152-4, 156-7, 350-1, 384, 386-7\\n esophagostomy 173\\n ileocolostomy 155\\n ileostomy 152, 154, 158-9, 394\\n jejunostomy 155-6, 643-4\\n in liver patients 349, 350-1\\n mucous fistulas 154-5, 337, 369\\n parastomal hernias 298\\n postoperative care 158-9\\n procedures 151-7\\n site 150-1\\n stomal ulcers 206-7\\nstreptococcal wound cellulitis 719\\nstress ulcers 191, 208\\nsuperior mesenteric artery (SMA) 329, 330, 333, 336, 499\\nsuperior mesenteric vein (SMV) 55, 338-9, 499\\nsupracolic compartment 111\\nsuprapubic catheters 564-5\\nSURGINET 730\\nsutures\\n anastomosis 141, 142, 143-4, 605\\n closure techniques 318, 612-20\\n material 141, 142, 611-12\\nSwan-Ganz catheters 71-2\\nsystem failure 32, 726-7\\nsystemic inflammatory response syndrome (SIRS) 8-9, 128, 653\\n\\nteamwork 31-3, 41-2, 109, 120, 635\\ntemporary abdominal closure (TAC) 136, 236-7, 700-3\\n see also laparostomy\\ntestis\\n torsion 544, 553-4, 561-4\\n trauma 570-1\\nthoracoabdominal incisions 102\\nthromboembolism\\n aorta 526-7\\n mesenteric artery 330, 331, 334, 336',\n", " 'md': '```markdown\\n# Extracted Content from Current Page\\n\\n## Text\\n- cecostomy 157, 386-7, 398, 400\\n- cholecystostomy 253\\n- colostomy 152-4, 156-7, 350-1, 384, 386-7\\n- esophagostomy 173\\n- ileocolostomy 155\\n- ileostomy 152, 154, 158-9, 394\\n- jejunostomy 155-6, 643-4\\n- in liver patients 349, 350-1\\n- mucous fistulas 154-5, 337, 369\\n- parastomal hernias 298\\n- postoperative care 158-9\\n- procedures 151-7\\n- site 150-1\\n- stomal ulcers 206-7\\n- streptococcal wound cellulitis 719\\n- stress ulcers 191, 208\\n- superior mesenteric artery (SMA) 329, 330, 333, 336, 499\\n- superior mesenteric vein (SMV) 55, 338-9, 499\\n- supracolic compartment 111\\n- suprapubic catheters 564-5\\n- SURGINET 730\\n- sutures\\n- anastomosis 141, 142, 143-4, 605\\n- closure techniques 318, 612-20\\n- material 141, 142, 611-12\\n- Swan-Ganz catheters 71-2\\n- system failure 32, 726-7\\n- systemic inflammatory response syndrome (SIRS) 8-9, 128, 653\\n- teamwork 31-3, 41-2, 109, 120, 635\\n- temporary abdominal closure (TAC) 136, 236-7, 700-3\\n- see also laparostomy\\n- testis\\n- torsion 544, 553-4, 561-4\\n- trauma 570-1\\n- thoracoabdominal incisions 102\\n- thromboembolism\\n- aorta 526-7\\n- mesenteric artery 330, 331, 334, 336\\n\\n## Images\\n- No images or graphs were identified on this page.\\n\\n## Tables\\n- No tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Extracted Content from Current Page',\n", " 'md': '# Extracted Content from Current Page',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- cecostomy 157, 386-7, 398, 400\\n- cholecystostomy 253\\n- colostomy 152-4, 156-7, 350-1, 384, 386-7\\n- esophagostomy 173\\n- ileocolostomy 155\\n- ileostomy 152, 154, 158-9, 394\\n- jejunostomy 155-6, 643-4\\n- in liver patients 349, 350-1\\n- mucous fistulas 154-5, 337, 369\\n- parastomal hernias 298\\n- postoperative care 158-9\\n- procedures 151-7\\n- site 150-1\\n- stomal ulcers 206-7\\n- streptococcal wound cellulitis 719\\n- stress ulcers 191, 208\\n- superior mesenteric artery (SMA) 329, 330, 333, 336, 499\\n- superior mesenteric vein (SMV) 55, 338-9, 499\\n- supracolic compartment 111\\n- suprapubic catheters 564-5\\n- SURGINET 730\\n- sutures\\n- anastomosis 141, 142, 143-4, 605\\n- closure techniques 318, 612-20\\n- material 141, 142, 611-12\\n- Swan-Ganz catheters 71-2\\n- system failure 32, 726-7\\n- systemic inflammatory response syndrome (SIRS) 8-9, 128, 653\\n- teamwork 31-3, 41-2, 109, 120, 635\\n- temporary abdominal closure (TAC) 136, 236-7, 700-3\\n- see also laparostomy\\n- testis\\n- torsion 544, 553-4, 561-4\\n- trauma 570-1\\n- thoracoabdominal incisions 102\\n- thromboembolism\\n- aorta 526-7\\n- mesenteric artery 330, 331, 334, 336',\n", " 'md': '- cecostomy 157, 386-7, 398, 400\\n- cholecystostomy 253\\n- colostomy 152-4, 156-7, 350-1, 384, 386-7\\n- esophagostomy 173\\n- ileocolostomy 155\\n- ileostomy 152, 154, 158-9, 394\\n- jejunostomy 155-6, 643-4\\n- in liver patients 349, 350-1\\n- mucous fistulas 154-5, 337, 369\\n- parastomal hernias 298\\n- postoperative care 158-9\\n- procedures 151-7\\n- site 150-1\\n- stomal ulcers 206-7\\n- streptococcal wound cellulitis 719\\n- stress ulcers 191, 208\\n- superior mesenteric artery (SMA) 329, 330, 333, 336, 499\\n- superior mesenteric vein (SMV) 55, 338-9, 499\\n- supracolic compartment 111\\n- suprapubic catheters 564-5\\n- SURGINET 730\\n- sutures\\n- anastomosis 141, 142, 143-4, 605\\n- closure techniques 318, 612-20\\n- material 141, 142, 611-12\\n- Swan-Ganz catheters 71-2\\n- system failure 32, 726-7\\n- systemic inflammatory response syndrome (SIRS) 8-9, 128, 653\\n- teamwork 31-3, 41-2, 109, 120, 635\\n- temporary abdominal closure (TAC) 136, 236-7, 700-3\\n- see also laparostomy\\n- testis\\n- torsion 544, 553-4, 561-4\\n- trauma 570-1\\n- thoracoabdominal incisions 102\\n- thromboembolism\\n- aorta 526-7\\n- mesenteric artery 330, 331, 334, 336',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 408.6, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No tables were identified on this page.\\n```',\n", " 'md': '- No tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'cholecystostomy 253'},\n", " {'text': 'cholecystostomy 253'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'colostomy 152-4, 156-7, 350-1, 384, 386-7'},\n", " {'text': 'esophagostomy 173'},\n", " {'text': 'esophagostomy 173'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'ileocolostomy 155'},\n", " {'text': 'ileostomy 152, 154, 158-9, 394'},\n", " {'text': 'jejunostomy 155-6, 643-4'},\n", " {'text': 'jejunostomy 155-6, 643-4'},\n", " {'text': 'jejunostomy 155-6, 643-4'},\n", " {'text': ''},\n", " {'text': 'in liver patients 349, 350-1'},\n", " {'text': 'in liver patients 349, 350-1'},\n", " {'text': 'mucous fistulas 154-5, 337, 369'},\n", " {'text': 'mucous fistulas 154-5, 337, 369'},\n", " {'text': 'parastomal hernias 298'},\n", " {'text': 'parastomal hernias 298'},\n", " {'text': ''},\n", " {'text': 'postoperative care 158-9'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'stomal ulcers 206-7'},\n", " {'text': 'streptococcal wound cellulitis 719'},\n", " {'text': ''},\n", " {'text': 'superior mesenteric artery (SMA) 329, 330, 333, 336, 499'},\n", " {'text': 'superior mesenteric artery (SMA) 329, 330, 333, 336, 499'},\n", " {'text': 'superior mesenteric vein (SMV) 55, 338-9, 499'},\n", " {'text': 'superior mesenteric vein (SMV) 55, 338-9, 499'},\n", " {'text': 'superior mesenteric vein (SMV) 55, 338-9, 499'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'suprapubic catheters 564-5'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'closure techniques 318, 612-20'},\n", " {'text': 'closure techniques 318, 612-20'},\n", " {'text': 'closure techniques 318, 612-20'},\n", " {'text': 'closure techniques 318, 612-20'},\n", " {'text': 'material 141, 142, 611-12'},\n", " {'text': 'material 141, 142, 611-12'},\n", " {'text': 'Swan-Ganz catheters 71-2'},\n", " {'text': 'Swan-Ganz catheters 71-2'},\n", " {'text': ''},\n", " {'text': 'system failure 32, 726-7'},\n", " {'text': 'systemic inflammatory response syndrome (SIRS) 8-9, 128, 653'},\n", " {'text': 'systemic inflammatory response syndrome (SIRS) 8-9, 128, 653'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'temporary abdominal closure (TAC) 136, 236-7, 700-3'},\n", " {'text': 'temporary abdominal closure (TAC) 136, 236-7, 700-3'},\n", " {'text': 'temporary abdominal closure (TAC) 136, 236-7, 700-3'},\n", " {'text': 'temporary abdominal closure (TAC) 136, 236-7, 700-3'},\n", " {'text': 'temporary abdominal closure (TAC) 136, 236-7, 700-3'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'trauma 570-1'},\n", " {'text': 'trauma 570-1'},\n", " {'text': ''},\n", " {'text': 'thoracoabdominal incisions 102'},\n", " {'text': ''},\n", " {'text': 'mesenteric artery 330, 331, 334, 336'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 885,\n", " 'text': ' mesenteric vein 338-9\\n prophylaxis of DVT 94, 634\\nthrombosed hemorrhoids 438, 442-3\\ntotal parenteral nutrition (TPN) 334, 641, 645, 682\\ntoxic megacolon 366, 367-8\\ntraditional enemas (African) 590, 591-3\\ntransjugular intrahepatic portosystemic shunt (TIPS) 342\\ntrauma\\n abdominal exploration 112-13, 114\\n anorectal 452-5, 479, 498\\n blunt 109, 113, 484-92, 500\\n liver 353-5, 491\\n in children 545, 554-5\\n colon 497\\n damage control 501-2, 693-4\\n diaphragm 126, 181, 479, 492-3\\n esophagus 163\\n imaging 37, 55, 353, 477, 478-9, 487-9, 566-7\\n liver 353-7, 491, 493-4\\n pancreas 494-5\\n pelvis 500-1\\n penetrating 13-14, 109, 112, 473-84, 500\\n liver 356-7, 493-4\\n in pregnancy 540\\n repair 492-502\\n retroperitoneal hematoma 499-500\\n small bowel 496-7\\n spleen 16, 490, 494\\n stomach 496\\n urinary tract 479, 495-6, 565-71\\n vagina 536\\n vascular 498-9\\n vena cava 357, 494, 498\\ntrichobezoars 285\\ntrocar placement 122, 324, 414\\ntuberculosis 575-8\\ntyphoid 578, 594-5\\n\\nulcerative colitis 154-5, 363-70, 433',\n", " 'md': '```markdown\\n# Page Content\\n\\n- **Mesenteric vein**: 338-9\\n- **Prophylaxis of DVT**: 94, 634\\n- **Thrombosed hemorrhoids**: 438, 442-3\\n- **Total parenteral nutrition (TPN)**: 334, 641, 645, 682\\n- **Toxic megacolon**: 366, 367-8\\n- **Traditional enemas (African)**: 590, 591-3\\n- **Transjugular intrahepatic portosystemic shunt (TIPS)**: 342\\n\\n## Trauma\\n- **Abdominal exploration**: 112-13, 114\\n- **Anorectal**: 452-5, 479, 498\\n- **Blunt**: 109, 113, 484-92, 500\\n- **Liver**: 353-5, 491\\n- **In children**: 545, 554-5\\n- **Colon**: 497\\n- **Damage control**: 501-2, 693-4\\n- **Diaphragm**: 126, 181, 479, 492-3\\n- **Esophagus**: 163\\n- **Imaging**: 37, 55, 353, 477, 478-9, 487-9, 566-7\\n- **Liver**: 353-7, 491, 493-4\\n- **Pancreas**: 494-5\\n- **Pelvis**: 500-1\\n- **Penetrating**: 13-14, 109, 112, 473-84, 500\\n- **Liver**: 356-7, 493-4\\n- **In pregnancy**: 540\\n- **Repair**: 492-502\\n- **Retroperitoneal hematoma**: 499-500\\n- **Small bowel**: 496-7\\n- **Spleen**: 16, 490, 494\\n- **Stomach**: 496\\n- **Urinary tract**: 479, 495-6, 565-71\\n- **Vagina**: 536\\n- **Vascular**: 498-9\\n- **Vena cava**: 357, 494, 498\\n\\n- **Trichobezoars**: 285\\n- **Trocar placement**: 122, 324, 414\\n- **Tuberculosis**: 575-8\\n- **Typhoid**: 578, 594-5\\n\\n- **Ulcerative colitis**: 154-5, 363-70, 433\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- **Mesenteric vein**: 338-9\\n- **Prophylaxis of DVT**: 94, 634\\n- **Thrombosed hemorrhoids**: 438, 442-3\\n- **Total parenteral nutrition (TPN)**: 334, 641, 645, 682\\n- **Toxic megacolon**: 366, 367-8\\n- **Traditional enemas (African)**: 590, 591-3\\n- **Transjugular intrahepatic portosystemic shunt (TIPS)**: 342',\n", " 'md': '- **Mesenteric vein**: 338-9\\n- **Prophylaxis of DVT**: 94, 634\\n- **Thrombosed hemorrhoids**: 438, 442-3\\n- **Total parenteral nutrition (TPN)**: 334, 641, 645, 682\\n- **Toxic megacolon**: 366, 367-8\\n- **Traditional enemas (African)**: 590, 591-3\\n- **Transjugular intrahepatic portosystemic shunt (TIPS)**: 342',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Trauma',\n", " 'md': '## Trauma',\n", " 'bBox': {'x': 72, 'y': 201, 'w': 44.78, 'h': 14.4}},\n", " {'type': 'text',\n", " 'value': '- **Abdominal exploration**: 112-13, 114\\n- **Anorectal**: 452-5, 479, 498\\n- **Blunt**: 109, 113, 484-92, 500\\n- **Liver**: 353-5, 491\\n- **In children**: 545, 554-5\\n- **Colon**: 497\\n- **Damage control**: 501-2, 693-4\\n- **Diaphragm**: 126, 181, 479, 492-3\\n- **Esophagus**: 163\\n- **Imaging**: 37, 55, 353, 477, 478-9, 487-9, 566-7\\n- **Liver**: 353-7, 491, 493-4\\n- **Pancreas**: 494-5\\n- **Pelvis**: 500-1\\n- **Penetrating**: 13-14, 109, 112, 473-84, 500\\n- **Liver**: 356-7, 493-4\\n- **In pregnancy**: 540\\n- **Repair**: 492-502\\n- **Retroperitoneal hematoma**: 499-500\\n- **Small bowel**: 496-7\\n- **Spleen**: 16, 490, 494\\n- **Stomach**: 496\\n- **Urinary tract**: 479, 495-6, 565-71\\n- **Vagina**: 536\\n- **Vascular**: 498-9\\n- **Vena cava**: 357, 494, 498\\n\\n- **Trichobezoars**: 285\\n- **Trocar placement**: 122, 324, 414\\n- **Tuberculosis**: 575-8\\n- **Typhoid**: 578, 594-5\\n\\n- **Ulcerative colitis**: 154-5, 363-70, 433\\n```',\n", " 'md': '- **Abdominal exploration**: 112-13, 114\\n- **Anorectal**: 452-5, 479, 498\\n- **Blunt**: 109, 113, 484-92, 500\\n- **Liver**: 353-5, 491\\n- **In children**: 545, 554-5\\n- **Colon**: 497\\n- **Damage control**: 501-2, 693-4\\n- **Diaphragm**: 126, 181, 479, 492-3\\n- **Esophagus**: 163\\n- **Imaging**: 37, 55, 353, 477, 478-9, 487-9, 566-7\\n- **Liver**: 353-7, 491, 493-4\\n- **Pancreas**: 494-5\\n- **Pelvis**: 500-1\\n- **Penetrating**: 13-14, 109, 112, 473-84, 500\\n- **Liver**: 356-7, 493-4\\n- **In pregnancy**: 540\\n- **Repair**: 492-502\\n- **Retroperitoneal hematoma**: 499-500\\n- **Small bowel**: 496-7\\n- **Spleen**: 16, 490, 494\\n- **Stomach**: 496\\n- **Urinary tract**: 479, 495-6, 565-71\\n- **Vagina**: 536\\n- **Vascular**: 498-9\\n- **Vena cava**: 357, 494, 498\\n\\n- **Trichobezoars**: 285\\n- **Trocar placement**: 122, 324, 414\\n- **Tuberculosis**: 575-8\\n- **Typhoid**: 578, 594-5\\n\\n- **Ulcerative colitis**: 154-5, 363-70, 433\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': 'prophylaxis of DVT 94, 634'},\n", " {'text': 'thrombosed hemorrhoids 438, 442-3'},\n", " {'text': 'thrombosed hemorrhoids 438, 442-3'},\n", " {'text': 'total parenteral nutrition (TPN) 334, 641, 645, 682'},\n", " {'text': 'total parenteral nutrition (TPN) 334, 641, 645, 682'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'traditional enemas (African) 590, 591-3'},\n", " {'text': 'traditional enemas (African) 590, 591-3'},\n", " {'text': 'transjugular intrahepatic portosystemic shunt (TIPS) 342'},\n", " {'text': 'transjugular intrahepatic portosystemic shunt (TIPS) 342'},\n", " {'text': ''},\n", " {'text': 'anorectal 452-5, 479, 498'},\n", " {'text': ''},\n", " {'text': 'blunt 109, 113, 484-92, 500'},\n", " {'text': 'blunt 109, 113, 484-92, 500'},\n", " {'text': 'blunt 109, 113, 484-92, 500'},\n", " {'text': ''},\n", " {'text': 'liver 353-5, 491'},\n", " {'text': 'liver 353-5, 491'},\n", " {'text': ''},\n", " {'text': 'in children 545, 554-5'},\n", " {'text': 'in children 545, 554-5'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'damage control 501-2, 693-4'},\n", " {'text': 'diaphragm 126, 181, 479, 492-3'},\n", " {'text': 'diaphragm 126, 181, 479, 492-3'},\n", " {'text': 'esophagus 163'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'imaging 37, 55, 353, 477, 478-9, 487-9, 566-7'},\n", " {'text': 'liver 353-7, 491, 493-4'},\n", " {'text': 'liver 353-7, 491, 493-4'},\n", " {'text': 'liver 353-7, 491, 493-4'},\n", " {'text': 'liver 353-7, 491, 493-4'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'pancreas 494-5'},\n", " {'text': 'pancreas 494-5'},\n", " {'text': ''},\n", " {'text': 'pelvis 500-1'},\n", " {'text': 'penetrating 13-14, 109, 112, 473-84, 500'},\n", " {'text': 'liver 356-7, 493-4'},\n", " {'text': 'liver 356-7, 493-4'},\n", " {'text': 'liver 356-7, 493-4'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'in pregnancy 540'},\n", " {'text': ''},\n", " {'text': 'repair 492-502'},\n", " {'text': 'retroperitoneal hematoma 499-500'},\n", " {'text': ''},\n", " {'text': 'spleen 16, 490, 494'},\n", " {'text': 'stomach 496'},\n", " {'text': 'stomach 496'},\n", " {'text': ''},\n", " {'text': 'urinary tract 479, 495-6, 565-71'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'vascular 498-9'},\n", " {'text': 'vena cava 357, 494, 498'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'trocar placement 122, 324, 414'},\n", " {'text': 'tuberculosis 575-8'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'typhoid 578, 594-5'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 886,\n", " 'text': 'ulcers\\n acute gastric 191, 208\\n peptic\\n bleeding 189-208, 424\\n perforated 18, 124-5, 209-20, 574, 601-2, 709\\n stomal 206-7\\nultrasound 38-9\\n appendicitis 38, 310\\n cholecystitis 243\\n gynecological conditions 531, 534\\n pancreatitis 224-5\\n SBO 270\\n trauma (FAST scans) 38, 479-80, 487-8\\numbilical hernias 297, 348-9\\nupper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595\\nureter\\n in diverticular surgery 415, 416\\n trauma 496, 568-70\\nureteric colic 57, 557-61\\nurgency, classification 24, 76\\nurinary tract\\n acute urinary retention 564-5\\n fistulas 403, 418\\n imaging 60, 566-7\\n renal colic 57, 559-61\\n trauma 479, 495-6, 565-71\\nurine output monitoring 70, 272, 565\\nuterus 540\\n\\nvacuum-assisted closure (VAC) 236-7, 700-3, 704, 720\\nvagina\\n colovaginal fistulas 418\\n examination 531\\n tears 536\\nvagotomy 203, 204, 217-18, 219\\nvariceal bleeding\\n esophageal 190, 195, 196, 342-5, 461\\n stomal 350-1\\nvena cava trauma 357, 494, 498',\n", " 'md': '```markdown\\n# Page Content\\n\\n## Text\\n- ulcers\\n- acute gastric 191, 208\\n- peptic\\n- bleeding 189-208, 424\\n- perforated 18, 124-5, 209-20, 574, 601-2, 709\\n- stomal 206-7\\n- ultrasound 38-9\\n- appendicitis 38, 310\\n- cholecystitis 243\\n- gynecological conditions 531, 534\\n- pancreatitis 224-5\\n- SBO 270\\n- trauma (FAST scans) 38, 479-80, 487-8\\n- umbilical hernias 297, 348-9\\n- upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595\\n- ureter\\n- in diverticular surgery 415, 416\\n- trauma 496, 568-70\\n- ureteric colic 57, 557-61\\n- urgency, classification 24, 76\\n- urinary tract\\n- acute urinary retention 564-5\\n- fistulas 403, 418\\n- imaging 60, 566-7\\n- renal colic 57, 559-61\\n- trauma 479, 495-6, 565-71\\n- urine output monitoring 70, 272, 565\\n- uterus 540\\n\\n- vacuum-assisted closure (VAC) 236-7, 700-3, 704, 720\\n- vagina\\n- colovaginal fistulas 418\\n- examination 531\\n- tears 536\\n- vagotomy 203, 204, 217-18, 219\\n- variceal bleeding\\n- esophageal 190, 195, 196, 342-5, 461\\n- stomal 350-1\\n- vena cava trauma 357, 494, 498\\n\\n## Images\\n- No images or graphs were identified on this page.\\n\\n## Tables\\n- No tables were identified on this page.\\n```',\n", " 'images': [],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text',\n", " 'md': '## Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- ulcers\\n- acute gastric 191, 208\\n- peptic\\n- bleeding 189-208, 424\\n- perforated 18, 124-5, 209-20, 574, 601-2, 709\\n- stomal 206-7\\n- ultrasound 38-9\\n- appendicitis 38, 310\\n- cholecystitis 243\\n- gynecological conditions 531, 534\\n- pancreatitis 224-5\\n- SBO 270\\n- trauma (FAST scans) 38, 479-80, 487-8\\n- umbilical hernias 297, 348-9\\n- upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595\\n- ureter\\n- in diverticular surgery 415, 416\\n- trauma 496, 568-70\\n- ureteric colic 57, 557-61\\n- urgency, classification 24, 76\\n- urinary tract\\n- acute urinary retention 564-5\\n- fistulas 403, 418\\n- imaging 60, 566-7\\n- renal colic 57, 559-61\\n- trauma 479, 495-6, 565-71\\n- urine output monitoring 70, 272, 565\\n- uterus 540\\n\\n- vacuum-assisted closure (VAC) 236-7, 700-3, 704, 720\\n- vagina\\n- colovaginal fistulas 418\\n- examination 531\\n- tears 536\\n- vagotomy 203, 204, 217-18, 219\\n- variceal bleeding\\n- esophageal 190, 195, 196, 342-5, 461\\n- stomal 350-1\\n- vena cava trauma 357, 494, 498',\n", " 'md': '- ulcers\\n- acute gastric 191, 208\\n- peptic\\n- bleeding 189-208, 424\\n- perforated 18, 124-5, 209-20, 574, 601-2, 709\\n- stomal 206-7\\n- ultrasound 38-9\\n- appendicitis 38, 310\\n- cholecystitis 243\\n- gynecological conditions 531, 534\\n- pancreatitis 224-5\\n- SBO 270\\n- trauma (FAST scans) 38, 479-80, 487-8\\n- umbilical hernias 297, 348-9\\n- upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595\\n- ureter\\n- in diverticular surgery 415, 416\\n- trauma 496, 568-70\\n- ureteric colic 57, 557-61\\n- urgency, classification 24, 76\\n- urinary tract\\n- acute urinary retention 564-5\\n- fistulas 403, 418\\n- imaging 60, 566-7\\n- renal colic 57, 559-61\\n- trauma 479, 495-6, 565-71\\n- urine output monitoring 70, 272, 565\\n- uterus 540\\n\\n- vacuum-assisted closure (VAC) 236-7, 700-3, 704, 720\\n- vagina\\n- colovaginal fistulas 418\\n- examination 531\\n- tears 536\\n- vagotomy 203, 204, 217-18, 219\\n- variceal bleeding\\n- esophageal 190, 195, 196, 342-5, 461\\n- stomal 350-1\\n- vena cava trauma 357, 494, 498',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 356.63, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Images',\n", " 'md': '## Images',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No images or graphs were identified on this page.',\n", " 'md': '- No images or graphs were identified on this page.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Tables',\n", " 'md': '## Tables',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No tables were identified on this page.\\n```',\n", " 'md': '- No tables were identified on this page.\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': 'perforated 18, 124-5, 209-20, 574, 601-2, 709'},\n", " {'text': 'perforated 18, 124-5, 209-20, 574, 601-2, 709'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'ultrasound 38-9'},\n", " {'text': 'appendicitis 38, 310'},\n", " {'text': 'cholecystitis 243'},\n", " {'text': 'cholecystitis 243'},\n", " {'text': 'gynecological conditions 531, 534'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'trauma (FAST scans) 38, 479-80, 487-8'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595'},\n", " {'text': 'upper GI bleeding 189-208, 342-5, 424, 461, 464-5, 595'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'ureteric colic 57, 557-61'},\n", " {'text': 'ureteric colic 57, 557-61'},\n", " {'text': 'urgency, classification 24, 76'},\n", " {'text': 'urgency, classification 24, 76'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'imaging 60, 566-7'},\n", " {'text': 'imaging 60, 566-7'},\n", " {'text': 'renal colic 57, 559-61'},\n", " {'text': 'renal colic 57, 559-61'},\n", " {'text': 'trauma 479, 495-6, 565-71'},\n", " {'text': 'trauma 479, 495-6, 565-71'},\n", " {'text': 'urine output monitoring 70, 272, 565'},\n", " {'text': 'urine output monitoring 70, 272, 565'},\n", " {'text': 'urine output monitoring 70, 272, 565'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'vagotomy 203, 204, 217-18, 219'},\n", " {'text': 'variceal bleeding'},\n", " {'text': 'variceal bleeding'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'stomal 350-1'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'vena cava trauma 357, 494, 498'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 887,\n", " 'text': 'venous thrombosis 94, 338-9, 634\\nvolvulus\\n in children 545\\n colon 287, 394-8, 593-4\\n in pregnancy 539-40\\n small bowel 267, 269, 287-90, 545\\n stomach 181-7\\nvomiting 28\\n Boerhaave’s syndrome 37, 163\\n hematemesis 191\\n SBO 267-8\\n\\nWhipple procedure 495, 497\\nwhite cell count 36, 309, 640\\nwitch doctors 590, 591-3\\nwound management 118-19, 450, 713-21\\n see also closure\\n\\nX-rays\\n abdominal see abdominal X-rays\\n chest 37-8, 164, 184',\n", " 'md': '# Page Content\\n\\n## Extracted Text\\n- venous thrombosis 94, 338-9, 634\\n- volvulus\\n- in children 545\\n- colon 287, 394-8, 593-4\\n- in pregnancy 539-40\\n- small bowel 267, 269, 287-90, 545\\n- stomach 181-7\\n- vomiting 28\\n- Boerhaave’s syndrome 37, 163\\n- hematemesis 191\\n- SBO 267-8\\n- Whipple procedure 495, 497\\n- white cell count 36, 309, 640\\n- witch doctors 590, 591-3\\n- wound management 118-19, 450, 713-21\\n- see also closure\\n- X-rays\\n- abdominal see abdominal X-rays\\n- chest 37-8, 164, 184\\n\\n## Notes\\n- No formulas were identified on this page.\\n- No images or graphs were identified on this page.\\n- No tables were present on this page.\\n\\nThis page primarily consists of a list of medical terms and references, with no additional graphical or tabular content to extract.',\n", " 'images': [],\n", " 'items': [{'type': 'heading',\n", " 'lvl': 1,\n", " 'value': 'Page Content',\n", " 'md': '# Page Content',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Extracted Text',\n", " 'md': '## Extracted Text',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- venous thrombosis 94, 338-9, 634\\n- volvulus\\n- in children 545\\n- colon 287, 394-8, 593-4\\n- in pregnancy 539-40\\n- small bowel 267, 269, 287-90, 545\\n- stomach 181-7\\n- vomiting 28\\n- Boerhaave’s syndrome 37, 163\\n- hematemesis 191\\n- SBO 267-8\\n- Whipple procedure 495, 497\\n- white cell count 36, 309, 640\\n- witch doctors 590, 591-3\\n- wound management 118-19, 450, 713-21\\n- see also closure\\n- X-rays\\n- abdominal see abdominal X-rays\\n- chest 37-8, 164, 184',\n", " 'md': '- venous thrombosis 94, 338-9, 634\\n- volvulus\\n- in children 545\\n- colon 287, 394-8, 593-4\\n- in pregnancy 539-40\\n- small bowel 267, 269, 287-90, 545\\n- stomach 181-7\\n- vomiting 28\\n- Boerhaave’s syndrome 37, 163\\n- hematemesis 191\\n- SBO 267-8\\n- Whipple procedure 495, 497\\n- white cell count 36, 309, 640\\n- witch doctors 590, 591-3\\n- wound management 118-19, 450, 713-21\\n- see also closure\\n- X-rays\\n- abdominal see abdominal X-rays\\n- chest 37-8, 164, 184',\n", " 'bBox': {'x': 72, 'y': 85, 'w': 262.83, 'h': 14.4}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Notes',\n", " 'md': '## Notes',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '- No formulas were identified on this page.\\n- No images or graphs were identified on this page.\\n- No tables were present on this page.\\n\\nThis page primarily consists of a list of medical terms and references, with no additional graphical or tabular content to extract.',\n", " 'md': '- No formulas were identified on this page.\\n- No images or graphs were identified on this page.\\n- No tables were present on this page.\\n\\nThis page primarily consists of a list of medical terms and references, with no additional graphical or tabular content to extract.',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': [{'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'colon 287, 394-8, 593-4'},\n", " {'text': 'in pregnancy 539-40'},\n", " {'text': 'in pregnancy 539-40'},\n", " {'text': 'in pregnancy 539-40'},\n", " {'text': 'small bowel 267, 269, 287-90, 545'},\n", " {'text': 'stomach 181-7'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'Boerhaave’s syndrome 37, 163'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': 'white cell count 36, 309, 640'},\n", " {'text': 'white cell count 36, 309, 640'},\n", " {'text': 'witch doctors 590, 591-3'},\n", " {'text': 'witch doctors 590, 591-3'},\n", " {'text': ''},\n", " {'text': 'wound management 118-19, 450, 713-21'},\n", " {'text': 'wound management 118-19, 450, 713-21'},\n", " {'text': ' closure'},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''},\n", " {'text': ''}]},\n", " {'page': 888,\n", " 'text': \"Since Mondor'$ times in the forties of the last century there was no other\\n book in surgery to be written 50 easy and witty_.\\n Boris D. Savchuk, World Journal of Surgery\\nThls; the fourth cdition of Scheln $ Common Sense Emergency Abdominol\\nSurgery; bullds thc reputatlon olthe thrcc prevlous editions:\\n worldwide benchmark, translated into half a dozen languages, this book\\nGuides sureons logically through the minefields assessmeni and\\nmanagement surcical abdominal conditions: surgery\\n concept may have been overtaken In many parts of the world by the\\ndeveiopmentot niche specialties, but the need for cohort of generalists\\nable deal competently with common surgical emergencies has not\\nBone JwJy: You recognize this need then this the book foryoul\\nTyro surgeons and experienced practitioners alike Wll benefit from the\\ndistilled wisdomcontained these pjbes . The direct, no-nonsensc\\nwriting stylc, supported by cntertaining cartoons_ Bivcs clcar guidance\\nwhile at the same time providing amusing insights into our collective Paul M;\\nsurgical psyche:\\nSomc ncw cditors and Juthors cnhance thc edition: Almost all\\nchapters have been revised to take account of new concepts and modern\\ndevclopments. New chapters have been added and some completely\\nrewritten often with emphasis on the importance of laparoscopic Ari Leppinlem Helsinki\\napproach:\\n This is NOI standard textbook Read itl You'Il not regret it.\\n 10570\\n 781910\",\n", " 'md': '```markdown\\n## Text Extraction\\n\\nSince Mondor\\'s times in the forties of the last century, there was no other book in surgery to be written so easy and witty.\\n**Boris D. Savchuk, World Journal of Surgery**\\n\\nThis, the fourth edition of \"Schlein\\'s Common Sense Emergency Abdominal Surgery,\" builds the reputation of the three previous editions: a worldwide benchmark, translated into half a dozen languages. This book guides surgeons logically through the minefields of assessment and management of surgical abdominal conditions. The surgery concept may have been overtaken in many parts of the world by the development of niche specialties, but the need for a cohort of generalists able to deal competently with common surgical emergencies has not.\\n\\nIf you recognize this need, then this is the book for you! Tyro surgeons and experienced practitioners alike will benefit from the distilled wisdom contained in these pages. The direct, no-nonsense writing style, supported by entertaining cartoons, gives clear guidance while at the same time providing amusing insights into our collective surgical psyche.\\n\\nSome new editors and authors enhance this edition: Almost all chapters have been revised to take account of new concepts and modern developments. New chapters have been added and some completely rewritten, often with an emphasis on the importance of the laparoscopic approach.\\n\\nThis is NOT a standard textbook. Read it! You\\'ll not regret it.\\n\\n## Image Identification and Description\\n\\n*No images or figures were identified on this page.*\\n\\n## Formula Extraction\\n\\n*No formulas were identified on this page.*\\n```',\n", " 'images': [{'name': 'img_p887_1.png',\n", " 'height': 1283,\n", " 'width': 885,\n", " 'x': 87.12,\n", " 'y': 72,\n", " 'original_width': 600,\n", " 'original_height': 870}],\n", " 'items': [{'type': 'text',\n", " 'value': '```markdown',\n", " 'md': '```markdown',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Text Extraction',\n", " 'md': '## Text Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': 'Since Mondor\\'s times in the forties of the last century, there was no other book in surgery to be written so easy and witty.\\n**Boris D. Savchuk, World Journal of Surgery**\\n\\nThis, the fourth edition of \"Schlein\\'s Common Sense Emergency Abdominal Surgery,\" builds the reputation of the three previous editions: a worldwide benchmark, translated into half a dozen languages. This book guides surgeons logically through the minefields of assessment and management of surgical abdominal conditions. The surgery concept may have been overtaken in many parts of the world by the development of niche specialties, but the need for a cohort of generalists able to deal competently with common surgical emergencies has not.\\n\\nIf you recognize this need, then this is the book for you! Tyro surgeons and experienced practitioners alike will benefit from the distilled wisdom contained in these pages. The direct, no-nonsense writing style, supported by entertaining cartoons, gives clear guidance while at the same time providing amusing insights into our collective surgical psyche.\\n\\nSome new editors and authors enhance this edition: Almost all chapters have been revised to take account of new concepts and modern developments. New chapters have been added and some completely rewritten, often with an emphasis on the importance of the laparoscopic approach.\\n\\nThis is NOT a standard textbook. Read it! You\\'ll not regret it.',\n", " 'md': 'Since Mondor\\'s times in the forties of the last century, there was no other book in surgery to be written so easy and witty.\\n**Boris D. Savchuk, World Journal of Surgery**\\n\\nThis, the fourth edition of \"Schlein\\'s Common Sense Emergency Abdominal Surgery,\" builds the reputation of the three previous editions: a worldwide benchmark, translated into half a dozen languages. This book guides surgeons logically through the minefields of assessment and management of surgical abdominal conditions. The surgery concept may have been overtaken in many parts of the world by the development of niche specialties, but the need for a cohort of generalists able to deal competently with common surgical emergencies has not.\\n\\nIf you recognize this need, then this is the book for you! Tyro surgeons and experienced practitioners alike will benefit from the distilled wisdom contained in these pages. The direct, no-nonsense writing style, supported by entertaining cartoons, gives clear guidance while at the same time providing amusing insights into our collective surgical psyche.\\n\\nSome new editors and authors enhance this edition: Almost all chapters have been revised to take account of new concepts and modern developments. New chapters have been added and some completely rewritten, often with an emphasis on the importance of the laparoscopic approach.\\n\\nThis is NOT a standard textbook. Read it! You\\'ll not regret it.',\n", " 'bBox': {'x': 114.82, 'y': 145.25, 'w': 236.44, 'h': 12.37}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Image Identification and Description',\n", " 'md': '## Image Identification and Description',\n", " 'bBox': {'x': 281.52, 'y': 214.05, 'w': 10.88, 'h': 6.93}},\n", " {'type': 'text',\n", " 'value': '*No images or figures were identified on this page.*',\n", " 'md': '*No images or figures were identified on this page.*',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'heading',\n", " 'lvl': 2,\n", " 'value': 'Formula Extraction',\n", " 'md': '## Formula Extraction',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}},\n", " {'type': 'text',\n", " 'value': '*No formulas were identified on this page.*\\n```',\n", " 'md': '*No formulas were identified on this page.*\\n```',\n", " 'bBox': {'x': 0, 'y': 0, 'w': 612, 'h': 792}}],\n", " 'status': 'OK',\n", " 'links': []}],\n", " 'job_metadata': {'credits_used': 902.0,\n", " 'job_credits_usage': 888,\n", " 'job_pages': 888,\n", " 'job_is_cache_hit': False}}" ] }, "execution_count": 10, "metadata": {}, "output_type": "execute_result" } ], "source": [ "parsed_result_json" ] }, { "cell_type": "code", "execution_count": 5, "metadata": {}, "outputs": [], "source": [ "result_json = result.json" ] } ], "metadata": { "kernelspec": { "display_name": "fullstack", "language": "python", "name": "python3" }, "language_info": { "codemirror_mode": { "name": "ipython", "version": 3 }, "file_extension": ".py", "mimetype": "text/x-python", "name": "python", "nbconvert_exporter": "python", "pygments_lexer": "ipython3", "version": "3.11.9" } }, "nbformat": 4, "nbformat_minor": 2 }